TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

CLIENT: I went to the theater last night with some friends of friends and it was really fun. I’m tired and really not hung over, but pretty hung over, so – oh, well, off to work I go. (laughs) It was good. It was a situation where I knew one person there. She’s a friend from church and I know her pretty recently. There were like 12 people. I think nobody knew more than half of the people in the group, so it was good. [00:01:00] I was surprised at how comfortable I was. I feel like at other times in my life that could be a nightmarish situation, but it was really fun. (pause) [00:01:59] I just last week had this long online conversation. A lot of Protestant Christian churches will have a Sadder supper on Maundy Thursday, but they then will follow with the Maundy Thursday ritual, and I think that’s really not okay.

THERAPIST: Sorry?

CLIENT: Sorry – Maundy Thursday is the day before Good Friday, so it’s this Thursday. It’s Maundy. I don’t know what it means, but not Monday Thursday. That confused me for a long time.

THERAPIST: [So they have the Sadder on Maundy Thursday.] (ph?)

CLIENT: It’s like a made-up Sadder. There are no Jews in the house at all. The idea is to explore the Jewish-ness of Jesus. Judaism post-dates Jesus, as we know it. The Sadder is later than the Eucharist in terms of historical development. [00:03:09]

THERAPIST: I see. They didn’t start having Sadders . . .

CLIENT: No. Jesus wasn’t sitting around with his disciples asking the four questions. (laughs) It just gets into a lot of Jewish/Christian religion stuff that sort of makes my skin crawl, notwithstanding the fact that I grew up doing this. They did this at my dad’s church when I was a kid. I loved it and thought that it was great. Then I went to college and was like – oh, it’s actually super offensive. History of anti-Semitism and Holy Week is a time to go out and kill some people. [00:04:02] Anyway, this had just happened and was in my mind and then a friend from church was like, “Hey, do you want to come to a Sadder with me?” I was like, “Yes. Yes, I really do.” (laughs) I was talking with Candace about it. Her boyfriend is Jewish and is pretty into it. She says it’s very important to him to have the tradition of inviting non-Jews to Sadder. I feel like that’s a very different thing than being like hey, we’re going to co-op this tradition for an hour before we get onto the good stuff. [00:05:01] (long pause) [00:06:04]

I’m staying late at work tonight. It’s Frank and Kim’s anniversary. They’re going out to dinner. I’m torn between “yes, this is something I’m happy to do” and “God, it’s going to suck.” (chuckles) I’m going to be at home for like seven hours, at most.

THERAPIST: You mean between tonight and tomorrow morning?

CLIENT: Yeah. Yeah. Maybe that’s an exaggeration. I don’t know how late they’ll be out. (pause) [00:07:26] Do you think that I basically am bi-polar? I guess I was thinking about how it feels like I really want to slow down and rest and, in some ways, I feel like I need to or I feel like I will need to, but then I just keep pushing; I just keep moving forward.

THERAPIST: I don’t think so. If I thought you were bi-polar, I would have told you by now.

CLIENT: Okay. Thanks. [00:08:15] What is it? What are the ground rules of that diagnoses? Most people who have a diagnosis like that sort of know it, but I also talk to people who are like, “Yeah, I was in treatment for several years and I didn’t know that my therapist was treating me for this thing.” That really doesn’t make sense to me. (long pause) [00:09:41]

THERAPIST: I haven’t really thought about it this way before, but I think this might be the way to think about it. The bigger category is formulation and the smaller category is diagnosis. That is my pronouncement for the day. Formulation we talk about all the time, in a way: “well, I think this is going on maybe because of that” or “maybe this is the way it works for you” or “if you felt like this because of that . . .” and we sort of talk about more or less central pieces of kinds of formulation of what’s going on with you or why [I’m sure about what you’re struggling with] (ph?) or other things like that. [00:10:42] You can say in sort of a general way that a lot of the stuff that you and I talk about to do with that is what could be thought of as neurotic type stuff, by which I mean things to do with emotional conflict and anxiety and depressive feelings – stuff like that. There is sort of a more elaborate historical meaning, but in terms of what we’re talking about, that’s kind of what I mean.

CLIENT: You shouldn’t say there is an elaborate historical meaning, because now I want to know that. (laughs) [00:11:28]

THERAPIST: Really, diagnosing bi-polar disorder or particular diagnoses that generally are thought of as having a primary biological component usually would be something like bi-polar disorder or (inaudible at 00:11:58) disorder, and then also probably things that relate a lot to post-traumatic stress disorder or certain of the dissociative disorders or also things like borderline personality disorder; all of these have environmental factors that contribute to them. [00:12:25] Depression or anxiety kind of have a biological component, of course, but usually you think more of what’s causing it, whereas even if something in the environment can cause a manic episode, you sort of think of the person as having a strong biological vulnerability to that or some borderline personality disorder by the time they get to your office. Those are really actually different formulations and they’re not formulations mostly in terms of what the circumstances are. They’re formulations in terms of you have ADHD, so that’s probably why you’re having trouble with this. Maybe there is also an emotional or personality piece, but when you’re having trouble and making careless mistakes all over your home, it’s really because of this. [00:13:17] So it’s not a formulation in terms of neurotic stuff, but it is a formulation in terms of a diagnosis and a biological piece. It seems to me most of the time, that’s what’s going on when you talk about formulation stuff. This is why I think you’re having these episodes where you’re not sleeping for days on end and blah, blah, blah; in the same way that if I thought it was something else, I would try to say that.

CLIENT: Are there situations in which you don’t talk about formulations?

THERAPIST: The example that I’m thinking of, I think there are times with . . . It’s going to be tough to tell if people have a borderline personality disorder. [00:14:14] You were wondering about it a while ago, and I think you don’t have this, to be clear, but sometimes it’s hard to tell someone who has borderline personality disorder that you can tell that’s what they have.

CLIENT: No, that makes sense to me.

THERAPIST: I still try to do that, but it takes a little while.

CLIENT: Is that because it’s difficult to find a situation in which they can hear it or difficult to find a situation in which you can tell them that without damaging the relationship?

THERAPIST: Most of the time, diagnosis is a huge relief actually. It’s good to know what’s going on. [00:15:06] Even if it’s something bad, you know; but I’ve seen a lot of people who are already associating with it and feeling stigmatized can feel so much more with that label finding it difficult. I think most people would agree. I also really do try to tell people.

CLIENT: Thanks. Thank you. This girl I knew in high school is a resident and she’s getting into psychiatry. She will post on Facebook occasionally and she will say things like “this patient was so borderline,” clearly using borderline as a substitute word for a fucking pain in the ass. (laughs) [00:16:11] Then the situation where, on the one hand, it’s like you have to be able to unwind. I have to let her do that. This is a situation where she’s keeping herself sane. On the other hand, I’m really not okay with that. (laughs)

THERAPIST: Right. (inaudible at 00:16:35) with that. I think you’re totally right and I get your point that, on the one hand, she needs a way to blow off steam. On the other hand . . .

CLIENT: Facebook is public. (laughs)

THERAPIST: It is public and it’s so much more honest to say “the patient is driving me nuts” rather than just putting it on the patient. In a way, that reinforces the power, the hierarchy. [00:17:07] In a way, that’s what she’s doing, I think – I mean from this distance it seems to me. If she had said, “Oh, my God, this person is really getting under my skin and I want to scream,” that’s not something you want to tell the patient and is honest and it sort of acknowledges her own vulnerability; whereas it doesn’t to just throw the diagnosis at the patient like that as if it’s all the patient’s fault or it’s all on the patient.

CLIENT: That’s one of the hard things about dealing with kids. Some days I’m like “they’re driving me nuts” and I’m like “this is as much me as it is you. I don’t know what to do about this.” (both laugh)

THERAPIST: I also think that with borderline personality disorder, in particular, I think we all have borderline vulnerabilities. [00:18:01] People with borderline personality disorder have more of them or they’re close to the surface.

CLIENT: It’s like an exaggerated nerve, what you fear . . .

THERAPIST: Yeah. Everybody has that place where they just feel too close in and to shriek-y and immediately ask them whatever they’re feeling and don’t think or it’s just way too much to contain and feel very disconnected from whomever and can’t stop to think about it. (pause)

CLIENT: Thanks.

THERAPIST: Sure. [00:19:00]

CLIENT: I was reading an article about a hospital – it might be Beth Israel – but there was a pilot program keeping patient’s notes open, having them be available to them. There seems to be some disagreement about it. (both laugh) (pause)

THERAPIST: Very interesting. (pause)

CLIENT: I guess what struck me was both everyone who seems to have an opinion seems to think that it’s very obvious that their opinion is the right one, both in terms of triggers and in terms of patients. [00:20:01] People seem to skew very much to “clearly this is the thing that we need to be doing because of this, this, and this reason” or “clearly this is a terrible idea” and similarly patients are “clearly it would benefit me to be able to see.” Actually, I don’t think I saw any patients that were like “no I wouldn’t want to do that.” I don’t think I would. I know that I can ask a doctor to read his notes, but I’m not really interested. I would be interested to see Dr. [Porak’s] (ph?) notes which, I guess, [if I was to think about it (ph?) . . . [00:21:01] There you have it. (laughs) (pause) Thanks. I did not expect you to answer the question. (pause) [00:22:00] I do find it very painful and frustrating when I do ask you something and you don’t answer. I find myself freezing, structuring the way I talk so that I don’t ever ask you anything and I really hate that. It feels very passive aggressive to me and I don’t want to be doing that. I come up against it in here.

THERAPIST: You asked me something very directly yesterday that I realized that I didn’t really follow up on or look at.

CLIENT: I don’t know what it was.

THERAPIST: Honestly, I don’t mean this in the way that if I thought about it more I would have answered it. I wouldn’t have. [00:23:01] What I mean is there must have been something quite important going on for you at that moment to have just asked like that in light of how much you don’t like to do that. I’m thinking of when you asked how many of my patients use the couch.

CLIENT: How do you decide? How do you make those distinctions, like what you answer and what you don’t? (pause) I guess if you tell me that . . . (laughs)

THERAPIST: No, that one I’ll answer. (pause) [00:24:27] It’s a tricky thing. I answered the question about diagnoses because it seemed to me to have as much to do with sort of another aspect of my role with you as with what I think was [transferrentially] (ph?) going on with the question. I can see how, in a way, if I said that I would not answer and left you to deal with, first, my not answering and also uncertainty about whether I might have diagnostic thoughts about you that I hadn’t said, for some reason, exploring kind of what sort of a bad guy you were dealing with who would know those things and not tell you. [00:25:40] That’s important, I think, but it seems to me there is another part of my role, which is to give you my best sense of what’s going on with you and it seemed like that was reasonably served by [my just saying my diagnosis.] (ph?) Whereas your question yesterday about how many patients use the couch, to me, seemed like you were trying, quite reasonably, to get yourself out of feeling so bad because the couch was so scary for you, though I can see how it would have been immediately helpful or not for me to answer – the uncertainty. It would have assuaged your uncertainty and anxiety in that way about it, but that seemed to me to be not the point, if that makes sense. [00:27:08]

CLIENT: Yeah, absolutely. (pause) This is a tough business. (long pause) [00:28:27] I feel like I got to the end of what I was thinking or lost track of it. (pause)

THERAPIST: I guess I am wondering whether you’re wondering about my diagnostic impressions of you kind of follows up from yesterday with the feeling that I am sitting here thinking about how you are doing this wrong. [00:29:32]

CLIENT: Yeah. Yeah. I guess it is sort of similarly related, but slightly different. I don’t know. (long pause) It sort of feels to me like maybe you think I’m doing things wrong or am thinking about things wrong or approaching things wrong and you can see or you know what I should be doing and you’re just sort of waiting for me to figure it out. [00:30:36] Then somehow it also feels like there is a lot at stake in my being able to figure it out. (long pause) [00:31:37] Part of me is like well why don’t you just tell me? (pause) And then a part of me says well there must be some (inaudible at 00:31:57). (long pause) [00:34:15] That’s what it felt like. Something like I can really tell that it’s not real. Some things I really can and that’s one of the things I really can’t. (long pause) (crying) [00:36:30]

THERAPIST: I think it’s maybe a kind of elaboration or a sort of [aversion] (ph?) of the fantasy that you have that I think we’ve seen a bunch before, that there is a right way; and if you figure it out or someone tells you, stuff won’t hurt as much. (pause) [00:37:25]

CLIENT: Yeah, I really believe that. (crying) (long pause) [00:39:23] I don’t know what to say. It makes me think about clothes. I don’t buy a lot of clothes, but I think a lot about clothes. I sew and I focus on it a lot. I just feel so sure that, if I can just wear the right things, then I will not be so afraid and self-conscious in public life. The thing that is awful about it is that it works a lot of the time (laughs), but not enough of the time, so it’s sort of like false (inaudible at 00:40:29). [00:40:34] It’s sort of like on the one hand, that’s a lot of energy that probably could be more profitably spent somewhere else. Then again, I really enjoy learning and thinking about fashion and design. Sometimes it’s really fun. Sometimes it’s really anxiety [proof.] (ph?) (pause) [00:41:39] (chuckling) The other thing I just thought of was the platonic ideal has a lot to answer for. (laughs) Just like there is a way for me to be that would be right.

THERAPIST: Like there is the perfect square out there. (inaudible at 00:42:02)

CLIENT: Yes, that’s me really. (inaudible at 00:42:05) (laughs) or like the whole idea of the ideal is that it’s not actually in the world. (long pause) [00:42:55] Sometimes what I wear does make me feel less vulnerable. I sort of keep chasing that. (pause)

THERAPIST: We should stop for today.

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