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Where Do Doorknob Comments Come From?
104 Plays8 months ago
Join hosts Fara and Grant on the latest Doorknob Comments podcast episode, where they delve into the intricate dynamics shaping the therapist-client relationship. They dissect the subtleties of this bond, emphasizing its profound impact on therapy efficacy. Ethical dilemmas like confidentiality and intervention in client danger are explored, alongside the significance of self-awareness and transparent communication. The episode navigates the therapist's role in addressing risk behaviors and physical health, while tackling challenges posed by clients with trauma or depression. The paramount importance of prioritizing client well-being resonates throughout the discussion.
P.S. Remember, therapy is a journey we take together, and every step reveals new horizons. Let's discover them together. Tune in now and let's continue the conversation.
Key Takeaways
- Dynamics of the therapeutic relationship
- Ethical considerations: confidentiality, intervention
- Client autonomy and decision-making empowerment
- Potential pitfalls of therapist self-disclosure
- Addressing unspoken and unconscious aspects of therapy
Resources and Links
Doorknob Comments
Dr. Fara White
Dr. Grant Brenner
Recommended
Transcript
Introduction and Decision Stress
00:00:00
Speaker
I've even been there myself. Yeah, but I have to decide this week. Oh, good. We have a little bit of time. It's Wednesday today. When is your decision due? Tomorrow morning. Okay. Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner.
00:00:18
Speaker
We're psychiatrists and therapists in private practice in New York.
Doorknob Comments: Revealing Hidden Thoughts
00:00:22
Speaker
We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time just as we're leaving the office, sometimes literally hand on the doorknob.
00:00:35
Speaker
Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out.
Exploring Unspoken and Unconscious Elements in Therapy
00:01:02
Speaker
In this episode of doorknob comments, we talk about the things that you can't talk about easily. There are things that we know we can talk about. It's very easy to be straightforward and direct. And sometimes we know the things we can't talk about or won't talk about.
00:01:18
Speaker
they're repressed, they're hidden by stigma or shame. There are those things that we may think about, but not bring up with our therapists or with other people. And then there's the bread and butter of therapy, which are the things that might be spoken about, the things that are possible to discuss. Farah and I talk about those things today, the unconscious or unspoken things, the possibilities,
00:01:42
Speaker
the way things come into being through predominantly speaking, but sometimes through action and especially how that plays out in psychotherapy. Yeah, great. I think that covers it. We really hope you enjoy hearing the conversation as much as we enjoyed having it.
Therapists' Advice: Impact and Challenges
00:01:59
Speaker
Yeah, we'll talk about everything from whether or not therapists should give advice and perhaps whether people should take it as well as to the less concrete aspects of how the therapeutic relationship develops over time to make space for more and more self-reflection and positive change.
00:02:19
Speaker
What do we hope listeners will get out of this experience, Dr. White? What I'm hoping is that we can talk a little bit about the things that happen that maybe aren't supposed to happen. Like let's say the therapist gives advice that the patient doesn't understand or doesn't agree with and thinks it's really bad or tells them something they maybe don't want to hear either about themselves
00:02:49
Speaker
like the therapist themselves, it's called like a self-disclosure, or maybe something about the patient's life. And then I guess the final thing to touch on is how to manage if a therapist says something, I would say it's like inadvertent, but hurtful, or that can be perceived as unkind. Something unintentionally slips out, whether it's
00:03:17
Speaker
How the how it's motivated is is an important question there. Totally. I've had that happen. I've had that happen rarely. It's more common, I'd say, in everyday life because we're not kind of watching what we say necessarily depending on the situation as carefully. Exactly. And I do think especially now as it's a good book, I feel like this is going to be a whole different vibe.
00:03:43
Speaker
So okay, let's start with this is like an easy way for us to ease into the topic.
Therapists' Roles in Social Media and Diverse Approaches
00:03:50
Speaker
What if a therapist gives advice that a patient doesn't agree with or thinks is bad? Well, first of all, do you think that therapists should be quote unquote giving advice? I don't know anymore, man.
00:04:06
Speaker
It depends how you're working. I actually don't think that's a tough question. Though I think it's a great question because I see this all the time on the social media platform formerly known as Twitter. What do you see? I see people asking that question or just making these blanket statements. Therapists shouldn't give advice. Therapists should give advice. Well, listen, in psychodynamic therapy, well, let's take a step back. Okay.
00:04:32
Speaker
when we talk about different approaches to therapy. Therapists don't agree on what therapy is. In a broad sense, we do. Therapy is meant to help the person. But in terms of the particular techniques, practices, goals, there isn't universal agreement, and there's different ways to approach therapy. I like to use the metaphor from geometry. There's two different kinds of geometries, what are called Euclidean and non-Euclidean geometry.
00:05:01
Speaker
And it depends on whether you start with the assumption or the axiom, the truth, that parallel lines meet at infinity or if they remain parallel forever.
Therapeutic Alliance: Importance of Relationship
00:05:13
Speaker
Well, I was gonna say, what do you think are the big sort of axioms?
00:05:18
Speaker
For me, one of them is the influence of the therapist. The other is the agency or autonomy of the patient. And with the caveat that that changes as a function of the patient's developmental stage. Right. And I think we would say that like that relationship between the therapist and the patient called the therapeutic alliance. Right. It's a different way of
00:05:43
Speaker
That's the Dr. Lee way of calling it. The Dr. Lee way, right? The therapist way is sometimes therapeutic relationship. Sounds a little different. Right, but I think that research tells us that the stronger the therapeutic alliance, the more effective the therapy is going to be. The therapeutic alliance accounts for 7% of the effectiveness of therapy.
00:06:10
Speaker
7% of the variance. That sounds like a low number because it is, but it is the biggest of the confirmed factors. Right. Which tells you how much you don't know. Right. Lucky number seven. So does that mean that people need to like their therapist and the therapist needs to like them? I don't think that's necessarily what it says. That is correlated with better therapeutic outcomes. Yeah, but I think that's a little bit
00:06:38
Speaker
It can be distinguished from, do I really believe this person is trying to help me? And let's say... So let's say that that liking piece, though, is a gray area and can be a slippery slope. Correct. Because the therapist, if you hear that naively, you might all do anything to be liked. Right. I'll give them every med they want. I'll change my schedule without any concern for my own scheduling needs. You know, anything goes. Right. Which is not... That wouldn't be good. It's not good, right, because then it...
00:07:08
Speaker
enables a certain kind of dependence. It doesn't allow the patient to sit with not being gratified and really discuss it. Right. So but I understand that wish. I think when sorry, when you say you can I just when you say you understand that wish, what what what do you understand? I understand the wish on the part of both the therapist and the patient to give each other everything and not to withhold.
Balancing Advice with Patient Autonomy
00:07:37
Speaker
especially if people are coming to therapy because they've had lots of relationships, including parental relationships or romantic relationships where things have been withheld from them. Like neglect, for example.
00:07:51
Speaker
like neglect, like a sort of lack of commitment or a disregard for someone else's feelings. And so a lot of times people are coming to therapy because they need their feelings to be validated. But if I were just a lack of expression of emotion, affection and love. Right. Right. Yeah. But then if the therapist is too loving, too validating,
00:08:17
Speaker
It might feel really good, but the patient might not move forward. And so I do think that sometimes as we're working with people, certain things can come up, right? Should I move? Should I go back to school? Should I leave this job? Should I stay in the job? Should I- That kind of like advice about big life questions. Right, get married, stay single. And I think it's really natural for people when they trust their therapist as they should to want
00:08:46
Speaker
someone's input on that, right? So like, let's go through different responses to that. Someone who gives advice, quote unquote, who's very coachy and who doesn't have the prohibition against giving advice or directing a person's life. Yeah.
00:09:02
Speaker
where they may be somewhat narcissistic if well intentioned and want to give them a nudge in the right direction maybe the therapist's own parents didn't give them enough guidance and they don't want to do that. That could be one of the unconscious thoughts going on or motives. You might say, I really think you should go to Carnegie Mellon instead of Dartmouth.
00:09:22
Speaker
I don't know who would ever say that. I didn't go to either. Carnegie Mellon has a great musical theater. Some therapists might say, I think you should go here and not there and this is why. What do you think? Or just do it, right? Another therapist might say,
00:09:37
Speaker
Well, I can't tell you where to go to school, but I can definitely think through it with you. How are you thinking about it? And let's talk about what it means for you to have this big choice and could go quote unquote deeper. Another therapist might say, okay, let's draw a chart of the pros and cons. What are your top three schools? Here's the column. I've got
00:10:02
Speaker
I've got my tool, right? Another therapist might just say, and I'm almost done, they might just say, that's not my decision. You have to figure out what you want to do. Right. And not show any curiosity. Yes. And I don't think any of those are necessarily wrong. I think the case for being more
00:10:21
Speaker
directive is that the therapist presumably is one of the only people you're outside of that patient's social circle. We're assuming that the therapist does have good intentions and that they are really saying what they believe is right, as opposed to family or friends, which may have may stand to
00:10:46
Speaker
benefit from some way if they can get someone to do what they want them to do, right? That makes sense. So when you say we're assuming the therapist is well-intentioned, well, we're not. But we would like to consider the situation where we are assuming therapists is well-intentioned. But we know that there are other situations where therapists may be driven by factors other than the patient's well-being.
00:11:13
Speaker
That's possible. I would say, especially now, it's very unlikely that someone would try to direct a patient to do something that's in the best interest of the therapist and not the patient.
00:11:29
Speaker
Yeah, I don't have data on that. And I think that's an important subject. But we're working in the situation where we have an ethical therapist who is aware that they may be motivated by their own needs beyond the ordinary needs that a therapist has.
00:11:49
Speaker
the healthy need to do a good job, the need to make a living. Yeah, so let's say that I would assume that most of the advice is coming from a good place, but the case against giving people those sorts of directions is really big. On one hand, we're perpetuating this idea that the patient can't make their own choices.
00:12:18
Speaker
And again, that's like infantilizing. We want them to be able to feel empowered, like they can think through this and they can do it on their own. Right. People who are interested, by the way, in learning more about the ethics around boundaries, we recorded, you know, a while ago, but it's very current with Jacob Appel, a psychiatrist and specialist in ethics, among many other things. So you can go look for that episode of Doorknob Comments with Jacob Appel.
00:12:47
Speaker
about boundaries and boundary crossings and boundary violations. But I think the point is if a therapist is giving advice and it doesn't matter how small or how big, it might be like I say, oh yeah, this coffee shop opened up around the corner and I know the patient likes trying new coffee shops. Like after the session, I may say, oh, check it out, right? And they hear that as an invitation to meet you for coffee.
00:13:16
Speaker
And then you go to your favorite coffee shop and you're like, oh boy. No, no, I was just thinking like,
00:13:23
Speaker
There are these things that happen outside of the frame or outside of the therapy that might be like, I really thought they would enjoy checking it out. And so maybe, and maybe I feel guilty because I have my own coffee there. Right. Who knows what can be guilty or you may, you may feel like that's your private space and why did I blurt that out? And can I ask you of a different example that comes to mind? What about something like a book recommendation?
00:13:50
Speaker
Would you suggest someone read a book or would you mention a book like, hey, this book comes to mind, but you know, it's up to you whether or not you read it, but here's why it comes to mind? Well, I think every time I give a recommendation. Do you give recommendations? I do. I do if I think something is going to be helpful.
00:14:11
Speaker
or I think it relates to, because I think that's also part of our job, right? I agree, but let me just be clear in what I'm asking. Yeah. So there's not gonna be any ambiguity about recommending medical treatment. Recommending lifestyle changes is likely to be a clear recommendation. Regular exercise as long as your cardiologist, your primary care doctor is okay as long as you're healthy.
00:14:35
Speaker
recommending something unrelated to therapy. Hey, I think you should try shopping at this great store. And by the way, I love that store. That's much harder to justify therapeutically. If you know someone loves coffee and you make a coffee shop recommendation, then you would ask yourself, why at this moment am I making that recommendation? Am I trying to get the patient to like me?
00:14:57
Speaker
But something like a book could be seen as a medical recommendation. And of course, someone made up a word, bibliotherapy. And I've read research that bibliotherapy is effective. So you can definitely think of it as a prescription, or you could think of it as something more vague. So how do you think about something like a book recommendation?
00:15:17
Speaker
Well, I usually try to put it into the context of why I think it would be helpful. And I think there are a lot of things of course that come to mind during therapy or even when we're talking about like how things are going in the treatment itself that I don't say, right? So if I am going to
00:15:42
Speaker
About books? About books, about shows, like, oh, this reminds me of that. Like, there are a lot of things that I don't share. That's an interesting point. I do hope you recommend books that I've written, though.
00:15:56
Speaker
to everyone. Like making your crazy work for you. I'm doubling your readership. I've noticed they're not in your waiting room actually. Yeah, I'll have to put them in the waiting vestibule. Staying with the joke, right? How would you feel if you go to a therapist's office and they're selling stuff? Books, vitamins, beads. When you go to the dermatologist, there's always an upsell.
00:16:17
Speaker
Yeah, yeah, yeah, but our job is different, right? So I think in that sense, we have to be very intentional and think through what we share and don't share. And you're right, sometimes things slip out in conversation. I think we're all more careful with people who we perceive as, well, either they're new to the practice, they are maybe a bit more fragile or skittish or they
00:16:46
Speaker
Right, so here's a little bit of peeking behind the curtain.
Psychodynamic Therapy and Unconscious Factors
00:16:51
Speaker
In psychodynamic therapy, and I'm trained in a lot of different forms of therapy, but I think I have sort of a long standing interest in psychoanalytic or psychodynamic therapy, which has to do with unconscious meaning and conflict and uncovering things. There's something called a psychodynamic formulation, which is basically
00:17:10
Speaker
a model that allows you to try to do your best job with a patient. And that involves a description of their history, like their developmental experience and how that's relevant, a description of the biological factors like medical problems, diabetes,
00:17:27
Speaker
a discussion of their psychology, things like unconscious conflict or unresolved problems that may be of interest, and how those things could play out within the therapeutic alliance, either in positive ways, but more often like trying to anticipate problems that could come up. Because this would be a good example of what you're getting at, which is, I have this thought, I'm thinking about whether or not to share it with the patient.
00:17:52
Speaker
Right, but you're saying that if you share the same issue, whether it's a fear of abandonment or... I'll give a personal example. I feel comfortable with this example because I've been open about it in my writing.
00:18:10
Speaker
I experienced early parental loss, meaning death. And so when I work with patients who have experienced the death of a parent at a young age, I will not automatically disclose that information by any stretch. And my default actually is not to share that personal information.
00:18:27
Speaker
I'm aware on one hand that it may create the sense with a patient that I can understand them better and that may strengthen the therapeutic alliance, but it may also lead to idealization and unrealistic expectations or a sense of intimacy which is not possible within the therapeutic framework.
00:18:44
Speaker
On the other hand, there may be times in the therapy where I do share that information if based on a number of different perspectives on how the work goes, basically theory and understanding of that particular person. But that would typically be rare and very limited in scope. And certainly it wouldn't become the focus of the conversation. But it would shift the therapy significantly. And I think that you would only do it. Right. And this is what people should know about
00:19:14
Speaker
disclosures on the part of the therapist, I think you would only do it if you thought that it would further the therapy or help the patient somehow. You're not doing it because you want them to know something about you.
00:19:27
Speaker
I wouldn't be doing it, hopefully, for an unhealthy narcissistic need. And I would be asking myself, you know, why do I want to say something, particularly if it's something that's in that kind of gray zone, which would require me to have that reflective function, which is a developmental achievement, right? Not everyone has that ability to have that holding space in their head and kind of have that dialogue with themselves. That's actually something you can get from therapy. Which we both have
00:20:00
Speaker
done copiously over the course of our training. Or they call that mentalization. That's the other fancy word for it. It's good to turn it off sometimes. You meet someone, are you analyzing me? I'm watching the game. Right. But I think I want to be sort of
00:20:18
Speaker
practical and maybe we can do like a little role play in terms of let's say you are the therapist and I'll be the patient trying to decide whether I should keep applying for jobs or should I go back to school? And I really don't know what to do, Dr. Brenner, and I want your input because I trust you and you know me really well. Should I go back to school or should I just, you know, keep applying for jobs?
00:20:49
Speaker
Well, I'm curious about the way you're putting the question. For one thing, I have other thoughts. Tell me what to do. I will in due time. Or maybe you won't want me to after we talk through it a little bit. Let's see, are you open to just holding a little bit of space while we work through this? I hear it's a big decision though. It's not an unusual one, right? I've even been there myself. Yeah, but I have to decide this week.
00:21:17
Speaker
Oh, good. We have a little bit of time. It's Wednesday today. When is your decision due? Tomorrow morning. Okay. I think that's good. If we need to, you know, if it's really weighing on you, we could schedule some extra time, but let's see. So you're presenting it as an either or a decision. That's sort of my first thought. I don't know why that's my first thought, but it's like either I apply for jobs or what was the
Therapist Responses: Role-Playing Scenarios
00:21:42
Speaker
other choice? Go back to school. Go back to school. I'm going to get an MFA.
00:21:45
Speaker
OK, and what are what are the factors that go into that decision for you and MFA? That sounds fantastic, by the way. I know you've wanted to tell me to get an MFA. I just feel like you want me to get the MFA.
00:21:58
Speaker
Well, I'd say on one level, I'm really rooting for you if you want to get an MFA. Absolutely. And, you know, I love art. You can tell by my office. So there's covered in art, like, you know, no big shocker there. Right. And still what I'm wondering about is what are the considerations that go into the decision for you and.
00:22:16
Speaker
Is it difficult for you to think about making your own decision, even if you do get input from people like me? And I wonder who else you've asked about it. You know, are you feeling like you can't make this decision yourself? Kind of. Okay, I think this is a good, we can pause the roleplay.
00:22:33
Speaker
I think I'm just going to keep role playing if that's OK with you. Who did the safe word? I think that what you were doing was really playing it safe. And a lot of times, if therapists come down too much on one side or the other. And it's important for patients to remember that your therapist is really just a person, and they're a person that you've hired.
00:23:02
Speaker
to help you. But if this person that you've hired to help you is giving you advice that you disagree with, it's okay to say that you disagree or that you feel like they're pulling for one thing and you're pulling for something else. Let's roleplay the other scenario where I'm not being curious and trying to stay with my obligation to you.
00:23:30
Speaker
Dr. Brenner, I don't know what to do. I've gotten into this great MFA program and I have to tell them by tomorrow morning whether I want to go or not, not getting any bites, applying for jobs. What do you think I should do? Can you afford it? I can take out loans. Do you think you'll be able to pay them off? Eventually.
00:23:49
Speaker
Yeah, do it. Why not? Like, you know, live your dream, right? You only live once. Hey, you know, I always wanted to be an artist, but, you know, it didn't work out that way for me, life, culture, parents. I think you should do it totally. Okay. Okay. Fast forward 10 years. This is so gratified.
00:24:08
Speaker
Now five years down the road. Okay, so now I'm an artist. I have my own studio and I create these incredible works and maybe I've had some success. You're making some money. I'm making some money, but I'm miserable and I suffer every day. I hate being an artist.
00:24:32
Speaker
Well, that's easy because you can just look for other jobs, but now your resume doesn't support that. When you come back to therapy and you're like, you gave me terrible advice. Like, you know, I trusted you and you betrayed me. Yeah. Or you're an artist and you're not making ends meet and you're like, I'm waiting tables and I've got a hundred thousand dollars in loans. And when I told you I could pay it off, you didn't question that at all. Like, where did you get your therapy degree from? A crackerjack box? Yeah, right. So that's the pay at all.
00:25:02
Speaker
Right. I used to have toys in them. Now they just have like little stickers to an online game, by the way. I didn't know that like a QR code. They used to have little toys. They have a little sticker and it's like, you know, yeah, QR code. Sorry. So I think we what we want.
00:25:23
Speaker
from or listeners to take from this that as patients, they don't have an obligation to their therapist, but they have an obligation to themselves to speak up if they are thinking or feeling something from their therapist. And I'm encouraging them not to keep it a secret.
00:25:45
Speaker
It doesn't mean your therapist is not gonna like you or think, well, what do you come here for anyway if you don't wanna listen to me? No, that's- You mean except with you though, right?
00:25:58
Speaker
You would have to be so narcissistically fragile. I mean, there are some people, some therapists who actually love getting into those types of, you know. If they're in a relationship. Right. They're like, bring it on. Yeah. I remember my analyst was like, why aren't you more argumentative with me? Yeah. All my other patients argue with me. And I was like, yeah, I know because like we're in school together and they all insist on telling me how they all argue with you, which I don't want them to do.
00:26:23
Speaker
And I'm like, I've had enough arguing with therapists in my life. I don't want to have that experience. And I understand how that may limit things. Yes. Yeah. I don't want you and I don't want our listeners to feel like they have to avoid an argument because we really look at it as there's a whole.
00:26:41
Speaker
thing, rupture and repair. Well, it's like the therapist's fragility and vulnerability that comes up. Karen Marotta, who is well known in the field, just wrote a book about the therapist's vulnerability. So sort of joking aside, I think you're making a very good point, which is pretty much, especially in psychodynamic therapy, again, the patient should free associate. That's a goal anyway. The door is open to say whatever is on your mind.
00:27:08
Speaker
Yeah, including things that you feel may make me uncomfortable. But then the therapist also has to be able to respond in a good enough way, not become defensive or, you know, shut it down. Yeah. And a lot of times though, working through those moments,
00:27:26
Speaker
Whether it's we gave bad advice or we spoke out of turn or we slipped and accidentally said something hurtful. Those are moments where we can all
00:27:40
Speaker
like learn and grow, and then it allows the therapist to become actually a better therapist for you. Because like if people are, let's say keeping certain things, like maybe it really bothers people that I drink my iced coffee.
00:27:59
Speaker
I'm joking, but you know what? I had a supervisor once who used to attack the calluses on their hand with a pair of cuticle scissors during supervision.
00:28:11
Speaker
And I asked about it and it was met with kind of like a sort of a detached like, oh yeah, yeah, you know, I have this problem with playing tennis a lot. And I couldn't have a conversation about it. And of course I wondered whether they would do this with patience, right? Which I'd be like, that's really strange. It seemed almost masochistic. At one point I brought in a gift of very, very good
00:28:39
Speaker
Hand cream After which he stopped doing that really so to the idea of things that are Partially spoken trying to address it with language with words with speaking with with someone whose trade is kind of words kind of didn't work what did work was sort of this action in this in the session and
00:29:02
Speaker
Right. Also, I took it as a communication that maybe there was something about the work we were talking about who was a very difficult patient to be supervising because the patient was not participating in therapy was to him painful. But also maybe there was a callus to be gotten through. Maybe. Well, I think you're definitely
00:29:25
Speaker
you know reading into things as as you do as one should and i don't know that that our listeners would necessarily do that but they could. Say hey listen i notice every time i talk about my boyfriend you start looking around for your chapstick.
00:29:46
Speaker
or something, or you cross your legs, you sit back in your chair, you sit forward in your chair. It's just getting worse. I thought you were going to say something like, you just seem distracted. Or you just seem distracted. I know, but we're not like statues. And so we do have body language and we do have physical needs.
00:30:05
Speaker
Whether it means something or not. We don't know, right? So what would you do if a patient said, hey, I noticed whenever I talk about my boyfriend, you do this particular thing and I'm starting to wonder if, like, do you notice that yourself? And I might say, well, actually, I wasn't aware of it if I wasn't aware of it. And if I was aware of it,
00:30:26
Speaker
I might say yeah I guess I all of a sudden kind of get uncomfortable when the topic comes up and people might say well why are you uncomfortable and
00:30:42
Speaker
And that might open up a conversation about something that I'm thinking or feeling, but not ready to say about someone's relationship. So in that case, though, you might go with self-disclosure.
00:30:59
Speaker
Or you might say, well, you might say to yourself in your head just to kind of end this episode of doorknob comments with this idea of what's spoken and unspoken. You might just say, yeah, maybe I get uncomfortable.
Unconscious Behaviors and Ethical Responsibilities
00:31:11
Speaker
Or you might say, I'm thinking of telling the patient maybe I get uncomfortable because the patient has kind of
00:31:17
Speaker
called something out. That in and of itself may make me feel a bit uncomfortable. I might think to myself, well, should I say anything? Really, really traditional therapist might not say anything. Someone might say, well, how do you feel about that? Another person might say, you know, that's really interesting. What was your reaction to me doing that? And how long have you noticed it? Like, let me get some more information about it. Another person might say, I'll try not to do that. Let's see what comes up.
00:31:45
Speaker
Is there anything that comes to mind for you about what happens when you talk about your boyfriend? I think any of those are classic, classical responses. I also think that ultimately what you want to get to
00:32:04
Speaker
You like to let your hair down a little bit. Well, I don't like to have secrets. Right. And so if I feel like I've been keeping a secret, I want to know, like, why have I been doing that?
00:32:20
Speaker
I don't think it's necessarily good for the therapeutic alliance. What I would try to do is find... Because there are things that I do that I'm really not aware of, of course, obviously. But then there are some feelings that I'm more attuned to within myself. But we all have our own blind spots.
00:32:39
Speaker
So this goes to self-awareness, right? Self-awareness and the idea of being in therapy. And there used to be an idea that if you completed say psychoanalytic training and you were quote unquote fully analyzed, you would like be in a place where you had no blind spots.
00:32:56
Speaker
And your own responses within the therapeutic framework would be taken out of the equation. And more contemporary therapists who think in this way, there are fields of therapy that don't really even look at counter transference dynamics, which I think is
00:33:12
Speaker
problematic because it's critically important for having a successful therapy for many people anyway, not in all cases. Going back to the beginning of the conversation, unless you're kind of getting coaching or very specific forms of cognitive therapy to change a behavior, the insight oriented therapies or the depth therapies, you have to be aware of what's going on in the room. And so to your point is like you said, that you don't like having secrets. Yeah.
00:33:39
Speaker
And so when a patient says, hey, I think you're doing something when I talk about my boyfriend, then your first impulse is maybe to alleviate some anxiety. Maybe I'm keeping a secret. Well, you know, maybe you're right. Maybe I do feel uncomfortable. But there's other hypotheses as to why you would have that behavior than your own discomfort, right?
00:33:57
Speaker
for sure, for sure. But I think being able to unpack that and being really honest about what I notice and what I don't notice and curious about how it affects someone else and getting all the information. If I just said, yeah, I don't like him and I don't think he's good enough for you.
00:34:14
Speaker
That's a value of psychodynamic therapy is honesty and truth will be reparative. Exactly, exactly. And if I just come right out and say it, I'm glad you asked because
00:34:28
Speaker
I think he's a loser. Then I'm really shutting something down, right? And on one hand, maybe I'm being fully 100% honest, but I'm not leaving room for my patient to say, but you know what? He has been really supportive of me throughout this whatever difficult period of my life and we haven't talked about it. That's a key idea.
00:34:54
Speaker
It comes up with the idea of fantasy and dreams in psychoanalytic or psychodynamic therapy a lot. So the idea is like similar idea. Someone tells you their dream and you say, let's explore it. And they go, can't you just tell me? I already googled it. And you're like, well, but that's not the point. The point is to explore it and see what kind of meaning comes out of it for you.
00:35:12
Speaker
not to be sort of reading the tea leaves is an analogy. You hear a lot, it's a bit disparaging, nothing against divination. But that's not what we do. We don't divine the future from dreams, though that's a valid way to think about dreams. But that idea that you're kind of like, well, I don't want to tell you what I think your dream means because
00:35:32
Speaker
we wanna leave that space open for you to share your own fantasies and associations and come up with your own meaning. And in that sense, it is really respectful of the patient's expertise. And I may have ideas about what different things mean in dreams. No question, I do. Maybe they do, maybe they don't for a given person. But if you exert yourself in that way with a patient, you may be shutting things down. So if you say maybe I do feel uncomfortable, you also may be shutting things down.
00:35:58
Speaker
Yeah. But I also want to be open to the fact that they could be picking up on something that I'm not picking up on. Right. Right. Yeah. And if we wanted to be like quote unquote OCD about it, we could we could try to pinpoint exactly what is the right balance for you with that particular patient of openness and respecting space.
00:36:20
Speaker
The other thing you may be thinking about is, you know, your own relationships, right? You may ask and you might not disclose that. You might not say, Oh, that reminds me of the guy I dated in college. He wanted, he wanted me to, um, you know, stay in New York, but I wanted to move to California to get an MFA. Right. You're right. Yeah, exactly. If I stayed in New York, I would have had to have gotten a job. Right. I think the only thing though, that, and this is, I have a question for you, right? Where if,
00:36:48
Speaker
you had a sense that your patient was in danger, whether I think emotional danger is more nebulous, but if you thought that a patient was doing something that put them in physical danger, how would you talk about that with them? Because I think that that is really, for me, why I don't like to keep certain things, because I might be worried.
00:37:12
Speaker
Well, in those cases, as a disaster mental health responder, this term comes to mind, people need to know you care before they care what you know. But I would certainly be candid and I would be clear and I would be supportive, non-judgmental, non-shaming and caring and make it clear that my primary concern was the person's short and longer term safety. But I do know therapists who wouldn't intervene.
00:37:37
Speaker
Right. And I think that sometimes when people are in therapy, they think like, oh, I'm safe. I'm covered. You know, it's like this assumption. And so I think another thing for patients or for our listeners to ask therapists is like, what would you do if you thought I was doing something dangerous?
00:37:56
Speaker
Right. Well, and to the same point, what I will generally do when I start working with someone is you discuss the limits of confidentiality. And it's in my treatment agreement. And it's like everything we talk about is secret. Like sometimes people will want to share something they did that may have been
00:38:16
Speaker
breaking the law. I'm not obligated to report that. The only thing I'm obligated to do is if I suspect there's a significant possibility of harm to yourself or others, I'm obligated to do something. It gets a little hazier, let's say, if you're respecting a person's right to drink excessively. Right, or they're telling you they're training for a marathon and they have to go for runs at four o'clock in the morning in the park when it's dark.
00:38:43
Speaker
Like there are all of these things that we do that could be perceived as dangerous. And so I guess I think it's okay for patients.
00:38:52
Speaker
to feel our concern. But those scenarios require, they all require what we call a risk assessment. Yes. So going for a run at 4am in the park, is that objectively dangerous? Should no one be doing that? You might say, are there other runners? You know, does the patient have specific history where they may be doing something unconsciously that could be harmful for them? Something like excessive drinking, I think is
00:39:15
Speaker
is an easier example because if someone is harmfully using alcohol or drugs, the majority of psychiatrists, right, would say, of course, you have to say something.
00:39:24
Speaker
Whereas I also know some therapists would be like, well, we're working on that, but kind of that's their choice. And I also know therapists who would say, I can't keep working with you if you keep drinking like this. I recommend, and I'm referring you for alcohol use disorder treatment. But I know other therapists who will kind of go along with it out of
00:39:46
Speaker
a stated respect for autonomy. But the clearer the risk is, I think the harder it is to not see it in that there's one right choice. But I also know traditional therapists who don't have that obligation to prevent harm and who may kind of be with a person through those difficult times. That can be a real dilemma sometimes.
00:40:09
Speaker
If you think that bringing up a concern for safety could interfere with the treatment alliance, ideally it strengthens it, but that doesn't always happen. Right. And I think that sometimes this is something that comes up a lot in my practice when I'm assessing someone who has a history of trauma or a history of, you know, serious depression.
00:40:30
Speaker
Like one of the lesser known outcomes is they may not have taken care of themselves for months or years. So they may not have been to the dentist. They may not have been to the gynecologist. They may not have fed themselves fruits or vegetables. Like all of those things are just very known to happen. And so that those things become part of our work together, right? You have time. What do you mean you have time?
00:40:59
Speaker
You have time to work on some of those things. Yes, but I think that they have to be part of the discussion. And I think that sometimes if people have been in therapy with someone who's maybe not a medical doctor, it's like, why are you asking me when I had my mammogram last? Why are you asking me about a colonoscopy?
00:41:17
Speaker
Well, when I say they have time, it also depends, right? If they have serious abscesses in their mouth, that can affect, you can get cardiac problems from that or brain aneurysms that are infectious. If you had an abnormal pap smear five years ago, then you don't have time before going to get that checked out. So you really need to do that assessment and not everyone is trained to do that. Yeah.
00:41:39
Speaker
and so that can be difficult. So we're winding down, we've covered a lot of territory. For me, this idea of what is in the middle? What is in between the stuff that's completely suppressed and no one will talk about it, it's stigmatized or it's buried or it's hidden, dissociated, repressed, and the things that you know you feel comfortable bringing up, there's a lot of space in there. Yeah.
00:42:06
Speaker
I think that's also why Dornov comments come up at the end of sessions. Exactly, because sometimes they just don't make their way in to be fully unpacked. And that's another thing.
00:42:19
Speaker
to kind of look at. That goes to the function of a part of the brain called the anterior cingulate cortex, which is a conversation for another time. Well, this has been really fun. I'm glad you talked about it. And we would love a rate and review. And thank you for listening.
00:42:39
Speaker
Thank you. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.