Music Alright, welcome back. I am joined today with Dr. Ali Riga and Dr. Jeremiah Stokes. We are going to be talking today about the power of counter-transference, of understanding your own counter-transference. We're going to be talking a little bit about reflective function, how that relates. Dr. Ali Regat is a cohort leader. And so as Jeremiah, this is the second year we've been doing cohorts with people that are listeners, that join. And it's exciting to meet people that have been listening for a while or maybe pretty new to listening. And we thought we'd come on and talk about the experience of that. And so yeah, maybe I'll just have Ollie start because Allie was once a. Member now has for a year been leading her own cohort. And what's been like for you? Okay. Well, let's see. Being a cohort member, initially was, you know, something that I had been looking for for a while. I'm just wanting to dive deeper into psychodynamic case conceptualization and case consultation with others. At that point, we hadn't really articulated reflective functioning and like therapist reflective functioning as much but then that sort of came to fruition during that time. That's my memory at least and and diving far more into like reflective responses and looking at how early childhood dynamics and personality may be contributing to how we show up in therapy. Our preferences in therapy are interventions, ways we may unconsciously collude with the patient, you know, ignore certain things, respond, value other things. And so that was something that I really dove much deeper into there. And then just sharing in this experience, hearing other people's cases, hearing their approaches, and like people with such different personalities and training that really just helped me think differently, more creatively. And then also, you know, attending to group process. I think that something that I really try to highlight now, running a group is, you know, this is sort of the opportune time, really a wonderful, you know, time to not only attend to the content, you know, of what we're learning because we are learning a lot. And for a lot of people coming into the group, you know, there's been no psychodynamic education training. And so it's a lot of new material and it's very dense. And as you've talked about, a lot on your podcast, the huge gap between theory and application, I think, is where a lot of people feel stuck. Like, OK, I'm sort of starting to grasp what this means as far as personality and levels of functioning and transference and counter-transference, but like, what now? So that's a piece of it. That's a huge piece of what we're doing is learning about that, didactic that way, teaching it but also really trying to support group members in attending to their counter-transference, their interpersonal process, their emotional reactions, feelings they're having that are uncomfortable, whether it's some sort of like like discussed, shame shame and embarrassment and the not wanting to come to group, wanting to speak up and not saying something, feeling inadequate, all of these things that that are constantly there, right under the surface. And so having that be a real focus of the group as well. Yeah, really good. Yeah. And Jeremiah, any thoughts as you kind of listen to this? And yeah, no, I think that's, I think that's a great overview. I think running this consultation group, it's, it's evident that people are hungry. They're hungry for more depth. They're hungry for more understanding, understanding the nuance, understanding the complexity that is our patients. And so I think there's been, I've really noticed this drive for more depth with regards to case formulation. I think the other part of this that has been fascinating to observe is the growth that I have seen in cohort members as it relates to their own personal experiences. And Ali referenced, you know, what some of those things could look like, whether it's through counter-transference or, you know, really engaging in a group in a really meaningful, connective way. I've seen professionals grow tremendously in terms of acquiring more knowledge of themselves and how that shows up in the work that they do with patients. And so I think what we've been able to facilitate

in this group is not only expansiveness as it relates to understanding cases and psychodynamic theory and depth, but also just really helping people understand themselves in a personal context and how they show up with their patients. Yeah, it's been, lot of fun. I used to lead groups for residents. Both of you have led other groups as well in the past. But I think there's something nice about there's no grade. This is not a gatekeeping exercise. So much of residency is you feel like you have to show up in a certain way just to get through. So maybe you hold back a little bit. There's a degree of vulnerability that isn't there. You don't wanna talk about Ali? Yeah, it's been, it's certainly we've had many discussions with how challenging this has been. And I know most group members, most cohort members have spoken to that. Have said like, this has been maybe the hardest part of this whole group is allowing myself to be vulnerable, opening up a little bit more. I think that many, many people that come have been in their own personal therapy before. And so there's, there is experience with that, but this starts to elicit all types of emotions that I think make many a bit uncomfortable and, you know, unsure of what and how to share, particularly in the role that we're in, because so often wearing this hat or the role of therapist or psychiatrist and pay like the you're not sharing or you're told not to. And that's something that we certainly work on through learning how to use counter-transference, which is, I know something that we'll talk about in a little while and why it's so important to do. Some of this self-reflective depth of work in this process is, you know, in effort to be able to use the counter-transference and transference in our work. But I would say, I don't know what you guys think, but I would say that that's certainly been an area where most members have felt surprised, a little reticent, to engage at times. Oftentimes there's, you know, a trickled on a fact of one or two people being willing to sort of jump in, dive in, and then others might open up more. But yeah, it's definitely an area that I think surprises people. Yeah, and I think that we're inculturated, at least in medicine, to really have a very strong social veneer. But if all you do is ever talk from the place of a social veneer, right? It's actually low reflective function. If you're not able to say what you actually feel or what you actually like have maybe some embarrassment about saying, you can't really get in touch with your counter transfer and say, all right? Like so I think this is the case for group members when they're like, gosh, I'm having this stuff come up for me. And it feels like if I share it, it's going to be too much. But I really care about every single member that's ever that ever worked with you know, like I think the best for them. They may fear that I'm critical of them. I'm really not. I really want them to thrive in their work and life. And I realize that we're all in process. And there are some things that we're going to have lower reflective for, and some things we're gonna have higher reflective function for. But the things that we already have high reflective function regarding, then we may not need to discuss those things at all. They're not distressing to us in the same way as the things, the memories, the events with the patients that maybe don't come out as smooth. Maybe there's a bit of difficulty even saying it out loud, right? That's usually where the good stuff is and where growth can happen. I was thinking about the place of disavowed emotion. Maybe we should talk a little bit about that, how the group really will feel whatever is disavowed. And this is something that it always surprises me, right? When someone, maybe they have a lot of disavowed anger, someone in the group is gonna feel that anger. Do you know what I mean? Yeah, yeah, it comes up all the time. And someone's sharing a case. I love going around and just hearing like one or two words of what's coming up for everyone in the group emotionally. Right? There's this, and I'm guilty of it too. Like there's this desire to leap in intellectualize and what might be going on here. But really making a point to say what emotion of being elicited for everyone right now. And oftentimes, they're, I mean, most of the time, there's meaningful data. And it might be about, it might be about the patients that we're talking about, but oftentimes it's about, it's about who's, you know about presenting and what might be there for them that is disavowed. I think when there is something that's disavowed emotionally, it's almost felt tangibly by the group. What I found though is that oftentimes it takes processing with the group for each group member to sort of assess and evaluate what am I feeling?

And so I found that let's say there's a member who has disavowed anger, it may not be indicated from another group member immediately. It may take 30 minutes of group discussion and processing for us to sort of arrive collectively. It's like, oh, so that's shame. Or that's a anger that you're feeling. And so I think when the group picked on that, which is disavowed, there's an additional step and group processing where we all work together to sort of discern what are we actually feeling in the room. And I think that's really important when we're thinking about counter-transference with our patients, because I think oftentimes, we're picking up on obviously things that are dis disavowed but we may not know exactly what it is. And so we need time to process that, we may need consultation, these are the cases that we bring to consultation. And so I think that's the magic of the group is when the collective sort of works together and explores it can really help reveal these unconscious processes, I think in a way that you don't get an individual consultation. Right. And the finding of the disavowed is an increase in the reflective process, right? Like if there is disavowed emotion, and if you just jump to intellectualization, you are staying at like a level four or a level three RF, right? And so intellectualization is disconnected. It's theory basically. You're trying it's distancing from the emotion. And this actually happens a lot in like different therapy communities. It's like someone shares something and it's like, well, this reminds me of the self-object transfer and some blah, blah, blah. It's like, well, that would be okay if it was connected with the emotion. But if it's just like, and then everyone's like, why? No clue what this person said, but no. You know, it sounds like really intelligent. And like, and so I think I think we can do a disservice to people are training because then they're like not able to, we should be able to talk in a way

that everyone understands.

And I've always thought about this from my podcast.

It's like every podcast episode,

everything I say should be understandable ideally.

I mean, some things are harder to understand than others,

but my hope would be I wouldn't over the complicate

the language for the sake of sounding intelligent, right?

Well, because that's a defense, right? And that's the beauty of the group is that if someone is in fact intellectualizing, you know, you have the group there to kind of stop and go, wait, what is this really about? What are you feeling underneath that? People. Yep. Yeah. Something else that's coming to me to the somewhat related is so giving voice to these qualities that are pretty that are common to people in our profession and normalizing those but also talking about, you know, and talking about the strength and the qualities but the vulnerability,

you know, in terms of how that might impact the relationship, the ability to look at what might be

meaningful data and the counter-transference, slipping into a particular role, responsiveness or enactment without really understanding what is being pulled for. Spending a nice amount of time on common factors of therapists, obviously it doesn't relate to everybody, but at least a few do to all. And I know Nancy McLean's talks about the depressive personality style. And so, commonly, a disavowed emotion that might be shared by the therapist, clinician, and patient is, you know, just about anger.

An inherent sense of guilt that is unconscious. And so it's not coming into the space. What's needing to be talked about and are brought into the open is ignored and unwittingly. and other common factors like this desired a nurture, a need to nurture, feeling responsible for the patient's well-being, feelings, this pressure to do and act. And I think that's why Nancy McLean's text initially for so many people in the cohort groups, they feel so connected and seen by this idea of not needing to do, not needing to act, but needing to focus a little bit more on the emotional space and attainment.

Yeah. but needing to focus a little bit more on the emotional space and attainment. Yeah, I find that so many of the cohort members come in and just feel a little at sea with with this idea of like I need to be doing something all the time. I have to make it better. A desire to be liked, a desire to fix. And that isn't really achievable. That's unattainable. Are you going to end up going in circles with many patients without this greater awareness of what might I be reacting to and responding to that is both inherent in my own personality and drives and wishes, but also what they're pulling for in me. That's been a major shift, I think, in cohort development and sort of what they're attending to. And I'll be honest, like sometimes I will find myself in my own head thinking, I need to bring this cohort value. I need to say things that are going to help them, equip them, like, am I doing enough, right? And then the problem with those types of internal thoughts is it takes me away from what someone is saying in the cohort. And so I almost like have to forget and have no, it's like I've prepared, you know, I've read the chapter article, whatever we did before, coming in, but then I also have to kind of just see what people bring in and kind of forget my need to sort of teach, be a podcaster, kind of, you know, put stuff out there that's valuable. Yeah, or have the answers, right? Like that's what it's like, I'm speaking of, you know, as like a therapist, you know, I feel all fall into that feeling like, oh gosh, you know, they're looking at me, I need to have the answer. And, you know, as like a therapist, you know, I feel all fallen to that feeling like, oh gosh, you know, they're looking and I need to have the answer. And you know, I'm almost better in my role as therapist, you know, being much more comfortable in the not knowing. And then in the cohort group really having to remind myself, like, this is this is the same thing sure I have I have training and I'm you know prepared and what you know we're going to be talking about and some experience but maybe I can bring to group but that there's also you know there needs to be space for my own not knowing and like bringing that to group and making space for that. And there's a lot of collective wisdom in the group members. Oh yeah. Yeah. Yeah. And I mean, I think that as the group facilitators, that's our way of practicing vulnerability. Right? So being present, understanding the fact that we don't know everything, our own shortcomings, I think that requires us to be vulnerable. And so I think in a way we're sort of modeling that, I think there's a lot of power, for example, in saying, I don't know, you know, like there's times where I'm asked a question in group, or when I was teaching classes, and I don't necessarily know the answer to that, And I think there's something, I think there's times where I'm asked a question in group or when I was teaching classes and I don't necessarily know the answer to that.

And I think there's something, I think there's something that can be modeled through that level of vulnerability.

And so I think as group facilitators, we're essentially doing the same thing. Absolutely. So, okay, getting back to counter-transferts a little bit, I guess we're still talking about counter-transferts,

but we're talking about group, maybe group level counter-transferts.

What emotion is disavowed, what emotions are felt, why do we feel the way we do? That's the reflective function question. If all you do is you feel anger and you have no clue why you feel anger. If you were in the adult attachment interview and they were like, well, why do you feel anger? It's like, well, I don't know, you tell me. You're the expert. It's actually a negative one, right? And so on the score from negative one to nine. So the question is, how do you get in touch with the why that you're responding to this client? And I think that it's like the why can lead to increased empathy. Okay, so the journey through the why, the journey through increasing reflectiveness leads to increased empathy. So what do you guys think about that idea? How does it lead through to increased empathy? Do you see that? Well, I think when we're questioned about the why, it forces us to try to have a deeper understanding emotionally of what's underneath all of that, right? Whereas if we, for example, if we intellectualize a response, or if we have purely an intellectual analysis of what's going on with our patients, I think we lack the depth and truly understanding their experience. And so I think by doing a search, and I think this can happen with the group, when the group sort of shepherds us into doing an internal search, we're able to sort of, through the emotional process, we're able to discern what exactly that's all about in the true meaning underneath that. Yeah, it allows different information to empathize with, right? You might be experiencing the emotion that the patient is feeling, right? so so you're really attuning to that level of pain or fear or shame and you're feeling that deeply. And so that allows for, hopefully for them to feel seen in that way. But there's another level of empathy that can come from counter-transparent information and our reactions. And that is sometimes what they're eliciting in us that might be a reaction whether it's projective identification or like a role responsiveness and that what are they trying to communicate to me right now that they don't know, that they can't articulate that's outside of their conscious awareness. And it might be rage or a desire to flee. like, we, if I can't wait till this is over, or a desire to just fix everything, you know, frustration of like this problem is clear. Let's solve it. So, but, but containing that. And, and here's where you get to more of the empathy of like, okay, on the one hand, this might be what many other people in this person's life is feeling. And so they're moving through the world in conflict of, say, like desperately wanting closeness, but this is what they're eliciting in people.

And they're not knowing fully how to get those needs met in a way that they would want to.

And at least for me, that does create

a significant degree of empathy.

...