Transcription
Hi, hi. Why are you running so late? Uh, let's see. Um, well, you don't have an answer. You're just going to sit there and be five minutes late? That's ridiculous. Uh, you thought my not answering right away was 'cause I wasn't going to answer? I mean, I don't know why you didn't answer. That's what I'm asking. But it's really annoying that I wake up early and come see 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 took a minute to to think, you thought I was like just being like wasn't going to say anything. Well, I was waiting in the 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 did, 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, it was your session and I just had something in priority. Yeah, is that what happened?
Well, no. Um, but I'm, I'm, I'm going, I'm still pausing on how that must feel like to think that with 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 you, I kind of get the picture more. It's the same thing my parents do. It's the same thing Tom does. Everyone does that. I'm no one's priority.
Yeah, well, uh, 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 well, why don't you just say sorry and we can move on? Well, 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, I just, you thought that my not immediately saying sorry, let's move on, was another way of just not caring about you? That I was just, my mind was elsewhere?
Well, if you cared, you'd just say sorry and be interested in how I'm doing, because 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 trying to exactly put together, you seemed a little angry, which I understand. So when you asked me a question, I, I took a minute 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, which I thought that you didn't like me anymore and you were not coming to the appointment 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.
Well, [Music] um, 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 do you want me to 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 when you weren't there, when you said you were going to be there.
Well, um, but did I ever say it was not okay to be mad? Okay, so I'm mad. You're fine with that? Okay. I'm, what, you're fine with that? I can just be mad at you? No, that's, yeah, sure. Uh, 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, 'cause I don't want you to be mad at me. Everyone's mad at me. But what, what were the signs right here that I was some being a [ __ ]? I'm always a [ __ ]. Oh my God. Okay, I'm sorry. Can we just move on?
Well, we could, but that's pretty, I mean, if I were just sitting there feeling, "I'm always a [ __ ]," I 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. It's rude.
Well, isn't that why we're here? I mean, that's the kind of reaction that seems related to almost everything that goes so wrong. So, um, slowing down can help. I mean, you really felt you needed to apologize to me. Yeah, I'm a bad person. I'm not nice to people and I just feel bad that I did that. I just thought you were leaving me. I thought that we weren't, you weren't going to come and you were ready to more or less chop my head off.
Yeah, well, I like [ __ ] it. I'll just leave and he can wonder where I am. I'm wondering where he is. That I know now. That's like mean, 'cause 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. At who? Right. At myself. But you were pissed at me a minute ago. I know. Yeah. Okay. What happened to that? I realized that I shouldn't be pissed at you. Things happen. Maybe you had something else to do, more important than me. There's a lot of other things in the world that are more important than me. You know, I understand 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 sound 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, philosophically, I think one might think there were more important things to the world than oneself. But the way you said it, it sounded like you don't count at all. I don't. 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, if 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, are you just assuming we don't? I'm putting me and Tom and 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, and 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 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. Who am I supposed to talk to?
Well, okay, you were there. Uh, 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, 'cause now I know you care 'cause you're sitting there and you're listening to me.
Well, do you care? Um, uh, 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 is if I were just to say, "Yeah, I care," that wouldn't stick for very long because people have said that to you and you 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 going on in your mind?
That's an inappropriate question. Why are you asking your therapist that? You got in trouble for asking your therapist that in the past and crossing boundaries. Why are you doing this again? You're a 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, and your eyes turn away. And 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?
MH. Yeah. So you seem to be hearing me now. Is that kind of 'cause you get it? That's how I feel.
Well, I'm glad 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 to have an impact. I don't know.
Yeah, because you kind of go running with something up here. Well, that's what Tom said. We went to dinner 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 my call. 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, um, dishonest. To be, I mean, he's probably at work, but there's, 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've known of how long now? Almost two years. Uh-huh. But I think it's, I think it's almost over. Well, yeah. Well, that sounds like it could be a crisis. But, uh, I just wanted to say, in the two years, have you had like solid evidence of his lying? Not with him, but with other people in the past. He, I mean, I, I think he's lying, but I've never really caught him lying. I've caught other people lying a lot.
Well, I'm sure it's painful to think he's lying. But, uh, well, tell me about the, "it's almost over now." What's, what's going to lead, what would lead to that? Because right now, I really do think he's lying. I don't know what. He seems distant, just like you seemed distant at the beginning of the session. Everyone just pulling away.
Okay, let's put a few things together. You said you had to end of therapy. 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 some. I mean, I wasn't committed to other therapy, so I ended up quitting. But 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. Well, 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 and maybe they don't want to be with you. Although, you know, there's evidence both ways.
Well, I'm sure there's evidence both ways. But 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 and didn't think about you, we probably wouldn't be continuing this very long, would we? So I'd like to know how the doubt comes in. What, what leads to that? The doubt about your negative assumption.
I was about to leave because you weren't here. Yeah. And then you were here. So all my thoughts about, "He's never going to 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 'cause you can't stand being in room with me for 45 minutes, or your kids needed something, or another patient's more important than me.
Yeah, suppose I just wanted to stop or cut short the. What, what would it be about you that I'd want to just get the least possible of, to just have the least exposure to? You don't know how to help me. I'm a lost cause. Uh, no one knows how to help me. I'm never going to 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 going to do for 45 minutes with this girl that just can't get better?
It 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 me that any change in my demeanor that? Well, last week our appointment, I did at 4:45 and I got into my car and it was 4:44. And this week you open 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.
H. I have to pay attention. Um, but do you want me to tell you when I'll keep my eye on the clock and I'll tell you when 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 be in the relationship fully because you're kind of checking on it all the time.
Well, I'm sick of being left by people. If people are going to leave me, I'll just peace out on them first. It's 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? But let's go back to what we said here a minute ago. Um, I'm, I've become hopeless about you. And you've concluded that because I ended the session a little ear.
Well, can we go one minute late today? Yeah, okay. Right. Um, but, uh, if I, um, if I'm hopeless about 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, I have no hope, but I'm just going on as though I still believed in. What would that imply 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 ini, it would imply I'm not being honest with you. You're not being honest. Honest. And you're anxious for what's going to happen if you, if you let me go because I'm not a stable person.
Well, let's look at those things. What would happen to your career if that happened? Yeah, but let's look at those things one by one. That would suck. I, I'd actually 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 don't you just tell me you're honest with me?
Well, I mean, that one, I, I will answer because I, 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, and just try and help you decide if it's maybe an inaccurate 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 when Mary's going to end the session, but anyway. Um, the other thing, do we have? Oh, well, Mary, never mind Mary. Do we have five more minutes, Mary? For this? Oh, Mary's not listening. This, okay. You know what? She's the one who does, who hands all my sessions early. Mary, you don't care about me. No, no, she doesn't care. No one cares about me. She doesn't care about any of you care about me. She doesn't care about me. Oh, I'm so. How are you? [Laughter] Doing? No, let's go back. Um, so you were thinking if this treatment goes badly and you quote, do something. What was the do something of this curri? What you, 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 about cutting your wrist. Yeah. Right. Threatening. Well, I'm glad you got to 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 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, um, how while you, you know, very convinced that other people are not really interested in you and can treat you badly, but you know, there's a little bit of you that would, uh, 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. Well, to say they're ridiculous things implies they are no meaning, they have no meaning and they're not worth thinking about. I think that I just really want people to 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 would they like me? Well, what do they like? That gets back to you're saying you're a [ __ ]. Yeah. I, you ultimately, that's kind of what we should be thinking about. But, you know, all this, uh, St and all this turmoil, you know, about other people almost seems to take us away from that conviction you have. If, 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 don't know you. Or if they do, you better they'd agree with you. So we've just got to clarify some of the ideas that are coming out. But you were going to tell me when the session time was up.
30 more seconds. Okay. Um, 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 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. Do you want me to say a here? Go back to? Should we stay here and you could have questions for both of us? Yeah. So all is all right. Free. Okay. Comments? Questions?
Isn't this mentalization based treatment? Well, Joel, it is, except we've been doing it since the 80s. So if it is, uh, 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, I should add though, I do think that TFP in, uh, the phase we call clarification incorporates most of what's done in mentalization. I think the differences come later in the treatment because I, I find that mentalization doesn't deal as much with internal psychic 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 bad object? The person's own identification with their aggressive and hostile feelings. From what I understand about MBT, that's referred to as the alien 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 sublimator 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, internal psychic conflict, conflict within the mind, and dealing with how to integrate aggressive and hostile feelings.
Yeah, I, I found interesting to see how you stuck with the present, just watching you and you mentioning her foot shake or her her general affect and and and realizing how difficult it can be to do that when someone is wanting a reaction out of you. It was just useful for me because I've, 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'm glad you w 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 she's saying about Tom, what she's saying 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 tried to explain, we think that what is being felt between the two is the most like, is the best channel for gaining some understanding. Poor Katie is stuck with the self-hatred. But we don't see self-hatred as 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 into 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. Yeah.
Oh, yeah. We got somebody in the back and then a couple of people here. Um, thank you very much for that, uh, demonstration. And I wanted to know what you do with, uh, countertransferential feelings 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 right. 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 communication: the verbal content of what the patient's saying, all the non-verbal information like the leg shaking and just the atmosphere in the room that's created, and then our countertransference feelings that are evoked in 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 within 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 and 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 any, any body's interested in learning more about TFP, Columbia Psychoanalytic Center, 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. But does that answer the question about? Thank you. Yeah. Okay. Oh, just hold on a second. Valerie. Yeah. Yeah. One of the experiences you have with someone with borderline personality disorder is they do have changes in thoughts and feelings very quickly. And sometimes that can be a defense against working on particular issues that are uncomfortable by just sort of always changing the ground so that there's no opportunity to really reflect and work through anything. So I guess one question is, how do you kind of deal with that tension of what you know, staying in the moment, following the, letting the patient guide things, versus sort of saying, "Well, 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, end where you kind of summarize and say, 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, 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 abrupt and, 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 was saying, "Well, you know, wait a minute now. Now you're beating yourself up. At the beginning of the session, you were 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. Uh, we tend just to leave things where they are and continue the next time and hope the patient. I mean, if the patient is 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, Mary? Or two? Okay, two brief questions. Yeah. Lavi and Val. Just really quick with regards to, um, mindfulness and just, I was struck with how mindful would move a practitioner into the capacity to hold that neutral stance and with the non-judgment. And I just, it was really neat to again be able to see that connection. Can you speak to that?
Well, only brief because I'm not so, uh, informed about mindfulness. The only thing I would say about mindfulness, if I understand it, which is not too likely, um, I thought mindfulness put you in touch with the moment, but without sort of being 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. Yeah. Okay.
Um, I just wondered, um, 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 work with her for this period of time and she still seems to be angry and closed off. How would you feel yourself about that?
Say I was cold. No, no, no. I don't mean you. I mean, how would you feel, Frank? I think Katie's remark was great because sometimes external reality. But anyway, no, I mean, I would have, in an ideal situation, tried to do more of what I did do. Was 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 so interested in 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.