The Psychodynamic Diagnostic Process: Nancy McWilliams

perfect perfect that's a psychodynamic diagnostic manual well we could just read it out loud show it to the audience I'm the co-editor but I'm not even saying disorders here because everybody's got personality no yeah sisoid paranoid narcissistic Psychopathic hysterical obsessional dissociative it's arguable that that's in the hysterical category dependent masochistic hypomanic counter dependent sadistic 9 10 11 they're 12 and a PDM but you know there are other types that are I forgot somatizing forgot phobic personality happens usually gradually and it's a complex uh combination of what's your temperament uh what aects were um important in your growing up what defenses did you learn to use who did you identify with and counter identify with for that matter how were you taught to support your self-esteem um do you feel good when you get over on other people or do you feel good when you do something that involves your sacrifice for the greater good uh how do you de deal with disappointment do you blame were you taught to blame or do you try to grieve and move on and solve a problem and accept what can't be changed babies differ on all kinds of measures um and and some kids are easy and some kids are hard and then there's an interaction between that and the family um you can have a temperament that the family appreciates and supports or you can have one that the family doesn't understand and they make you feel there's something wrong with you and then you have have on top of your temperament developmental challenges that might be handled in one way or another by the family you have uh neglect or trauma or overcontrol or any one of a number of different ways that your family deals with you that you then learn to uh accommodate to and the basian brain is a prediction machine and it's basically saying you know this kept happening to me when I was young that's how I expect the world to be now trauma at any age can disrupt personality so can substance use um so I used to think that there must be an alcoholic personality there's not you know once you get somebody sober you see what the personality was before they developed a substance use disorder I've always been fascinated with individual differences and not just diagnostic differences but how does it influence your therapy if you're talking to somebody who is an adopt D who is a twin who is of A different race from you who is of a you grew up in a different class rank than you who is a Hindu if you were brought up Christian uh there are all kinds of things that go Way Beyond diagnosis that involve our adaptation to another person and trying to make an egalitarian supportive but helpful relationship with them it when I go to other countries it's interesting on that level they often tell me what's the common personality type in their country so for example uh the sweds told me that they were schizoid um the Italians told me they were hysterical uh the polls told me they were post-traumatic the Russians told me they were narciss no masochistic um in Norway they told me they were avoidant in Australia they told me they were counterdependent um when I in Singapore they told me they were obsessive compulsive okay in Japan they told me people tended to somatize so it's very interesting how cultures will shape dominant personality Styles when I ask them uh how do you think about Americans in terms of our dominant personality types they look a little bit shy and they say narcissistic because you know we're America we're great um there's a lot of narcissism these days narcissistic personality we live in a culture that uh changes quickly where we don't know who we are we're we're all anxious about our status um we're in a culture that breeds narcissistic problems and in American culture we have an official um kind of language about individual rights which uh privileges the idea of my individual authority to whatever commit genocide or you know various other things that have done in the been done in the name of individual rights of some people uh the most common kinds of personality I would say and there's some research on this it's depressive personality that's also the most common type of personality in therapists interestingly enough they move toward other people they're interested in other people they're quite self-critical they're sensitive to separation they're very sensitive to criticism when they are criticized they tend to assume that there is something bad about them in contrast for example to people with a more paranoid psychology who when you're when they're criticized they go right to what's wrong with you okay uh so depressive people use injection whereas paranoid people use projection injection turning against the self um sociophilosophy myself I I need to keep demonstrating that I'm suffering either to show that I'm a good person or to maintain a relationship I mean there are some people who are so severely masochistic that they stay in abusive relationships because for them it's worse to be alone than to be hit okay that's a masochistic organization um and it doesn't mean you love pain it just means that youve your um strategies for survival developed from a situation in which you couldn't have been separated you had to live with your abusive parents because otherwise you know you'd starve to death um so it's not like they seek this but it's a pattern that they've learned that their attachment Paradigm is that um if I'm suffering you'll pay attention to me they often have histories where their parents neglected except when they were injured or sick uh so that is a recognizable type of Personality too you can have all the same DSM symptoms and be either more depressive or more self-defeating um self-defeating patients usually come in with depressive problems but they approach therapy as an opportunity to complain about other people you know uh usually and they they put sort of pressure on the therapist you're supposed to be fixing my life you know I I've been victimized uh the bad people are out there you know what are you doing about it um it's often very subtle but if the therapist is just paying attention to their own um subjective experience you begin feeling like there's more going on here than just depression this person keeps reenacting the idea that you've got to help me but you're going to fail some of the things that have made clinical thinking uh less popular are the pressures of drug companies who love categorical diagnosis because if you have an illness they can Market a drug for it you they don't want to hear about complexity and context and dimensionality um if you're insurance company you want to have okay all you have to do is get rid of the symptoms you know they don't do that with other illnesses but they do do it with psychiatric illnesses as soon as you're reduced in the symptoms that's it it's like curing a fever and then the disease is gone you miss a lot when you diagnose that way for example you can't tell by the DSM description of depressive disorders whether it's what Sydney Blatz work suggests is an injective depression where the subjective experience is I'm bad I'm evil I'm I'm a terrible person and and there's a lot of guilt versus whether it's an anaclitic depression where the person feels uh I'm empty I'm hungry I need an attachment life is meaningless without an attachment those two kinds of subjective experiences of depression have exactly the same vegetative signs they meet the same DSM criteria but they have different implications for treatment there are two anxiety centers in the brain what pens up calls the fiercest system and what he calls the Panic grief system which is the attachment system uh and and people have tried ssris for them because ssris are supposed to be good for anxiety but if you haven't differentiated between Annihilation anxiety and separation anxiety you're not even medicating properly they're mediated by different neurotransmitters the fear system is the legacy of our uh Terror that a predator is going to eat us so evolutionarily it's the the system tells us we're going to be destroyed you know most of us don't feel Annihilation anxiety too easily but I felt it on 911 some people with paranoid psychologies feel that all the time uh separation anxiety is a different subjective experience of anxiety it's um in the Panic grief system where if you separate any young mammal from its parenting mammal you get first of all very great anxiety and searching behavior and if you take fmis of the young mammal and the mothering mammal um the same part of the brain in the mother is uh lighting up as lights up in the child that system is mediated by serotonin the fear system is not what calms the fear system are the benzos and the downer drugs so very often people we see who have a paranoid streak also have a substance use disorder based on you know barbituates or benzos or the downer drugs generally alcoholism let's take uh paranoid people they have the trait of suspiciousness and distrust that's not false it's they can be described that way but they also may have the trait of over trusting people that they idealize like my cult leader is Flawless or Stalin would never have hurt anybody it's better to think about their psychology in terms of um not the trait of Suspicion but the preoccupation with trust distrust Sullivan said paranoid people don't have a normal level of trust and distrust they're on one end or the other same with schizoid people they they tend to have the trait of withdrawing from closeness but if you get to know them they have a lot of preoccupations with wanting to be close feeling lonely um you know I'm not using the DSM version of skitso here but the traditional idea uh they they may have moments of Exquisite closeness with other people from which they Retreat so it's the closeness distance theme that defines them if you're a a patient with a schizoid psychology and I don't get that about you I may because I have a depressive psychology be moving toward you trying to comfort you trying to offer you stuff but your experience of that is going to be you're impinging on me you're in my space I'm not comfortable so with a schizoid person I've learned to sit back and check in on how overstimulated they may be feeling in this particular point so that's a kind of gross implication but for all the personality types there are implications for treatment if they're mostly paranoid but also have elements of a lot of other things their issue is going to be trust versus distrust possibility of betrayal if they're mostly obsessive compulsive they're going to be concerned about control discont control neatness messiness promptness lateness all of those issues obsessive compulsive used to be very common in our culture it's less so now these are people that are very um organized around what's what's right to do what's um what's timely what's conscientious what's neat what's fastidious with obsessive compulsive people it's the theme of control discont control uh you can look at the trait of fastidiousness but most obsessive compulsive people also have a dirty drawer because there's some place where they're out of control if they're mostly histrionic they're going to be interested in gender and power and sexuality and they'll have some symptoms expressing preoccupations with those areas um and you know you can talk about those different unconscious preoccupations if you are um a powerful heterosexual male treating um a a female who has somewhat hysterical Tendencies You don't want a man flain to her because her psychology is that she um feels like the inferior or or weaker gender um and so you want to help her find her own solutions to things rather than come in like you know what she should do because that's a replication of the sense that men have the power women don't have it if you don't have the power all you can do is try to use your sexuality to even up the power disparity and that usually goes badly um but there are other kinds of personality in which if you simply keep asking the patient well how have you thought about that what would be your solution to that be how do how do you feel about that and what implications do that have for your life they feel like you're being evasive you know with a paranoid patient they want to know what you think yeah it's a it's a very different interpersonal environment narcissistic I think we all have an image of narcissistic not so much the more shy closet narcissistic people uh sometimes I get patients who come to me saying just make me popular if I were popular or if I were rich or famous then I'd be fine that's just the clip side of I am rich and famous and popular and I'm wonderful uh it's the same set of preoccupations it's the same personality narcissistic people use grandiose ideas to defend against shame and you see both sides if if you have an arrogant narcissistic person the kind that the DSM describes and they have a terrible injury uh you know they aren't promoted they lose their job they lose their beauty they lose the things their wealth whatever it is that they're constructing their grandiosity on then you see the shamed anxious um humiliated version of it or what some people have called closet narcissists or Glen Gabbert has called the hypers sensitive narcissistic person dependent personality I've never liked that diagnosis particularly um but uh that's not uncommon either both men and women it has different appearances but where you you kind of don't know who you are or what you're after except as defined by another person like I'm Tom's wife and Jane's mother and U Sonia's teacher and everything is uh defined in a uh a complex array of connections I don't I don't particularly like it because I think we are all interdependent and uh it becomes a problem only when there's some kind of shift where you don't have your attachments and then you have to figure out where you're going like you retire you don't know what to do with yourself or you get divorced and you don't know who you are anymore um but that's a that that kind of personality has been researched Robert Borstein has done wonderful research on it and it is a useful concept and not very uncommon I've seen a number of counter dependent people you know people who have this um they're you know they're it's like the manic to the depressive it's the polar opposite I need no one I'm fine and this is not always a narcissistic thing it's sometimes I I can't depend on anybody I'm going to depend on myself I never get sick I always take care of myself there is that version of psychology too um I'm probably forgetting some of the big ones Psychopathic is not too unusual uh that's what the DSM calls antisocial personality disorder but I really don't like the DSM description because it's all about like the consequences and the social damage of it and it doesn't look at the internal experience which is I have to depend on omnipotent control everywhere I I my worth is dependent only on what I can make happen uh I'm under stimulated I'm going to attack the world manipulatively I don't care about other people I I I like to get over on other people and they often are in very powerful positions generals you know presidents presidents of countries um presidents of of Corporations because you love power and that's what organizes everything um and and you love power even more than you love you know the narcissistic gratifications of being seen as powerful then that's an increasingly common um kind of personality structure I think in personality it's almost always the case that people have some combinations of things maybe they're a little schizoid and a little obsessional um I'm I'm depressive and hysterical let me take another sip te here how are we on time Gary um I'm still okay thank you so much I think the levels of organization are very important for people to keep in mind because if you're a beginner and you've been told that such and such a treatment whether it's biological or psychological is the treatment of choice for this condition and you get a patient who's at the psychotic end of that spectrum and it makes your effort to do the evidence-based treatment makes it worse your response is going to be some other person could have made this work because this is the evidence-based treatment I'm a bad therapist it's very different to work with somebody with let's say um a depressive psychology who's at the healthy to neurotic range versus if they're in the borderline range versus they're in the psychotic range if for example you don't understand the dimentionality the fact that um you can have let's say an obsessive compulsive disorder at a a level of Personality organization that's very high functioning and the way that would present itself clinically is the person would say I've developed this compulsion uh I know it's crazy um it it's happened ever since my brother died uh I want to get help with it and they're clearly relating to you as a person who's well-meaning and intending to help them that kind of person is going to be a very good candidate for exposure therapy which is an evidence-based therapy for obsessive compulsive disorders but if you have exactly the same symptoms and you've had them as long as you can remember and your parents taught you this and you don't really think it's a problem and furthermore you fervently believe that if you don't carry out your compulsions a disaster is going to happen and you look suspiciously at the therapist as if when they tell you maybe you should move toward the objects you're afraid of contaminating you they look like uhoh you're a contaminator and they treat you more like a persecutor that person's going to take quite a long time in Psychotherapy before they could ever do an exposure treatment so the therapist gets demoralized and they don't realize they've been trying to apply a technique that was developed for higher functioning people with people who are suffering much more deeply than that and nobody's telling them that so it's been important to me to get the word out there that there are different levels of Health although at all the levels there are healthy as well as disordered parts of the celf well at the high functioning level um almost every therapy is useful we're talking about people who have pretty good attachment security who can make a relationship with a therapist with the assumption that even if the therapist says something that's temporarily painful to hear the therapist is well intentioned you don't immediately go to you were trying to hurt me you can observe complexities in yourself and in other people um you ask a person at this level to describe the people in their family you get a real three-dimensional picture of a person there at the high functioning level it's easy to feel positive toward the patient it's easy for the patient to feel positive toward you if you hurt their feelings they'll tell you so and so on um the patient will appreciate that you're trying to help so you can move into various ways of trying to help them um they try to cooperate uh they don't have unrealistic goals you can make um a very realistic treatment goal U framework with them they don't don't test boundaries they accept your boundaries um and if there are inevitable ruptures of the Therapeutic Alliance they're easily repaired you know all you have to do is say I'm sorry I think I was too um clumsy there or I I I got it wrong and uh I'm sorry that that will fix it with people at this level so they are the patients that we get very few of but they're a delight to work with um and tradition psychoanalytic technique was test driven on patients like that okay and those of us who've been through psychoanalysis we were treated pretty much like that um you know say what comes to mind uh deepen it if you can get deeply into your feelings if you do that with somebody at the borderline level they'll get deeply into really traumatic feelings and they won't be able to put themselves back together again at the neurotic level they feel a catharsis um and they feel at the end of session kind of relief um that now they've gotten it out of their system but also at the healthy level um people can acknowledge painful realities they don't use a lot of denial they they kind of are clear about things that they're up against um that helps them with the capacity to grieve for painful realities um so again I would assume with somebody who's able to describe the nuances of what's happened to them that I could move pretty quickly with them toward grieving rather than blaming themselves or others um at the healthy end of the spectrum people use um the very adaptive defenses like having a sense of humor about themselves or uh sublimation is a Frid like these analogies to to chemistry and he talked about sublimation as the capacity to turn something that might be primitive in its Origins into something socially useful so if I'm exhibitionistic and and uh I I like to show off my body as a two-year-old that might eventually turn into my wanting to be an actress or a singer for example or if I have a sadistic streak I can turn that into very valuable social use by becoming a surgeon you get to cut people up but for good causes that's the idea of sublimation you turn you know something that was originally primitive into something very valuable um so higher level defenses like that intellectualization and such are characteristic of people in this high functioning range whereas people in the borderline and psychotic ranges don't really um have a lot of of those defenses we all have primitive defenses but they don't have the others um so at the borderline level you see more insecure attachment a lot of anxious attachment especially for the dsm3 version and 345 version of borderline um you you see sometimes type D attachment which is based on the strange situation you know research with kids where um kids will relate to the parenting person with these um combinations of like clinging to the mother and biting her you know and that's clinically very um resonant you know I think most of us who've practiced for any length of time have seen a number of patients who treat us as you're the only one who can help me and I hate you you know both at the same time you know I I I I hate you don't leave me it's a common phrase to describe the inner world of these people that's that's a type D attachment disorganized disoriented attachment and it's usually based in traumatic experience or terrible neglect um the all good or all bad images of self or others um the patient who cannot work with me if I'm a republican uh maybe that's based on some some realistic stuff uh about you and I have to have minimally similar values in order to work together or maybe this is a person who you know seeks to constantly locate problems very simple- mindedly in terms of one group that you should exterminate intensity is part of the borderline picture it doesn't always take the um form of the kind of uh obvious intense affects that um you see in the acting out versions of borderline psychology but uh certain schizoid people feel what one of my schizoid friends calls Pro Pho aect like one of the reasons they withdraw is they're just totally overwhelmed so intensity of affect not being able to modulate your aect is part of the problem of being at the borderline level and you rely on primitive defenses let me see if I can name those without looking at my notes uh those are splitting that's where you see all good and all bad denial withdrawal primitive forms of projection like projective identification where I project something on you and I do it in a way that kind of makes it true so what's an example um if a patient comes into me and and says I'm finding myself worried that you're critical of me and I say to her uh I'm I wonder if because you had a critical mother you're kind of expecting criticism and you may um feel that I might be like your mother if she's just projecting she can see that she's projecting that on me and she'll get interested in do I do this with other people but another patient comes in and uh says I'm worried that you're critical of me and I do my maybe this is about your mother thing and she says yeah it's my bad luck to get a therapist exactly like my mother you um that's uh projective identification because when I'm on the receiving end of this I'm going to feel very critical you know I may not have started out critical but it's as if they project it and they're still identified with it so you're still in it with them so that's a more primitive process than being able to stand back and look at what you may have projected um omnipotent control I can make anything happen you know is that's you see that in Psychopathic people um primitive forms of idealization and devaluation you know we all idealize and devalue but there's a difference between I admire you because I like certain qualities you have and you hung the moon and if I'm exactly like you then all my problems are solved or you know you're irritating me in certain ways uh versus um you're one of the bad people I hate people like you you should be destroyed um that's that's um primitive devaluation where where you move right to blame and destruction because there are a lot of patients that are stuck in what Melanie Klein called the paranoid schizoid position when something goes wrong they want to see all good and all bad and they want to blame and of course we all do that when we're under stress if your lover breaks up with you the first thing you think of is not well I can understand why it was hard for her to stay with me because you know she comes from such and such a family and you just go right away to the you know you hate her um she should die after 9/11 we didn't hear people saying you know we have to understand why people in the Middle East so why there are all these young men that hated us so much that they're willing to die what's happening in that culture we heard about the axis of Evil and we're the good guys and we've got to go fight them and we heard nothing but blame and we all do that under stress but some of our patients do that in every situation and we have to help them learn how to understand you know the separate subjectivities of others the fact that things aren't all good or all bad and borderline as it arose among clinicians was um an effort to talk about the dimensionality between so-called sanity and psychosis that there was a group of people who were too troubled to be considered just neurotic and they weren't troubled enough to be considered psychotic so they're on the borderline between neurosis and psychosis that's how the term arose and then when dsm3 decided they had to include something about borderline in 1980 and they didn't want to talk about anything dimensional they took a type of borderline and they namely a more histrionic self-d dramatizing uh affect disregulated kind of borderline and then and they made that the definition so we now have this hodgepodge of some people using the term in the original way as a level of Personality or organization and some people using it in the DSM way so when I say it I'm thinking of it in the dimensional way um primitive forms of dissociation like just becoming someone else which you see in uh dissociation dissociative identity disorder um acting out uh when young children are are suffering emotional states that nobody helps them name and nobody helps them with they either act out or they get sick so both acting out to try to dramatize what's going on because that's the only way you know how to express it or getting sick because the body is expressing all this are two primitive ways of dealing at the borderline level I've done an interesting thing in recent years of looking at all the different evidence-based approaches to borderline psychology starting with karberg but also looking at um Peter F's work uh gvani uh leotti uh Clara muchi uh Marshall linahan Jeffrey Young um Gregory and Raymond up in Syracuse um Russell MIRS in Australia um there are a lot of people who've worked on therapies for borderline Psy psychology and what interests me is not who's right or who's better it's what have they all found in common about dealing with this range of people so here's my list of um what they all have in common they all first of all put their primary emphasis on watching the relationship uh you can't take the relationship for granted the way you can with an neotic person who'll tell you if they suddenly feel like you did something insensitive you have to keep monitoring are you okay with what we're talking about is this feeling all right to you how's this pace for you are you feeling okay talking to me what are you finding yourself worried about all of that Here and Now concern with the alliance is important with that group that would feel kind of infantilizing if you kept doing that with somebody in the neurotic range they say yeah yeah I'm fine move move on um borderline patients you expect that they're going to be ruptures often very painful ruptures and often very early in the treatment and that a lot of the work is going to be about repairing those ruptures that's not just something that once in a while happens it's the work um right now it seems like you can feel me only as a persecutory person um is it possible you can imagine that I had any other motive other than to hurt you they know they're difficult they know that you know they can have a a strong impact on you in fact one of the implications for seeing somebody in the borderline range is not to be too neutral because they know that that they have strong impacts on you and they appreciate it if you acknowledge that so if at the borderline level come someone comes in and says you know I know we've been talking about how I shouldn't be cut hutting anymore but well look and they start dripping blood on your carpet um you're mad at me aren't you yeah you know you sound like a stuffed CH if you say well let's investigate your fantasy that I'm angry at you you know you have to say something like look it's my job to help you be less self-destructive right now you're being more self-destructive that doesn't make me happy what's it like for you to see the anger on my face that'll go a lot further than trying to treat them as if they're an neurotic level person that you can be more you know blank with you want to open a space Jessica Benjamin writes about doer versus done to formulations that we all get into but I would say especially characterize this level who's the doer who's the done to and you want to open a third space is there another way of thinking about this that would make sense of it they all the second thing they all emphasize is you need to be explicit about the frame your limits your bound boundaries your contracts you may have to contract about self-destructive Behavior what is going to be the consequences if you attempt suicide what are going to be the consequences if you cut yourself or do other um self damaging things um they have to be really clear and you have to expect that the patient's going to test them again at the neurotic range if you if you laid out at the beginning things like okay uh we're going to meet at 10:00 on Tuesdays and Thursdays if you feel bad between them I don't want you to call me after 9:00 at night and I don't take calls on weekends I do read texts but I don't respond to them you might have to go through all kinds of stuff like that with people in the border line level and then you have to and and and the frame isn't a magical communally agreed upon set of rules it's the rules that work for you in your setting that are you know the rules of your hospital or the rules of your private practice that allow you to do your job so some people will let patients call them on the weekends and some people aren't comfortable with that and it's important as a therapist to model somebody with boundaries so many people in the borderline range have had their boundaries violated Often by sexual abuse they need the therapist to stick with the boundary and it's often very hard like one of the things that happens is um the patient gets into their traumatic history and 2 minutes before the end of the session they're in fetal position um you know crying uh reliving some traumatic experience you still have to end the session on time um you you can you can do that kindly you can say I'm so sorry that this came up at the very end of the session I am going to have to stop at the end um which is in 2 minutes uh please feel free free to sit in the waiting room and get yourself composed and uh but I am going to have to stop and then the next session you listen for the patient coming in with all these themes of arbitrary authorities and uh people who don't care how you feel and you know people who care more about their own schedule and by the 30 minutes into the session you can say something like I wonder if you had a really negative reaction to the fact that I ended the session on time uh last time and then can tell you off and they can learn that it's okay to tell you off that it's natural to be angry about limits um but you stick with the limits uh the same way with um a child who you know wants to say stay out all night you say I'm sorry you got to you got to be in by 11 um those are the rules and then they'll come in at 11:02 and then you have to say okay no no internet for a day or or whatever is going to be the consequence that you've already set up and I I find that therapists have a very hard time with this we're often not trained to do this uh we're we our training has a lot to do with uh making us more empathic but with borderline patients for their safety they need to know that we stick with our limits very often what feels like a test of whether we can be flexible yeah is really a test are you going to rationalize changing the rules on me and all of a sudden start molesting me you so sometimes you know you're being tested you're not sure what the test is but usually with people in the borderline level the safest thing to do is keep your boundaries very clearly until you know your patient really really well the therapist has to be more emotionally expressive um binary Dil dilemas can be expected to come up like the patient puts you in a bind where you know if you do a it's wrong and you know if you do B it's wrong you have to have a way of talking about that my and and the different theorists of borderline psychology have their different ways of doing that my way is usually to ask for supervision from the patient to you know to say something like look as your therapist because I want to remind them I'm trying to help them as your therapist I'm not sure what's helpful to you when you fall silent like this part of me says I should be drawing you out but then I'm the one with the agenda and you're responding to it and I may be drawing you in a different direction you want to go in so another part of me is saying um well just wait until they feel comfortable talking to you but I'm afraid you'll feel that as abandonment my not being interested what do you want me to do when you become silent like this um and sometimes they say you you're the doctor you figure it out but at least they've gotten the message that you're trying to help them and sometimes they have a solution why don't you ask me such and such a question I think that would help me talk or what why don't you just wait and then they'll test you to see if you can wait I had one guy that I did that with and he spent three sessions saying nothing nothing but we had made the deal that okay I would wait until he felt able to talk and then the fourth session he flooded me with images of the ways that he was um acting out sexually um with men that were um uh not using condoms and um you know putting himself in quite great danger um so again that the sort of framing the Dilemma from your perspective not telling the patient you're trying to put me in a dilemma but saying I find myself not sure which way to help you um help me with this um help me be a better therapist basically you need to be more emotionally expressive you need to expect intense counter transferences that never goes away I mean I had the fantasy when I started this business that you know I would get good at working with borderline patients and then the the fact that they were difficult wouldn't bother me I would just you know oh yes they hate me but it it never happens that if you're really there um you're going to feel very powerfully not always negatively I mean we we think sometimes that the problem is that it's negative but I've had patients where I wanted to REM them have them move in with me um you know it can be uh loving in a kind of consuming way too and that's not a great thing to act out but you should be aware of what that means if that's what you're feeling there's something being evoked in you and the the last thing I want to say about working with people in the borderline range is with that group you really need consultation and supervision you really need to talk to other people um uh all the people who write about borderline psychology talk about working in a team where they present cases to each other kernberg still presents his own patients to the people on his team Marsha linahan used to do the same thing for an hour and a half with her team um it it's a difficult kind of psychology so uh you need help at the borderline level people are still in tou with consensual reality at The Psychotic level they get very confused by it they get confused by the boundary between self and other I had a patient once who um I started noticing that he would um cut himself off and change the subject if he began to feel his own pain and I called that to his attention at this time relevant to your previous question I was thinking this was a person in the neurotic range um and I I said I think I'm seeing this pattern where when you start to feel sad you change the subject and he said oh yeah I know I do that and I said well what's going on in you when you do that and I think I was expecting him to say I'm not ready to go there yet or I don't want to start crying or you know I I just want to move more slowly but what he said was well I can see I'm hurting you okay he saw sympathetic sadness on my face when he was starting to get sad and he felt he was damaging me he couldn't imagine that I was uh a separate person able to feel compassionately for his suffering you know he had to stop damaging me that is a a psychotic level confusion between his mind and my mind um that's a very subtle version of it I mean some patients come in and say I know you're the devil because I can see the horns and the tail and that's not too hard to figure out but there are a lot of people who have never been diagnosable as schizophrenic or psychotically manic or depressive but who are very confused about what's inside and what's outside and who have peculiar beliefs that they're very invested in and uh those people are fragile they also have primitive defenses but the defenses aren't working for them in any way and they are often in a state of Terror so the main thing to understand about that group is that they're terrified they probably need some medication for the terror and it's probably Annihilation anxiety so you know whiff of H doll is probably better than some of the more addictive um benzos for example but um and I'm I'm not a psychiatrist so I'm talking a little bit beyond my competence but that's my clinical experience and they also need a therapist who's constantly in touch with the fact that they may be making profound misinterpretations um I had a patient for example who was late I'd worked with her for about five years and I thought she was pretty much in the low borderline range but um I said it's not like you to be late to a session she said oh yeah it took me longer than usual to boil all my sheets and towels and I I said you boil all your sheets and towels and she suddenly looked at me with g grave distressed and she said of course I boil all my sheets and towels haven't you ever heard about germs what kind of mother doesn't boil all her sheets and towels every morning and I could feel myself having gone from you know somebody she idealized who was sympathetic in her mind to somebody she was profoundly afraid of because maybe I was one of the contaminators right so that goes beyond borderline uh and and that requires the the the therapist always to have a focus on safety with people at the psychotic level uh it's somewhat different um you have to put the emphasis on safety and that may mean deviating from your usual style it may mean that the patient needs the door to be open because they're afraid that they're going to be trapped in there with you or you may have to say if you want to look around the office to be sure that there are no bugging devices is here it's okay with me and you have to ask them periodically are you feeling reasonably safe just trying to be open about your inner life there's a tone that's important with people in The Psychotic range that I've had a lot of trouble trying to capture I I know a number of people who are really good with this population whether they are diagnosed schizophrenic or whether they're simply at the crazier end of um the personality spectrum and they have this wonderful capacity to be very egalitarian you know very respectful uh I'm just another human being trying to help and at the same time being authoritative enough that the patient feels okay I'm working with somebody who knows what to do because people in this range are so terrified they need to feel like there're with someone competent but not with a competent person who talks down to them uh respect has to be the primary attitude in this kind of so the way that would look is um Bertram Karen who was great with this population used to say to delusional patients oh that's brilliant the theory that you came up with to un understand what happened to you it's brilliant and the patient would say so you agree with me and Karen would say well actually I don't but that's only because you know I come from a different angle of vision of you than you did I am older than you were at the time you came up with this brilliant idea and I I've had certain kinds of training if you want to hear how I would make sense out of what you describe I'd be glad to tell you up to you so you hear the combination of I know what I'm doing you know this is a delusion from my perspective but I'm so admiring I'm learning so something from you I think the uh the core of a respectful attitude is looking up at somebody not in necessarily in an admiring or idealizing way but in a way of you have something to teach me I can learn something from you that's absolutely primary with this group because they have such histories of humiliation if you're a little bit crazy you're going to get humiliated um by your peers growing up and being humiliated is a terrible risk factor for developing psychotic psychology if you're bullied um you are much more likely to have a psychotic diagnosis later on so you want to be an anti-h humiliator when you're with these people you have to um normalize more I mean psychotic people often have fusions of um perception and meaning or fusions of um affect with behavior they'll feel terrible about a thought as and and you might have to say you know thoughts themselves uh aren't dangerous you you should be able to think any thought you have sadistic envious greedy whatever and then you make the choice whether you want to act on that in any way but you crucify yourself for the thought but so you're teaching the person there's a difference between what's inside and and what's outside um there's a certain amount of educating that goes on with people at in this level and you can do it not by heavy-handed dactic stuff but for example um I had a woman in this range who came to me really upset at herself felt she was a horrible person I think she used the phrase the spawn of Satan um because she had found herself having the fantasy of strangling her teenage daughter so I was just about to go into this lecture about how well you know most parents have fantasies of strangling their oppositional Teenage Kids now and then but I realized she was so sensitive to humiliation that if I took that stance it would sound like I was coming from oneup talking to talking down to her what most parents feel so I I said oh tell me about it when my daughters were that age I wanted to strangle them three times a day that made us equal that imparted the lesson without my being a heavy-handed educator two other things about working with people at the psychotic end of the spectrum it's really important for them to feel like you appreciate that they're trying to solve a problem with their symptoms that that there's a health seeking aspect to whatever crazy thing they've come up with and if you can uh appreciate that then they're willing to look at how this might also be maladaptive under the current circumstances and finally you want to be conversational and active with that group even more than with borderline patients you you might want to talk about yourself you you might want to um chat about things that are important to the person you don't worry about not being blank with this group if you're blank you just make them crazier so let's let's yes let's bre how do you do first sessions I mean what comes to mind the patient comes in and my main concern in a first session is to make a relationship with the person the uh empirical literature shows that the relationship is the most important element of therapeutic progress I had one patient who told me I was too warm um and I said I'm sorry I can't do a personality transplant but what's the problem with my being warm he said I'm afraid I'll get all crying and regressed you have to be yourself in this role you can't seem like you're following a script patients want to meet a real human being so the first question I asked them is you know what brought you here or how can I help you because I want want to find out uh what brought them here at this particular time then I asked them how they understand their suffering I mean what is their own theory of why they've gone off the deep end or what however they describe what they're suffering you know relational issues family issues um occasionally they don't know you know they just suddenly got depressed or they suddenly got anxious and then I'm thinking about well what might have consciously kicked this off maybe it's the anniversary of the death of somebody maybe their child got to the age that when they were sexually abused uh maybe it's an anniversary reaction of some kind I usually ask patients if I remember do you mind if I write it down it helps organize me and I find most people appreciate that they they appreciate being listened to as opposed to the more contemporary rushed psychiatric interview where you try to just you know check off what are the DSM signs that you might have so if I'm taking notes about things like what happened to them I I explain that this is just for my use this doesn't go into the the actual record um so you know if anybody doesn't want me to take notes I won't but it helps me you know I'm always anxious at the beginning of meeting a new person and it it gives me some to hold on to and something to do with my hands so it's helpful for me yeah to make me at ease and if I'm at ease then I can help the patient be at ease but what I'm trying to do in the first hour is um make a relationship I always ask in the first hour is there anything you want to know about me sometimes people want to know what are your credentials or um occasionally they ask a question that's too intimate like have you ever had a lesbian affair um at which point you know I'll say you know that that just feels a little too intimate but tell me why that's really important for you to know two or three times in a 50-year career I've had people um ask me a question that I thought was too private to answer usually they ask me questions that I do answer because the first meeting uh is about trying to make a relationship so if they ask me you know are you a Republican L some people have been asking me that because they really don't want to work with a republican um some people ask me if I have kids and fortunately I do if I didn't have kids that would make me a little self-conscious but I think I would have to answer it you know actually I don't but it seems that's very important to you and and you're wondering whether you can trust somebody who doesn't know what it's like to be a parent from personal experience so I I do answer what questions they ask me in the first interview I try to draw out the patient for at least half an hour um and then I try to make some intervention that tells the patient that I'm listening and trying to figure out a way to think about this problem so I I try some kind of intervention like boy it sounds like you've had an awful lot of loss in your history and not too many opportunities to grieve is that right right so I then and then I will say something so it looks like we'll be working on turning your depression into normal grief which is a process you will get over unlike depression which can just sink you for a long long time at the end if they want to work with me I say what I'd like to do is next session I'd like to take a really full history from you you know your childhood what your parents were like who were the main people in your life what's your work work history or sexual history or social history anything you don't want to answer just tell me but I'm going to be really intrusive U for for this meeting because I need a context to understand what you've come to me about today is that all right with you and then I do that the second meeting some people you know they they are pretty tur and uh I can go to taking some history in the first meeting but usually the first meeting is more feeling out the problem itself there's C certain things I always ask about in that interview one is substance use another is any history of eating disorder these are things that people are ashamed about but in the be beginning they're willing to tell a mental health professional later on when you matter a lot to them they're even more ashamed but they remember they told you about it um same thing with sexual history I sometimes ask them about stories about them as a kid any family an otes about what they were like as a kid I try to get a feel for their temperament I always ask them their earliest memory because like a good psychoanalyst I do believe that that's very uh organizing uh to how they experience the world at the high functioning level we're talking about in the neurotic to healthy range you can observe complexities in yourself and in other people um you ask a person at this level to describe the people in their family and you get a description something like well my father he was a military guy and he sometimes ran the house like you know a barracks and I was a bit afraid of him because he was really strict but he went to every game I ever played he cheered me on he supported me through my college education he came to every graduation I know he loved me you get a real three-dimensional picture of a person there um but some people will say well my father was a monster or my father was just a useless alcoholic or my father he was he is the best you know I want to be just like him well what do you admire about him everything you know and you you don't get any Nuance or sometimes you get um tell me about your father I don't know he was just my dad you know where they can't bring this person to life so one of the reasons for asking in the first or second interview to describe people in your life is to see whether the person thinks in all good all bad categories or blanks out or whether they can really bring a person to life the same is true for their self description well if I do hear that they have only you know stereotypes uh of themselves and other people I try to drill down on that a little bit as the CBT people say and and see if they can mentalize at all meaning that's Peter F's word for really getting the separate subjectivity of other people or what philosophers call theory of mind I I say do you have any sense why your mother behaved that way what do you know about her history identity integration uh is an important concept because you know that if the person has it you can assume a pretty good Rel relationship as long as you're trying to do your job well you know you're going to screw up but you know that they're going to be able to say ouch I didn't like what you said I think that's wrong uh or they're capable of that anyway there are a lot of implications of whether the person has identity integration or not it's pretty similar to kohut's idea about identity diffusion as being a problem yeah it's the person feels easily fractured and confused about who they are um you say to a patient with identity diffusion how are you experiencing me right now um You Look troubled well I don't know I'm just very confused I are you calling me a bad person they can't stay with you and I are working together on a part of myself that's been giving me trouble it's like uhoh you just fractured me into a million pieces and I have to pick them up it does um Orient me toward not necessarily spending a lot of time at least early in treatment talking about their difficult past because very often they think about that past in terms of heroes and villains and persecutors and victims and it's hard for the therapists to know exactly what happened it's better to work in the here and now when you get this it's like how are you feeling toward me right now when I said that you looked like I had really criticized you um do you get that I was trying to give you something helpful even if I did it clumsily and you can work with that but if you work with somebody who doesn't have that they could you know decide you're a persecutor and walk out of treatment or they could get really compliant because they don't want to get on your bad side and a lot of therapists are not trained to feel the difference between a patient who's being compliant and a patient who's really working with them as a collaborator in this process when we work with a borderline patient we make them a much more competent adaptable self- soothing person with a very intense psychology that's never going to be easy for them at the psychotic level you know if it were just a developmental thing you'd think that they would start looking borderline when they're starting because that's the next step up but that isn't what happens what happens is they become a very well-compensated person who is dealing with a lot of an you know Annihilation anxiety but doesn't have to be delusional anymore to do so um so in terms of the levels um you want to help people become a better version of somebody at that level in terms of the types there's an old psychoanalytic Chestnut uh you can change the economics but not the Dynamics meaning you can help um an obsessive compulsive person uh find much better ways to deal with anger than let's say rituals or um various kinds of intrusive thinking but you're not going to turn that person into a hysterical person or a depressive person they're still going to be obsessional organized they're just going to be a much more flexible have much more range be able to use a much wider group of defenses not feel quite so um rigid I think think if you approach a patient with the idea oh we can get this completely eradicated whatever it is they wouldn't believe you it's it's realistic but it in it may feel like it doesn't match with the therapist fantasies of total uh transformation of somebody else but for example with a traumatized person you're never going to be able to make them a person who wasn't traumatized but you can help them become um not so much self-defined as a trauma Survivor as a person who happens to have had trauma in their history and who's coping with the consequences of that very well I think we all wish we could turn them magically into somebody who'd never had a trauma but that's not going to happen and they know that any closing words to students of therapy I think I would recommend that they read all the stuff stuff and then forget it you don't have to have all this in your head in order to be a good therapist basically you have to care about other people be humble be interested in them want to help them set a tone where they can correct you when you stumble you're the process is going to move forward and if it doesn't then you get a consult with somebody who can help you figure out whether you have made a misdiagnosis and missed something or whether you're a bad fit with this patient or whether it's just taking a long time okay I'm very grateful for thisy thank you so much you're very welcome this was fun okay perfect it's fun to just mouth off about things that are important to me for a long time well I I glad it's fun for me too

Channel: Picturing It With Elliot

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Id: NNvTjWKa5VQ

Length: 69min 2sec (4142 seconds)

Published: Sun Jan 07 2024