Frank and Patient

hi hi why are you running so late ah let's see well you don't have an answer you're just gonna sit there and be five minutes late that's ridiculous uh you my not answering writer wavers cuz it wasn't gonna answer I mean I don't know why you didn't answer that's why I'm asking okay it's really annoying that I wake up early and comes to you and you can't even be on time yeah well I do apologize but I was struck by the fact that what I thought was to commit to think you thought it was like just being like wasn't going to say anything well I was waiting in the office like where is he is he even here yeah you were waiting and there wasn't any sign whether I was here or not what went through your mind at that time did he leave is he not here for me like everyone else in my life God so you thought did you think I just forgot your session or no I thought you didn't care enough to come that I knew you'd rivers recession and I just had something a priority yeah is that what happened well no but I'm still pausing on how that must feel like to think that we've got an arranged session and we've committed both to the treatment and I would just put some priority over you so that yeah I get a kind of get the picture more the same thing my parents do it's the same thing Tom does everyone does that I'm no one's priority yeah well I can't speak for Tom or your parents but on the other hand you almost seem to be still thinking that here you know that I want you to say sorry and we can move on that's that's a good question I could have just said sorry let's move on but I well before I say what I was doing I just said Magee's you thought that my nuts immediately saying sorry subhan was another way of just not caring about you that was just my mind was elsewhere well if you cared you just say sorry and be interested in how I'm doing cuz I'm not doing okay clearly okay I want to hear about that but just before we go on I when you came in I'm a trainer exactly that's good you seemed a little angry which I understand so when you asked me a question I had to committed to reflect on the whole situation but that's different from what you imagined you thought it was like so I was actually trying to figure out how to put this all together I thought that you didn't like me anymore and you were not coming to the point meant to see me yeah yeah that's what was on my mind too because I was kind of taking that in but it's just so quick you couldn't have imagined that I was reflecting you thought I was just just absent in a different way I mean either way you weren't here mmm well that's where we might have a somewhat different point of view but I you know I can't question what you're feeling but I can just suggest we reflect on it because don't just say sorry okay I'm sorry I'm mad at you I'm really sorry I just I really needed to talk to you and you weren't there when you said you were gonna be there well um but what did I ever say was not okay to be mad okay so I'm mad you're fine with that I'm what you're fine with that I don't see Maddie you know yeah sure but what I was struck by was you were apologizing for something you might have had a right to feel so I just wonder it almost seemed like you felt I was I don't want you to mad at me everyone's mad at me but what-what were the signs right here that I was a bad I'm always a oh my god okay I'm sorry we just move on well we could but that's pretty if I were just sitting there feeling I'm always a that probably would want to think about it a little before moving on because I mean you're five minutes late I've been five minutes late before and no one treated me like this I don't know why I'm treating you like this rude well isn't that why we're here I mean that's the kind of reaction that seems related to almost everything yeah so slowing down can help I mean you really felt you needed to apologize to me yeah I'm a bad person I am NOT nice to people and I just feel bad that I did that I just thought you weren't leaving me I thought that we were you weren't gonna come and you were ready to more or less chop my head off yeah well I thought like it I'll just leave and he can wonder where I am I'm wondering where he is not I know now that's like mean because you did show up yeah I know it's frustrating but um and that's happened with Tom I guess all the time obviously yeah boy can you say a little bit more about what the leg shaking might mean I'm just pissed yeah that who right now myself but you were pissed at me a minute ago no yeah okay what happened to that I realized that I shouldn't be pissed you things happen maybe you had something else to do well we're important to me there's a lot of other things in the world that are more important than me you know I understand how when you say that and I if I just were to hear that statement I would assume that fits into how most of us feel but the way you say it makes you do not feel like that you do not feel like more things are more important than you you do not have this horrible disease yeah but you see just philosophically I think one might think there were more important things the world than oneself but the way you said it it sounded like you don't count at all oh if I counted you would have been on time Tom would answer my calls my parents would come to support me and not just go to my brother's games and care about my sisters no one really cares about me well you know there is this like repeated link between I don't care about me I don't care about me no one cares about me but if if you don't care about you who are you just assuming we don't time putting me in telling your folks together or I mean it's getting a little confusing right now because you were saying I didn't and now you're saying you don't I'm confused too I don't know if you do yeah all right well I think the confusion is probably a step in the right direction um but you seem your state has changed a lot since we began the session you were angry now there's a different feeling how would you describe it I mean I wanted to come in and talk about how Tom hasn't answered my calls in three days and I come here to talk to you about that and then you don't answer the door uh-huh it's like okay can't call anyone can't talk to anyone whom I suppose talk to well okay you were there I saw that but now you're in a very different state that seems like you're almost like kicking yourself for having felt that a few minutes ago yeah cuz now I know you care cuz you're sitting there you're listening to me what do you care that's an important question and you know I could easily say yeah I care but my experience of you and hearing about your life as if I were just to say yeah I care that wouldn't stick for very long because if people have said that to you and you're still doubt so I think it's more important to look at the doubts and the evidence and what happens and so and so forth but as you ask me if I care what's what's your what's going on in your mind that's an inappropriate question why you asking your therapist that you got until refreshing your therapist down the path and crossing boundaries why are you doing this again you're horrible freaking person you know when you get into that cycle of just bashing yourself my sense is you move away from me some you're sort of like this in your eyes turn right and it seems to me you get into your own internal thing there and it's as though I don't make much of a dent when you're in that cycle I'm not sure if that's right but do you see what I mean yeah so you seem to be hearing me now is that kind of can you get it that's how I feel well I've got to hear that I feel very alone when I feel like this but it's just so quick to get like into that cycle and in my experience it just kind of shuts off what really is going on between you and me and I wonder if that happens with Tom and the folks and stuff like that when there's a like five minutes of waiting and you get revved up and then whatever happens next it's almost too late for that haven't pack I don't know yeah because you kind of go running with something up here well that's what Tom said we went to do the other night it was a great night he left for work the next day and then I called him he didn't answer my call I called him again he answered recall then he texted me saying I'm at work I can't talk what's up and I said you can't talk you don't love me and he said Katie we had a great night last night why are you so upset I'll call you after work and it's like why can't people just answer me like is he really at work that's a scary thought that he might be that dishonest I mean he's probably at work but there's always a chance he's not at work and he's lying to me well you know the man I don't um so you don't know how long now almost two years uh-huh but I think it's I think it's almost over what yeah yeah well that sounds like it could be a crisis but uh I just wanted to say in the two years and have you had like solid evidence of his lying not with him but with other people in the past he I mean I think he's lying but I've never really caught him lying I've got other people lying a lot well I'm sure it's painful to think he's lying but well tell me about that it's almost over now what's what's gonna leave what would lead to that cuz right now I really do think he's lying I don't know what he seems distant just like you seem distant at the beginning this session everyone just pulling away okay let's put a few things together you said you'd had to end up at thurb I don't know if you said you had to you said you did end other therapies yeah and it's something was related to something going on between us right now you had something that mean I wasn't committed to other therapy so I ended up quitting it was because the therapist wouldn't answer my calls or would show up a couple minutes late and I just didn't think they cared about me so I was like it you don't care about me I don't care about this yeah that's understandable if that's an accurate assumption but what's happened I mean like a minute ago five minutes ago you thought I didn't care about you but it seems like that's not so fixed an idea right now there's some doubt about that yeah I I don't know uh-huh but that's again that's why I think we should stop and reflect about this because I I don't want to speak for Tom or your parents or the other therapists maybe they lie maybe they don't want to be with you although you know there's evidence both ways well sure there's evidence both ways what there's evidence that your assumption is wrong about that but the confusion here could be very beneficial to us because if you just if you didn't have any confusion and we're convinced that I just wanted to get rid of you like I didn't think about you we probably wouldn't be continuing this very long would we'd like to know how the doubt comes in what leads to that the doubt about your negative assumption I was about to leave because you weren't here yeah and then you're here so all my thoughts about he's never gonna come you did come you're just late so now I'm just wondering why you were late which I still don't have an answer to what do you imagine either you wanted to cut our appointment short because you can't stand being in a room with me for 45 minutes or your kids needed something or mmm another patients more important than me yeah suppose I just wanted to stop or cut short this egg what what would it be about you that I'd want to just get the least possible after this having the least exposure through that you don't know how to help me I'm a lost cause ah no one knows how to help me I'm never gonna feel better so I'd want to cut down contact with you because my own feeling hopeless about you maybe you just don't think I can get better so it's like what am I gonna do for 45 minutes with this girl that just can't get better mmm it's really sucks how long have you had this idea that I'm hopeless about you not that long and is there have there been any signs from B that change in my demeanor that well last week our point man I did at 4:45 and I got into my car and it was 444 and this week you opened the door five minutes late it's like every session I'm I'm always five minutes early and I'm always willing to go five minutes later and seems like when I leave your office it's been a couple minutes early for the last couple weeks mm-hmm I have to pay attention um but don't want to tell you when I'll keep my on the clock and I'll tell you why we have 23 minutes left right now okay um but I kind of feel like what's getting reproduced here is what happens in other relations you just have to monitor everything so carefully you can't just write be in the relationship fully because you're okay checking on it all the time well I'm sick of being left by people if people are gonna leave me I'll just peace out on them first ridiculous that's why I'm kind of thinking Tom maybe on the break-up with you how would that feel how would that feel Hey but let's go back to what we said here a minute ago I'm I've become hopeless about you and you conclude that because I ended the session a little well can we go one minute late today yeah but if I if I'm hopeless about you and continuing to see you with the same plan we came up with a few months ago that kind of implies something about me if I have no hope but I'm just going on as though I'm still believed in what with that about me that you don't think I can get better no that's your but if I if if your assumption that I don't think you can get better is accurate and I'm still seeing you with the same agreement we had an if you would imply them nothing honest with you you're not being honest and you're anxious for what's gonna happen if you if you let me go because I'm not a stable person but this look at this what would happen to your career if that happened yeah but let's look at those things one by one I would suck I'd like you like to focus on you for the moment we can think about the impact on my career later but right now you're at least partly thinking you're sitting in an office with a therapist who's not honest with you and I'm wondering what that's like it's shitty yeah well are you honest with me why just tell me you're awesomely well I mean that one I really answer because I'm being as honest as I can be but again I think the issue is those kind of confirming statements don't often convince you of anything and I'm just trying to open up more your doubt so we can look at it wonder about it then just trying to help you decide if it's maybe an accurate or inaccurate perception you're sitting with a dishonest therapist because that would be a pretty bad situation to be in it would yeah and the other thing I don't know what Mary's going to end the session but anyway the other thing do we have a weber in the primary do we have five more minutes Mary for this Mary's not listening this guy you know what she's the one that's all myself there you don't care about me no no she doesn't no one cares about me she doesn't care about don't you care she doesn't care about me oh I'm so how are you doing no let's give it um so you were thinking if this treatment goes badly and you quote do something what was the do something I'm just curious about you what what have I done in the past what the patterns we talk about every time someone leaves what do I do well so far it's usually having your wrist yeah right with threatening well I'm glad you got too threatening because you know we've seen moments here where it looked like we could relax a little bit think together that doesn't last too long before it gets kind of tense and you begin to wonder if I'm honest or dishonest and when you begin to think that way you kind of get into a position of what you I think accurately called threatening and then it kind of just could escalate into a really bad situation so I just think before we wrap up it would be important to think about how while you you know are very convinced that other people are not really interested in you and can treat you bad leave it there's a little bit of you that would consider threatening me and kind of making me squirm and stuff like that so what do you think about that side of things I mean I know I do ridiculous things what's to say they're ridiculous things implies there no meaning they have no meaning and they're not worth thinking about things like and I just really want people care about me I care about people I just want people to care back for me I understand that but I'm trying to look at the things that get in the way of that and this kind of retaliatory thing seems like it doesn't help well when people like me I get confused why they would like me well what do they like that gets back to your saying you're a yeah ultimately that's kind of what we should be thinking about you know all this storm and all this turmoil you know about other people almost seems to take us away from that conviction you haven't if you're living with that I don't know how it's going to be possible to get close to anybody because if they like you you're going to think they they're not they don't know you or if they do you better they'd agree with you so we just got to clarify some of these ideas that are coming out but you were going to tell me what the session time was up 30 more seconds okay anything else you'd like to say are you going to be on time next week well I'll certainly make my best effort but I would like to add that with that kind of feeling in the air that could create a tension and then I understand better what it's like for you every day that if you don't do things exactly perfectly it's a disaster so I can tell you I'll make my best effort but I hope if I'm not able to do that you'll still be here okay all right all right now we'll have some discussion thank you reciprocity should we stay here you could have questions for both of us yeah so he's already free okay comments questions isn't this mentalization pastry book well Joel it is except we've been doing it since the 80s if it is I guess we were pretty good about having a crystal ball to know what was going to come up 15 years later I mean I should add though I do think that TFP in the phase we call clarification incorporates most of what's done to mentalization I think the differences come later in the treatment because I find the mentalization doesn't deal as much with intrapsychic conflict and in particular it doesn't deal with what we see as the internal bad object now that's jargon but what do I mean by the internal better view the person's own identification with their aggressive and hostile feelings from what I understand about MBT that's referred to as the aliens self which is the product of a traumatic experience and it's never a part of the self it's just sort of stuck as an element whereas there's a basic theoretical difference that every human being has all kinds of loving feelings on one side and angry and hostile and aggressive feelings on the other side which can be put to very good use through subliminally channels but I think that what we do I was trying to do this with Katie is to help her see sure she's got angry stuff she's got hostile stuff but it's better to own it to integrate it and to see that it's part of the self so I would say we work more with number one interest like a conflict conflict within the mind and dealing with how to integrate aggressive and hostile feelings yeah it's interesting to see how you stuck with the present just watching you and you mentioning her foot shaking or her general effect and and realizing how difficult it can be to do that when someone is wanting a reaction out of you and it was just useful for me because I I'm pre licensed and I'm trying to do this and it was it was just very useful to see you stick with something that was quite difficult well I brought that up because you really have to train yourself to do that because there's so much data there's so much information you know what the patient is saying what you're saying about calm but you think about her parents and you you have to really know what you think is going to be the most beneficial area to focus on and as I try to explain we think that what is being felt between the two is the most like that is the best channel for gaining some understanding poor Katie is stuck with this self-hatred and but we don't see self-hatred is just a state of affairs it's an action it's an action of self towards self that's often projected so to try to get her to realize she's involved in an ongoing action that is getting externalized with me I hate her that's why I kept her waiting so she's putting it to me what is part of her and we really try to keep it in the moment because we think that's when the most understanding will be gained about issues that are related to every aspect of her life oh yeah we got somebody in the back and a couple of people here thank you very much for that demonstration and I want to know what you do with the counter transfer n shil in TFP what are the things you do with it well it's a big question and I suspect you're asking do we disclose them or just more often use them is that part of your question yeah that's because I didn't have time to go into it but a big part well let me just take a brief step back and say when we're doing this work we pay attention to three channels of communications the verbal content of what the patient's saying all the nonverbal information like the legs shaking and just the atmosphere in the room that's created and then our countertransference feelings that are evoke din us and we assume that a patient who's working with dissociated states in the self can activate in others feelings that they can't quite get in touch with in themselves it could be loving feelings it could be hating feelings so we tend not to disclose our countertransference except I think I did a little bit in this session at one point we more often use them to get information about what's in the patient that they're not aware of and sometimes to begin to introduce something into the discussion without saying whether it's from the patient or from us it's like in the room you know we just talk and sort of then try to locate it whether it's more with one side or the other I don't know if I can go into more detail without you know taking a long time about the ins and outs of countertransference and if anybody's interested in learning more about TFP Columbia psychoanalytic centers I'm going to do an online course through them starting in September so you could sign up and we could do all the fun stuff in that course I think is that answer the question about China thank you yeah okay oh hold on a sec eval yeah yeah one of the experiences you have with some of the boiling personality disorder is they do have changes in thoughts and feelings very quickly and sometimes that can be a defense against working on ticular issues are uncomfortable by sort of always changing the ground so there's no opportunity to really reflect and work through anything so I guess one question is how do you deal with that tension of what you know staying in the moment following the pit letting patient guide things versus soaring single let's stop a minute and look at what happened here and then also just in terms of the overall session is there some point near the end where you kind of summarize and say but it basically come to some kind of agreement about well what overall what was this session about or overall what did we you know talk about today or yeah two questions so let me answer first I agree with it's really confusing because poor Katie she went from being furious at me to being you know terribly guilty about herself and you have to follow the brup tand and sometimes dramatic changes in self state and you have to be the historian for the two of you because the patient when they're in one state doesn't tend to have much of a recollection of the other so that's why I'm saying well you know wait a minute now you're beating yourself up at the beginning of the session you're beating me up let's look at the big picture it takes a lot of training just to gain that awareness of the whole combination of things and you just try to keep it all in mind and sort of help the person be in touch with the different parts that they are only in touch with sequentially we tend not to summarize at the end of a session we tend just to leave things where they are and continue the next time and hope the patient I mean if the patient's like really distressed we'll discuss it but usually we just leave things open for reflection I see Chris is getting ready and I see we have two more do we have time for two more questions merrier too quick okay true brief questions Laurie and Valerie just really quick with regards to mindfulness and just I was struck with how mindfulness would move a practitioner into the capacity to hold that neutral stance and with the non judgement and I just it was really neat to again be able to see that connection in can you speak to that well only brief because I'm not so informed about mindfulness the only thing I would say about mindfulness if I understand it which is not too likely I thought mindfulness put you in touch with the moment but without sort of being in contact with stuff outside the moment is that accurate yeah as long as you can put that in connection with other moments that came before and after I would say that sounds similar okay I just wondered I realize it's not a real situation and she's not but she sat like this at the beginning and at the end of the session she was still like this and I wondered how you would feel knowing that you worked with her for this period of time and she still seems to be angry and closed off how would you feel yourself about that no no I don't mean you I mean how would you feel Frank I guess I think Katie's are markers because sometimes external reality but no I mean I would have in an ideal situation tried to do it more of what I did we just say you know when you get caught up in this thing about beating yourself up you just seem to leave me out and I would have referred to this as her leaving me out because for somebody who's not so interested being close to people she gets into her own thing and shuts out the rest of the world so I would have kept referring to it that way right thank you

Channel: NEA BPD

Views: 78,341

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Id: 14fW-VUiCQA

Length: 32min 47sec (1967 seconds)

Published: Tue Jun 25 2013