Episode 205: Beginning Treatment with Jonathan Shedler, PhD

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Article Authors: Jonathan Shedler, PhD, David Puder, MD

In this podcast titled Beginning the Treatment, Drs. Puder and Shedler discuss the crucial first sessions with a new patient. Dr. Shedler emphasizes the importance of establishing the therapy “frame,” or the arrangements necessary to do the work of therapy and give it the best chance of success. Part of the frame is a consistent appointment schedule, which provides the continuity to address underlying psychological issues, and the predictability and structure that allows patients to truly open up in therapy. In this portion of the interview (transcribed and edited), Dr. Puder and Dr. Shedler role-play a session with a new patient who has been missing appointments.

The discussion began with Dr. Puder asking about how to handle patients who exhibit avoidance, such as those who miss appointments, or are reluctant to commit to weekly meetings. He asked Dr. Shedler about his approach to patients who show a higher level of avoidance or hesitation.

Shedler (00:24:08):

Part of what we want to do in therapy is create a space where it becomes possible to hear from  all of the different facets of the person, including and especially the ones we don't usually get to hear from in words. So, let’s think about the patient you mentioned who agrees to come weekly, then starts missing sessions. What does it mean? Well, we hear from one part of the person in words: I want to come weekly, I want to do this work. Another part of them is communicating loud and clear, except not in thoughts and words. It’s communicated in actions, by missing sessions. We work to put words to what's being communicated. We might say to that patient:

Shedler(00:24:08): [role play begins]

I understand part of you wants to be here and agreed to come weekly, but I think another part of you is communicating something else, not in words. I wonder if we can start to hear from that part… the part that would prefer not to come here, or would prefer not to come here so often. I wonder if we could hear what that part has to say.

Puder (00:25:33):

Oh, no, no, no. I, I was just, uh, I just got really busy and, you know, I know I missed three sessions, but that's like, you know, I was busy and I was doing things, and I just, I honestly just lost track of time and I just, you know, I forgot.

Shedler (00:25:52): I understand that things came up and you lost track of time. But, you know, one of the things we learn as therapists is that there are layers to our experience, and things can have a lot of meanings, not just one. Three times in a row suggests there may be something more going on that deserves our attention. And yeah, I understand, something came up this time, and something else came up the time before, and so on. There are external things that can get in the way. But I think there may be more to this than meets the eye. And I wonder if, instead of sort of batting away my curiosity…

Puder (00:26:55):

Well, you know, I paid you for the three sessions and I, I apologize. I don't, I don't know… nothing is coming to my mind…

Shedler (00:27:04):

Let me interrupt for a moment, because I'm not looking for an apology. I understand you paid, it's not about that. It's about—and I could be mistaken, I'm open to understanding it differently—I think there may be a part of you operating here that's communicating something, not in words but in actions. And I wonder, because I notice that you batted my comment away very quickly when I said, maybe there's more than meets the eye. And you're like, “no, no, no,” very quickly. You responded so quickly, there was no time to take in my comment and let it sink in, give yourself some space to think, see where your thoughts go. There really wasn't space to notice what other thoughts, feelings, images, memories, whatever, might have come up. And that's why I'm suggesting that perhaps there's something more to understand here, and there could be some value in making some time and space to see what we can understand.

Puder (00:28:48):

Well… one thing that comes to my mind is when you shut the door at the end of our last session, you shut it louder than usual. And, I thought that you were really glad to have a door between us, especially after what I shared last session, which I feel embarrassed about sharing.

Shedler (00:29:18):

Say more about that.

Puder:

<laughs>

Shedler (00:29:21): [commentary on role play]

I know it's hard in a role play, but this was an important moment. The patient has just made a shift. He went from, it means nothing, I just lost track of time. To, this might have something to do with my feelings about the previous meeting. And two things are already emerging. The first is the patient’s concern that I don’t want to see him, that I was glad to be rid of him. He’s feeling rejected, feeling that I don't want to be here with him. That's really important. The second thing is his sense of shame about what he shared with me.

The shame is tied to the feeling of rejection. He told me something that feels shameful. And the underlying concern in the background is that I think ill of him for it, that I’m judging or criticizing him. But I don't want to rush in with that interpretation because it's too soon. The patient has just put these ideas on the table for the first time. It's new, they've only just put words to it for the first time for themselves. It hasn't fully sunk in.

So, think about what we do in psychodynamic therapy. The three major areas of technique are clarification, confrontation, interpretation. Interpretation comes last. Clarification means we want the patient to elaborate. We want them to say more, let it come into sharper focus, let them feel it. We want it to become palpable in the room. So I want him to elaborate on this feeling that I was glad to shut the door on him. That he felt ashamed of what he told me, that he’s filled with worries, concerns, fears about what I think of him.

Let’s jump back into the role play, because I just condensed a lot of the work of the session right there. But once the patient has elaborated on these thoughts and feeling and they’re out in the light of day, then I could say something like:

Shedler: [resumes role play]

No wonder you weren't thrilled about coming back for your appointment. If you felt that I was glad to be rid of you, that I couldn't wait to shut the door in your face, why would you want to come back? It makes sense that you wouldn’t.

Puder (00:32:05):

Yeah. It, it just, um, it's really so it's like, it's like weird because I was thinking about it all week and, uh, I even had a dream about it. It's weird to, to obsess about how loud you shut the door all week. I feel silly for even imagining that was, I don't know, that I cared so much or thought about it so much. That, that feels silly to me.

Shedler (00:32:37):

It feels silly that you want help? That you came here for help.

Puder:

Yeah. I mean, you know how… [trails off]

Shedler:

It feels silly that it's important to you. That this matters.

Puder (00:32:55):

Yeah. It feels, it feels important. Yeah. And I guess I didn't want to, you know, talk about this because I felt like the more I talked about it today, the more likely you would fire me or something. I couldn't help but see, like a, a frustration expression on your face there. Were you thinking about firing me?

Shedler (00:33:24):

No, not at all. The expression on my face… you mean, just right here, right now? It wasn’t frustration, I was trying to formulate my words because I want to say this carefully. Because, first of all, you are right. This is important. You didn't come here for sport. You came here because you need help. It is important. And you told me some things that, well… I hear you judging yourself very harshly for the things you told me. And, I'm getting the impression that it, it's really hard to believe I wouldn't be judging you as harshly as you've been judging yourself.

Shedler (00:34:31): [commentary on role play]

Let me make an aside here, for those listening. What did I just do there? I interpreted a projection. I want to let everyone in on my thought process. The patient feels ashamed. They are judging and criticizing and condemning themselves. They feel they are bad and that's their internal experience. Another way to say it is, something inside of them is passing judgment on something else inside of them. But they're attributing that judgment, that condemnation, that shaming, to me. So what I really did when I said, “it's hard to believe that I wouldn't be judging you as harshly as you're judging yourself” is, first, I'm putting the experience into words. I'm describing what is happening. And I'm planting the seed of an idea, that the judgment is coming from inside them, not necessarily from me. So let's pick up the role play from there.

Shedler: [role play resumes]

It's hard to believe that I wouldn't be judging you as harshly as you're judging yourself.

Puder (00:35:46):

You know? I, um, I hear that from you. And I, I think to myself, well, of course that's the right thing for you to say, you know, that you don't judge me.

Shedler (00:35:57):

I notice we get into a bind though. Damned if we do and damned if we don't. If I do judge you, that just confirms your worst fears. And if I say, no, that's not what's going on, that’s not what I’m thinking, then you quickly explain that away, so in your mind, I'm still judging you. So, I notice, it puts you in a bind either way. But I wonder…

Puder (00:36:33):

But how could you not judge me for missing three appointments? Like, I would judge myself. Like, if I had a client who did that, I might, I might fire them. I don't know, if I had a client like that, I would fire him right away. So, um, no, I have a hard time seeing how… how could you not judge me?

Shedler (00:36:59):

Because I understand that you, and for that matter, everyone who comes to treatment, is really of two minds about being here. You've come because you're looking for help. But there's another part of you in the mix. A part that feels like, this is awful. No one would want to deal with me. My therapist wouldn’t want to deal with me. There are reasons why people miss sessions, do all sorts of other things to try to, try to protect yourself from things that are really pretty uncomfortable. It's difficult being here. I think it's hard for you to believe that when I bring up the missed sessions, I’m actually bringing it up out of curiosity, because I do believe there's something to understand, and that's part of the work of the therapy… getting to hear from the parts of you that we don’t usually get to hear from.

Puder (00:38:03): [commentary on role play]

Okay. I think that's good. I think, I think we can move on topics, because I'm a little bit uncomfortable with this. No, I'm joking. <laughs>. I'm like, it's hard to know if, it's hard to know if I'm still in the patient role or if I'm not anymore.

Shedler (00:38:16):

I’m interested in you observing yourself in the patient role. I’m curious what came up for you when I said, “It's hard to believe that I wouldn't be judging you as harshly as you're judging yourself.” What was your reaction?

Puder (00:38:40):

I thought to myself, at this point in treatment, you have a lot more context for understanding why I would be so judgmental of myself. And so I thought to myself, you know, maybe, maybe you are being honest that you have compassion and it's not just, uh, intellectual, the correct thing to say, you know?

Shedler (00:39:09):

Well, I mean, it's true. I'm not saying it because it's the correct thing to say. I'm saying it because it’s what I'm thinking. But your response is what I was going for, which is always to open space where it becomes possible to think and feel and experience and communicate more than before. We work in therapy to open that space. It's variously been called in the literature reflective space, or analytic space, or mentalization. It’s space to think and feel and reflect beyond what was possible before. So I'm trying to open space. Sometimes, patients are working to collapse the space. When you said at the beginning, “no, no, no, I just lost track of time. It means nothing,” that's collapsing space. I'm working to open the space, to think and feel beyond that. It’s just a moment in time but it had the desired effect; something inside you said, oh, maybe I could think about this differently. Like, maybe there's something more here than I realized.

Puder (00:40:29):

Hmm. Yeah. So, I did, I appreciated that.

Puder [additional comments, added after interview]

One way of understanding why this is such an effective way of doing therapy is to understand how, by asking certain questions, the therapist can increase “reflective function” in a client in the session and also over time with other core attachment figures. John Cologon and colleagues in 2017 published a pivotal article called “Therapist Reflective Functioning, Therapist Attachment Style and Therapist Effectiveness” which found that 70.5% of therapist effectiveness was linked to their own reflective function scores, as measured by Peter Fonagy’s “Reflective-Functioning manual” from 1998. It assesses the depth of the therapist’s reflections of their own and other’s internal emotional processes, scored from the transcription of the therapist’s Adult Attachment Interview. In Dr. Shedler’s questions, you can see him working to increase the internal reflectiveness of the patient around the attachment with the therapist.

Shedler (00:40:32): [commentary on role play]

To circle back, you asked how I handle it when a patient wants to come only every other week. This is how. Before I jump into making a decision, I want to go through this process with the patient. It’s working with defense and resistance. There are good reasons why the patient is on the fence about coming, and they need to know I understand that. There’s discomfort. They’re trying to protect themselves. Part of them hopes for help, part of them wants no part of this. We need to hear from all the parts because if we don’t, the parts we don’t hear from will start running the show. So my preference is not to make a decision before the patient and I understand what it is that we’re really deciding.

What makes the person want to come weekly? How could it be of value to them, what could we do together here? Like, what happens if they come weekly? I don't want to tell them, “this is the work we’re going to do.” I want to show them, by actually doing the work. And the patient thinks, oh, so this is the experience of being in therapy. Oh. This is a little different than what I thought. Like, this does feel useful to me. That's where I'm trying to go.

So, the therapy frame is not about following rules. We don’t say to the patient, this is how we do it, my way or the highway. We say, these are the conditions that will give us the best chance of working in a way that will be helpful to you. But I understand some of it doesn't sit well with you. Let’s talk about it. Let's talk about it all. This is all part of the consultation phase, where we sort out what we are here to do, and how we will go about doing it.

Puder (00:42:18): [commentary on role play]

I love that. I love it, because it's like, it's not jumping prematurely to tell me what's going on. Okay, let's go, let's go back into the the role play.

Puder: [role play resumes]

Yeah. So I was afraid, I was afraid, um, Dr. Shedler, that you were going to, you were going to fire me. And one, one thought that came to my mind right now was, I had a previous therapist and it never really got off the ground. And she, uh, the therapist said something like, I wasn't idealizing her enough. She didn't use those words. It was, it was like, um, she said, most of my clients who come to see me, they know who I am. They know what they're getting into and they don't have any hesitation. And she said that I felt too much hesitation.

Shedler (00:43:18):

That doesn't sound very good at all.

Puder (00:43:21):

Yeah. It was, it was very, um, it felt, it felt a little bit like, uh, it felt rejecting and, and, not allowing me to explore my, my hesitation.

Shedler (00:43:36): 

Well, I think you're right. I mean, it didn't leave a lot of room for you to have your own experience. And I'm just imagining, trying to imagine myself in your situation, and it must have felt like shit to be spoken to that way, treated that way.

Puder (00:43:57):

I, um, yeah, I felt like it was a, a little bit, yeah. It's almost like I'm speechless right now thinking back at that. Because it was, it was so painful.

Shedler (00:44:12):

I can imagine. So, that sheds more light on things. I mean, no wonder you're of two minds about coming to your sessions here. You don't want a repeat of that experience.

Puder (00:44:34):

Yeah, absolutely that. I think, I would hope there's some part like we just did earlier, that we could explore if I was hesitant, that's helpful to me.

Shedler (00:44:55):

I would like to do that also. And it sounds like you absolutely did not experience the previous therapy that way. What I would like to do here, I would like to be able to do things together in a way that makes it possible to talk about anything here.

Puder (00:45:17): [role play ends]

That's good. Shall we move on from the role play? We'll have to get a vote from Twitter to see if people want us to continue more role plays in the future.

Puder: [additional comments, added after interview]

As providers, we often have intellectual knowledge, like therapy takes time, and depth work will create the desired long-term changes patients are looking for. However, patients might be hesitant for a variety of reasons and not want to engage to the level necessary for the changes they desire. Dr. Shedler masterfully creates a reflective space to allow for exploration of unspoken things going on between the patient and the therapist, and also historically what went on to create a bit of hesitation as well. You could see empathy in Dr. Shedler’s responses, but I also felt him as a real person responding with authentic and not staged or rehearsed lines. Lines like “it must have felt like shit to be spoken to that way, treated that way” or “that doesn't sound very good at all” come off as a real reflection of Dr. Shedler’s congruent reaction to hearing about the experience with the previous therapist, who seemed to expect idealization and no ambivalence (in this case, a real story about myself with a prior therapist with whom I was starting treatment). In the real encounter I had with a therapist like this, I was myself trying to be honest about my ambivalence, an honesty that was not met with curiosity but rather rejection. When Dr. Shedler gave me his reaction to it, it felt authentic and humanizing, not only of how I viewed him, but also of how I viewed my own prior experience of ambivalence.  

In another portion when Dr. Shedler pointed out, “It's hard to believe that I wouldn't be judging you as harshly as you're judging yourself,” I experienced this both as empathy for the reality of what was transpiring between us, but also revealing that perhaps the judgment is not from Dr. Shedler, but something deeper in me that I could look at. Further, perhaps his tone and overall curiosity and openness to explore what might be going on led to an internalized reduction in shame that allowed me to experience this as something that did not make me bad, but rather something that might be looked at with curiosity and understanding.

There was also another interesting shift that occurred in me, and I am curious to hear if others listening had this experience, who have followed Dr. Shedler for a while on Twitter and his writings. The dialogue seemed to shift my conception of him from just an intellectual giant to someone who seemed three dimensional, multifaceted and warm. The curiosity and wonder with which he approached the dialogue seemed void of judgment and harshness, which shifted or increased my sense of depth of him as a person.  If you also enjoyed this podcast, tag us both in a tweet (@davidpuder and @jonathanshedler) or send me a message here. 

References:

Cologon, J., Schweitzer, R. D., King, R., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style and therapist effectiveness. Administration and Policy in Mental Health and Mental Health Services Research, 44, 614-625.

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual version 5 for application to adult attachment interviews.