Good morning, Dr. Malisbury.
How are you doing?
Well, not so good. I've got a leak in my office ceiling, so I may be interrupted at any moment. So that gives me an adequate excuse for being late this morning.
Really appreciate you establishing a chance that things can make it a little bit messy. Our frame might get a little different today.
That's right. And you know, that's the thing about those leaks. You got to address them right away because if you got a little leak, Maybe it'll turn into a big one or maybe it'll stay a small leak and it's going to start making little bits of your ceiling soft, weak and moldy. It's almost as if that brings us back. Yep.
Maybe you're talking about something else. Brings us back to our last episode, right? So you're saying make sure you address things quickly before they grow and cause real problems.
Yeah, if you detect any kind of a problem, a divergence or mismatch in the therapeutic alliance, a rupture in the therapeutic relationship, or some kind of a boundary crossing or a frame violation, I recommend that's addressed explicitly and relatively quickly, if not right away. So last week we were going over some hypotheticals, and I suppose we're continuing with part two today, right?
Yeah, I think today's going to be a continuation where we kind of go over different, you know, case scenarios and play out, you know, just our thoughts on them and maybe how we would respond to them. I do want to jump into the cases, but before we do that, there's actually two things I wanted to ask you about. We're talking a lot about the frame and I'm curious, you know, We've been talking about it as a very abstract concept.
And I'm curious what in your treatment, and again, we are psychiatric providers providing, quote unquote, medication management. If you could walk me through what your frame is, what your boundaries are, what you establish with patients. I'm curious about like, what are the things that you're relatively strict on? in regards to timing, in regards to if patients are late, in regards to missed appointments. I'm curious if you could maybe like give us a little bit more details about your specific frame.
Yeah, I guess at the outset, what I want to say is it matters a little bit less whether or not you correspond to my style. What matters is that your Boundaries and frame match all the patients that you're seeing in that setting. That's way more important. That being said. Mine is going to be tailored towards my practice style, my practice setting and my patients. Right. So it may not apply at all to what you do and keep that in mind.
Probably one of the main things I'm very. careful about is I want to make sure I'm the one setting appointments with the patient. And I want to make sure that as much as possible, both of us keep a commitment to the specific time and date. This is not always possible, right? It's normal to have cancellations, reschedules, but we want to keep as much as possible to the right time.
And that applies to the start time too. I want to start on time with patients and I want them to start in time with me. To that end, unless there's something extremely urgent, if the time into the session has elapsed enough, let's say over 50%, so that you cannot have a meaningful visit, I'm not going to attempt to give the full visit. I'm going to tell the patient, we missed the time today.
We can't have a meaningful visit. Let's check in really quickly to make sure things are in a stable position for you, and we're going to have to reschedule. Obviously, this applies to going over time. You want to avoid going over time as well, but that's a, you know, lots of a concern for most people, I think. Most people know to cut off things early enough so that they can prepare and be ready for the next patient.
That's probably the number one thing that I'm very, very, very careful about, that not necessarily everyone is. Certainly not every doctor's office is. I know this is a common one to be careful about, but I think it's worth emphasizing. The second thing is I try to be extremely clear about two things. Why we're meeting, basically the modality of the treatment, and also diagnosis. Okay, and treatment recommendations.
I want to be extremely clear Whether I'm meeting them for a formal psychotherapy, which I don't do these days, or if it's medication management. And I explain the difference in the way I explain it personally. And I inform them separately of the need of psychotherapy and that simply talking to me about your recent stressors or your functioning is not a psychotherapy. And then diagnosis is extremely important.
It's basically the same as giving a formulation in psychotherapy. It's really, really important and it's key to building the therapeutic alliance. So similarly, I will tell them my working diagnoses and update them over time if that changes because that informs the treatment recommendations. I would say those are the major ones.
Yeah, I love that. And I think a lot of the early stressors that I experienced and things that really were difficult and annoyed me and led to burnout were aspects where I didn't do those things. So as I've practiced more and more, I'm very, very explicit about the kind of work we're doing. And that I'm not, like you mentioned, like I'm not 80% of therapy. I'm not 50% of therapy.
That I'm not a replacement for therapy. And the work we're doing is medication management and we focus in on that. And that's absolutely essential for every visit. I also think a really important thing that we're talking about is, you know, we're mentioning our boundaries in regards to you said you're really protective of the time. And I used to think it was, you know, it was good to be flexible that, you know, to let patients, you know, like let them know that I care.
But what I realized is that for a large portion of the patients, the boundaries aren't this annoying thing that just protect us. It's actually the core aspect of treatment. And that's not all patients, but for patients that are really pushing boundaries, the boundaries aren't nuisances that get in the way. They are the treatment. So when I'm too flexible on boundaries, when I'm too forgiving, when I'm too like I don't acknowledge my own boundaries, I don't acknowledge my own resentment towards patients.
I'm actually ignoring the crucial aspect for treatment for that patient. I think that really helped me to focus on setting limits super early on late appointments, on missed appointments. I don't just go like, oh, no worries. You're 10 minutes late. We still have 10 minutes. Let's get this done. We focus on it and we talk about it. As someone who wants, you know, my nature is to be agreeable and to be flexible.
So it took a lot of time and genuine directed effort to spend time when I can see the patient's upset and just wants to talk about something else. But it's no, you know, you're 10 minutes late. This is the third time in a row it's happened. Like, we really need to talk about it. What's going on? Like, is this is being late something that occurs in your life?
You know, other aspects of your life. Is it, you know, is traffic getting in the way and you just don't you don't see it coming? Like, let's figure out what's going on. And it's really changes how treatment goes and also my resentment. Like, I've been a lot less burnt out because I protect my boundaries. We talk about things and I don't build up resentment over time.
Yeah, you know, the boundaries and the frame practiced appropriately and communicated appropriately, of course, protect both the treatment process and the patient. And it's not both. And also, in addition to those two things, you, the clinician, right? You're going to be less burnt out. I'll give a counterexample of something I ran into recently. This is not just about appointment times. If you don't follow uniform rules and procedures for your clinic, you're going to run into problems and it's just bad patient care.
For example, if the patient is angry at one clinician in a group practice and makes a complaint, you should have a procedure that you follow for every single complaint. and follow it uniformly. It doesn't matter how angry or upset that patient might be when they lodged a complaint. If you respond to a patient being angry and upset and out of bounds, or if there is no rule, you immediately call 30 minutes later and then immediately approach the complained about professional 30 minutes after that, that's not helping anyone.
For example, Let's say there was no strict rule or boundary violation and it was a matter of differences in patient preference. You have not given the patient enough time to reflect and to calm emotionally. The patient is still dysregulated. You're not going to get good information and it's escalating the situation and it's also teaching patients that they can act out and they will immediately have someone to triangulate with another person right and it also interrupts the workflow for a clinician right it's a bad practice management regardless of who's right or wrong in that particular situation we want to help people become independent and part of independence and being adult is unfortunately delayed ratification Right.
That's the nature of a clinic. A clinic is not an emergency room. A clinic is not urgent care. A clinic is a place where you have to and you get to learn to wait and to sit with yourself.
Absolutely. um i want to move on um we are going to get to part two of what we were talking before but there's one topic that came up last time um that i i want you to expand on because i actually um don't necessarily know if i agree with what you were saying um you were talking a lot about reality and saying with a patient like that's you know uh saying that's not what occurred in reality to a specific patient i'm curious A lot of, you know, relational schools are teaching, you know, the relational aspect of, you know, postmodern interpretations that reality is co-constructed and there's no one whatever.
How do you define reality?
It is interesting that you talk about the co-construction and, you know, that kind of bent with the relational schools. I believe you're in one of the epicenters for that particular disease. Sorry, folks, calling it that. I mean, in a way, so am I. But... Well, this kind of takes us out of the realm of psychiatry, but like so many things in psychiatry, we have to get into a little bit of philosophy to orient ourselves at all.
You're free to disagree on my interpretation of reality, but what I teach in the context of psychiatry, at least, is that, well, first of all, reality exists. That's one of my assumptions, that there is some fundamental reality. And then secondly, that we do not have perfect individual access to reality. Okay. But, you know, related to that, some people have more access to reality than others, but it's not possible for one party to tell them.
So therefore, Reality is co-constructed in the sense that reality is shared. It's always some emergent property of perception of various subjects interacting with a fundamental realness. So you can't have your own reality, just like how you can't have your own private language. It doesn't work. Reality is something that we negotiate with others, but not just two people. It has to be as many people as we can possibly incorporate into the discussion.
You're seeming to allude that it's some sort of like group consensus. Like if there's 20 people and 19 people aren't hearing voices and one person is, then the reality is that that person's hearing voices. It gets a lot murkier with a lot, you know, with more abstract concepts, if you're talking about political affiliations or, you know, and the part that I was having a tough time grasping is given your definition, which seems to imply that the necessity of many minds kind of coming to a consensus.
You were saying in a treatment saying that that's not reality, which is tougher for me to grasp because it is literally one person's reality versus another person's reality. So where do you feel that you can say that's not reality to a patient?
Well, that's one thing I'm going to have to specific about i don't think i would ever say um not purposefully to one particular patient that's not real or that isn't reality i might suggest it even strongly uh most of the time it would be to ask them if they're willing to consider an alternative interpretation as reality or to ask them how much do you really believe that What percent would you rate that at right now?
Something like that. Sounds a little CBT, but I do do that with the psychotic patients. So I not only measure frequency of being bothered by or perceiving delusional beliefs, I also will ask, how much do you really believe that? Could it be something else that shows you sometimes the nature, the source of the apparently delusional belief, but that's getting off topic. I would say that unfortunately, and this does not sound very nice, but I think it's true.
The most clinicians, most good clinicians have a better grasp of reality. Not because of a fundamental characteristic of the clinician, but because of the role of the clinician. a proper clinician has contact with more sub realities than the average patient this is not true of every patient some patients are going to work a job where they come into contact with interview talk about conversate with many different kinds of people from many different walks of life but your average clinician at least has access to many more viewpoints because our role properly is more to pull information out from others and to listen to them.
So generally, we can say that we have a little bit more expertise or at least experience in how different people would respond, think and feel about different situations. So in a sense, we already have more access to shared reality than any individual person. But I don't think that's enough for a clinician. I think clinicians should also be constantly comparing their responses and checking in with the larger crowd of general people.
and also general clinicians. So I do think to be a good clinician, you should stay in contact with many other clinicians, and you should also keep your fingers on the pulse of the community, so to speak. You should be aware of trends, memes, current events, current art, old art. You do need to be a bit of a polymath in culture, I think, to be a good clinician.
I'm friends with the anti-psychiatry community in that I can hear what you just said. They're going to be saying like, you know, that's the most invalidating thing possible. And what I'll say is, let me just say, I know tons of psychiatrists, of clinicians who are not connected to reality and fully out of their minds. Absolutely agree. And I think maybe to integrate what you're saying is that there's a lot of hoops that are necessary to jump to be in this position.
Like, Getting going to college, getting into medical school, performing well on tests, passing some professional competencies. And a lot of these hoops are somewhat of a reality hoop. And there are people who are able to jump it and they're not connected to reality. But there's a lot of people. It does filter out a lot of people. Yeah.
It filters out a decent amount of people. I don't even think that's the main operating factor. And I agree. I'm sorry. I'm not very nice about my appraisal of other clinicians, I'll have to admit. I would agree that there are too many clinicians who don't have good reality testing. Too many. Because, again, reality testing is about consensus. And it's about listening to many different people. Really listening and hearing, not just judging.
And having a broad awareness of the ins and outs and the balances of multiple different kinds of issues. That's really hard to have. So, you know, yes, there is some filtering effect in the training process and licensing process. But when I said good clinician, what I mean is that the good clinician does have better reality testing if and only if that good clinician has purposefully and actively and deliberately paid attention to and listened to so many different perspectives other than their own.
I was trying to integrate our perspectives, but let's keep pushing on. So we were talking last time about what happens when a patient falls in love with their psychiatrist and presenting different little scenarios and kind of reviewing how we think about them. Why don't we start off?
Who wants to present first, you or me?
Why don't you present the next one?
Okay, sure. So, um, let's say that at one point, a few sessions, decent amount of time into working with a psychiatrist, um, You ask, so what have you diagnosed me with? Maybe this psychiatrist is not of the bent that I have to tell you every diagnosis and anything like that. And I'm actually not one of those. But if you discover that a long time later, you were actually diagnosed with another trauma and stressor-related disorder at the first visit, but the psychiatrist didn't mention it, what would you make of that?
Or would you feel a particular way? Would you be insulted, unhappy, confused? What do you think the average reasonable patient would respond with?
I think the scenario you're saying is that essentially many weeks into a treatment or months into a treatment, a patient finds out that they have a diagnosis that they weren't actually aware of and they only became aware of it because they asked explicitly. Is that the scenario you're bringing up?
That's the scenario.
You know, I'm actually glad I think you talked about it in the beginning. I think it's absolutely crucial. And part of my treatment frame is that me and the patient are on the same page in regards to what the diagnosis is and my degree of confidence in that diagnosis. A lot of providers will say like, oh, diagnoses are just for billing. So patients will find out later that they're they'll go like, hey, doc, you know, I got a bill and it turns out I'm diagnosed with bipolar.
I thought we never talked about that. Or, you know, there's I mean, bill for borderline personality disorder. We never talked about it. And some providers hand or there's like, oh, you know, diagnoses are for billing. I really, really strongly disagree with that. to me, how I think about treatment is we're working together. One of the main things we're doing is developing a diagnosis and treating that diagnosis with evidence-based treatments for that diagnosis.
And I think you can't really skirt that. And if you're not doing that, oftentimes you're treating symptoms and treating symptoms work sometimes, but there's just a lot of flaws in that method of treating. So I think One thing that I've really, really worked on is how I communicate diagnoses and how I communicate confidence in diagnoses. There are things that a lot of patients, a lot of providers have difficulty talking about personality disorder or talking about trauma or they don't talk about the trauma because they're, you know, it's something it's like, I don't know if it's complex PTSD or borderline personality disorder.
So let's just keep making pretend it's depression and throwing escalating. Yeah.
A lot of kind of transferential motivations there. Yeah.
In terms of how I think of how treatment progresses is you work on a patient to figure out the diagnosis. Then you communicate the interventions that you have at your exposure, exposure, your exposure. whatever. And you and the patient come to a decision about which treatments you're going to use that you feel you're capable of using. And for the aspects that you can't do, you provide referrals or discuss with the patient how to go about getting that treatment.
So I Almost there are occasions that we don't come to an agreement in diagnosis, but can still work together. But for the most part, the vast majority of my patients understand their diagnosis and we're working together to confirm that we're on the same page.
So, yeah, it's got to be collaborative. Totally agree with all things you're saying. You know, I would say it doesn't matter if you don't believe in the DSM or in diagnostic constructs because they believe in you. You know, kind of a little joke. But yeah, society believes in it. The law believes in it. The billing and insurance people believe in it. I don't care if you don't believe in it.
Then you're not living in reality. You're not in the shared reality. And if you believe in it in a different way, then you better take a little time and explain that carefully and in a way that your patient will understand. If it's important enough to be your primary treatment diagnosis, if it's important enough to go on a bill somewhere, you should at least explain it. Even if your explanation is, I don't personally believe that you have this, but I feel that I must do it in order to further the treatment process.
I'll accept that. What I won't accept is having a diagnosis that isn't communicated except in very certain small scenarios. Do you have any exceptions to the communication of a diagnosis at the first confirmation?
We've talked about this before, I believe. I think what you're alluding to is more psychotic disorders where patients are following a treatment that is, maybe I'll just answer the question, patients with a psychotic disorder that don't agree with their diagnosis but are following the treatment anyway. I'm okay with the fact that we're on different pages. I do, but I don't withhold the information. I communicate to them what I think and then say, but it's, it's, you know, it's not important again.
And we brought this up. It's, it's important for patients like that, that they're getting the treatment that is treating their, their disorder more so than they believe in the diagnosis. Like I said, I'd rather have a patient who says, doc, I don't have schizophrenia, but I take my clozapine than a patient who says I have schizophrenia, but I hate antipsychotics and refuse to take them.
Yeah, and I guess your answer reflects on my principle. I don't have a blanket rule. I will say that the purpose of a diagnosis is to further the treatment. So if disclosing a confirmed diagnosis, even one that you believe, would definitively and you know would hurt the treatment process or the patient or interrupt it in some unrepairable way, that is a reason to at least temporarily withhold it.
But I do think that there is too much lack of diagnostic discussion in the general practice of mental health. But, you know, in some ways, that's understandable because are most people really being prudent and careful diagnosticians? I'm not so sure. I think many people are doing vibes based diagnosis out there. And if you don't have the data, how are you going to discuss it with the patient?
Yeah, and I think two common scenarios that the diagnosis, one common scenario in the diagnosis withheld is personality disorder. And I think that's the absolute most important diagnosis that the needs to be communicated and talked to about the patient. I just see more and more that the patient and the providers making pretend that treatment is major depressive disorder in the back of their mind know that there's a personality disorder, but don't communicate it.
And it's really setting up for bad treatment outcomes. Yeah.
Well, I think often the clinicians are afraid. They're afraid of what everyone and themselves feel and think about personality disorders. Sometimes I've run to clinicians who don't even really fundamentally understand personality disorders. They really apply the diagnosis like person I don't like or unpleasant person. But that's really not what it means. Right. But we have other episodes for that discussion. Maybe we should move on.
All right, let's move on. So I'll present the next case. This is a patient who was being seen on Zoom for three years. So all the appointments were on Zoom at two years, let's say. Then she found out that they could have an appointment in person. So they set up a time in person. And she was really excited. She wore a dress. She did her makeup. She decided to look good.
She wanted to impress the clinician. On arrival, when she first saw the clinician, she went and gave him a hug. He barely patted her on the back. The patient says she now feels grateful that he didn't escalate the physical contact. Later, she talked about this hug with her therapist. Oh, wait, no, I'm changing the thing. In the session that was in person, the patient told, the psychiatrist told the patient that the, hold on, I'm messing this up.
The patient. Go ahead. Okay.
The patient had talked about how her therapist had asked her advice on one of her clients. So this particular patient is an ADHD coach. The psychiatrist said that that was a major boundary violation. The patient respected the professionalism, but... now sees that he only avoided sloppy behavior that could clearly be documented. That was a little sloppy, but.
So I see two major things there to comment on. The first is the ever debated, no clear answer. Do you make physical contact with your patients? Do you hug your patients? It's a big thing. There are even some therapists who believe in physical contact body work. Okay. whatever that means. I don't know what that means. I'll tell you this. I am an anti-hug person. Of course, that extends to my ordinary life.
Your personal proclivities for closeness or separateness will inform you. But I do think that escalating or allowing more and more physical contact is just, you know, uh road to hell paved with good intentions in many cases maybe you're fine with it maybe you can get away with it i think it just depends i do think it's opening things up to make the treatment relationship seem more like a ordinary relationship than is appropriate Personally, I keep it to handshakes.
I'm fine with a good handshake. You know, some people don't even like that. Some people want the fist pound. I've even taught residents a trick I have. This is not something you can communicate well over a podcast, but for patients who try to hug you, You can angle your hand when you reach out for a handshake as a barrier with your forearm in front of you to make it difficult for patients to forcibly hug you, which is a technique that I came up with.
It's up to my own invention, so you can try that out for yourself. What do you think about the physical contact issue?
Well, I think it's loaded that you talked about how you hate hugs and have a very specific self-defense technique to protect against them. But that's for another day. Well, yeah, I think one thing we're talking about and when it comes to boundaries, it's especially when you're starting out and you don't have a ton of experience, it's best to just follow the rules relatively strictly. And I think something like a hug is something that should only be done or violated once you have a lot of experience, you know what you're doing, you can understand the meaning of it.
And if you're a relatively new clinician, essentially, if you're listening to this podcast, you're probably not at that level where, you know, you have you have enough experience to think through the meaning of it. Um, so I think the rule, like rules are meant to be broken once you can recite the rules without, you know, you haven't memorized. And I think most people aren't at that point.
And I think a lot of clinicians are comfortable breaking rules before they actually fully understand them and, uh, you know, fully integrate them. So I, I agree. I think as a general rule, I just avoid hugs and it can make for awkward things. And that like, sometimes You're saying the path of least resistance would just be to accept the hug because it's less awkward. I've gotten more comfortable with being uncomfortable and being awkward, even though it goes against my nature.
I think that's a skill that I've developed. My natural instincts are... to make the person feel comfortable, to make it an easy thing. And I really had to work on, you know, like stopping a hug is, is very unnatural and it takes, it's like a skill to be able to negotiate what occurred and be able to talk about it and say like, you know, I totally understand like this would have been, you know, that you were hoping for a hug.
It just as one of my personal things, like one of my rules is I just don't give hugs to patients. And you get better over time so that it gets less awkward.
Yeah. It's, it's really important. I think what you're highlighting, you gotta get comfortable with being socially unusual as a mental health clinician, the whole, endeavor is socially unusual we have to understand that you know while we try to replicate certain early experiences for treatment purposes or at least echo them for treatment purposes it's the whole thing's unnatural it's a very special social role so i i recommend that uh to continue on my anti-hug train so far because i just want to mention one more thing i think one of the things i can take issue with with it versus handshakes is Let's be honest.
For most clinicians, do you hug every patient? Do you initiate the hugs? Does every patient initiate a hug with you? Would you be comfortable initiating a hug with every patient? You see what I mean? That's why I don't like the hug thing. It's hard to universalize. Handshakes, very easy to universalize. Fist bumps, very easy to universalize. It's really about what you do across all your patients, hearkening back to what we were saying earlier on about a shared reality.
yeah yeah i think that's a that's a great point um there's a second issue with this one right the second issue being um the therapist talking about asking for advice
um yeah a therapist asking a patient for advice on other patients of the therapist right Well, I mean, let's leave aside even the recommendation against advice giving in clinical treatments that are more psychodynamic. Well, I guess you mentioned something off air. You know, I don't really believe this. I think that a lot of people can, um, interpret, uh, something as having gone in a certain way in a session.
And it's really more a product of their personality or the way they perceive things. Right. And, um, for example, I like the example you gave. What was the example you gave about what might've happened to cause a patient to say that the therapist asked for advice?
Uh, how I interpret it, what happened was, uh, a patient was talking about a book that was like really helpful for them. And I can see a therapist going like, oh, what book is that? You know, I think it was like, if there's an ADHD book that the patient was like, oh, it really helped me. It's like, oh, that would be great. I actually could probably share that with my patients.
Yeah. Which I don't think the average reasonable person would interpret as asking for advice, but one person could potentially, or even many people could potentially see that as asking for advice about other patients. Right. You know, that sort of touches on something that maybe we should discuss, which is if we define reality the way we did, what types of patients may have deficits in accessing a shared reality, a consensus reality?
Well, yeah, I think almost definitionally the, you know, borderline personalities.
Maybe you should explain for any listeners who aren't aware of the origin of the term.
Yeah. I mean, I feel like every medical school Hammers is in, you know, borderline was originally named that because it was the borderline of neurotic, neurotic being healthy personality and the psychotic personality. Psychotic personality is someone who has no reality testing. So someone in the borderline range has almost like intermittent connection with reality testing in that it At their baseline, when they're unstressed, usually they have ability to reality test.
When I say reality test, essentially, you know, acknowledge and be aware of reality and see where they're diverging from it. And under moments of stress, they can enter into almost psychosis where they're disconnected from reality.
Yeah, I guess what's worth mentioning is that this is just a very human issue and it's not limited to people with a psychopathology that's diagnosable, right? Anyone under stress is going to probably have some limitations in their ability to consider and understand perspectives of other people. In a way, you could say this is adaptive. You know, if you're at wartime, Trying to empathize too much of your enemy is probably going to result in loss and therefore group selection for people who do not empathize with the enemy during wartime.
We can theorize in that direction. But I think while a lot of people have heard that particular definition, I'm not sure how widespread it is for people to understand why that might be the case. I also am not sure that we have a consensus in the field about why reality testing can be impaired beyond A late onset or later onset or episodic psychotic disorder, right? We're all aware of bipolar depression with psychotic features either of those mood states and schizophrenia type disorders Delisional disorders those impair reality, right?
We're aware of reality being compared under conditions like anorexia or obsession obsessive-compulsive disorder, but how can it be that? someone's reality is impaired relationally, generally speaking. I'm a fan of the fundamental developmental issue. I guess you can call this a lot of different things, but I suppose in the end, I'm seeing a little bit more agnostic on the why I'm just giving more information on the mechanism, which is the mentalization explanation.
Right. I think that for whatever reason, partially genetic temperamental and partially, you know, parenting, essentially, some people are going to have less ability to do what's called mentalization. They're less able to model other people's minds. right you can call it forming a broad differential diagnosis of why people do what they do you can call it a theory of mind you can call it a lot of different things but it's not just about coming up with rational cognitive reasons it's also being able to appreciate the internal emotional experiences of other people and now people have referred to splitting or inadequate parenting or trauma as ideologies i don't think there's any one particular ideology part from i am a fan of a particular interpretation of beyonds containment as a theory of why people can have deficits in mentalization i know i'm mixing up a lot of different schools of theory right now but i i do think that there's a fundamental action that some people manage to get more of and some people manage to get less of from a very early age and it's simply uh how often in your life has someone carefully listened to and paid attention to your internal experiences and then communicated their findings back to you in a way that you can accept this is as simple as an infant feeling bored or tired of playing with something, and the mother is saying, oh, looks like you're not so interested in that anymore, are you?
Probably the apex reflective listener container that we have a lot of video of in history is Carl Rogers. It seems like his entire treatment process was only that, which you can take issue with. But I would say that it's the lack of that, for whatever reason, The reason can be trauma. The reason can be innate in the infant. The reason can be because of the parenting style.
The reason can be because of external stressors or lack of resources. But anything that can interrupt the amount of that you get is what's responsible for later problems with self-direction and interpersonal reality testing.
So, Keeling Spanser, you're saying that someone who had a lack of mirroring will have a more difficult time assessing reality because of difficulties assessing the mind states of others? Is that... Yeah. Yeah. Essentially.
I think mirroring is an inadequate description of what happens there. I would, you know... basically nail down all those different parts. The infant has an experience, the caretaker observes and feels about the internal experience, digests it, that is makes hypotheses and turns it into words, and then communicates it back to that infant in some kind of words. that whole process every step is important and why is that important i i think that you can't perceive your internal state until you get that done to you enough times um having your internal state put into symbols and reflect it back to you right so reflection of this type is not just some kind of a pure mirroring it's not just an agreement or a validation right uh there's it's more complex than that So, yeah, if you can't understand what's going on inside yourself, there is no way that you're going to be able to understand what's going on potentially inside of somebody else.
And then there's no way you're going to be able to communicate about those things to yourself or to other people.
Now, I think using the terminology that I think that Beyond uses, and I want you to help me to find it. I think what you're saying is that the, I said mirroring, but you elaborated a little bit more as what's going on, allows the alpha functioning to develop. Can you define what that is?
Let's not use his terminology if we can. I love Beyond, but let's not use his terminology.
The thinking apparatus.
The thinking and feeling apparatus. There is some thing within all human beings, well, hopefully within all, maybe not some very special people, but most people have the capacity or can develop the capacity for thinking thoughts in language and feeling emotions about them. In a regulated way, in a regulated way. OK, that is the capacity that needs to be developed. And that capacity, I think, is probably developed by getting enough resources and specialized attention to your internal world from caretakers throughout your development.
So anything that can interrupt that, be it a medical illness, a trauma, lack of resources, or your own genetics, can potentially impair your self and interpersonal functioning long term. And that's the group that we're talking about clinically when we talk about borderline conditions and just more minor levels of personality impairment and personality functioning impairment.
Now, to circle back to the case study and kind of tie in what we're saying, this is why I think it's so important to have a really, really strong formulation on a patient and how you formulate their personality functioning. And you don't need to be a personality theorist to be able to do this. The basic gist is, is this person relatively healthy in their personality functioning or unhealthy in their personality functioning?
And with patients who are unhealthy, you really need to tighten and have your boundaries be very, very strict. Because the scenario of a patient presenting something and... I've done that before where a patient presents me and say, oh, this is really helpful. Thank you. I might share this with other people. I don't think that that's inherently a thing that you need to avoid. But I think when you pick up on a lot of personality pathology, you really need to be intentional with these things.
And if someone is in a borderline range or you're picking up on a lot of personality problems, keep your boundaries tight and make sure you really think about those things and try to avoid those things. So I think to normalize, it's not that you become unhuman and stop responding to just normal nice things that occur in a therapeutic relationship. I don't think it's inherently bad to say, wow, this is really great.
I might share this with other patients. I think it can be bad if you're picking up on a lot of personality pathology and you do it anyway.
Yeah. So there is basically a change in technique warrant. And as you say, the main thing that we want to make sure of is that people are getting very clear and concrete reminders and initial advice, not advice, education on the frame and boundaries of treatment. But I think many clinicians have the experience of and have noticed that there's nonetheless testing, right? And maybe even not purposeful actions or behaviors from certain patients that threaten the normal confines of the treatment, the normal frame and boundaries, right?
One popular one is, of course, doorknob commons, you know? Let's say... At the end of a very enjoyable session for a patient, the patient tells the psychiatrist, you know, I think we really have a special doctor and patient relationship. Okay. Ooh, how do you handle that? Let's say the psychiatrist hypothetically looks angry and says, we have a professional doctor and patient relationship. And then ends the session.
How would you have handled that?
Well, you know, you're bringing up... I think it's... Let's talk about how the thing throw it. You know, talking about doorknob comments, you're then mentioning a few different... Like, as a clinician, you're put in a scenario where there's a few things you need to think about. The first thing is you need to protect your time. So let's say, you know, you have a great session and the patient brings up something super important to be talked about with two minutes.
Oh, by the way... I'm trying to think of, I think I might have overdosed on, I actually overdosed on lithium two days ago. You need to do an assessment of how important it is to talk about there, right there, and do the full assessment of how how much you need to deal with this right now, and also protect the boundaries of the session is over, I need to protect my time, I probably have patients in the future.
So you have to think through those two kind of conflicting things. Then the second part you're saying is just the kind of the response to a patient saying we have a special doctor-patient relationship. I actually agree with the content of how he responded or with what he said, not necessarily the emotion. But again, I don't necessarily know if that emotion is what occurred. You know, if a patient says something in regards to your relationship, that's not true.
We talked about it a little bit last time. You need to very firmly and unambiguously explain how you see things. So I think a very I think the statement is relatively unambiguous. It's very clear. Yeah. I just think it needs to be elaborated on. I don't think it should end there. We have a professional-doctor-patient relationship. I agree with that statement, but then you need to dive into why they think it's special and explain to them that that's not the case.
Yeah. I think it's maybe a little too abstract just to say professional. Some people might understand that, but if you're in the situation where there's already something a little wobbly or unclear in terms of negotiated reality between two parties I think you have to get very very concrete you want to avoid abstractions you might get as concrete as possible I suppose yes so then we can't necessarily assail the specific statement that's being made but I think in any situation like this in the doorknob common you're going to be thrown off kilter as a clinician So you better try your best.
You're going to fail sometimes to keep your composure and try to keep it warm, interested, and connected to the next session. So that would be my advice. I would probably respond with, well, I appreciate you telling me that. I'm curious by what you mean by special. As I see it, we have the typical special. doctor-patient relationship that I try to have with all my patients, you know, a good working alliance, and that we're taking care of these things for your benefit.
I think it's important that we discuss this the next time we meet. So keep that in mind, and I will too. Now in a second, now in psychotherapy, you could see if they bring it up independently at the start of next session, and make a note of that, and maybe even point it out. But for med management, If they don't bring it up, I'm immediately bringing them and going to talk about it at the start of the next session.
Yeah, I think it's worth talking here about the fact that for some patients, part of their pathology is being incredibly clever about the binds that they put you in. Because, you know, this scenario that we're describing is just full of different binds and that like, Time limits almost up. The provider probably just wants to finish the appointment. But there's also this super loaded thing that kind of needs to be addressed now.
So you're putting this bind of like, oh, God, how much how much do we talk about this right now? It definitely needs to be talked about it. And those sort of scenarios are difficult. Patients with certain pathology are incredibly skilled at creating those scenarios, those double bind scenarios that no matter how you respond, you're gonna disappoint the patient. No matter how you respond, you're gonna cause a problem.
I'm just gonna acknowledge that part.
Oh, yeah. And I guess to counter or add on to that, it's very American and there's a tradition to see it as purposeful, this kind of behavior, you know, and maybe it is, at least in part. But I always wonder about how much of this is automatic and that lack of capacity rather than something more purposeful. I even wonder about the truly psychopathic and antisocial. I wonder how much of it is really deliberate in the same way that a neurotic person would do something.
Or is it just the default mode of a human being that hasn't developed the thinking apparatus to automatically do this kind of stuff, just kind of echo the past? I have no idea.
I think I think what makes it confusing is I think it's deliberate, but I think I'm kind of saying it's deliberate, but it's not the same mechanism of deliberateness that a regular person is when they're deliberate. It's not like it's like conniving of like, oh, I'll do this very mischievous thing. Right.
Yeah, it's volitional. I suppose I should clarify my terms under the law. I'm thinking of like murder. criteria okay deliberation at least in my state means that you have a careful consideration of the risks and benefits of your actions and then premeditated would be that you thought about it before you did it even a little bit right and then I can't remember the last one under the law but purposeful or volitional it's basically that you did actually decide to do it instead of doing it on accident
Yeah, I think a lot of patients act out their conflicts and truly because they're on. It's weird because they're unable to think about them because it's so overwhelming. They act them out.
And yeah, exactly.
That's that's what makes it especially difficult, because if you were to even try to make explicit what's occurring, it will potentially upset the patient. Yeah.
So it is a little bit of a tightrope walk. I think that's why Marsha Linehan talked about how it was like being on a seesaw with the patient, moving forward, moving back. in terms of keeping the balance. With certain pasts, certain patients, you do need to be a little bit more deliberate, a little more careful, and it's challenging. But I do think it's rewarding work. It's not for everybody.
If this is not the kind of work that you think you can do well and responsibly, refer out. Don't be afraid to refer out. Or rely on a very strict and concrete and reality-based agreement about what you're going to do, even maybe down to the amount of time you're going to meet. even for a med management visit. And don't forget to read the good psychiatric management book.
All right. We're getting at 50 minutes. Should we try to do one more?
We could end. We can do one more. Up to you.
I should do one more. I don't know if it's going to get anything good. After a patient comes in, she had a vivid dream of hooking up with the psychiatrist in the office. In the dream, she enjoyed it while it was happening. She felt sad after because she was thinking about how the psychiatrist had crossed boundaries. The patient told the psychiatrist about the dream. The psychiatrist looked extremely uncomfortable, avoided eye contact, and asked, so you do like my boundaries?
The patient replied, I love your boundaries. I hate them, but I love them more.
It reads like a chapter out of Fifty Shades of Grey or something, not that I've actually read it. That's what I imagine it's going to read like. You know, I like this one because it touches on two things. It touches on something that could feasibly happen in some scenarios and how we might respond. But it also touches on the broader concept of dreams and their importance. Now, we're not going to litigate that in the last five minutes, but I would say that dreams are immensely important.
to even a medication management visit in your understanding of the patient's psyche and their problems and their values. And some, I don't know who originated this, have said that the first dream a patient independently brings into you is extremely important. It may be a message about your therapeutic relationship. okay um so first anytime a patient brings in a dream i do at least like to give a little bit of psycho education and express curiosity at the same time to say that that dream is important in terms of understanding yourself and i don't have the answers for you but i think if you reflect on it and think of all the different things you might come to some interesting things if there's time in the med visit because they're relatively simple and you can do essentially we've been um You can even dream analyze a little bit and come to some interesting conclusions.
I've been able to do that maybe a handful of times. But how do you approach this sexual dream being shared with you? I would immediately reorient.
Sorry, sorry. I'll let you get to the sexual one. I want to talk about this before you move to the sexual one. I don't know if I agree. I don't I don't know. Um, if making dreams a regular part of medication management is, is helpful. Um, just because I feel like it's such a personal intrapsychic process, um, that really requires, in my opinion, uh, like therapy, regular meetings, um, and really understanding a patient that I would do it as like a one-off, you know, a little fun thing, but I would explain to the patient that I don't, it's really counter to the main work that we're doing in medication management.
I think it depends. It just depends on how you approach dream analysis, I think. I wouldn't remember, a lot of people think that dream analysis is the clinician interpreting the dream, but really it's up to the patient, right? So I just try to lead the patient and reflect on what do you think this could relate to in your life that's been stressing you out or that you're worried about or you're thinking about a lot.
And then I go to those concrete issues specifically. If the patient is not one that can do that, I simply will stay agnostic and say, well, I'm sure it means something very important to you. And I encourage you to figure that out, especially in psychotherapy. Now let's talk about your medications. So yeah, you got to do it within the confines.
I think dreams mean different things, different people, too. And I think it's worth if you hear someone have like really great, like loaded dreams that like you're picking up a lot of meeting. I would refer them to like a potential dream journal or a psychoanalysis that analyze dreams. Yeah, exactly. Even my own method. There are some people I know who have like these just incredible loaded dreams that contain all this information that like really important and all these unconscious conflicts.
I'm someone I barely remember my dreams. I was in analysis and I was so frustrated because I kept trying so hard to remember my dreams and I just wasn't able to. And I like lost so much sleep trying to track my dreams and try to get them. And I would like at best get like a one little like one second snippet. Yeah. Yeah. I mean,
different analysts even have different approaches, I think, and theories and thoughts about dreams, even if there's kind of a professional consensus there. Personally, not being an analyst, I don't see dreams as true in themselves. I don't think that they are fundamentally true in themselves. I actually see them more like informed tea leaves. They are some product of your real working interior and your awake mind. But the value in it is how you interface with it when you're awake.
OK, that's the value, not any kind of fundamental truth quality. I don't know if that is relevant at all or even makes sense. Hey, I think we forgot to talk about the transference kind of transference one.
We don't have time for that. We still have to talk about the sex part. Yeah, I agree. It's almost like dreams are mythology that are hyper-customized to you. Yeah, exactly. So we were talking about the sexual aspect of the dream. Oh, yes.
I don't have to comment too much on that. First, I would immediately know that in my own head that there may be a erotic transference forming and we're going to have to really be clear about that. Right. And secondly, I would probably say, you know, well, that's quite interesting. And I suppose I wonder if it touches upon anything else that you've been feeling while you're awake. And I want to.
let you know that it's actually very common to develop feelings that might not make sense about your treatment provider, including myself, doesn't mean that it's real. And certainly it would interfere with your treatment if we take it as anything other than a sign of your underlying thoughts and feelings in your life and not really about me. But it is worth talking about. And I want you to let me know if you think that there's anything going on between us that is getting in the way of you getting appropriate professional treatment, because that's what I'm trying to give you.
Wonderful. And I think go back to part one on if things get to. Yeah. Yeah.
We didn't talk about transference and countertransference definitions and how people look things up on the internet and how we might be able to define things for them. But, well, you know, there's going to be other episodes.
Yeah.
Not on this topic, though. I feel like the enthusiasm was less than I would have expected. But, you know, you never know of these things. People seem to like medication stuff the most.
Yeah. Yeah. And I was going to say, I don't, I don't think this warrants a part three. I think we got to.
No, no part three. We're cutting it off.
Um, I think it brings up good topics, but you know, we got to follow the views.
It'll come back. If it's important, it'll come back. You don't have to intervene every time. If it's important, it's going to come back in a future session.
Yeah. Um, I'm not sure what we're talking about next time. I guess we'll, we'll figure it out. Um, figure it out.
Any, I think there's a break coming though, isn't there? Are we anticipating a break?
potentially. We'll see.
All right. Until next time.
All right. Have a good one. you