Glen Gabbard: “The Difficult Patient”

Outline of Lecture

I. Introduction

  • Dr. Glen Gabbard is the 2018 recipient of the American Psychoanalytic Association’s Master Teacher Award [1].
    • Quote: “I am very grateful for this award. Teaching is something that I have always found very important. It’s a way of passing on knowledge from generation to generation” [1].
  • Dr. Gabbard finds teaching to be very important because knowledge can be passed on and benefit future generations [1].
  • He credits his deceased mentors for helping him through difficult times [2].

II. Defining the Difficult Patient

  • A psychoanalyst is someone who pretends not to know everything [2].
    • Quote: “A psychoanalyst is someone who pretends not to know everything. We are constantly learning from our patients and our own experience” [2].
  • There is no single definition of a difficult patient [2].
  • Dr. Gabbard shares his experience working with difficult patients at the Menninger Clinic [2].
  • He warns against the “kiss of death” in psychoanalysis, which is being known for working well with difficult patients [3].
    • Quote: “There is a kiss of death in psychoanalysis. If you get known as someone who is good with difficult patients, you will get all the difficult patients” [3].

III. Characteristics of Difficult Patients

  • One sign of a difficult patient is that they may not say much in therapy [3].
  • Dr. Gabbard gives an example of a patient who would not come to therapy sessions [3].
    • Quote: “I had a patient who would come to therapy sessions and just sit there in silence. He wouldn’t say anything. That was a difficult patient for me” [3].

IV. The “Usual” Patient (a Myth)

  • Dr. Gabbard describes the “usual” patient as highly motivated, insightful, and grateful [4].
  • He argues that the “usual” patient is a myth [4].
    • Quote: “We all have this idea of the usual patient who is highly motivated, insightful, and grateful. But that’s a myth. Most patients are not like that” [4].

V. The Difficult Patient May Be Subjectively Created

  • Dr. Gabbard argues that therapists may contribute to making patients difficult [4].
  • He suggests that therapists may project their own issues onto patients [4].
    • Quote: “Sometimes we make patients difficult. We project our own countertransference onto them and then we get frustrated when they don’t behave the way we want them to” [4].

VI. The Importance of Consultation

  • Consulting with colleagues is helpful because it can help therapists identify their blind spots [5].
  • Dr. Gabbard suggests that consultation should be an ongoing part of analytic work [5].
    • Quote: “Consultation is essential. It can help us to see our blind spots and to work more effectively with difficult patients” [5].

VII. Audience Questions

  • A question is raised about how to avoid blaming oneself for patient difficulty [6].
  • Dr. Gabbard suggests writing about difficult patients as a way to understand them better [6].
    • Quote: “If you are struggling with a difficult patient, try writing about them. It can help you to understand them better and to develop a more effective treatment plan” [6].
  • Another audience member asks about avoiding the focus on symptom cure [7].
  • Dr. Gabbard advises against promising symptom removal and emphasizes the importance of managing expectations [7].
    • Quote: “We should not promise our patients that we can cure their symptoms. Our focus should be on helping them to understand their underlying conflicts and to develop healthier coping mechanisms” [7].
  • A third audience member brings up a situation where a therapist tends to avoid patients with difficult personalities [8].
  • Dr. Gabbard emphasizes the importance of understanding the therapist’s countertransference [8].
    • Quote: “If you find yourself avoiding patients with difficult personalities, it is important to explore your own countertransference. What is it about these patients that makes you feel uncomfortable?” [8].

VIII. Conclusion

  • Dr. Gabbard is awarded the Master Teacher Award in recognition of his exceptional teaching skills [9].

Gabor Mate explains Sensitivity, Creativity and Pain in a Traumatizing Culture: dialogue with Sia

Sia talks to Gabor Mate about her psychotherapeutic journey. In this interview, we get a sense of what psychotherapy for Sia is about, how it helps us transcend our fear of feeling difficult and often painful emotions.

Sia reveals her personal challenges suffering from somatic symptoms like Hashimoto’s, and addictions.

I enjoy this interview because it also reveals how Gabor is able to hold Sia’s emerging emotions throughout the dialogue.

Sia is an example of a kind of client who has had quite a bit of work done. The tendency is to “talk about” experiences rather than “being in” the experience. He tells us how he is not as interested in labelling and seeing phenomena as disorders, and his disdain for medical doctors who are not able to inquire about childhood.

By interrupting her deflection from points of painful feelings, giving space to emerging experiences he finds connection with her, and we also find connection with her watching the video. In a way, Gabor invites Sia to show her face and not hide it.

Interestingly, towards the end of their dialogue, as they thanked each other, Sia said, “…that almost made me cry, but that would hold up the interview…so… I kept the… for later…” This is possibly the replay of the trauma which she mentioned at the beginning of the video, where she recounted having cried as a young child and her caregivers were absent.

Sapolsky: The Biological and Psychological Link to Major Depression

Depression is crippling, pervasive, prevalent and worth studying.  Depression is also a major cause of disability.

The focus of this article /lecture : What has biology, what has psychology got to do with depression?

What is depression? Depression is suffered by people who don’t recover from major setbacks.

Symptoms of major depression: a biological disorder with genetic predisposition with early childhood influences.  Sapolsky means this because we can compare people who stay positive

  • *Anhedonia: the inability to feel pleasure,
  • *grief & guilt severe to take on “delusional quality” (unable to see things in positive light and choose to dwell on negatives).
  • *self injury
  • *psychomotor retardation… too exhausted to do stuff.
  • *not able to cope / heal.

Vegetative symptoms of depression:

  • *trouble sleeping: wake up early and not able to go back to sleep.
  • *Different way of being alseep
  • *decreased appetite
  • *overactive stress response: increased metabolic rate / muscle tone
  • *rhythmic patterns of depression (cycles / seasonal)

What goes on in the brain with major depression?

15:30 Neurotransmitters. In depression, implicated are

  • * Norepinephrin (NA): Drugs which are MAO inhibitors inhibit deactivation of NA. Tricyclic antidepressant, increase effect of NA. Blood pressure drug that decrease NA, patient gets depressed. Lack of NA has something to do with anhedonia. NA has effect on pleasure sensation. Antidepressants of this sort takes long to work on depressed people.
  • * Dopamine : has something to do with anhedonia
  • * Serotonin: SSRI Prozac works on serotonin re-uptake. Helps with Psychomotor retardation / obsessive sense of grief.
  • * Substance P (neurotransmitter) is about pain.  When drugs supress substance P, depressives get better.



This is a neurochemical-mobile diagram showing the relationship between key neurotransmitters and their receptors (Tretter et. al. 2010).  The neurotransmitters described here belong to the activation of the left side of the diagram. So, in major depression, can we say that the mobile would be tilted to the right?

23.30 Neuroanatomy: Lymbic system, Cortex.

Depression is rumination, and the body responds to it, as if there were a real danger / setback. “What depression is is the body getting too many sad thoughts and the body going along with it. The brain stimulates the body to activate the fright-flight mode.

Sapolsky mentions the Anterior Cingulate Cortex, implying that it is a part responsible for depression.  This part, when severed from the rest of the brain, also removes pleasure sensation.


Cg25 is the subgenual cingulate . it is part of the pleasure-depression regulated region. As we can see in the diagram, the connected regions are complicated. The goal of pharmacology is to get involved in the modulation of activity in these different regions.

One can see here the balance between the vegetative-somatic controls and cognitive centers of the brain. In depression, the cognitive centers become “depressed” while the active somatic control contribute to the tension felt in the body. 



(Mayberg 2005). Regional cerebral blood flow changes (CBF PET) in patients being treated by deep brain stimulation (DBS) for major depression at baseline (row 1) and after 3 months (row 2) and 6 months (row 3). Treatment was considered successful based on psychological tests (Hamilton). Sagittal (left) and coronal (right) views. Baseline CBF abnormalities are seen relative to age- and gender-matched healthy control subjects (NC): increases in subgenual cingulate (Cg25) and decrease in dorsolateral prefrontal (F9), ventrolateral prefrontal (F47) and anterior cingulate (Cg24) cortices (row 1, patients 1–5). Three months of DBS relative to baseline (row 2, patients 1, 3, and 5): decreases in Cg25, hypothalamus (Hth), anterior insula (ins), medial frontal (mF10) and orbital frontal (oF11); increases in prefrontal (F9/46) and dorsal cingulate (cg24). This basically shows the difference between the depressed state in the brain where Cg25 is over-activated and the anterior cingulate and prefrontal areas are under-activated, and the more normal state where the activity is opposite.  


Hormones involved in depressive episodes:

  • *Thyroid hormone. Hypothyroidism is also associated with major depression.
  • *Female hormonal cycles. Ratio of estrogen to progesterone.
  • *Stress hormone: adrenaline, glucocorticords/cortisol  36:00  — depletes Dopamine.

Biology, however is not enough.

39:00 Freud on melancholia. The difference between mourning and melancholia (Freud , 1922). Mourning allows one to recover. Melancholia is the rumination and wallowing, which is depression. Absence of mourning leads to guilt, followed by aggression turned inward to the self. Depression is described by Sapolsky as such.

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How does one explain the biological with Freudian ideas?

42:00 Experimental Psychology

Psychological stress is pathological extremes of learned helplessness, loss, lack of control. One has no possibility to release the stress, by doing something, or talking to someone who is willing to listen.

E.g. loss of parents before 10 yrs of age, there is more tendency of suffering major depression.

Stress is the intersection of the bio and psychological. Depression seem to be genetically linked, but there also other components that are equally relevant.

47:00 Serotonin re-uptake genes? No empirical proof to show that “relevant” genes alone leads to depression. Childhood experiences have as much to do with incidence of major depression (Ogilvie 1996).

Glucacorticoids regulate the function of this gene. Hence stress has an influences (Caspi et al 2003).

In the study of Mayberg which treated patients with deep brain stimulation, the patients, following treatment, describe their experiences as :
“All patients spontaneously reported acute effects including “sudden calmness or lightness,” “disappearance of the void,” sense of heightened awareness, increased interest, “connectedness,” and sudden brightening of the room, including a description of the sharpening of visual details and intensification of colors in response to electrical stimulation. ” This is similarly described when individuals are effectively treated with psychotherapy (see the student say, “the colors are bright”, to which Perls call it the mini satori in this video of therapy session with Fritz Perls) and also described in psychedelic experiences.  Many meditative exercises also provide for this change of experience.


Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., … & Poulton, R. (2003). Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science301(5631), 386-389.

Freud, S. (1922). Mourning and melancholia. The Journal of Nervous and Mental Disease56(5), 543-545.

Ogilvie, A. D., Battersby, S., Fink, G., Harmar, A. J., Goodwin, G. M., Bubb, V. J., & Smith, C. D. (1996). Polymorphism in serotonin transporter gene associated with susceptibility to major depression. The Lancet347(9003), 731-733.

Sapolsky, R. (2009). Stanford’s Sapolsky On Depression in U.S. (Full Lecture). Youtube. url:

Tretter, F., Winterer, G., Gebicke-Haerter, P. J., & Mendoza, E. R. (Eds.). (2010). Systems biology in psychiatric research: from high-throughput data to mathematical modeling. John Wiley & Sons.

Bollas: Psycho-Pharmaceutical use, like war, can impair empathic feelings.

This is not an article against the use of psycho-pharmaceuticals. Antidepressants, antipsychotics etc. use save lives and alleviate suffering but have side effects. The individual is left to choose: work through mental suffering by talking to someone, or use a medication but numb out the possibility to feel human empathy. Ultimately the use of these drugs leads us to dependency and destroys our ability to interact with others in a contact-ful way. The result is existential loneliness.

Christopher Bollas, in the Q&A session of this lecture recorded in video below, gave a thought provoking opinion on how psycho-pharmaceuticals like antidepressants, anxiety drugs, and pain killers reduces a persons capacity for empathy.

Empathy and Your Loved Ones

Empathy is what make a person human. It helps us to have relationships and build bonds of love with others. If  one of your loved ones –spouse, children, siblings, etc.– suddenly loses his/her empathy, you have lost that bond with that person, because this person is no longer able to relate to you as another human being. At best, to this person, you are but an object. He/she is not able to feel for you or care for you.

Taking painkillers, according to Bollas, does just that: strips off the empathic nature of a person. He cites an interesting article of a study written by Mischkowski (2016) entitled From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain, to illustrate this fact.

Bollas says that taking psycho-pharmecuticals is not the same as taking medicine for physical ailments. If one has a problems related to the mental state, talking to another person is the cure. The challenge is to find someone who would care to listen without judging or controlling you. Such a professional is called a psychotherapist.

ADHD Diagnosis Robs Children of their Capacity for Empathy

People do have the right to take medications to alleviate their suffering. Bollas is, however, concerned by people giving medications to children for psychological disorders. Children have no rights to decide if they want to be incapacitated in a way that they can no longer feel emotions. Not feeling emotions free us from unpleasant feelings, and it also causes us to live in a lonely paranoid world stripped of feelings of being loved. The person may have people loving him, but he cannot feel the love. In turn he will not be able to love back, and end up losing relationships.

When children get diagnosed with ADHD (attention deficit hyperactive disorder), the child is suffering NOT because of the disorder itself. The child is reacting to stressors in his life and environment that causes him suffering.  In fact, it is the parents who suffer as a result of the child’s behavior, and many are desperate for the fix… which they can get through diagnosis of ADHD. The drug erases that child’s ability to feel the suffering, and wipes out his ability to feel empathy as well.

Bollas believes that the children are victims of stress put on them by society’s expectation and the educational system.

War Kill the Humane Part of the Soldier

Military training and work… boot camp turns you into a killer. In combat, you also kill people. If you keep doing it, you’re going to be shattered. It is called ptsd. this is the consequence of sending people to war. When you send people to war, you kill off the the humane parts of the personality. At war, if one is empathic or thinks too much one becomes a danger to one’s unit.

“(W)e need to continue a kind of a political cultural anthropology that consistently deconstructs our social delusions in a way that we as societies continue to cover up our own destructive processes, because most societies have parts that are extremely destructive.”




Bollas, C. (2016). Christopher Bollas: Mental Pain. Video on Youtube. Townsend Center for the Humanities.

Mischkowski, D., Crocker, J., Way, B. (2016).  From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Social Cognitive and Affective Neuroscience, Volume 11, Issue 9, 1 September 2016, Pages 1345–1353, Retrieved from


Projective Identification

Otto Kernberg explains what Projective Identification is:

Projective Identification is one of the primitive defensive operations that goes together with splitting and primitive idealization and omnipotent control.

It is a primitive form of projection of attributing to others what one cannot tolerate in oneself. It is characterized by combination of attributing to somebody else what the person is experiencing but cannot tolerate. While they are still capable of maintaining empathy of what they experience but cannot tolerate. There is also a tendency to induce behavior in the other in effort to control the other person to absolve themselves.

Basically it is an insidious method of inciting emotions, which one cannot come to terms with in oneself, in another person. This as a means to control the other person. 

A possible example of such an occurrence is someone who is insecure and envious of another. This person creates situations whereby he/she incites envy and/or competition in the other person.

It could also someone controlling a group. A manager may have a paranoid ideas of the team being disloyal to him, begins to behave in ways to incite feelings of mistrust between the members of the company.


Extra Notes (see Video attached) on Child abuse and projective identification:

Identification of the aggressor : being a ghost to chase the ghost away, stockholm syndrom (Anna Freud’s).  Ferenczi’s idea of identification with the aggressor: The abused child behaves in the way the abuser wants to protect himself from the abuser, by appeasing and complying.

The child introjects the abuser’s feelings: he feels both innocent and guilty. There is a clash of feelings. The abuser, to make himself feel less guilty induces the guilt on the child victim. The parent / abuser projects the impart feelings (also known as projective identification, a term Melanie Klein coined later on) on the child. He induces guilt on the child. The child introjects the shame and feels guilty.

The client should be allowed to express their criticism on the therapist, or they will turn on themselves. These negative feelings are not just negative transference. When the clients can voice their critic in therapy, it is a breakthrough. It is a break from the childhood pattern.


Moments of Uncertainty in Therapeutic Practice: Interpreting Within the Matrix of Projective Identification, Countertransference, and Enactment

Projective and Introjective Identification and the Use of the Therapist’s Self (The Library of Object Relations)

Projective Identification: The Fate of a Concept (The New Library of Psychoanalysis)

Projective Identification and Psychotherapeutic Technique

Heinz Kohut: Selfobject

This is an introduction to Psychoanalysis, Self Psychology,  Heinz Kohut 1913-1981.

Kohut introduced selfobject. This is in dealing with Narcissism that is prevalent in the years after 1950s.

There are following therapist-client interaction:

  1. Mirror selfobject: the client uses therapist as someone who praises him, like a mother. The patient is addicted to mirrors due to not having a mother that glows at them.
  2. Ideal selfobject: Idealizing the father. Transference to the therapist that idealizes the therapist. Many therapist cannot tolerate this.
  3. Twin-ship selfobject: Identifying with the therapist. Seeing eye to eye.
  4. Adversarial selfobject: Bump up constantly against each other. Self definition is promoted because there is acceptance.
  5. Abstract selfobject : Belief in God, Posterity, or Past relationship sustain self-esteem.

Kohut also introduces Disintegration of Selfobject –> leads to emptiness, self aggression, addictions, emptiness depression.

Dealing with addictions:

How does Analysis repair disruptive cycle of emptiness…?  What has happened that led you to do this? Going to stripclubs, etc… What set you off this time?Make patients addicted to therapist / therapy.  That is a way to help patient get rid of the addiction.Some people are also addicted to anger. They use anger to hold them together. What is really valuable in psychotherapy (Interpersonal Schools of Psychotherapy):

“Sustained empathic enquiry.”

Decentering: Look at pattern from patient’s perspective. Try to set aside feeling attacked. Sometimes the patient’s perspective is psychotic. But it is still his/her perspective! So we take it for what it is.

Disruption- Repair Cycle

Kohut’s theory of cure: when there is a disruption, try to understand, what happened to the patient. The patient feels ultimately understood. Repairs the disruption.

Transmuting internalization takes place. 

Reestablishment in the disruption. The more he is able to be empathic to himself. He is able to build his own selfobject.

Like Kleinian, Self-Psychology works with the internalized selfobject.

Kernberg is opposed to Kohut. He sees Narcissist is suffering from conflict and not deficit like Kohut.  Narcissism is seen as manic defence. Profound feelings of emptiness, envy… Helping narcissist become depressed… but this can be lead to client to be very very depressed /suicidal.


How this relates to Gestalt Therapy Theory

The opposing view of Kohut and Kernberg is a reminder that analysis is a way of researching what goes on in the human mind. It is an attitude of seeing, and not a end to understanding “facts”. This makes psychotherapy sciences much more real and dynamic than natural sciences.

In Gestalt therapy, the narcissist is “not able to feel anything”, and thus has found a way to deflect from him/herself any stimuli from the environment. It is a safety mechanism he/she learned as a child. Most oftently the child has good reasons to shield him/herself from perceived or real danger.  This deflection mechanism becomes automatic, and the adult is not aware of his/her own situation, because the not feeling is second nature.

The disadvantage such persons have is that he/she does not enjoy relationships and often feel threatened / miss- trusting  and always aggressive (active or passive) towards others.

Gestalt therapist realize that when a behavior is not in awareness, it is impossible to talk to the client about it, and expect the client to experience a shift in his/her “nature”. Much of the work has to arise from non-verbal communication and feedback from the therapist.

Jane Tangney: the Difference between Shame and Guilt

Shame and guilt are uniquely human emotions. These are emotions that does not exist in infants up to a certain age. In other words, shame and guilt are emotions learnt, and this learning coincides with the infant’s discovery of the self, when the infant becomes self conscious.

In the lecture below, June Tangney explains the results of her research in this area.

What is the difference between shame and guilt?

According to Tangney, shame comes with the awareness of (or the judgement of) the self as having done (or being) something wrong or unacceptable. Guilt is related to the judgment of the deed (ones behavior) that one has committed.

Shame is also extremely painful relative to guilt. Shame is a feeling of being defective, a sense of being small, exposed, powerless. Shame can last for short or long periods of time. When one feels shame, one tends to want to isolate themselves.

Guilt is different. It comes with remorse, and people who feel guilt are typically drawn to taking reparative action, rather than isolating themselves.

Link between Guilt and Empathy

Empathy is a state of feeling the other’s feelings, and it brings us to altruism.

@ 24:00 Guilt and empathy are connected. Tangney’s team of researchers have found correlation between propensity for the feeling of guilt and people’s ability to step into somebody’s shoes (to be empathic). Meanwhile the other more self-absorbed, pseudo-empathic responses are related to shame.

When a person talks about a shame related feeling in a situation, there is less concern for the other and more focus on the self. When the feeling is that of guilt, the concern is for the other’s feelings.

Shame, Anger and Aggression

The research also found that proneness to shame also related to proneness to anger and aggression. People who are prone to shame, also tend to manage their aggression in a more un-constructive way.

Shame in Family Conflicts

There is therefore correlation with studies of shame in family conflicts and domestic violence.

People prone to guilt are more likely to live a more “moral” life.

Shame and Guilt are not Equally “Moral” Emotions

On the condition that we do not mis-interpret shame with guilt, the findings show that guilt feelings do not cost the person psychologically (as otherwise thought). This means that so long as we do not judge ourselves, but judge the deeds instead, we are in a better situation to cope with the psychological aspect of having done something deemed as inappropriate.

Proneness to shame, on the other hand has been linked to vulnerabilities to depression, anxiety, eating disorder etc.

This also brings to attention how society treats incarcerated people.

Adapting to a more Guilt-Prone style and less Shame-Prone style

Research showed no real inter-generational link in shame and guilt proneness.

Longitudinal studies show that teenagers that are in the guilt proneness fare overall better than  their shame-prone peers.