Episode 234: Transference Focused Psychotherapy, Borderline Personality Disorder, Narcissism, with Frank Yeomans, MD

Podcast Host: David Puder, MD

Transcription Editing: Al-Baab Khan, Joanie Burns

Reviewer: Erika Vega, MD

By listening to this episode, you can earn 2.0 Psychiatry CME Credits.

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Dr. Yeomans is the President of the International Society of Transference-Focused Psychotherapy (ISTFP) and is a leading figure in the development and dissemination of Transference-Focused Psychotherapy, an evidence-based psychodynamic treatment for personality disorders. He has co-authored several influential works on TFP, including:

• Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide (2015).

• A Primer on Transference-Focused Psychotherapy for the Borderline Patient

His work emphasizes the importance of understanding internalized object relations and their manifestation in the therapeutic relationship, aiming to promote personality integration and symptom reduction.

David Puder:

I thought we'd start and talk about what is, maybe for those who are less familiar and we're really speaking to an audience here of mental health professionals, people in training. They've probably heard about transference-focused psychotherapy [TFP]. I imagine they all know what transference is, but I'm hoping, in this discussion, to pull out some of the nuance of the uniqueness of the approach. On the podcast, we've talked about reflective function and how transference-focused therapy uniquely improves reflective function [see also episode 213]. So I'm wondering if you could introduce broadly transference- focused therapy and where it is today in terms of research.

Frank Yeomans:

Certainly, I'd be happy to try to do that. It might turn into a lengthy answer, but when you said that, going back to your statement, most people are familiar with transference. That's probably true. But there's also a common misperception, misunderstanding of transference, which is that it's the past being repeated in the present. That leaves out the mind, because what is actually being activated in the present when transference occurs isn't an accurate version of what happened in the past. It consists of the activation of mental images, internal representations of people, experiences, relationships that are laid down as memory traces in the mind, but often become modified and sometimes exaggerated by the processes of the mind and unconscious processes that we think about when we think about a psychoanalytic approach. Or there are fears, there are desires, or anxieties. All these have an impact on the way the memory traces are laid down into the internal representations.

So when I talk about transference in general, I'm gonna refer to the title of one of Kernberg's early works, which is Internal World and External Reality. The idea is that in the course of the development of any individual, they internalize images, as I said, representations of themselves interacting with others. These become paradigms or templates for later experiences. So transference is first of all, it's a universal phenomenon. We all transfer onto each other. Anytime I meet somebody new, my first encounter with you, there are traits, aspects of you that will activate in me, memories of, and this is largely unconscious, but you know, I'll think of, you know, “He kinda reminds me of X, Y, or Z.” So I'll project onto you characteristics that may or may not really fit who you are. The challenge in adapting to reality is taking in who the other is.

So you get a precise, an exact sense of them that might be different from your initial reaction based on some kind of images that are activated in you. So it might help at this point to give, what I think is a fairly dramatic example, and it's actually the clinical experience that convinced me to work with this approach. I had just finished my training as a psychiatrist and was working at a hospital, but also started a private practice. And one of my first patients was a man with a combination of borderline and narcissistic personality disorders. We can talk about each of those later if you'd like. But in any case, like a lot of patients with narcissistic personality disorders, he had kind of an angry, aggressive, devaluing stance toward me a lot of the time. He was kind of a tough cookie, to put it in plain English.

In any case, in one session, this guy who was usually angry and critical told me a story that's of something that happened to him when he was a kid, five, six years old. It's a very sad story, and it brought tears to my eyes, which is not what usually happens when I'm in a therapy session, but can happen anyway. So he noticed that, and he said, you have tears in your eyes. And I simply said, yes. I didn't know what else to say. Then he looked at me very closely, he kinda scrutinized me and said, in all seriousness, he said, “You are mocking me.” So that is an example of transference where the internal representation, the other who is mocking you, so prevailed over what seemed like kind of clear evidence to most people that I was sympathizing with him, that his transference onto me was what we call a paranoid transference.

“The other person doesn't like me,  is critical of me, is mocking me.”  And if your transferences are so strong that they prevent you from getting an accurate take on reality, then it makes it hard to adjust to life and to have success and satisfaction in life. And our patients tend to have those kind of distorted transferences where the internal image prevails over the external data that they're taking in. So in a more typical case, it's the patient who just assumes when you look at the clock to know when to end the session, that you hate them and wanna get rid of them. And that's a transference triggered by a minor external event, but leading through a massive projection.

Puder:

Can I ask you about this? So his comment, he said, “You're mocking me.” He's seen you. You're feeling emotionally distraught. So he's unable to empathize with your true experience. His reflective abilities about you and what you're really doing are off. Very off. Right. Was the paranoid transference there, the fear that you're mocking him, was that tied into the actual trauma of what happened to him when he was five years old? Like was in that five-year-old instance of him going through that conflict, was there some aggression maybe that was disavowed and now is pointed at you, his therapist?

Yeomans:

I think that's very likely the case, but it is a good point to bring up because a lot of therapies, and this is one way in which transference focused psychotherapy differs from more classical psychoanalytic psychotherapies, a lot of therapies would jump to the past and say, “Oh, in that experience, did you feel your parents (who were the people involved in the interaction, as I recall), you know, were criticizing you unfairly, putting you down, mocking you?” Then, let's try to distinguish then from now. In transference psychotherapy, we would consider that focus on the past to be an avoidance of what's happening in the here and now, because we think it's more effective therapeutically to work with what the patient is feeling in relation to you. Rather than say, “Hey, let's look at the past 30 years ago.” So you can, let's put it this way to say, “Okay, you know, you took in these ideas that people were supposed to care for you or mocking you because your parents seem to have done that.”

Yeomans:

This man is going through life on a daily basis, misperceiving others. So we do not try to correct the distortion. If it would work, I'd be happy to correct the distortion. I'd be happy to say to him, “No, please trust me. You know I'm sympathizing with you. I'm not mocking you.” But it doesn't work to say to somebody who's incapable of trust to say to them, please trust me. They're not going to. So you have to enter into the projection. You have to be able to carry the projection so that you and the patient can look at it together. So instead of saying, “No, please understand, I'm not mocking you.” My response, I mean, this was ages ago, would've been something along the lines of, “That sounds like a terrible experience to come to therapy for help and to wind up with a therapist who's mocking you. Let's think about that together. I'd like to hear more about that.” First of all, your willingness to entertain the negative projection, the negative transference usually is an implicit sign, “Maybe you're not so bad”,  because anybody who's really negatively inclined to would've said, “Oh, no, no, let's not go there.” So my willingness to say, “If I'm mocking you, let's think about it”, opens up reflection.

Puder:

Okay. So, how would you feel if I pretended to be this patient? And we kind of go into this scenario right there and see what happens.

Yeomans:

We can give it a try.

Puder:

Let's give it a try. Okay. So you, you had just said to me that statement, so I'm gonna go from there. Okay. 

Well yeah, I'm here. I'm paying money to be here. And like, I'm telling you this awful, awful event that happened to me when I was five. And all of a sudden, like, you're like mocking me. And I'm just like, what the heck?

Yeomans:

Well, I guess it's not just at age five, but right now your life is full of really awful events, including what's happening between us. And I can understand your depression when a helper, or a so-called helper, seems to be the opposite. It must be awfully frustrating to seek help and to encounter the opposite--  mockery.

Puder:

Well, I feel like, you know, somehow you're doing this kind of psychotherapy gymnastics around me right now, but I can't believe I caught you mocking me.

Yeomans:

So I'm trying to weasel out of what, in fact, I think  of you really, which is kind of a negative critical mocking stance. So I'm trying to put the veil over that and retreat to my pretend position of sort of being a concerned caretaker. That's what's going on.

Puder:

Yeah, exactly. Like how, you know, I tried to call you and then it took like three days to hear back just the other week. And, this is just another example of this. It's like, if you really cared, you would've called me back that day. I was in absolute crisis.

Yeomans:

So it's important that this is coming out so clearly now. I guess you felt this for a while, but didn't bring it up. And again, I wanna try to sort this out because it's a pretty sad situation in life when even the person who's supposed to help turns his back on you, doesn't care enough to call back. And now it seems like the kind of mockery you see in me has broken through. One thing that's implicit in all of this is the view that I'm dishonest. You know, maybe we should think about that because you seem to feel that I'm pretending to be one thing and I'm really another. Let's open that up, please.

Puder:

Yeah, I mean, there's part of me that's like, I know a couple weeks ago I wouldn’t have, I think, I don't think  I thought I saw you that way at all. I thought you were the greatest, you know, doctor ever. But somehow, all of a sudden, it seems like you're just like all the other shitheads in my life that have preceded you.

Yeomans:

Yeah, I can see that. That's confusing. And I do remember when you seemed, you know, to think I was a good guy. So therapy is about trying to figure out things that are confusing. Maybe you've figured out or decided once and for all that the good guy thing was nonsense. And that, you know, I'm like everybody else: I don't like you, reject you, internally, mock you. But on the other hand, this seems to be a little bit of that first part, which by the way, might not be the whole story either, because that seemed to be a little too good to be true. But in any case, I think you're struggling with something. It's not totally out in the open what you're struggling with. 'Cause I think it's not fully in your awareness, but at the same time that you have this negative feeling toward me, you're still coming here. So that's kind of contradictory and we should work to figure out how to sort out that confusion.

Puder:

You know, I haven't told you a dream that I had this week about you, and I think it might relate. I had a dream that we had ended a session and I had left, but the door was cracked, and I overheard a phone call with you and some colleague on the phone, and you were laughing about me with this colleague. And then when I woke up, I felt like it was so true, like it actually had happened, but that I was, I felt just absolutely betrayed. Yeah. That was the end of the dream.

Yeomans: 

When did you have the dream?

Puder 

Last night.

Yeomans:

Oh, just last night? Okay. Well, it seems like it's the same thing as what?

Puder:

What we're talking about.

Yeomans:

Yeah. You feel it has materialized here. Then, in spite of my, what you see as a facade of interest in you and wanting to help you, that in my mind, the honest reaction I have is to think you're kind of a pathetic human being. And you know, like I say, talk more about that.

Yeomans:

Well, lemme just say, you know, because what I'd like to do is, I'm trying to understand what in your mind would lead to my thinking, “You're a pathetic human being.”

Puder:

Oh, I mean, I think it's like a deep fear, you know? I mean, and you know, when I was, some of the early situations that I had where I felt some level of betrayal.

And I think it's a fear that I have.

Yeomans:

Being betrayed and being pathetic are not exactly the same thing. I can understand your feeling betrayed, but what I see now is a kind of feeling pathetic. Where, you know, we've seen so many instances where you disqualify yourself, attack yourself, put down an effort you've made. And I think what's happening between us, as you see it, goes on in your mind – within you – in other words, you against you– the way you see me against you right now.

Puder:

Hmm. Yeah. And so I think I'm confused because it seems like you're not against me right in this moment. You're curious about how I'm observing you. 

Yeomans:

Let me just finish Yeah. That I say that is another possibility. It's very important to figure out which of the two possibilities seems more real. 

Puder:

Well, I think I'm curious 'cause you've done this a lot. Like what would the patient say at this point? Would they soften, you know, in their kind of observations? Would they get more reflective? Would they dig in?

Yeomans:

I would say more often than not, no. Because defenses are very strong. When I say defenses, I mean, especially when we're talking about people with borderline level personality disorders, splitting defenses where–which we should discuss at some point–the person can't get in touch with their own aggressive feelings and sees all the aggression in the other, as this man is seeing all the aggression in me. I'm trying to get him to see there's some aggression in him. Which in fact, he turns against himself. But to answer your question about what patients usually do. Usually, they say, “Oh, you're just,” you know… what will they say? “You know, you're just running circles around me. You're just trying to use the psychobabble to cover up what I know is true.” So you can't expect every intervention to lead to increased insight, but you just have to continue with it, stay committed, and assume instances like this will happen again and again.

Yeomans:

And when you're lucky and you've accumulated enough mutual experience, one of those moments will lead to the person thinking about what you're saying and beginning to reflect and take it in. We have some research along those lines. One of our colleagues, Yogev Kivity and his other researchers published a paper about what leads to change and to the reflective functioning you mentioned. And it is what, in his paper, he calls “bids for reflection.” In the traditional TFP literature, we call it “confrontation.” A lot of people say that's not a good word– It applies to a hostile confrontation, but it really means doing what I tried to do with you in the clinical vignette. Say we've got this and we've got that, and they don't seem to fit together. How can we reflect on them? So, short answer to your question is most years the patient continues with their defensive projection, but if you keep going, eventually they begin to reflect.

Puder:

Yeah. Oh yeah. I think it's okay. So I think there's a couple things that I was trying to embody: the idealization early on in treatment and then this kind of became the devaluation, right? So I think this is a lot of what clinicians have seen. It's like, initially the patient is like, you're this all good, perfectly nurturing, you know, figure who really gets me. You truly understand me. Finally, I have a clinician that has enough expertise to help me. You know, you hear like a bunch of these strung together and you start to get a little bit worried as an experienced clinician, like, “Oh, okay. There's something deeper going on here.” Right? And then the devaluation, right? So, he's currently in the devaluation, where now you're malevolent, incompetent, cold, rejecting. And this is partly what you consider a borderline level of functioning, right? So not neurotic level of functioning. Not psychotic. Borderline level of functioning. There's a lot of this idealization – devaluation.

Object Relations Theory and What Is Behind Borderline Level of Functioning (00:22:12)

Yeomans:

Yeah. But let's talk about the basic theory, because to understand what's behind idealization and  devaluation, I think we have to take a little review of object relations there. Is that okay? So object relations theory is a branch of psychoanalytic theory that emphasizes the self in relation to the other [see also episodes 192 and 231]. Early Freud posited neurotic conflicts based on an internal struggle between an impulse, a drive, and a prohibition against the drive. So, you know, somebody wants to have sex, but they think it's bad and they get a symptom. And, you know,  I'm simplifying, but in any case, some later analysts came along, and the one I'm thinking of in particular is Melanie Klein, who said, well, people do have drives. They have sexual drives, they have libidinal drives, and libidinal means more than sexual, it means affiliative, you know, attachment related you know, wanting to have or satisfying relations with others.

Yeomans:

So there are libidinal drives in the broad sense, and there are aggressive drives– anger, wanting to strike out, wanting to…combination to assert oneself and defend oneself. Not all aggression is bad. It can involve competitiveness and assertion and competition and creativity. Anyway, the idea is that if you have those drives, libidinal ones and aggressive ones, you don't just feel a drive, you feel a drive in relation to the object of the drive. If you're feeling you wanna connect to somebody, you have the idea of with whom you wanna connect, or if you wanna, you know, have some kind of competition with somebody, there's an object of that. So given that emphasis on the connection of the drive to the object of the drive, we can then look at infant development. And the newborn takes in a lot of experiences, and it's complicated because of neurobiology and the myelin, myelination of the brain, and so on and so forth.

Yeomans:

But, and you know, there's still a gap between the analytic theory and neurobiology. Although the gap is narrowing. So in this theory, in the early year or year and a half of life, as it is posited – experiences with the caretakers are, by the infant, seen as either perfectly satisfying or totally depriving, because there's no concept of object constancy. If you're being, you know, caressed and fed and kept warm and cozy, you're in heaven. But if you're uncomfortable, you're cold, you're hungry, you're soiled, and the caretaker isn't there, you don't have this feeling: “Oh, I know, mom will come around. You know, just give her a little time.” You don't have that object constancy. You're in pain, you're suffering, and you perceive the other as the source of the suffering. So you're either in heaven or in hell. The other is totally caring for you in an ideal way, which doesn't correspond to reality, by the way, or the other is persecuting you, not just unavailable, but persecuting you.

So, in object relations theory, the early makeup of the mind is divided between the segment of the mind that's about positive, ideal experiences and negative persecutory experiences. Interestingly, this corresponds to some neurobiology because it seems like the brain areas where positive affect is located and the brain areas of negative affect are different brain areas that require cortical intervention to bring them together. And we think therapy can help with that. So in any case, if you go through life where things are either perfect or terrible, you don't adapt well to the complexity of life because life isn't that way. So to go back to your concepts of idealization and devaluing, patients often come in projecting, “I finally found the ideal therapist –this guy knows everything. Everything's gonna be perfect.” Now, that positive side of the split internal world is just as pathological as the negative side – that's all about paranoia and rejection and harm. Because the positive side doesn't correspond to reality. You never find the perfect caretaker. No matter how much you're in love with your partner, they're not gonna be perfect. So you have to accept that. But people with splitting, when we talk about splitting, we mean the splitting between the all good and the all bad. People with splitting expect perfection. And for a while they might continue with you with the illusion that they found that, but inevitably there'll be disappointment and then it flips into the devaluing. So let's talk about what happens in successful psychological development. Oh, by the way, that split organization is called the paranoid schizoid organization. It's called schizoid because it's split. Why is it called paranoid? Because in that mental organization where aggression and libido, fondness and aggression are totally divided, the person experiencing aggression is not comfortable seeing himself or herself as the source of the aggression.

They tend to project the aggression and see it as coming from outside. So as soon as you begin to get close to somebody, you're nervous, you think something bad is gonna happen, rejection, harm, so on. So in successful psychological development, we move from the paranoid schizoid position – the radical separation of positive and negative, and the projection of anything aggressive on others – to what, interestingly, Melanie Klein called the depressive organization, which doesn't sound great. Who wants to be depressed? But it's more specific than that. If you integrate those two radical polarized extremes, two things happen. One, is you have to give up and you have to mourn your belief that you can ever find the ideal other, or that you can ever be the perfect ideal self. You have to give up on thinking anybody can be ideal, and that's kind of a sad awareness. The second thing that happens when you begin to integrate your positive and negative emotions is that you begin to have awareness and take some responsibility and consciousness for the aggressive feelings you always saw as outside of you. So it's a painful trajectory from splitting and projection to integration and mourning the ideal object and accepting that one has one's own aggression. I'd like to give you a clinical example in a minute, but does this help understand why patients come in with the idealization and then inevitably switch to devaluing when you don't meet their perfect expectation?

Puder:

Yeah, I think the thing that I would love to hear from you, kind of like how it fits into this, is the idea of identity diffusion [see also episodes 88, 170, 225, 231].

Yeomans:

Yeah.

Puder:

Can you integrate that into how you…does that fit somewhere into this?

Yeomans:

Oh, it's perfect, in fact, it's good you bring that up because in our model of the mind of personality and of personality disorders and it's treatment, identity is the core concept. Whether the identity is integrated or fragmented and diffuse. It's important when we talk about identity, to think about how we mean it. Because a lot of people, when they think about identity, think about identifications. You know, what's my gender? What's my sexual orientation? What's my ethnic affiliation? What's my nationality? What's my sports team? What are my interests? So there are all kinds of elements of identity. And when we talk about identity, that's not exactly the level at which we're talking. We are talking about identity as the ability to be in touch with and grasp and manage the full range of your internal emotional states. In other words, does your identity allow you to assume and connect with the full range of who you are as an emotional being?

That's a different level of identity. It's a very core sense of identity. Do I have an integrated identity? Means, have I gone beyond the paranoid-schizoid position where everything was polarized and fragmented so that I could not have a stable emotional existence? I was buffeted back and forth between idealization and devaluation. I don't have that core sense of emotional stability where I get it. I can be loving, I can be angry, I can adore somebody, I can be rageful with somebody. So our sense of identity integration is to be integrated emotionally, not to reject, but often project parts of your emotional self.

Puder:

Okay. Like so I've been, I've been reading thinking about identity diffusion. I was reading about this guy Salman Akhtar. Six characteristics. You know, and is this what we're talking about, the same thing? Or is that slightly different? His six characteristics were temporal discontinuity of the self, lack of authenticity, feelings of emptiness. Emptiness is kind of different from loneliness because there's a hollowness. Just feeling like, just like a shell. A lack of identity around gender, a lack of identity around sexuality. So just kind of like a diffusion beyond just like, who am I? What am I doing in the world? Is this kind of what we're talking about? 

Yeomans:

Akhtar is a really brilliant guy, and I haven't read exactly what you're talking about. I would agree with the first part. I wouldn't talk as much about the second part. The emptiness. Can you mention the first three things you said? One was emptiness versus loneliness. So I wanna talk more about that.

Puder:

Like the discontinuity in the self.

Yeomans:

Yeah. And discontinuity in time. Yeah.

Puder:

So it's like a quote from him: “The past, present, and future are not integrated into a smooth continuum of remembered, felt, and expected existence for these patients” (Akhtar, 1984).

Yeomans:

Yeah.

Puder:

So that's one of them. Temporal discontinuity of the self like a chronology of how they see their life. A lack of authenticity. Here's a quote, “Act as someone else they know would act, not in a manner that is genuinely their own” (Akhtar, 1984).  So they put on different faces, so to speak. Feelings of emptiness is like a hollow shell – lacks capacity to fantasize for a person or experience in the midst of, in contrast to a lonely person may fantasize for connectedness with someone. They don't have that fantasy for that other person.

Yeomans:

Yeah. Let me say I think that's a nice delineation of what we call identity diffusion. And it has to do, I'm trying to bring this all together around a concept with the development of a core sense of self. If you remain split and you're flipping back and forth: I love this person. I hate this person. Which, by the way, has internal correlates. Which is, I love myself. I hate myself. As I was trying to point out in our patient role play, he was very rejecting of himself. At the same time, he saw me as rejecting. You don't have that ballast, that core, that integrated foundation on which to build. You're just flipping back and forth between two states that never come together. That leads to emptiness. That leads to a sense of not development over time, but just time passing without development.

Dr. Kernberg has an interesting article about what he calls the destruction of time (2008). Because, if we consider time from the subjective point of view, what is our experience of going through life and the passage of time? Kernberg's idea is that we sense time as we build and grow as a self. As we enrich who we are, we add to our sense of who we are, we become more complex and we add to what we've done and what we plan to do. If you haven't yet achieved emotional integration, you can't develop because you don't know whether you're loving or hating. You can't combine the two. And if you're always jumping back and forth between two things, you don't have that foundation upon which to build. A lot of my patients say to me, “You know, the worst part of having borderline personality disorder is not the acting out when I'm maybe hurting myself or having a rage attack or something like that.”

And we should get back to the experience of aggression in the borderline patient. “The acting out isn't the worst part. The worst part are those moments when I'm sitting alone by myself and I feel totally empty.” We have to, as therapists, try to empathize with what that is like. It's pretty horrifying. Pretty scary. And a lot of the acting out is to escape from that core feeling of emptiness. And if you do have that feeling of emptiness and unclarity about who you are, then you are gonna mimic other people. You know, “I'll do what this one does. I'll do what that one does.” So, I agree a lot with what Akhtar says.  I wanna invoke another title of one of Kernberg's books. He has a title called, The Inseparable Nature of Love and Aggression. And I think that relates to this concept of integration.

A lot of my patients who are stuck in that kind of naive belief that you can find the ideal, say, I know I'm getting better because I'm going out with this guy and, you know, we were having a really good time, but then I, you know, I, I don't think I can sustain it or, you know, I ruined it all because I got angry at him. I felt angry at him. And I say, well, yeah, but let's look at that. Do you feel you can really know somebody in depth, have a lot of shared experience, and it's all gonna be positive. If that's your goal, you're not gonna have any deep relationships, because in intimacy, deep connectedness is gonna include negative feelings as well as positive ones. That's a more concrete example of integration.

Puder:

In one of your YouTubes, I forgot which one, but you said something like the, the strongest identities are based off of religion, philosophy, or art. Did you say that? 

[Exact quote from timecode: 33:45: “we can certainly maintain a belief in ideals, but it's better to find your ideals through spirituality or through art or through philosophy and ethics”].

Yeomans:

No, I didn't, but I'd be happy to talk about it. 

Yeomans:

Well, I don't know who said that. I think you might've heard what I said about religion, philosophy, and art. Which is that that’s where you can idealize. I said, you know, when I just went over the object relations theory, where you go from the split organization, paranoid, schizoid to the integrated, more complex organization where you give up the idea of perfection and finding the ideal in another person. I wanna emphasize that I'm not totally cynical. I don't think you're not allowed to have ideal beliefs, ideal values. They might be embodied in a spiritual system, an ethical system, and artistic pursuit and aesthetic pursuit. So I think ideals are laudable, but look for them where they might exist and not in another person or oneself.

Puder:

Okay. Thank you. Thank you for that clarification. So, okay. So is someone inevitably always going to be in the depressive position? Is that where they stay forever?

Yeomans:

Well, first of all, when somebody advances to the depressive position, that really enriches life. As I said, you lose the idealization and you have to take responsibility for your aggressive feelings. But then you're in much closer contact with reality. You can really engage with others more fully. You can engage with your work, your projects more fully. So when patients make that shift to the integrated to depressive position, we help them work through the sad feelings about mourning the ideal object, and usually the guilt feelings about having their own aggression. And we try to help them see they can, what we call sublimate or direct or manage their aggression so that it can have positive applications, not negative ones. But when you mentioned the transition from the paranoid schizo split position to the integrated depressive one, unfortunately that's not a development that necessarily takes place once and for all. People like you, I assume, and me, I hope, who are in the integrated depressive level, under certain circumstances, we can regress back to splitting if we're under enough stress or if we just want the pleasure and simplicity of splitting.

Yeomans:

Because splitting allows you not to think as much. Splitting is simple, but in a way it's reassuring when your mind functions according to splitting. You know what's good, and you know what's bad. There's no ambiguity. So, if for example, you go to a, up here in the Northeast, it would be a Red Sox Yankees game for two hours. You can allow yourself to regress, to forget about all the complexity of the world. You know, your team or the good ones, the other team, or the evil ones, and you can enjoy that for two hours. The problem is that political leaders can appeal to splitting when they say, we are all good. The only problems are outside of our group, everything bad is outside. That's just like the borderline patient who says everything bad is in the other. I am, I don't have any bad traits. So I think there's a seductive splitting. You don't have to think as much, and you're told what's right and what's wrong.

Puder:

I, and I think there's a, I mean, if you look at both sides of political spectrums, it's very common that the person will adopt all of the policies of one side. Right. It's very rare to find someone who's nuanced and parses out different policies. And can see good and bad. So I think we all do kind of enjoy and revel in at times this splitting as well within our sort of tribe, right. And is that, well, a natural process?

Yeomans:

We can until the system breaks down. Because in that tribe mentality, people are not taking responsibility for themselves, but only blaming the other. And then when you get enough of that going on, somebody's gonna get into violence and it's gonna fall apart.

Puder:

Okay. So I think this is a really good aspect I like about depth therapy [see also episodes 154 and 208], is you get the person to a place of taking some responsibility. Yeah. Rather than just blaming purely all their situations they found themselves in. But do you find that there's also this kind of over exaggeration of like, all of life's issues that you have are because of the traumas that you've faced, right. And, and does this kind of like, push against transference-focused therapy, which is kind of like, “Hey, we're taking responsibility for…”?

Yeomans:

No, you're bringing up a very big issue, and  a controversial one; and an area in which we sometimes get accused of being insensitive and non-empathic. So let me give you a clinical example first, and then I'll get back to that trauma question. Because, when we talk about taking responsibility for one's own aggression, we should speak for a moment about the concept of acting out. Everybody talks about acting out, but the true meaning of the term has been lost at this point. When clinicians say, “Oh, he or she acted out”, it usually kind of means they misbehaved. But the definition of acting out is to put into an action, an emotion. One cannot consciously stay with that one cannot tolerate in oneself. So you discharge the emotion through action instead of feeling it and thinking about it. So here's my example. A patient of mine came to therapy saying that even though she made a suicide attempt, she wanted me to understand she didn't have a psychiatric illness.

That all of her problems were caused by her monster husband, who made her life so miserable that any woman married to him would sometimes rather be dead. And unfortunately, that can be the case, and I, at the beginning of therapy, I had to consider that that might be an accurate description of her life. Anyway, a couple of months into therapy she comes into a session and says, “I told you how awful my husband is. Can you believe he forgot our wedding anniversary? He knows how much that means to me. He's awful. He's callous. He's cruel.” In the meantime, before that session, I had received a phone message from the husband who said, “Doctor, I don't know what to do. I forgot our anniversary. And I know that's bad. and I know that, you know, is something my wife cares a lot about. But she got so angry at me that she picked up the TV and threw it across the room at me.”

Yeomans:

So in the session, I said to my patient, “ Well, I can understand your hurt feelings and how bad it was that your husband forgot your anniversary, but he left me a message that you threw the TV at him.” You know, I said that calmly, not condemning her in any way, staying neutral. And she said, “What else could I do? I was upset.” It's different to say I was “upset” than to say I was “rageful and angry”. She felt a discomfort that I believe was rooted in her rage and anger, but she didn't wanna feel, “I'm rageful and angry. I wanna get rid of this emotion. So I'll throw the TV and then I'll sort of get it out of my system.” So if we see acting out as the discharge of something, one cannot think about, our job as therapists is first and foremost to get people to think about what's in them that is true–difficult for them to think about on their own. Now, how does that tie into trauma?

Puder:

Wait. Can I ask this sort of a side question on this? How do you feel when the family member calls you and gives you information like that? Because sometimes it can put us in a difficult position, right? Sometimes I'll get an email from a mother or father, you know, and it's like, you know, sometimes it is a little bit like, “Okay, what is reality here?” Right?

Yeomans:

Oh, very much so. But I'm glad you asked that. In TFP we're, even though we're based on psychoanalytic concepts and techniques, we are more open to contact with other persons in the patient's life. You know, classic analysis is the analyst or the therapist and the patient. That's like totally hermetically sealed. But with patients with severe personality disorders in the initial evaluation, we emphasize you have to evaluate a person and discuss what the nature of the treatment will be and what the conditions of the treatment will be. You have to have all of that in place before you begin the therapy. So anyway, part of that assessment in our practice increasingly involves bringing in the parents. If it's a young person who's very dependent on the parents or the partner, if it's somebody who's living with somebody or very close to something. And why do we do that?

We do that, because first of all, most people don't understand personality disorders. Most people, and I think this is a problem with American psychiatry, most people just think about symptom disorders. “It's a depression. It's an anxiety disorder. So there's gotta be a medication for it.” Well, you can be depressed because of the way your mind works, not because your neurons aren't firing. Right? So if we, one of our steps of beginning treatment is after our assessment to have an open discussion with the patient about our diagnostic impression. If it is a personality disorder, we say that. We explain it in simple English. We emphasize the new understanding of personality and personality disorders, that it centers around difficulties in the way one thinks about and feels about oneself and about others. That's in the alternative model of the DSM-5. And then we bring in the family with the patient present, and we have the same discussion.

Why do we do that? So first of all, they won't have unrealistic expectations that there's just a medication that hasn't been tried yet, or ECT [electroconvulsive therapy], or TMS [transcranial magnetic stimulation] or something like that. And secondly, because there's a common misconception that you can't expect much from a person with a personality disorder; and we don't find that to be true. We think you can expect a lot, but I don't mean to say this in the sense of putting a burden on the patient, but opening the patient up to their potential so they don't see themselves as medically disabled for the rest of their lives. They can get better, as many do. They can have a much more productive life.

Puder:

I think that's so important, because especially, I think people think, “Personality disorder. You have this for life.” And, and I think that a lot of people with BPD or borderline level functioning, they take on illness as a narrative about themself. And then, you know, what you're challenging is that identity of illness.

Yeomans:

Yeah.

Puder:

And like, “I am an ill person. I will always be an ill person.” Yeah. Which is why I get, I've turned so many people from bipolar to unipolar and personality disorder because it's like, “No, like there is hope.” Right? Yeah. You don't need to be on medication your whole life. If you have a personality disorder. Actually, the new standard with the APA, American Psychiatric Association, the borderline personality disorder, is not medication, isn't going to treat borderline personality disorder (APA, 2024). It may treat some of the comorbid issues, but not actually borderline personality disorder.

Yeomans:

That's the most important message from this whole discussion. I hope your viewers have stayed with us long enough to hear what you just said.

Puder:

So, go on. I'm with you. Okay. Anyway, I'm like,  we're on the same team here.

Yeomans:

That's very important. Anyway, after having had this initial contact with partner or parents, whoever it may be, with a patient present, I said, “You leave it open that if those parties think there's something important to communicate to you, they can provide you that information.” The patient usually says, “you're violating my confidentiality.” And I say “No, because I'm not telling them anything. I'm just letting them know if they have a concern they think I should know about, they can tell me. And that doesn't mean I'll necessarily believe them. You know, maybe  they'll say something and, you know, you'll say, that's not accurate, and maybe it'll be their issue and not yours or ours.” So anyway, that, I hope, is an answer to how we would deal with information from a third party.

Puder:

Yeah, that's good. 

Yeoman

The trauma.

Puder:

We're talking about trauma. Yeah. And the reason why I'm bringing this up is because I've been thinking a lot about complex PTSD, BPD and the odds ratio when you go into like adverse childhood experiences [ACEs]. When you go into, like, when a child has four to five, the odds ratio of either one of those is like 20. It goes way up. And so, I personally see it's not enough to have a lot of ACEs to develop BPD, but it's like a part, it seems to be a part of that process [see also episodes 92, 115, 203, 204, 215, 217, &  224].

Yeomans:

Yeah. Well, it gets complicated. So first of all, let's think about what Freud called the complimentary [sic]  series [complemental series]. It's a basic concept where he sees two main contributors to psychopathology. One is temperament. And the sort of emotional raw material one is born with. Some people have much more fiery and intense temperaments than others. So temperament could be the main factor in the development of a personality disorder. But the other part of the complimentary [sic] series is developmental experience. And the adverse childhood experiences you're talking about can be a good example of that. So in Freud's model, he says, you know, any individual might have their own proportion of the temperamental contribution to the pathology and the developmental. But let's go back to what you said about complex trauma and borderline personality. Let's rewind to the 1990s. I was running, I was the unit chief on an inpatient unit where we had all patients with relatively severe borderline personality disorder.

Yeomans:

And we would like to invite people who might contribute to our knowledge to come and talk to us. And at that time, and is kind of a resurgence of it now, there's a very strong emphasis on trauma as maybe the most important factor in the development of personality disorders. So Judith Herman, who writes and researches you know, trauma, a great deal along with her colleague, Bessel van der Kolk, came and spoke to us. And her work is really good. But I think she, and we are not on the same page about borderline personality disorder, because she said, “You know, you guys don't understand borderline personality disorder is a misconception. All of these patients you have are trauma patients and you should see them and treat them as trauma patients.” What is the difference there? The difference is what you said about most trauma models. I'm not saying all– because I'm not totally versed in trauma models, but they would not see any contribution of the patient's own aggressive feelings.

They would see aggression in the patient, not as the patient's innate inherent stuff. But as the result of traumatic experiences, which have been introduced into the patient's mind from outside. Mentalization based therapy is sort of a good example of this. They talk about the alien self. Their model of BPD is somewhat different from the TFP model. It's interesting 'cause both are considered psychoanalytic models, but I think TFP goes deeper in terms of looking at the core deep conflict in the mind between libidinal feelings and aggressive feelings, loving and hating. Whereas in MBT, they say, what happens is that the borderline patient has had experiences of trauma growing up, so they have in their mind an internal image of aggression that has been introduced to their mind from the outside. And that is, to use their word, colonizing their mind. And as you help them to think and reflect more clearly to mentalize their internal states and the internal states of others better, that alien aggressive element just kind of goes away.

Yeomans:

I consider that a little naive. I think that everybody, you, me, and everybody I have ever encountered, you know, part of the human nature, part of human nature is some aggression. We wouldn't have survived as a species otherwise. The problem is how in touch with that are you and how do you manage that? So I think what happens with BPD patients is, as we know, let me just give a little reference to research and then I'll get back to the clinical example. Studies have shown that about 70% of patients with BPD have had experiences of trauma. But first of all, if you look more carefully as Joel Paris, up in Montreal did, the trauma isn't all major trauma. But I think, more importantly, is to reference a study that shows that if you start by looking at the general population, and you look at the subgroup of the general population who have experienced trauma, and you study that group of trauma experiencing individuals, the majority of them do not have psychiatric conditions.

Yeomans:

So, you can't say trauma equals the development of psychopathology. We think it has to do with the way trauma is processed. And we're not saying that trauma doesn't have an impact, but let me reference a patient of mine who is a, actually a lovely young woman in her early twenties who was lovely except when she was making serious and violent suicide attempts. In a session in my office, she banged her fist on the arm of the chair and said, “I'd rather be dead than think I have anything in common with that awful abusive father of mine!” And I said, 

“I think you just defined your problem beautifully. You'd rather be dead than think you have anything in common with him. Whereas, as a matter of fact, you almost undoubtedly have something in common with him because we all have some angry, aggressive feelings, part of who we are. I think your problem is that when you feel the first emergence, the slightest inkling of an aggressive feeling in you, you can't think about it, accept it, and work with it. The slightest inkling of an aggressive feeling in you activates the internal representation of a totally abusive father. And then you think you don't deserve to exist.” 

So the problem is that the trauma introduces into the person's mind images of aggression that are excessive and not easy to tolerate.

Puder: 

Yeah. I'm following you. I have a couple thoughts. One of the thoughts is that I've studied micro expression. So I look at small moments of flashes on the face of people as they talk to me. And often, you know, anger is given a bad rap. People don't like to think that they are angry. People don't like to imagine that they're angry. And my conception of anger has shifted over the years as I've watched people. Because they not only flash micro expressions of anger when they're frustrated at their spouse or in an argument, but they flash it as well when they're talking about what they're passionate about, a book that they're writing, an artistic endeavor. It's a passion project. And so I've reconceptualized anger as it's the energy to overcome an obstacle to move towards a goal.

And so I agree with your conceptualization that we have this drive, right, which I would say is aggressive. This aggressive drive, a drive that's maybe competitive, maybe at its worst, it's envy to a place that it doesn't allow friendships. Maybe at its best, it's a drive that allows people to accomplish worthy things, that improve society, improves your family, improves yourself. So that's my first thought on what you said. 

The second thing is when I think about what we've talked about BPD on prior episodes, and we talked  about some early studies by Chess, Thomas, Rutter, and Birch (1963) [see also episode 115] , they did a study of 141 children that they followed. And it was this longitudinal study where they classified people as easy, slow to warm up, and difficult. And 10% of the kids were difficult from a very young age.

And the difficult ones they described as often irregular in feeding and sleeping are slow to accept new foods, take a long time to adjust to new routines or activities, and tend to cry a great deal. And they followed these children and the difficult children accounted for the largest proportion of kids that had behavioral problems later on. And, and so it was Dr. Cummings, who has been on my podcast a number of times,  he was emphasizing that a lot of the kids that potentially develop BPD have this kind of like temperamental sensitivity, higher aggressiveness. And then, if they don't go through traumas, maybe they don't develop BPD, but with a wrong environment, lack of empathy, lack of connectedness, maybe a disconnect between parenting styles, disconnect between personalities. Maybe they develop something that looks more like BPD. Maybe they, you know, we know that attachment disorganization has something to do with it. The beta's [β’s] pretty small. Emotional dysregulation and adolescence has much higher beta. I'm kind of like agreeing with you and kind of adding on this layer. And I think that with, so coming back to this idea of aggression and the positive sense of like personal responsibility taking ownership is sometimes disavowed and someone ends up in this kind of like, victim, hero, persecutor.

Yeomans:

Yeah.

Puder:

And the trauma therapy ends up in that place where the patient is always the victim. The therapist is always the hero. And the bad things in life are always the persecutor that happened earlier in life. And it's a very seductive place to live. But, it also kind of leaves them in that illness narrative, which I think keeps them stuck.

Yeomans:

Yeah. There's so much coming. First of all, I really endorse this emphasis on micro expressions. That's when a lot of what is split off and not in awareness comes through in facial expressions, nonverbal communication. Second, what was Chess’ work you're referring to? Yeah. I haven't thought about that in ages. I'm very glad to hear you refer to that because it should be given more importance in the current day. Or maybe it's just me. But you know, I haven't thought about that in a long time. But getting back to what you just said about therapist-hero, patient-victim, abuser. Outside that's where we sort of upset the apple cart, if you will. Because, we don't accept this hero role in TFP. And this is where the role of therapeutic neutrality comes in. We're often criticized these days for what we call neutrality. Can I talk about that for a minute?

Puder:

I noticed it in our back and forth. It's like you were not really overly reassuring. Right? And, you were curious. And I was almost about to like, push you on it in the role play, but I decided not to shift gears and be like, I feel like you're really distant right now. You don't really care. It looks like you're almost bored. 

Yeomans:

You could be quoting a session I had yesterday. But go ahead.

Puder:

So go ahead. Tell me.

Yeomans:

That's the point. We stay neutral and that doesn't mean indifferent. We care a great deal about our patients. We react emotionally to our patients. We tend to keep our emotional reactions inside and to reflect upon them. That gets to countertransference and how one can use that. But if you're not explicitly endorsing, and I'll use the word “validating”, 'cause that's so important in DBT, the patient, often you're considered suspicious or negative, and then you just don't get this hero treatment that you would get if you said, “Yeah, it must be terrible to have had that dad who was so awful.” I mean, I wouldn't necessarily not say that. I mean, it was terrible to have that dad. But then I might say, “But if we only talk about him in the past, I think we're missing something that goes on in your current life.”

And that's when you sort of stop from totally supporting a projective defense, and you begin to be open to a deeper look inside. And that's when you're not the hero anymore, because you're saying something that connects with the patient's doubt about themself, but they had doubts about themselves before they came into your office. They just want you to reassure them. They shouldn't have any doubt. But instead of that, we're saying, what are your doubts about what is there in you that you're concerned about? Maybe if we thought about it, you could sort of get to know yourself more fully. 

Puder:

What if I had said to you in that role play, “Dr. Yeomans, it's like, I feel  like as you're responding to this, to me, like I sense there's so much dispassion, and I would expect you to at least react a little bit to me saying that you were making fun of me. Like it seems like you're just kind of apathetic to that accusation.”

Yeomans:

Again, I'm channeling assess…I'm trying, it's a tough position because you're being…Oh, I know. Let me let see,

Puder:

Go ahead.

Yeomans:

So essentially you’re experiencing me as a combination of indifferent and neglectful.

Puder:

Yeah. It's like, for some reason, that feels more true than you being the abuser. You know, it feels like, it feels like it's a form of abuse to just neglect me and to be apathetic.

Yeomans:

So what you would like is for me to hardly endorse the position you're taking and just say, if we could just get you beyond what your parents did to you, you know, you sort of deal with life better, be able to have better relationships, feel better about yourself. Is that the model you have in mind?

Puder:

It's like I'm talking to a, a door and  I just want some…

Yeomans:

Well….

Puder:

Something other than this. I mean, it's just like even the speed at which you said that it's like lulling me into some sort of hypnosis or something. I don't know if that's like part of what you're trying to do.

Yeomans:

Well, I don't mean to be sarcastic, but the kind of thing you're asking me for. You've had a number of times over kind of long periods of therapy. So first of all…

Puder:

Yeah. And I know they were all like, I hate them all. You know? Like, they're all, well, some of them had some decent parts, but most of them were like all, you know, just quacks. They were quacky. 

Yeomans:

Let's get back to here. Okay. You know, I am speaking slowly, so I'm a robot without any feeling about you. And that reflects my lack of interest, Am I getting it right?

Puder:

Yeah. I don't know. Maybe. Maybe I'm just one of a hundred patients of yours and you like, you know, it's just like, “Okay, here we go again.” You know.

Yeomans:

That I get this.

Puder:

What do you mean you get, what do you mean? What does that mean? You get it.

Yeomans:

Now? I get why it is so depressing, your life. I mean, I don't think I'd say, yeah.

Puder:

It's like you're the person who's supposed to care the most. And when I sense that you don't care at all, it's like, it's like a dagger into my heart.

Yeomans:

Well, I can understand if you feel that after coming here now for three months, twice a week, that I don't even see you. That I kind of just have this boilerplate response to the person who came before you and the person who came after you. That would leave a person pretty sad and desperate. So there I do get it.

Puder:

Yes. Thank you for that. Yes. It leaves me sad. It leaves me desolate. It leaves me feeling like, “What the heck am I doing here?”

Yeomans:

Yeah.

Puder:

Like, did I choose wrongly? Am I crazy to think that you'll be able to help me?

Yeomans:

Well, that's the question. What are you doing here? Because, like I said before, in spite of all the dissatisfaction and  I guess pain you're experiencing here, you keep coming. So I just wonder if there's something else going on.

Puder:

Why, you're the person who's supposed to tell me what I'm doing here. Not me. Like, I'm not the professional.

Yeomans:

I have a hypothesis. So my hypothesis is that in spite of all surface appearances, our repeated meetings have activated some feelings in you. Negative, positive, both. But we're seeing the negative ones. We're not really seeing a whole lot of the positive ones. And yet you're coming here and continuing to do so, so just, it's something positive, but it seems really scary to you.

Puder:

And I'm embarrassed about how honest this conversation is right now. Like, this is very uncomfortable for me. I usually am not this honest.

Yeomans:

Well, do you, would you agree with me that honesty might be useful and helpful in therapy and what are? What would you usually hide? I don't think what you would usually hide would be your criticism of me. And you're saying, I'm a robot and don't care and mock you. I think what you might be hiding is that you kind of wish we had a good connection. But that's scary to think about.

Puder:

It's scary to think that you don't care.

Yeomans:

Well, but see, that's what…

Puder:

I desperately want to know that you care. Like, do you? 

Yeomans:

Yeah. But I don't think I could say anything that would convince you. I think we have to continue with what you're experiencing here and what's noticeable. I think you could agree or disagree, is that you feel safer with the negative feelings than with the positive ones. And when you said you were being a little more honest here, I think it had to do with maybe communicating something positive. But that's like really going on thin ice for you. 'Cause that's not your general experience in life.

Puder:

Hmm. I think if you were to gimme a hug, I think that would convince me that you appreciated me.

Yeomans:

Well, I disagree, because you've had that kind of therapy before. And I think to ask for that is to short circuit what you're feeling right now to short circuit that tug of war in you right now. “Can I trust him? I'd like to, but I can't trust him. He's gonna hurt me.” I'd rather stick with the tug of war than try to put it to a premature close. 

Yeomans:

I was gonna say, you know, that's just not something I think would be therapeutic, or be helpful, and could kind of complicate matters.

Puder:

Okay. Let's debrief. Okay. So this is like something that you experience with patients. It's like this, the neutrality kind of can engender. So Nancy McWilliams talks about, like, it's the, the tetra of the hero, the victim, the persecutor. And then she says the fourth,  the uninterested observer. Right. Which the therapist can kind of get pulled into. So that's like another level of transference, right?

Yeomans:

Yeah. But the key is to being…maybe the word is too strong, but almost passionately interested in your patient. Concentrating on them, devoting your attention to them, and even in spite of your feeling as a patient that I speak slowly and without any affect. Over time, our belief is that that solid commitment to the patient is going to sink in at some level. But I also wanna say, I don't wanna portray this as simply a corrective emotional experience, but it's important to maintain that focus, that concentration, and that commitment because patients push us outta that position. Patients provoke us by provoking countertransference reactions where we can get angry at them, we can reject them, we can distance ourselves from them. It happens particularly with narcissistic patients. We haven't talked as much about narcissistic patients, but let's, for a moment. Patients with classic borderline personality disorder have almost universally an insecure attachment style as do patients with other severe personality disorders.

But there are different subtypes of insecure attachment and borderline patients. Classic borderline patients generally have what's called the preoccupied insecure, which is ruminating about the other person in the interaction. “What is he thinking about me? How did he think about the last thing I said? Does he think I'm stupid?” If the patient is worried about you and your responses, you have a ton of material to work with. So, the classic narcissistic patient has an insecure, dismissive form of attachment. You don't matter at all. I could care less about you. So what studies and clinical experience have shown is that when the therapist is subject to that dismissive attitude of the patients, most often they mirror it and they back away and they become dismissive and devaluing of themselves. That's why I say for you to maintain intense interest and commitment is not a given. A lot of therapists are derailed from that because of the countertransference reactions that are elicited in them, elicited in them from the patient. 

Puder:

Interesting. Okay. So yeah, somehow their detachment as a sort of a mechanism of staying connected to mom, right? So it's like the classic picture. If mom leaves the room, there's toys, they're distressed, but they're pretending as if they're playing happily with the toys. Mom comes back and they don't even look at her, you know, but they really are in a distressed state. Their cortisol is high. So that's more of that avoidant attachment style. So you're saying that that occurring in the room when they are like that somehow that this is the way that I'm thinking of it. It's like our mirror neuron representation of that countertransferentially wants to distance ourself or become a little bit more disengaged.

Yeomans:

Yeah. Right. So anyway, to get back to whether it's a corrective experience. Emotional experience or not, your ability to stay committed, interested,  and devoted to the patient, in spite of all of the storminess and the kind of negative feelings that can arise and sometimes wishes to distance herself. That in and of itself isn't enough to make the patient sort of reconsider if somebody might really care about them. Because if you take the guy who saw my tears as mockery, you have to do some interpretation before he can take in my commitment in him and interest in him, you have to help him see that he is putting in me something that exists within him. And, like I said, when we were doing or discussing the role play, the mocking person is part of his own mind towards himself that he exports to others. If we get him to see that it exists within himself, then maybe he will be less inclined to automatically see others as rejecting and be able to take in their caring about him in a way he couldn't before.

Omnipotent Control (1:19:50)

Puder:

Okay. How does the kind transference of omnipotent control kind of fit into that? Like where they’re agenda setting, boundary testing?

Yeomans:

Yeah, I'm gonna refer to your notes that you sent to me about topics that might come up, because in a way that's totally understandable. You wanna talk about different types of transferences devaluing, erotic, childlike, regressive rejecting, and the controlling omnipotent. But the first thing I wanna emphasize is that given the internal fragmentation of the patient's mind, you can have rapid shifts from one transference to another. You were talking about that to some extent when you talked about going from idealization to devaluing. But you kind of talked about that as though it was like a once and for all shift. But depending on the circumstances, people can, not consciously, but just in effect, hop back and forth from one way of experiencing themselves in relation to you to another. And it can be a little bewildering until you have time to think and observe it.

So given that understanding, the transferences can shift a lot. And that's a lot of material for our reflection and engagement with the patient–the controlling or omnipotent transference makes perfect sense. It's a manifestation of the primitive defense mechanism of omnipotent control. The individual feels that usually through the way they verbally interact with the other, they have to control the interaction. Why does that make sense? If your mind is organized the way I described in the paranoid schizoid form, then by virtue of your projection of any aggressive stuff onto the other, others by definition aren't safe. They're either gonna disapprove of you or abandon you, or criticize you or hurt you. So as you get close to other people, what's the only reasonable thing to do? Control them. If in your gut you think they're a threat, you have to have control. How does this manifest in a psychotherapy session?

Can I give you an example? Because it'll take a few. So, a patient started therapy and she was such a classic example of seeing all the hostility outside of her. Everybody mistreated her–family, people she encountered, the waitress at the restaurant, the checkout person. Everybody she felt was critical and disapproving and rejecting and mean to her. Anyway, so she starts therapy and for session after session, she comes in and talks nonstop with kind of a pressured speech, which helped me understand why for many years she was diagnosed as bipolar. Pressured speech, you know, kind of a hypomanic style. Anyway, after the six or eight sessions of this, I did what is the main shift if we're considering the difference between TFP and more classic therapies perhaps in particular classic psychoanalytic therapies.

Yeomans:

I shifted from following the content of what she was saying, because all the stories were the same. “This person treated me badly. That person treated me badly.” You shift from the content to the interaction. This is something that most therapists have a hard time doing because you're taking the focus away from what they're saying to what's happening. And I said, “can we think for a minute about what's going on between us?” And she said, “You're interrupting me.” 

“Yeah, I realized that, but I had something I felt might be useful to think about.”

 She said, “What's wrong with you? You told me at the beginning of therapy, I was supposed to just come here and say everything on my mind. That's what I'm doing. You're interrupting me.”

 So I said, “I also said that, you know, sometimes I might have an idea to think about that I like to introduce. So, you know, that's kind of what I'm trying to do now.”

She goes, “Alright, what's your stupid idea?” She was very angry and devaluing. 

So this is where I'm gonna say in like three minutes, what took 20 minutes to go over with her, because you have to be so tactful. This is where you begin to challenge the patient's defenses of projecting everything on the other. 

I said, ”You know, if we think back on all these sessions we had, could we agree that the kind of pattern is you come in and you talk, and there's really kind of no room for me to participate. Or, you know, my job is to sit and listen and take in.

“What's wrong with that? That's what you told me to do.”

I said, “Well, as I said, nothing's wrong with it. But we might wanna kind of understand something about it. And let's just start by describing what happens. Would you agree that, you know, your style of speech and talking, you know, without interruption, let's just say maybe that has a little bit of a controlling quality to it.”

You have to be very tactful. I was kind of surprised because she said, “Well, maybe it is a little controlling. So what?”

So I said, “well, you know, that's up to you if you wanna be controlling. You have every right to be controlling. But I think it might help to think about what motivates that and the impact it has on relations.” And in a way that surprised me, she burst into tears and she said, “if I didn't control you, you'd leave me like everybody else does.”

Perfect example of what I was saying, omnipotent control. If the other is gonna do something to you, you have to hold them in your grip. But ironically, it's the holding others in your grip that makes them run away from you. So that's an example of omnipotent control and how I might work with it with a patient.

Puder:

Wow. Oh man. Yeah. I had stirred up some stuff. 

Yeomans:

I mean, the main point is I had to do what therapists have a great deal of difficulty doing it. You say, let's stop listening to what you're saying and let's look at what's going on here. For some reason, that makes therapists nervous. They don't think they have a right to do it. It made you nervous. 

Puder:

No. It's just. Well, there's something about when I was a resident, I had a really good attending who was like, you know, the more you tell me about this person, it's like, she's talking at you, not with you. And so is that kind of like omnipotent control through the speech? Is that the…

Yeomans:

Yeah, and that's why, and here, I have very strong feelings. That's why a lot of psychotherapy has a real bad name within the world of psychiatry. And in the medical world, a lot of our colleagues say, “Oh, you know, psychiatry really isn’t medicine, especially if you're doing psychotherapy.” Well, that really annoys me. But when I get residents coming to me and saying, “Well, I inherited this case and she's been coming to the clinic for 20 years,” and then the resident starts presenting material and all the patient does is what my patient was doing, and she's been doing that for 20 years with one resident after another, that's a waste of a valuable medical resource–my psychiatry resident’s time. He should just be a sympathetic listener, if that's what you wanna give the patient, get her a reading group or something like that. But you know, we are trained to help people, not just to absorb, I mean, not just be a sympathetic ear. We're too highly trained and too valuable a resource. that resident should be saying, “What is it you're doing here with me that we could understand might be related to the fact that you don't have a lot of other people you're close to in your life.

Puder:

That's good, man. I feel like I want to get to some other stuff that might relate. 'Cause I feel like erotic transference can sometimes have that flavor, where it's like out of the fear they want to control. Interestingly, I've done episodes on transference here, and I've had people reach out to me by email saying like, “Hey, I find myself in this situation. I'm a patient. I have this therapist who's, you know, 50 years older than me, but for whatever reason, I feel like erotically charged towards them. And how do I make sense of this?” Sometimes I'll say things like, “Well, maybe, you know, have you told the therapist this?” But I'm curious how you have dealt with this over the years, and I know it's like something people might have interest in hearing.

Yeomans:

Oh, sure. And it's also important because you have to distinguish between the erotic transference, which is based on loving libidinal feelings and the eroticized transference, which has the look of an erotic transference, but that is perverse and destructive. We can talk about both, but basically that patient you initially referenced who says, “You know, he's 50 years older than me, but I have these loving feelings and sexual feelings. How can I understand that”–she should mention it to the therapist. And generally, those feelings are based on what we'll just go back to again and again, which is an internal representation of an idealized object that doesn't exist in reality, but that the person is projecting onto you. So when a patient, just to give you an example, a patient of mine came in and said, “You know, this has gotta be our last session.”

“Why?”

“Because I have to confess I'm in love with you, and it's hopeless because you could never feel for me the way I feel for you. And it's embarrassing and it's humiliating.”

So one approach to that is to say, “You know, I realize how uncomfortable this is, but the great thing about psychotherapy is we can talk about everything, understand things, help you move forward, nothing's gonna get acted upon.” So I said, “I know how hard and awkward it is, but you know you've been coming here for a couple of years, I'm sure you have some sense of who I am, but on the other hand, you know, since I don't talk about myself, there are probably a lot of things you don't know. And I'd like to hear more about how you imagine me and how you see me.” And she started describing somebody that was so perfect, so ideal, that even as she was listening to herself, she began to chuckle and say, “I guess that kind of person couldn't really exist.” So that's just a simple– simplification, a sort of a reduced version of how one might deal with that.

Puder:

I mean, part of me is like, well, maybe you are a great human. Here you've dedicated your life to helping people, and you've written books to help other people learn how to help other people. So like, what's reality? Maybe you are this archetypal male, right?

Yeomans:

I think that's idealization.

I'm thinking about a supervision I did last week. Maybe, I'm trying to put the focus off myself.  A therapist, who's a really good therapist, was presenting a case…It had to do with the therapist being made to doubt themselves. But the reason that came to my mind is you're saying, yeah, I have written books and I have, you know, dedicated a lot of my life– certainly not all – to helping other people, but you know, I have my flaws, I have my weaknesses. 

Puder:

Then why don't you tell me some of them? I mean, it would be helpful for me as a patient to know your flaws. Why don't you tell me your flaws?

Yeomans:

I'm more interested in the fact that you can't imagine them, because if I just give you a list of my flaws, you're gonna go on with this idealization and find somebody else to pin it on. So I think we'd be better off looking at how you manage to blind yourself to anything that might be less than perfect about me, and stay stuck in that perfect view. And we should also think about how important it is for you to do that. How much it means to you, how sad it would be to get beyond this idea somebody could be the way you're imagining me.

Puder:

I'm just convinced that if you don't tell me some of your imperfections, I'm just gonna inevitably not be able to un-idealize you. So I think that the only way I can get to a more balanced view is by you telling me the truth.

Yeomans:

Well, let's look at what's going on right now. Clearly, I'm not so perfect because you're having to increasingly control me to get what you want from me. So if you're putting such increasing demands on me, it sort of implies I'm not gonna give you what you want. That in and of itself is a problem, isn't it?

Puder:

Well, I think the very nature of the therapy relationship is you're not gonna be able to gimme what I want. It's gonna end some time. And our age discrepancy. At some point, you're gonna die before, you know, what if I need you 20 years from now, you know?

Yeomans:

All right, let's get back to the here and now, Not 20 years from now. You're saying to me, tell me an imperfection. If you don't tell me an imperfection, I'm gonna keep idealizing you. That's of interest to me. Because if you have to control the other to feel okay in the relationship with them, including me, what does that mean about who the other really is? I guess you're thinking that I'm not so perfect because I'm not giving you what you want. Never will. And that the only way for you to get it is to demand it and insist upon it. That doesn't seem like a very harmonious relationship.

Puder:

Touche.

Yeomans:

Okay. You always have to stick with what's going on in the here and now.

Puder:

Oh, that's good. That's good because it's that omnipotent control transference that are leaking back in, right?

Yeomans:

Yeah. And anytime you have that controlling, it implies there's no trust of the other.

Yeomans:

But let me just say one more thing. The funny thing about the erotic transference is it's harder for patients to work with than the paranoid transference or the negative transference- paranoid, negative, sort of the same. So the therapist comes into supervision, you know, it's terrible. “You know, my patient thinks I don't care about them and thinks I mock them and thinks I secretly don't like them.” And you say, “Well, you have to keep in mind, this is a very simple concept. They're not talking about you. They're talking about what they're projecting on you. They're talking about an internal element of their mind that they're sticking onto you. It's not you.”

“Oh, yeah. Well, that's perfectly logical because I'm a nice guy and I don't dislike my patients and don’t wanna get rid of them.”

Then the therapist, a year later, comes and says, “This is terrible. My patient is saying she's in love with me.”

Which we don't always get to. I'd say most cases don't get to an explicitly erotic transference. But then the therapist says, “What do I do now?” You have to say, “As I said to you, look at what they're projecting on you.” This therapist, who thought it is totally unreasonable to think the patient sees them as a bad guy. the same therapist might think, “oh, they're in love with me. That's kind of logical. I'm a nice guy.”

Puder:

Oh, man.

Yeomans:

Yeah. You have to get them to see that's not the real picture.

Puder:

Yeah.. I once had a supervisor who said it's like she was a patient at one point, and she said that she had some, you know, these kind of feelings towards her therapist. And the therapist turned to her and said, “Look, I could be a one-eyed cyclops, and you would have these feelings.”

Yeomans:

That's interesting. I wouldn't say that. You know, why?

Puder:

Why?

Yeomans:

That's telling the patient, you are wrong to have these feelings.

Puder:

I think it was more. I think the tone was more like, “These feelings that you're having towards me are more to do with the process of what's occurring in therapy than me as a person.”

Yeomans:

I could see a moment for that maybe, but I don't like…Your perception of me is wrong. Because there, like, going back to the guy- am I a friend or am I a foe? You want him to struggle with it internally instead of saying, “Your negative view of me isn't really connected to me, it's all projection.” That's saying, “You know, that's your problem. And the real problem is figuring out whether to believe in or not what you're projecting.” And I don't wanna short circuit that process by saying, “It's all you. Get over it. Problem is in you”

Puder:

You want them to be more reflective. And want to short circuit the reflectiveness of what's going on.

Yeomans:

Yeah. You wanna entertain the possibility that maybe you are an uncaring, mechanical robot who treats all his patients the same way and has no feelings for any of them. To honor that projection, as I said right at the beginning, paradoxically, is a way to increase the patient's nascent, sort of fledgling little bit of trust in you when you can say, “You know, let's think about that. Let's reflect on what you're feeling. Let's not dismiss it a priori.”

Puder:

Okay. So I think there's a couple questions we should definitely sort of hit real quick before we kind of wrap this thing up. One, would be the frame. I think a lot of the transference occurs in the frame. So I think we could probably devote two hours just to this, but attendance of therapy, reporting thoughts or feelings, the fee. How do you do contacts between session? Like what if…

Yeomans:

Can I go into an example of that? Okay. Because that's so important. Our position at TFP is that therapy takes place in the sessions and communication outside of the sessions is something we don't do. Except, for two reasons. One is practical needs like rescheduling or if you're having a true emergency. Now we can go back to what a true emergency is. But anyway, let me give you this example. A therapist comes into supervision, mid-career therapist, analytically trained, doing a kind of a typical psychodynamic therapy with a 40 something year old woman who is depressed a lot of the time, not successful in her work, and not successful in her love life. Can't get an intimate relationship going. Anyway, In the course of the therapy, the lady starts sending emails to the therapist. It begins as a trickle, but it becomes a flood.

So the therapist comes for TFP supervision and says, “You know, what do I do? I don't know what to do with all these emails.” He hadn't yet established the frame that you and I have been talking about, like limiting communication. So in the supervision, I said, “Well, I think you should say to the person, you're gonna recommend some modification in the form of therapy you're gonna do, you're gonna make it more structured. You’re gonna explain to her, you think that would have more benefit. And part of the increased structure would be that these communications between sessions stop. And as I said, only occur under two circumstances.” So that evoked, and by the way, if you wanna evoke transference, just stick to your frame of treatment. All my supervisees say, “All your patients have strong transferences to you. My patients just talk about all kinds of other stuff in their life. They don't have transferences.”

Yeomans:

You want transference? Go back to the frame. Be careful about the frame. So anyway, the therapist says, “This lady, you know, okay, so this, you know, revision in our model of treatment is that we don't have all those email contacts,” and that evoked transference. “What, you're abandoning me, you don't care about me.” And this allowed the therapist to analyze what was central to their interaction and to her pathology. She was finding in him, through her behavior, that I can send an endless number of emails to my therapist and the God-like perfect giver therapist will accept them and take them in and maybe respond to them. That was the enactment of an unrealistic internal image of the perfect provider. Why was her life a failure? Because she was going through life expecting to find a boyfriend who would be that perfectly giving. Why was she a failure at work? She expected herself to be perfect in ways that were not realistic. She was always critical of herself. So when the therapist said, “You know, we can't continue with all these emails,” that brought to the forefront what had been enacted, which was her wish for somebody perfect. And what needed to be analyzed was the fact that this wasn't gonna happen, and the way they were doing therapy was perpetuating an illusion rather than looking at it and understanding it and moving beyond it. 

Puder:

Okay. That's good. Yeah, that's good. 

Okay.  I'm not gonna say too much on that. I just want to kind of, as we're kind of wrapping up our time.  I really appreciate it, and there's a lot of things here that I think it's gonna be of great value to my audience. 

And thank you so much for your time and, and thoughtfulness and everything. 

But  I wanted to see if there's anything else that is on your mind. That you feel like you just want to definitely talk about it. Is there anything else there?

Yeomans:

The one thing I don't think we've talked about enough, or one of a number, but the main thing is the difference between a classic narcissistic personality disorder patient and a classic borderline personality disorder patient. I refer to this a little bit when I talked about the difference in attachment style, the borderline preoccupied versus the narcissistic dismissive. But if we look at the internal structure of the narcissistic patient at the core, we find the same identity diffusion, the same kind of stew of unintegrated representations of self and other. You know, idealization, devaluing, feeling good, feeling bad, having dependency wishes, rejecting them, having fears, having desires. All that turmoil of unintegrated affects exist in the narcissistic patient, but the narcissistic patient unconsciously in their mind create a structure that seals over and hides or prevents access to that inner turmoil. We call that structure the pathological, grandiose self.

Yeomans:

It's a self story, a narrative of the self that provides a sense of unity and integration of the self, but it doesn't correspond to reality. It reassures the patient that they're okay, but it doesn't hold water. Simple example, the failure to launch young adult. The guy who finished college, because of his own self criticisms and insecurities, can't get involved in any kind of work. So he kind of retreats to the basement of, or the attic of, the parents' home and says, “I'm writing a novel.” So what sustains his self-esteem? I'm a novelist. I am writing a novel. So that's my purpose. That's what defines me. But years can go by and nothing much happens. And they’re falling far behind the curve. They hold onto their identity as the undiscovered novelist for dear life. And when they come into therapy, you have to help them move beyond their grandiose narrative and get in touch with all the painful longings and insecurities that they have, that they're defending against by this narrative that seems to reassure them, but doesn't have grounding. In reality, it's harder to work with narcissistic patients than with borderline patients.

Puder:

I think one of the things that the mentalization people said that was really kind of like was like an aha moment for me, and I think you just resaid it in a different way. But it was like, people with BPD, they crumble when there's an attachment injury. Boyfriend breaks up with them, they get suicidal. NPD, they crumble when there's a self-image injury. 

Puder: 

Lose a job, wake up to the reality that no one will read their novel. You know, like the incongruencies. That's kind of what you're saying or would you put some…

Yeomans: 

That's interesting, I hadn't thought of it exactly that way. I think that makes sense. But in that formulation, what I don't find is what, in our model, we see as the protective, pathologically protective of the narcissistic narrative. Because the way you just formulated it, the borderline patient is gonna get in touch with all their anxiety and distress when there's a relationship failure. And the narcissistic patient will get in touch with it when there's a kind of a functioning or performance failure. But in our experience, the narcissistic patient, the very ill ones, managed to avoid those moments of crisis by an entrenchment in a narrative that can go on unabated for years. And so it's not as easy to access their distress. 

Puder:

Okay. Because in the midst of losing the job, the narrative psychologically stabilizes them.

Yeomans:

Well, you know, to some degree. I give the example, first of all, if it's the kind of narcissistic patient I usually do, they don't have the job to begin with. But so they lose their job. And instead of saying, “You know, I guess there's something wrong with the way I performed there.” It's like, “You know why they fired me? Because I'm the only person there who was truly honest. They all would compromise. I would never make compromises. That's the only reason that firm makes any money. All the other people there would look the other way when something wasn't done right. I don't have that, you know, I'm above that. So, sure. They didn't like me. They didn't like me because of my level of honesty, not because there's anything wrong with them. The problem is with them and their lack of honesty and their compromising nature.” So, you see how the narrative, the narcissistic grandiose narrative repairs the injury instead of opening it up.

Puder: 

Yeah. Yeah. That's really good. And it's still that, like borderline level of functioning with the splitting, the good-bad split with the identity diffusion.

Yeomans:

When you help the person see beyond their grandiose narrative, when this lady began to see, maybe it's not so simple that she's just morally superior to everybody else in the world. She begins to get in touch with longings to connect to other people, wishes for dependency that she's never been able to act on because she's too afraid of getting rejected. And the midphase of working with narcissistic patients, it's extremely painful and distressing to them. And you have to overtly empathize with that and say, you know, you're getting in touch with stuff now that's making you feel worse than when you began the therapy. I'm sorry about that, but I don't know any other way to really get better, except to get in touch with all this stuff that I think was there from the beginning, but that you were fending off.

Puder:

There's one other epiphany on narcissism. I want to kind of bring out and see what you think about it. I'm a big fan of the Big Five [see also episodes 92, 95, 97, 98, 99, 100, & 101]. 

Yeomans:

Oh, okay. I'm not, but let's go ahead.

Puder:

So, in this study (Samuel, et al., 2008), they looked at narcissism versus BPD and how they map on the Big Five. So borderline personality disorder had very strong links. And, if you're watching on YouTube, you'll see the slide I have on this with neuroticism.  With all the facets of neuroticism. With anxiousness, with anger, hostility, anger, hostility was pretty strong. These are effect size…. Sorry, they're not correlations. So the effect size was about 0.5 for anger. Hostility for depression. Self-consciousness was 0.35. Impulsiveness, 0.34. Vulnerability 0.4. These are pretty strong effect sizes. And then for other facets in borderline personality disorder, there's some reduction in warmth and positive emotions in the extroversion domain. There's some, in the agreeableness. There's lower trust. Lower straightforwardness. Lower compliance. And in the conscientiousness domains, there's lower competence, lower dutiful, lower self-discipline, and lower deliberation. 

In the narcissistic in the only neuroticism domains that are lower…. Sorry, higher. Higher, like more neurotic is the anger, hostility. . Now this is a self-reported scale. I have to say this. So this is self-perception, so it's not necessarily reality. Right. It's not like the family member did this for them. A little bit more impulsive, but not too much more. And then the other ones that are different in the narcissistic personality was the low agreeableness. Specifically, the ones that were very low were modesty and straightforwardness. Straightforwardness is, do they, questions like, can you be Machiavellian? Can you pull someone, you know, do you enjoy something like that? Modesty is, you know, how do you view yourself compared to other people?  So any brief reflections  on that, or is that helpful or interesting to you?

Yeomans:

Well, as I said, I'm not a big fan of the Big Five because I find it a little reductionist.  But the way you divide it up into the subcategories is more interesting. But it's actually lucky for me that it's time to stop, because I have to. I'd be happy to look at that graph if you send it to me and have a little more time to reflect on it. But I don't have anything much off the top of my head to say about it.

Puder:

I really appreciate your time. I know we're wrapping it up here. If someone was listening to this and they were really wanting to do a training in that. What is the pathway to become someone who's a certified transference-focused therapist?

Yeomans:

Well, I hope people might wanna do that. I do find it a helpful form of therapy for many people and an interesting way to do our work. So I would direct the person to two organizations. One is a group called TFP, New York [https://www.tfpny.com/]. You can just Google that group and we can direct people towards trainings. And the other one is the International Society for Transference Focused Psychotherapy [https://istfp.org/]. The website there is istfp.org. And on that website, there's also a lot of information about trainings. But we're very eager to train people. We enjoy it, and we find the people who come for training usually find it rewarding. So I hope, and maybe you could post those websites. Okay.

Puder:

That's good. And then I think we should just say this for the record, 'cause you're gonna have a lot of people reach out to you who want you to be their therapist. Do you have openings at this point? Or if a patient was listening to this, and they were like, “I need this type of therapy,” where do they go?

Yeomans:

Yeah. First of all, I don't have any openings at this stage of my career. I'm devoting myself more to teaching and supervision than to practice. So, I'm sorry I don't have any openings, but I would go for referrals to the TFP New York website or to something I mentioned to you, David. It's a wonderful organization, part of the Department of Psychiatry here at Weill Cornell Medical Center called the Borderline Personality Disorder Resource Center. Website is [https://www.nyp.org/bpdresourcecenter]. And over the years, we have established a database of clinicians, not only in this country, but in many other countries who are trained to treat borderline personality disorder. Because even with all the advances that have been made over the last decades in understanding BPD, how to treat it, and teaching more and more therapists about it, there is not an adequate number of therapists for this patient population. So if you're looking for a referral, go to [https://www.nyp.org/bpdresourcecenter]. Or if you're looking specifically for TFP, you could go to TFP, New York.

Puder:

Awesome. Thank you so much. Appreciate you. Love to have you back on.

Yeomans:

Well, I have a feeling that could happen because you make the two hours go by very quickly with interesting questions and comments you had. So thank you.

Puder:

Alright, well thank you so much for your time.

Yeomans:

You're welcome. Bye-Bye now.