Episode 275: Working with Transference: Timing, Technique, and the Here-and-Now with Jonathan Shedler
This episode is awaiting CME Approval
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In this episode, I’m joined once again by Dr. Jonathan Shedler for a question-and-answer session with members of the psychodynamic psychotherapy cohort. Together we examine the practical realities of recognizing and working with transference as it unfolds, moment by moment, in the session.
Rather than staying at the level of theory, we focus on the clinical decisions therapists face in real time: How do you know when a patient’s feelings toward you reflect a meaningful transference pattern? When does an interpretation open space for growth, and when does it risk overwhelming the patient or derailing the process? We discuss how the work changes across levels of personality organization, the handling of negative and erotic transference, the importance of the therapeutic frame, triangulation, idealization and splitting, devaluation, projection, and projective identification. We also explore the indispensable role of the therapist’s own countertransference as clinical data, the necessity of ongoing consultation and supervision, and how to respond to patients who chronically seek reassurance.
Why Transference Is Always Present in Psychotherapy (01:44)
Shedler:
Helping the patient to find words to describe their experience, which is often metaphorical, or listening to the patient's stories and understanding them metaphorically. For example, a patient might talk about going to see their physician and they thought it was a minor issue (this actually happened). Actually, the test results were very troubling, and it turned out they had something fairly serious. I hear that metaphorically: “They're telling me about their doctor's visit, but they're telling it tome, now, during our therapy session.” So I also hear it as a metaphorical commentary perhaps on the experience they're having here and now. So I don't bring a stockpile of stories to tell patients. I get curious with them and try to expand the space for the patient to notice and attend to more of their experience.
Puder:
That's good. Yes. Okay. What are indicators that it is an appropriate time to address the transference? When, how often or how early, and how do you address it?
Shedler:
Yes. That's a tough question. So, first of all, we're always addressing the transference. The transference is never not there. Right? And the countertransference is never not there. If there's two people in a room, interacting, and they're alive, there's transference and countertransference [see episodes 29, 41, 254, 267, and 270]. So, I would rephrase the questions like, “How do we make constructive use of the transference?” Well, that's such a potentially big question.
Riege:
Can I break it down a little more just based on my cohort and thinking about what was driving this question in large part? As we said, we have people from all different types of practice and different developmental points in their professional lives. But this idea, and you'll probably speak to this at many points today, how much of the time are you really focusing on the transference versus the content of what's coming up? Early on, are you allowing for more time for the story and the content? Or are you initially, right from the beginning, bringing in issues of the transference and countertransference more overtly?
Shedler:
We try to create a relationship where the patient can talk as freely as possible. The instructions to the patient are, “(To share) whatever you notice here, whatever you become aware of here, whatever comes to mind, for our purposes, it's important.” Try to say it so we're not overly structuring it (related to) what the patient has to talk about. And then I'm going to divide your question into two sub-questions. As a practical matter, we have to be very, very attentive to negative transference. You can let positive transference ride, we'll deal with it later, but very early in treatment, really from the first meeting you know, the negative transference, if it's not made explicit, if it's not conscious and talked about and acknowledged, can blow up a treatment before it even starts.
Shedler:
For example, you make some observation or comment or whatever, and the patient starts defending themselves, there's a negative transference there. You said what you said for whatever reason, whatever clinical reason you had, but the patient heard it as a criticism. So we have to make that negative transference explicit. Right? Or it could sink the treatment. It is really as simple as saying, “You know, you heard that as criticism. You felt like I was criticizing you, right?” So I'm just taking something that's pretty close to the patient's conscious experience, and I'm putting it into words and I'm saying, “You know, I can hear this. You know, there's room to talk about this. Let's talk about it directly.” So that's one version of attending to the transference.
Shedler:
Any negative reaction that the patient has early on, we don't want to brush over it. We really want to recognize it, attend to it, put words to it, and invite the patient to discuss it. Now, there's another kind of transference interpretation, which I think is really your question, which is, when do we break? These are sort of the big guns of therapy. When do we bring this in? So there's the content of what the patient is saying, there's the transference of what they're doing with us and showing us in the room. That's actually more important. But what we're really listening for is when we can hear parallels, see parallels between the content of what the patient's saying about things that happened in other times, other places, other relationships. Right? And what's happening here and now in the room. Right? So that's the best kind of transference interpretation, the one that bridges the gap.
Shedler:
I have a patient who, it's been an ongoing theme. She's had a couple of previous failed therapy attempts. She'll sort of get a little dysregulated and then somewhere in there she'll start to tell me about a previous therapy when the therapist actually said in one way or another, “This is too much. I'm not up to handling this.” So I might say, “You know, that came up, your thoughts went to this previous therapist just on the heels of telling me about this overwhelming experience.”
Shedler:
“It makes me wonder, you know, whether you're concerned that you're going to be too much for me right here, right now.” So it's really very close to the patient's experience, but I'm making a link between something that happened in their past and then something happening in the room. So we want to listen for those links and, and actually there's three links. It's the links between things that happened in past formative relationships, often parents or siblings, or an important teacher; things that are happening in current important relationships, with a partner, spouse, girlfriend, boyfriend, some important attachment figure; and the therapy relationship. So past relationships are important, present relationships, the therapy relationship. And when you hear the same pattern and you connect the dots and say, “Oh, here it is in these three areas. Here it is, right between us.” That's really the ideal kind of transference interpretation. It links it directly to things that are important in the patient's life. So, is that a good answer? Good enough answer?
How Personality Organization Changes Transference Work (09:03)
Riege:
Yes. I imagine a piece of this is also informed by your conceptualization of the patient’s level of organization. Like, someone who has more mature defenses, who's more in the neurotic range of functioning. It might be easier to have this discussion and more accessible to have this discussion earlier on, potentially. Or is that not the case?
Shedler:
No, that is the case. And, as you go into the borderline range of functioning, that shifts things. So what I just described we call psychoanalytically, a genetic interpretation. Not genetic in the sense of genes or genetics, but genetic in the sense of the person's developmental history (Kernberg, 2016). When you're dealing with somebody who's in the borderline range, genetic interpretation takes it too far out of the here and now experience in the room. So generally, we don't want to make genetic interpretations. We want to focus, certainly through the early stages of the treatment, on what's happening right here, right now. So in my first example (I might say), “You know, you felt like I was criticizing you.” That happened yesterday and it actually didn't go very well. Because the patient's response was, “Well, you were criticizing me.”
Shedler:
And then you get into what people who are writing about mentalization based therapy (MBT), Fonagy, Bateman, and their group [see episode 206]. They are really very good at this. Really staying in the here and now, something like, “I couldn't understand why it landed on you that way or why you interpreted it that way. I wonder if you could imagine other reasons why I might have said that.” And the patient might say “Because you're critical of me.” “Well, yeah, okay. Yes, that's certainly one way to understand it. Just, you know, humor me. Like, what else could you imagine?” You're trying to sort of expand their capacity for mentalization, that is their capacity to think in terms of the other person's motives and intentions. Right? And it stays very much in the here and now for quite a long time in the treatment [see episodes 227, 260, 268, and 274].
Riege:
Thank you. Yes, that really answers that.
Stokes:
You mentioned the past formative transferences, as sort of the sources of what's coming up. When you're dealing with patients who aren't ready to go there, don't have the capacity to go there, do you bring it back to the here and now? For example, let's say you draw a connection to their father and you bring that up in the dialogue and they're not in a position where they can receive that or process that. Do you then bring that back to the interpersonal dynamic between you and the patient?
Shedler:
Yes, exactly. So the problem that you have when you're dealing primarily at the borderline level of functioning is, if you look at it through a mentalization lens, there's really a deficit in their ability to imagine somebody else's internal states, motives, and intentions. As well as a deficit in their recognition of their own internal state. You're really working on that. If you look at it through a transference-focused therapy lens [see episodes 170, 239, and 250], they are really different sides of the same coin. What the patient is responding to is their own projections. There's a certain rigidity to the projection where the projection isn't, “Well, this is how I'm interpreting it.” The projection becomes, “No, this is a fact.” So, yes, if I tried to make a transference interpretation that had the genetic component that linked it to something outside the room and the patient couldn't go there, I would say, “That was a mistake on my part.”
Shedler:
“Let's come back to the here and now.” Right? Then, it becomes, you know, “How are you seeing me now? Like, what's your understanding of how I'm listening to you and what I'm thinking and experiencing when I respond to you?” Who are you right now? Right? What are you (the therapist) experiencing on your end of the relationship, right? So yes, short answer, you have to come right back to the relationship. And there's a general principle in all psychodynamic therapy, which is that the process takes precedent over the content. And by the process, I mean what's going on interpersonally right here, right now between the two of you. So I really, really believe that the dividing line between a master clinician and not a master clinician is the ability to shift from being immersed in the content of what the patient is saying and shift attention to what's going on in the room right here and now between us and to address that.
Shedler:
And if you guys take nothing else away from today, when you're feeling lost, or bogged down, or you and the patient are not tracking with each other, or you're not understanding something, let go of the content. And just think, “What’s happening here in the room between you and I, between us?” And you can even say it that way to the patient. Right? “Something just happened between us. Like, something just shifted. Now, you know, if it's true, I'm not really sure what happened, but something changed, you know. Do you notice it also? And, help me understand your experience of what just happened. Who am I to you? Who do you think you are to me?”
Shedler:
So we're inviting reflection of the process. Sometimes you get a lot of pushback from the patient. “That's not what I came here for. Why is that of interest? You think they're the most important thing in the world? Why do I want to talk about the relationship with you?” And we need to know the answer to that. We need to be able to respond. And the answer is some version of, “Because, by virtue of being human, this is how we're built. We tend to recreate and repeat relationship patterns throughout our lives, and we repeat them wherever we go. And, in your case, it's caused problems for you.” And I'd link it specifically to why the patient is here. “And, what happens between us here is a window into these relationship patterns. Right? If we can understand something about how they repeat here with us, that understanding would then spill over into your other relationships. Right? So that you have some freedom. So you don't have to spend the rest of your life repeating the same painful or self-defeating patterns.” So, you know, when we make these same transference interpretations or we shift the focus to the interaction in the room, we really need to know why we're doing it, and we need to be able to explain it transparently to the patient.
Puder:
Okay, let's jump into some more difficult ones. Okay? We're going to ratchet up.
Shedler:
Because they weren't the difficult ones?
Managing Erotic Transference and Protecting the Therapeutic Frame (16:24)
Puder:
We started with some softballs for you. How have you dealt with sexual transference, erotic…?
Shedler:
The patient’s?
Puder:
The patient’s erotic transference towards you. Sexual feelings. How have you dealt with that in the past? What's your approach?
Shedler:
It's just another transference to explore. Right? So, I mean, everything gets really, really simple once you have an understanding of the concept of the therapy frame [see episodes 205 and 231]. Right? Therapists, trainees especially, often misunderstand - they think the frame is a series of rules to follow. And it's not. It's not rules. The frame is sort of the ‘rules of engagement’ for the therapy relationship: What we do here, and how we do it. So, part of the frame is what we do in therapy is we talk about things. Right? Anything that you think or feel is fair game for therapy discussion. In fact, it's something invited in that we want to hear about. Right? Within the rules of engagement, which are - it will stay in the realm of thoughts and feelings and fantasies and not be acted on.
Shedler:
Once you understand that as the therapist and you're rock solid, “This is what we do.” Right? Well, then it's thoughts and feelings and words like anything else. And we treat it like any other transference. But I think behind your question is, when you start getting into the borderline range of functioning, right? You start to get patients that don't really, that really don't separate thoughts and feelings from actions. Right? Now we're dealing with those projections, “No, you (the patient) really do want to sleep with me.” Or, you know, whatever form it takes.
Riege:
I'm curious about people in the more neurotic range. Where they might have more of a sense of, “Oh, this is inappropriate to this setting.” And so they disavow that part of themselves. Either it's too shameful or it's disavowed. And so it's there, but it's unsaid. How, if you're attuning to that, as something that might be something coming up, how would you approach that?
Shedler:
Well, yeah, that's a really good question. So, I mean, this is, if you think diagnostically, I don't mean DSM diagnostically, I mean psychoanalytically case formulation diagnostically, this is a real dividing line between neurotic and borderline level functioning. Right? The person at the neurotic level of functioning typically feels guilty and ashamed and hesitant and they're not going to come out with it directly. Especially, these cross sex therapy pairs, where the patient thinks it's inappropriate. But now you're dealing with old fashioned, garden variety conflict and defense: “I feel certain things, I have certain desires, wants, and something inside of me says, ‘But no, it's not okay. You shouldn't feel it. You shouldn't talk about it.’” The patient at the borderline level of functioning is more likely to act it out. Right?
Shedler:
It's not buried under the surface. Right? I mean, they're being openly seductive. Right? Or openly salacious. Right? So, at the neurotic level it's hard for the therapist to deal with because often the therapist also feels uncomfortable with the topic. But the way we deal with that kind of neurotic conflict for anything is, we listen to the derivatives. Which is to say, that we pick up on the metaphor and we really want to signal to the patient, first of all, that we hear it. Second of all, unlike the patient, hopefully we're not passing judgment on it. And third, like everything else, it's something to be curious about that we could think about. Right? Like, it might hold some meanings.
Shedler:
So sometimes I use humor. I was treating a pretty high functioning person who was a PhD psychologist, and it was the situation you described, but she was pretty straightforward about it. She's like, “Yeah. I have some thoughts and feelings, but, you know, it wouldn't be appropriate for me to say, because, you know, rules and boundaries and frame.” She had the idea of frame, but was misusing it here. She said, “You know, it's like, it's not appropriate for therapy.” And I used a little humor, and I'm like, “I think you misunderstand that the rules are for me, not for you. I'm the one who has to follow the rules. You get to say whatever you think or feel.” And so we broached the topic that way. And it took quite a while, but, you know, you really want to continually invite it into the room and communicate to the patient that this is just one more pretty normal, common human response, and so much more grist for the mill.
Puder:
I think there was an example in one of my groups where it wasn't a psychodynamic case. Does anyone have an example of this that they feel doesn't fit this kind of approach? And maybe want to share it? You can jump in? Otherwise, I could kind of give what (information) I remember. Okay, no one?
Shedler:
Great. I mean, it comes up all the time. Look, just from my take of your little postage stamp windows on the screen, you guys are young and good looking. It's going to come up. It is coming up. You may or may not be attending to it, but it is going on between you and patients.
Riege:
Do you want to stay with this, give more of an example, David?
Puder:
I kind of want someone to give an example where they felt unequipped and get some feedback, but I'm not seeing anyone who wants to jump in. So I think it could be a little bit different if it's someone who's coming off of meth and you're in the inpatient [facility/unit] as a psychiatrist, you know; and it's obviously just inappropriate.
Shedler:
But you're not doing psychotherapy under those conditions. You're managing. Right? That (situation) is psychiatric management.
Shedler:
Yes, if you're doing psychotherapy, meaning you have an ongoing relationship, you are both expecting and planning to meet on a regular, ongoing basis. And the purpose of the therapy is deeper self-understanding, self-awareness. Right? And not for its own sake, (but) deeper self-understanding so the person can free themselves from being destined to live out the same unhappy patterns over, and over again. And so the person can be more whole. Right? If the person is, if there's splitting or dissociation, you know, more whole and integrated. If the person is in the borderline range, in the neurotic range. (If) the person is conflicted and certain parts of their experience are welcome and get to be seen and heard from, other (parts of their experience) not, right? We want to hear from all of the sides of the conflict. Right? So when I say “more whole”, the person's sense of themselves encompasses more of their experience.
Shedler:
If it's that kind of therapy, then sexualized transference is just one more kind of transference.
Clinical Example: Triangulation and Seductive Presentations (25:00)
Shedler:
What do we look for in the transference, right? The person is repeating difficulties in their life. It's not a one-time thing. I mean, it's a pattern that we can see recur and ideally they can see recur. We're listening for that theme, but we're also looking for the convergence of that pattern with a pattern that's happening in therapy.
Shedler:
So, this really depends on their capacity for insight and reflection. But that's a pretty fertile ground for interpretation. And the interpretation, you know, you think of it in terms of scaffolding up to the interpretation. And the scaffolding is clarification, confrontation, and interpretation in psychoanalytic work. Clarification is, you know, “This is happening. Let's bring it into focus. Let's recognize this.” So they might be telling you about one of these difficult triangular relationships that they get into, and the clarification might be, “That sounds like another one of these triangular relationships that always involves some sticky situation with a third person.”
Shedler:
The clarification doesn't ask the patient to do anything, right? It is just sort of bringing something that we think is important into focus. Or, (it could be) asking the patient to elaborate and say more. And (asking the patient) are you getting that right? Are you getting that wrong? Can they clarify the experience? The confrontation is, “What about that? Let's think about that.” Confrontation is not confrontation between therapist and patient. It's asking the patient to confront themselves with more of their experience. Basically, to pay attention to it. “Let's pay attention and let's really think about it.” Interpretation is making a link that's not already apparent. And in the example you gave, once it's established, I might say something like. “See, here's the triangular relationship that you're describing….”
Shedler:
“Here's the kind of thing that gets you in trouble” for this or that reason. “Here it is, it seems to be happening again in this situation you're describing.” That's the scaffolding, and once that's established, then you're in a position to say, “You know, it seems to me that there's a way that that same thing is happening here between us.” And (the patient might say), “What do you mean?” I might say, and I am just making this up, “Well, you're telling me about how this person is in the position of having to see or hear about what's going on between you and this other person. And this third person is seeing things that you’re either trying to draw them into something or trying to let them know they're not included in something.”
Shedler:
‘You know, there's something in the way you and I are talking about it, and it seems like I'm in that same person's situation. Do you see how there's something similar happening in what you're telling me about, and what happens between the two of us right here, as you tell me. Now I'm the witness to something.” And, then it becomes a question of curiosity, right? Because what we're really after is curiosity. I mean, we're always sort of testing the limits of the person's capacity to get curious about themselves. “Do you see how this is happening here and there?” “Oh, I never thought about it that way. I mean, I guess I am putting you in that position.” “What about that? Let's think about that together. You know, help me understand what that means for you, just right here, right now.” So that's a way of working with it.
Shedler:
And I will add, and I know there's other questions, but the thing that gets in the way for therapists, especially younger therapists, is we're uncomfortable with our own sexual feelings toward the patient. “I'm not supposed to have it. I'm only supposed to have like, benign physician-ly or therapist-y feelings toward the patient.” No. We're supposed to have the full range of all of the normal feelings that we have in all of human life, right? Within the frame of anything I think and feel is fine, but there's a frame about what we do and don't act on. So then I'm like, you know, feeling attracted to this patient, or I'm feeling put off by, repulsed by this patient, whatever it is, more than I normally would. My internal process as a therapist is that I should notice that.
Shedler:
Say, okay, well how much of this is about me, you know, my life situation, the kinds of things I'm attracted to or put off by, turned off by? How much of it is about something going on in the relationship with the patient, right? And so by doing that internal work, that is what prepares us to say something that's helpful to the patient. If we back away from it, “Oh, I'm not supposed to think that. I'm not supposed to be attracted to my patient. Bad thought. I shouldn't think that.” Then we close off a channel of information. Because our feelings are, in part, created in response to something happening in the relationship. I saw somebody wave a hand. Daniel?
Daniel:
Yes. Thank you. This all makes a great deal of sense. I find myself sort of wondering about the issue of the behavior itself. How much of that comes into the interpretation?
Shedler:
So, the question is, the question becomes, “Why is the patient doing that?” And then, you know, how do we work with them so that they can start to get a sense of why, right? So you just put a hypothesis on the table. The hypothesis, either true or not true. We don't know in advance. You have to explore it. Right? So one hypothesis is there's something performative, it's a defense. If it is a defense, if they weren't doing this, what else might they be talking about? Right? So if there's something that starts to feel sort of repetitive or scripted in how the person presents and we think, “Oh, okay, that's not free association.” We're looking for free association, which is just really say whatever comes to mind, be open to attending to whatever we notice. But the person isn't doing that, so we could think of it as a defense or resistance, right? Another hypothesis is they want to enact something with you, right? They're trying to titillate you. They're trying to get a response. I don't know, so that maybe you should feel left out, not them. There are a whole lot of hypotheses.
Shedler:
So one option might be, just in a very wide open way, I say, “There's a way that you've told me about this situation, that situation. Now, again, it seems like you're telling it,” and I just say it directly, “In a way, that seems like you want to tell it in a way that's titillating for me. You know, I'm curious about that. Help me understand that.” And, of course, when we say, “Help me understand that,” what we really mean is, “Let's hear more so that we both have a chance to understand it.” Right? We ask the patient, “Help me understand it,” but part of what we mean is, “Let's look at it and think about it so that we can both understand it.”
Shedler:
So, you know, the patient says, suppose, “Well, I didn't really think about it that way.” “Yeah, I know, but now that I've put it on the table, and it's out in the open as something that we can think about, I wonder what your thoughts are about this.” So that's part of the scaffolding. That's clarification - here's something I want to bring into focus. Confrontation is just clarification plus an expectation that the patient should pay attention. That's really all it is. And then we see where their associations go and what comes up. Right? We tune our ears to (listening for), “Is this taking the place of something else that they might be talking about? Is this repeating something else?”
Shedler:
If it starts to sound like it's taking the place of something, you say, “You know, I notice there's a kind of pattern there, just to make one random example, almost like you feel like your role is to entertain me, or to perform something for me, or to keep me titillated. I wonder what that's about?” And then we listen to what they say, and maybe we get to be able to say something like, “Maybe it's easier to do that than to pay attention to whatever else might be coming up? Huh, I wonder about that.” So we're just continually inviting the patient to take things that they do pretty reflexively and automatically, and slow down enough to pay attention to them and to recreate some space to notice more, just a bit more than they noticed previously. And to think about the bit more, and to put that into words. Right? And that's the process that's transformative. Right? We're trying to create spaces, pauses between things that otherwise happen very quickly and automatically. Pauses to notice and reflect. And out of those pauses comes the understanding, and the freedom, and flexibility to maybe be able to do something else.
Idealization, Splitting, and the Therapist’s Countertransference (35:48)
Stokes:
A lot of great information. You’ve alluded to some countertransference. And I think the group is curious about how you've dealt with countertransference, particularly idealization, and if there has ever been any sort of idealization dynamic with a patient that you can recall. If you'd like to share about that.
Shedler:
Yes. Well, for me, idealization is like waving a red flag, because I know what comes on the heels of idealization. Right? So there's, I mean, there's sort of milder, like neurotic level idealization, which we could see as, you know, positive transference. The patient wants to feel cared for, feel like they're in good hands, feel like you're, you know, somebody who knows what's what, and knows how to help them. But then there's idealization in the sense of, you know, a borderline level defense, which is half of devaluation, you know, which is the defense of splitting. Right? Is that what you're referring to?
Stokes:
Yes.
Shedler:
So there's something very seductive about when it comes up, especially with narcissistically organized patients. There's something very seductive about the idealization. Because if we have our own narcissistic vulnerabilities—and we all do—it becomes very tempting to kind of join the patient in this mutual admiration society.
Shedler:
You know, we're like, “Oh yeah, we're both so special together.” But you have to remember, you're on one side of a split. You're now the good idealized object and where they're splitting, you could very easily, and if the treatment goes well, you will end up on the other side of the split and you'll become the bad, devalued object. So, you know, again, how do we work with splitting? Actually David had a wonderful podcast with Frank Yeomans, and I thought Frank Yeomans did a masterful job of illustrating working with a certain kind of splitting [see episodes 234 and 254]. Something that often goes along with either idealization or, let's stick with idealization, is that it's a kind of omnipotent control. It's not just that you're seen as idealized, you're expected to behave in a way that's consistent with the idealization. And you find there's a way the patient is managing you into being that idealized person. And what Frank did in the podcast that illustrated so masterfully is, he noticed the countertransference. If you can notice the seduction to feel like, “Yeah, I am a better and smarter therapist than the last five people this person saw, because I'm really that good.” Right? I get pulled into that, hopefully just momentarily, and then you're like, “Oh, yeah, I know that feeling.”
Shedler:
Hopefully you notice that. Then the next thing is, I notice that I'm feeling managed. I'm supposed to talk about certain things, and I'm not supposed to talk about other things. I'm supposed to talk about things in a certain way. So we can make that explicit. Right? Because there's something very limiting about this. If you have to be the idealized object, in a way, you don't get to be a full human being. You don't get to make mistakes, which we all have to make mistakes because we're human. If you do make mistakes, they can't be acknowledged and recognized. Right? They have to be sort of like reshaped into something that the patient can idealize. So what Frank does is bring that more into focus, like, “It wouldn't be okay for me to fall short in this way.”
Shedler:
And, I forget the specifics, but the way that you're feeling managed, and basically what he does say is, ‘“But you know, there's more to it than this. You see me as wise or the one with the answers,” or whatever it is, whatever form the patient's idealization takes. “But there's another side to this because in seeing me that way, and in sort of shaping our conversations so that I am that to you, it suggests that there might be another way of experiencing me in the background that's dangerous or that you need to protect yourself from.” “No, no, you're the greatest doctor.”
Shedler:
“Well, yeah, but that's not the whole truth, right? The fact that you're managing our interactions in the way that you do, right? Tells us that there's a part of you that's worried about another side of me. What about the side of me that screws up? What about the side of me that misunderstands? What about the side of me that, you know, gets it wrong? It seems like there's a way that we're doing something here to protect yourself, and me, from encountering all of that, right?” So basically, what he is saying is, “There's two parts to the split: for you it's, ‘I'm this or I'm that.’ But for me, and maybe with some work for both of us, maybe we could see that it's, you know, some of this and some of that.” So he's always inviting the patient to bring together the split experiences that the patient is really working to keep apart.
Puder:
Okay, so let me jump back to your prior example. The patient says, “All my previous therapists, I was too much for them.” She's telling you this story of her awful trauma. She's saying, “You know, I'm remembering back as I'm telling you this story, how this previous therapist said, ‘This is too much for me.’” Is that a subtle idealization of you? Or is she fearful of you abandoning her?
Shedler:
No, she was terrified.
Puder:
Well, okay.
Shedler:
Yeah, it didn't have a narcissistic flavor. But okay, I've also had patients like, “I've seen five therapists in the past and they didn't understand me and they weren't good enough, you know, but you, now I know I'm in good hands.” That's idealization.
Puder:
So was it more the abandonment fear, do you think?
Shedler:
From my patient?
Puder:
From your patient, that you would abandon her? Like these previous therapists abandoned her in the midst of…
Shedler:
Yes, I think it was two things. One was the abandonment fear. But it wasn't a fantasy, it had really actually happened. And the other was her own fear of overwhelming pain, rage, just overwhelming feelings. Right? So I heard it as, “I'm afraid it'll be too much for you if we get into certain things. I'm afraid it's too much for me. I am too much for you. I'm too much for myself.” And it gets much more complicated than that, but really, in a very basic sense, the solution to that is the therapy frame. I never said this to her, but in my mind, it was always that everything we say and do here is thoughts and words. Like, really, within our 45 minute session, what's the worst thing that could happen?
Containing Devaluation, Projection, and Projective Identification (43:54)
Puder:
Are there any examples of devaluation that have occurred in your practice? And how did you deal with them?
Shedler:
If it's really sort of borderline or narcissistic devaluation.
Shedler:
And this really applies to any kind of projection or projective identification. Right? The difference being (that with) projection, the patient sees you as somebody that you're not. Right? And is pretty insistent that it's true. Projective identification is when they do that and they also somehow manage to get you feeling, and maybe acting, like the person that you're not. Right? So it's a defense for two. Right? It pulls the therapist into it, and one way or another the patient pulls, pushes, manages you into the role that they're projecting. There's really only two things that you can do that are wrong. If it's a devaluation, it's usually, you know, pretty offensive. Nobody likes to feel devalued. We (might) get angry, or we start to feel inadequate, “Whoa, what if the patient is right?”
Shedler:
Like, “Oh my, what if I totally missed the mark? What if I'm not good at doing this work? Maybe I shouldn't be a therapist at all.” Right? So, there are two things that therapists are pulled to do that we want to not do. One, is to take on the projection. Right? And we start feeling really in doubt about ourselves or helpless or hopeless in our ability to do the work. And we have to let ourselves feel that. That's part of it. Hopefully, we then bring an observing ego online and say, “Well, wait a minute. I don't feel this way with all of my patients. There's something going on with this specific patient. What is it that's going on between us? What's happening? Why am I feeling this way with this person right now?” Right? So then I shift from (thinking) I'm a crappy therapist to maybe this is information about the patient and about what's happening in the relationship.
Riege:
No, this is good. Oh, go ahead, David. Sorry.
Puder:
I want to hear about some examples. That really stung.
Shedler:
Oh yeah. Let me come back to that. There's a principle here that I want to explain. So there's just the two things we don't want to do. One is, we don't want to be taken over by the projection and basically say to the patient, “Yeah, you know, you're right, I am these bad things,” and continue to feel and act that way. Right? So, we don't want to be overtaken or swallowed up by the projection, that's one thing that happens. The other thing that happens is the therapist gets really offended and angry. Glen Gabbard has this wonderful phrase, he says that the therapist wants to take the projection and cram it back down the patient's throat and say, “I'm not the one being angry and oppositional and impossible, you are, and here's why.”
Shedler:
“And you did this and you said that.” Right? But that's not helpful either. So to answer your question, how do you work with it? We talk about containing the projection. Containing the projection is not agreeing with it and basically conveying to the patient, “Yeah, you're right. I am this awful person.” And, it's not cramming it back down their throat, and sort of counter attacking and turning the tables on them. Right? Containing is, and this literally came up just yesterday, “I'm not in a hurry to disabuse you of your idea. This is how you're experiencing me, right? That would feel really crappy if you have a therapist who you think is in this just to have the upper hand, you know, to handle you and manage you, right?”
Shedler:
“That would feel really shitty.” So, notice I'm not saying that it's true, that I'm in fact doing this and I'm really jockeying for the upper hand. But I'm also not saying it's false and trying to convince the patient otherwise by saying, “Let me tell you why it's not true.” What I want to do is allow them to have their perception of me. This comes back to the therapy frame. There has to be a mutual agreement. Things are going to happen, things are going to go wrong in the session. A mutual agreement, whatever happens, we'll continue to meet, we'll make our best effort to talk about it with each other, that's what we do here. That's different from all the rest of life. All the rest of life you have your projections and act on them and play them out.
Shedler:
And the same pattern repeats over and over again. Here, we're going to do something different. You're still going to have your projections and play them out and repeat them over and over again. It's still going to happen, but we're going to talk about it. We're going to explicitly make it part of our treatment contract and part of our frame that one of the things we do here is talk about what happens in our relationship. And so, containing the projection is allowing the person to have their experience, neither agreeing nor disagreeing, and empathically recognizing their experience. What I tried to do when I said, “That would feel really shitty if you think that I'm in it to get the upper hand. I mean, what a horrible position that would be.” Right? And I'm not playing coy.
Shedler:
I am sincere, like that would genuinely feel like. But I'm also leaving it as an open question. Right? That's her experience. It's a fact that it's her experience, but it's an open question. What's happening between us that's leading her to have that experience of me? And whether there could be the potential to have other experiences of me. So that's what containing the projection is. So don't do two things. Don't let the patient sort of bowl over you and get you feeling like, “Oh God, I'm no good.” But don't be in such a hurry to disabuse the patient of their mistake either. Treat it as something like, let them have their experience and let it become a topic for exploration.
Shedler:
So to answer David's question, suppose the patient responds by saying, ‘Ha! See, I knew it! You are trying to get the upper hand.” “Well, I didn't actually say that. I mean, I'm hearing you and I'm getting that's your experience of me and why it feels like shit for you. I mean, I’m getting, that's your experience. I didn't say that that's what I'm thinking or doing. I'm focusing on your thought. I didn't say that was my experience. I'm focusing on the experience you’re having.” And then, if you have a particularly difficult patient, like the one I had yesterday, it's like, “Well, that's another way of getting the upper hand.”
Shedler:
But most patients aren't that difficult. Thank God.
Why Ongoing Consultation and Supervision Matter (51:21)
Puder:
What advice would you give to the therapist who has maybe some depressive personality style stuff that's very inwardly critical, devaluation feels very hard, they ruminate on it outside of sessions. What would you say to that person?
Shedler:
That’s a great question, because it’s actually the most common configuration. Most therapists—most solid, good therapists—tend to have some version of a depressive personality style. Hopefully, a neurotic-level depressive style. When a patient projects, projective identification is a really interesting process. The patient doesn’t project into a vacuum. What makes it a projective identification is that the projection hooks into something already inside of us—something that’s already there, just waiting to be activated. Right? The patient finds a way to tap into that part of us, and that’s when it can turn into a difficult enactment. Because the therapist is very likely to feel what’s being projected—especially early in your career—but actually, this continues through much of your career.
Shedler:
I mean, this is really tough, challenging work. We’re constantly faced with something new—something we haven’t seen before. It’s almost an occupational hazard for therapists to question and doubt themselves. And we also have this special way of beating ourselves up. A common version of that goes like this: when treatment goes well and the patient seems to be improving, we credit the therapy and the method. But when things aren’t going well—when the patient is not having a good reaction—we blame ourselves. That’s a pretty common trap we fall into. If we can really recognize that pattern in ourselves, hopefully we can take a bit of distance from it and say, “Oh, right, I recognize that again.” Sometimes, though, that’s exactly where your own therapist or a clinical supervisor becomes essential—to help you step back from that self-blame instead of getting lost in, “Oh my God. I suck. I have no idea what I’m doing.”
Shedler:
Sometimes you really need another person, a second or third party, to step in and say, “Wait a minute. You don’t always feel this way. You didn’t feel this way about the patient you told me about two weeks ago. Something different is happening here.” And that’s when you can start to step back from it. In classical analytic language, that’s the shift from an experiencing ego, being lost in the experience, to an observing ego, where you can step back, observe what’s happening, think about it, and try to understand it. But to do that, it often takes another mind in the room. I’d say, we never really outgrow the need for clinical consultation. For at least the first five years of your career after licensure, it’s a good idea to have a supervisor or clinical consultant you meet with regularly.
Shedler:
And, you know, if you’re later in your career, like me, you might not have regular weekly supervision anymore, but there’s always someone you can reach out to when you hit a struggle and think, “I need another mind on this.” You really never outgrow the need for clinical consultation. If you’re working with borderline-level patients, which includes the more severe end of narcissistic pathology, you especially need that kind of support. The projections and projective identifications are so powerful; you can easily get sucked right into them. Having someone else there to help you think is essential. What’s interesting is that every evidence-based treatment for borderline personality disorder has this built in. They all include extensive consultation or supervision for the therapist. That’s true whether it’s a psychoanalytic approach like TFP or Marsha Linehan’s DBT (dialectical behavior therapy) [see episodes 115 and 245], that’s the common thread.
How to Respond to Reassurance-Seeking Without Colluding (56:03)
Puder:
Yes. Jeanette here says, “How do you respond to a patient who is very sensitive to judgment and asking for reassurance about how you view them?” Do you provide reassurance?
Shedler:
No. It’s tempting to offer reassurance. We all feel that pull. Most of us who go into this field are pretty tenderhearted people. We want to help. When you see someone in pain, reaching for reassurance, it really tugs at your heartstrings. You want to comfort them, to say something that will make them feel better in the moment. But what we have to remember is that when we do that, we’re actually participating in the very pattern that maintains the problem. The “cure”, giving reassurance, is in fact the “disease.” It leaves untouched and unexplored what’s really going on inside the patient that keeps them so continually in need of reassurance. We can think of this as a kind of projection also, though more often it’s the kind of projection you’d see at a healthier, neurotic level.
Shedler:
The patient is genuinely worried that you might be thinking poorly of them or judging them harshly. But we, as the therapist, have to remember, the call is coming from inside the house. The judgment isn’t coming from us; it’s coming from the patient. They experience it as if it’s coming from us, or at least they worry that it’s coming from us, but in reality, it’s originating inside them. With a healthier-level patient, one way of working with this is to help them become aware of that dynamic. Because if the call is always perceived as coming from outside, there’s never a solution. Every new person becomes a potential source of judgment, and the cycle of seeking reassurance just continues endlessly. This often shows up when a patient is hesitant to tell me something, they’re afraid I’ll think less of them, judge them for it. That’s usually where this pattern emerges most clearly.
Shedler:
They think I’m going to think less of them—that I’ll judge them for whatever it is they’re about to share. One gentle way of interpreting that kind of projection is to understand it as a form of transference. I might say something like, “It’s hard for you to believe that I wouldn’t be judging you as harshly for this as you’re judging yourself.” In other words, it’s a soft way of suggesting, maybe this doesn’t belong to me, maybe this is something that belongs to you. What I’m really trying to do is open the door to explore the patient’s own internal harsh judgment, and the whole interconnected network that comes with it: their associations, memories, and fantasies. Somewhere along the line, they’ve internalized a relationship with some important attachment figure, someone critical or judgmental, and that internalized relationship continues to shape how they experience us in the room.
Shedler:
But now that judging and criticizing, it’s theirs. It’s them judging their own “filth,” so to speak. When we can start making those links, helping the patient connect what they’re feeling in the moment to earlier experiences, that’s when the work deepens. Ideally, the patient might say something like, “You know, I don’t know why this comes to mind right now, but it reminds me of when I spilled milk as a kid and my mother punished me and wouldn’t let me watch TV for a week.” And when that happens, we can start making the connections. I’d usually pause there and appreciate that association, saying something like, “It’s as if the part of you that spilled the milk and got that harsh response, that part of you is here with us in this relationship.”
Shedler:
“There's a way you're expecting the same treatment from me.” And the patient starts to differentiate what's past, what's present, what's another relationship, what's this relationship. And that's really the work. And that leads to psychological change that the patient takes outside of the consulting room. Right? Something shifts and is different about them. Right? That changes how they relate to other people and in real life. Right? So the goal of the work isn't, we're not doing this so they have a better relationship with us, although that's the vehicle, you know, we're doing it so they can have a better relationship with us because that understanding and knowledge of where things go wrong and how and why then transfers over into real life and the patient is different. And then you start really enjoying their company. Because they've become really cool and interesting and you like seeing them. And around that time the patient decides that their relationships are really going well and they're better and they don't need therapy so much. And that's like the tragedy built into being a therapist. You know, like just, and I guess being a parent also, I like, you know, like just around the time that you are really getting something out of this relationship too. Because they're so engaging and open and pleasant and, you know, around then is when the patient starts thinking and should be thinking, “Yeah, I think I got what I needed here.”
Puder:
I think Dr. Latall had a question.
Puder:
She said, “Is this consistent with children?”
Shedler:
Oh, you know, I don't know. I don't work with children, so I can't really speak with any expertise. I mean, with children we're kind of often trying to develop a, maybe, sort of a precocious capacity for self understanding in the service of overcoming a particular symptom or difficulty. I mean, so we are working toward understanding, but it's really a whole different way of working. I'm not the ideal person to ask.
Riege:
Going off of what you were just talking about, what if there's a transference there, in like the reassurance seeking, but the patient's like, “I'm boring you. I'm just worried that I'm boring you. You don't want to see me.” All these things.
Using Countertransference as Clinical Data
Shedler:
If we provide reassurance, we are entering into an enactment. Right?
Riege:
Right.
Shedler:
We're living the transference and the countertransference versus understanding.
Riege:
So you're not providing reassurance. And I understand the reasoning behind that and, but what if you are feeling all of their fears, right? What if, in the moments when you're feeling incredibly bored and they're worried you're bored, or you're feeling sleepy or whatever, or you're feeling like they are too much, or you just want them to go away, and that's their big fear, right? You're not going to say that, obviously, but how do you approach that?
Shedler:
Well, you might say it actually. Right? So we don't want to unless the patient is functioning at a psychotic level and even then there's some truth to it. I mean, you know, the patient, however distorted the patient's perception of us might be, it's also based on some reality that they're picking up. And you know that the truth is, we're not always at our best. Sometimes we're tired, sometimes we're preoccupied with something in our life. Sometimes we actually get bored. Right? And it's about the patient. I mean, we never want to sort of damage their reality testing. We never want to gaslight them by denying the data of their own senses. So sometimes it's actually very appropriate to say, “You know, yeah, you're right. My attention wandered.”
Shedler:
Or, “You know, yeah, I'm not my best today. You know, I am tired.” Right? Sometimes we want to acknowledge that. Right? If the patient is saying something that's true we don't want to contradict the data of their senses. But then it gets into a much more complicated transference countertransference issue, which is, you know, so I have to think about, as nondefensively as I can muster in the moment, “Did my attention wander? Am I bored? Am I feeling overwhelmed?” Oh, and then I want to start to try to disentangle, is this something that's just I'm bringing with me, or is this something specifically in response to what the patient is doing? And it gets into the question of self-disclosure in therapy. I would say if there's a principle involved, what can be helpful to disclose in the therapy is our reaction to the patient in the here and now of the session.
Shedler:
What's generally not helpful to disclose to the patient is information about us and our lives. Right? So suppose I'm feeling bored and it's not because I'm preoccupied or worried about my taxes or, you know, like there's something about what's happening in the room. Say, “You know, you're picking up on something. I mean, I was feeling a little tuned out, you know, and my attention was wandering.” And you have to be so careful. Patients are, so many patients are so primed to hear something like this as, you know, shaming or judging them. And we're a hundred percent not after that. We're after curiosity. So we have to be very alert to the patient's, you know, readiness to feel shame. I say, “You know, my thoughts were wandering in a way they don't usually.”
Shedler:
“And some of that is me. And some of that is us. I wonder if we could think together about what might be going on here, that resulted in this experience I'm having, what experience you are having of yourself, of me.” Like, can we expand the field of what we're going to talk about? Am I or am I not bored because they're boring? Can we expand that to, well, okay, you are being boring just here, just now. But that's the beginning of a conversation, not the end of the conversation. So something I often say to the patient is that, you know, we all have our little, you know, minds and phrases that come up. It is like that's the opening sentence of a whole chapter or maybe a book.
Shedler:
And often the patient wants to treat it as the final sentence in the final period. “Well, I'm boring.” And I might say that it's like, “You're treating it like it's the final concluding sentence. I think we might look at it as the opening topic sentence. There's like a whole book to be read here.” Right? “There's something going on between you and me here that we're both experiencing in the ways that we do. But, you know, just right now, I don't think either of us understands that something here, here's something we can talk about and think about.” And I'm also thinking, I'm not saying it, because this would really start to sound shaming at this juncture, “I'll bet I'm not the only person that this patient bores.”
Riege:
Right.
Puder:
Great. Let's see. Well, this has been wonderful. I think we got to wrap it up so you can get to your next thing. Thank you so much for coming on, Dr. Shedler. I know we have some super fans here. Some people are very excited for you to be with us and I won't embarrass them by calling them out by name.
Shedler:
Oh, I'm looking at all the icons. Or, what do you call them? The emojis. Thank you. That's lovely. And I'll just say, you guys have been, I mean, just a lovely group. This is really fun for me. And everybody who asked questions was asking really good, thoughtful questions. And I can tell that this group is really thinking clinically and psychodynamically about the issues, which is really nice to see. It doesn't go without saying, in training these days, there's something special here.
Puder:
Awesome. Well, okay, we'll leave it there for today, guys. Thank you. Good to see all your faces. Thank you Dr. Shedler. Thank you guys.
Shedler:
Thank you all. Yes, I agree. It was good for me too.
Additional episodes with Jonathan Shedler, Ph.D.
Episode 144: Psychodynamic Psychotherapy with Jonathan Shedler, Ph.D.
Episode 168: Obsessive-compulsive Personality and the Personality Continuum with Dr. Shedler
Episode 185: Narcissism with Jonathan Shedler, Ph.D.
Episode 205: Beginning Treatment with Jonathan Shedler, Ph.D.
Episode 241: Depressive Personality Style with Jonathan Shedler
References
Kernberg O. F. (2016). The four basic components of psychoanalytic technique and derived psychoanalytic psychotherapies. World psychiatry : official journal of the World Psychiatric Association (WPA), 15(3), 287–288. https://doi.org/10.1002/wps.20368