Episode 273: Nancy McWilliams on Shame, Transference, Personality Disorders & Becoming a Better Therapist

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Introduction (00:00)

Welcome back to the Psychiatry & Psychotherapy Podcast. I’m your host Dr. David Puder.

Today I’m sharing a conversation with Dr. Nancy McWilliams. She has authored several books, including, Psychoanalytic Diagnosis (1994; rev. ed. 2011), Psychoanalytic Psychotherapy (2004), and key Editor of the Psychodynamic Diagnostic Manual (2006; 2nd ed. 2017, 3rd ed 2026). We originally recorded this with my yearly psychotherapy cohorts, with myself, Dr. Riege (Re-Ga) and Dr. Stokes doing the majority of the interview.  None of the contributors have any conflicts of interest to report for those of you getting CME through our website psychiatrypodcast.com

Here are the top four things we cover:

• How to actually work with shame: why self-acceptance often matters more than self-knowledge, and why simple reassurance usually fails

• How different therapist personality styles (schizoid, depressive, hysterical, narcissistic, and others) shape countertransference and clinical strengths

• Projective identification and how to handle intense, sometimes overwhelming countertransference

• Love, trust, and protecting the therapeutic frame — including clear guidance on early boundary setting and stalking dynamics

Let’s get into the conversation. Here’s my interview with Nancy McWilliams…

Puder:

Welcome back to the podcast. Today we are joined by renowned psychologist-psychoanalyst Dr. Nancy McWilliams. 

So we've been going through your book, Psychoanalytic Psychotherapy, and then Psychoanalytic Diagnosis will be the second half. So people are pretty familiar with you and your thoughts. And we have some general questions. We'll start, and then I think we'll have time for people to jump in and ask questions as well. So that'll be the format.

McWilliams:

Okay. That sounds easy. I don't have to prep.

Riege:

No, no prep.

Puder:

No prep. Allie, do you want to…? I'm going to pin you here, Nancy. Ali, do you want to jump in and ask the shame question?

Working with Shame (01:42)

Riege:

Sure. There's so many places to begin, but I think with the chapter that we read most recently, and what we've been talking about a lot is there's a quote that really stood out. “The idea that self-knowledge is one goal of psychoanalytic treatment, but a more profound goal is self-acceptance”, (McWilliams, 2004, p. 137) and how challenging this is when a patient is deeply ashamed. I mean, of course we all have parts we're ashamed of, but particularly a patient that is driven by so much shame and there's a multi-part question. We can take it in any direction you see fit. And so I'll say it and then we can take it from there. How do you help patients talk about shameful aspects of themselves, and how does exploring and sharing the shameful parts lead to a positive outcome, particularly how do you do this when a patient does not believe there can be any acceptance of the shameful parts? Like it's really disbelieving of that. And maybe provide an example of how you frame this rationale to a patient who doesn't buy in or can't fathom ever really talking about it or accepting it.

McWilliams:

Well, you know, I suspect I'm going to say this in response to a lot of the questions today. It often depends on your knowledge of the individual patient. And I would probably do it differently from one patient to another, but to try to generalize, I do several things. One is that I sometimes say very explicitly, “You know, in one way, I'm an old fashioned Freudian. I think this process doesn't work unless you're trying to say everything, even if it's socially inappropriate, even if it's hostile, even if it's critical of me, even if it's something you're ashamed of. If you find it hard to say something you don't have to push yourself to say it, but you could at least flag it to me that you're having trouble bringing something up. And we can look at why.”

McWilliams:

And that often gives an opportunity to go into who shamed them. How did they learn that this idea was shameful? Some patients need you to explicitly make a distinction between feelings and impulses on the one hand, and actions on the other if they were brought up by parents that shamed them for feelings or even in a religious community that said there were good thoughts and bad or impure thoughts. I'll sort of take that on directly and say, “That's not my understanding of what you should judge yourself for, because everybody's got very bad thoughts. The question is whether you act on them, if you're trying to cleanse yourself of bad thoughts, you are in for a lifetime of disappointment in yourself. Because we are mammals, we have aggression, we even have sadism.”

McWilliams:

“We have all kinds of very unpleasant aspects of ourselves: envy, resentment, disgust, contempt. Those are normal feelings. And it sounds like something in your background made you feel like it wasn't okay to have those.” I don't mean to enact them and to treat people with hostility, but even to have hostility. So I sometimes do a certain amount of that to try to really reframe how they're thinking about whatever part of themself is so shameful in their mind. But I also will use humor sometimes, or just I haven't seen much positive come from simply trying to tell somebody that they shouldn't be ashamed. You know, that really constantly talking about how, well everybody isn't that normal? Everybody has that. I might say that kind of in passing, but I find that reassurance never works. And instead I'll attack the self-shaming part of them.

McWilliams:

Like, “Where did you get the idea that you're uniquely bad somehow? What makes you so much worse than all the rest of us?” You know? Because they can take that in. Oddly enough, when you attack the self-attacking part, they kind of feel they can listen to that because they get that you're attacking something about them, and they feel they deserve that. But you're attacking their self-attack. So I do a fair amount of that. “Oh, I forgot. You are too shameful to even join the human race. You know, one of these days you might want to rethink that.” That kind of thing often moves it along. Just naming it helps. Sometimes, “Am I picking up that you're ashamed of what you're telling me?” Sometimes people tell you behaviors that they've done that they should be ashamed of.

McWilliams:

I mean, shame is not entirely a crazy emotion. It's one of the ways that tribal cultures and larger cultures help people not to act out destructive parts of themselves. They shame them for behaving in certain ways. They can over shame them, and that's a problem. But you don't want a shameless culture, you don't want people to behave shamelessly. So sometimes I differentiate between, “Well, it seems to me that it's reasonable to feel ashamed of your doing that, although I hope over time you can forgive yourself for that, because you're not the first person who's done that.” As you well know, shame is actually harder to get rid of than guilt, because with guilt, you can, guilt is very difficult for other reasons. But with guilt, you can do something to compensate, you can apologize, you know?

McWilliams:

But since shame involves being seen in all your ugliness, you just want to crawl into a hole in the ground. It's not something you want to call attention to and try to undo. It's like, “Oh God, the ugliness of who I am has been on display for everybody to see.” So it's a particularly toxic effect. And sometimes people don't even want to name it because they can't bear to feel that exposed. There are some patients, especially people in the psychotic range where I am more self-disclosing, more conversational, and I will say something that I think they're ashamed of. For example, an example would be one of my patients who was very paranoid and who had been humiliated about all kinds of things in his life. He confessed to me in a shamefaced way that he had struggled with irritable bowel syndrome.

McWilliams:

And I said to him, “Oh, that's such a difficult thing. I had a long siege of that when I was in my twenties. And fortunately it was one of the things that my analysis changed.” And he said, “You admit that you had that? That's such an ugly condition.” And I said, “Yeah, but a lot of people have it.” So, you know, and to, to just acknowledge something that is without the shame that I think the patient is ashamed about. Like, “I see we have a break coming up and actually I hate separation, so I always get anxious around separation. So we'll have to pay some attention to that.” Just to model that stuff that somebody else might feel ashamed of is all in the human condition, helps people. But ultimately, I think that any kind of therapy and perhaps especially psychodynamic therapy is its exposure therapy.

McWilliams:

You know, it really is exposure on a grand scale. The person tries really hard to tell you everything and finds themselves with all kinds of feelings about that, and you accept them. You don't make a big deal out of, “Well, you know, that's okay, don't you?” You just say, “Yeah, so you wanted to kill so and so. I can understand why,” and try to make it just a natural thing. But I don't think people are surprised when therapists are nice to them. If they've seen mostly cooperative pleasant parts of the person, but they're very moved when they've shown you their ugliest parts including their hostile parts toward you, and you're still welcoming them, that actually makes a difference. Does that cover the general territory of what you…?

Riege:

Absolutely.  Yes.

Negative Transference, Fragility, and Therapist Countertransference (12:02)

Puder:

I think with that, I was thinking about a type of transference I've seen lately where it's like they can almost “fragile” the therapist and imagine that they would really hurt the therapist's feelings if they said something mean. Or if there is any negative transference. How does that relate or how do you sort of address that or notice it? 

McWilliams:

Sometimes I don't see it. It's one of those transferences that actually makes me angry. Because in my personality, I'm invested in, “Bring it on. I can tolerate it. And if you're trying to be nice to me because I would fall apart, I feel insulted.” You know, I remember once, years ago, one of my patients, she was in analysis with me, and there was  a book party for me when one of my books came out. And I think it was a book party, but at any rate, she wasn't on the list of invitees because she was in treatment with me. But she heard about it. But, she didn't know whether it was a surprise event for me or not. And she didn't ask anybody, but she got it in her head. And this fit with her transference toward me as somebody that, like her depressive mother, she had to take care of.

McWilliams:

She began seeming very blocked in treatment. And I am turning myself into a pretzel, trying to figure out what's going on. She's not talking about this. She was hurt that she wasn't invited. She was envious of the people who were invited, and she didn't want to talk about it because maybe it was a surprise, and she'd be blowing the surprise. And when I found out, I finally said to her, “I give up. There's something that's bothering you and I don't know what it is. What is going on?” And she finally confessed. And it was a very interesting enactment because she could have asked somebody, “Is this a surprise party for Nancy?” She kind of grabbed onto the opportunity to feel like she was taking care of me, because that was familiar to her. She knew how to relate to a mother figure that way.

McWilliams:

But my irritation with her was quite obvious. When she finally confessed what had been going on because I felt, “You've been making me work like a dog to try to figure out what's going on. You haven't been following the basic rule of just reassociating and talking about everything.” I've sometimes had a patient tell me, “Oh, I want to talk about this novel I've read, have you read it?” And if I say, “No.” “Oh, then I don't want to spoil it for you.” And that irritates me. “Listen, I'm your analyst. You're supposed to talk about everything. So you spoil it for me, big deal. That's not as important to me as that you keep talking about the things you're interested in.” So I think I have a particularly reactive countertransference when people are taking care of me.

McWilliams:

When my husband died about 20 years ago, the news went around my grapevine like a flash. And I called everybody the day after he died and said I'd had a death in the family and I was going to take three weeks off, and then we would resume in such-and-such a time. And I had a lot of patients who would come in and they'd go, “Oh, how can I talk to you about my trifling problems when you're going through this bereavement?” And I pretty much had to say to them, “Listen, I really appreciate that you want to take care of me at a bad time for me, but if you really want to take care of me, let me do my job.” Yeah. So, I react badly to patients who think I'm fragile and they have to leave certain things about themselves undisclosed with the rationalization that I couldn't bear them.

Stokes:

And I'm curious, what is it about, maybe you as an individual, that has that countertransference response? Is it something that's happening situationally in your life? Or is it more of a personality, your personality style?

McWilliams:

No, it's a personality thing.  I lost my mother when I was nine, and when latency age kids lose a parent their role in the family tends to, I mean, teenagers will act out. Younger kids will regress. Latency age kids will tend to try to show, “I'm okay. Who needs a mother? I'm going to be self-reliant.” And I was actually, when my mother was dying, I was told, “Your mother is dying. You're going to have to be more self-reliant than a lot of kids your age are. And it's not going to be easy, but we trust you to do that.” So that became part of my self-esteem, that “I'm tough. You don't have to take care of me.” So I, my poor husband. My current husband complains about this a lot because he will do something for me, and I'll say, “Did I ask you to do that? No.” Is it because I immediately think he thinks I need that? Rather, I've gotten better over time. But he's also gotten good at saying, “I have an idea that I think might be helpful for you. Do you want to hear it?”

Puder:

So, every four months, I email you and ask you to come back on the podcast. You're not offended by that, by that continual question?

McWilliams:

No, I'm flattered by it. But if you said, “Oh, Nancy, I know you're so busy. But you know, could you possibly?” I'd rather you be very direct and say, “We'd love to have you on the podcast again. Here's what I have in mind.” And I can either tell you whether I can or I can't do it. There's some way in which, for me, as a person who was an ambitious female really before the feminist movement appeared in the 1970s, there's some way in which I easily feel that especially men are telling me, “There, there. Don't bother your little head with this.” Because in the fifties, that was the way men actually behaved toward women.

Therapist Personality Styles: Strengths, Vulnerabilities, and Countertransference (19:13)

Riege:

So, speaking to your ability to rely on your own self-knowledge of your personality, but your countertransference to sort of pick up on what might be going on based on your personality, I wonder, can you speak to the strengths and vulnerabilities of different personalities of therapists?

McWilliams:

Yes. 

Puder:

Shall we start with one in particular, maybe?

Riege:

Sure.

McWilliams:

What would you like to start with, David?

Puder:

Maybe schizoid.

McWilliams:

Alright. Schizoid people tend to be quite good therapists, or at least good at psychodynamic therapy. They're extremely sensitive people. And if your main defense is withdrawal into your mind, or maybe withdrawal into a fantasy world you don't have to distort. So schizoid people don't tend to use defenses like repression, reaction formation–the more distorting defenses. They see a lot of stuff that other people are defending against. So they naturally get the unconscious, the psychoanalytic therapy makes sense to them. And they have a conflict about closeness and distance and how close to get to other people. They often appear to be very distanced and aloof, but if you get to know them, there's a longing for closeness that coexists with that. And being a therapist is a nice resolution of that conflict because you get closer to your patients than anybody's ever been (McWilliams, 2011, ch. 9).

McWilliams:

And yet you don't have to take your hair down all the time. And, you're protected by the fact that the session ends, you know? There are very clear boundaries. And so you get a lot of your needs for intimacy met without the feeling of risk. That goes with most social situations where you get easily overstimulated and impinged on. So there are a lot of people with schizoid psychologies in psychoanalytic work. I think Winnicott had this psychology. He's always described as shy and quirky and not very sexual. And even his concepts, you know, like the third or the transitional space going on being, impingement is something that he emphasized a lot, which is a very schizoid kind of experience of often a depressed parent who's impinging on you, too overstimulating.

McWilliams:

So the downside of being a schizoid person and a therapist would be sometimes you can get overstimulated. And you need time to refuel. Often, my schizoid colleagues tell me that at the end of the day, they want an hour to themselves. They don't want to see anybody. They don't want to have to talk to anybody. People with my psychology, which is more hysterical, are also extremely sensitive people, and I think we're good in the role if we can get past some of the hysterical defenses, like a kind of performative style. And as you, I've already said here, we are reactive to gender issues and we have to keep paying attention to that. But those two psychologies are very tuned-in kinds of psychologies to other people, even though they look very different. Depressive psychologies are the most common psychologies for therapists to have.

McWilliams:

At least that's what a study in Australia found out. And that's been my experience of, I mean, I have a big streak of that. And most of my colleagues, I would say, are pretty depressively organized. Meaning that they tend to be self-critical. They use introjection rather than projection. If somebody criticizes them, their first assumption is, “Oh, there must be something right about that.” They don't tend to do the paranoid thing, “That's your fault.” You know? If their patients get better, they credit their patient's hard work. If their patients don't get better, it's their fault. And they like being close to people. They feel it's a very attached kind of psychology with sensitivity to attachment and separation, sensitivity to other people's pain and a feeling of some pleasure when they relieve pain. They tend to be people who are trying to help the depressed part of themselves by helping the depressed other, even though you can have a depressive psychology and have never had a clinical depression. 

McWilliams:

Narcissistic therapists have to work harder, I think, to try to really get inside their patient's experience. But they can be quite good therapists, over time. Sometimes their perfectionism works on their behalf. I guess one of their vulnerabilities would be a vulnerability to thinking when people have an idealizing transference toward them, that they're enjoying it too much. You know, this is how they should be treated. So it's harder for them to find the devaluing side of the patients’ feelings. Psychopathic people should not be therapists because they don't see others as subjects. They see them as objects to manipulate. There've been only a few psychopathic therapists that I know about, in psychoanalysis at least, you know, from my inferences about what their psychology was. Interestingly, Ernest Jones was pretty psychopathic. He was very close to Freud, but Freud privately called him the “Liar from Wales.”

McWilliams:

Masochism is, in one way, it's a plus if you have a kind of masochistic tendency, because you'll roll with a lot of stuff. But where you run into trouble as a therapist is setting limits on people and modeling not being masochistic because it's not really helpful for masochistic patients if you're being self-sacrificing and being more and more giving, with the idea, that at some point, they'll see how good you are and they'll be able to take in that you're better than the people that have persecuted them in their life. And that's always a loser. It's much better, for example, if your patient runs into trouble with money to say, “I can really understand why you would want a lower fee, but I've gone as low as I can go with my fee. That's how I make my living.”

McWilliams:

And let them get angry at you. That's much more therapeutic than saying, “Oh, you poor thing. I'll reduce my fee.” And then you end up resentful, especially when they drive up in a BMW after you do that, or when you can see that you're reinforcing their masochistic pattern. What they learn is, “The worse off I am, the more I'm going to get stuff from other people.” And you don't want to set that tone. 

Paranoid people. I haven't known too many therapists who were essentially paranoid. Edgar Levenson used to say that he felt he was essentially more paranoid. He was a very big influence to the interpersonal tradition in psychoanalysis. But usually, if people feel they're paranoid, they don't announce it. But paranoid people, even though they suffer a lot internally, they are also very sensitive. The risk they take is that sometimes what they think is understanding a patient is a projection of what it would mean if that were them saying the same thing. Who am I leaving out?

Puder:

Obsessive, hypomanic, dissociated, dissociation.

McWilliams:

Okay. And obsessive. Obsessive people can be very good therapists because they have such integrity. I mean, they're trying very hard to be the best kind of therapist they can be. That's important to their self-esteem. But they do tend to join the patient in intellectualizing. So I periodically have to talk back to my own obsessive side when I'm explaining something rather than exploring something. 

Hypomanic, the only person I know who's a therapist who's called himself hypomanic, actually, he called himself hypomanic with obsessional defenses is Salman Akhtar. And I think he's quite a good therapist, but I think he also probably overextends himself easily. I don't know too many examples of that, though. Usually hypomanic people have trouble with the sustained relatedness that is required for psychotherapy. It wouldn't be their first choice of profession.

McWilliams:

And it does involve using a lot of denial. And if you're using denial, you've got an additional obstacle to understanding people. If you're brilliant, like Salman, that doesn't get in the way. But for most of us, it would get in the way.

Dissociative, there are a lot of dissociative therapists. A lot of therapists are trauma victims, and they get easily triggered. And I think the important thing for them is to try to figure out what triggers them and not work with patients like that. So if, for example, you have a sexual abuse history, you don't want to try to treat pedophiles. You may have to during your training, but once you have control over who you see, you just don't want to retraumatize yourself. It's hard enough being a therapist. But they certainly have a feeling for how trauma can take you over. Some of the best people in the movement to try to understand dissociative patients have significant trauma in their own background.

McWilliams:

And that was what partly made it possible for them to see this group of people that the rest of us weren't seeing yet. I'm thinking of people like, I don't know his personal history, but I would say Richard Kluft, Cornelia Wilbur, Frank Putnam, Ira Brenner,Christine Courtois, a lot of people that originally put dissociation on the map in the 1980s were people who knew something about it. Judith Herman, I think was not traumatized herself, but she identified…it was important to get women talking about this. In the eighties, we saw this perfect storm of the feminist movement where we were listening to women's experience, the Vietnam vets were starting to talk about their trauma finally, 20 years after it happened, and people began realizing how much trauma there was out there. But Judith Herman's book [Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror (1992)] was a groundbreaker where she basically said suffering sexual abuse does the same thing to your psychology that combat trauma does. And Jennifer Freyd later called it betrayal trauma. So she's the one that reframed it. I remember a time when people would talk about incest as if it were like this forbidden satisfaction of some Oedipal desire rather than the drastic exploitation of a child's helpless dependency by a predatory or clueless parent.

Working with Dissociation and Dissociative Patients (33:15)

Riege:

How do you, and we don't necessarily have to jump here, but how do you work with someone who really uses dissociation as a defense or has a dissociative transference?

McWilliams:

I don't know if there's such a thing as a dissociative transference. Exactly. Okay. I think in different self states

Puder:

Let me describe the dissociative transference. It is kind of like what we're thinking. Because, we've talked about this prior, as a question. It's when you may be making an interpretation or something towards them, it's like they space out during that.

McWilliams:

Okay.

Puder:

so it's like their brain doesn't even register what you, the therapist, said, maybe, during something, you know?

McWilliams:

Well, that does happen a lot when you're working with dissociative patients. And I will just try to name it. “Are you still here? You know, I feel like you've zoned out. Did I go somewhere that you're not ready to hear?” And I do a lot of basic grounding. “You look like you've gone into another place.” If they're outright, DID [dissociative identity disorder], I say, “Am I talking to somebody other than who I was talking to before?” And sometimes they'll say, “Yeah, why are you trying to help her? She doesn't deserve it.” You know, you've got this split going on. And the literature on working with dissociative patients is pretty clear. You always act as if all of the parts of the person are in the room and they're all hearing you, whether or not they're identifying as the person talking to you at the moment.

So, for example, when a hostile alter personality emerges, they're often angry and even a little threatening. He said, “Listen, I know you are trying to help Marie and I think she's scared of you, but I understand you're trying to help her, and you're afraid that I'm trying to hurt her.” So, “I get it. But you're not allowed to threaten me.” You know? So I, with frankly DID people, I do accept the premise that their experience is that they're different people at different times. With more ordinary dissociation, like people zoning out on me, I sometimes miss it for a long time because people learn to pass. They learn to cover. One woman that was a frank DID patient that I worked with for several years told me when she stopped treatment, that she was somewhat disappointed that she wasn't as gloriously integrated as she had hoped originally that she would become.

McWilliams:

But she said it's such a relief not to have to dissimulate and lie anymore. “I used to spend all my time. People would confront me with stuff I'd done in another state of mind, and I didn't remember it, and I would try to develop a cover story. Oh, yeah, I guess I was angry that day. Sorry. You know, and now I can just say, you know, sometimes when I'm under a lot of stress, I dissociate and I don't remember what I did. What did I do? I'm really sorry.” And it took a tremendous weight off her that she wasn't having to constantly pretend not to have this tendency. So again, it depends upon the patient, but I often begin to know that there's a dissociative process going on when I zone out, when I think I'm listening, and then I realize I've been thinking about what to buy at the grocery store instead of really hearing what they're talking about. I bring myself back and I will say something like, “Wow, I think I was just zoning out a bit.”

McWilliams:

“Are you fully here? Somehow you and I, I think we're both up in the clouds.” So again, it depends on the person.

Stokes:

Nancy, I think we have a question. Right? We have a group  member. Aurielle has a question specifically about transplants. Aurielle, why don't you go ahead and ask Dr. McWilliams directly.

Intense Projective Identification and Countertransference Experiences (38:04)

Aurielle:

Hi. Thank you so much for being here today. I actually have a question that came up at a time when I was going through some countertransference, some really, really difficult projective identification issues. To the point of becoming physically ill, seeking medical help. I would just share really quickly that reading your psychodynamic diagnosis book, there was a very specific passage which actually really helped me in my processing of this. And that led me to asking a question that is, I'm curious to learn about your most intense experience or experiences with projective identification and countertransference. More specifically, how did it feel for you? What about it affected you so deeply? And what is your most effective strategy or tool that helped you process and work through it?

McWilliams:

Well, I'll just go with what comes to mind. I mean, I've worked with a number of patients who are so intense that they activated me a lot. But one that is particularly memorable to me was I had a somewhat paranoid patient who was very sensitive to any indication of rejection. And he had very rejecting parents, and he was one of these people who scans you all the time. And it's exhausting because you keep feeling like if your face twitches in a way that he thinks is negative, he's going to go right into, “What are you thinking? You were critical of me. I know it. You may not know that you're rejecting toward me, but I know you are.” I mean, he was poised to project into me his whole internalized drama that he's going to be rejected.

McWilliams:

And one day he came to the office and the door was locked. My husband had thought I was finished for the day, and I had an office with a separate entrance that then there was a stairway and it went up to a second floor office. And my husband was just securing the doors at night and thought my day was over and locked it, but I didn't know that. And I heard the patient at the door, and I went down. I said, “I'm so sorry. I don't know how that got locked.” And he said, “Oh, okay.” And I thought, with his whole rejection thing, I better investigate this. So he sat down and started talking about something else, and I said, “You must have had a reaction to coming through the door and finding it locked.” And all of a sudden he looked terrified.

McWilliams:

And he later explained to me that (and this is the way you can get sort of screwed up in your own mind when you're working with a person for whom some virtually psychotic reality feels like the reality), he said, “When you brought it up, I couldn't think of any reason for you to bring that up, except if you knew it was true that you were rejecting me.” So, he gradually let in the idea that somehow there were professional reasons for my checking with him about that. It didn't have to be that that was the actual feeling that I had toward him. That I didn't want him in my office. That I basically hated him. And this interaction happened several times over the course of a long treatment where he was sure he knew better than I did, that I hated him.

McWilliams:

And through projective identification, I wouldn't say that I felt exactly hateful toward him. What I mostly felt was the terror that was behind his hatred. I was terrified that I was going to lose him as a patient, that I was going to hurt him, that I was going to do more harm than good. And one time when we went around on this he was so certain that I was being naïve and self-deluded, and he knew what I really felt that I started to cry. And that's what broke it. I didn't do it in a deliberate way. I just said to him, “I don't know how your conviction is so complete that I somehow hate you. I feel helpless. Because everything becomes evidence of that.” And he later told me that the fact that I actually cried about it made him believe that maybe I wasn't just rationalizing. So, you know, there's nothing in our textbook that tells us if you're out of all other things to do, burst into tears. But, you know, sometimes the things that actually get to patients are not the things that are in the rule books.

McWilliams:

But that was a particularly challenging case. I really loved this guy. He was a very tenderhearted person, but his conviction was pretty psychotic. And he saw it everywhere. I had another patient that I got out of it with a similarly outside-the-book experience. I had this patient who was pretty narcissistic, who had had a depressed mother. And he came down every morning to see her sitting at the kitchen table with a cigarette in one hand and a coffee cup in the other hand, staring into space. And, you know, she was almost never fully alive, and in the transference, he used to come in and say something like “Oh, you look really tired today.” And I would, wanting to analyze it as a transference, I would say something like, “Gee, I'm not aware of feeling tired.”

McWilliams:

“Is there some reason why you might want to tend to see me that way?” And he'd say, “Oh, you know, I'm a very sensitive person. You may not know you're tired, but I can see that you're tired.” So he would always sort of try to one up me by, “He was a sensitive person.” He would walk in and he'd say, “Oh, you look depressed today.” And I would say, “Gee, I'm not aware of that. What's going on with your perception of me as depressed?” He's, “Oh, I know you're depressed. You just kid yourself. You are depressed.” You know? So what actually moved that treatment along was I was pregnant, and he hadn't noticed. And I got into my sixth month before this super perceptive guy noticed, and I had to call it to his attention. We went through the usual thing.

McWilliams:

“I know you want to look at this as a transference, but it's about you. It's not about me.” And I finally said to him, “If you're so sensitive, how come you haven't noticed? I'm six months pregnant.” And he stared at my belly and he said, “Oh my God, you really are.” And that was the first time he rethought the possibility that maybe his conceit, that he always knew better than I did, what my state was, might be affected by his own psychology and not just mine. So a couple of times I get rescued by some reality because it's so hard for people to believe that what they are projecting on you might be their stuff and not yours.

Puder:

I'm going to pull in Dr. Littal here.

Littal:

I'm pulling myself in.

Puder:

Go ahead. Ask a question.

Love, Trust, and the Therapeutic Relationship (46:35)

Littal:

I wanted to know your thoughts on the relationship between love and trust within the therapeutic relationship, both from the therapist’s point of view and from the patient’s.

McWilliams:

Well, I think one of the things that drives people crazy is not only not being loved, but not having their love accepted. If you're a child whose parents seem indifferent to you, who don't light up, who don't respond to your love of them, you're going to get damaged by that. And to the extent that the therapy relationship is curative, just because it's a different relationship than what you've had previously with authorities. You have to be welcoming to all of the patient's feelings about you, including their love,  without breaking any boundaries. And they have to have evidence that you care about them, that you're really interested in them. I don't typically tell patients that I love them, but they can tell that there's love in their relationship just by my commitment to them. Trust usually takes a bit longer.

McWilliams:

Patients will find it easier to love you than to trust you if they've been betrayed in their history or horrifically neglected. So epistemic trust is the core to any kind of secure attachment. And it takes a while to build. There's empirical evidence that if you got one of the insecure attachment styles, it's pretty robust. I mean, if you're three years old and you're in the strange situation paradigm, and you test as having avoidant attachment, when you're 33 years old, you'll probably test as avoidant attachment on the adult attachment inventory. But there are, at least Philip Shaver's empirical work has demonstrated that if you are in a loving relationship, like a good marriage or partnership, if you have a really close other in your life for at least five years, you start to test more securely attached.

McWilliams:

If you have intensive therapy, that can happen over two years. So at the end of the second year, you actually do see shifts in attachment style toward a more secure attachment. And that's basically the evolution of trust. When patients know that they don't trust me (and often, they do know that at the beginning), I say to them, “I'm aware that there's nothing that I can say that is going to make me more trustworthy in your eyes, because from what I hear of your history nothing has given you any foundation for feeling that other people are trustworthy. But I am hoping that I can be trustworthy enough that over time you actually take it in that I can be trusted, but you don't have to trust me now. In fact, you can't choose to trust me.” Now, I'm quite aware of that.

Littal:

I think it answers about 80% of my question. The other piece is, do you feel like you need to have some sort of trust for your patients? Or how does that work for you with a long-term relationship?

McWilliams:

If your patients aren't trustable, you certainly have to set conditions in which they can't act out in ways that are problematic. For example, I've had colleagues whose patients were fascinated with them and befriended their children on Facebook and tried to get interesting information about their therapist from the kids. One patient of one of my colleagues joined AA [Alcoholics Anonymous] because she learned that the therapist's son was in AA and she became his sponsor and then came into treatment announcing that she was the sponsor of the therapist's son.

Littal:

Oh my gosh.

McWilliams:

I have another colleague who's patient joined her swim club because she wanted to hide in one of the cubicles and look through the slats to watch her therapist undress. I don't think we get good training in this at all. We get a lot of training about how to be empathic, but most therapists are naturally empathic. That's why we went into this field. We don't need a lot of training in how to care about people, but we need training in how to set limits that ensure that we have the conditions of labor under which we can practice. So you have to set limits with your patients. “Look, you are not allowed to befriend my kids on Facebook. You are going to have to tell my son that you can't be his sponsor anymore.”

McWilliams:

“If you want to continue, we'll have to stop the treatment. I don't want my life to be overlapping with yours. That gets in the way of me doing my job.” And, we have to stick with that. We don't have to absorb everything that some desperate patient inflicts on us. I've had a couple of colleagues who were stalked and they put up with it too long. And in one case, the person's office was burned down by the stalker. So if you have a patient who starts to stalk you, it's a serious thing, and you’ve got to immediately set boundaries on it or refer the patient to a higher level of care, because that's a dangerous psychology.

Protecting the Therapeutic Frame: Boundaries, Stalking, and Self-Protection (53:02)

Puder:

So maybe you could define what stalking behavior is, if there's any others that clinicians should be concerned about? And then if there's any nightmare stories that, I know people have reached out to you more, you've probably heard more of these stories than the average clinician. Any stories come to mind in particular?

McWilliams:

The stalking stories are usually, by the time they get to me, they've elaborated in ways that are really hard for the therapist to get out from under. So it is a good thing to know something about the psychology behind that. I don't know why they didn't put it in the DSM because it's a well-known syndrome. Erotomania is what it's typically been called. And it's really an obsessional preoccupation with another person that includes attraction and hostility. The hostility is often unconscious, but it's a paranoid syndrome in erotomania: “I believe that you really want me.” That's the projective identification of my own craving. But it's paranoid in that it's denied in the self, and it's seen as coming from the other person. “If you weren't so wonderful, I wouldn't feel this way.” And it can be so powerful that even people who've brought stalkers up on charges, like if they've gotten a legal prevention on the person coming in their orbit, and the person disobeys the ordinance and it gets to court.

McWilliams:

Reid Meloy, who's an expert on this, told me that the stalker so firmly believes that they were encouraged, that this was really what the stalkee wanted, that they can often persuade a judge and a jury, because you can see how it would happen. The therapists are nice people. And when you realize somebody's impinging on you much too much, you might, this happens to non-therapists, too. A kind thing to do would be to say, “Listen, you're a very nice person, but I don't want to have that kind of relationship with you.” And then their defense attorney gets on the stand gets you on the stand and says, “Didn't you say, ‘You're a very nice person?’” And the stalker is sitting there going, “I was encouraged. I was seduced.”

McWilliams:

And it's really a powerful, paranoid condition. It was first, interestingly enough, it was identified in women who would have these reactions to men of higher status. It was thought to be a female disease originally because people would get preoccupied with the local duke or earl, you know, back in the 1700s, and they would follow him and make his life miserable. And celebrities, of course, often have at least one stalker. That's our contemporary version of that. But therapists become important to patients. And if they have that dynamic, you can be in real trouble. So you have to, you have to sense it early and then set limits on it really clearly, and have consequences for the limits. You know, “I told you not to befriend my kids on Facebook. It's come to my attention that you have a different name under a different social media handle. You've done it again. I'm sorry, we have to stop.” And you leave it there. The self-protection that we have to pay attention to as therapists has been pretty much minimized in our training I think.

Puder:

Any questions on this specific topic from anyone? Anyone have any concerning people? They can just jump in the chat and I'll bring them in. Or raise your hand.

Stokes:

Or maybe even tendencies that are concerning. So maybe if they don't necessarily fit this full psychological profile, maybe there's certain behaviors that have been exhibited throughout treatment that are concerning.

McWilliams:

Give me an example on where you would start getting nervous with a patient? What would be some of the behaviors?

Stokes:

Are you asking me, Nancy? Yeah.

McWilliams:

Yeah.

Stokes:

I would say if there's overt behaviors that start to infringe the frame where I've established parameters, I've established boundaries.

McWilliams:

Yeah, exactly what you said. Violations of the frame. If they start calling you in the middle of the night, if they happen to have been in your neighborhood. And I think we are reluctant to set limits very early. because we want to understand them first

McWilliams:

There's a book by a woman [Doreen Orion], I think it came out about 15 years ago, it's called, I Know You Really Love Me. It's her description of having been stalked by a patient. Ian McEwen wrote a novel [Enduring Love (1997)] about being stalked by a gay guy that became obsessed with him or with a character in the book. So that was interesting because it was the same gender. Often it's a heterosexual phenomenon, but it can be a gay phenomenon too.

McWilliams:

I think we're seeing, I think we're seeing more of this in recent decades. There are a lot of desperate people out there that want to cannibalize. 

Stokes:

Can you explain cannibalism and from a transference perspective, just so the group understands, because I don't know if everyone understands that.

McWilliams:

I just mean that you, you feel consumed by a patient.

McWilliams:

They put the emphasis on the dependency and the erotic attraction, the love, and that's not there, but it's all merged with a lot of aggression. You know, “You're good enough to eat, so I'll destroy you.”

Stokes:

And it's so hard to put into words of how that feels to be on the other end of that.

McWilliams:

Jeremiah, you want to go ahead?

Personality Combinations, Autism vs. Schizoid, and Interactive Dynamics (59:24)

Stokes:

Sure. So Nancy, obviously there's been an uptick in autism diagnoses in the last several years, and I think,  from a psychoanalytic perspective, what are some of the ways that you distinguish autism from schizoid personality? Perhaps the overlapping features, because I know as a clinician, and then working with a lot of other clinicians, particularly who will come to me for consultation, and I'm not directly working with the patient, a lot of times they'll present the patient as an autistic patient. But then it sounds, and feels, more like a schizoid personality structure. So if you could just share with the group if there's any process that you have to distinguish the two, that would be great.

McWilliams:

Yes. They look a lot alike superficially. Both groups are highly sensitive to stimulation from outside. They may have certain rituals that deal with the stimulation. The main difference is in two areas. I think they may have a sort of similar neurological pathways that are operating. But two things. A schizoid person may withdraw from other people a lot, but it's not because they don't understand what's going on in the other person. They read social cues, they just don't want to comply with them because of their conflict about it. So a schizoid person may have trouble hugging his child because that feels like a lot. But they know children need to be hugged, you know, they get it. An autistic person, you may have to tell them,  “It's good for children if you hug them once in a while.” And they'll go, “Oh, okay.” And they can do the behavior. 

McWilliams:

That's one thing. How much do they really read social cues and how much is they're not reading it versus how much are they reading, but finding it too hard to play their role. The second thing is that schizoid people live in this world of imagination that's very rich, and autistic people… you know, I do think there are some overlaps and as we learn more about neurodiversity, I think we're going to learn a lot more about all the different ways you can, all the different brains you can have. But my grandson is on the autistic spectrum, and he had trouble with other children. That's how we first sort of noticed it because other kids had an imagination. And so when he was three, some other kid would come up to him and say, “I'm a lion.”

McWilliams:

And my grandson would say, “You are not a lion. You are a kid.” And his mother had to teach him about imagination. The kid is imagining himself being a lion. And now that he's older, he will say to his mother, “Oh, is that an imagination thing?” So again, he's a loving kid. He's a warm kid, but he doesn't get those processes. Schizoid people, again, can have extraordinary imaginative lives. And they're quite clear what the difference between that and reality is. They can play, in a way. So those are the main differences that I've noticed. But I think our diagnoses are, all of our diagnoses are problematic because the DSM and ICD have gone in the direction of trying to define everything based on what's externally observable. And sometimes what's most important to people is the internal experience, which they don't always share right away. 

Stokes:

Wonderful. Thank you.

Riege:

I think there's, there's a lot of hands up. Why don't we, why don't we open it up to some of the group members? What do you think?

Puder:

Let's do it. Karli Pond, I'll bring you in here.

Karli:

So one of the things that I would love to hear your thoughts on is I think this question came from a little bit working with couples, but then also kind of in the therapist-patient dyad. I'm curious what your thoughts are about combinations of particular personality styles or how they might interact–reading through Psychoanalytic Diagnosis and understanding the kinds of styles within individuals and the defenses that come up. I'm just kind of wondering if you have any thoughts about particular combinations or ways in which things might combine and certain styles might pull on certain aspects of our own psychology–if we're hybrid or just kind of anything in the interactive kind of dynamic between people, if that makes sense.

McWilliams:

Yes. I mean, most of us have elements of more than one personality style. And, if you really want to get to know somebody, you end up learning what their specific story is. What is their narrative? How do they understand the world? What is the theme of their life? And it can often involve combinations. My own personality, as I said, is somewhat hysterical, somewhat depressive. It's very common to have a combination of schizoid and obsessional, the kind of person that Jeremiah was talking about, who combines paranoid with psychopathic is altogether too common. And our legal system doesn't help us with that either, because the legal system insists that you be one or the other. You can't be, if you're psychopathic, you're not crazy. Those are mutually exclusive diagnoses, but plenty of people are both psychotic and psychopathic, paranoid to a psychotic degree. And psychopathic depressive and masochistic tend to go together a lot. 

Karli:

Would you say those combinations find each other in different people? Like, do you see, I don't know if you've ever worked with couples, or just kind of in your experience, do certain styles tend to find one another and have more hostile or more equanimity in terms of their combination? Or like with your personality, do you have certain styles and patients where you're like, “This seems to work really well,” and others that you're like, “Wow, this sucks. This is not a good combination” Something like that between people?

McWilliams:

The only combination that I've noticed over time as a common combination is schizoid and hysterical. They have certain things in common, like their level of sensitivity. So in some ways they're similar. But let's say, it's a schizoid man and a hysterical woman. They are drawn to each other like magnets sometimes, because the schizoid man admires her comfort with other people and her expressiveness. And she admires his capacity to stand alone and reflect. And, you know, then they get together. And in couples therapy you get these pursuer dynamics because her way of solving a problem is to move closer to him. And his is just, “Get out of there.” And that's actually something that you can interpret and they can see, and that they can, she can learn to give him space. He can learn to move toward her when she's upset instead of avoiding her when she's upset.

McWilliams:

So that's a pretty common one. But I've seen all kinds of combinations and I think for me, I've enjoyed working with all different kinds of patients. I think the ones I have the hardest time with are people who are profoundly narcissistic because they don't really love. And I don't mean ordinarily narcissistic. We all have narcissism. But your malignant narcissists, that are very, very hard to reach. There's a reason Freud thought they were untreatable. And it wasn't until the 1980s that we had literature that allowed us to conceptualize ways that they might be helpable to move more toward the capacity to have “I-Thou” relationships rather than like, show off, or idealize, or devalue relationships. 

Puder:

Awesome. Thank you so much, Karli. Okay. Let me unpin you.

McWilliams:

I think Grant had his hand up for a long time.

Puder:

Oh, okay. We'll do Grant next. Go ahead, Grant.

Authenticity, Self-Disclosure, and Becoming a Better Therapist (01:09:00)

Grant:

Hello, nice to meet you. Thank you so much for coming. I'm a large fan, so I'll probably just get that out of the way. 

Grant:

I don't know how to really word this question so that it's the most, maybe socially appropriate, but I've never been analysis with you, obviously, or any of the leading minds of psychoanalysis, but there's something about the way that you speak and the way that you write that I find different from the other leading minds and a pleasant one, I find. So I was more curious if that was something that you experienced as well, maybe that you feel differently. Some theoretical differences that you feel, and what would those be? 

McWilliams:

I don't think it's theoretical differences. I think it's a combination of personality and feminism. I wanted to represent my own voice and not to try to sound like a mansplaining expert. But I think I'm just very lucky. I have absolutely no memories of ever having been shamed. I have had some painful experiences in my history, but I was never shamed. I was always supported in my confidence. So I always hated it when I felt people were using obfuscating jargon and not talking like real people. Interestingly, Freud was a very good writer and stylist, and he was very down to earth. That's one of the reasons that he became so popular in the heyday of psychoanalysis, was that he was very direct. And Theodor Reik, who influenced me a lot, also was, and very self-disclosing. And I, from the time I was adolescent, people used to say to me things like, “You're so sincere.”

McWilliams:

So I think that comes from never having been shamed. I think I'm just incredibly lucky that way. It's very interesting to me with my diagnosis book, frequently people will tell me, “What I really like about the book is the stories. When you give a vignette about something, and there's one story I really love in that book.” It's always the same story. Right? I bet some of you are associating to it right now. It's that I, in the flush of a rescue fantasy, I loaned my car to a psychotic patient and he drove it into a tree. And I think people are so pleased to hear that I could be that stupid. But I think that's what we need, is mentors who talk about how hard the work is, what kind of mistakes they make, how easy it is to make those mistakes. So as a writer, I haven't been particularly self-protective to protect a certain image, and I think people are grateful for that.

Grant:

Yes. I agree. There's something about the way that you model that that brings down the authority that analysis has where you give this interpretation and you are this professional, but yet at the same time, you're supposed to be creating a space where we're both human. And sometimes I find that when I read, I feel like the doctor, whoever's writing, has kind of lost sight of that in a way. And I find when I lose track of that, and I'm fighting that, because I'm new. I look back at your writings and I just…. So that's why that's the stem of my question. So thank you for answering and thank you for setting a good model.

McWilliams:

Thank you.

Riege:

Inherent authenticity, which is so true to your character. I think that sounds like it comes quite naturally, that authenticity in your writing. But the use of self-disclosure, as well, allows so many to just feel seen and takes away some of the shame I think, or fear. 

McWilliams:

Good. So it's hard enough learning to be a therapist without alienating jargon. 

Riege:

Great. Baab. Go next.

Al-Baab:

Yes. I actually had two questions, but I thought one may be a better segue from the last one so I'll ask that one first and then maybe throw in the other one if you want to answer that one too. But the one thing I wanted to ask is, what skills as a psychoanalyst or a psychodynamic therapist do you think can be learned through training or just through your career? And then, what skills do you think are inherent to who you are? So it becomes almost like, you are kind of born with the superpower and, because of that, that is what makes you a good therapist or a good psychoanalyst. 

McWilliams:

Well, I think an awful lot of what makes people a good therapist or a good analyst is just natural human qualities that haven't been snuffed out. Like, curiosity about other people, respect for other people. We haven't theorized respect a lot, but I think that's even more important than empathy. You know, for people to feel you're approaching them with the attitude that you're interested in learning from them. And many therapists have that naturally. If you don't have that naturally, you can learn a lot of things, but it's always going to be a little bit of, I don't know, a performance.

Al-Baab:

Yes.

McWilliams:

And  I've had a couple of supervisees over my time that they just don't have the intuition that I think most good therapists naturally have. So, I will say something like “Well, did you ask this guy about what his substance use is? Because he's mentioning all these addictive things in his family?” “Oh, no. I probably should have done that.” Whereas, it wouldn't be a matter of my going through a checklist of what I should ask. It would've been a matter of just my hearing intuitively that, “I should ask about this.” But some people don't have that. Now, the guy I am particularly thinking about, he's okay as a therapist. I don't think he's had quite as many successful experiences as some of us, but he's not doing harm to people. But I can't imagine his patients don't feel like there's something missing.

Al-Baab:

No, that's a great way. Because I think about it even from a clinical or a medical standpoint, there's a difference between a doctor and a caregiver. And the doctor is technical, like, “I'm going off a checklist of diagnoses.” And then the caregiver is actually bringing humanity back to the relationship. And so I think that's kind of a beautiful way to put it, is just understanding that there's a human at the end of it, not a diagnosis. 

McWilliams:

Not, you're treating a person with appendicitis. You're not treating an appendix.

Al-Baab:

Exactly. You're treating a person with it. 

McWilliams:

But some people have all the words and none of the music. You know?

Al-Baab:

That's great. Thank you. I wanted to quickly circle back because we were talking about stalking and harassing. And the question I had for that is are these patients coming in for other reasons? And then, through that, those sessions that kind of intense psychopathic transference happens where they exhibit those stalking, harassing behaviors, or are they actually coming in for that particular? 

McWilliams:

They never come in saying, “I worry that I'm a stalker.” I've had a couple of people who were worried that they were a stalker, but they weren't stalkers. They were just obsessionally concerned that there was something wrong with them and that was what they grabbed. No, they always come in for anxiety or depression.

Al-Baab:

Wow. And then that is what would come out. Like, there'd be like some thing that would happen from that, and then would you be able to tie that through? Because when we talked about Shedler, he talked about patterns. So would you be able to see in other instances in their life, as they're talking about it, where that behavior is common or coming up again and again?

McWilliams:

Well, that's one reason I think it's important to take a history. “So what went wrong with each relationship that's been important to you?” If they've been in therapy before, “What ended the therapy?” Because that's going to happen to you, whatever happened there, and you have to make it come out differently or figure out that maybe this person needs a higher level of care. I think we're seeing more in our outpatient clinics and private practices, of this kind of behavior, partly because we don't hospitalize dangerous people anymore the way we used to be able to do.

Al-Baab:

Gotcha. Thank you so much. Also a huge fan.

Stokes:

Heidi, you had something.

Heidi:

Hello.

McWilliams:

Hi.

Heidi:

Think collectively we're saying you're a badass.

Heidi:

It's this, you have a keen ability to be a human, and I just appreciate that, the permission to be human.

McWilliams:

Good. Since we're all stuck with being human. Right?

Heidi:

Exactly. And I'm newer in the field, but I wasn't trained very well in personalities. So your book on personalities diagnostically, the one thing that was really helpful, and I just wanted to say thank you for this, was in working with a schizophrenic patient. You had talked about normalizing how scary their thoughts are. And I did that with my client and to see his relief and the way he could move towards me, and the way he opened up to share more with me, it was really valuable. So, thank you. 

McWilliams:

Oh, good. That population, the psychotic population, they have been so badly treated over the last 50 years. I mean, when we got the antipsychotic medications in the fifties and sixties we were so impressed with how they could calm a person in a state of absolute terror and aggression and misery. They were so impressive that, you know, we started saying, “You're going to need to keep this medication going for life.” And we started telling them that they had a condition like diabetes, where they just had to get on these medications. And we stopped offering them therapy, and we started offering them groups to manage themselves that mainly were groups to keep them on their medications. And I'm not at all anti-medication, especially for somebody with acute psychosis, but we overmedicated them and we haven't given them any therapy.

McWilliams:

And even if you're on antipsychotic medication, you have stuff you should be able to talk with somebody about. So we've really made no progress with that group at all. And now they're learning that long-term excessive use of antipsychotics damages the brain as much as, or more than, untreated schizophrenia. So we have to develop, we have to refine our effort to try to, these are people we all went to kindergarten with, who lost their minds in a particular way. Freud says that the mind is like a crystal, if it gets whacked, if it undergoes certain kinds of stress, it will fracture along the lines that are inherent to that crystal. And I think that's a beautiful metaphor. With some of us, under stress, dissociate. Some of us become neurotic. Some of us become borderline. Some of us become psychotic. But we're all human and we all need relationship. So, that group is particularly underserved and mistreated. I think they're told that  they have schizophrenia as if it's an alien condition that infected them, that they just have to medicate forever as opposed to they've had a hard life and they lost their mind.

Heidi:

Yes. It really helped me dispel my misunderstanding of what schizophrenia was and how it had, and look at where that came from. And, to your point, it was the monsters that they had been created out to be years ago with institutionalization and so forth. So, yes. Thank you.

Gender Care (01:22:28)

Hi. I'm a huge fan too. But there has been a search in the use of gender affirming care, and I wanted to hear your views on it.

McWilliams:

I'm not even sure I like the term “gender affirming care”, because very often patients' problems are, they don't know exactly what to affirm. They're very conflicted about who they are. There are some people who know that they're a man trapped in a woman's body or vice versa, and they've always felt that way. And they're pretty easy to help. They just need somebody who will witness their effort to put their physical body into parallel with who they know themselves to be. An awful lot of other people are harder to help because they worry that they're trans. They don't know if they're trans, maybe they're gay, maybe they're trans. They need to have a place to talk about all that without a therapist having an agenda for them. And I worry about the immediate agenda that you should get surgery and hormones as much as I worry about the agenda that you shouldn't, you know, you should make your peace with the gender that you were assigned at birth.

McWilliams:

I think we have to open space for people. For so many years we were pathologizing homosexuality, and it was just a matter of majority people thinking that anybody who was different from us, heterosexuals, must be pathological. And that was very, very damaging. And I think it's more complicated with trans people. For example, in dissociative identity disorder, sometimes people often have alter personalities of another gender. And so they are trauma victims. And you need to figure out what each personality is doing in the system with them before you make any global decisions about who they should decide that they are in terms of their gender. So it's very complicated, but you have to give the patient space to tell you their story. I've known people whose lives got immensely better once they transitioned. And I've known some that transitioned and were very disappointed about it because they believed that it would solve all their problems to make the transition. And they discovered that life still hurts. So I just don't think we should get enthusiastic that we know more than a patient does about what they need.

Puder:

Great. Gotcha. Thank you. Okay. Let's see if any other people want to jump in the chat to ask a question. One of my questions for you is, with the transference of idealization when is it too much? Or when is it a nice amount of idealization that's a nonthreatening, like, “Okay, I'm going to let this just, I'm not going to analyze this.” versus when is it like too much where it's like you have to address it, and then how do you address that?

McWilliams:

Again, this really depends on the patient and the combination of the patient and the therapist. But there was a big conflict about this in the eighties. In the general discussion about how you treat narcissistic patients when they idealize you. There were really two different viewpoints. Heinz Kohutsaid idealization is a normal part of development. If the patient's idealizing you, you just accept it. They slowly have to go through a developmental process that they weren't able to go through. They either had a parent who wasn't good enough to idealize in the first place, the way children need to idealize their parent at around age three or so, where they think you hung the moon. Or they had a parent who was very defensive about being deidealized when the kid got to an age where they realized that their kindergarten teacher knew more about asteroids than their mother and starts putting you in perspective. If they were able to go through that, they're not going to turn out narcissistic if they got stuck (Kohut, 1971; Kohut, 1977).

McWilliams:

They need to go through idealization and then deidealization with you. And you don't have to interpret it. It just happens during the therapy. That was Kohut’s position. Kernberg's position was not that idealization is, you know…I think he would say some kinds of idealization are normal and people go through that, but he felt if you were diagnosable as a narcissistic personality, you'd gotten off track and you were using idealization to defend against, let's say envy. And so he would interpret that. He would say something like, “I think you want to believe that everything I do is right. Because if you saw me as sort of struggling to understand you, you would be terribly disappointed in me.” Or, “If you feel like I am idealizable, then you're struggling with envy toward me. And do you notice that every time I talk you interrupt me or you tell me you already knew that?”

McWilliams:

I think that's it. Interestingly, Kernberg worked with more of the devaluing narcissists and in cohort more with the idealizing narcissists because they were in different settings. But I've had patients that make Kohut look good and patients that make Kernberg look good. There are some patients that you can't analyze their idealization as a defense. You simply have to put up with it. A pretty common evolution in therapy, in my experience, is that people start out with a very benign idealization. It's not bothering you that they idealize you. It seems to be actually helping the treatment that there's a kind of a natural wish to do well for you. But there comes a point where suddenly it bothers you. And you can tell that the person doesn't want to feel certain other things, and they're using it as a defense.

McWilliams:

So it started out as a normal developmental thing, but now it's a defensive thing that doesn't feel good. And when that happens, I think it's always valuable to talk to a colleague about it, but I think you should trust your countertransference. It's telling you something. Maybe the person has moved on, has grown, and now is capable of not idealizing you, but they're hanging onto it because they're used to it. You know? So I don't think you can generalize about which way to go. Some people are too fragile to do anything other than be who they want to think you are. And other people, you do them a big disservice if you let them leave therapy thinking that you are so brilliant because when somebody's idealizing you, inevitably, then they're seeing themselves as less than you want. You want them to end therapy not thinking that they had the best therapist in the world, but that their therapist was good enough and a good process ensued and the therapist didn't make too many mistakes and they're moving on. You know?

Puder:

Yes. That's good. That's helpful. Thank you.

McWilliams:

I didn't have a lot of idealizing patients when I started my practice. I had a lot more devaluing patients. You know, “You look pretty young to be a therapist.” Or, “Where did you get your training?” Or, “Did you read that on page 52 of your manual?” I mean, I got a lot of that kind of low-grade devaluation and I had to learn to, for patients who needed to do that, and it wasn't analyzable yet, I had to learn to roll with it and say things like, “Yep. I guess I just am not a good enough therapist.” or, “You know, you are a genius at finding everything that I do wrong. It's really impressive.” And modeling that I'm not threatened by the fact that they're deidealizing me or devaluing me. It detoxifies it some, to be able to roll with it that way.

Frequency of Sessions (01:31:54)

Puder:

Let's see. Okay, we have a question on the frequency of visits. I think that Shedler has a stance of like, it has to be two [per week] to get the, but I'm a little bit more loose. I see a lot of weekly patients. I've some twice a week patients [see episodes 144 and 205]. What's your take on this and has it changed over time? Like frequency of visits?

McWilliams:

I used to do a lot of three or four times a week psychoanalysis, but that was back when insurance companies happily covered that. That's hard for patients to do now. And so I think we've all adapted in the field and it's really different from one patient to another. Some people do quite deep work at once a week, and some people you can see them four times a week and they never get to the stuff that you think they need to deal with. So I don't think there are rules about that. We've wasted an awful lot of ink with the frequency wars in psychoanalysis. What is real psychoanalysis? Is it three times a week or four times a week? What's the minimum number of times you have to see to make a difference? I think it's fairly common for people to say as a general rule (and perhaps this is what Jonathan [Shedler] actually said)...

McWilliams:

As a general rule, it works better to see people twice a week. Because, when you're seeing them twice a week, they're not spending the whole, you know, half the session, giving you the weekend review before they get into their stuff. If you hurt their feelings on Tuesday, you know that on Thursday. You can try to repair that. You don't have to worry that they're for a whole week, they're dealing with you're having made a mistake or they're having brought something up at the last minute that you didn't handle well. So I prefer to see people twice a week. But I've had some patients that did well once a week. I loved seeing people three and four times a week. It really deepened the treatment and I learned a lot about the depths of certain kinds of psychologies.

Serena:

Bouncing off that topic, I was wondering if there are any ways you changed how you worked with patients to work better with the once a week structure that insurance companies are so hyped about?

McWilliams:

Probably. And I don't know how much of it is the difference in frequency and how much of it is just relaxing into the role. You know, I have a colleague who says, we all start out as principlists. We're trying to put into practice certain principles and we're following certain rules that we've been taught as how you're supposed to be as a therapist. And as we mature, we become consequentialist. We, in other words, we judge what we do by what we expect the consequences to be. So we don't tend to have rules about “you always self-disclose here. You never self-disclose there.” You kind of feel, “If I were to disclose such and such here, what would be the consequence?” And so you make your decisions in a looser way based on accumulated experience with what you can expect the consequences to be.

McWilliams:

So I don't know how much of it is that I just have loosened up. Also, when you get as old as I am, you tend to feel like, “Listen, life is shortened. You got to get going.” And I think I move in on stuff a little faster than I once did. So, I don't know how to separate those things out. But I do think I'm more interactive at once a week, a little more self-disclosing, a little more likely…and I've been influenced by the relational movement to say more about, “What's going on between you and me?” Not, “How are you feeling about me?” But, “Do you think you and I are involved in something, in a reenactment of what you've been describing in this time? Because here you're saying this, I'm doing that, it sure looks like, you know, the past has come into the present here.”

McWilliams:

And so I own more of my own accountability for what's going on than I once did. Because, at once a week, you can't be quite as anonymous because you don't know what they're doing with what you've let sit out there without engaging with it as much. It's hard to describe, but I think I'm more active, more self-disclosing. Like, “I'm finding myself anxious here. You're telling me this without any anxiety and I'm feeling anxious. What do you think is going on? It feels like I'm carrying your anxiety.” I wasn't trained to do that. But that's often a less toxic way, from the patient's perspective, of saying, “You're defended against feeling your own anxiety.” You know, that would be a one person way of saying it. A two person way of saying it is, “I'm feeling something that I don't think you're letting yourself feel.”

Puder:

All right. One last question. Amanda, you're up.

Working with Children/Adolescents (01:37:47)

Amanda:

Okay. I wrote mine in the chat. I wanted to know, what general advice do you have for working with child and adolescent patients? Specifically, countertransference, transference, and even self-disclosure, like building trust. With adolescents I've found that I've been a lot more loose, but I’m trying to keep that balance by being authentic but also keeping within the frame.

McWilliams:

Yes. I haven't worked with adolescents or children for a while. I did it early in my career for maybe 20 years. Then, I had my own children, and I was sitting on the floor, playing with tinker toys enough. And also, it's harder work working with kids and adolescents. My colleague, Beverly Stout in Atlanta, does. She has a whole practice of working with adolescents and kids. And she's a person of incredible energy. More than me. But when you're working with kids and adolescents, you're inevitably working, to some degree, with the parents because whatever the role of the child is in the family system, as they start getting better with you and changing, the family system tends to fight back. They're used to them being the identified patient. And if you don't help the parents, and the family to adapt to the change in the patient, they are, I've seen very often, the patient gets yanked out of treatment. So it's twice the work really. But you have to. The parents have to feel like you're not blaming them, that you appreciate their genuine concern for their child, that you respect them, and they are going to be highly alert to any talking down that you might do to them. So being very conversational and flexible with them is important while keeping the regular boundaries about time, fee, email, all the other things that we set boundaries about. 

Puder:

Thank you, Amanda. Okay, well thank you, Nancy, for your coming on and your time. We really appreciate it so much. 

McWilliams:

This is really fun. And thank you for these thoughtful questions.

Stokes:

Thank you so much. 

McWilliams:

Thank you so much. My pleasure.

Puder:

It's great.

Stokes:

I have to say, so we all have our own little cohorts and my cohort was very, very excited about having you on. I don't think I could even put it into words. So we're very grateful for you showing up today.

McWilliams:

Well, thanks. It's not too hard to do. I really like talking to other therapists because it's an isolating profession.

Puder:

Absolutely. 

McWilliams:

We need each other.

Puder:

Yes. This is wonderful. Thank you so much for your time. And we'll leave it there for today, guys. Thank you for coming.

Additional Episodes Exploring the Work of Nancy McWilliams

• Episode 171: Nancy McWilliams on Mental Health, Transference, and Dissociation

• Episode 265: Primitive Defense Mechanisms Explained: Sexualization, Dissociation, Acting Out, Withdrawal, Denial, Splitting, Omnipotent Control, Projective Identification

• Episode 266: Understanding Mature Defense Mechanisms in Psychotherapy: Nancy McWilliams Framework with Clinical Examples from the Tuesday Cohort

• Episode 267: Cohort Group Consultation and Reflective Function: Transforming Countertransference into Clinical Insight

References

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books. https://search.worldcat.org/cs/title/25048720?utm

Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. International Universities Press. https://openlibrary.org/books/OL11189053M/The_Analysis_of_the_Self?utm

Kohut, H. (1977). The Restoration of the Self. International Universities Press. https://search.worldcat.org/title/The-restoration-of-the-self/oclc/2985743?utm_source=chatgpt.com&__cf_chl_f_tk=baDgdi.kToQr7P9S0.0KLT4CIvL7AKQCi3eHh6NxVXg-1783960375-1.0.1.1-Lu4jSZuyyLD0PWPjeswx7nFNhD4Jk0DVPMHkVw827mE

McEwan, I. (1997). Enduring love. Jonathan Cape. https://www.penguin.co.uk/books/354999/enduring-love-by-mcewan-ian/9780099276586

McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. Guilford Press. https://www.guilford.com/books/Psychoanalytic-Psychotherapy/Nancy-McWilliams/9781593850098

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/contents

Orion, D. R. (1997). I know you really love me: A psychiatrist's journal of erotomania, stalking, and obsessive love. Macmillan. https://www.doreenorion.com/orion-works.htm