This is a conversation with Frank Yomens, initially recorded as part of a special guest speaker series offered to our cohort groups. The groups consist of professionals who have enrolled in small group training opportunities to deepen psychodynamic formulation, reflective function, and facilitate the how of bringing complex cases into a place of thriving. The conversation is generally a question and answer format and we encourage cohort members to develop questions for people like Frank Eelman's. We've also had Nancy McWilliams and Jonathan Chedler on and different things that may not be released. And we encourage the cohort members to ask questions and really deepen our understanding of things like transfer transfer and some counter-transferents in the process. So in this conversation, Frank discusses counter-transferents quite extensively, a little bit on transfer and project event identification and using detailed examples that bring concepts to life. A few details were edited out for privacy purposes, but I'm really excited to share this content with all of you. I was struck by Frank's way of inviting the disavowed projected emotion or transferences into the room without over disclosing or intellectualizing. I hope you enjoy. One of the things I was thinking about with you specifically though is like the role of counter-transference, how you use that therapeutically, and how you supervise people and help people kind of overcome their, or kind of work with their own counter-transference. Sure. Sure, in my own practice in thinking counter-transferences becoming more and more important, I think it's one of the things that psychodynamic therapy has to offer that's missing in the other models. Just brief reference years ago when we did an RCT where one of the the cells was DBT, which of course helps a lot of people, as we observed what was going on in the TFP cell and in the DBT cell. We've had the DBT people did a lot of good work, but they didn't have a concept of counter transference. They didn't know how to use their reactions. They had their reactions, but they didn't have this understanding of feeding it back into the work. And when I talk about feeding it back into the work, the way my colleagues and I handled counter-transference is not to disclose, not to say, you know, this makes me angry. I'm feeling anger. I'm whatever. We talk about something as a feeling, there's a feeling here. I don't know if it would help to give a sort of elaborate example from the game. We would we would love we would love a great example and okay. A lot of people have watched your YouTube's.

And so anything that's like that you haven't spoken about

is probably the most interesting example.

Yeah, I don't think I gave this example in a YouTube

because I think it's too detailed.

And it might be, well, it's a long time ago.

So I don't think I'd be recognized.

But I also wanted to say in a couple of weeks I have to give a telekin Amsterdam about psychotherapy and AI. Now I didn't just have a loose association, I'm connecting that to counter-transference because I think it's when we work with counter-transference that we can do more than AI will ever do. I think AI is probably capable of a lot, and I could talk about that later. It's surprised me. But, and Frank, just to let you know, I just posted an episode on that today. Oh, cool. Where we talk about the suicides and the psychotic breaks that people have had in the midst of using AI. Right. Specifically, the psychophantic nature of AI to only affirm and then like, I'm going to send you the article. The article is like, I spent hours on this and my team spent hours. Probably it's like, it's one of the best articles written on this. So I'm excited. That's perfect. Thank you. Anyway, let me talk about project identification, which of course is a very intense experience of counter-transference. If you know Rackers article, what's his first name? Hiner cracker. Way back from the 50s, it's I think the best thing

written about counter transferences,

called like understanding and uses of counter transferences.

And in that article, he distinguishes

between concordant counter transferences

and complementary counter transferences.

Should I go into that or does everybody already

have a grasp of that?

No, I would go into that. You're going to it. Okay. Yeah. Anyway, concordant, same as counter transference is the basis of simple empathy. So your patient comes in there, bummed off, it just failed to test, they're disappointed. You feel disappointed, concordant. Complementary counter-transference is when you're, it's what I call, a form of deeper empathy, because you are empathizing with what is in the patient's mind that they are not yet in touch with. It's too painful to be in touch with. So you're feeling what is split off from their awareness. So the simple example is the kid comes in, failed the test, he's bombed out, you feel bombed out. And the complimentary counter-transference would be he comes in, failed the test, and your reactions, I knew it. He's a useless lazy SOB. So, you know, you're not supposed to say anything about that. You'll notice, gee, look how critical I'm being. I wonder if that's a split-off part of his mind. He's just feeling bummed out, but maybe he's attacking himself with the kind of things I'm feeling now. And that actually could explain why he's so chronically depressed if he's going through life with a part of himself that is doing to him what I'm experiencing right now. And how can I begin to get him aware of that? Now, what I'm talking about in terms of counter-transference, I think obviously as a of the relation to object relations theory. So I'm talking about a model of the mind where the building blocks of mental experience, psychological experience are internal representations of self and other that are linked by strong emotions and drives. So when I talk about using counter-transference, I'm talking mostly about working with what we in the object relations world call the borderline level of organization, which is a broader concept than borderline personality disorder. It essentially is any personality disorder based on melony concept of the of the paranoid skit disorder organization, an internal mental structure where there are diets, experiences of self and relationship other that are like ideal and perfect in your in heaven because you're found, you know, the caretaker who's never going to fail you and so on and so forth. And on the other side of this with internal world, it's all hell. It's suffering and persecution and anger and so on and so forth. People who don't meet your needs. And the problem with the split internal organization is since you, even though it might not be fully conscious in your mind, you still believe in some kind of perfect

possibility. Anything that's short of perfect, that's totally negative in your mind. So anyway, I think when you're working with this patient population, and by the way, the reason is called the paranoid schizoid organization. It's schizoid because it's split, but it's paranoid because individuals with this psychological organization

generally aren't fully aware of the aggressive part of their internal world. They're not comfortable with that. They have a, you know, malaise about that, so they projected and see it in others. So they're paranoid about the world in general. They can't get close to people, so, and it's so forth, which by the way, going back to DBT, you might later on say, I'm obsessed with DBT. A lot of patients who have had DBT that has helped them symptomologically, come to us and say, you know, I don't cut anymore and I can control my affects better, but I can't manage to really find an intimate relationship. My understanding of that is because they haven't integrated the aggression that they project, and when they begin to get close to somebody, it's like, oh, they're going to reject me, they're going to criticize me, they're going to hurt me in some way, so it can't be comfortable with somebody else. So let's go back to the elaborate example of counter-transference where I finally understood years after I had been taught in my psychiatry residency about projective identification, I finally understood it. And projective identification, by the way, is what complementary counter-transference is. and the patient somehow finds the way to activate in you, emotions that they can't, they're just in some possible, for them to feel themselves, although they can act them out, as you'll see in this example. But in any case, when I learned this as a resident psychiatry, I said to myself, you know, that's how it's almost mystical. My professor is telling me that my patient can make me feel something, it's not my feeling, it's the patient's feeling. I was very skeptical of that. It sounded a little focus-pocus to me. Anyway, here's what happened. I'm working in a hospital. This was back in the 90s. And although it barely exists, in fact, I don't think it exists at all anymore. We had very long-term units. I was a unit chief on what was called the long-term unit, which the average length of a stay, believe it or not, inpatient was a year. The hospital also had acute units, which were like three to four weeks, then it had intermediate units where the average length of the straight was three to six months. You need to know this because the patient was admitted to an intermediate length unit. 25-year-old guy made a vicious suicide attempt, cut himself really deeply, comes into hospital, and what's the problem? Smart guy, college student, he had missed some years of college, so he was a little behind for the usual schedule because of his illness, but the problem is that when he shows up on this intermediate unit. he seals over and he's the ideal patient. He's like a good boy scout. That was my internal representation of him. I was not on that unit, but I heard about it. So, you know, he says smart things in the community meetings when the nursing staff is having trouble with one of the difficult patients. He's very helpful and tries to calm the patient down. So he's great, but nobody could get a hand on why does he try to kill himself periodically. It would just burst out in and see a little further. Anyway, so after a couple of months, the staff on that unit said, we don't know what to do with this guy we're getting nowhere. Let's discharge him. Now, in those days, you would say to somebody, you know, we're starting your discharge phase, which meant two or three more weeks, which would be more than a whole hospitalization time. Anyway, so you do discharge planning and you find a therapist and you get all the things in place. Anyway, when the guys heard we're starting to plan your discharge, he said, you've been I think twice about that. So they said, why is that? Because, you know, I'm not ready for discharge. In fact, you know, if you guys are going to discharge, I could get to a side of the guy. So they put him on what's called 15 minute checks, which most of you probably know what it is. But in case you haven't worked on an inpatient unit, the man is confined his room and a nursing staff member goes by every 15 minutes to make sure he's okay because of the threatening things he said. Now you might say, why did he so much not want to be discharged? Here's my hypothesis. He had a very narcissistic personality. He had to be the king of the hill. In an inpatient psychiatric unit, he could fairly easily feel superior to people, population of people who had clear impairments. In the outside world, his king of the hill status was very threatened by other high-functioning people. So, here's what happens. Now, I'm going to tell you this. I was going to apologize, but I won't apologize because you have to be willing to work with very strong affect if you're going to treat these kind of patients. He's in his room and nursing staff comes by and says, how are you doing? Fine, fine, fine. In between the 15 minute checks, he took a little nail clipper and very methodically, and I'm telling you this, because everybody thinks acting out with personality disorders is always impulsive. It can be methodical. So nursing staff, how are you doing? He says, fine. Then he rolls up his sleeve and he starts clipping away what we call the anti-cubital fossa, the internal part of the elbow. And, you know, he did it. I'm just laughing as a defense, but anyway. And, you know, the nursing staff would come the next time. He'd cover up the Kant he was making and then you know when the nursing staff would come the next time he cover up the country was making and then When the nursing staff left he would ice he took a while to isolate this big vein that exists right here in your Inner elbow and then when he had isolated the big vein He clipped it and so the next time the nursing staff came by there's blood all over the bed. So they decided not to discharge them, but to transfer them to me. Thank you very much. So anyway, I became his therapist. And here's what happened. I'm meeting with him three times a week, three times a week, individual therapy in the hospital. And I was getting nowhere. He sealed over. He's the boy's guide. Everything's fine. No indication of any problem and so and so forth. So after a couple of months on my unit, we decided the same thing that we would have to discharge it. We can't keep somebody indefinitely. We don't feel we have any kind of handle on them. So he was told that he was gonna enter discharge phase and he comes into my office for the therapy session. He says, Dr. Jermins, you know, I'm so lucky to have had you as my hospital therapist, you know, in my lifetime, I've had 10 therapists already. Now that I'm new, anything, you're the only one who never helped me at all, all this idealization, which of course was justified in this case. Well, no, I wish, but in any case, that's the ideal side of the split internal world. So, he says, I just want to know if you'll be my therapist when I'm an outpatient. Can I go outpatient therapy with you? So this was the end of the session. And I just invoked reality. So I said, you know, we have to look into that. We have to consider a number of things. We have to consider, you know, if our schedules are compatible, we have to look into payment issues. So, but remember what I said about the split internal world. But the other person isn't giving you perfect caretaking, which would have run, yes, we'll do it, then it's no go to hell. So he comes into the next session. He sits down and he says, this is going to be our last psychotherapy session, even though he was going to be in the unit a couple more weeks and he could have come three times a week. I said, oh, what's that? He said, well, it's a waste of my time coming to see you. So I felt very comfortable wearing familiar territory. We got the two sides of the split internal world. I'm idealized one day. I'm devalued the next day. I just proceeded like, okay, I know how to deal with this. I was, yeah, and you proceed with curiosity. Like, I don't understand because last time he said I was the best therapist who'd had numb uses it. And usually the patient says, oh, yeah, how can I understand that? I felt both things that they don't add up. But he didn't go into that reflective process. He said, I'll tell you what happened. I had an epiphany after the last session. And you know what? I never thought you were a good therapist. My epiphany was to come to the awareness about me. He said, I am such a good person that I realize I'm willing to sacrifice my own interest for the sake of pathetic individuals like you, that I only asked you to be my therapist because I knew how devastated you'd be if I didn't do that. And then it's just dawn on me. Don't

go into therapy with an idiot just to save his feelings. You're a very good person, of course, he's the son. But don't sacrifice. I mean, you can be a good person without being a martyr to this jerk who thinks he's so smart and special. Anyway, so here's where start start getting to counter-transmit. I'm trying to work with that contradiction and trying to sort of see if maybe my usual approach, yeah, but maybe there was something to the idealization and we could think about the two ways you have feeling about me to get that. No, I never felt you were any good. I realized it was my own goodness. There was going to sacrifice my interest for your pathetic puny little ego. So anyway, this just went on and on and on. I'm only giving you a small dose of it. And about halfway through the session, I'm sitting there, getting all smug, it was really impressive how he was portraying himself as the best person on earth because he would go so far as to sacrifice the interests for those awful dumb people like me. So I'm listening to this thing, what the hell do I do now? And I tried everything I have in my toolkit here. And in the back of my mind, and I remember it to this day, all this was 30 years ago. First, there was like a fog in the back of my mind, or like a mist. And then out of the mist started to dissipate, I had a visual image before a conscious thought. I had a visual image of strangling him to death. Yeah, so I noticed it and I said, oh, that's interesting. You're thinking about, you want a stranglest man. So, you know, I'm listening to him. You have to sort of listen to yourself and listen to the patient at the same time. I mean, as I'm continuing to sort of engage in some sort of interaction with him, I said, you know, you don't usually think about strangling your patients. In fact, I said, I think this is probably the first time I've ever thought about strangling a patient because there's a rule of thumb. It's a little simplistic, but we call transference, that we say the operational definition of transference is anything that comes out of the patient that's kind of more than a standard deviation from what might be considered a normal reaction to something. So transference is something the patient does that's out of the ordinary. Counter-transference if it's provoked by the patient because we have to remember that counter-transference could be our own issues. But counter-transference evoked by the patient is something that's not normally part of our internal repertoire. So I said, you know, I've never thought out so I'm giving a patient before. This must be what they tried to teach me 10 years ago in my residence. This must be that project of identification. He's getting me to feel something that's very important in his mind, in his internal world, but he can't access it. It's too distasteful for him. And yet I started thinking, that's what comes out whenever he makes

where he's really vicious, so sad to jump.

He's attacking that hateful part.

Then I said to myself, it's all about hate.

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