psychiatry podcast

Marijuana and Mental Health

On today’s episode of of the podcast, I will discuss marijuana use and how it affects mental health with Daniel Binus, the chief psychiatrist at Beautiful Minds, near Sacramento, California. Also joining us is a third-year medical student, Victoria Agee.

David Puder, M.D., Victoria Agee

Why are we even talking about marijuana?

There are a few reasons we believe this is important to talk about. First, as medical professionals, we often see patients who want help with their anxiety, depression, ADD and suicidality. They say they use cannabis, and that they need cannabis, to help calm those symptoms. When we explain the research to them, it still takes them awhile to let go of their habits and embrace other forms of therapy and medication that is a better long-term option.

Also, we head into a time when marijuana is being legalized, there are tons of THC companies that will benefit from suppressing this information and even suppress these studies we will reference here. Hiding this information could be detrimental to society’s mental health. While there are some potential benefits to one component of marijuana (CBD), something I will review in the future (evidence is fairly young in that field), the THC component can be highly damaging to mental health.

Whether or not people are willing to admit it, cannabis is actually highly addictive. One of the symptoms of addiction is intellectualizing reasons for use. Not only does it change the way the brain functions, it changes the way we see and perceive the world. It also changes our visual and spatial abilities. If you’re an architect or use math in your job, it deeply affects those abilities as well. THC stays in your brain a long time—it can be weeks (or even a month) before people get the full function of their brain back and the fog has cleared.

What is the research on cannabis?

Ganja is from the cut tops of leaves (5-8% THC content) and hashish is from the resin and is therefore more potent (10-20% THC content) Delta-9-tetrahydrocannabinol (THC) is the most commonly used substance worldwide.

It causes long-term changes in the brain

Recent research shows that consistent cannabis use will change the way your DNA is expressed in the brain. It will upregulate and downregulate proteins in the brain, and can change the morphology of the way it works. Marijuana, in fact, leads to changes in our genes over time, called epigenetic changes (Szutorisz, 2018). So the initial effect may be pleasure or fun, but long term, it can create changes that take months to develop in a way that people don’t understand why they are having new issues that pop up. Basically, it’s not changing your gene structure, but it is changing the expression of those genes. Anytime you make positive food choices or develop a consistent exercise routine or make physical changes, epigenetic changes occur that are healthy for long term change (see my episode on diet and exercise)

It’s not surprising that marijuana also causes similar changes in the brain, but not in a healthy way.

When people use cannabis heavily, it causes our endogenous cannabinoids that naturally occur within the body to shift, which can create a disruption in our natural release of cannabinoids. This actually creates a direct correlation between heavy cannabis use and lower IQs (He, 2019).

It lowers intelligence

Studies show that over 20 year cannabis use, people lose an average of 6-8 IQ points. That means you could go from intelligent to average, or even average to below average.

It affects men’s sexual health

In a survey of 8,650 people, women had no association with any of the sexual problems from marijuana use. Men, however, had significant associations between daily cannabis use and reporting an inability to reach orgasm (OR 3.94), reaching orgasm too quickly (OR 2.68), and reaching orgasm too slowly (OR. 2.05).

Among the 424 men who reported reaching orgasm too quickly, there was an association between frequency of cannabis use and the extent to which reaching orgasm too quickly was experienced as problematic  (F- 2.85, P <0.01) (Smith, 2010)

Routine usage of cannabis (more than once per week) was also associated with a nearly 30% reduction in median sperm concentration and total sperm count after adjustment (Gunderson, 2015).

It increases risk for psychotic disorders

Multiple studies have shown a link between marijuana use and psychotic effects that demonstrate that it is definitely causal in contributing to psychotic disorders.

A meta-analysis of 66,000 individuals showed that heavy cannabis and average cannabis users were 4x and 2x, respectively, as likely to develop schizophrenia or other psychosis-related symptoms compared to nonusers (Marconi, 2016).

In a study that came out this year (2019), young adults who used cannabis were about 1.5x more likely to develop depression and suicidal ideation and 3.5x more likely to attempt suicide (Gobbi, 2019).

It has negative effects at any age

Cannabis exposure during gestational development has a direct correlation to drug-seeking behavior later in life. Early life cannabis exposure (adolescents) upregulates expression of Penk mRNA, an opioid neuropeptide in mesocorticolimbic system, which has direct causal link to enhanced behavioral susceptibility to heroin use as an adult(Szutorisz, 2018).

Studies also show that in teens, even a few uses of marijuana makes them predisposed to depression, psychotic disorders and suicidal ideation.

It causes impaired social functioning

It increases the amount of impulsivity and hostility in daily life. It increased hostile behaviors and also paranoia of others being hostile. It also deadens the ability to detect microexpressions and create social connection so that it may remove appear to improve social anxiety. However, it's not an actual solution, because it prevents someone from presenting their real self.

How to help a patient who uses cannabis

Cannabis can potentially help the symptoms of anxiety, ADD, depression, and a whole host of mental health issues initially. The problem is that cannabis fundamentally changes the brain in a way that causes long-term damage. Not only that, but if people are using cannabis as a coping mechanism for their mental health issues instead of therapy, they will not deal with the underlying issues, only medicate the symptoms.

When a new patient comes in and reports regular marijuana use, I highly recommend for them to get off of it, for at least the course of therapy. However, it also is important to mention that the first stance to take with every patient is empathy. I tell them there is no shame in their marijuana use. I liken it to them using a log when they’re in an ocean—it helped them keep their head above water because it floated. But when a rescue boat comes along, if they try to heft the log into the boat, it won’t work. With proper therapy, with the boat, they won’t need the log for survival any longer.

I even tell them they can get back on it after the therapy if it hasn’t helped them. When they are off of marijuana, they have the ability to be present and really process what they will need to process in therapy in order to get over anxiety and depression.

When they do take the symptom suppressor of marijuana away, often they will experience a flood of emotions and memories. Maybe cannabis was the best thing our patients could find in the moment, but there are obviously better ways of helping them deal with their pain.

In conclusion

I have a very extensive worksheet of all of the research about cannabis in my Free Resources Page. It’s important to understand the depth of the ways THC can affect our patients lives and mental health.



How to Help Patients With Sexual Abuse

On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.

We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.

What is childhood sexual abuse?

“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”

The facts:

  • 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005)

  • 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994)

  • 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009)

How does it affect health?

Statistics show that 20-40% of survivors have no negative effects later in life. This is dependent on the response of caregivers. If someone was supported, protected, validated and responded to in a therapeutic way, the child has a higher chance of resiliency, which occurs through secure attachment. If the child has secure attachment, they can usually move forward with their lives.

What Simonton’s study shows is that women who were silenced, shamed or not given a voice to resolve those childhood sexual trauma issues have more mental and physical health issues than normal. If a woman was in a multi-dimensionally unstable family—drug use, no structural stability, alcoholism, revictimization—they are less likely to have resiliency.

Bodily representations of chronic stress:

Women who experienced childhood sexual abuse that was never recognized by a loving caregiver demonstrate biopsychosocial health problems both in childhood and later on in life. Sexual abuse causes intensive stress, and there are many subsequent health issues that stem from it.

What we see is the body begin to break down in the face of cortisol and other stress-related hormones that are released over years of unresolved trauma. One of the first indicators that drives them to seek medical help is usually a physical ailment. Often the patient experiences a few health issues, and ends up medicating the physical things, but the underlying cause is never treated.

These show up in many different ways, but there are some predominant issues such as:

  • Migraines

  • Bladder problems

  • Hypertension

  • Anxiety

  • PTSD

  • Depression

  • Chronic fatigue

  • TMJ

  • Irritable bowel

  • Fibromialgia

  • Non-epileptic seizures

  • Diabetes (chronic stress makes it more difficult to control)

If your patient does have a chronic illness, that does not mean they have experienced childhood sexual trauma. However, if they are retaining stress from childhood sexual abuse, they are more likely to develop comorbid mental and physical health issues later on.

Helping patients who have experienced sexual abuse

Because we are meaning-making creatures, we assign values to situations in our lives. If something good happens, we assign positive meanings to it—we are good people, we are highly valued, we are loved, etc. If something bad happens, we assign meaning to it—we are gross, we are worthless, we are disgusting. As we internalize these beliefs, we begin to act according to those meanings in ways that further damage our bodies and minds.

So how do we help our patients revisit the meaning they’ve assigned to these traumatic experiences? Simonton’s research shows different programs and therapies that can help patients cope with the trauma and relief their symptomology.

Ask them their story

It’s important for a patient to feel they are revealing their story slowly and gradually if that’s what makes them most comfortable. Simply asking for them to tell their story, then helping them unpack the information if they mention sexual abuse, is the best way to go about it.


Don’t lead the witness

Some therapists who have been sexually abused themselves, or who are particularly drawn to sexual abuse victims, can tend to transfer other patient’s experiences and make conclusions about patients who maybe have not experienced sexual abuse. If this is the case, the therapist can sometimes “lead the witness” by suggesting and leading the patient to believe they have experienced this when they have not.

Get the right team around them

It takes a good team to help someone recover from the trauma of sexual abuse. A good friend and family support group, plus therapists and internal medicine doctors (if the patient is on medications for their comorbid physical ailments) will all bolster the patient’s healing process. As a therapist, try to work with the patient’s internal medicine doctor to get a complete picture of the patient’s whole health. That way, as the patient heals, their medication can be managed accordingly.

Family involvement is critical to patients improving quality of life. Women who had a partner or sibling did much better and received the fullest benefit of having someone with them for home care and help. Also, someone with a spiritual base or community demonstrated higher health quality of life throughout intake and therapy.

Having someone with the patient who can be there day in and day out leads to a much higher success rate than when they have isolated experiences with the therapist. What is difficult is when a person experiences positive change in their therapy, but goes back to a rigid family who relates mostly to the patient’s illness. Illness can even create a continuing underlying family rule of keeping the victim in her lower, negatively associated role.

This also helps the women establish a new relationship with whoever they bring to therapy with them in a sexual abuse program—it helps them re-relate to a person in a new healthy way. They are no longer just the victim, they can portray new goals for healing and see rapid growth alongside their partner, family or sibling.

Get them back in touch with their bodies

Many people who experience sexual abuse learn that their body is their enemy, a conduit of pain. They learn to dissociate to be able to survive, and that ability carries over into adulthood. Dissociation is a powerful tool that helps them be able to mentally “leave” their body so they can withstand physical pain or trauma.

One fascinating note Simonton made is that patients never recounted physical pain when they talked about their trauma. Their minds were so disconnected from their bodies that they had no memory of the physical consequences. Women who do this have been carrying this unchartered territory of pain in their physical bodies for so long that by the time they reach adulthood, they have to learn to reconnect with their bodies.

When we start to break the meaning apart to help patients begin to heal, we have to very delicately focus on what it means to reconnect their mind and body.

Getting patients refocused on their bodies and unearthing the resident trauma that is causing the stress-related illnesses will help them unlock their emotional and mental healing processes. They have an opportunity to discover that their body has a story to tell. By reconnecting to their bodies, they give it a voice to process its trauma.

How to listen well

There are a few things you can do to make sure your patient feels heard and validated when they open up about their sexual abuse. “Witnessing” is an important one. Some people who’ve experienced sexual abuse have stories that were never heard or validated.

When someone shares a trauma story and it is not validated (shame and silencing might have occurred with their family) it can re-damage the patient. When they share and feel validated, it can be a healing experience for them.

Asking them how it makes their body feel when they share about their experience is also important. It connects the somatic representations with the emotions and thoughts, which is important because these patients have most likely dissociated from their emotions and bodily sensations in general, but more so when they talk about their experiences.

How to listen, empathize and not take on the emotional repercussions of trauma

Hearing stories of trauma is difficult as an empathic therapist.

  • Make sure you practice what you preach—have your own therapist to help when you need it.

  • Find a colleague who also helps people through childhood sexual abuse and go speak to them about your feelings.

  • Determine a way you can take care of yourself when you get home from your work day. Create a space where you can enjoy your family, spirituality and recreation (including cardio and strength training).

  • Develop a treatment team of colleagues that works together to process through the difficult stories you are each hearing.

  • Ask fellow therapists how they feel—check in with your coworkers and fellow therapists to make sure you are each sustaining your own health.

What therapy techniques work best for the sexually abused?

  • EFT - Emotionally focused therapy for couples is an effective, research based spousal support therapy system. This teaches the spouses to be effective witnesses in the trauma story and is able to bring the support to inside of their home.

  • DBT - Dialectical behavioral therapy is incredibly helpful for people who are struggling with PTSD related to childhood sexual abuse.

  • Transference Focused Psychotherapy

  • Mentalization Based Psychotherapy

How can you tell what patients should be in regular, weekly therapy versus an intensive outpatient therapy for sexual abuse?

Many excellent outpatient therapists are doing a great job at treating patients who have experienced childhood sexual abuse. There are a few specific factors that could mean your patient would be better treated in a more intensive outpatient programs, such as:

  • If they are in a multi dimensionally unstable family where their health is being impaired. (AKA If they do not have a support system at home.)

  • If they are medically fragile because the body is beginning to break down.

    • Some outpatient programs have internal medicine staff to ensure the patients who are medically fragile are being physically supported.

  • If your patient doesn’t seem to be thriving or processing well, recommend them to an intensive outpatient program, with the idea that when they become more stable, they will titrate down to weekly therapy again.

  • If the patient is on so many medications, recreational drugs or alcohol that it puts them in a dissociative state where they are unable to concentrate and do deeper therapy work, an outpatient program might help support them while they come off of medications and process the difficulty of their trauma. (Many therapists don’t realize how much medications can dull the mind and make therapy very difficult.)

    • After a few weeks, some patients may need to be detoxed before they can fully process the emotional trauma.

During supportive forms of therapy, who should the patient bring with them to be a support?

The family is not always the most supportive group for the patient. There could be a partner or friend who is therapeutic and non-judgemental enough. However, it’s important to encourage the patient to bring someone they feel completely safe around. This person is supposed to help the patient grow and move forward, to make good choices outside of the therapy office. This person must have the best interest of the patient in mind, and not prefer the old maladaptive patterns the patient was in. They must support the patient in their growth and journey of health.

Many patients end up in relationships that are similar to the dysfunction of their trauma. How do you encourage a patient to find or make a friend that is healthy and can support them?

  • Help the patient identify their feedback loops, through identifying their early narratives and early meaning-making experiences.

  • Start to make changes as to how the person sees themself so that they see themselves as worthy. This is the best way to have lasting effects on their relational patterns.

  • A victim is a victim because they have a perpetrator. If there is no longer a perpetrator because they’ve surrounded themselves with healthy people, the patient is able to shed the victim narrative.

From chronic pain to thriving

We have found that patients who receive therapy are able to reduce the negative biopsychosocial effects. They are getting back to school, getting new jobs or raises at work, setting new goals.

Some people get stuck and lose hope, they don’t see it’s possible. Eventually though, if they keep seeking help, they are able to have breakthroughs and change their lives.

If you’re interested in learning more, here are a few podcasts and articles about emotional trauma:

How to Treat Emotional Trauma

How to Fix Emotional Detachment

Emotional Shutdown - Understanding Polyvagal Theory

***If you have been sexually abused, or think you have been sexually abused, connect with a therapist who specializes in this.


The science behind forgiveness and how it affects our mental health

What is forgiveness?

On this week’s episode of the podcast, I talk about the power of forgiveness. It’s scientifically proven that forgiveness can affect our health. As mental health professionals, this has important impacts both personally and professionally. I have also included a downloadable PDF for you to give your patients to help you walk them through the act of forgiving.

As a therapist, when I say the word “forgiveness,” my patients can shut down if I don’t explain it properly. Why? Because just the need for forgiveness is proof that they have been wronged. When we are wronged, it can be hard to let go of that hurt. That’s why I wanted to start out by saying what forgiveness (and this episode) is not about.

Forgiveness is not:

  • It is not approving.

  • It is not excusing the action, denying it, or overlooking it.

  • It is not just moving on (particularly not with cold indifference).

  • It is not forgetting or pretending it did not occur.

  • It is not justifying or letting go of possibly needed justice.

  • It is not calming down.

  • It is not a bargain or negotiation.

  • It is more than ceasing to be angry.

  • It is more than being neutral towards the other.

  • It is more than making oneself feel good.

  • It is one step towards reconciliation, but it is different from reconciliation, which requires a sincere apology from all parties.  

  • It is not dependent on the one you forgive—that would give the other power to control you by keeping you in your bitterness. Consider Corrie Ten Boom, who forgave the Nazis after losing her family in the Holocaust, or Marietta Jaeger who, after her daughter was kidnapped and brutally murdered, was able to forgive. People can forgive, even when the person who wronged them is unknown or dead.

  • It is not a one time event, but may need to be repeated (sometimes the hurt comes back, sometimes you need to start every morning with forgiveness).

  • It is not a restoration of full trust (trust takes time to develop or to be reinstated).

So what is forgiveness?

The Definition of Forgiveness:

Forgiveness is a process. It involves allowing yourself to feel the negative emotions you justly have towards an offense, and really putting the wrong into words in a congruent and authentic truthful way. Then choosing to release it, either giving it to a higher power, or letting it go to a cosmic sense of justice, or earthly legal justice system, and then continuing the process until negative affect is replaced with peace, empathy and compassion. When someone forgives they no longer have a portion of their daily life consumed in negative feelings towards the person or situation.  

“People, on rationally determining that they have been unfairly treated, forgive when they willfully abandon resentment and related responses (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principle of beneficence, which may include compassion, unconditional worth, generosity, and moral love (to which the wrongdoer, by nature of the harmful act or acts, has no right)”  (Enright, 2015).

Elliot (2010) cited Enright and Fitzgibbons (2000) and came up with two types of forgiveness:

Decisional forgiveness: the experience of granting forgiveness without eliminating the emotion, but in this, resentment may continue. It involves a cognitive model where therapist works with the client one time to make decision to forgive.

Emotional forgiveness: the patient must demonstrate changes in emotion and motivation toward their offender.

Studies show that:

Decisional forgiveness can reduce hostility, but it is only marginally effective in improving stress levels or emotional health (Elliot 2010 citing Baskin and Enright 2004, Worthington 2007). This means that emotional forgiveness is the goal of all forgiveness therapy.

What’s the most effective way to help our patients forgive?

Individual therapy that accomplishes Enright’s 4 phases over 20 encounters is “clearly most effective” way to actually accomplish forgiveness. (Elliot 2010 citing Lundahl 2008)

Why should we care about forgiveness?

Forgiveness isn’t a “nice thing to do,” it has real health ramifications that have been thoroughly studied, and it’s a fact that the act of forgiving can be a real change agent in therapy and long term health.

Here are the studies:

  • People who live with depression and a history of maltreatment have an upregulation of their inflammatory response compared to those with no history of maltreatment (Danese et al. 2007 as cited by Elliot 2010)

  • Unforgiveness is reflected in specific cortisol levels, adrenaline production, and cytokine balance (Elliot 2010 citing Worthington 2005)

  • Cause-effect relationship between pain and anger is similar to the anger-depression relationship. some studies show that just the anticipation of pain is associated with anger. (Okifuji 1999)

  • Chronic pain often arises from injury, or accident, thus anger is directed usually at the one responsible, or oneself. (Greenwood 2003)

  • General intensity of anger is important, but also specific targets of anger seem to be essential factors in understanding adaptation to chronic pain. Some research has shown that inward anger is more common in those with chronic pain vs. those individuals with different targets of anger. A study using the MPI (multidimensional pain inventory- a 60 item self reported inventory to assess different aspects of chronic pain) showed that 88 people endorsed anger at themselves and scored 0.38 on the anger inventory. Those that endorsed anger at other targets all scored below 0.30. Anger should be viewed as a multifactorial construct in chronic pain. (Okifuji 1999)

Specifically, in chronic low back pain, a preliminary study of 61 adult patients with chronic low back pain (31 recruited from pain and palliative clinic, and 30 recruited from community) showed patients with higher scores on forgiveness-related variables (‘current level of forgiveness’ as measured by Enright Forgiveness Inventory and ‘forgiveness self efficacy’ as measured by the Forgiveness Self-Efficacy Scale) reported lower levels of pain, anger, and psychological distress.

Patients who scored  (Carson 2005) analysis revealed that “state anger largely mediated associations between forgiveness variables and sensory pain, whereas the association between current forgiveness and affective pain was mostly independent of state anger.”

What is bitterness?

When someone continues to hold on to unforgiveness, they can become what we would call “bitter.” Bitter people are exactly like that word describes—so steeped in resentment that they become unpalatable.

Clues that someone may be bitter:

  • Do they continually replay past hurts over and over?

  • Do they hold onto the pain?

  • Do they try to avoid someone?  

  • Do they quickly get angry with someone?

  • Do they speak trashfully or verbally malign someone?

  • Do they find that their bitterness is more associated with the proximity of the person who wronged them than the magnitude of the event?

  • What percent of their emotional energy is spent on this topic?  

* Recurrent resentment affects all relationships and takes up room in one’s emotional life.

What does research say about bitterness?

  • Ten years or more after a divorce, ½ of women and ⅓ of men are still intensely angry at their former spouses, and anger becomes an ongoing, dominant presence in their children as well (Wallerstein).  

  • Forgiving people have been found to have a lower blood pressure at baseline. (Larsen 2012)

  • “Recalled experiences of betrayal that were less forgiven were associated with greater cardiovascular reactivity as indexed by greater diastolic blood pressure, mean arterial pressure, and rate-pressure product…higher trait forgiveness was negatively associated with lower resting blood pressure and better post-stress recovery.” (Lawler 2005 citing Lawler 2003)

  • Those who measured high in hostility, 20-25 years later, had higher rates of heart disease (Shekelle 1983, Barefoot 1983).

  • When discussing the narrative of injustice, those with an understanding of forgiveness showed less anger expressions (Tina Huang, “Cross Cultural and Real-Life Validation”).

How can someone forgive?

If the previous studies about the negative effects of not forgiving aren’t enough, let’s look at some of the positive effects of forgiving.

Personal health results of forgiving:

  • Changes anxiety into inner peace, reduces symptoms of depression, anger, and paranoia (Dr. R. C. Hunter, 1978).

  • Genuine acts of forgiveness lead to overall improvement in the person’s emotional maturity and increases the capacities for courage, nurturance of others, and love (Dr. Morton Kaufman “The courage to forgive” 1984).

  • Reduces fear. Impulses of anger and revenge subside and are replaced by more appropriate expressions of anger (Dr. Richard Fitzgibbons).

  • Hypertension may be reduced (Huang 1990).

  • Patients with fibromyalgia who were taught forgiveness education had a significant decrease in symptoms (Lee, 2014).

  • Incest survivors showed significant improvement after a 1 year forgiveness education process (Robert Enright, 1994, 1995).

  • A study that looked at 20 psychologically abused and divorced women, some who had remarried and some who had not. All participants scored above 41 on the Psychological Abuse Survey was considered indicative of a present and serious pattern of emotional abuse. Randomized between forgiveness therapy (FT: based on the Enright model) with an alternative treatment (AT: anger validation, assertiveness, interpersonal skill building). The study found that the FT group showed a greater improvement in forgiveness, self-esteem, state anxiety, trait anxiety, depression, environmental mastery, finding meaning, post-traumatic stress symptoms all determined by pre-and post surveys and questionnaires. The FT group had an effect size of 1.79 and represents a shift from below normal levels to normative levels. (Reed 2006)

Spiritual Connection

Some patients highly value their higher power. You can ask them to turn to their spiritual power and ask for the grace to have the willingness to forgive. They can give the spiritual power the opportunity to work in their lives in that way. Some have had powerful forgiveness experiences with their higher power.

Steps in the process of forgiveness:

How can we help our patients forgive those who have wronged them? Sometimes our patients have experienced things that can hurt to even hear about. Helping them move from trauma and anger into a place of forgiveness so they can live a healthy emotional life can be difficult to navigate. But, it is a worthy journey to pursue.

Here are the steps I walk through with my patients using a workbook sheets I have created. I have included a FREE DOWNLOADABLE PDF below that you can give to your patients to fill out. It walks them through the steps in detail, giving them a drawing to fill out and journaling exercises with specific questions to answer that will help them process their trauma and grief.


Further Reading on Forgiveness:

“Forgiveness is a Choice” Enright

Bradley, L. A., McKendree-Smith, N. L., Alberts, K. R., Alarcón, G. S., Mountz, J. M., & Deutsch, G. (2000). Use of neuroimaging to understand abnormal pain sensitivity in fibromyalgia. Current Rheumatology Reports, 2, 141–148.  

Brand BL, Alexander PC. “Coping with incest: the relationship between recollections of childhood coping and adult functioning in female survivors of incest.” J Trauma Stress. (2003):185–93.

Enright, R. D. Forgiveness is a choice. (2001) Washington, DC: American Psychological Association.

Fernandez, Ephrem, and Dennis C. Turk. "The Scope and Significance of Anger in the Experience of Chronic Pain." Pain (1995) 61(2):165-75.

Greenwood K, Thurston R, Rumble R, Waters S, Keefe F. Anger and persistent pain: Current status and future directions. Pain. (2003);103:1–5.

Knight JR, Hugenberger GP. On Forgiveness. Southern Medical Journal. (2007). 100(4):420-421.

Larsen BA, Darby RS, Harris CR, Nelkin DK, Milam PE, Christenfeld NJ. The immediate and delayed cardiovascular benefits of forgiving. Psychosom Med. (2012) Sep;74(7):745-50.

Lawler, K. A., Jarred W. Y., Rachel L. Piferi, Rebecca L. Jobe, Kimberley A. E, and Warren H. J. The Unique Effects of Forgiveness on Health: An Exploration of Pathways. J Behav Med Journal of Behavioral Medicine (2005). 28(2): 157-67. Web.

Lee YR, Enright RD. “A Forgiveness Intervention for Women With Fibromyalgia Who Were Abused in Childhood: A Pilot Study.” Sprituality in Clinical Practice. (2014). 1(3):203–217

Lichtenfeld S, Buechner VL, Maier MA, Fernandez-Capo M. Forgive and Forget: Differences between Decisional and Emotional Forgiveness.PLoS One. (2015) May 6;10(5):e0125561.

Moons, Wesley G., Naomi I. Eisenberger, and Shelley E. Taylor. "Anger and Fear Responses to Stress Have Different Biological Profiles." Brain, Behavior, and Immunity (2010) 24(2):215-19.

Muscatello MR, Bruno A, Scimeca G, Pandolfo G, Zoccali RA. “Role of negative affects in pathophysiology and clinical expression of irritable bowel syndrome.” World J Gastroenterol.2014;20:7570–7586.

Okifuji A, Turk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosom Res. 1999;47(1):1–12.

Reed GL, Enright RD. The Effects of Forgiveness Therapy on Depression, Anxiety, and Posttraumatic Stress for Women After Spousal Emotional Abuse. Journal of Consulting and Clinical Psychology. (2006). 74(5):920 –929.

Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. “Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial.” Pain. (2011).152(2):361–9.

Strang S., Utikal V., Fischbacher U., Weber B., Falk A. “Neural correlates of receiving an apology and active forgiveness: an fMRI study.” PLoS ONE. 9:e87654 (2014). 10.137.

White, JM. “Pleasure Into Pain: The consequences of long-term opioid use.” Addictive Behaviors. (2004). 29:(1311-1324).

Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000. 4(4):276-86.

Witvliet CVO, Phipps KA, Feldman ME. Beckham JC. “Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans.” J. Trauma Stress. (2004) 17:269–273.





What is Transference and Countertransference?

On this week’s episode of the podcast, I talk about transference and countertransference. It’s the fourth episode in my four-part therapeutic alliance series where I discuss best practices on dealing with the doctor - patient relationship.

Here are the three previous episodes:

Part 1 - Introduction

Part 2 - Logotherapy and Meaning

Part 3 - What is empathy and how to improve it

What is transference?

Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.

It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)

How does transference work?

The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.

When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.

There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.

Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states.  To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.

That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.  


This is where it’s important to understand transference, and to be able to give your patient a safe place to express their emotions.

When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.

Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.

Positive Transference

Negative transference isn’t the only type of transference—there is also positive transference, where you remind the patient of a positive relationship they had, so they feel deeply connected to you. People with borderline personality disorder are very quick to attach, usually commenting that they have never felt so close to a therapist before. When someone does say very positive things to me, especially in the first few sessions, I let them know that it’s also okay to express negative feelings towards me as well.  

Transference-focused therapy

Kernberg wrote about transference focused psychotherapy. He hypothesized about the developmental birth of borderline personality disorder. By exploring and integrating these “split-off” cognitive-affective units of self and other representations, patients will be able to think more coherently and reflectively. They will be more realistic and accurate in their thoughts, feelings, intentions and desires about themselves and others. Integration will allow for increased modulation of affect, coherence of identity, increased capacity for intimacy, and improved functioning (Kernberg 2008).

Levy (2006) studied transference focused psychotherapy (TFP) vs dialectical behavior therapy (DBT) vs supportive psychodynamic psychotherapy for borderline personality disorder. He found that TFP had increased secure attachments (whereas the other 2 did not change it), with increased narrative coherence. It also improved reflective function—the ability to mentalize the thoughts, feelings, goals of another person.

What are some common transferences?

  • Sibling rivalry

    • Competitiveness, comparing, jealousy.

  • Maternal

    • Possibly see you as nurturing or abusive.

  • Paternal

    • Possibly wants you to solve their problems, asks for direct advice.

  • God

    • Where they want you to be all powerful or omnipotent.

  • Erotic

    • One of their primary attachment figures might have sexualized them, so they might yearn for erotic attention and affection. Perhaps a patient falls in love with you, or someone similar physically to you.

  • Idealizing or contemptuous

    • They could view you as a savior, or feel contemptuous to you.

  • Passively hoping for a miracle

  • A person prone not to trust will view the therapist with suspicion

  • A person who struggles with anger will have anger towards the therapist

  • Transferences are influenced by age, gender, clothing, bodily attributes, context, vocabulary & choice of words, personality characteristics

  • Be a certain way to have you stay connected with them  

How do deal with transference in therapy:

Here is the main, overarching principle when dealing with transference: have empathy. Be empathic. Be open to their feedback. Don’t take things personally. Be connected with your patient. Developing a therapeutic alliance requires you being connected, and being connected requires you to allow your patient to explore their emotional world with you. That requires psychological safety.

When you are a safe place, they will hopefully be able to connect, and you can help them identify their transferences so they have a chance at developing healthy relationships in the future without bringing their past with them.

If my patient had a previous therapist, I always ask them, “What went well and what did not go well in your past therapy relationship?”

Other questions I ask are:

  • “How would you like your past therapy to have been different?”

  • “When you felt disappointed and misunderstood, were you able to share that feeling with your therapist?”

  • “In what ways would you like your relationship with me to be like your experience with your last therapist?”

  • “What are some of your worries about what you might experience in your treatment with me?”  

When I can tell they don’t want to come to therapy. I normalize their feelings so they feel like they can share with me.

  • “This is a laboratory where we look at what goes on between us, and when you tell me you are mad at me, I am going to be excited about your sharing your feelings, good or bad.”

  • “What are you feeling about leaving me for the day?”

  • “What did you do when you were young and something bad happened to you?”

    • “Go to mom? Go to Dad? Go out alone?”

    • “When you looked for help how were you responded to?”

    • “Were you comforted? Did it help?”

    • “How did it make you feel when you wanted somebody to help your upsetness?”

    • “I want to be with you in this moment of sadness and loss.”

When you sense an empathic strain, mending it is priority number 1. I might say, “Help me understand what I might not have understood here.” Or, “If I said something that makes you feel worse about yourself then let’s talk about it now.” Try to prevent an empathic strain from progressing to an empathic rupture in your relationship by catching the strains early on.

Here are a few tips to handle when patients exhibit strong emotions towards you:

  • Be enthusiastic and curious about patients’ experiences when coping with intense feelings.

  • Be particularly encouraging about them discussing their feelings, and especially their feelings towards you. Whereas in the past there might not have been a  safe place to get angry, they are entitled to want to have a different experience with you.

  • Say explicitly that they are allowed to have all of their feelings (including loving and hating) in the therapy relationship and that they will be dealt with in words and not in actions.

  • Convey to them that they can feel secure and accepted and not reproached or rejected, even if they have negative feedback or feelings towards you.

  • You can work cooperatively to help them process and modulate their emotions.

  • You can explore together what actions might be appropriate for them when the flooding feelings erupt and they are unsure about what might happen as consequences.

  • Complicated emotions are inevitable: the opportunity we offer is to enhance ways of coping with desirable as well as disruptive emotions. Emotions may be congruent with experiences in the past, but not necessarily appropriate in the present context in which they recur.

When we are young, we are unable to metabolize emotions correctly, especially in the face of trauma or an unsafe caregiver. When we age, we transfer those patterns of belief onto every other relationship in our life, trying to recreate that. When you, as a therapist, offer a safe environment for a patient to experience those strong emotions, you are helping them rewire their belief system around those emotions. It allows them to interact with every other person in a new way.

Countertransference:

The original and narrower definition of countertransference centered around the therapist unconsciously experiencing the patient as someone from their past (similar to transference). Now, countertransference is seen as the therapists’ total reaction to the patient.

First, it’s important to note that therapists need to practice what they preach: do the work in your own therapy so you can identify your own transferences. The less clouded your vision is of what’s happening in sessions, the better. For example, one therapist saw nearly every patient as a trauma victim, and occasionally led them to believe they’d been traumatized as well in the same way.  

Countertransference is seen as a source of important information about the patient: it can be a major diagnostic and therapeutic tool. “Countertransference is an instrument of research into the patient’s unconscious.” (Paula Heimann)

Now it is seen as a jointly created reaction in the clinician (some reactions from the therapist's past, some induced by the client's behavior).

There are continuously fluctuating levels of influencing the transference and countertransference by contributions from both patient and therapist during all their interactions. My mentor, Dr. Tarr, said, "To every relationship we bring learned expectations from past encounters.”

One way to handle countertransference to make sure you are coming from a healthy place is to use your left brain to integrate with, and therefore dampen, the right brain. Learn from what you are feeling during the session, but observe yourself with curiosity.

Another form of possible transference is sexual attraction towards a patient. Studies show that 85% of male therapists at some point have erotic arousal towards a female patients. Obviously, it is important to not act on or tell your patient about those feelings.

You should also allow yourself to mirror the patient’s emotions, as to follow the patient’s emotional movements and unconscious content.  

Before a patient enters the room, check in with yourself. How are you feeling? What are you feeling?

Here is a checklist I like to use before my sessions with patients. It is based on 7 basic emotions:

  •  Disgust

    • I dislike him/her.  

    • I feel repulsed by him/her.

  • Attraction

    • I have compassion for the patient.

    • If they were not my patient I would want to date him/her.

    • I feel sexually attracted to him/her.

    • If he/she were not my patient I would want to be their friend.

    • I look forward to sessions with him/her.  

    • I wish I could give him/her what others never could, protect him/her like no one could...

    • I feel I understand him/her.  

    • I have warm, almost parental feelings towards him/her.

    • I self-disclose more about my personal life with him/her more than with other patients.

  • Sadness

    • I wish I had never taken the patient on...

    • I feel sadness/depression in sessions with him/her.

    • I feel guilty about my feelings towards him/her.

    • I feel guilty when she/he is distressed or deteriorates, as if I must be somehow responsible.  

  • Angry

    • I feel dismissed or devalued.

    • I feel annoyed in sessions with him/her.

    • I feel criticized in sessions with him/her.

    • I feel angry with him/her.

    • I feel anger at people in his/her life.

    • I feel competitive with him/her.

    • I feel used or manipulated by him/her.

    • I have to stop myself from being aggressive or critical with him/her.

    • I feel pushed to set firm limits with him/her.

    • I feel resentful working with him/her.

  • Dissociation/Shut Down

    • I feel confused in sessions.  

    • I am overwhelmed by strong emotions with him/her.

    • I feel hopeless working with him/her.

    • I feel like my hands are being tied or that I have been put in an impossible bind.

  • Sensorium issue

    • I feel bored in sessions with him/her.

    • My mind wanders to things other than what he/she is talking about.

    • I feel sleepy when talking with him/her.  

  • Fear/Anxiety

    • I feel anxious/frightened working with him/her.

    • I fear I am failing to help him/her.

    • His/her sexual feelings towards me make me anxious or uncomfortable.

    • I fear being incompetent or inadequate to help him/her

    • After treatment ends I worry about him/her more then most patients.

It is completely normal to have feelings—both good and bad—towards patients. We are humans, not robots! Sometimes it might seem like you’re supposed to be perfect or void of feelings towards your patient, but that doesn’t allow a living, growing, healthy therapeutic alliance towards them. The important thing is to notice how you feel, without self judgement. Then, deal with those feelings in a healthy manner, like through seeking out your own therapy, getting a mentor, etc. However, sometimes merely allowing yourself to notice the feelings and owning up to the feeling of anger, attraction, boredom, or sadness, is enough to dissipate it.

It’s easy to be busy after a session. It’s better to practice noting your feelings. After all, how can we help our patients express and normalize their feelings if we cannot do it for ourselves?

Conclusion

If you are a mental health professional, I would love for this to be your community. We are in these trenches together, and it’s pretty common for therapists to feel totally exhausted and burned out from all of the countertransference. I hope that through this community, we can develop better practices, help each other, and grow together.

If any of you have any questions or listen to the podcast, I’m active on social media. I’d welcome any feedback you have. My social handles are: Instagram @Dr.DavidPuder, Facebook: @DrDavidPuder, or Twitter @DavidPuder




How Empathy Works And How To Improve It

What is empathy?

Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values.

In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate.

Cognitive empathy

Cognitive empathy is also known as perspective taking, and it can help someone understand another’s personal experience. It also tends to reduce interpersonal aggression. Cognitive empathy is exactly what it sounds like—cognitively understanding someone’s situation, emotions, and motivations. When we understand someone else, we are more likely to view their behavior as similar to our own.

  • One study of Asperger syndrome showed they had lower cognitive empathy but NOT affective empathy. (Dziobek, 2008)

Affective empathy

Affective empathy is about a shared emotional experience, one of feeling together. It uses the mirror neuron system, which I will discuss later on in the article. Affective empathy forms powerful emotional relationships.

  • Boys with higher aggression had ½ the affective empathy, but the same level of cognitive empathy, as the non aggressive control group (Schechtman, 2002)

Compassionate empathy

The third form of empathy is compassionate empathy, which is also called empathic motivation, prosocial concern, or sympathy. This is when you feel moved to help another from how to experience their reality.  

The science of empathy

Mirror Neurons are sharing neurons

Our brain has neurons solely designed to mirror other people. From birth, when we focus on another's movements, emotions and intentions, our brain lights up automatically, and largely unconsciously, around 10% the same way. Our own body-state can be derived from someone else outside of us. We can therefore understand and map out the mind of others by placing ourselves in a comparable body state. This process is important for empathy, intuition, transference, countertransference, enactment, projection, internalization and intersubjectivity.    

The discovery of mirror neurons:

In 1992, while studying a monkey's brain with electrodes attached to the motor area (the area that lights up when movements by the body are made), researchers accidentally discovered that not only would the neurons become activated by the monkey reaching out to pick up a piece of food, but also when the researchers made a similar movement. Later, the same team published a paper that showed that there were mirror neurons responding to mouth actions and facial expressions. Further studies confirmed that around 10% of neurons in certain areas of a monkey's brain had mirror abilities. Later, these studies were expanded to humans.  

Current research:

A recent study summarizing the data of 125 fMRI studies of humans (brain imaging that shows what is active), found that there were many areas of the brain with this capacity. (Molenberghs, 2012) Beyond seeing actions performed by others and having them represented in our brain, there are 3 other areas of the brain that are activated in a similar fashion:

  • Ever wonder why watching people embrace enthusiastically at an airport is fun? When you observe someone being touched, a similar area in your brain (the secondary somatosensory cortex) activates in a similar way as the person being touched.  (Keysers, 2004)

  • When you only hear something, like someone cracking open a peanut, how do you know what is occurring? Another study showed that there was a similar brain circuit firing in both doing the action and hearing it, and just hearing it. This study also showed that those with higher scores on perspective taking (ability to slip into another's shoes) had stronger activation of mirror areas! (Gazzola, 2006)   

  • When we watch someone grieve at a funeral, ever wonder why we feel their sadness?  When you feel emotion, you experience the emotion in your brain, like they are to a lesser extent.  (Gaag, 2007)

    • When normal college students looked at photographs depicting emotions, out of their awareness their own face muscles depicted the same emotion on an EMG.  

    • “We are hard-wired to feel what other experience as if it were happening to us.” (Marco Lacoboni)

    • We used to say, metaphorically, that ‘I can feel another’s pain.’ But now we know that my mirror neurons can literally feel your pain.

    • “Mirror neurons dissolve the barrier between you and someone else.” (Vilayanur Ramachandran)

Now researchers are saying that the mirror neuron system is involved with:

  • Understanding another's actions and intentions

  • Neural basis for the human capacity of empathy

  • Learning new skills by imitation and rehearsing

Non-empathic types—the Dark Triad

The “Dark Triad” refers to three types of disorders that cause people to have low empathy for others. The big common denominator for these people is a deficit in affective empathy, but after matching for primary psychopathy, the others are no longer predictors of low affective empathy (Wai 2012). The Dark Triad consists of: narcissists, Machiavellians and psychopaths. People who have narcissistic traits and machiavellian traits often have some primary psychopathy traits as well.  

Individuals high in narcissism had positive feelings when looking at sad faces and were accurate at recognizing anger (higher cognitive empathy may be bias at grandiose self reporting). Individuals higher in primary psychopathy (they can usually maintain cool composure and carefully execute planned behaviors with a lack of morality, whereas those with secondary psychopathy respond to their negative emotion when they harm others) felt positive when looking at sad, angry or fearful images and more negative when looking at happy images, and were rather inaccurate at identifying all emotions.

Machiavellians felt negatively with happy images and positively with sad images, while they tended to inaccurately identify happy or sad emotions.

Empathy and the medical field

  • Studies show that empathy declines in third year of medical school (both for men and women, but women are higher in empathy in general)  (Hojat, 2009) but that doctors can also increase their empathy through certain practices. (Riess, 2012)

  • In a study of 20,961 patients, primary care providers with high empathy have been shown to have lower rates of metabolic complications compared to moderate to low scores (4.0 per 1,000 patients vs 7.1 and 6.5 respectively) (Canale, 2012).  

  • There have been many studies that show both cognitive and affective empathies ability to change patient care when high and low empathy are demonstrated. For example, there is a correlation to a doctor’s ability to more accurately diagnose depression and anxiety, understanding interactions, more positive patient outcomes, increased therapeutic alliance, more patient satisfaction, and fewer malpractice claims. Doctors who showed higher empathy were more likely to have their HIV patients take their medications (Flichinger 2015).

Research on “Therapist Effect”

  • Some doctors or therapists have better outcomes. Empathy seems to be important in therapist effectiveness and can be increased.  

  • Different studies show outcomes vary between patients, of which 5-12% can be attributed to a particular therapist.   

  • One study of 91 therapists over 2.5 years: the best therapist showed a change of 10 times the average mean, the worst showed the an average increase in symptoms.  (Okiishi, 2003)

  • Higher interpersonal skills has been linked to better outcomes when studying therapist effect. (Anderson, 2009)

  • Higher-empathy therapists have higher success regardless of theoretical orientation. Lower-empathy therapists linked to higher dropout rates, relapse rates, and weaker therapeutic alliance. Empathy was shown to have an effect size of 1.22-1.43 when independent observers rated empathy for substance use outcomes. (Moyers, 2013)

  • In a big study on therapist effect (69 therapists, 4,580 patients), they found that years of experience, gender, age, profession, highest qualifications, caseload, degree of theoretical integration did not predict outcome. The amount of time spent targeting improving specific skills and reviewing therapy recordings predicted client outcome.  

Can we improve our empathy?

Studies show that we can. Here are some things that can improve your ability to empathize:

  • Optimize your sensorium—keep yourself healthy. When you are tired, hungry, chronically stressed and with poor focus, it will be harder to enter into the experience of another.

  • Try to understand the person’s emotions that you are with.

    • A study showed by trying to pay attention to emotion mimicry was increased (linked to affective empathy)

  • Read fiction (Bal, 2013) allow yourself to be transported into the book.

  • Work through our “countertransference”

    • Talk through difficult situations

    • Patients have different ways of relating—learning to understand others, to see their way of being as “adaptive,” can be empathy promoting.

  • Learning to read emotions and body language more accurately  

  • Learning to accept feedback

  • Calming your own hyperarousal through practices like mindfulness

  • Tuning your mirror neurons

  • Noticing when connection or disconnection is occurring

  • Practice empathy towards viewpoints that are not your own

    • Becoming mindful of the emotion, the distress, the meaning behind the distress

Can therapists lose our empathy?

Studies show we can experience empathic strain and rupture. Empathic failure may lead to aggression. It is hard to empathize when we feel subjected to powerful influences from patients: complaints, requests, accusations, subtle seductions, bits of blackmail, challenges.  Throughout history, rulers have decreased empathy in their warriors and people by stirring up disgust towards those they seek to kill.

We are more likely to empathize with those we interact with frequently, find similar to us, or find thoughtful and kind.  We need to humanize people’s actions and see them like us, to not lose the part of us that could consider that we too could be in their situation.

Consider the stages of empathy:

I think of empathy in terms of 3 categories: the moment to moment emotional experience, the meaning and context of the emotion in their life, and the subjective experience evoked and created by the unique connection I am having in the here and now with the person.  

Level 1: There are moment to moment flashes of emotion on someone’s face, changes in body language, and current distress. Empathy can be experienced by just witnessing a flash of emotion and allowing the person to know you see it and that you hear them. During this, we can try to understand the person’s emotions, and ask them to verify what they are feeling, if we are correct in our questions, such as if they are feeling sad or angry about something.

Tuning into their experiential state and then asking if you are on the right track: (note if the patient gives a different word then do not contradict) can be helpful.

  • Ask them a few questions to clarify:

    • Perhaps you feel happy?

    • Perhaps you feel frustrated?

    • Perhaps you feel sadness?

    • Perhaps you feel disgusted?

    • Perhaps you feel concern or fear?

    • Perhaps you feel a sense of pride?

    • Perhaps you feel disconnected or numb?

    • Perhaps you feel a sense of embarrassment or shame?

  • Use their own words and repeat what you hear from them:

    • Patient: “I just feel so tired and sad all the time.”

    • Doctor: “It makes sense you feel tired because you have been so busy with your new jobs. In light of your recent losses your sadness also makes sense.”

  • Matching rhythm of voice, tonality, emotionality.

    • Matching an infant's cry rhythm (but not intensity) calms and regulates the infant

  • Imitation

  • Recognition of what the patient hopes for:

    • I hear you have hopes for… desires for… dreams for… aspirations for...

Level 2: This is where we try to know the context of the flash of emotion, the distress either in the distant past (how early relationships informed it) or recent life situations. Sometimes the quantity of distress is only as high as it is because it is linked to prior loss or prior trauma. We can find the context of the emotion by matching their emotionality, their demonstration of emotions on a level that we feel is appropriate. We can look at the meaning of the emotion and the context of the meaning of that emotion in their lives. We can also empathize with the meaning of the emotion once they’ve identified its context.

Even if they flash anger towards themselves, but maybe they in doing that are not accomplishing the energy of the emotion, and they are missing how the anger can help them accomplish their goals. Thus when the anger is pointed at themselves, we can explain that the anger should be pointed outward, and give energy to action.

  • Example: anger towards self looks like, “I am worthless” instead of anger towards abuser: “he should not treat me like that, I will set up a boundary.” The empathic statement can be “it must be hard to feel the anger pointed at yourself, telling you that you are worthless, and perhaps although it was adaptive to do this growing up, makes it hard to set boundaries now.”

Level 3: This level is when the person is having emotion that occurs because of their relationship with you. It is the interpersonal, and commenting and empathizing with any distress (or positive emotion) that your relationship is creating is a level 3 empathic statement. When a patient demonstrates anger towards their therapist, it’s helpful to ask if they are feeling anger towards you and if they feel comfortable talking about that emotion.

We can create psychological safety for a patient to give feedback to us by telling them we like to hear what they are feeling towards us. For example, my mentor, Dr. Tarr, tells his patients:  

“I very much want to hear your positive and negative feelings, particularly about me, and particularly negative ones. It will be helpful for you to share any feelings of disappointment, feelings of not being understood, feelings of not being responded to or criticized, or mannerisms or things I say that affect you undesirably. I hope you can understand that this is not a usual social situation, where you don’t tell people negative thoughts, here I hope you have the courage to say them out loud. It will be very helpful to say it has it is happening; we can learn much more than if it comes out later; we know it’ll be hard—but this kind of a laboratory where we discover what goes on between us.”



Perinatal Mood and Anxiety Disorders

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In this podcast and article Dr. Kelly Rivinius, a licensed clinical psychologist who helps women suffering from PMAD, gives her insights about PMAD, its risk factors, prevention, and her own experience with perinatal OCD and anxiety.

David Puder, M.D. and Kelly Rivinius, Psy.D. have no conflicts of interest to report.  


Article the accompanies this episode go: here

Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy

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In this week’s episode of the podcast, I’m going to be emphasizing the meaning that I, as a therapist, can help draw out of other people’s experience through a therapeutic alliance.

David Puder, M.D., Kristen Bishop, Brooke Haubenstricker, Mikyla Cho

In the celebrated book Man’s Search for Meaning, author Viktor Frankl wrote about his intimate and horrific Holocaust experience. He found that meaning often came from the prisoners’ small choices—to maintain belief in human dignity in the midst of being tortured and starved and bravely face these hardships together.

“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl

Frankl argued that the ultimate human drive is the “will to meaning,” which could be described as the meaning to be found in the present and in the future. For example, I have had patients who are suicidal, yet they would not kill themselves, despite part of them desiring death, because they would not get to see their grandkids grow up. The meaning of the future moments and being able to help their grandkids in some small way empowers them to keep going to treatment.

People’s meaning keeps them going, even when other drives, like sex or desire for power, are completely gone. In this way, Frankl noted, “Focus on the future, that is on the meaning to be fulfilled by the patient in his future…I speak of a will to meaning in contrast to the pleasure principle (or, as we could speak also term it, the will to pleasure) on which Freudian psychoanalysis is centered, as well as in contrast to the will to power on which Adlerian psychology, using the term ‘striving for superiority,’ is focused.”

This idea led to the beginning of a new type of therapy—logotherapy.

Helping a patient find meaning

Being unable to find personal meaning in our lives can lead to depression, hopelessness, anxiety, and suicidality. As a physician, I see this often, and I try to help my patients find meaning in their lives. However, the approach I have learned from Dr. Tarr (my mentor), and from my studies, is different than the normal approach of just asking people, “What is your purpose?” or, “What is your vision for the future?” The technique I use is based on another principle called “psychic determinism,” which means that everything has meaning. There is nothing that a person says, no flash of emotion, no change in body posture that is meaningless.

When you believe this, you view the patients’ words differently. The meaning may not be readily apparent; it may be expressed in primary process mentations and have an unconscious-type meaning like dreams, which may be difficult to understand. Suffice to know at this point that the mindset we have when we approach people is that everything they say has meaning; every sequence of thoughts that they say is deep and valuable.

We start from small moments of meaning that are coming from their words, their body language, their microexpressions, your experience of them in the moment, and we take those small moments of meaningfulness and start to verbalize what we find meaningful. Listening to our patients and helping them to understand the hidden meaning in their lives, even in the midst of work or difficult times, can help them withstand trauma, stress, and hardships.

No rambling is random

Sometimes patients will talk for awhile, changing subjects rapidly, and we may think it is random, but it isn’t. Even when schizophrenic patients talk, there is meaning behind what they’re saying. When we allow for free association, we can derive a sense of meaning from the commonalities in topics that come up.

For example, a patient might be talking about how they are angry at their significant other, then immediately report that when they were young their mother would often yell at their father, and their father would cower in his room in silence. How is their current anger related to how they felt as a child watching this drama? How might the two be linked? What about the microexpression of disgust that flashed as they reported both topics.  

As you look deeper, the meaning becomes more evident. In this particular situation, the disgust or revulsion they experience recollecting their father’s cowardice magnified the disgust they felt toward their significant other. Understanding the link and the uncovered meaning helped them tolerate the intensity of that negative feeling, and helped them develop new meanings about their current and past experiences.

Even hallucinations and delusions generated by some mental illnesses have meaning. When I’ve given patients antipsychotics and they’ve adapted to the medicine, we explored their hallucinations and they were able to see why they wanted to believe in an alternate reality—it gave them a sense of power or control, or related to a deep underlying fear in some way. As we developed meaning in their real lives, they felt more comfortable in their actual reality.

When we sincerely believe that everything the patients say has meaning, the patients themselves feel meaningful. Ascribing meaning enhances the patient’s esteem tremendously and makes them feel safe enough to continue to freely associate. Incredible progress can be made with patients in this way.

To get people to free associate, you need to reduce the shame enough to get people to feel safe enough to be able to share their uncensored thoughts and feelings.

Empathize with the meaning

“Men are not moved by events but by their interpretations.” - Stoic Epictetus

Relationships can allow for deeper understanding and meaning to develop in life. To strengthen our relationship with our patients, we must understand what they’re saying and then empathize with that meaning.

We often think in the context of our own lives, and as therapists or physicians we need to allow people to be the experts of their own lives. A word or phrase may mean something completely different to our patients than it does to us, so we must ask the patients to help us understand their interpretations and the meanings they assign to the events they’ve experienced. It is important that the patient communicates their meanings and that assumptions aren’t made. Misunderstandings can cause feelings of isolation, leading to strains or ruptures in the relationship. If this happens, try to reconnect, as this conveys respect.

Try to deeply connect with the patient emotionally through empathy and listening. Listen to what is said, what is not said, and what makes the patient defensive. We can listen to the rhythm, the sound, their vocal cadence, and watch their face for emotional cues.

Even if we believe the patient isn’t entitled to the emotions they are experiencing, we have to search for the meaning they’ve assigned to their pain. That meaning is what we can empathize with, no matter the circumstance. When we empathize, we can join them in their distress or enjoyment, and we can develop a deeper therapeutic alliance that is patient-centered and emotion-centered.  

“To feel with a patient and share distress and hopelessness and mistrust of the future, is therapy. You are an observer in taking history, but you’re a participant as a therapist. To share together, is therapy.” - Dr. Tarr

Meaning develops emotional endurance

People who have chronic pain who believe they are enduring it for a deeper meaning report feeling far less physical pain compared to those who do not report a deeper meaning. Even in birthing units, women report the highest amount of pain, but also often the highest amount of satisfaction. The child being born gives meaning to the pain, and this meaning is so powerful that some women choose to endure the pain instead of accepting medication.

Help patients find meaning in their symptoms. Most symptoms are adaptive, even eating disorders, cutting, and other harmful behaviors. These things have helped people cope with the realities of their lives in some way. We don’t want them to judge their symptoms, but we want them to identify what the meaning behind them.

To really connect with a patient, we must convey to them through our words and actions that they mean something to us, and that we empathize with the meanings they’ve assigned to their lives.

Here are a few phrases I like to use that convey to the patient that I want to connect with them:

  • “What we are talking about together is meaningful.”

  • “We want to make sure we are understanding each other.”

  • “I think I know what you mean. Please tell me if ______ is what you meant. I want to make sure I am understanding you and that we are in tune with each other.”

  • “If you feel I misunderstood you, please tell me right away so we can clear it up as soon as possible.”

  • “We will know together, find out together…”

  • “Could you give an example, elaborate on that, I want to be sure I understand what you are sharing with me.”

  • “I can understand in part how that interaction would make you feel that way.”

Logotherapy, created by Viktor Frankl, helps patients understand and develop meaning in their lives.

Viktor Frankl’s book not only chronicles how the principles of logotherapy helped Frankl survive the Holocaust, it also recounts his observations of how others used meaning to retain their human dignity during times of great suffering. So what is this “logotherapy” that helped people survive?

Essentially, logotherapy is a meaning-centered approach to psychotherapy. Frankl first published his ideas on logotherapy in 1938, and it is now known as the “Third Viennese School of Psychotherapy.”

The Viktor Frankl Institute lists the three principles that are the basis for logotherapy:

  1. Freedom of will

  2. Will to meaning

  3. Meaning in life

The core tenants can also be elaborated in another way, as done by the Viktor Frankl Institute of Logotherapy in Texas:

  1. Life has meaning in all circumstances, even the most miserable ones.

  2. Our main motivation for living is our will to find meaning in life.

  3. We have freedom to find meaning in what we do, and what we experience, or at least in the stand we take when faced with a situation of unchangeable suffering.

Frankl noted that there are a variety of ways in which we can find meaning, such as by our actions, our experiences, our relationships, and our attitude toward suffering. Indeed, logotherapy has been utilized to help treat a variety of psychiatric illnesses, such as anxiety, depression, obsessive-compulsive disorder, and even schizophrenia. Currently, there are several logotherapy institutes around the world in Africa, Asia, Europe, and North America that focus on educating the public about logotherapy and applying it to find meaning in people’s lives.

Here are some studies about logotherapy:

  • One study (May, 2010) found psychological safety and psychological meaningfulness was significantly related to engagement in work. 73% of the variance in engagement in work was able to be explained, with 62% coming from meaningfulness and 42% coming from psychological safety.

  • One study (Mahdizadeh, 2016) of patients after heart surgery found that those receiving logotherapy had improvement in mood. Additionally, this study found that logotherapy did not change the physical capabilities of the patient post surgery. However in the patients who had little to no symptom relief and continued limitation of functions post-op, it still showed an improvement in mood 6 months after the study was completed.

  • Another study (Robatmili, 2014) had the logotherapy group work on describing what was meaningful, setting goals, and then had the group facilitate each other moving towards their goals. In this treatment group, the “meaning of life” scores increased and depression scores decreased. Discovering and pursuing meaning is facilitated by helping through the following steps: (a) establishing the therapeutic relationship; (b) increasing insight regarding identity, values, and goals; (c) reframing meaninglessness and depression; (d) discovering meaning within the meaninglessness and depression; and (e) pursuing the fulfillment of meaning.

  • Once you have some positive attributes, you find other positive attributes—like a snowball effect of developing positive meaning in life. One study (Zhang, 2018) showed this after surveying 1,000 elderly people in Hong Kong. There was a higher level of meaning associated with happiness, health status, and decreased healthcare utilization.

  • Another study (Mahdizadeh, 2016) showed that when educational interventions based on the main concepts of logothearpy were made, it lead to an improvement of the patient’s quality of life after CABG surgery in persons over the age of 35 (specifically, scores in QOL were improved psychologically).

  • In one study (Mosalanejad, 2013), an infertile experimental group that used logotherapy showed significant decreased psychological stress scores.

  • One case review (Southwick, 2006) looked at adding a meaning-based intervention into the treatment of chronic combat-related PTSD showed positive enhancement of outcome when combine with traditional therapies and medications.

  • A study of women with breast cancer (Mohabbat-Bahar, 2014) showed logotherapy to be helpful at reducing anxiety.  

  • I also discussed a study (Thomas, 2014) regarding how structured sessions helped cancer patients improve their sense of meaning in life.  

  • A qualitative interview study on nursing home residents (Drageset, 2017) found that meaning could be found in physical and mental well-being, belonging and recognition, personally treasured activities, and spiritual closeness and connectedness.  This present study also showed a link between well-being of patients’ hope for an improved state of health and are in accordance with previous studies showing significant associations between meaning, hope and well-being among older people in nursing homes.

  • Finally, a study (Leveen, 2017) explored how poetry can be used to increase a sense of meaning in physicians caring for patients.    

Conclusion:

By focusing on what is said by our patients and those we care about and by believing that everything that is said has meaning, we can increase our connectedness with them.  We can also slowly find the deeper sources of meaning and purpose which can help make sense of suffering and physical and emotional pain.






What is psychodynamic theory?

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On this week’s episode of the podcast, I interviewed Allison Maxwell-Johnson, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey.

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient’s emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist.  

The history of psychodynamic therapy

Sigmund Freud is known as the father of psychodynamic therapy. He practiced in the late 1800’s and early 1900’s. Some psychiatrists and therapists think that Freud has been debunked because he is a controversial figure. But my colleague, Allison Maxwell, and I, think his impact on furthering the mental health field has been positive.

Historically, people with borderline personality disorder, somatic disorder and post traumatic stress disorder (PTSD) were all grouped under the title of “hysteria.” A few hundred years ago, these people would have been killed as witches, put in asylums, and there wasn’t much ability to, or interest in, digging into their psyche. There was certainly no warmth or empathy given to them.

Freud began to grapple with those deeper, tougher issues, claiming it wasn’t just a medical disorder. He gave empathy, and a level of connectedness to his patients that hadn’t been done before. As the first psychoanalyst, he was a pioneer in his field, and he figured out that having an emotionally connected relationship with his patients (he would even have is patients over for dinner and go for walks with them) could actually heal the patient.

Affect

Affect is something therapists need to pay attention to when it comes to each individual patient. It’s about noting the facial and emotional state of the person. Is the patient emotionally flat or expressive? Are they depressed or happy? Are they peaceful or agitated?

We focus on their emotional state and try to lean in to understand what a patient is feeling during a session. As the doctor or therapist, what is the emotional reaction you're having to the patient, in the moment? Analyze the situation—both your feelings and theirs. Ask them for clarification on their feelings, then ask yourself how you can use that information to understand and connect with the patient emotionally.

There are multiple emotions going on which can be conflicting. We need to ask ourselves if we can empathize with the distress that is in the room.  

It’s not only about intellectually understanding what’s happening with a patient, or diagnosis. It’s about understanding how to create an emotional connection and help someone.

Transference

A therapist applies the principle of transference when we pay attention to the emotional state the patient has towards them. If the therapist reminds them of their abusive father, and they react emotionally, it’s a classic transference situation.

Understanding transference can help a therapist remain empathic and curious, even when a patient is angry at them. Transference can be seen in their complete reaction towards you, both from their past, and how you are interacting with them.  

Countertransference

As therapists, we are also humans. We will have reactions to the patients we work with.  Countertransference is the complete reaction we have towards our patients, both coming from how the patient reminds us of people from our past, and our reaction towards the things that the patient is uniquely doing.

The unconscious exists both in our patients and in us. If we can keep countertransference in our awareness as therapists, we can try to understand what is happening interpersonally—why we do or don’t like our patient, and why we feel angry or upset with our patients.

As therapists, we should not react to our patients out of direct emotion, but understand that countertransference is happening, and be curious about the meanings behind our feelings, and their feelings towards us.

Studies that show psychodynamic theory works:

  • For the curious, read this article by Jonathan Shedler, “The Efficacy of Psychodynamic Psychotherapy” PDF

Mentalization-based therapy

Mentalization therapy is an emotion-focused therapy for people with borderline personality disorder. It helps them question whether they are accurately mentalizing, or understanding, their own experiences and their therapists emotional experiences. The positive effect of mentalization-based therapy is measurable. It has a mean effect size of 1-2, meaning it is 1-2 standard deviations from the control group—it works.

People who were in and out of psychiatric hospitals with suicide attempts, after mentalization therapy, can have great success in achieving a normal life.

  • Study on Mentalization based therapy with 8 year follow up: PDF

Transference Based Therapy:

  • Article on transference focus therapy increasing a patient’s narrative coherence and reflective function: PDF

In conclusion

As therapists, including psychodynamic principles can help us connect with our patients. It will protect us from burnout, and give our patients the chance to feel emotionally connected with someone, in a corrective and healing way. It can be incredibly rewarding, rather than draining, when we feel connected, and our patients usually express gratitude as they heal.



Advice for medical students applying to psychiatric residency

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Timothy Lee has talked to thousands of medical students about how to applying for residency programs, and here, he gives us a few tips on how to make it through the gauntlet, and how to have your best chance at landing the program you want.


Here is what Timothy Lee says:

Stay calm

Many students have been fine tuning their personal statements, and trying to get their resume just right, or hurrying to press the faculty to write letters of recommendation. It can be very stressful.


It’s okay to turn in information a little bit later, in order to have all of the paperwork you need. It’s even okay to review your statement after you’ve already turned it in. No one will lower their opinion based on that. You will need to have applied for the majority of the programs you are interested in by early or mid-October, otherwise the program director might wonder if you’re applying to them later as a backup plan.

What matters in a personal statement?

Every program director will have different opinions on what you write, and every program director will be looking for different things from your personal statement. For some people, it’s a chance to get to know the applicant a little bit. For others, it doesn’t really matter that much.


As long as your grammar and syntax are competent, you should be fine. Some people don’t worry about the format, and others are more particular. To be on the safe side, if you have access to a good mentor, run it by them. Also, don’t be too wordy—stick to a page and a half.

Do step scores matter?

Step scores are a very convenient screening tool for what matters, but there are studies that show that step scores are not directly correlated to success in residency performance. They are helpful, but are not the end-all-be-all. It’s only one part of the picture of an applicant. However, if you are going for a highly-competitive school, you might need to worry about step scores a bit more.

Apply to the right number of programs

The number of programs is not the only way to increase your chance of success of getting in. Pay attention to the types of programs you are applying to as well. If you are applying for a good number of programs, make sure at least half of them are are ones you are a solid and potentially attractive candidate for.

Keep a good perspective

Ultimately, you are more than your CV, step score, or personal statement. If patients like you, that’s going to go a long ways. Your patients won’t know your scores, or where you graduated from medical school. They will know if you were competent, caring and connected. That is ultimately what matters.


Therapeutic Alliance Part 1

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What is a therapeutic alliance?

The therapeutic alliance is a collaborative relationship between the physician and the patient. Together, you jointly establish goals, desires, and expectations of your working partnership.

Every interview with a patient, whether it’s for diagnostic, intake, evaluative, or psychopharmacology purposes, has therapeutic potential. The treatment starts from your first greeting—how you listen, empathize, and even how you say goodbye.  

It’s built from a partnership and dialogue, like any other relationship. It’s not built from medical interrogation. It’s not about pulling medical information to be able to make a diagnosis. We have to make it a positive experience for patient, so they can begin to talk about what's negative in their lives.

The therapeutic alliance is full of meaning, and it uses every emotional transaction therapeutically. If they get angry, sad, or have fear you will abandon them, as a therapist, it’s our job to figure out how to help them through that feeling within the relationship. The doctor can express desire for the patient to share, in real time, how the patient is feeling, even about his or her relationship with the doctor.

Why do we care?

We all know that some talk therapists have better outcomes than other talk therapists. What’s interesting though, is that some some psychiatrists’ placebos worked better than other psychiatrists’ active drugs. One study of NIMH data of 112 depressed patients treated by 9 psychiatrists with placebo or imipramine, found that variance in BDI score (a score that measures depression) due to medication, was 3.4% and variance due to psychiatrist was 9.1%. One-third of psychiatrists had better outcomes with the placebo than one-third had with imipramine.  

Another book argues that the therapist is more important to outcome than theory or technique. Many other studies have shown that therapeutic alliance directly correlates to success rates.

What builds a therapeutic alliance?

Research shows there are a few things that grow therapeutic alliance:

Expertness

  • Facilitating a greater level of understanding

  • When residents are worried they are an imposter, I tell them that humility is good, but realize that you have experience that most will never have, medical school, being highly educated, being around vast different ways of thinking and reflecting on the world...

Consistency

  • Structuring your office to run on time.

  • Being consistent to respond to refill request, lab results, or patient’s questions.

Non-verbal gestures

  • Eye contact

  • Leaning forward

  • Mirroring of emotion occurs naturally when people pay attention to emotion

Maintenance of the therapeutic frame

  • A dual relationship (eg, dating) breaks down therapeutic alliance. Patients will test the frame. It can be helpful to say, "There will be positive and negative feelings between us and what will be safe is to talk about them."

Empathy, attunement, positive regard

  • Patient: “Therapist is both understanding and affirming."

  • Patient: “Therapist adopts supportive stance.

  • Patient: “Therapist is sensitive to patient’s feelings, attuned to patient, empathic.”

  • Research has found that for beginning therapists, setting and maintaining treatment goals is harder

  • Research has shown that strength of therapeutic bond is not associated with level of training

  • Therapist should appear alert, relaxed and confident rather than bored, distracted and tired

Foundational concepts of the therapeutic alliance

Our profession gives us a privileged glimpse into the human heart and mind. Each patient is idiosyncratic, unique, precious. Each patient has unique strengths which we should place focus on.  Some therapists can be in a hurry to find out what's wrong, but we should also want to find out what's right with our patients.

Our own feelings, as therapists, about the session are not intrusions but clues. If you are experiencing boredom, perhaps you are not understanding the main point the patient is trying to explain. Be curious for what you are missing. If you start feeling something different than you did at the beginning of the encounter, notice it. Try to empathize for the patient with what changed.

Our goal is for the patient to feel understood, heard, accepted, felt. To be understood is to be accepted.

A strong alliance will provide a "Corrective Emotional Experience"  (Franz Alexander), which means past relational pain and difficulties are worked out in a new relationship. When your subjectivity (your feelings, thoughts, goals) come into contact with the patient's subjectivity, a unique "intersubjective relationship" is formed from your mutual influencing of each other. A new dyad (2 coming together) is formed by looking at new meanings, understandings and connectedness. As a therapist, you are a “participant observer” as you observe the patient’s behavior and also become a “significant other” in their life through your interactions (Harry Stack Sullivan).

Here are some things to consider on a first encounter with a patient:

The patient will feel: examined, fear being seen as crazy, fear of not being liked, discouraged, hopeless, helplessness, needy, fear you are a mind reader, or even fear that you sleep with your patients.

In developing this relationship, it’s important to understand they can formulate defenses that are adaptive. Try to empathize with that underlying emotion. Starting with what's an adaptive response and solves something, looking for what’s maladaptive does not.

The patient may question your competence. They might say you look very young to be a doctor. The appropriate response would be to dig down and see why they are feeling what they are feeling. Say something like,"Perhaps you were looking for someone who looks older; of course you’re entitled to worry about how competent I am and how much I may be able to help you."

Therapists are always worried about being ineffectual. It's very natural to feel like an impostor in our position. It’s also normal to feel—when someone's angry at us, our mirror neurons lead us to be angry back.

Always face the patient, without desks between you, lean slightly forward, give appropriate eye contact, and do not do excessive note taking (you should be observing at least 90% of the time). Ideally, a clock is positioned behind the patient which can easily be seen by you without making obvious movements.

On Listening: An Active Process

Connection is non-verbal, and is equally as important as verbal communication, sometimes more so.

  • Omissions (what is not said) in the patient's stories and memories are important.

  • Point out common patterns you hear.

  • If every time you say something to the patient he says "no, that's not it" then point out that to the patient.  

  • Be aware when asking "why" questions, you are likely going to arouse the same defensive emotional reactions that occurred when the patient as a child was asked "why did you do that?" by the parent.  At times, "why" can communicate disapproval. For example you ask, "Why do you feel that?" And they say, "I DON'T KNOW! Are not you the doctor!"

  • Dr. Tarr has some good advice on nonverbal communication: "I participate. I respond. I react to my patient and to his verbal and nonverbal communications.  At the same time I observe what's going on, what the patient is saying and what he is not saying. I am particularly attuned to evidences of anxiety, to what I am feeling and thinking, and where, if anywhere, the interchanges are going. I am wondering how best to formulate for this particular patient what I observe that may help him feel understood and responded to."

  • Observe that defenses (sublimation, reaction formation, intellectualization), although they reduce anxiety, may misrepresent reality.  

  • Assume an attitude of "reverie," like a good maternal object, receiving toxic stuff from patients and then giving it back to them in a detoxified form (Wilfred Bion).

  • Create a "holding" place for patients in which patients have a transitional or play space (Donald Winnicott).

  • Listen in a way that notes what the patient is trying to say about your relationship.

    • Patient: "I feel lonely even when I am with people."  Doctor: "Do you feel lonely here with me now?" Patient: "No, I feel you understand me somewhat."  Doctor: "I want to know if there are any times where you feel more lonely in our sessions, it will help me to understand what is going on between us."

  • Listen to their moment to moment change in emotions.

    • Try to enter a bit into their feeling, be present with them, mirror the emotion/feeling, use their own words, ask them to find their own words.

    • If you don’t get why they are sad, then stay with it, ask them more questions, have them deepen your understanding of it.

    • Once they feel you truly understand the effect will change. When people feel heard, deeply understood, it is pleasurable.  

    • Shame- patient looks down

      • “I can understand why talking about this must be difficult.”

      • Perhaps as you talk about this you feel…”

      • Try to find the adaptive function: “I hear switching to a new doctor is hard, I think that is a common experience, I think it is adaptive to be hesitant at first in what you share, we are just meeting."

    • Anger/Frustration:

      • “Would you say that as you mentioned this you feel frustrated.”

      • Find the adaptive function: “your anger here seemed to have the goal to protect you and your family”  “your anger likely kept you alive!"

    • Sadness

      • “Perhaps you are feeling sad as you say this?”

      • Find the adaptive function: “it makes sense that you feel sad here, I think crying and feeling sad shows how much you valued your dad and therefore the loss hurts that much more."

    • Disgust

      • “I am wondering if you feel disgusted by this?”

      • “I hear you feel disgusted…” (ask with a questioning tone).

      • Find the adaptive function: “Feeling disgusted by how your sisters turned on you and cast you out of the family makes sense, it sickens you to see the level of their resentment and bitterness."

    • Fear

      • “I hear a deep concern or perhaps fear regarding this.”

      • “Might there be a deep concern or perhaps fear regarding this?”

      • Find the adaptive function: “After your traumatic event, it makes sense that you would no longer want to put yourself in that situation, it sounds like you are trying to protect yourself."

Listen to the patient’s goals, purposes, aspirations, fears, hopes, values, meanings.

How do you create and maintain a working alliance:

Be sensitive to empathic strains and prevent them from developing into empathic ruptures.  

Ask for feedback. Reflect on the "we" aspect of the encounter. If the intervention/participation failed to have the desired result then look at what went wrong with the communication.  

  • “As we were talking together when did you really feel we were on the same page?”

  • “When did you feel we were understanding each other?”

  • “When did you feel we were communicating meaningfully?”  

  • “When were you feeling disappointed?”

  • “When did you fell I was not responding enough?”  

  • “When did you feel frustrated, misunderstood, or impatient?”

Be able to define and predict interpersonal conflicts that may cause a disruption of the shared empathic relationship. Set the groundwork for openness.

For example:  

Doctor: "Tell me about your past psychiatrist?  “What worked and what were your disappointments with your past psychiatrist?"

Patient: "He was kind of a jerk."  

Doctor: "Can you tell me more about that?"  

Patient: "He always would just stare at this computer, and often answered his pager during sessions."  

Doctor: "Thank you for sharing that, I will stop typing and finish this later, I hope that if you ever have any feedback for me you will know that I will want to hear it, even if it is negative, and will appreciate knowing your experience of things."

Patient: “Ooo I was not talking about you.”

Doctor: “Ok, nevertheless it is a good reminder to not be focused on the computer, but if you are bothered by things or frustrated it will be helpful to know.”

The therapeutic alliance is an incredibly powerful relationship, and if it is managed with care, it can affect positive change in a patient’s life.

In future episodes on therapeutic alliance I will dig deeper into specifics of it, and pull upon the depth of my mentorship from Dr. John Tarr.

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