August 16, 2012

Just Because You See It, Doesn't Mean It's Gone

subway.jpgThis is a post for psychiatrists/psychologists who do long term psychotherapy, sorry everybody else. Pandering to my base. It's an election year.

This is the email I got:

Dear Alone:

You wrote a while ago:

No one ever asks me, ever, "I think I'm a narcissist, and I'm worried I'm hurting my family." No one ever asks me, "I think I'm too controlling, I'm trying to subtly manipulate my girlfriend not to notice other people's qualities." No one ever, ever, ever asks me, "I am often consumed by irrational rage, I am unable to feel guilt, only shame, and when I am caught, found out, exposed, I try to break down those around me so they feel worse than I do, so they are too miserable to look down on me."

If that was what they asked, I would tell them them change is within grasp. But.

I might be asking myself something like that. If I tell you a story would you tell me what you think?


Imagine a crowded subway, and a beautiful woman gets on. Hyper-beautiful, the kind of woman who can wear no makeup, a parka, earmuffs and a bulky scarf and that somehow makes her look even prettier. A handsome man about her age in an expensive suit gets up and says, "please, take my seat." She smiles, and hastily sits down.

What happened? Raise your hand if you think this is a sexually motivated act, i.e. Christian Grey isn't so delusional that he assumes she's going to have sex with him, but in a Hail Mary, longshot kind of way it's worth the price of standing for three stops.

Now raise your hand if you think he was just being nice-- he would have done it for any woman. Huh. Really? Then why was he sitting at all?

But why does the woman think she got the seat? Does she think, "the only reason he gave me his seat is because the Hail Mary is worth the price of standing for three stops?" Or does she think, "no, come on, he was just being nice."

We can't be certain why Hugo Boss gave up his seat. But if the woman picked b, we know something about her: she sees the world as intrinsically nice, it's a place where random kindness exists and hence must be a reflection on the physics of the world, not her specifically-- "New Yorkers are so nice!" she says, and she actually believes it.

In other words: the goodness is in him, not in her.


One of the frustrating things for therapists is a patient who is unable to see reality. Maybe it's a guy who takes every little thing his ex does as a sign she wants him back; or it's a college kid who is failing his classes because he thinks it's more important to "help Jen with the crisis she is going through"; or maybe it's a woman who thinks men aren't interested in her.

In the course of therapy she explains she wishes she could meet a good guy, nice, with a good job, someone like the guy on the subway. And you're stumped, didn't she meet a guy on the subway who was exactly like the guy on the subway? "Oh, no, he wasn't interested in me, he was just being nice."

You can guess the backstory: father left when she was 8, mom was always telling her she was too fat and too skinny, an "overly critical maternal superego" which is different than a paternal superego because it yells at you not when you sin but when you fail. This is the mom who doesn't want you to have premarital sex, of course, but a girl like you should be dating the captain of the football team. So the men who do ask her out, the ones she ends up dating-- fearless, calf tattooed men who make their attraction to her explicit, even vulgar, so she can't help but know that they want her and what they want from her. Meanwhile, these guys then treat her like crap. So she lives her life thinking that the only people who like her-- the people she has to settle for-- are... not great.

Genetics took care of her body but the upbringing affected her vision: the childhood of never good enough filters her present reality, obscures it, she can't see what is plain to everyone else, e.g. she's beautiful. So the process is to uncover the reasons why her view of reality is distorted and help her realign with reality. Use insight to strengthen her damaged ego, or, if you want a ten step approach, block automatic thoughts. In short, to understand that she is good, that men do find her attractive, not just the brazen ones, not just jerks.


If you think of narcissism as grandiosity you miss the nuances, e.g. in her case the problem is narcissism without any grandiosity: she is so consumed with her identity (as not pretty) that she is not able to read, to empathize with, other people's feelings. She doesn't care to try because it conflicts with how she sees herself. Ergo: Giorgio Armani was just being nice.

I recognize, of course, the countertransference: that I am attracted to her, it is impossible not to be. Of course I'm also in full control of myself, I don't break the boundaries of treatment. But I also see that she doesn't see I'm attracted to her, in fact I often observe how little attention she pays to my "feelings." She treats me as if I am a voice only. Once I had a cast on my forearm and she made no mention of it. What does this suggest?

Two or three years later, nothing has changed except-- she drinks more. Huh. Things did not go according to plan.

What happened? What happened is my analysis of the countertransference was purposefully self-serving, "see, I'm a good therapist in detecting this" which defended me against the truth: yes I was able to admit to myself that I was attracted to her, but what I was unwilling to admit to myself-- that anyone outside of me would see immediately-- was that part/all of my eagerness to help her was that she was beautiful; and the way in which I know to impress beautiful women is by giving gifts, helping-- as it was with my own mother. Not that I was so delusional as to assume she'd have sex with me, but in a Hail Mary, longshot kind of way....

And since I was having those feelings, and those feelings are BAD, "inappropriate" as we say in therapy, then it is entirely likely that rather than not correctly seeing reality, she saw it and guarded against it: by deciding that men--me-- don't want to have sex with her, they are just being nice.

What I didn't consider is that her blindness to the desires of men is necessary to her sanity-- that she doesn't want to believe that every man's interaction with her is sexual; she doesn't want to have to live in a world that only sees her naked. She wants the world to be... nice. Take as the origins anything you want, maybe abuse, maybe she started noticing at 15 how all the neighborhood fathers looked at her a little differently than they looked at the other girls; too many date rape close calls, jealous girlfriends, whatever you want.

Which means that my push to get her to see reality is interpreted by her as yet another sexual advance-- because it is. When she walked in she was able to block out the possibility I was attracted to her, but through diligent application of reality testing I forced her to see my erection-- "look, I really want to help you understand what you do to me!"

Fortunately for her she doesn't exist, I made this story up, but it serves to illustrate an important point: rather than assume people are too damaged to interpret reality, the default assumption should be: all of this is a defense against change. (1)


Here's a story I didn't make up, though I've altered it to simplify a complicated situation and protect his anonymity.

Joe had a girlfriend, and though they were happy the relationship seemed to run it's course, and she took up with another man. Despite this, she couldn't fully let go of Joe, so they still talked and texted and met once in a while.

During talks some things came up, notably things about Joe, notably Joe's apparent indifference in the relationship. For example: "I was also hurt," she said, "that when we broke up, it didn't seem to bother you."

Joe told me it did bother him, perhaps more in retrospect (now realizing how much he liked her), but he wondered if his lack of emotion wasn't a signal of a larger problem- an inability to connect.

So: multiple texts, chats, and, at one meeting:

We met and we cried very much, she said she was sad that we weren't together, but it still made sense for her to be with that other guy. We ended up kissing and crying at the same time. After that I didn't see her for about two weeks. But we continued to talk, she'd said that she missed me, and I missed her too. She said she'd been crying everyday since she that last meeting, wondering if....

Because of that I arranged to see her again, but this time she said she had made up her mind and decided to be with the guy. She also said very quickly that she fantasized about us getting back together someday, but not now. In this kind of situation I always try to be strong and say that the person is not responsible for me, but this time I collapsed and cried. I asked her if she still loved me, she said "Yes, but it can't be right now". (2)

Eventually they meet again, and on the way home... things get murky. He says he badly wanted to kiss her, but she did not want to.

"She stopped me. I said "Ok, then I'll leave", but then she asked me to stay. She said she was divided, and very anguished, she thought she was doing something wrong. I said it was not wrong, because she loved me and love can't be wrong (or some similar catchphrase). I tried to kiss her again, this time she didn't resist but she wasn't very passionate either. I noticed she was very sad. I said I loved her. She said "stop it", and ran off.

So I'm trying to think what I did wrong, and what I'm asking myself is:

- How could I not pay attention to her feelings, making her anguished just because I needed that kiss? I see that I was extremely selfish that day-- here she was crying and ambivalent, and all I felt was horny-- and throughout the whole process I could only think that I wanted her for my own needs and forgot about how she felt.

Even though I always asked her if she wanted me out of her life and she said no, why do I even need to ask? Why couldn't I just see that she was crying and tried to comfort her instead of trying to kiss her?


How do I stop hurting people?

I know that I'm only thinking about that because I had a loss and I miss her a lot and I want to be a better person so I'll have a better life, but still it's good to become a better person and stop hurting people.

This time I really want to change who I am because who I am is not working.

I wrote a reply about their relationship, which highlighted her ambivalence and how such ambivalence in women is often resolved. However, he wasn't really asking for advice about the relationship, but rather advice about being a better person. Was he wrong for pressuring her when she was so conflicted? Did he ignore her feelings? How can he change?

He wrote back (excerpts):

1. I see her ambivalence and her conflict. Maybe I'd have an easier time if I just said "I want you, dump the guy"....

2. I feel jealous now that she accepted the "no more texts or dates or anything". Because at first the fact that she fell in love with someone else didn't stop her from expressing love towards me. Now it did. Now I'm jealous....

4. Yes, I feel guilty for the day when she was crying and all I could think of was trying to kiss her. I didn't use strength, didn't hold her or anything, she accepted my kiss but very sadly. Sometimes I think about it and it feels almost like I raped her. This fact specifically is what made me write to you: I wouldn't share that thought with anyone who's close to me. Is that shame or guilt? Or both? I know that she didn't see it that way because later that day we talked and she told me she didn't want me to leave her life and she couldn't forget me. Which is consistent with your interpretation.

4.a. I had noticed narcissistic behavior in me before several times and I've been trying to change. For instance, somehow I thought I'd look ridiculous giving someone a gift so I didn't usually did that, no matter the circumstance. I originally thought giving a gift was about me, a reflection on me, not about the person receiving the gift. When I came back from Denver I brought a Broncos jersey for my little brother, but I was worried about what my father would think of me and about my choice of a gift, and stuff like that, but I focused on how my brother would feel receiving the gift. It may sound silly but for me that was a big deal. It pisses me off that I forgot to pay attention to her feelings in this situation.

My reply:

I now understand that this kiss is what prompted your email, this specific incident. I recognize you feel guilty for pressuring her into a kiss. And she was crying, which should have stopped you (you believe) but it didn't. If you were blind to her feelings you could say, in retrospect, you are a selfish person without empathy who doesn't notice other people's feelings, who only does what he wants. But it wasn't blindness (you tell me), you knew full well she didn't want to kiss you, yet you proceeded anyway. This makes you even more of a narcissistic monster. Is this a correct hearing of your story as you intended it to tell me?

The problem is that you are telling me two stories.

On the one hand, you are telling me a story about your "guilt" over taking advantage of her vulnerability and kissing her when she didn't want it. Which is odd, because apparently kissing her wasn't really an example of taking advantage of her-- she didn't think so, right? She told you so herself later. So then it was a kind of dialogue: her ambivalence wanted a firm response, and you (against your ordinary nature) were surprised to find yourself compelled to give it to her.

You kissed her; you say-- your words-- that she didn't see it as any kind of "rape"-- but did she feel any guilt for kissing you? For cheating on her boyfriend? I'm not saying she should or should not, merely that one would expect her to be wrestling with her guilt. But instead on the phone later she is discussing yours, making you feel like you did nothing wrong. If you follow me so far, then talking to you and easing your guilt isn't primarily because she cares about your suffering, but because it allows her to avoid looking at her own. If you "forced" the kiss-- and by saying you didn't force it she is saying it's okay that you did--- in forgiving you she would be benevolently implying the fault was yours and she was blameless. This isn't malicious or intentional, this is all unconscious, it is performance: can I trick my superego? Since I was crying, how much could I really have wanted it?

But none of that is important, because there's a second story.

Your next paragraph to me describes narcissism-- my "specialty"-- and worrying about how a gift would be seen by your father, and (ultimately) doing the right thing and focusing not on your feelings but on your brother's. But how can I not read that paragraph and think:



"I thought giving a gift was about me, not about the person receiving the gift" which is, "what will you, TLP, think about this, now that I am thinking about other people's feelings? Will you be critical like my father, or will I get your approval?"

I know you'll counter that you in fact did give a gift to your brother, but the juxtaposition of the example you chose from 10 million other possibles cannot be a coincidence. Which is why it is important to
focus on the words.

So what is the right interpretation of that paragraph, 4a? Why does it follow so logically from 4? Why are you telling it to me? Like all these things, it's a defense against change: "see? I think about other people's feelings."
But that's the narcissism. The narcissism isn't forcing a kiss on her; the narcissism is the thinking that all of these events with your ex are entirely yours to decide, to bear the responsibility of. She is merely a supporting cast member that wasn't nearly as sophisticated, insightful, intuitive as you. You want to bear the guilt because it shows you-- and me-- you are a better person.

Please understand that this is not a judgment of you, it is (my opinion) of how you see yourself.

Your first story is the age old story of unresolved feelings for each other, oozing out between the clenched fingers of a tightening fist that thinks it can will emotions into control. But the insight for you is that your "narcissism" isn't a lack of empathy but the opposite: other people are all little brothers, ex-girlfriends, supporting cast, who are less able to make good decisions,
so the world needs you to do it.

I would say that ethically you are still supposed to act as if you had unilateral responsibility; but simultaneously you have to be able to see the other as a fully autonomous, free, aware person.

In summary: you could feel (a little) guilty for kissing her when you knew it was wrong; but the real problem for you is that you naturally reduced her to a person with less agency than yourself.


The problem with therapy-- include self help and mind hacks-- is its amazing failure rate. People do it for years and come out of it and feel like they understand themselves better but they do not change. If it failed to produce both insights and change it would make sense, but it is almost always one without the other.

In Joe's case, it is supremely tempting for both patient and therapist to focus on the problem he is describing-- "I feel guilt over pressuring the girl, does this make me a narcissist?" And the therapist can generate a series of insights which the patient accepts, which although correct lead nowhere.

What's missing is an analysis of the transference. Joe added an entire paragraph 4a which was-- superfluous? It served only to stroke my ego, i.e. "you've helped me, here is an example where I was able to apply your lessons." It's that paragraph in its seeming uselessness that reveals his real motivation in writing me and hence his actual problem. He's offering ME a story about how he forced himself on a girl- and was legitimately bothered by doing it-- but telling it to me is basically saying, as in 4a, "here's an example where I did something bad but I also feel guilt about it-- if I feel guilt, I must be changing-- see, I learned the lessons!" He specifically references the difference between guilt and shame because he knows I know that narcissists never feel guilt, only shame. So rather than that guilt being evidence of self-awareness, that guilt is a trick for my approval. He sounds like he's asking for advice, "how can I change?" but what he wants is in the transference: "Dad, did I do good?" It is that seeking of approval that is the heart of his problem, not his relationship with women, not his "narcissism" of kissing her when she didn't want to.

A really good therapist will be able to get to this kind of depth; someone who will not take the chief complaint at face value, but will focus on the words.

And yet: still this will fail to produce any meaningful change. Insights plenty, but no change. Is it because I am wrong? No, it's because I am not Alone.


It's a cliche in psychiatry to "analyze the transference" but never mind no one bothers to do this much anymore; it is completely impossible to do this.

I may have been quite clever in telling him the interpretation of the transference in 4a, but the problem is that when I told him "you are seeing me as a kind of father" I was saying it AS his father. Not: I stopped being me and became his father; but from the very moment I responded to him, every single word I wrote was coming from his father. You can't step outside the transference, there is no objective place for me to stand and tell him my thoughts, and there's no safe distance for him to stand and hear them. So if I say, for example, that I do or don't think he handled his ex correctly, I am saying that as his father-- i.e. critical, judgmental, kind, forgiving, whatever.

If I think that by explaining the transference to Joe I somehow dispel it, as if it were an illusion that once explained could never fool him again-- then I won't understand that while I offer further insights or interpretations, while my lips are moving, all he is hearing is: angry at me; love too easily obtained therefore of no value; thinks I'm a fool; thinks I'm a genius.

Then what Joe will do to me, his therapist, is exactly what he does to his own father: try and fool me into giving my approval. And if he doesn't get it one way he'll trick me another. His email can be understood as just this kind of a trick; the focus on the guilt over the kiss is a way of saying got me, "see? I'm changing! Validate me!"

Here is another danger: if I (TLP) think that when I explain things to him, that he and I step outside of the transference and speak objectively-- as if we are talking about Joe while he is sitting in the other room-- if I think this objective stance is not only possible but desirable-- then what I am teaching him to do is to self-observation, I am training him to examine his own actions and thoughts as if he were a neutral person inside his own mind. But that other person would be me. Grant me 50% of the time I'm awesome. What about the rest? Would that person have helped the beautiful woman on the train, or driven her to alcoholism?

Given that the problem here is a kind of narcissism (a description and not a judgement) then by fostering self-observation I am actually worsening his narcissism. And he will inevitably say, "I know myself better, but I'm still doing the same things."


So it becomes important not to fall into that trap, to foster change and not just insight. If I was actually his therapist then the correct thing to do would be NOT to tell him all this, but rather to note it to myself as information: "this is the nature of the transference." It's hopefully of some use in an email because since we don't have any kind of relationship; since I am not likely to meet him, it's better that he understands how this works than. But in therapy there is no value in it to the patient.

In fact, as his therapist, my urge to explain it to him would be my own unKantian narcissism: using him as a means to show off. Telling him my great insight is the same as my desire to help a beautiful patient: it is for me, not for them. In therapy we see a reversal of my often repeated maxim: if you're saying it, it's for you.

And so what? What's wrong with giving advice? Because (in his case) he doesn't want advice, he wants validation. And if he doesn't get it from me, he'll do what he already told me he would do: "...I was worried about what my father would think of me... but I focused on how my brother would feel receiving the gift." In other words, he'll find someone who does. This is his real problem: the constant search for approval from Dad, women, wherever. And of course it will never be enough, because that's the nature of the pathology: if he gets validation he'll be temporarily appeased, but eventually devalue it because if it was obtainable by him, it must be valueless.

I can infer from this that he sees his father as generally right but overly critical, and Joe says to himself, "I'm a good person, everyone else thinks I'm a good person, but no matter what I do I can't convince my father of this." This is self-doubt, and it quickly becomes: "I've fooled everyone else, but my usual tactics don't fool my father" and so Joe is trapped between hating his Dad for being so mean but still/therefore suspects he's the best judge of character out there, which means Joe suffers not from high self-esteem, but low self-esteem. This is why my approval (if I were his therapist) is so important to him and simultaneously so damaging: "TLP is equivalent to my father. I may not be able to get my father's approval, but if I can get TLP's then it confirms that I am good." And change is thus unnecessary. The point there is that he doesn't want to change, he wants a reason not to change, he wants to be seen as good without having to earn (whatever it is he believes is necessary to get) his father's approval.


Therapists should understand the imaginary transference but not play into it, and instead stay outside, an abstraction, an inexplicable mind that already knows all the answers but doesn't tell them (because telling them is inside the transference.) Whose silence is taken by the patient to mean something-- and the answer to the patient's problem is how they interpreted that silence.

This is why I know that though Joe will "like" my email to him very much, think it helpful, it is this post that he won't like that will actually help him more. He can't say anything to me here, there's no dialogue, the post just is: all he has is what I've written here and his feelings about it; and it is those feelings, not my post, that hold the answer for him.

The moment the therapist speaks, he stops being a symbol of knowledge and becomes a person to be fooled (or loved or devalued or punished or whatever the nature of that particular transference is.) A post, a story, and the (mostly) silent therapist are the opposite: a screen to project on so that patient or reader can then ask, why does this make me feel like that? (Or, more rigorously: "what do you want from me?")

This is why readers probably find the my posts about other readers' problems so powerful. When you read a post about my interaction with someone else, you are assuming the role of that outside neutral observer that is impossible inside the dialogue. Not completely, of course, there is always some fantasy about who I am and who Joe is, what we are like, but clearly you are more outside our transferential situation than we are.

For these reasons, I am becoming convinced that the only real way to "personal growth" outside of direct action is through careful study of fiction. Of course stories may have an intended meaning, but a well written story allows you to ask not just "what does the story mean?" but "why do I think that this is what the story means?" As in The Second Story Of Echo And Narcissus: "The story is the pool... what do you see in it? It's a reflection and a projection..." (3)


1. If you want to observe the extent to which you are not in control of your countertransferential feelings (women included), get a swimsuit model as a patient-- and let someone else watch you do the therapy. Do you dare? I once had the magical opportunity to watch as a resident was told in rounds that the patient being transferred to him by the graduating resident was "gorgeous, a model". Someone threw a switch, he changed immediately: more professional; softer, more articulated speaking; more mature-- all before he ever saw her. It was as if some part of him said, "yes, it makes sense I would be chosen." But even more impressive was how the rest of the residents treated him over the course of the year. There was some envy but his patient elevated him in their eyes, as if he was a better person, a better therapist. (Similarly: all on-call psychiatrists have had the secret feeling that a doctor's chaotic patient is a reflection on the doctor.) They asked his opinion on matters when it was neither necessary nor even... a good idea. His proximity to a beautiful woman who came to see him made him more of a man-- and of course he wasn't dating her, it was random chance he was picked-- but it gave him a kind of merit as if he had had something to do with it, which was in retrospect silently justified, "he must be good if she stayed with him." This was true of the female residents as well, and, most importantly, the attendings. (I wonder how they would have interpreted it if she stopped coming.) The simple fact that he was appropriate in the sessions was enough to indicate his talent. It should be no surprise that with this amount of unexplored countertransference from him (and all of his colleagues) that no progress was made in her therapy.

2. Though this post isn't about the woman, please observe that she is running a kind of story here, the theme of which is, "I desire the feeling of desire." She likes emotional energy. She breaks up so that there is a deep sadness (Act III) so that there's back and forth resulting in the climax of reconciliation. "We're in love!" Importantly, in order for her to get what she needs from this narrative, they don't actually have to get together in Act IV, it is only necessary that she sees her life as a story with these four acts-- so the breakup is only possible (or easy) because she anticipates that at some point in the future there is an Act IV. NB: no mention of Act V. She isn't aware there is one, which is her life's problem, which is why this story will repeat with her other relationships, including the one she's cheating on now.

3. It would be an interesting experiment to read a story and write down your feelings and interpretations of it, and then return to the story a decade later.