So good afternoon or good evening everyone, depending on where you are, I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry. I wanna welcome you to today's webinar and our series titled Advanced Addiction Psychotherapy, which is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today and to offer you these live trainings that will be held the second Wednesday of each month from 5.30 to 7 p.m. Eastern time. Today's presentation is titled Dynamic Deconstruction of Challenging Interactions When Working with Difficult Patients. Our next presentation will be in February when Dr. Bruce Leis will talk about CBT for addictive disorders with a focus on content and process. You can check the AAAP website for updates on other upcoming speakers. Welcome, everybody. Thanks for your attention today. We're happy to have Dr. Robert J. Gregory, MD, speaking for us. And he is a professor in the Department of Psychiatry at the SUNY Upstate Medical Center. He currently serves as the director of the Psychiatry High Risk Program, a recovery-based outpatient treatment program for suicidal youth and young adults, which he founded in 2017. Dr. Gregory is also the developer of an evidence-based treatment called Dynamic Deconstructive Psychotherapy, which is what we're going to be talking about today. And this was initially developed for borderline personality disorder and co-occurring substance use disorder, but is now used trans-diagnostically in the Psychiatry High Risk Program and aims for transformational healing of core vulnerabilities to suicide. The PHRP recovery-based model has been designed, has been designated by SAMHSA as a best practice in suicide prevention. And he was also given the 2023 American Psychiatric Association Silver Award in Psychiatric Services for Innovative and Effective Mental Health Services Delivery. Dr. Gregory has authored multiple empirical papers and does trainings nationally and internationally. So thank you very much, Dr. Gregory, and I pass it off to you. Great, well, thank you for that introduction and welcome, everybody. I'm delighted that you're here. I'm hoping this can be as useful to you as possible as you struggle with some challenging patient encounters. I thought what might be most helpful is presenting a model to help understand these interactions better. And it's kind of an interactive model that I'm presenting. And then I'll be running through some vignettes and maybe show a couple of clips at the end. And then I, and really then at the end, I wanna save some time for you guys to maybe share some dilemmas that did not come up in the vignettes. And we can kind of figure out how we might approach those particular situations. It's amazing how many different challenging situations and interactions come up, especially with substance use disorders. I have to say that substance use disorders is one of my strong areas of interest along with borderline personality disorder and suicidality. And I find them, I find this population really very personally challenging. So I'll be focusing on that with the vignettes. Let me see if I can move forward the slides here. So just objectives, as I said, present a model. And then I'm going to introduce a concept to you that actually our own emotional reactions and impulses that we have with our challenging patients can actually provide some information for us. And that there's some, I hope some practical implications as well for you in regards to how to intervene. I am going to be presenting quite a bit of information though. And I believe the slides will be available to you after this presentation, if you wanted to review those or dive in a bit deeper. So I wish there were an algorithm for difficult patients, but really it's more interactive. And you really need to understand the importance of the doctor-patient relationship. And we know from actually 30 years ago and thousands of studies that the working alliance is really important as predictor of outcome. Whether you're doing psychotherapy, whether you're doing med management, the most reliable predictor of outcome is the quality of the doctor-patient working alliance. And the working alliance, as I said, has a lot of research on it. And it's divided into either two or three factors. One is the bond. What kind of bond we're able to form with our patient. And the other is agreements on the goals and tasks of the treatment. So raise a metaphorical hand. If your heart sinks a little when you see that patient on your schedule, a patient leaves AMA on your shift, you've gotten into a control struggle with a patient, or you felt unsafe, or you were made to feel inadequate. I see a thumb climbing up the screen here. Or you've wanted to refer your patient to a colleague. I suspect these are things that we can all identify with. I'm seeing a flood of thumbs coming up. That's pretty awesome. I've never seen that function before. So how do we define a difficult patient? What are some features here? And I'm just going to make these rhetorical questions rather than, you don't need to try to answer on the chat, but just to think about. And these are some features that certainly come up with me. Patients who are non-compliant or non-adherent, those who are threatening or disrespectful, unappreciative or uncooperative, may be hard to relate to or detached. Doesn't get better. Treatment refractory. This is a tricky one because I really, in my experience, we as doctors or healthcare professionals have a need to get people better. That's part of why we went into medicine, right? We want to help people. And when people don't get better, it reflects on us and our own feelings of competency as a physician. And so we have certain emotions that come up when treatment refractory. Controlling or demanding patients, of course, or attention-seeking, enjoying the sick role, maybe not having what we would consider a legitimate reason to be sick. And one way of thinking about these is the patients are not conforming to what we need from them in order to be helpful. Is that fair? They're not conforming to what we need from our patients to be helpful. So what do we need from our patients? How do we define a likable patient? So we need them to appreciate us and be friendly towards us, not hostile or demeaning. They need to need our help. They need to have a legitimate illness. They need to want our help. In other words, to respect our expertise, do as we advise, to get better, which means they benefit from our expertise and not hurt or threaten us. And we could say that difficult patients are patients who do not meet our needs. So I'm sharing this just to highlight the interactive nature of challenging patient interactions. And it raises a question, why would these features persist in certain patients despite repeated negative interaction with their providers? Because they're not getting their needs met. We're not getting our needs met. And yet you find that certain patients will continue to be difficult in our eyes. And we, of course, are difficult in their eyes. But you'd think with learning theory, they would learn, okay, this was a really negative interaction. I'm going to learn to do things differently. But I think this concept of embedded badness will be helpful. And this will be kind of a unifying construct as we talk about difficult patient encounters. So what do I mean by embedded badness? What I mean here is that on the surface, maybe a patient can appear to have good self-esteem, be positive, even be grandiose. But underneath the surface for a difficult patient, there's a sense that they're evil or defective or worthless or ugly. And then this has, embedded badness has consequences. So one consequence of embedded badness is rejection sensitivity and self-doubt. So it's like having an open wound and there'll be mood reactivity, depression or suicide risk when they perceive that there's rejection. Even if we don't mean the rejection, even if they're misinterpreting rejection, but still to keep in mind that there's that rejection sensitivity and then the self-doubt creates internal conflicts about justification. Do I have a legitimate illness? Do I have a right to be angry? And continually seeking validation from others that they are justified. And we'll be getting into that a little bit deeper a little later on. So what are some treatment vocations? One is we need to support self-esteem even if the patient appears that they have plenty of self-esteem to know that they don't beneath the surface. So we can highlight positive attributes of patients and maintain what I call a judgment-free zone in your relationship and unconditional positive regard. And it can be very hard to be in a judgment-free zone with patients with addictions. I find myself wanting to wag my finger at them very often. But realizing that underneath maybe the grandiosity or get out of my emergency room is someone who's very vulnerable. Secondly, to medicalize and normalize their illness. So I'd encourage use of medical terms instead of moral terms. So I suggest the use of abstinent instead of clean. Alcoholism or alcohol use disorder instead of alcohol abuse or drug abuse or substance abuse. The word abuse has a potentially derogatory connotation and ethical connotation as if the person is an abuser or abusive. And it's really these concerns. It's because of these concerns that that term was removed from the DSM in DSM-5. And then you can discuss drinking or drug use as being not entirely in their control and link that to step one of AA and NA. And so you would think that, it's a lot more difficult than it sounds. Any of you who have talked to them about their addiction not being in their control, you'll find it's a very difficult thing for them to realize. And step one is admitting that you're powerless over your addiction, right? That's step one. And that's the hardest step for them to grasp. And it's also kind of hard for us to grasp as their providers, because you would think that maybe that's getting them off the hook, right? If they're not, aren't we kind of getting them off the hook so they're not taking responsibility by saying, hey, you're powerless over it. I mean, they're already blaming everyone else in their life. And now we're saying, hey, this isn't in your control anyway. It's kind of a paradoxical intervention, but the reason it's helpful to emphasize the powerlessness over their addiction, whether you agree with it or not, the reason it's helpful is that it's because of the embedded badness. And by getting them off the hook, they're actually paradoxically able to take responsibility for it being a problem and start to do something about it. So relapse, I believe you're all in the addiction field. And as you know, relapse is part of addictions. It's chronic relapsing conditions. And they may be so ashamed and discouraged after relapse that they give up on themselves in recovery. You know, I might as well, might as well just give up. So here's a suggested intervention after relapse. Relapse is nothing to be ashamed of or embarrassed by. Alcoholism or drug addiction is a chronic relapsing medical condition over which you have limited control. That's why step one of AANA tells us that we don't have control over our drinking. And if we don't have control over it, then there's no more shame in relapse and there isn't getting a heart attack or stroke. You don't have control over it. Many people forget that fact and beat themselves up every time they relapse and give up on themselves in recovery. But the important thing is to get right back on the saddle after relapse. Even though you have limited control over your drinking or drug use, what you do have complete control over is deciding to get into treatment and to stay in treatment. And if you do that, the relapses will become less frequent and less severe. It becomes like a blip on the radar screen instead of something that totally messes up your life. So rejection, sensitivity, and self-doubt are one consequence of embedded badness. The other is something I call hiding, a defensive avoidance of authenticity with the idea being if anyone really knew them, they would immediately be rejected. So they hide and some will create a false self and the hiding leads to a sense of alienation and often emptiness. Here's a real case example. This is a young woman with actually severe alcoholism and borderline personality disorder. She says, I'm good at acting around my friends and then I think they are seeing something of value that isn't really there. I try to show some positive attributes I don't feel are actually in me. So it's hard to know whether people value you for who you really are or just right. It's like if anyone really knew me, would they even like me? So the patients may create to cope with embedded badness, a kind of false self where they are molding themselves to what they think the doctor expects of them. They're molding themselves and not only doctors but other people in life, molding themselves to their expectations, kind of creating this mirror. They may be scanning us at any time for what our reactions are. So treatment implications support authentic relationships and that means right from the very beginning, right during your initial evaluation, you try to foster a sense of ownership for their own treatment and recovery. And that starts with a chief complaint. They may say, oh, I'm only here because, you know, my wife thinks it's a problem. You know, well, what about you? What would you like to get out of treatment? You know, if anything, how have things been going? And sometimes, you know, for some patients, it takes me 25 minutes to flush out a chief complaint but I spend the time because it's really important to foster a sense of ownership of their own treatment and recovery. And then they have a goal and then you lay out a pathway to recovery, which is a task, right? And invite them to walk with you there. So you start establishing agreement on the goals and tasks but they have ownership for those goals. It's not your goals, it's their goals. And then instead of when you see someone who, you know, is discouraged about themselves, instead of reassuring patients about their likability, try to create a safe space for them to practice being authentic with you. And you can do that by painting a target on yourself and welcoming disagreements or mixed feelings toward the doctor and the treatment. So long as it's not hostile, right? You don't want them hostile, but you do want them, you do want to create space for them to disagree or even criticize what you were saying or doing. And this may come as a surprise to you as well, this recommendation. But you know, an old couples therapist once told me, that's always stuck with me, that if two people in a relationship are always agreeing, it means someone's always giving in. There's no authenticity there. So how would we do that? For instance, if the patient is talking about how their family minimizes what the patient's going through, you could ask, I wonder if you sometimes feel that I also minimize what you're going through. So paint a target on yourself. And then try to react. Let's say the patient says, yeah, sometimes I do feel that way. Instead of coming up with some defensive explanation of how they're misinterpreting you, try to provide acceptance, not agreement, but acceptance. So here's an example of that. Patient says, you don't care about me. You're only seeing me because you get paid. You could ask, give an accepting comment or question, like what is it like for you to have a doctor who you think just wants money and doesn't care about you? So notice I say you think, so you're not agreeing with them, but you're not disagreeing either. You're accepting what they're saying without agreeing with it. And this is one of the most powerful techniques that you can use with a demeaning patient. And one of our videos at the end demonstrates that. You're providing a different kind of experience for them, a response that they really do not expect. So a third consequence, and we'll spend some time on this, is a defensive avoidance of self-awareness. So another form of hiding. And people use the four Ds for this. One is distraction. Another is drugs or alcohol, or dissociation or denial. So these are not all conscious mechanisms, but you've probably heard many patients talk that, yeah, I drink or use drugs to numb myself or when I feel distressed, or they may dissociate and go numb in that way, or they may use denial. Denial is more than a river in Egypt. It's a defense mechanism and actually pretty complex. And we'll go into it in some detail here. It's a denial of external reality. And part of it is, so one aspect of the denial, what I call the denial system is a fantasy of omnipotent control. Mark Twain once quit, quitting smoking is easy. I've done it hundreds of times. And the addict will say the same thing, but not get the humor of that. And that's why the cage questionnaire is so helpful as well, right? Have you ever cut down on your drinking or on your drugs? And they'll say, yes, I've cut down hundreds of times, or maybe not hundreds of times, but they will answer yes to that because they have that fantasy of control and they try to cut down repeatedly as a way of proving to themselves that they do have control over their addiction. And it's why step one of AA is so important and such a difficult step for them to admit that they're powerless over their drinking or drug use, because it really challenges their fantasy of omnipotent control. And that's why this is, of all the steps, this is the most difficult step for them to grasp. So second aspect of the denial system is a polarized schema. Some people call it a splitting. And so it's this kind of black and white system and two aspects of polarized schema. One is polarized value, idealized or devalued. And what you see around drinking or drug addiction is that they'll either say that, there's nothing wrong with it and what's your problem? Or they'll say, it's just a nasty habit that doesn't do anything good for me. So they have value, they have difficulty, sorry, holding both aspects in their mind at the same time, both what they like about it, what they don't like about it, and really the heart of motivational interviewings to help them come to a more informed choice around their drinking or drug addiction. They'll also have polarized schema around agency. And what I mean by agency is who's the agent of change, who's responsible, who's to blame. Agency can either be a good thing or a bad thing. For instance, if you're on a soccer team and you score the winning goal, that's a very positive agency. On the other hand, if you're the goalie on that team, you would on the opposing team and had missed the goal, then you also have the agency and that's obviously a bad thing. So agency isn't necessarily good or bad, but you can come up with a two-by-two kind of table depending on whether agency is in the self or other, or value is in self or other. And so have four different states of being, each of these potentially a different kind of difficult patient. So these are, they have names to them and it's a kind of complex concept, I realize, but people I've trained have found it an extremely helpful concept. So I'm going to run through it and if you don't fully get it, it's okay. I'll give you some resources too if you wanna dig a little deeper. So for instance, if someone has value in their self, so has a more grandiose self and devalues others and blames other people, other people are responsible for their problems, we call this angry victim state. On the other hand, if someone believes they're the cause of all their problems, so they have the agency, and believes that other people are better than they are, that's a more depressive state, we call that guilty perpetrator state. Helpless victim is a more regressed state where both agency and value are in the others. And demigod perpetrator is a more antisocial state where both agency and value are in the self. So as you can see, each of these has certain, certain feel to them, personality traits. So angry victim state, if the focus is more on the grandiose self, they'll be more narcissistic. If the focus is on the bad other who's causing all their problems, they'd have some more paranoid flavor. Often there's a combination of both narcissistic and paranoid traits. So I'm going to give you some vignettes to bring this home a bit. This is a 19 year old female, she says, I get so sick of people coming to me for advice. When my friends are talking about what jerks their boyfriends are and how unfair their parents are, I keep thinking about suicide because no one around me thinks I'm going through anything at all. So, there's a metaphorical question for you to think about, ponder. Is there any evidence of polarized schema of agency or value? And I would argue, yes, right? All the value, is the value in self or other here? The value is in the self, right? She's a kind of heroic figure. People are coming to her for advice and others are devalued. So, yes. And then who is the agent of change? Who is the cause of all the difficulties? Is it her or is it the people around her? And I think you would say, yes, it's the people around her. So, value is in the self, but agency is in the other, meaning that this person is in the angry victim state. And so, she's very adamant about her position, but what's being split off there? What's being split off is her own sense of shame. And this schema, by blaming everyone else, it actually is a way of holding on to self-esteem. If everyone else has a problem, I can feel good about myself. So, this state has a function of helping her hold on to self-esteem in her schema. Here's another client who I had treated this client, this patient for, let's see, this was in weekly psychotherapy for six to nine months and had been doing really well, but then said, came up with this. She started to desire, this is a person with a history of prostitution and severe drug addiction, but had been abstinent and was actually trying to work towards a nursing degree, which she did eventually get, by the way. But she says here, when I cut my feelings off, I feel strong. I feel that I can conquer anything, like I could do anything. I think it's a good thing that I don't allow myself to be weak and caught up in my emotions. Part of me enjoys that fast money. And it's not even about the act because I don't even feel with the act. It's just about the money. And this is, I've treated a number of prostitutes and they often have this kind of grandiosity and feeling like they're in control of the situation. And who has the value here? The value is in her. She's strong, she can conquer anything. Who has the agency? She also has all the agency and control here. And this would be an example of demigod perpetrator state with antisocial traits. And so what's being split off from consciousness here? Why would someone go into this state? It's protective. It's a protective state. There may be a fear of vulnerability in relationships. And so this helps her to feel invulnerable. She never needs to feel hurt again because she's cut off from her emotions. And there's also some gratification in this state, the excitement and power. So this is a very, those of you who have worked with people with antisocial personality disorder know that it's a very hard state to deconstruct because it's gratifying and it's protective. Okay, here's another one. On the one hand, my husband is so supportive. He believes in my abilities more than I do and has ideas on how I might be able to capitalize on them. On the other hand, I'll be thinking we're having a chat and he'll say, you haven't shut up for more than five seconds this entire morning. I look back on it and realize, you know, I was kind of babbling. I admit that early in the morning, I do tend to babble. So she kind of never got to the other hand, right? So who has a value here? Is it her or the other person, her husband? And I think you would say the husband is the one who has value. He's the supportive one. And she's the one who's the cause of all the problems. So she has the agency. She's the cause of the difficulties because of her babbling in the mornings. She caused this relationship problem. So that combination of agency in the self and value in the other is a guilty perpetrator state and it's a more depressive state. And why would someone go into that state? And if you think about it, it's really to protect that relationship. You often see people in abusive relationships going into this state because if they're the cause of all the relationship difficulties, it allows them to stay in that state, sorry, stay in that relationship. And so they'll sacrifice their own self-esteem in order to maintain the relationship. Whereas an anger victim state, they'll sacrifice the relationship in order to protect their self-esteem. So it's just the opposite here. And of course, what's being split off from consciousness is her really anger towards her husband and feeling just how unfair that is, that she can't state that, right? She starts to. She says, on the other hand, I'll be thinking we're having a chat and I'll say, you haven't shut up for five seconds, but then she'll turn back to blaming herself. Okay, last one. When you did the intake, you listened carefully to me. You're the first doctor who's understood me and you diagnosed my eating disorder. But after I got home, my mom told me that she thinks I don't have an eating disorder. Why would she dispute a diagnosis that the doctor thought was true? So I don't know if any of you have had the experience of a patient saying you're the first doctor who's understood me. It's a wonderful feeling that we get when that happens, but it's important also to take that with a grain of salt. So who has a value here? Really, you do as the doctor, as the patient's doctor. The mother is devalued. The patient is neither valued nor devalued. They're kind of in the background. So all the value is in the other and the agency is also in the other. This is the patient's in the background while the mother and doctor kind of battle it out. And this is kind of a classic splitting that you see a lot on certainly on inpatient units where you have maybe the resident being idealized and the nurse devalued or vice versa. And you have some staff saying this patient doesn't have anything legitimate going on with them. They're just attention seeking. They should be discharged right away. And other staff who say, no, can't you see how this person's been traumatized and needs some more tender loving care. Dr. Gregory, there's a couple of questions about what is agency? Can you maybe spend a couple of minutes just describing that a little bit more? Yes, thank you for those questions. So there are different ways that that term is used. The way I'm using it now is as the agent of change. Who is the agent of change? Who is making things happen in any given scenario? So in this scenario, really it's the doctor who made things happen by diagnosing the eating disorder and the mother who made things happen by disputing the diagnosis. So they have the agents, they're the agent of change here. They have the agency. In this case, the agent of change is the patient, right? Because it's a patient who caused this bad interaction with her husband. How did she cause that? By babbling. So in this vignette, the patient is the agent of change. The patient has the agency. So agency is in the self and the value is in the other, in the supportive husband. In this one, who is the agent of change? Is it the patient or others? And it's the patient, right? She can conquer anything. She's the one who makes things happen. She is the agent of change. And in this situation, what's the cause of the patient's distress? It's other people, not herself. In fact, you don't see her doing anything here. All the action is, are things done to her by these unappreciative people who are minimizing what she's going through. So they, other people are the agent of change. So I hope that clears things up. If not, please ask another question. Dr. Gregory, I just wanted to jump in because there's a lot of kind of comments going on the chat for people, which is fine, but it also, some people are saying it's distracting. So for those of you who find it distracting, you can just unclick on the chat icon and X out the chat box. And then I think that'll solve the problem for you to where you won't get any notification, but for the rest of you that are participating in that, you'll be able to continue in that way. So I hope that's helpful. No, thank you. All right. So why would people, why would people go into these different states? We've already hinted at that a little bit. In demigod perpetrator state, there's a fear of vulnerability. This was the one, the patient who is desiring going back to prostitution and drug use. I can say that I did a follow-up a few years after ending therapy and she had become a nurse working full-time and taking care of her son and decided not to go that route of not go back to drug use and prostitution. But it was protective, as she talked about so eloquently. It helped her to feel, the state helped her to feel strong and invulnerable from other people. And as I said, it's gratifying as well because of the power, feeling of power and excitement that comes with this antisocial kind of state. And then this more regressed state, the helpless victim state, it can protect against feelings of helplessness by turning to other people. And there's also a gratification of being cared for by other people as well. Angry victim state, the suicidal 19 year old, we talked about, it's actually protective for self-image if everyone else is to blame for her problems. And then guilty perpetrator state, we talked about, this was the patient with the abusive husband or at least a not very understanding husband. There's a fear of separation or disillusionment. And so in order to stay in the relationship, they'll protect the other image in order to, and sacrifice their self-esteem to keep the relationship going. So therapeutic implications, and this is particularly true if you're trying to do therapy with a patient, not just seeing them every few months for med management. You can ask about possible split off or alternative meanings or emotions while avoiding taking sides. We'll talk about how to do that. You can ask the client to hold opposing meanings or emotions simultaneously to integrate them. So going back to this example, you could say, when you say that other people are minimizing what you're going through, I can't help wondering whether you yourself also minimize what you're going through and don't take yourself seriously. So you obviously have to say that in a supportive way because they're trying to protect their self-esteem here, but you're bringing in the other side. You're bringing in their sense of shame, their devaluing of themselves, and helping them to explore that and be open about that. You follow that. So she's complaining about everyone else minimizing what she's going through. No one around me thinks I'm going through anything at all. So, but then you bring it back to her and say, I wonder if you also minimize what you're going through. This client, how would you open up meaning here? When I cut off my feelings, I feel strong. You could ask, are there any downsides to cutting off your emotions and not allowing yourself to be weak and vulnerable? And in fact, there were huge downsides, obviously. But you're allowing her to think about that and take ownership of that. And she may say no, and that's okay. You're opening the door though. And maybe at a later date, you can try opening it again and might get a different response. So this one with the really kind of off-putting response, awful husband here. You could ask, does part of you wonder whether your husband was not as supportive as he could have been? So you're bringing in the other side there. And for this person who was diagnosed with an eating disorder, you can try to give her some ownership for all the agency, all the value is external, but you could ask her, what do you think? What do you think about this? What do you want to do? Does part of you also question whether you have an eating disorder? So to give her some ownership. So went through some tough concepts there. I'm hoping they're useful for you though as you think about different scenarios. And of course, as I said, I'm happy to, I'd love to hear some other scenarios that you've been in and been through. So a third component of the denial system is what I call interpersonal enactments. And as I've said, one reason I really like working with addicted patients is that they really challenge me personally even more than borderline personality disorder. For whatever reason, patients with addictive illness really push my buttons strongly. I don't know if they do yours. I'm guessing they do, and the way they push my buttons is not in a very good way. It's actually, they push my buttons to respond counter-therapeutically to them. And I'm often, in fact, almost always pulled into some kind of control struggle with them, a control struggle I'm calling an external conflict. And one way of thinking about that is they'll create an external conflict in order to avoid an internal conflict over their substance use. So the problem isn't, should I drink or shouldn't I drink? The problem is, you know, I want to drink and I'd be fine with it if I just didn't have this doctor on my back all the time or my wife on my back all the time, et cetera. Here's a real scenario. This is a patient I saw when I was doing consults on the consult service a while back. This was a 50-year-old male with chronic alcoholism. And he looked like he'd been through the ringer, been through multiple rehabs. And really when he entered the room, when I entered the room, I was just suffused with a sense of hopelessness. Why even go through the motions? Of trying to help this person get into rehab one more time. But the patient says, doc, you've got to help me with my drinking. It's killing me. And it was killing him actually, had all sorts of complications from his drinking. So I went through the motions. So I said, you know, this is a shortened version of what I said. I know that alcoholism is a terrible illness and can get pretty discouraging, but most people need to go into rehab more than once before achieving a lasting abstinence, which is true. And here are some referrals. So, you know, did my usual spiel, which took a minute or two. And then the patient says, but I don't want to stop drinking. So here we are, just like two minutes into our encounter and already we're in a control struggle, right? The patient went from, doc, you got to help me with my drinking, but I don't want to stop drinking. So this is how they draw us in though, right? They'll draw us into a control struggle and as a way of avoiding their own conflicts around their drinking or drug use. Let's look at this one too. If we were, if you're not too sick of this thing yet, you know, what is your emotional response to this 19 year old? What do you feel compelled to say to her? So if you're like me, I don't actually have a very positive emotional response to this 19 year old. You know, what I feel compelled or empowered to say is, yeah, wait, what you're saying, let me just get this straight. What you're saying is that you're thinking about suicide because people are coming to you for advice? I mean, let's get serious here. So my natural response would be something like that, which of course I wouldn't do, but that's kind of my natural response. But if I were to say that, what would be the result? The result is that I would be doing what everyone else in her life, what she thinks everyone else in her life is doing, which is minimizing what she's going through. I keep thinking about suicide because no one around me thinks I'm going through anything at all. And yet she's pushing my buttons to give exactly the same kind of response that she's getting everywhere else in her life. And so I'm bringing this point up because it's kind of a key point here that not only are the patients molding themselves to our expectations and creating a false self, but they are pushing our buttons to mold us to their expectations. So she was expecting me to minimize what she was going through. That's her schema that people don't understand, and she's this heroic victim. The 50-year-old with alcoholism was doing the same thing, pushing my buttons in a way that perpetuated his schema that everyone's trying to control his drinking and he likes it. That's the schema of the moment that these patients have, and yet they're pushing our buttons to perpetuate their schema. And this really gets back to my original question was why do these persist? And they persist, I believe, because they get into the same kind of interactions over and over again where they push our buttons to in ways that reinforce their schema rather than deconstruct their schema. So they're kind of stuck in this rut. It's not a rut that they enjoy being in either. And so it raises a question, is it possible for us to respond differently from what our patients expect, or are we just human vending machines where they push our buttons and out comes the expected response? So each state of being pushes our buttons in different ways. In the guilty perpetrator state, remember that person wanting to return to prostitution, we'd have a tendency to appease them. We might feel charmed by them. We might feel intimidated by the antisocials, and our natural response is to want to appease. But the more we appease, the more powerful they feel, and the more they'll maybe escalate things. On the other hand, angry victim state, such as that 19-year-old, we want to devalue. We feel scornful or irritated by them. And our natural response, the way they're pushing our buttons is to give them some reality check and devalue them. But the state is trying to protect self-esteem. And so we would actually be reenacting and perpetuating their state rather than deconstructing it. The helpless victim state, unless they're very regressed, we actually feel gratified. You're the first doctor who's understood me. And we have a natural pull to rescue or parent them. Whereas guilty perpetrator state, the more depressive we want to, we feel compelled to intervene. They make us feel helpless or inadequate, and we try to rush towards other interventions. And the more we intervene and the more those interventions fail, the more they feel like they're a hopelessly bad case and may become more suicidal. So it's a key point that, and the implication, of course, here's some implications. One is to maintain clear boundaries with patients because they will push our buttons to cross boundaries, especially helpless victim state. We need to be self-aware and accepting of our own emotional needs and reactions, even if those are negative. It's what we do with them that becomes either therapeutic or counter-therapeutic for our patients. So self-awareness is really important. And then an implication there is what if we respond differently from how our buttons are being pushed? What if we provide what I call a deconstructive experience for our patients where every fiber of our being, if every fiber of our being wants to devalue them, what if we provide a different kind of response? And what you'll see is if you're able to do that, you'll see the patient leave that state. It can be a very, very powerful therapeutic tool. And if we have time, the videos demonstrate that too. If we have time, we can look to see how that's done. But your counter-transference is your compass. And the more strongly you have an urge to say or do something, the more important is to take a step back, figure out, okay, why am I, I don't usually say these things to clients or patients. You know, why am I having this urge to do this right now? And take a step back and maybe provide a different kind of response from how your buttons are being pushed. So back to this vignette, how might we respond differently from how our buttons are being pushed? So our buttoning is being pushed to minimize what she's going through, but maybe it would be to paint a target on yourself here. See if it's in the next slide. No, let me go back. So instead, what you could say is, you know, what you're saying is that people are minimizing what you're going through. I wonder if it sometimes feels that I'm minimizing what you're going through. That would be a totally different kind of response. It's painting a target on yourself when you're wanting to really go after them. And what you'll see is if you can do that, it can be a very powerful experience for the patient. In Derrida's terms, it's an opportunity for the self to appear other than itself. It deconstructs the schema. It allows a new opportunity, a new perspective, not only on other people's reaction, but even on themselves. It opens up new possibilities in relationships while shattering the mirror. And in fact, we even looked at this set of techniques empirically in a research study, and we found that the use of these techniques actually correlated very strongly, very strongly, point eight, with improvement in social functioning. Okay. So I think we have, we could either go through dilemmas or maybe work through one of the videos. Yeah, I think going through one of the videos would be great. Okay, let's go through one of the, I have two videos, let's go through one of them. I'm going to play it first. I can interact with you on any level you care to interact on. I'd be more than happy to discuss with you the finer points of Freud or Jung with you. You're a physician and a psychiatrist, so I may not be able to keep up with you 100%, but I can give you a run for your money. Because one of my many pen pals over the years has been Jung's great granddaughter. It sounds that you're very well read, and in many areas, not only psychiatry. I have over 400 books at my house, and I've read every one of them. That's impressive. They're not there to gather dust. They're there to be read and used. Whether it's the handbook on physics or a tale of two cities, they've been read and they've been used. Wow. Somebody went to the trouble to write the stupid things, at least I can do is read them. It's fair, you know, that's how it works. The downside of that is, it's easy to use that as a defense mechanism. As long as we're talking about that, we're talking about me. All right, let's see if I can, I hope this isn't the evaluation of the talk here, but let's see if I can move to the next slide. It's sometimes a little tricky to do that. Okay, so what I'm going to do is, I'm going to go through this line by line, and you can think about your emotional reaction to this man. Usually people laugh. It was a, so, you know, that kind of scornful counter-transference. And so, you know, how would we feel compelled to respond? Maybe a bit of a reality check. So what medical school did you go to? Maybe something like that. Because there's an implied, there's a grandiosity and implied devaluing of me as their psychiatrist. So instead of giving them a reality check, this psychiatrist does the opposite and uses a technique called mirroring, but, which was developed for narcissistic patients in particular, it was developed by Heinz Kohut, who developed self-psychology. But really, so the way you define mirroring, Kohut defined mirroring as the gleam in the mother's eye in response to the child's exhibitionistic display. So in other words, instead of giving them a reality check, you actually mirror their grandiosity. You say, oh wow, that's amazing. So the doctor says, it sounds like you're very well read in many areas, not only psychiatry. Totally opposite from what the psychiatrist is wanting to say to this person. So the doctor understands the patient's grandiosity is simply a way of fending off shame and that a reality check would enact the patient's expectation to be humiliated, would only reinforce his grandiosity. So instead of giving a patient a reality check, the therapist provides an unexpected paradoxical response and mirrors the patient's grandiosity. So that's a little bit more eloquent way of saying it. And the patient goes on. I've read over 400 books at my house. I've read every one of them. So still remains grandiose. The doctor mirrors again, saying that's impressive. And continues to brag. They're not there to gather dust, they're read and used. Whether it's a handbook of physics or tale of two cities, they've been read, they've been used. Wow. Somebody went to trouble to write the stupid things, the least I can do is read them. But then notice there's a switch. And patient says, it's fair, you know, that's how it works. The downside of that is it's easy to use that as a defense mechanism. And the patient starts to look kind of sad. No longer grandiose. As we're, as long as we're talking about that, we're talking about me. So all of a sudden, you went from this grandiose patient, within two minutes of using your countertransference, responding a different way, you all of a sudden have a likable patient on your hands. So it's a paradoxical, you know, we're afraid of using mirroring because we're thinking, oh, well, we're so the grandiosity if we mirror it. But because it's driven by shame and fears of humiliation, and fears of humiliation, remember the embedded badness, it's driven by shame and fear of humiliation. By giving the mirroring, you actually, they're actually able to drop their grandiosity. They don't need to defend against their shame anymore. And they're able to be real with you. And all of a sudden you have a likable patient. All right. Any dilemmas the audience would like to share? Or would we want to watch one more video? Maybe as the audience is thinking about their dilemmas, we could watch the next video because that first one was very helpful. Great. Great. So this is a 25-year-old pregnant female with co-occurring borderline personality disorder, alcohol use disorder, very severe alcohol use disorder, actually, and has just had a relapse. I kind of want to strangle her at this point, but this is this is how it goes. I'm just not even sure that I want to do recovery. I think that's an important insight when you say, I'm not even sure I want to do recovery. And can you say a bit more about that? Well, the only reason that I'm doing it right now is because everybody else wants me to. Like my mom, she'll like hate me if I don't go to the rehab place. And it's the same with my grandmother. They just don't know what to do with me anymore. Do you remember our conversation on the phone the other day? You said, I really need to go into rehab because I drank again and I don't want it getting out of control. Well, because part of me doesn't want to keep drinking. I mean, I know that like, it's just not right putting all of that poison inside of me. And plus, when I drink, I do really stupid stuff and something really bad could happen to me. Does it get confusing then as to what other people want for me and what I want for myself? Well, I know what's best for me because all I get from drinking is trouble. But to be honest, sometimes I just don't feel like putting in the effort, like to stop. I'd rather just keep going. So what you're saying is there's a big part of you that doesn't want to keep drinking. And another part of me that does. All right. Let's see if I can get to the next. Okay. So let's break this down. So let's break this down. So I was kind of horrified to find that she presented with saying, I'm just not sure that I even want to do recovery. So I feel concerned. I feel angry. I feel an urge to remind her of her unborn child and what could happen to the fetus if she continues to drink. But she's inviting a control struggle, right? This is, that would really be perpetuating her current schema. I would be taking on the concern and that she's experiencing, that she's splitting off and not saying. So I need to provide a different kind of response. So instead I kind of do a little bit of mirroring here and some exploration saying, I think that's an important insight. Instead of strangling her, I say, that's an important insight. When you say, I'm not even sure I want to do recovery. Can you say a bit more about that? So instead of falling into the trap of taking on her concern, that's currently being split off from her awareness, I provide a gentle exploration. She says, well, the only reason I'm doing it right now is because everyone else wants me to. My mom will hate me if I don't go into rehab and it's the same with my grandmother. They just don't know what to do with me anymore. So she's taking no ownership here. The agency is in totally externalized. It's everyone else who wants her to. So this is consistent with the angry victim state. And then the way I try to open it up here is actually using, I try to bring in the ownership that she, her concern that she had mentioned that she was going to be in rehab for a while. I try to bring in the ownership that she, her concern that she had mentioned the previous session. So I remind her of a conversation on the phone, which is I think just a couple of days before our session. And she said, I really need to go into rehab because I drank again and I don't want it getting out of control. So instead of externalizing agency, I try to internalizing it by reminding the patient of her previously stated concern to quit drinking. And she responds to that. She remembers and says, well, part of me actually doesn't want to keep drinking. Like, you know, it's not just right putting all that poison inside me and I do stupid stuff and something really bad could happen to me. So she's taking ownership. So now I try to bring both sides together at the same time. Does it get confusing then as to what other people want for me, external agency and what I want for myself, internal agency? And she responds. She says, well, I know what's best for me because all I get from drinking is trouble. But to be honest, sometimes I don't, just don't feel like putting in any effort, like to stop. Rather, I just keep drinking and drinking. So in response to these interventions, she's moved into a more reflective and integrative state. So what you're saying is a big part of you doesn't want to keep drinking and another part of me that does. So it's pretty consistent really with motivational interviewing here. But the key here is providing a different kind of response from what I was feeling compelled to say. So three takeaways here. The more adamantly opinions are expressed, the more likely patients are splitting off and defending against owning the opposite opinion. So the more, let me just repeat that, more adamantly they're expressing one opinion, the more likely they're splitting off and defending against owning the opposite opinion. So you try to open things up and bring in the opposite. The stronger, second, the stronger you own your own emotional reaction, the stronger your own emotional reaction to a patient's opinion, the more likely the patient is defending against the opposite opinion. So when we have really strong emotions about a certain opinion, you want to, that's also a sign that they're splitting off something there. And then thirdly, the stronger your own emotional reaction to a patient's opinion, the more important it is that you respond differently from what you feel compelled to say or do. Keep the conflict in the patient. That's especially true. Keep the conflict in patient is especially true in working with patients with substance use disorders. So before we go into other dilemmas that you might have, I just wanted to say that you could go to this website if you want to learn more, you can go to upstate.edu slash DDP. You can get a free PDF of the treatment manual of dynamic deconstructive psychotherapy. And there's also a web-based training manual modules are certainly in there, but in the manual is a chapter on states of being. So you could read that chapter. And of course, consultations and trainings are available. I have an upcoming book should be out in November, Therapeutic Dilemmas with Suicidal Clients, with Guilford Press, which will also go over some of these points. And also just feel free to email me with any questions. I'd be happy to field those. So we have about 12 minutes left. If you do have dilemmas or things you want to run by me. Yeah, there were a couple of dilemmas that people talked about and we'll read them to you. And I just wanted to mention that it's nice to hear again that it's normal for us as clinicians to have negative counter-transference towards patients. And that doesn't mean that we're bad people. This is just a natural response to behaviors of all different types. And so it's very helpful for me to remind myself of that. That doesn't mean I'm a bad person because I have a reaction that I need to resist against. No, thank you. And in fact, hiding those feelings from ourself, we'll have less control over them and they're going to come out in subtle ways and things we say or do. Exactly, I always, it's like the Jungian shadow. It'll come out sideways and the shadow will grow over time. So David, do you want to first one? Sure, I was getting the second one teed up actually. Okay, I'm going to start with Samantha. Thank you for your example. I'll just read it, Dr. Gregory. There's a couple parts to it. She says, I had a situation where a patient kept invading my space and entering into restricted areas for patient care. And when I would ask him to stop and make appointments, he would claim he was working out there and trying to lose weight or confront me about not being happy with his care, et cetera. Eventually I walked him to the front desk to meet more of the staff and show him where to check in and reiterated the boundary. He could not come in that space without an appointment. He blew up and screamed, this is bullshit, I'm never coming back here. And then told his case manager that he never wanted to work with me again. And she then confronted me because I was not being supportive of him losing weight. And if you could help me navigate that better, I would greatly appreciate it. Yeah, okay. So one question that comes up is what state the patient is in. And so what was the counter-transference with this patient who was invading your space? Was it one of intimidation? And that was actually hard to set boundaries in that situation? Or was it one of feeling anger that this patient was invading your space, maybe which would be more consistent. So the intimidation would be more consistent with demigod perpetrator state. And you need to then set clear boundaries and with demigod perpetrator state, the antisocial patient, they'll often do that kind of testing early on and to see what they can get away with. And they'll try to change the parameters there. Well, I need to sit here. I need your lamp here. And doing that kind of testing and then maybe putting in a lot of profanity. And if you don't contain it, if you don't contain those boundaries, it escalates. And they tend to respond very well to boundaries, not blowing up like that. The blowing up like that implies more an angry victim state where that person may have been demanding of more time and attention because they deserve it. They have this grandiose self. They felt that maybe no one was taking them seriously. As I said, the counter-transference can be a clue to that. It would be a more irritated, just scornful counter-transference. And for that one, because it's driven by shame or fears of humiliation, you have to tread lightly actually with boundaries and actually try to paint a target on yourself, provide experiential acceptance, do mirroring in order to deconstruct that. So setting boundaries is, I think, in some ways really tricky in an angry victim state because of their sensitivity to shame. They might see that as, you're not seeing them as having legitimate needs. And I suspect that that's what happened in this situation. So it's a difficult situation to be in. I sympathize with that because it is hard to set boundaries, but it's also important to set boundaries. But to do it in a way that supports their self-esteem at the same time as best you can do that. And I don't know what the boundary was or the space. I don't know. I would have to know the exact circumstances. So the next one was, I recently had a patient that was complaining about me to the medical assistant who roomed her. She was diagnosed with a renal stone in the emergency department. She was blaming me and was upset that I asked her why she never followed up with a nephrologist. She felt that I scolded her when asking her this question. What do I say to her when I see her again? Should I have her see another provider? Yeah, this is also probably angry victim state or helpless victim state, one of those two. You know, if it helpless victim state, you would see maybe, you know, they're all externally focused and they're going to have some doctors who they really like and idealize and other doctors who they devalue. And you get this triangulation. And in that situation, the best thing to do is to try to de-triangulate. And if you're on the bad side, if you're on the negative side of a split, it's very hard actually to restore that. You kind of have to, you have to, first of all, work with an idealized doctor or clinician and try to come up with ways of decreasing the splitting. And in the emergency room department, that's kind of impossible to do. It's, you know, you're not in a kind of a therapeutic setting where you can work long-term with that. And with angry victim state, and actually even with helpless victim state, you know, one thing you can do is paint a target on yourself. You know, what was it like, you know, having me, you felt I was criticizing you for having your kidney stone. If I heard it correctly, I didn't, I might've misheard some of the words. You know, what was that like to have a doctor who you think wasn't, was blaming you? You know, I can only imagine. Well, first of all, I want to thank you for having the courage, you know, to share that with me. And I can only imagine what it was like to have a doctor who you feel, you know, is blaming you for your own illness. You know, thank you very much for sharing that with me. So, you know, notice I'm not apologizing there. I'm not even agreeing with what they're saying, but I'm expressing acceptance. And I'm doing a lot of supportive comments to support their self-esteem. Since, you know, they're struggling with that self-doubt, you know, do I have a legitimate illness? And now you have a doctor saying that, you know, in their belief that they don't have a legitimate illness. So I don't know if that gets to the exact scenario or concern. Well, one thing that I'll add to that is that oftentimes when I'm working with trainees and I have a challenging patient, sometimes I'll hold the space of being the one that the patient can be angry at. And then oftentimes the trainee can be the person who holds the more positive space. What are your thoughts on that? Yeah, yeah, I think that that often helps so long as it's a conscious, you know, conscious effort and the trainee realizes that you're doing that and not let, oh, my attending is really bad, yeah. And, you know, I'll figure out what's really going on with you. You know, so long as it's a conscious effort, I think that that can, I've seen that actually happen that to be able to work sometimes, you know, splitting like that, the triangulation can sometimes be subtle and creep up on us. It happens a lot with the therapist versus the bed manager. You know, they may complain about the person who's prescribing, for instance. They may go to the therapist, complain about the psychiatrist, not giving them the controlled substances that they need in order to feel better. And it's easy for the therapist to fall into that kind of split and say, oh, you better go talk with your psychiatrist and really tell your psychiatrist what's, you know, and it just kind of feeds the split instead of deconstructing it. Well, I think we're just about out of time, David. So I think we'll end up finishing there. Once again, Dr. Gregory, thank you very much for speaking with us today. And I definitely feel smarter for having participated in this. And we look forward to seeing everybody next month with Dr. Bruce Lee talking about CBT. Well, thank you very much for inviting me. It's been a privilege and an honor to be able to talk with you today. So, you know, it's dangerous out there. So I appreciate you guys on the front lines with very challenging patients.

Addiction Psychotherapy

Dynamic Deconstructive Psychotherapy

Borderline Personality Disorder

Substance Use Disorders

Patient Interactions

Therapeutic Relationship

Embedded Badness

Rejection Sensitivity

Defensive Avoidance

Boundary Setting

Doctor-Patient Alliance

Non-Confrontational Communication