Episode 254: Countertransference and Transference with Frank Yeomans, MD

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Participants: Frank Yeomans, MD; Jerimiah Stokes, Ed.D., LMHC, NCC; Allison Riege, PsyD., LPC; David Puder, MD
Transcription Editors: Bridget Pieroni; Joanie Burns, DNP, APRN, PMHNP-BC; Allison Riege, PsyD., LPC

Intro:

 This is a conversation with Dr. Frank Yeomans, initially recorded as part of a special guest speaker series offered to our cohort groups. The groups consist of professionals who have enrolled in our small group training opportunity aimed to deepen psychodynamic theoretical foundations, improve therapist reflective functioning, and facilitate the “how” of bringing complex and foundational dynamic concepts into clinical application. This conversation is generally a question-and-answer format; we encouraged cohort members to develop questions for Frank after listening to my previous podcast with him [see also episode 234], as well as questions that have arisen as group members become more familiar with the concepts of transference and countertransference in their own work.

Frank discusses topics of countertransference, transference, projective identification, using rich and detailed examples that help bring these concepts to life. A few details were edited out for privacy purposes, but I am really excited to be able to share this content with you all. I was struck by Frank’s way of inviting the disavowed, projected emotion, or transferences into the room without overdisclosing or intellectualizing. I hope you enjoy.

Transcript:

Puder:

One of the things I was thinking about with you specifically though, is like the role of countertransference. How you use that therapeutically and how you supervise people and help people kind of overcome or work with their own countertransference.

Yeomans:

Sure. In my own practice and thinking countertransference is becoming more and more important. I think it's one of the things that psychodynamic therapy has to offer that's missing in the other models. Just a brief reference, years ago when we did an RCT where one of the treatment cells was DBT, which of course helps a lot of people, as we observed what was going on in the TFP cell and in the DBT cell, we thought the DBT people did a lot of good work, but they didn't have a concept of countertransference. They didn't know how to use their reactions. They had their reactions, but they didn't have this understanding of feeding it back into the work. And when I talk about feeding it back into the work the way my colleagues and I handle countertransference is not to disclose, not to say, you know, “this makes me angry,” or” I'm feeling angry,” or “I'm upset,” whatever. We talk about something as a feeling: “There's a feeling here.” I don't know if it would help to give a sort of elaborate example from the get-go

Puder:

We would love a great example.

Yeomans:

Okay

Puder:

I know a lot of people have watched your YouTubes, and so anything that you haven't spoken about is probably the most interesting example.

Yeomans:

I don't think I gave this example in YouTube because I think it's too detailed, and it might be, well, it's a long time ago, so I don't think it would be recognizable. But oh, I also wanted to say in a couple of weeks I have to give a talk in Amsterdam about psychotherapy and AI. Now, I didn't just have a loose association. I'm connecting that to countertransference because I think it's when we work with counter- transference that we can do more than AI will ever do. I think AI is probably capable of a lot, and I could talk about that later. It's surprised me…

Puder:

And, and, and Frank, just to let you know, I just posted an episode on that today [see also episode 253].

Yeomans:

Oh, cool.

Puder:

Where we talk about the suicides and the psychotic breaks that people have had in the midst of using AI.

Yeomans:

Right. And so dangerous.

Puder:

Specifically, the sycophantic nature of AI to only affirm. I'm gonna send you the article. I spent hours on the article and my team spent hours on it. It's one of the best articles written on this. So I'm excited to share.

Yeomans:

That's perfect. Thank you. Anyway, let me talk about projective identification, which of course is a very intense experience of counter transference. If you know Racker’s article. What's his first name? Heinrich Racker, way back from the fifties. It's, I think, the best thing written about countertransference. It's called The Meanings and Uses of Countertransference (1957). And in that article, he distinguishes between concordant countertransference and complimentary countertransference. Should I go into that or does everybody already have a grasp of that? 

Riege: 

No, I would go into that. 

Yeomans:

You'd go into it. Okay. Anyway, concordant, same as countertransference, is the basis of simple empathy. So your patient comes in, they're bummed out, they just failed a test, they're disappointed. You feel disappointed - concordant. Complimentary countertransference is what I call a form of deeper empathy, because you are empathizing with what is in the patient's mind that they are not yet in touch with.

It's too painful to be in touch with. So you are feeling what is split off from their awareness. So the simple example is the kid comes in, failed the test, he's bummed out, you feel bummed out. And the complimentary countertransference would be, he comes in, failed the test, and your reaction is, “I knew it. He's a useless lazy SOB.” So, you know, you're not obviously gonna say anything about that, but you'll notice, gee, look how critical I'm being. I wonder if that's a split off part of his mind. He's just feeling bummed out, but maybe he's attacking himself with the kind of things I'm feeling now. And that actually could explain why he's so chronically depressed if he's going through life with a part of himself that is doing to him what I'm experiencing right now, and how can I begin to get him aware of that.

Now, what I'm talking about in terms of countertransference, I think obviously has a clear relation to object relations theory. So I'm talking about a model of the mind where the building blocks of mental experience, psychological experience are internal representations of self and other that are linked by strong emotions and drives. So when I talk about using countertransference, I'm talking mostly about working with what we, in the object relations world, call the borderline level of organization [see also episodes 185, 231, 239, and 247], which is a broader concept than borderline personality disorder. It essentially is any personality disorder based on Melanie Klein's concept of the paranoid-schizoid organization. An internal mental structure where there are dyads experiences of self in relation to other that are like ideal and perfect. And you're in heaven because you found, you know, the caretaker who's never gonna fail you, and so on and so forth. And on the other side of this split internal world, it's all hell.

It's suffering and persecution and anger and so on and so forth. People who don't meet your needs. And the problem with the split internal organization is since you, even though it might not be fully conscious in your mind, you still believe in some kind of perfect possibility. Anything that's short of perfect gets totally negative in your mind. So anyway, I think when you're working with this patient population, and by the way, the reason it's called the paranoid schizoid organization, it's schizoid because it's split, but it's paranoid because individuals with this psychological organization generally aren't fully aware of the aggressive part of their internal world. They're not comfortable with that. They have a, you know, malaise about that. So they project it and see it in others. So they're paranoid about the world in general. They can't get close to people, so on and so forth.

Which, by the way, going back to DBT, you might later on say I'm obsessed with DBT. A lot of patients who have had DBT that has helped them symptomologically come to us and say, “You know, I don't cut anymore and I can control my affects better, but I can't manage to really find an intimate relationship.” My understanding of that is because they haven’t integrated the aggression that they project. And when they begin to get close to somebody, it's like, “Oh, they're gonna reject me. They're gonna criticize me. They're gonna hurt me in some way.” So you can't be comfortable with somebody else. So let's go back to the elaborate example of countertransference, where I finally understood years after I had been taught in my psychiatry residency about projective identification. I finally understood it. And projective identification, by the way, is what complimentary countertransference is.

It's when the patient somehow finds the way to activate in you emotions that are impossible for them to feel in themselves, although they can act them out, as you'll see in this example. But in any case, when I learned this as a resident in psychiatry, I said to myself, you know, that sounds almost mystical. My professor's telling me that my patient can make me feel something. It's not my feeling. It's the patient's feeling. I was very skeptical of that. It sounded a little hocus pocus to me. Anyway, here's what happened. I'm working in a hospital, this was back in the nineties, and although it barely exists, in fact, I don't think it exists at all anymore. We had very long-term units. I was the unit chief on what was called the long-term unit, which the average length of stay, believe it or not, inpatient was a year.

The hospital also had acute units, which were like three to four weeks. Then it had intermediate units where the average length of stay was three to six months. You need to know this because the patient was admitted to an intermediate length unit. 25-year-old guy, made a vicious suicide attempt, cut himself really deeply, comes into the hospital. And what's the problem? Smart guy, college student, he had missed some years of college. So, he was a little behind the usual schedule because of his illness. But the problem is that when he shows up on this intermediate unit, he seals over and he's the ideal patient. He's like a good Boy Scout. That was my internal representation of him. I was not on that unit, but I heard about it. So, you know, he says smart things in the community meetings when the nursing staff is having trouble with one of the difficult patients.

He's very helpful and tries to calm the patient down. So he's great, but nobody could get a handle on why does he try to kill himself periodically? It would just burst out and then seal over. Anyway, so after a couple of months, the staff on that unit said, “We don't know what to do with this guy. We're getting nowhere. Let's discharge him.” Now, in those days, you would say to somebody, “You know, we're starting your discharge phase,” which meant two or three more weeks, which would be more than a whole hospitalization now, anyway, so you do discharge planning, and you find a therapist and you get all the things in place. Anyway, when the guy heard we are starting to plan your discharge, he said, “You better think twice about that.” So they said, “Why is that?” ”Because, you know, I'm not ready for discharge.”

“In fact, you know, if you guys are gonna discharge me, I could get suicidal again.” So they put him on what's called 15 minute checks, which most of you probably know what it is, but in case you haven't worked in an inpatient unit, the man is confined to his room and a nursing staff member goes by every 15 minutes to make sure he's okay because of the threatening thing he'd said. Now you might say, “Why did he so much not wanna be discharged?” Here's my hypothesis. He had a very narcissistic personality. He had to be the king of the hill. And in an inpatient psychiatry unit, he could fairly easily feel superior to people, a population of people who had clear impairments. And the outside world, his king of the hill status was very threatened by, you know, other high functioning people. Anyway, so here's what happens.

Now, I'm gonna tell you this, I was gonna apologize, but I won't apologize, because you have to be willing to work with very strong affects if you're gonna treat these kind of patients. There, he's in his room and the nursing staff comes by and says, “How are you doing?” “Fine, fine, fine, fine.” In between the 15 minute checks, he took a little nail clipper and very methodically, and I'm telling you this because everybody thinks acting out with personality disorders is always impulsive. It can be methodical. So, nursing staff, “How are you doing?” He says, “Fine.” Then he rolls up his sleeve and he starts clipping away at what we call the antecubital fossa, the internal part of the elbow. And, you know, he did it. I'm just laughing as a defense. But anyway and you know, the nursing staff would come the next time.

He'd cover up the cut he was making, and then, you know, when the nursing staff left, he took a while to isolate this big vein that exists right here in your inner elbow. And then when he had isolated the big vein, he clipped it. And so the next time the nursing staff came by, there's blood all over the bed. So they decided not to discharge him, but to transfer him to me. Thank you very much. So anyway, I became his therapist, and here's what happened. I am meeting with him three times a week. I had three times a week, individual therapy in the hospital, and I was getting nowhere. He's sealed over, he's the Boy Scout, everything's fine, no indication of any problem, and so on and so forth. So after a couple of months on my unit, we decided the same thing, that we would have to discharge him. We can't keep somebody indefinitely if we don't feel we have any kind of handle on them. So he was told that he was gonna enter discharge phase, and he comes into my office for the therapy session. He says, “Dr. Yeomans, you know, I'm so lucky to have had you as my hospital therapist. You know, in my lifetime I've had 10 therapists already. None of them knew anything. You're the only one who ever, you know, helped me at all.” You know, all this idealization.

Puder:

Which was justified in this case.

Yeomans:

Well, no, I wish. But in any case, you know, that's the ideal side of the split internal world. So he says, “I just wanna know if you'll be my therapist when I'm an outpatient, can I go to outpatient therapy with you?” So this was the end of the session, and I just invoked reality. So I said, “You know, we have to look into that. We have to consider a number of things we have to consider, you know, if our schedules are compatible, we have to look into payment issues.” So, but remember what I said about the split internal world. If the other person isn't giving you perfect caretaking, which would've been “Yes, we'll do it,” then it's “No, go to hell.” So he comes into the next session, he sits down and he says, “This is gonna be our last psychotherapy session,” even though he is gonna be in the unit a couple more weeks, and he could have come three times a week.

I said, “Oh, why's that?” He said, “Well it's a waste of my time coming to see you.” So I felt very comfortable. We're in familiar territory. We've got the two sides of the split internal world. I'm idealized one day, I'm devalued the next day, I just proceeded like, “Okay, I know how to deal with this.” And you proceed with curiosity. Like, “I don't understand, because last time you said I was the best therapist you'd had, and now I'm useless.” And usually the patient says, “Oh, yeah.  How can I understand that? I felt both things, and they don't add up.” But he didn't go into that reflective process. He said, “I'll tell you what happened. I had an epiphany after the last session, and you know what, I never thought you were a good therapist.”

My epiphany was to come to this awareness about me. He said, “I am such a good person that I realize I'm willing to sacrifice my own interest for the sake of pathetic individuals like you, that I only asked you to be my therapist, because I knew how devastated you'd be if I didn't do that. And then it just dawned on me, don't go into therapy with an idiot just to save his feelings. You're a very good person. Of course, he's disowned, but don't sacrifice. I mean, you can be a good person without being a martyr to this jerk who thinks he's so smart and special.” Anyway, so here's where we start getting to the countertransference. I'm trying to work with that, you know, contradiction and trying to sort of see if maybe my usual approach [would work]. “But maybe there was something to the idealization and we could think about the two ways you have feeling about me together.”

“No, I never felt you were any good. I realized it was my own goodness that was gonna sacrifice my interest for your pathetic, puny little ego.” So anyway, this just went on and on and on. I'm only giving you a small dose of it. And about halfway through the session, I'm sitting there getting all these insults. It was really impressive how he was portraying himself as the best person on earth, because he would go so far as to sacrifice interests for those awful dumb people like me. So I'm listening to this thing, “What the hell do I do now?” And, you know, “I tried everything I have in my toolkit here.” And in the back of my mind, and I remember to this day, oh, this was 30 years ago. First there was like a fog in the back of my mind, or like a mist.

And then as the mist started to dissipate, I had a visual image before a conscious thought. I had a visual image of strangling him to death. Yeah. So I noticed it and I said, “Oh, that's interesting. You're thinking about you wanna strangle this man.” So, you know, I'm listening to him. And you have to sort of listen to yourself and listen to the patient at the same time. I'm thinking as I'm continuing to sort of engage in some sort of interaction, I said, “You know, you don't usually think about strangling your patients.” In fact, I said, “I think this is probably the first time I've ever thought about strangling a patient.” Because there's a rule of thumb, it's a little simplistic, but we say the operational definition of transference is anything that comes out of the patient that's kind of a more than a standard deviation from what might be considered a normal reaction to something.

So transference is something the patient does that's out of the ordinary. Countertransference, if it's provoked by the patient, because we have to remember the countertransference could be our own issues, but countertransference evoked by the patient is something that's not normally part of our internal repertoire. So I said, “You know, I've never thought about strangling a patient before. This must be what they tried to teach me 10 years ago in my residency. This must be that projective identification. He's getting me to feel something that's very important in his mind, in his internal world, but he can't access it. It's too distasteful for him.” And yet, I started to think that's what comes out whenever he makes one of these really vicious suicide attempts, he's attacking that hateful part. Then I said to myself, “It's all about hate.” So then I said, “What do I do with that countertransference?”

Now, some people say, you disclose your countertransference. Think of how, I'm gonna say crazy, that would've been if I'd said to the patient, “You know I just wanna let you know at this point I'm hating you.” He'd say, “Proof! Proof! You're a bad therapist! Therapists shouldn't hate their patients.” So disclosure would've been awful. So I was fumbling around in my mind and I was thinking, “What can I say?” And I just said the following, I said, “You know, you can decide not to come back to therapy with me again, and this could be our last session. And, you know, whatever you do from here on in therapy with me, with somebody else, I just have a feeling that it would be important to consider and think about and just have some kind of thinking about hatred.” That's the best I could do.

So I didn't say I was feeling hatred. I just said, “There's hatred here to be thought about, to be contended with.” And that kind of caught him in his tracks. It's not what he expected. It surprised him. He toned down. He did come to the other sessions before he was discharged with me. He did go into outpatient therapy with somebody else. But from what I heard from her, the outpatient therapist, he wound up doing quite well. So that's an example of projective identification, AKA complimentary countertransference. Now I'm gonna say, because often we in the world of TFP get criticized “Oh, you don't give empathy to the patient. You're harsh, you're critical, you're confrontative.” Well, we say we give more empathy than you do, because we just don't give simple empathy based on concordant, you know, countertransference, you're sad, I'm sad. We give complimentary countertransference, which helps the patient get in touch with what they literally have not been able to get access to up until then. And that's the wonder of countertransference.

Puder:

I think no one in this group, by the way, Frank, I don't know if you're projecting on us that we were critical of you, but we're not.

Yeomans:

Oh, okay.

Puder:

I was thinking back when you went through training, you learned about projective identification. People aren't learning about this anymore. In this group, we're talking about these kinds of things, but I think what I've heard over and over from people in training is that they're not learning about that. And then my second thought is, I think when providers feel that countertransference, that hate maybe, it almost becomes a moral injury on the provider. Okay, this is kind of what I'm seeing, because the provider is not regulated to feel that and to know how to feel that. And then they feel bad about feeling that.

Yeomans:

So that's a training issue and a personal issue. I mean, there might be some individuals, I wouldn't be one of them who could be a really good psychodynamic psychotherapist without having had their own, in my case, analysis or psychodynamic therapy. By the way, I want people to know, because everybody thinks I'm a psychoanalyst, but I'm not a fully trained psychoanalyst. And I say that because I think you could do really good psychodynamic psychoanalytic work without being a full blown analyst. In any case, what you're saying, David, is really important. I know somebody, a colleague of mine, specialist in personality disorders, well respected, published, and in a conversation with the person not that long ago, she said, “Oh, who believes in projective identification anymore anyway?” And I think there's a simplification, a reductionism going on in our field. But people just deal with symptoms.

They don't deal with the underlying subjective experience. And if we're only dealing with symptoms, we're never gonna help our patients truly get better as a person. And let me just say, because you're touching on something, when you say the therapist doesn't like to feel hate, they kind of would probably feel uncomfortable, maybe not know what to do with that. I just gave a talk a month ago: What keeps psychodynamic therapists from doing what they know they should do? It's fear. When you need to try to help a person see something about themselves that they're not seeing. They're not seeing it because it's painful to see. So, I swear, now that I've started thinking about it more consciously, in half of the supervisions I do, the therapist will start to present a case and they say, “Well, I was gonna say this, but I was afraid I would hurt the patient.”

Or occasionally, “I'm afraid the patient would hurt me.” Usually not physically, but by getting devaluing or insulting or something like that. Or, “I'm afraid that if I say what I think I should say, the patient's gonna drop out of therapy.” So we have to work on our ability, first of all, to contain the negative affect because the patient can't tolerate it. Now, this guy, you could say he was full of negative affect. Look at what he could do to himself, his suicide attempts. But that was negative affect expressed in action, in behavior. He never felt it. (He) did it to not feel it. It's like what I said in that interview with you last year. The lady who threw the TV at her husband said, “Well, he was aggressive because he forgot our anniversary.” She didn't see any aggression in her behavior. She was just discharging something she couldn't allow herself to feel. So we've got to accept being the bad object for a while.

Riege:

And so you say, “For a while,” I'm gonna jump in here real quick. How do you know, how do you assess when it might be appropriate? So like this case example, he was leaving and so it was sort of time where, I doubt it was impulsive, but it was like speak now [because] he's leaving, you know, maybe you wanna talk about anger. But if this was someone that you were working with, how do you assess how long to contain something, whether it's negative affect, like if their ego, if they wouldn't be able to hear it at all, like if, you know, denied or when there might start to be some space for integration.

Yeomans:

Yeah, that's a good question. When I say “contain it”, I don't mean not name it. So even if this had not been possibly the last session with that patient, once I was aware of it, I probably would've said, let's take your hypothetical case. If this were the middle of an ongoing therapy, I might say, you know, “It doesn't have to be right now, but sooner or later, it's just seems like we might benefit from thinking about hate.” Now, the patient might be surprised. “Why do you say that?” “I don't know, it just seems around somewhere, you know, we talk about something being in the room.” 

Riege

Yeah. Okay.

Yeomans:

So

Puder:

I like that.  So, “I'm feeling there's some hate in the room.” Is that it? Or you said this hate, “There is hate to be contended with.”

Yeomans:

Yeah. Yeah. And I mean, it is clearly opening up what could be a can of worms because this patient was curious about it. But the patient can say, “Well, I don't know what you're talking about. Where is that from? I'm not feeling any hate.” Then I would say, “You know, maybe I'm wrong somehow.” I'm trying to think of what I might say if the patient were saying, “Where's that coming from?” I'd say, “You know, I could be totally off base, but I have some hunch that it might be relevant.” That might be as much as I'd say. But then I might say, “And now that I think of it, the way you've treated yourself at times could be seen as hateful, you know, the cutting and suicide, I don't know.”  You kind of take that attitude like the Detective Colombo, like, you know, “I really don't know but let's think about it.” 

Puder:

What about, like the anger Kernberg (mentioned) in his interview that I did, he said the one thing therapists need the most is to get in touch with their own aggression [see episode 239].

Yeomans:

Yeah.

Puder:

Are we talking about the same thing here? When I think about aggression, I think about keeping the frame, you know. But, what are the things that you're thinking of in terms of like, as you've supervised people, like what does it mean for a therapist to be in touch with their own aggression?

Yeomans:

Well, can I use an example I used recently in that lecture that I got Otto’s okay to use? Because I said to him, “You know, years ago, I remember you're using this example in teaching. I just wanna make sure I got it right.” And this example is one of those instances where people either love Kernberg or hate him. So, it's very similar to my example, but it's his version of it. He's teaching about what you've just brought up, David, our need to be in touch with our own aggression, because the way I understand the human being is that everybody has aggression in them. It's just genetically a part of us. We would not have survived as a species without it. And I really like Freud's work Civilization and Its Discontents (1930) about the fact that civilized societies have advanced more quickly and changed and evolved more quickly than neurobiology.

So, a lot of psychopathology comes from having drives, but we can't just act out in civilized society. Aggression being one of the main ones of them. This is what I think Otto means by being comfortable with aggression. Because if you don't allow yourself to feel your aggression and to somehow channel it through a fantasy, it gets blocked in you. And then you get stiff and your work isn't so good, and you probably collude with the patient to find some outside bad guy. And so having freed himself of a very intense…oh, I've got a great example of countertransference I wanna give you in a minute. But you know, if you can sort of be comfortable with it in you, then you can work with it.

Puder:

And I think this is what we're seeing with a lot of like, ‘every ex that you've ever had is a narcissist’ kind of language. 

Yeomans:

Yeah. 

Puder:

Like pop psychology. It's like, everything bad that's happening to you is because of everyone else. And you are this loving oracle of glowing love and compassion.

Yeomans:

That’s mistreated and misunderstood

Puder:

Which AI is saying the same thing to people. Interestingly, it's parroting this sycophancy.

Yeomans:

Yeah. It's like an echo chamber. You know, you just hear what you think and it's kind of the opposite of therapy. It might give the person support in the moment, but it doesn't help them function better in the world or feel better in the world. I mean, they feel better as long as they're being overtly validated, but they don't feel better when their life is going downhill and their relations are all shot to hell. But can I give you an example where I shifted from a concordant countertransference to a complimentary one all in the same session? Okay.

Puder:

That's good. Yeah.

Yeomans:

A 35-year-old woman comes to therapy, and this is relevant, after one year of CBT by a very good CBT colleague of mine. But at the end of that one year, the colleague said, “You know, I'm not sure we're getting anywhere. Maybe you'd be better off with somebody like Yeomans who does a different kind of therapy?” So the patient comes to me.Wwhat's the problem? First of all, when you present a case always, “What's the problem?” 35 years old, chronically depressed, periodically some suicide ideation, no attempts, very, very, very upset because she can't find a man to marry and have a family with. She's desperately eager to get married and have a family. But it's not happening. She can't get anywhere with dating. So, you know, I do my evaluation, I make a diagnosis. And she seemed to be what I'm sure you're familiar with when we talk about a covert narcissist, she was not arrogant or grandiose on the surface, but she thought she was the most morally correct and well-behaved person on the planet.

And she had this devaluing kind of condescending way of interacting with others. And you could see how, you know, you wouldn't wanna go on a second date with her. So she was relatively successful in her profession, but other people, and some of them now younger, now that she's 35, get promoted instead of her. But she would say, “That doesn't matter to me. They get promoted because they're willing to make compromises. I would never make a compromise. I'd rather live by my values than compromise.” Anyway, maybe that's good. But it was a little rigid. And so anyway, we started the therapy, and this is what I mean by containing the aggression for a while. Even though she acted or behaved in therapy, like a very proper patient comes in, associations, stories, and all the kind of material one would want, I noticed that pretty much whenever I made an intervention, she would either roll her eyes or wrinkle her nose.

Now, you know, it's clearly a sign of a devaluing part of her. With somebody less rigidly and fragiley (it's funny, it's a combination of rigidity and fragility) narcissistic, I might have not waited so long to say, “You know, it's kind of interesting, I think it might be worth reflecting on the way you react to a lot of what I say with rolling your eyes or wrinkling your nose.” But I thought, “She can't hear about a flaw in herself. It's not part of her self representation.” So I'm three or four months into the therapy, I thought, I'm just sitting there getting the eye roll and the wrinkled nose. I'm sitting there thinking, “Okay, you know, it's time to mention this. She can't be oblivious to this.” Or maybe I just couldn't contain it anymore. So I said, as tactfully as I could, and by the way, when you're doing this kind of work, you have to at some points not follow that so-called golden rule of psychoanalytic work, which is pure free association.

You have to say, “I'm interested in what you're saying, but there's something else that might be worth thinking about.” You shift gears, otherwise you could just collude with their defensive posture forever. So I said, ‘You know, it's interesting what you're saying, but I just thought we might benefit from reflecting on something that I've noticed.”  “What's that?”  “Well,” I tried to be very tight about it, I said, “You know, not infrequently when I say something, you react, roll your eyes or wrinkle your nose,” trying to not sound critical. And I said, “You know, that kind of suggests something where you might not be having a positive reaction to what I'm saying, but maybe, you know, it's too, you're too polite to say something negative. And, you know, maybe that nonverbal communication is expressing something a little disapproving,” and I escalated, I intentionally escalated my vocabulary.

“You know, maybe you're communicating something a little disapproving or a little devaluing or maybe even a little condescending.” She said, “What, me?! Condescending?! You’re the most condescending person I've ever met in my life. I haven't mentioned it so far because this is my therapy - it's not your therapy. That's your problem. If you're in therapy, and I hope you are, I hope you're discussing your condescension.” So when I was young and naive, I would've stuck to my guns and said, “Well, look, I'm not the one rolling my eyes and wrinkling in my nose, so maybe we should look at that.” You can't force something that's being projected back into the patient prematurely. You do what we call therapist centered work, or working within the projection. Work with how they're seeing you without yet bringing it back to the patient. So I said, “Oh, I wasn't aware of how condescending I am.”

“Can we talk more about that?” Now, first of all, that disarms the narcissistic patient. Because they expect you to fight back, and they expect you to say, “I'm not the problem. You're the problem.” The basic dyad in the narcissist is somebody's superior and somebody's inferior, and they expect everybody to want to impose their superiority. And when you don't take the bait, then they're kind of curious: “What's this experience? What's this? Who's this being in front of me? He's not defending himself. He's not reacting, he's not fighting back.” And you become an object of curiosity. But anyway, that's not where the countertransference came in. I mean, it did. But a year into the therapy, this very well behaved patient comes in and sits down and starts laying into me in a way she never had before. Not unlike the guy I talked about, you're gonna think this is just what all my patients do.

So she comes and she sits down, and this previously well behaved patient says, “You know what? I've been coming here a year and I haven't got one ounce better. In fact, I've gotten worse under your watch. I've gotten worse.” And then she had this plea like, she's horrible, you know, just terribly suffering victim, which she was in a way. She said, “I came to you, I confided in you. I put my life in your hands. I put my future in your hands. You were supposed to help me. You just sat there and watched me deteriorate. I've gotten worse and worse. A year has gone by. I'm no closer to getting married. I'm no closer to having a family.” So I could have defended myself because in fact, I could have pointed to some signs of progress, “And the last time you dated a guy it lasted longer than usual,” and so on.

But when somebody's that into enacting a dyad, don't take the bait and fight back. Just contain it. So I'm sitting there, in fact, I can remember this session. I was like holding the arms of my chair like I was in a rollercoaster and just trying to make sure I could stay, you know, without getting bounced out of the chair. And, you know, she's going at me: “You shouldn't have the right to call yourself a therapist. You know, you should give up your license. You should be a cab driver, an Uber driver.” Yeah, that's a new thing now, Uber (this is years ago). So, you know, she's really laid into me. So here's my first countertransference, a concordant countertransference. She's enraged at me. I'm enraged at her. So you have to let yourself go through it. So she's saying, “I haven't learned anything from a year here.”

“And you know, you're useless and you're worse than useless.” So my fantasy… you have to let yourself have your fantasies: “Well, you know, the door's right there and you know, you can use it and you don't have to come back.” But my fantasy got more sadistic because I thought if I said that, I pictured saying that. And she looked like really surprised. Like I'm just saying she could leave. So my fantasy was when she looked surprised, I said, “What's the matter, honey? You don't know how to use a door? Well, you know, maybe you've been coming here a year and you haven't got anything else outta it, but before you leave, I'll teach you how to use a door. That little bronze thing is what we call the doorknob.” So, you know, I'm spinning this out in my mind, just letting myself feel this rage.

But halfway through the session, I started having a complimentary countertransference. I started feeling, “Maybe she's right. Maybe I am no good.” I was really feeling that. I thought, “Maybe I should be an Uber driver.” I felt like, you know, “Maybe I don't help anybody.” I'm really feeling this. I remember having this little image. I thought, “Maybe I'm not at all significant. Maybe I'm just like a little grain of sand on the beach.” So, you know, I went from being enraged to feeling totally worthless. And then I said to myself, “Oh, that's what she's been defending against all this time. That's what her narcissistic perfectly correct, goody two shoe's image is defending against in the core of this woman. She feels nothing. She feels she is nothing. She feels she amounts to nothing. I've gotten beyond her defenses.

But here's the thing, psychoanalytic psychotherapy is great for having ideas, but defenses are so strong. You can't just offer an interpretation that directly. I mean, if this were some sort of very simplistic textbook of therapy, I might have said, “Oh, you know what? Here's something maybe we should think about. You know, you tend to go through life with this very correct proper self image. And you know, that's fine. But now that I think of it,” again, I wouldn't refer to my countertransference, I might say “Maybe at a deep level, you don't feel like you amount to anything. And so to not feel like you don't amount to anything, you have to be perfect.” I think that would be an accurate interpretation, but it's not the moment to give it. She's too worked up in her rage at me. The rage, which, by the way, is at the root of her feeling like nothing because the root of narcissists’, empty core feeling is they're always attacking themselves aggressively and saying they're no good. Anyway, so what happened? I got this understanding that she's defending against the feeling of worthlessness, but I didn't think she would accept it. I thought it was too intellectual. So she's going on and we're like 30 minutes into the 45 minute session. And at one point she said, “I went to that CBT therapist for a year, and that was useless. I've been coming to you for a year, and it's exactly the same experience.”

And then I thought, “Maybe I understand better now why my CBT colleague referred this patient out. Maybe it was getting too intense to contain.” So the first time in the session, I had what I thought might be a useful intervention, and I said, “You know, maybe you're right. Maybe it's exactly the same as what happened with the CBT therapist, but if you think about it” (appealing to some observing ego in her, or reflective functioning, if you wanna call it that) “If you think about it, maybe there's one little difference.” And she thought for once, and she said, “Yeah, you're not telling me to go somewhere else right now.” And I think that somehow helped her become aware that I was able to contain something in her that she couldn't consciously feel in herself. And she certainly felt nobody else would allow her to express to them.

So this poor woman was suffering with the idea - I'm obviously giving sort of abbreviated vignettes about these - she had a pretty traumatic history. So she had a right to feel rage and, you know, anger. But she didn't think the world gave her that right. And she was convinced that without the proper presentation, anybody on earth would turn their back and walk away from her. So when she said, “Yeah, you're not telling me to go somewhere else,” showed that we both understood, maybe this part of ‘you that's just burst out now, unseen before’ is something we can experience and think about and try to sort of put in its place. So that's another example. Other questions or comments on that?

Puder:

Yeah, I think that's such a good case example. I imagine people have some questions. Let's kind of stay on that. Jeremiah, you had something.

Stokes:

Well, Daniel had a question, but I was gonna say, by doing that, Frank, in essence, you're maybe meeting an unmet need for her for the first time in her life.

Yeomans:

Yeah.

Stokes:

Right?

Yeomans:

Yeah, I agree. How would that influence your work? I mean, would you say something about that?

Stokes:

Well, I think by identifying that you're the first person to stay with her in that experience, I think you're a unique presence in her life. And I think it opens up an opportunity to go to places where she's never gone, certainly professionally, but maybe interpersonally before in her life.

Puder:

But Jeremiah, I think Frank is actually turning the question on you.

Stokes:

Okay.

Yeomans:

What would you say? Yeah.

Stokes:

To what exactly?

Yeomans:

To her at that moment

Yeomans:

How would you use that insight? It's a very good answer.

Stokes:

Oh okay, I would say, “I'm curious if maybe this is the first time that someone has stayed with you through this feeling or through this experience, or remained present with you through this experience?” Or, “What does it feel like for me to potentially consider sticking around with you through this?” 

Yeomans:

Yeah. I think those would be both good. I tend to be very parsimonious because I worry a little bit about feeding the patient an idea. So I like your idea, but I think my intervention would be more like, “Is this new for you?” And then see where she went with it. Yeah. But I think we're both on the same page. By the way, I asked you what you would say, because one of the things about psychotherapy is we all have ideas, but an idea doesn't help the patient. You have to figure out what words can you use with the patient to use that idea. And I think your words were good, and my words were a little less precise, but, you know, try to open up her mind to it a little bit more.

Puder:

I think, and I'll call on the people that are raising their hands in a second, my idea is that to feel you not reject her and not leave her, like everyone she's dated, like the other therapists, so there's a theme, is kind of the counter to this grain-of-sand-type of feeling. Like, “All I am is a grain of sand.”

Yeomans:

Yeah.

Puder:

And so I would say, and I'd be curious what your reflection on this would be. I think I would say something like, “I think that what I've heard from you is that there's part of you that really thinks that what's gone on here and what's gone on in the last therapy has not been helpful and you haven't achieved your goals. And I agree you aren't in a long-term relationship. And I think the significance of the hard work that you're doing - showing up, trying to do this type of work to try to accomplish your goal - and the futility of that would feel like a grain of sand like experience. And yet, the comment that you just made is really curious to me, that I haven't left you like the previous therapist. And I'm wondering if that somehow relates to what's going on here between us. Like if that changes the dynamic at all?”

Yeomans:

Okay. I hear you. That's more complex. I like to give just little bite-size interventions because I think you have to start with the affect and then get deeper. So, you know, although it's interesting, you're validating her experience that the therapy was worthless so she's turned the therapy into the grain of sand. I think that's an interesting idea. But again, I would just want her to spend a fair amount of time reflecting on the experience that somebody doesn't turn away because she expresses rage and anger. And so I think I would limit it in the moment to saying something like before when I said, “Is this new for you?” and then, “Are you surprised that I still wanna work with you?” See, I'd stick with just the rageful affect and show that we can contain that. Because my concern about your intervention, David, is it's very smart, but it's almost a little abstract compared to the raw experience of emotion that I'm trying to help us both be more comfortable with. 

Riege:

You would want that immediate intervention to be framed to have immediate reflection inward: “What is coming up for me right now, like emotion-wise,” you know, because typically until this point, this has been an unconscious interpersonal pattern where she either immediately acted out to try and get rid of the emotion or control the situation, like control what the other person's doing. But in that moment of recognition of you not leaving and this being new, like, you know, “What are you feeling right now?”

Yeomans:

Umm, yeah, it's like let's just sort of have this experience together.

Riege:

Yeah.

Yeomans:

“It seems like it's having an impact on you that, you know, you could kinda chew me out for half an hour and we're still here. You haven't destroyed this. I haven't walked out or you haven't destroyed it.” So, again, I would just try to help her think about, to immerse her in the affect of the moment. Yeah. Al-Baab, if I'm saying it right?

Al-Baab:

Yes, you are. Thanks so much for coming here. Huge fan. One comment/question I had in thinking about this case was that it seemed that this new experience she was having with you not leaving and engaging with those negative thoughts that she had. (And) because it's a new experience, I was thinking, “Okay, she's probably having this conflict in her mind of previous men or previous relationships around which she's been able to kind of build her reality. And so, the fact that this situation she's in is conflicting with her previous experience, it's creating almost a challenge to her. And then that's inciting this anger that she's having. And that anger is again, coming from the fact that she may have to lose this defense that she's built up, lose these walls that she is being challenged to think about”. And in my mind, I'm thinking, “Okay, if those are the emotions she's probably dealing with and going through, I would then probably ask her to pause and think, ‘Do you trust what's going on here? Do you trust me?’ And I think that will then make her think, ‘Wait, why am I not doing that and why am I then projecting that I don't?’”

Yeomans:

Yeah. The last sentence confused me a little bit, but let me just talk about the trust issue with patients who have pretty much gone through life in the paranoid schizoid psychological organization. I always use this phrase, it sounds a little bit like a wise guy: “They don't trust trust, they only trust mistrust.” But I think that's what you're saying. If you're being mean and rejecting them, they can think, “Oh, this is real.” You know? So she did have a way of getting attracted to not so nice guys or going out with a nice guy and being very devaluing of him. So when this session is over and she goes home, her defenses are gonna start emerging again. I think that's what you're talking about. [She might think], “Was that for real? Was he acting? Was he just pretending that he wasn't wanting to tell me to go to hell?”

So then, you're not going to like all in one linear process get her to begin to see that she can trust people. She's gonna go back and forth, and you as a therapist have to figure out how to pick up on this. Sometimes patients say, “That wasn't real last session. You were just acting. I know you want to get rid of me.” But sometimes, you have to sense it and then you help them. Sometimes I say, “You know, it is hard for you to experience something positive. You don't trust it. If this were negative, you’d trust it. That's what we have to work with.” And that can work. Now, before we get to the other questions, I wanted to say something that I get to at the end of my teaching about narcissistic personality disorder.

Because my whole take, I mean, my simplistic take on narcissistic personality disorder is the patient's gonna devalue you. The patient's gonna try to provoke you. The patient's gonna try to show their superior to you. You have to contain that for a very long time, often months and months, and not react. Because we have research about unfortunate countertransference enactments. But if you, oh, and here's the little secret. When the narcissistic patient is devaluing you, and sometimes very cleverly, you have to say, “This is painful. This is annoying, but I know it's because they're suffering deep down inside.” So if you can maintain an empathy with their deep suffering, you can contain the devaluing. So my message is, whatever happens with the narcissistic patient, stay committed, stay curious, stay involved and devoted to working with them. And eventually that begins to sink in as an alternative relationship

dyad in contrast to the superior/inferior. And when I say that to people, they say,”Okay, Yeomans, you just finally admitted what you provide is a corrective emotional experience. It's as simple as that.” But I say, it's not as simple as that because if you do not interpret the paranoid transference, you can be as nice as a person can possibly be, and it's not gonna be experienced as such. So it's a combination, and I can give you an example later, but I wanna see the next questions. You can be as nice as you want forever, but if the person ais strongly into a paranoid projection, they're not gonna see you as nice. But why don't we go to Daniel and then Serena?

Daniel:

I had a question about the therapist's reaction. I mean, you tell the story and it's an emotional experience for you. You start to feel like, “Maybe I should be an Uber driver.” And this signals to you the emptiness, the worthlessness that she must feel. And yet, I imagine that intellectually that interpretation was already pretty clear to you in the previous months, that the way she was living her life was suggestive of an inner worthlessness. And so I'm trying to understand the sort of difference, I suppose, between the intellectual and the emotional understanding within the therapist. Does that make sense?

Yeomans:

Yes, it makes a very good point because I mean, certainly with my understanding of narcissistic pathology, I'd always assumed there was that devalued empty core sense of self. But I'm trying to think….  Oh, I know what I was gonna say. She had a way up until that session I just summarized, of kind seducing me into a certain admiration of her. She was very smart. She could discuss things in a very interesting way. So I don't think I had experienced on a gut level that emptiness. And, and I mean, this is another thing I teach my students. I say I went into becoming a therapist with the idea that it's all about having smart ideas that are gonna change how the person is, but the ideas are far less important than the affects. So, just to get back to your question, Daniel, I had that formulation in mind, but I didn't really feel it in my gut until that moment. And that's when I thought I could work with it more meaningfully, eventually. I didn't bring it up in that session.

Daniel:

That makes a lot of sense.

Yeomans:

Thank you. Okay, Serena.

Serena:

So, this may or may not be a rabbit hole. And if so, feel free to treat it as such. But my experience, so far, trying to take care of people with narcissistic and borderline tendencies is that they do evoke very strong countertransference and aggression on staff members. And a lot of staff members in group practices or inpatient settings insist that the only proper way to treat these patients is to challenge their delusions immediately and their distorted thinking. Do you have any experience with how to address this disavowed countertransference on the part of mental health professionals?

Yeomans:

I haven't had that exact experience. Because when I was doing inpatient work with a team, we were very much into the therapeutic community model. And, you know the idea of group process. So we'd be having these very frequent staff meetings, everybody to process their stuff. So what's the alternative model? You're saying that somebody should say to the patient, “That's off base. That's not an accurate perception. That's not what's really happening.”

Serena:

Yeah. 

Yeomans:

Well, I mean, I guess they need a lot of education. But seriously, the education could pay off because patients who are convinced of what they're projecting aren't gonna give it up by being told that's not real. Let me just go back to that example I was tempted to give a little bit ago about how you have to work with the paranoid transference before the patient can feel your commitment to them.

An early patient in my practice was a mid-thirties guy, borderline and narcissistic and very angry all the time, very critical of me, very devaluing of me. So, I used to kind of brace myself for the sessions and wait to be told once again, how stupid I was. And to contain that. That's okay. But in one session two or three months into therapy, he said something that was very touching. I think I used this example in our interview, David. It was very sad. Something happened when he was a kid. And it was just a very sad thing to imagine happening to a little 5-year-old. So it brought tears to my eyes, which of course I didn't mean or want, but, you know, that is what  happened. So he looked at me and he said, “You have tears in your eyes.” He said it with a kind of a not so positive tone, and I didn't know what else to say.

So I said, “Yes.” And he looked at me really hard, like scrutinizing me. He says, “You are mocking me.” So that's an example of a projection that really distorted external reality. So if I followed what I think you're asking, Serena, I would say, “No, trust me. I wasn't mocking you. I really feel sympathy for you.” That wouldn't go anywhere because he would just say to himself or to me, “Oh, you're just trying to make up for your mockery. I saw your true colors. You pretend you're a caring therapist. You just mock your patients.” So, the training of the staff has to be, to understand a little bit more about projection and working with it. In fact, we have a little branch of transference focused therapy called applied TFP. And it is meant to help mental health workers in any setting, acute inpatient units, emergency room, doing psychopharmacology on the consult liaison service in the hospital. Just think in object relations terms. Think about, “How is the patient perceiving me?” and factor that into your interaction with them. “It must be hard to adhere to this medication I'm prescribing if you think that really I don't care about you or even have it in for you in some way.” And so you're empathizing with their projection instead of saying, “Your projection is wrong. And just take this the way I prescribe it. A and trust me I'm here for you.” Which they won't believe at all. So does that touch on the question?

Puder:

I think it did.

Serena:

Yes. It did. Get in a position to educate other staff members and look into applied transference focused psychotherapy.

Yeomans:

Yeah, I can send you an article. I can send it to David. He could send it to everybody. I think it gives a good summary of what I'm trying to explain.

Puder:

I think as well, like how has it gone? I think if I had a person that was professing, “This is the way that we should do this.” Like, how is that going when you do that? How do you feel that's working for you? Is it successful? Does it make the patient more agitated? 

Serena:

The confrontation usually leads to the staff deciding that the patient would not be helped by the modality of treatment that they're offering and sending them elsewhere.

Yeomans:

Oh

Puder:

Yeah. So, you know, interestingly, when motivational interviewing came out, the contrasting view was a very shame oriented approach. And they found that the shame oriented approach actually drove alcoholics further into their addiction.

Yeomans:

Yeah.

Puder:

And so if you can Google that or see if you can find that early research. Because I think that's what I would argue with them. And I would use the same level of assertiveness that they're telling you to have for the borderline I would use with