Episode 270: Disengagement Precedes Enactment: Mastering Countertransference with Dr. Karen Maroda

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Welcome back to the Psychiatry & Psychotherapy Podcast. Today I’m [David Puder, MD] joined by Dr. Karen Maroda, a psychoanalyst, assistant professor of psychiatry at the Medical College of Wisconsin, and author of several influential books, including The Power of Countertransferenceand the second edition of Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship.

Before we begin, let me give you a quick roadmap so everyone is on the same page. In this episode, we’re going to talk about two things that come up in almost every therapy relationship: countertransference and enactments.

• Countertransference simply means the therapist’s own emotional reactions to the patient — irritation, boredom, helplessness, anger, attraction, guilt; feelings that are triggered by the patient but often connected to our own personal history.

• An enactment occurs when these unprocessed feelings lead both therapist and patient to unconsciously “act out” relational patterns in the session instead of talking about them. Common examples include a therapist suddenly snapping in anger or making a sarcastic remark after months of suppressed irritation, becoming chronically late or distracted specifically with one patient (passive-aggressive enactment), gradually allowing more and more extra phone calls, texts, or emails until boundaries erode, or unconsciously slipping into a critical, overly reassuring, or “rescuer” stance that mirrors the patient’s past relationships.

Dr. Maroda’s central idea is that most enactments are not sudden. They are usually preceded by a period of emotional disengagement, the therapist starting to withdraw, zone out, dread sessions, or become overly passive or accommodating. The conversation explores how we can catch that disengagement early, understand why it happens (many of us have histories of parentification or caring for depressed parents), and use honest but constructive disclosure of our feelings instead of letting things build up.

You’ll also hear a live role-play where I step into the shoes of a therapist struggling with a demanding patient, and Dr. Maroda demonstrates her approach in real time. By the end, you’ll walk away with practical tools for staying more emotionally present, setting healthier boundaries, reducing shame around difficult countertransference, and turning potential pitfalls into deeper therapeutic connection.

Whether you’re early in your career or a seasoned clinician, this episode is full of candid, clinically useful wisdom. 

Introduction 00:00

Puder:

All right. All right. Welcome back. I'm joined today by Karen Maroda, Dr. Karen Maroda. She is a refreshingly candid, unflinching, and clinically courageous psychoanalyst. She is assistant professor of psychiatry at the Medical College of Wisconsin, maintains an active private practice treating and supervising clinicians to a large degree, and is the author of four books, including The Power of Countertransferenceand newly released second edition of Psychodynamic Techniques and the Analyst Vulnerability [Psychodynamic Techniques:Working with Emotion in the Therapeutic Relationship and The Analyst’s Vulnerability: Impact on Theory and Practice]. Welcome to the show.

Maroda:

Alright, thank you, Dr. Puder. It's a pleasure to be with you.

Puder:

So today, I was thinking about just jumping into a quote of yours, and then we'll kind of unpack it. And I think the reason I always like to start with what we're going to be talking about today, we're going to be talking about countertransference. We're going to be talking about enactments, how to stop enactments from happening, and effective disclosure. We're going to have a role play. 

And so here's the quote: “Disengagement typically precedes enactment. It is defensive seeking to avoid threatening stimuli from the patient. And internal conflicts over guilt and shame enactment may well be the unconscious effort by one or both parties to reengage after withdrawal. It succeeds in stimulating deep feelings, essentially forcing renewed emotional engagement” (Maroda, 2022, p. 125). Okay. So I think we need to start by defining enactment, and then maybe we'll go backwards and talk about how you think we can prevent enactments from happening.

Defining Enactment in Psychotherapy: Discrete Events vs. Broad Definitions (01:42)

Puder:

Okay. What is an enactment?

Maroda:

Well, that's not as easy of a question to answer as you would think, Dr. Puder. It's evolved. The concept’s evolved over time, which is why people are understandably confused about it. Originally, it was defined as a very discreet event that involved both people being emotionally triggered and acting out. But over time, people have preferred this whole idea that it really reflects this ongoing, total communication, conscious and unconscious, between the therapist and the patient. I do not subscribe to that very broadened definition. And even some of the people, like Lew Aron, who said, we do risk, we have the danger of using a term or expanding a term that then becomes meaningless, often in the way that empathy was used, you know, after a cohort. So I prefer the discreet event.

Maroda:

I think it's more helpful clinically, and an enactment is when people, and no one denies that the discreet event is enactment. The idea is that many people want to broaden it beyond the definition. So I want to stay with enactment as a discrete event, which is kind of this mutual triggering of therapist and patient. They both get triggered, and it's based on a transference. “Countertransference collision” is the word that Richards [Arnold Richards, Ed.D.] used. There's a colliding. It's unexpected. It's uncontrolled. It's often discombobulating. The therapist is going, “Why did I do that?” Or, “Why did I say that?” And it's very mysterious, and it usually involves a strong emotional reaction. And the proponents of enactment, and say it's a very positive thing, are saying this: having this emotional conflict is positive—it gives both people the opportunity to work through feelings that are actually going on subterraneously in the treatment.

Risks of Enactments (02:38)

Maroda:

So it brings things up, brings it out to air out and to discuss and to work through. That's the argument for enactment. The argument against waiting for an enactment is that often these enactments can be destructive, and they're not just always pure emotional exchanges either. Examples of an enactment can be like the analyst saying something sarcastic and the patient taking offense. Or the borderline personality disorder patient, who naturally fears abandonment, and is criticizing the therapist and the therapist says, “Well, maybe you should find another therapist.” That's an enactment. But there are other, more subtle enactments, like falling asleep, or just fantasizing, or going off into their own world. Disengaging emotionally and emotionally abandoning the patient during a difficult time. Extending sessions, cutting sessions short, canceling a patient at the last minute who you've been having some type of internal conflict with.

Maroda:

So we can't assume that because there's an enactment, and I've treated people where the therapist's enactment involved them—the therapist totally losing control and screaming at them that they were impossible, that they were untreatable. And many people who write about enactment say that it can be, while it can be very helpful, and it can bring things up that were heretofore hidden, it can also be very, very destructive and it can ruin a treatment. So what do I propose instead? I propose that the answer is to be more aware of our feelings. I always tell people that the feelings that come out in an enactment, whether it's falling asleep or yelling at the patient or criticizing them, those feelings were present and in awareness prior to the enactment. What may be true, and often is true, is they're not in the forefront or fully aware at the time of the enactment. And that's why they get acted out. So what I favor instead is being more fully self-aware, accepting those feelings, being curious about them, and maybe trying to find a way to address them with the patient, sometimes involving self-disclosure of your experience of the patient. And I can give you an example of one of my own enactments that I was not terribly proud of.

Puder:

Yes, that would be great. Why don't you give me an example of something you're not proud of.

Maroda:

Okay. Alright. I was seeing a woman who, in my own defense, was very difficult. You know, some super intelligent patients, they litigate. You know, I mean, they have incredible defensive systems that are engaged very quickly and easily. And this woman was like this. She really couldn't tolerate any negative feedback from me. And she was talking about her son, who was in his early twenties, living at home. And she often brought him up because he had actually had a suicide attempt as he was graduating from college, and was briefly hospitalized. And he spent years living with them. And I found myself getting increasingly irritated by this. And even disgusted, impatient. I kept wanting to go, “Why are you doing this? You're enabling him.” He didn't work for long periods of time, and he was very intelligent.

Maroda:

Did very well in school, somewhat on the spectrum, but, mildly so, and fully capable of working and doing other things. He just had trouble with relationships, intense relationships. So he was lonely, but I'm not saying she shouldn't have let him live there. But not only did he live there, he didn't do a thing. He was waited on hand and foot. He didn't clean up after himself in the kitchen. He didn't have to run the dishwasher. He didn't have to do his laundry. And the more I heard about this from her, and the more she said, “Well, he just needs all of this TLC and because he's somewhat special needs and he needs all of this love.”  And so, I knew for quite some time that I was getting very upset about this. And finally one day I just said to her, “What are you doing? Why do you keep infantilizing him? You just treat him like a baby and you're playing to all of his weaknesses instead of his strengths. How is he ever going to be independent and whole if you keep babying him?” Which, of course, she did not appreciate.

Puder:

She didn't appreciate that truth.

Maroda:

No. And, and I said it pretty much that way, and even with more irritation that I was feeling at the time. And I was clearly inappropriately disapproving of her.

Puder:

It built up for weeks and weeks and weeks. And it all came out.

Maroda:

Exactly. And that's what happens with enactment. And all of a sudden, like, you just feel compelled to do something. That's how you know that it's an enactment, when you feel compelled to do something. I felt compelled to tell her how she was screwing up her son. She responded with, she looked, she got very annoyed, very hurt, very angry, and she said, “Since you don't have any children, I don't think you're in any position to be critiquing my parenting.”

Puder:

Okay. 

Processing Enactment (09:04)

Maroda:

And I was very hurt and humiliated by that response.

Puder:

Oh, yeah. She struck back.

Maroda:

Oh yeah. She knew my vulnerability. So you can see how each of our vulnerabilities are colliding in this moment. And it was in the first year of the treatment, so when we had a fairly good relationship, but it created a rupture between us. It took us several sessions, or even more, to try and work through. And what really helped was that I did disclose. She said, “How did you feel when I said that to you?” And I said, “I was hurt. I was hurt.” But I said, “I understand you. You came at me because I hurt you. I hurt and humiliated you and made you feel,” she told me later, I made her feel like she was a bad mother. 

Puder:

Yes.

Maroda:

There's an enactment with a capital E.

Puder:

So, an enactment, there's a role that you and the patient are both talking through. Correct? Through the transference/countertransference. Maybe through the therapist's own reaction.

Maroda:

It's a mutual triggering. Yes.

Puder:

It's a mutual triggering that leads to an event. I often see, or kind of help people figure out if they've had an enactment, “Have you ever behaved towards this particular patient in a way that you've never behaved towards anyone else?” Unless, I guess, you're having the same enactment with each person. 

Maroda:

Probably, I was just saying, but we have enactments with other people in our lives, as well, but I think the whole feeling that it was uncontrolled, there's a sense of regret. There's a sense of like, “What was I thinking? What was I doing there that was not good?”

Puder:

But I think my point is that you're behaving in a way that you normally don't behave. Correct?

Maroda:

Yes. 

Puder:

And if you behaved the same way towards every patient, then maybe that's not an enactment. Maybe that's your own stuff coming. 

Maroda:

You're just a bad…

Puder:

Yes. So, okay, so you behaved in a way that was unique. It led to a rupture and somehow you were able to move it forward. You know, some people will just be like, that it's done. Right? Like, therapy's done. That's the end. There's no coming back. And so you talk a lot about an alternative to enactment.

Maroda:

You know what? I should also point out that what I collected is the idea that she's triggering me. The question then is why was I so triggered by her enabling her son? And the reason I was is that my twin brother was very excessively pampered by my mother. 

Maroda:

And she played to his weakness and babied him because he had been a blue baby. He had the cord wrapped around his neck and he almost died in utero. And so he always had an anxiety problem as a result of that insecurity and anxiety. And she pampered him to make up for, you know, because he was an anxious baby out of the womb. And she just kept playing to that weakness. And he had tremendous strengths. He was very intelligent, he was handsome, he was… and she just kept playing to his weaknesses and babying him. And it just drove me crazy that I could not get her to stop doing it. And that's why, that's my past colliding with the patient. So I couldn't, that's why I couldn't bear her babying her son. And I wanted her so badly to stop.

Puder:

So babying, kind of like excessive empathy over, like coddling kind of entering into the never ending childhood, treating the Peter Pan.

Maroda:

Yes. Not expecting him to accomplish anything or do anything. 

Puder:

Yes. I've had a couple of those. I mean, obviously, we all have these types of clients that end up, and it's like how do you give that information? Or, if looking back, okay, let's say you were to start to feel this tension again with a new patient.

Maroda:

Right.

Puder:

How would you do that differently?

How to Handle Future Triggers: Increased Reflectiveness & Avoiding Forcing Change (13:05)

Maroda:

Well, I think I would be more aware of how it was triggering me and try to work through that internally, you know, and I would try to be more constructive and have her look at this with more curiosity. And to some extent, I think we all have to accept that people have attitudes or behaviors that they, at least at that moment, are not interested in changing, and we can't have the agenda of forcing that change on them.

Puder:

Yes. So increase your own internal reflectiveness regarding where this is coming from, why you're feeling the strong emotion. Also thinking about where is her disavowed assertiveness. Right?

Maroda:

Why does she need to do this? Right? I mean, she herself is very accomplished and so was her husband.

Puder:

What is trauma, the early childhood? Was there something that led her to start this sort of journey? I imagine you found that out in the years.

Maroda:

I did. I think I didn't fully appreciate it at the time, but her own mother had not been very nurturing.

Maroda:

Both her parents, they were high achievers, had very high expectations for achievement and accomplishment, and little empathy for any weakness or neediness.

Puder:

So she had gone the polar opposite. She had swung the other direction.

Maroda:

Far, exactly. Overcorrecting.

Puder:

Overcorrecting. She was giving maybe something that she yearned for continually.

Maroda:

Yes, I think so.

Puder:

Yes. Yes.

Maroda:

Another common enactment is, and I've done this, I think all of us have done this, the really dependent patient who's always seeking advice and is lost. And then, when they keep doing things that are making poor decisions, and then, “I don't know what to do,” or whatever, and then you start giving them advice, even though you know you shouldn't be doing it. And then that might go well briefly. So it gets reinforced, but then eventually the patient gets angry, feels infantilized and says, “Why are you always telling me what to do? You're just like everybody else.” Because the dependent patient feels helpless, everybody else tries to tell them what to do. So we do not want to be repeating that. Right? But it's very easy to fall into when they behave that way in sessions, especially over time.

Common Enactments (15:15)

Puder:

Yes. Okay. So it's like you get pulled into this dyad of operating in a way that you normally wouldn't operate. Giving more advice, succumbing to the desire of the patient to receive the advice initially, but then maybe they feel infantilized.

Maroda:

Yes. And I think feeling very uneasy and questioning yourself and not feeling good about the interaction. Those are, you know, post-enactment. I think those are all signs. Like, “What was I doing there? And this was as much about me as it is about the client.” 

Puder:

Yes. Okay. Nice. Okay.

Puder:

I think a lot of literature on enactment is to reduce the shame of the clinician. Like, “This is normal. This happens.” Do you agree with this statement? First of all, I mean, this was the vibe I got when I….

Maroda:

Yes. Oh yes, definitely. In fact, I was appalled. I was doing some other, Googling enactment, and the Chicago Psychoanalytic Institute, of which of course, is close to me. I know a lot of people there. They have it on their webpage that it's a technique and that how valuable it is, and that people should, like, the implication being that everyone should be using it and pursuing it. Which is, to me, an oxymoron, since the whole point is it happens spontaneously and it's out of control and it's uncontrolled and unconscious to unconscious. So it's an oxymoron and it's a huge endorsement of enactment that I of course disagree with.

Maroda:

The ongoing assumption is that it's all grist for the mill. But people say that about a lot of things. People say that about multiple relationships. When I talk to people, they, I think we have a tendency, I think one of our greatest weaknesses is that we have a tendency to rationalize things that are not therapeutic. Like seeing them as a couple, then seeing each one individually, and then often seeing other members of the family, essentially becoming like the concierge, the mental health concierge for the family. And I think that that does not end well. It's not advisable, but I've talked to clinicians who do that, and they just say, “Well, I know things I shouldn't know, but I just sit on it and it doesn't impact the treatment.” And if you're seeing both people in a couple and one's having an affair and the other one doesn't know it, and the spouse is lying about it, but you're treating both of them and you know that the husband or the wife is cheating, but you can't say it because….  I mean, to me, that's crazy making.

Puder:

It's crazy making.

Maroda:

Yes. And I think it's the same thing with enactment is that we like to think, because again, I think as you pointed out, because it offers us the opportunity to reengage and get some relief, there's like this emotional storm that happens in the relationship, and both people are somewhat relieved and sometimes can be very relieved that they're now reengaged. But all the people who talk about enactment say this too—the downside of enactment is that sometimes these enactments can be very hostile, very insulting, very disruptive, and it can be very, very difficult to come back from.

Puder:

Okay. So, okay. So we're now rewinding to kind of like your case, and your case is that disengagement precedes enactment. And so we have to become aware of that disengagement. Tell me about this.

Maroda:

Okay. Yes. Well, again, if you look at the case examples, I'm a voracious reader, and whenever I get an idea, I think, “Okay, I'm going to read all I can on this, and I'm going to see. I'm going to test my hypothesis to the extent that I can through looking at other people's case reports.” And I just did a book review not long ago by a well-known analyst who was giving such a case where he was talking about how this patient just kept bringing up this boring, repetitive complaint about a family member. And he was just getting so disengaged, so bored, so irritated by this person and he couldn't get him off that dime. Just always was doing that, getting kind of whiny about it. And he talked about being disengaged for months, and even consulting with people.

Maroda:

And his consultants said, “I think maybe you should tell him.” But he was afraid of hurting him. But then he finally did and this is quite often, if not always the case, he actually didn't do an enactment. He avoided enactment by actually getting ahold of his feelings and finding a constructive way to tell the patient, “What is the deal with you talking about this family member all the time? And I'm finding myself being disengaged,” and I forget what else he said, but the patient said, “Wow, this is the first time I've ever felt close to you.” Or, I often quote Steve Mitchell's famous case. In fact, we were just talking about this at the IARPP [The International Association for Relational Psychoanalysis and Psychotherapy]  meeting and people love this because it just seems so out of character for Steve Mitchell.

Maroda:

But it was funny that he had a patient who was criticizing him a lot as she became more independent of him and she had been quite adoring. And they were very close, but she was becoming very critical. And he said, “I found myself getting very angry and having negative thoughts toward her, but because of my therapist guilt, I became even more solicitous and empathic toward her.” Which, of course, irritated the patient, because patients who are continually provocative are looking for a human response. I think we overlook that so often, and that we think that it's the better part of wisdom to remain passive and unresponsive when we're actually thwarting the therapeutic effort in doing that. So, along those lines, she became even more aggressive toward him. And then, he said, finally,  “If I weren't your therapist,” or something. She said, “What? Doesn't this bother you? Why aren't you getting angry?” He said, “Because I'm your therapist and it's my job to manage this.” And she said to him, and remember, they have a longstanding relationship, and she said, “Well, if you weren't my therapist, if I saw you on the street, and I talked to you like this, what would you say?” And he thought for a minute, and he said, “I'd say, ‘F*** you’.” 

Puder:

Okay.

Maroda:

And they both, she laughed. They both burst out laughing.

Puder:

So it confuses me a little bit because I'm like, “Okay, what's the difference between, you said in an enactment, the therapist may burst out with some emotion.”

Maroda:

Yes.

Puder:

And in this pre enactment, “how to deal with disengagement”, you share emotion that you're having. Right? So what is the difference between those two things?

Maroda:

Well, I think I understand why you're confused. Because an enactment, and this may seem like hair splitting, but an enactment would've been if she was actually in the act of criticizing him.

Maroda:

He said, “F*** you.” I mean, that would just be enormously disconcerting and inappropriate. Right? But instead, they were having this meta moment where she, where they're both standing back and looking at the relationship and what's happening. And she's saying, “I can't believe you don't show any anger.” And he's admitting that he does feel it. And then she's saying, “Well, what, what would you say to me, if you weren't a therapist?” Like, “How angry are you?” So they were actually engaging. But in enactment, what often occurs is that the therapist does not do that, does not get to that point, and will act out and say something sarcastic, or use an obscenity, or do something with rage. Which then is destructive. Their conversation ended in laughter because they had been talking about okay, what's really going on here.

Puder:

So I had [Frank] Yeomans on, and I know you listened to that episode [see episodes 234 and 254]. And Frank Yeomans was talking about how sometimes he'll say something when he has countertransference, like, “There's anger in the room.” Or, “There's corruption in the room.” Right? Is that enough? Is that enough to say that it's in the room? Or is that, it seems like you would say something more specific? I guess I'm trying to distill what is this approach that you have and how would you differentiate it between that?

Direct vs. Indirect Countertransference Disclosure (23:35)

Maroda:

Well, “in the room,” I think lacks ownership. I mean, I understand it's an attempt maybe to diffuse the intensity, perhaps of the anger. I don't know. But “hatred in the room” just doesn't do it for me. You know, I just, I'm more in favor of some direct communication. And I'm not saying he should have told that patient that he hated him, which he said, I believe, on the podcast that he did in those moments. But I think he could have, from my perspective, I would've recommended talking about that. He could feel that this guy hated him. And in the moment, he could say that, ”I'm getting the feeling that you hate me right now. And then the patients could say, “Yeah, I do.” Or, “I don't. And are you hating me?”

Puder:

Well, but what would you do if the patient didn't bring up the question of the therapist hating him? What would you disclose, or how would you disclose if you felt hatred towards the patient?

Maroda:

Well, I think hatred doesn't arise that often. I think a person has to be in the moment to generate hatred, and has to be pretty abusive. You know, short of that, I think hatred is more likely to result from suppressed anger and frustration over a long period of time. So I don't think hatred is a commonly used disclosure. And it certainly isn't by me. I've used it maybe one or two times in my forty-year career. So I would not, but I will say “angry.”  I will say to a patient, like this patient I talked about who was insulting me, I will say, “You know what? I'm really getting irritated by you continuing to insult me. Now, obviously, you're very angry with me, but insulting me is not winning me over.”

Maroda:

“You're not achieving your goal of influencing me by insulting me. That's alienating me. So can we find a way for you to talk to me about your anger or disappointment, hurt, that doesn't involve insulting me?” And I think that can be very productive because the person who insults me is also insulting other people. You know, the person who continually insults their therapist. And, bringing that to attention and saying, “This isn't good for our relationship. Okay? I don't like it.” You know, I think that that's constructive and helpful.

Puder:

So I was thinking about disengagement and how does that show up. And I made a list of disengagement things to kind of look at and see if you have any other ones to add. Because we're talking about in this relationship with a patient, you, as the clinician, start to feel disengaged, maybe because you have unexpressed frustrations that have built up, maybe because there's unspoken things you haven't brought into the here and now. What's going on? And so maybe the clinician could become lost, less spontaneous, less engaged, having to pretend to be warm, don't find themself exploring as deeply as they could with a client. Allowing endless tension, not pushing back on demanding behavior, pretending to be present but feeling bad that their mind is often leaving, dreading sessions, finding themselves more quickly to give advice, you know, kind of more superficial engagements. Any others, or any sort of differences that you would add there?

Maroda:

I would add some of the points that Lang [Peter Lang, Ph.D.] made many decades ago. He was one of the first people to outline the fact that anger has to go somewhere and that therapists often become very passive aggressive when they're angry, which further destroys the relationship or denigrates it. And he'll give an example, like the patient you dread to see, you'll be late or you'll be late for that session. You'll cancel and reschedule a lot with those patients. With the repressed guilt over the anger, you'll fail to keep proper boundaries or collect fees. You'll make interpretations that are somewhat insulting either to the client or his or her family members that alienate the client. So that there's a lot of passive aggressive behaviors too that therapists can engage in when they're angry.

Puder:

Okay. So if as a clinician you're feeling this, then there's the potential, according to your theory, and I actually think this is really good clinical wisdom, that a possible enactment is brewing if you don't become aware of your own subtle anger, and then find a way to get in touch with why you're angry. And, possibly the reason anger is not a good or bad thing in my mind, it's a way of overcoming an obstacle. The obstacle is the disengagement. There's something that's not being expressed, something that's not being addressed. Maybe you're not being as truthful as you need to be with the client about things in their life.

Maroda:

Yeah, absolutely. Absolutely. I think you, you nailed it completely.

Puder:

Okay. And so that truthfulness with the client, I want to zoom in on that. So this is something that I think you speak about really well in, by the way, get this book [The Analyst’s Vulnerability: Impact on Theory and Practice]. Also, you can actually listen to the first chapter. There's a podcast I found where it's like the whole first chapter of The Analyst’s Vulnerability is there [listen here]. And it's great. So if you're thinking about, “Would I like this book?” You could listen to one chapter and it'll totally draw you in. Okay. But the thing that we're zooming in on right now is how to be truthful. Okay? How do we be truthful, in a constructive way? In a caring way? And one of your, one of your things that I've sort of been challenged by is if you don't feel like being empathic, then pay attention to that moment. Right?

Maroda:

Yes.

Puder:

Okay. So what are some of your thoughts on ways to be truthful or how clinicians fail to be truthful in these moments of tension?

Reflective Function, Parentification & Therapist Vulnerability (29:54)

Puder:

You know, and maybe the better question is this: Okay, I talk a lot about reflective function (RF). And to deepen our own reflective function in the midst of our countertransference, is, I think, the first step for us to maybe become less emotionally aroused by the countertransference [see episodes 29, 41, 254, and 267]. And you talk a lot in your book about the type of clinicians that become clinicians. Right? Parentification, depressed mother. And so one of the things that I think that you're doing in the book, that you don't even talk about doing, is by engaging our story as clinicians, our own story, in the midst of the countertransference is deepening our own reflective function.

Maroda:

Absolutely. Yes. I think I say that I wish The Analyst’s Vulnerability was the last book I wrote. I mean, the Psychodynamic Techniques [Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship] book is a second edition. So I don't count that as a new, entirely new book. But my last big idea recently was The Analyst’s Vulnerability. And I say, “I wish I would've had the understanding to write that book first.” 

Puder:

Okay.

Maroda:

I wish that would've been my first book, because it's the starting point for everything, I think, which is understanding all the dynamics that result from us having been parentified children. And the point of the book is that it goes beyond the usual discourse about, oh, which many people have noted, well, a lot of therapists had depressed mothers. Winnicott [Donald Woods Winnicott, M.D.] famously said his job was to keep his mother alive—his depressed mother alive. And so I said, okay, we probably all had some kind of depressed, you know, family member, probably mother, maybe had to attend to. But there's never been any dialogue about, okay, what are the repercussions of that? Then how does that impact not only our vocational choice, but how we think about the work? What residue of feelings and motivations we have that impact both our theoretical formulations and our technical choices and decisions, and how that gets passed on from generation to generation and doesn't change because we are inadequately aware of and encouraged to examine our own motivations and needs and how they impact our daily work.

Maroda:

And that's the starting place in my mind, as you pointed out, that you can't really manage all of your feelings consistently and well to the advantage of the patient if you don't have that self-reflected function and that high degree of self-awareness. Now, ideally, in an analytic world, that would come from your longtime personal analysis. That's the idea. But in reality, that doesn't happen very often because like for me, my analyst refused to get angry with me, ever. And I found myself, as you know, as a young person, right out of training, going into analysis, I felt very frustrated by that. And sometimes, I would try to provoke her into getting angry just because she wouldn't show those feelings. And I remember one day I was kind of insulting to her, and I came in the next morning for my session and I said, “I'm really sorry. I was kind of frustrated with you, and I got a little nasty there. I want to apologize for that. And I could tell you were angry, getting angry with me. The pursed lips, the tense face.”

Maroda:

You know, the face says it all.

Puder:

Microexpression, micro-flashing of the eyebrows down and together here [see episodes  15, 16,  17, and 118].

Maroda:

Yes, exactly. So I could see her gritting her teeth, and she just went into absolute denial, “No, no, no. I understand. It's because you have this frustration from your childhood and you were feeling this,” and just talked it away. And I said, “You know, I don't want that. And I don't think it's helpful to me because it doesn't help me to manage my feelings and be accountable and responsible for what I do.”

Puder:

That would be called hyper-mentalization, or like, almost like an intellectualization. Right? Because it's moving further away from her own emotional experience, and kind of projecting it on you.

Maroda:

And like Paul Wachtel says, I think one of our functions is to help our patients see how they're repeating whatever negative behaviors that they have in the world in the session [see episodes 222 and 255]. And it's depriving the client of the opportunity to get that feedback. If she would've said, “Yeah, you went too far and you know, I care about you, but I was really angry. I didn't like the way you talked to me,” that would've been so much more beneficial and therapeutic for me than for her to rationalize my behavior.

Puder:

Right. Right. So, okay. So one thing I was thinking about, as a clinician, is some countertransference. Right? They're starting to get frustrated. Maybe they don't even recognize the frustration. So maybe they're getting disengaged. They're feeling more disengaged. If you were to ask them, “Why are you feeling disengaged?” And they would say, “I have no clue. You're the therapist, you tell me.”

Maroda:

Yes.

Puder:

That's actually a -1 in the reflective function scale. Right? Because it's like a denial. And it's the antithesis of reflection, kind of like attacking the person asking the why question. Right? And so your therapist wasn't quite that bad. Your therapist was kind of more like around a 3 or maybe a 4. There was some projection on you, “This isn't my issue, it's yours. You're just imagining me angry. I'm not really angry. I'm the Yoda. I am perfectly calm in all situations.”

Maroda:

Yes. At all times. Right.

Puder:

At all times. “Continue to idealize me.” Actually, pure idealization is actually a 3. So it's still, you know, this is a 9-point scale. And so what we're trying to sort of, or what you're trying to sort of elicit, what we're discussing here together is by engaging our own developmental story, we can increase our reflectiveness. Right?

Maroda:

Absolutely. Yes.

Puder:

So, first of all, to recognize the actual emotion might be anger. That's okay.

Maroda:

Yes. Normal human reaction.

Puder:

Why do we feel angry? Maybe the patient, and you're describing multiple situations. The patient may be attacking you. Maybe devaluing you. Right? That may make sense of some of the anger. But there may be issues of why it would be hard to express the anger if you had a depressed mother, if you had a mother where you couldn't be angry with.

Maroda:

Or if you had a mother, some of the people I've treated had mothers who would get very angry or would guilt them and cry. “Why are you being mean to me?” You know? So I said, the thing we don't look at is how powerless we were. You know, we might have felt powerful at certain times and special because we could intervene in our families of origin. We could succeed in soothing, or entertaining, or diverting some conflict. And so it became, it was intermittent reinforcement, I like to say. So we could feel successful and special at times, but ultimately, as Searles [Harold Searles, M.D.] said, “We were doomed to failure.” And that failure to actually heal and change the family situation leaves us feeling inadequate. I think it leads to early career people, especially, feeling like imposters and feeling guilt about anger and wanting to dissolve it and transcend it, rather than own it.

Puder:

Right. It's like Wachtel talks about that then this anger is not allowed. It’s disallowed, or it's not allowed. It's disavowed anger. So we have to get in touch with that disavowed anger [see episodes 222 and 255].  

Maroda:

And other things, frustration, helplessness, and as I said, we weren't in a position to confront our families. That just wasn't possible and/or desirable because that wasn't our role. Our role was to make peace. And so I think one of the arguments I make is that we naturally take that sense of powerlessness and passivity into adulthood and into our role as therapists. Therapists are very, very, very often very passive, excessively passive.

Role-Play (38:22)

Puder:

Okay. So this is the perfect segue, I think, to a role play.

Maroda:

All right. 

Puder:

Let's do, I know you treat a lot of therapists and so I'm going to be pulling from different themes of your book and kind of trying to get from you how you would actually help the therapist in the here and now. So let's say this is actually a patient of yours, who's a therapist. So here, shall we just jump into it? 

Maroda:

Sure. Go ahead. Okay. 

Puder:

So I've been thinking about your book and I realize that I'm having a really hard time confronting a patient. I feel very detached from this patient. I feel really guilty about my detachment. You know, I had this mother that was depressed often. And maybe I'll get more to like, what are the things that are coming up for me about that story. And I know I was a peacekeeper and I know that I was her confidant. But with this client, this older female client, I'm having a hard time having boundaries with her. She's calling all the time. I'm taking her calls. It's taking me away from my family. And I'm having a really hard time feeling positive towards this client now.

Maroda:

Well, it's understandable because she's intruding on your personal life. And what do you, what feelings are you having toward her as she's doing this and as this continues?

Puder:

I'm feeling a lot of guilt that I am failing to save her. I'm failing to help her. I feel like no matter what I do, it's never enough. So I'm feeling a lot of self criticalness and so I actually had a dream about this last night, or I felt like it was maybe about it. So maybe I'll just tell you the dream.

Maroda:

Sure.

Puder:

So, okay, I'm in a cabin with a couple patients, and a bear is at the front door. It's clawing its way through. It finally breaks down the door, and then I have a gun. And I'm feeling frozen. The bear's about to attack the patients, and I shoot, but I end up shooting my own foot. And the bear freaks out, runs away, and I'm bleeding. And I sit down in a circle with the three, there's about three patients or something, all older females. And I'm having to listen to them while I'm bleeding out. And I'm doing a very poor job because I feel upset that I'm listening to them. But I'm also upset that I'm bleeding out and I'm not doing anything about it. And then I realize one of the patients is not my patient, but my mother, and I focus on her, and all of a sudden she falls over and I start doing CPR on her. And then all of a sudden the cabin, there's like a sinkhole or something, and we're falling into the hole. And that's when I wake up with this kind of like jerk.

Maroda:

Wow, that's a powerful dream. So always, my first question, of course, is what do you make of all that? How do you understand that dream?

Puder:

I sense that it's illustrating both some of my childhood, of even when I felt like I didn't have a lot of capacity or I'm bleeding out, so to speak, I would just listen to my mom. So, you know, after I got out of Pizza Hut, working at 11:00 PM, making sure my brother was put to bed, I would sit there for like two, three hours listening to my mom talk about her day. Things like my dad's infidelity, current boyfriend issues, weird sexual things I didn't really want to hear. And so I had the thought in my mind, like I would, sometimes I would just kind of space out. Sometimes I would like, so these are the kind of thoughts that come to me, I'm associating when I think about this dream. Not wanting my brother to have to listen to her, so I'd put him asleep and then I would listen so that she wouldn't talk to him, so at least he would sleep. 

Maroda:

The compassionate sacrifice. But that's a terrible, terrible burden for a child.

Puder:

Yes. And I don't think I realized that when I was going through it, but now when I look back I'm like, “Gosh, this is really not healthy.”

Maroda:

Yes. Very unhealthy. Well, you were robbed of your childhood, as Alice Miller has said. And it's interesting, so much of this was initially written about, in the seventies, and yet it just all died. We'd never picked up these things, but he talked about it, and Searles talked about it too, the inevitable rage that results from that. The anger, the resentment over having been robbed of your childhood. And that's what therapists feel a lot of guilt about. And it just sits there because it's never addressed, often even in their own treatment, is the resentment and the rage they felt, in addition to the compassion. It's not, instead of, it's not like you really just hated your mother. There's this natural ambivalence that arises from being the parentified child. You're special. You do everything you can. You desperately want them to be okay. You love them. And at the same time, you've lost your childhood and you're unfairly burdened on a daily basis and have no power really to change that. It's Prometheus on the rock, you know, it just happens over and over again every day, and you just have to keep addressing it. And that's a great burden for anyone.

Puder:

Yes. As I'm listening to you, some of these names, I have not read these things and I feel bad that I haven't read them yet. And maybe if I had read them, maybe that would heal me.

Maroda:

No.

Maroda:

What heals you is getting in touch with and feeling, not feeling guilty about your rage. You know, it's hard to feel guilty about, it's hard to feel rage at someone, at your own mother, for example, who you love and want to restore. And I think the only route to resolving that, it's not reading something, although the reading helps when you see compatible views and conclusions, but the route is to really internally experience that rage, like in the dream that it's the bear coming in the room and your patient is now the bear coming in the room that you want to shoot, but you can't shoot the mother, so you have to shoot yourself instead.

Puder:

I'm feeling guilty. It's really hard for me to even come into these sessions knowing how great of a therapist you are, for me to share how hard it is for me with these patients. I feel some level of a fraudulent imposter just even struggling with this. I feel like I shouldn't be a therapist if I'm having these thoughts, if I'm having these kinds of dreams.

Maroda:

I think that's rather harsh, David. I wouldn't say that. I think that….

Puder:

I worry that you secretly feel critical towards me, even though you're putting off that you don't feel that right now. I don't know.

Maroda:

I'm actually not feeling that at all. In fact, I'm feeling sad for you, that you had to do this, work till 11 o'clock at Pizza Hut and then come home and tend to your mother for hours at night. I think that's sad,  and I feel a lot of compassion towards all the therapists who feel guilt about their anger toward their mothers and other family members that they had to take care of. I think it's a natural thing, but it's all  natural to be upset about it. It's natural not to understand it. It's natural to feel somewhat fraudulent if you're a therapist and you feel it. But I think those are the things that are natural that you have those feelings. You know? And I think it's a failure in our training and the whole ethos of our profession that we have never adequately addressed how natural those feelings are and how they can be easily stimulated by our patients and how paralyzed we can get with a patient, like this woman who demands these calls from you.

Maroda:

And, you know, it's easy to get into a situation like that because none of us are going to say, “Well, I would never talk to a patient in crisis on the phone.” Right? I mean, we all do it. We all have done it. But in some cases, that escalates, particularly with borderline patients that will escalate to a call and another call and another call until the situation is out of control. And at that point, the therapist is so frustrated and angry and having such angry thoughts, like, “I'd like to blow this bear up with a gun.” And that becomes guilt producing and disabling and you just kind of sink into the quagmire of that transference countertransference situation.

Puder:

Yeah. I think, I don't know if I resonate with being the one to shoot the bear, like the bear is the patient. That feels very distant for me. I know it's in the dream. But I think I feel more when I'm talking to this person, I start to kind of just think about other things. Well, it's like, it's more of like I'm aware that my mind is jolting elsewhere. And it's not doing that with all my clients. Just with this one, particular person.

Maroda:

Yes. Well, you know what another interpretation for your dream is? That you're shooting the bear is actually your own anger.

Puder:

Yeah. Okay.

Maroda:

And that's what you want to shoot and destroy is your own rage. So that's another possible interpretation. I don't know if that resonates with you, and that you disengage to avoid that experience of rage at your patient.

Puder:

I feel with this particular person, it's gotten to a point now where there are three or four extra calls per week, but I never feel it's enough. And I felt it distinctly when I was on vacation and it was like my wife is asking, “Who's calling you all the time?”

Maroda:

Oh, sure.

Puder:

And she's starting to get upset at me, and then I have two people that are kind of upset at me, and then I'm just trying to manage the mutual upsetness.

Maroda:

Yep.

Maroda:

But avoiding confronting the issue.

Puder:

Okay.

Maroda:

I mean, clearly, I mean, I always say that the way to measure whether any kind of additional contact has been helpful is if the patient ratchets down, calms down, you know, and does better. It doesn't mean they won't ever need another phone call, but it is always a negative indicator if the demand for calls or attention outside of session escalates. If it escalates, then you're placating an aggressive patient and not dealing with the real situation at hand, which is here that patient's need to control you, to be intrusive, and that somehow is a repetition of her past and things that she does with other people. But she succeeded in, you know, bullying you into submission to accept these calls on the basis that she needs them. But if that were true, if she really needed them and was benefiting, they would decrease in frequency, not increase. So I think this is an out of control situation that needs some new intervention.

Puder:

Okay. So I tried to say, “Hey, I'm on vacation. Let's schedule an extra session,” but then the emails keep coming or the phone calls keep coming. The texts keep coming. So I said, “Hey, if you continue to call me, I'm going to have to block your number. You can email me.” And then I had to block her. And then the emails keep coming; and these are long emails. It would take me 10 minutes. I recorded my time to read the email one time, and it took me 10 minutes just to read the email. And the emails just kept coming and coming and coming. 

Maroda:

Well, speaking of Frank Yeomans, you've interviewed him and [Otto] Kernberg about TFP and transference-focused psychotherapy [see episodes 234 and  239]. And, you know, one of the basic tenets of that program is limiting extra out-of-session contact, because it's something that often happens with borderline patients, and it's not helpful or therapeutic, and you just simply limit that and say no. So what are your thoughts about doing that? I mean, I think you've lost your authority when you have to block her number.

Puder:

My thought is I feel guilty. That despite having the knowledge, the knowledge doesn't seem to be enough.

Maroda:

Your guilt is greater than your intellectual awareness that this is not therapeutic. 

Puder:

Ultimately, the guilt is driving the… the guilt is thick in this moment.

Maroda:

All right.

Puder:

What do you think of the role play so far?

Maroda:

I think it's pretty good. I think it's pretty good. And I don't think this is a rare event. I don't think you're presenting something that doesn't happen every day. But I would say, and I do say to my supervisees, if I can't help them through that, to understand that what they're doing is actually counter therapeutic, they are submitting masochistically to an aggressive patient, which only reinforces that behavior. And I, one of the tenants about TFP that I really agree with, is that limit setting is just extremely important. It's vital to a successful treatment. And I try to help people to see, and it often helps, that what you're doing is not helpful. What you're doing is not therapeutic. What you're doing is reinforcing and reenacting a sadomasochistic relationship. And that is not in any way helping. Not only is it not good for you, it's not good for the patient. And that if you really can't work your way past some of that, I would advise you to go back into your own treatment to discuss how that is, even with the knowledge and acceptance that you're feeling this, that it's not therapeutic, it's not good for the treatment, that you still continue to do it, I think means you've got some things still to work out.

Puder:

Right. Which is why, in the role play, this person is seeing you. I think this is so important to talk about. I'm also mentalizing, if I had a client that was listening to this, this might be really uncomfortable. Right? And they might understand why I have what we call “the frame”; and why I don't do sessions outside of sessions. Right? I don't do email therapy. And it's harder to rewind. If you've extended yourself, if you've gone into an enactment, it's harder to rewind and build a frame.

Maroda:

It is, for sure. 

Puder:

It can be acutely painful. So it's easier to kind of set out with the frame of, “This is how treatment takes place.” Right?

The Therapeutic Frame: No Vacation Calls & Preemptive Planning (53:45)

Maroda:

Absolutely. Yes. I don't communicate with people on vacation. So when people say, "Can I call you? Can I email you?” “No.”

Puder:

Okay.

Maroda:

No. And if it's someone who's really in severe distress, you can have a backup person that they can contact. But can you call me while I'm on vacation with my family? “No.”

Puder:

I actually have, you know, I have a small practice here, and I have certain clients that I know vacations are hard. I might have them schedule an appointment with, or just say, “Hey, you can schedule an appointment with one of my other clinicians while I'm gone.”

Maroda:

Yes.

Puder:

As a preemptive, you know. This is something that I've learned in doing private practice for a while. So, the dream. Let's go back to the dream, because I feel like there were some themes and I feel like as a person in the midst of the therapy, I wasn't wanting to fully make it easy for you. Right? So I was not fully reflecting on this in a way that was at the highest level of reflective function.  

Maroda:

Okay. Alright. 

Puder:

But this is a perfect illustration, in my mind, of this dynamic. Which, you know, I lead cohorts with psychotherapists. You actually came to a special event and talked at one. Thank you so much for that. It was wonderful. And I've seen this trend a lot where the therapist can beat themself up. They can shoot themself. And so I felt like it just came to me, this image of what this would be like. 

Masochism, Meaning & Suffering in Therapy (55:15)

Maroda:

Well, the classic phrase, “I shot myself in the foot.” Meaning….

Puder:

Yes. And I was thinking I had this patient once that was in Vietnam. He's probably passed away by now, so I don't mind sharing the story. He was in the middle of a firefight, and his trauma that he had never told anyone. You know, there's always the trauma that the vet will tell everyone, and there's the trauma they don't tell everyone.  So the trauma came out when I was talking to him and his foot started twitching violently during the discussion of this firefight. And it was because he had accidentally shot one of his own guys in the foot during the firefight. And this was his guilt. This was his moral injury. So this is coming to me while I'm talking about this story, but it's like this kind of idea of this intense, you know, you're supposed to be defending and instead you shoot your own foot or your colleague's foot. And it's an illustrative picture of this masochistic nature. Right? Here's this anger that you should have maybe towards the bear. Or the bear's anger is so disavowed that you turn the anger on yourself and you shoot yourself in the foot.

Maroda:

Yes. I couldn't have said it better. That's exactly what happens, I think, every day in therapy.

Puder:

And then you're bleeding out; and instead of tending to your own needs, your own emotional needs, you're continuing to take care of other people. Right? And unfortunately, I mean, this is, to some degree, we have to do this as doctors. We, it's like we're enculturated into this. I've had so many doctor patients, they're on call, they're in the middle of the night, they're exhausted, yet they're continuing to take care of other people. It's like, this is the role. This is what we're enculturated into. And there's intense meaning and purpose in that. Right?

Maroda:

Exactly. Right.

Maroda:

But some of it is, I think, an illusion. I think if you're on the phone all night with patients and also to the detriment of your marriage, or partnership, which….

Puder:

Absolutely.

Maroda:

I mean, you might feel that martyrs, you know, glory and superiority, “I'm so wonderful. I'm so giving. I could do all this.” And again, I think that's fleeting satisfaction. At the end of the day, if you realize that's not really helping anyone.

Puder:

Right.

Maroda:

How are you ever really going to authentically feel validated? I think it's an illusion.

Puder:

Okay. So a hundred percent the masochists' “death ground” of sorts, in my mind [see episode 261]. So we think about the worst possible situation for the narcissist. It's like the fall of their image. Their public image gets shattered. Newspapers, legal battles, people calling them awful things in the news. This is the loss of their job.

Maroda:

Aging. Aging and loss of power.

Puder:

Right. The psychopath, the loss of power, the loss of control. They control this empire and it's taken from them. Right? That's the psychopath's worst thing. The masochist’s worst thing is the loss of meaning. And so it's incredibly meaningful to suffer for other people.

Maroda:

Yes.

Puder:

So to be told that suffering is meaningless could be a threat to themself and of their own personhood.

Suffering for the Right Reasons: Boundaries vs. Endless Caretaking (58:33)

Maroda:

That is a really interesting point, David. But I think that our job is inherently one of suffering, regardless. We can't eliminate suffering when we sit in a room all day with other people who are intensely suffering. We are experiencing suffering. In fact, I'm sure you've had patients, and I've had many patients say, “Are you really okay with this? This isn't hurting you to be with me when I'm suffering or when I'm so depressed?” And you know, I won't go into how I answered that, but I do. But the point being is that suffering is part of the job that we've chosen. And there's plenty of masochism right there, and meaning, and it is meaningful, really. There is something somewhat, there's something kind of spiritual and can be very deeply meaningful about sitting with a suffering person. But I think when we extend it to the idea that it's our job and our responsibility to save them from that suffering, that's when we fall. You know?

Puder:

And I would say, suffer for the right reasons.

Maroda:

Yes.

Puder:

So to suffer and never expressing any frustration could be not the right type of suffering. You may need to suffer by learning how to express the frustration in the right way. Right? And so to suffer in a way that is not meaningful is the challenge that we have as clinicians as we grow. So earlier on, there may be clinicians out there who are listening to this, who are like, “Okay, I'm on the call with this patient, but they really need me and they need me multiple times a week. And it seems to be what's holding them together.” Right? And I think what your challenge is, and it's a good challenge, is that maybe the suffering needs to be in the difficulty of putting up the boundaries that then allow the patient to grow in the right way.

Maroda:

Absolutely. Yes. You said that perfectly. Absolutely. That we don't really help our patients with their suffering by treating them like infants, not acknowledging their sense of agency, their potential for managing their own feelings. That if we are constantly being the person who soothes them and comforts them, it's like people who say, who always want to pick up their baby the second it cries. I remember, I was treating a woman who ran a daycare and had advanced degrees in childhood education and development. And she's said one of the hardest problems she had with parents who brought their kids in is they would say, “Well, if my baby or my toddler cries, you will pick him or her up right away, right?” And she said, “Well, no. We don't do that. We give them a little bit of time. We never let a baby scream and be out of control. But children learn to self-soothe. It's a natural process.”

Puder:

Yes. And if you, for the first three months, pick up the baby…

Maroda:

Right, exactly. But after that, you give them a little time to try, and then it's only if they can't manage that, you pick them up, and otherwise you deprive them of the opportunity to self-soothe. And I think we make that same error as therapists. We rush in to try and soothe our patients rather than being there with them on that journey toward acceptance of their feelings and the ability to see that they're no longer helpless children, and that they can learn to manage their own feelings.

Puder:

Right. 

Maroda:

So we're caretaking instead of empowering.

Puder:

Right. There's plenty of suffering in just sitting with people that are really depressed or really anxious. Like, that is that. Plenty. In and of itself is plenty. Having boundaries and then having your own, being aware of your own gratification.

Maroda:

Yes.

Therapist Gratification (01:02:13)

Puder:

And this is one of the other big, sort of, kind of unique things that you talk about. A lot of people are not talking about, as therapists, we're entitled to some degree of gratification. Right? Most would say, “Well, financial gratification.” Right? Of treating patients. But also, you know, it's incredibly meaningful to hear people, the depth of their stories, the depth of the, you know, for me it's gratifying to feel close to someone and hear the depths of their mind. Right?

Maroda:

Sure.

Puder:

But, what other gratification are we allowed to have?

Maroda:

Well, I think, you know, again, I don't like to say like I'm the sole proprietor of this point of view. People have mentioned it, it's just never been taken up seriously enough, about dealing with our needs. Not only our negative feelings and how we deal with them, but the pleasure that we get. And to be able to say that without feeling guilty. I mean, most therapists will agree that they have a tremendous sense of intimacy, getting their intimacy needs met, and sometimes actually too much so, to the detriment of their other relationships. And people have a hard time sometimes retiring or giving up their practices, because there's almost nothing in the world you could do for a living, where you get to be intimate with people all day long. I mean, that's tremendously gratifying for us. Most therapists will say they don't like small talk. They're not often very good at it. 

Puder:

Yes. Absolutely. Small talk is like…. And I've had a lot of people who say that before they became a therapist, they had a hard time in their adolescence having small talk. They wanted deep, meaningful connections for the decade and a half before they became a therapist or whatever; and it's like finally, when they became a therapist, they were like, “Oh, wow. These are my people.”

Maroda:

Yes, exactly. This is what's meaningful for me. This is, so, it's okay to say that there's meaning from the intimacy that we have with them. We don't have to be martyrs to find, to get meaning, and that we're helping them, but they're also helping us. They're giving that just that depth of all the things you can talk about, all the things you can say that you never would. Those conversations that I have with my patients, that I go really deep with them, the conversations I have all day, I would never have out in the world with almost anyone. And, you know, it keeps you in touch with your humanity in a way that's just also this whole spiritual sense of us all being connected, the way we're connected with our patients. I mean, it's deeply gratifying.

Maroda:

And I always say, every patient of mine who's really significantly improved, and changed their life, they've helped change my life too. They've made me not only a better therapist, but a better person. And a more confident person, and a more empowered person. So that all of these things become mutual, to a degree. And I've matured and, I think, developed in a way that I never could have if I weren't a therapist. Plus, there's also just the pleasure of being with someone who you like, or someone who is funny. Somebody who can be playful with you. Someone, you know, the times you get to just laugh. And, recognition with someone, the idea that we're both on that road toward trying to embrace the truth, even if it hurts. It's just something. It's a rare event. It's a hot house. I always say it's a hot house relationship, and that hot house can easily, if the temperature's wrong, things can go bad very quickly. But if you can maintain that, it's, you know, you get this beautiful orchid.

Puder:

One of the things I've heard from you, that I didn't hear from other supervisors I've had in the past, is that you should enjoy the clients you choose to work with. You should be interested in them, be curious about them naturally, or that you should somehow select the type of person, and you shouldn't feel guilty about that selection. Tell me about that and tell me how you do that.

Maroda:

Okay. Yes. I get a lot of questions about that, because, you know, people early in their career, or people who are in clinic groups, or agencies, it can be very difficult to select their own patients. But I always say, to the extent that it's possible for you to do it, don't take people just for the money, even though you have your school debts to pay off, and I am sympathetic to that, for the simple reason that the treatment will not go well. And I unfortunately used the word “like” originally, and I regret using that word because people think I mean it in a superficial sense like, you should like everything about the person. And, of course, when people come to us who have maladaptive behaviors, we're not going to approve of everything they do or say, nor should we.

Maroda:

So I don't mean “like” in that sense of, “Oh, this person's so nice. This person's so much fun.” I mean, I've really altered that view to say it has to be somebody that you can see yourself engaging with, and that you can see, I ask new clinicians to try to imagine this relationship down the road. Imagine yourself longer term with this person if you do longer term treatment. And how do you imagine that going? And what do you think you could get from this patient? What does this patient have to offer you, do you think? Like, I'll note that a patient who's very insightful and deep, I think, “Oh, wow, this person, I could be really insightful and deep here. You know, this is an opportunity for me to do this.” Or a person who has a great sense of humor or insight, it's like, “Wow, this could be moments of joy for me during my day.” Even though I certainly wouldn't stay with humor throughout the session.

Maroda:

But, I mean, this person has things that are, I find that I respect. And even people who can be very obnoxious can also be very uplifting, and you can have a transcendent experience with them. So I don't mean in the popular sense. I mean, can you imagine a meaningful, gratifying relationship with this person to some degree, and that you can maintain curiosity and interest? And if that doesn't exist in the beginning, it's like any relationship. If you're not interested or engaged from the beginning, that's not going to get better. That's going to get worse. And if, when people say, “Well, I feel guilty not accepting that patient and I worry, who will treat them?” I say, there's someone for everyone. And there is. It's just like saying, “Well, if I don't date this person, who, who will date them?”

Maroda:

You know, the people find someone, and they will. And the people that you're going to be successful with are the people that you can be engaged with and interested in and have feelings for. And if you don't have that, don't treat them. Because taking someone on that you don't have that with, I like to invoke ethics. You know, if you want to be relieved of your guilt, understand that ethically to take someone on who you can't successfully treat, is not viable. It's partially an ethical decision. Am I going to take this person on who I don't feel good about? I'm not that interested in? I might even have some feelings of revulsion or disgust. Or, I'm going to take that person on and they're going to stay potentially for a long time, spend a lot of money. And for what? Because if you're not engaged, there's no therapy taking place.

Advice for Early Career Therapists: Learning from Mistakes & Patient Selection (01:09:36)

Puder:

So do you think that's something that is kind of like a luxury of being a well-established clinician? Because I feel like, for a lot of the people who are listening, they're starting their practices, they may not even fully know who they are not going to work with.

Maroda:

Well, again, that's an excellent point, David. You do learn that over time. You learn the signs so that you don't get in too deep, you know, you're in for 6, 8, 10, 12, or more sessions, and you suddenly realize, “I can't stand this person. I don't even want to see them.” That's more problematic. And I think you're right. It's something you definitely learn over time. You learn through your failures. And I don't expect early career people to never, you know, I certainly made those mistakes. I certainly took on people because I had an open hour. Honestly, I took on people who were suffering, and I thought, “Oh, I can help them.” And my grandiosity of youth, and discovered I couldn't help them anymore than the five therapists that they saw before me.

Maroda:

And, you know, you do have to learn. You can't be taught everything or have everything resolved in personal treatment. There's a learning curve, unquestionably, and we all still make mistakes every day. But you have to make more major mistakes in your early career, I think, to learn. And I wouldn't fault someone for that. I think the point is, do you learn from it? Do you say, “Wow, I guess I've learned that if I feel this way with this patient in the beginning, this isn't going to go well. Or if I treat this person with this disorder that I can't relate to at all, and I'm not sympathetic to, I'm not going to do a good job.” So you do learn over time, certainly. And you get better at finding a way to not treat that person. To say, “No.” To screen for them, too. That's a skillset in and of itself.

Puder:

Yes. And I would say, if you're a patient listening to this and you've had a clinician say that they didn't want to work with you, or that they referred you to someone else, don't feel bad about that. They probably have their own reasons that are beyond you. Right? And it's probably a gift to you, to refer you out. And I'm curious how many, what percentage of patients you take or not take? And maybe, this phase of your life isn't a good phase to look at for that question, but maybe 10 years ago, what percentage of patients would you tell, “I think you'd probably be better fit for someone else, or this particular person.”?

Maroda:

I would say, I probably took about 80%. Which is high. And, that's the other thing, I take pride in my retention rate. Always have, throughout my career. That's a good sign, too. If your patients stay with you and get better, you're probably making some pretty good choices about who you're treating. If you, given that half of people leave after the first one or two sessions, statistically, if you're able to get people to come in and stay and make progress, then, again, your decisions are probably pretty good. If they're leaving a lot, they're no showing a lot, and not just a single patient, but across patients, then you have to question selection, at the very least. But I think that part of the reason I had such a high retention rate is that I do have a website. I always encourage people in private practice, have a website that describes who you like to treat, how you work. And that will help in this selection. People who don't want that are less likely to call you. And over the years, as I became known, because of my writing and speaking, I tend, and that's still true, I get a very high quality of supervisee to start with. And people I'm delighted to work with. 

Maroda:

And, patients who know what I do, know who I am, have maybe even gone in and read some of the things I've written. So they've already worked on the match themselves. It's kind of like a pre-match that occurs, if you're well known.

Puder:

Yes, absolutely. Yes.  I sometimes have given the advice to young clinicians to write articles on the patient's issues that you really enjoy treating.

Maroda:

Yes. Yes. That's good advice.

Puder:

Put those out there in the world. Or, for  semi-young clinicians, it's like, okay, if we're going to design an episode, if you want to get referrals from a particular type of patient, let's work on that pain point that would lead to that person coming in. Right? So I imagine, at this point in your career, you've written about clinicians that have depressive mothers and parentification, you probably find that type of person coming to your office more commonly, just by the very nature of talking about it. Right?

Why Therapists Treat Other Therapists (01:14:27)

Maroda:

Well, I say what prompted The Analyst’s Vulnerability was that it was actually the opposite. As I became better known, I was getting more and more therapists coming to me for treatment, and I realized that the parentified child and the guilt and the fear of conflict, the fear of doing harm was really omnipresent. It wasn't just some therapists who felt that way, virtually every therapist I treated felt that way, and with varying degrees of severity of parentification. But I thought, “Wow, this is something that we never talk about.” And I was just stunned and I thought I need to write about this. So the writing about the guilt, the feeling like a fraud, the martyrdom, all those things emanated from my experience treating clinicians, not the other way around.

Puder:

Yes. And I've seen it as well. A lot of clinicians have had that therapist role with their parents. I had this one person, Dr. Johnson once said to me, “Kids, natural leaders, leaders that we see as adults, that are leading, probably were organizing on the playground leading, organizing everyone, organizing the game.” Natural. Sure. Therapists probably listened from a young age. Right? Like they have had years and years of experience of doing that, playing that role. 

Maroda:

Well, I think we were naturally…I write about the fact too, that we were selected by our families to be the peacekeeper and the soother and the comforter, because we had those natural abilities and strengths.

Puder:

Right. 

Maroda:

So there was something and then that was cultivated and utilized to help the family. And then, you know, the rest is history.

Puder:

Yes. And, for people that have role reversals that have those things, it was in the story. Right? Earning money at a young age to support the family, taking care of the younger brother, listening to the mom talk about sexual things, weird things. Right? The mom would say things like, “You are the only one that understands me.”

Maroda:

Hence, the specialness and the narcissistic gratification.

Puder:

Yes. The ideal being idealized in the masochistic role.

Maroda:

Yes. Yes. It becomes, “This is how I have value.”

Puder:

“This is how I have value. This is how I get positive attention.” What little positive attention there is. You know, and then that becomes reinforcing. 

Maroda:

But it's interesting. That can often lead to a lot of tension between siblings.

Puder:

I think I've always seen it as a powerful role, but it's also a powerless role, as you mentioned. Yes. Because you don't really have the power as a kid to make your parent better.

Maroda:

Right. It feels powerful, in the moment, when you can soothe them or, you know, be successful in that moment, and you get praised for it. But ultimately, you were destined to fail. And then, even a lot of people like, Andrea Celenza, and many other people talk about how we have to, our role then is we're really trying to redeem ourselves. And Searles talked about that, too. We become therapists so that we can repeat that past and succeed this time. There, we’re no different than our patients in that respect. And that in every treatment we're repeating, that we're going to be successful over time, in a way that we weren't. And that's part of why we can often easily get frustrated and angry with patients who are not cooperating with that agenda and not getting better as fast or in the areas where we want them to or need them to redeem us.

Puder:

Right. Right. And I think not to feel guilty about that gratification when it's done well within boundaries. Right? When it's done well with patients that are getting stuff from us. Right?

Maroda:

Yes. Oh yes. I think [Josh] Cohen makes that point, if we're getting gratified in the service of the patient, you know, and that their improvement and acting therapeutically, why should we feel guilty about being gratified in that process and being enhanced ourselves, personally, in that process?

Puder:

Yes. I think this is a really good place to maybe start to wrap up our discussion. I think this was a really good discussion. I think there's obviously a lot more that we could learn from you, but, you know, they get one and a half hours of conversation to start them on this journey. What would you say in closing to someone who's listening to this and they're like, “Gosh, I have a lot of improvements to make. I'm not sure where to start.” What would be some of your closing encouragement?

Closing Advice: The Necessity of Personal Therapy for Clinicians (01:19:10)

Maroda:

Well, I always encourage people who, you know, these days, many people say they don't have the time or they can't afford their own treatment. And unless they're becoming psychoanalysts, where they have to get their own treatment, I'm a bit concerned that so many therapists are practicing without any of their own personal treatment. And I think that's a mistake. I don't know how you can adequately be sufficiently aware of your deepest feelings and conflicts if you have not gone for some type of long-term treatment. It doesn't have to be analysis. Doesn't even have to be an analytic clinician in terms of what the research says. Although, I recommend psychodynamic approach, of course, because that's what I do. But I think any long-term treatment offers that opportunity, potentially. And if you haven't had your own treatment, I think it's almost impossible to be sufficiently aware of the different conflicts and issues that you have that are going to be stimulated by your patients.

Puder:

Yes. A hundred percent. Yes. Totally, totally agree. I've had the opportunity to hire clinicians over the years, and if I get a whiff that they've never done their own treatment, I don't know if I can refer patients that are calling my line to you, if you've never done your own therapy.

Maroda:

Well, you know what happens, David? Is that when the patient regresses and starts expressing all of this deep feeling, right? And, you know, sobbing and being anxious and calling, “Is this okay?” looking for an explanation of what's going on? And the therapist freaks out. The therapist can't educate the patient about the process because they've never been through it themselves. And they often take regression as decompensation, and shut it down, depriving the patient of their opportunity to have their deepest feelings that they can't show anywhere else, and depriving them of the opportunity to be vulnerable. And so, I would say, if you haven't had your own treatment, don't try to do deep, long-term treatments because you won't do it well.

Puder:

Yes. Some of the clinicians that I've seen over the years, that get in the most dire situations with patients, never did their own psychotherapy, depth psychotherapy, and then started seeing a client twice a week. 

Puder:

And one of them ended up in an affair. A female client. 

Puder:

They get overstimulated. hard to not get into what you would call a, what was that? Countertransference? What type of countertransference?

Maroda:

Countertransference dominance. 

Puder:

Yes. Countertransference dominance. Yes. But I think what you're talking about is, it's harder to not be dysregulated yourself in the midst of a very dysregulating patient if you yourself have not gone through the process.

Maroda:

Yes. Of allowing yourself to be dysregulated, you know, allowing yourself to face your own…. And I can say, I was astounded in my own treatment. I remember saying to people, “I had no idea how crazy I was.” I mean, it's like, you could be really high functioning, but when you start, you're going in for hours a week, and reassociating and having this relationship. Mitchell and many people talk about that. All of us have, and Otto [Kernberg], and his revised discussion of regression [see Aggression in personality disorders and perversions (Kernberg, 1992)], it's like all of us have that potential. And it's not because we are hiding a traumatized child necessarily, at all. It's that vulnerability and that those intense feelings are part of the human condition. And as we become adults, we learn to socially put that aside, even to ourselves, but it doesn't mean it's not a sign of severe pathology for those intense feelings and longings and sadness to come to the surface. And if you have to understand that and have been through that yourself….

Puder:

Right. You have to. And, it can be a little bit dysregulating to look at. I actually think reading your book, I could see that being a little bit dysregulating because it's like, here's a lot of nuggets of what happens and what's truth. And it could be dysregulating to challenge beliefs. Challenge things that have thoughts that have protected you. But inevitably, truth is a good thing to expose yourself to, like a behavioral exposure to your own internal world to the reality of what's going on between you and patients. So you're not just colluding with the conspiracy and mediocrity.

Maroda:

Or joining their panic and desperately trying to fix them or shut them down.

Puder:

Right. Yes. It's like if you feel that panic, how do you expose yourself to situations over time that allow you to not feel as panicked? Right? Just like, there has to be incremental exposures, which to some degree, is your own personal story and your own depth. 

Maroda:

Yes. Over time you just go, “Oh, yeah. I know what this is.”

Puder:

Yes. Awesome. Well, okay. Thank you so much for your time. This is, I think this is a good place to wrap it up.

Maroda:

Yes. Well, it was great fun talking with you. Thanks for inviting me.

References

Kernberg, O. F. (1992). Aggression in personality disorders and perversions. Yale University Press.https://archive.org/details/aggressioninpers0000kern

Maroda, K. J. (2022). The Analyst’s Vulnerability: Impact on Theory and Practice. Routledge. https://www.routledge.com/The-Analysts-Vulnerability-Impact-on-Theory-and-Practice/Maroda/p/book/9781032040837