Episode 273: Nancy McWilliams on Shame, Transference, Personality Disorders & Becoming a Better Therapist
July 17, 2026
AI Summary
5 min readNancy McWilliams begins with a deceptively simple distinction: guilt you can apologize for, but shame makes you want to disappear. “Since shame involves being seen in all your ugliness, you just want to crawl into a hole in the ground.” This sets the stage for a practical, personality-grounded conversation about how therapists actually work with the hardest material patients bring—and with their own reactions to it.
Working with Shame: Exposure, Not Reassurance
McWilliams is blunt about what does not work with shame: “I find that reassurance never works.” Telling someone they shouldn’t feel ashamed only adds to their sense of being misunderstood. Instead, she targets the self-attacking part directly. She might say, “Where did you get the idea that you’re uniquely bad? What makes you so much worse than all the rest of us?” The patient can absorb this because they already feel they deserve attack—but the attack is now aimed at the shame itself, not at them.
Continue reading the full summary in the app — free to try.
Read Full Summary →Free • No credit card required
Never miss an episode of Psychiatry & Psychotherapy Podcast
Get every new episode summarized in your inbox — free, ~5 minutes to read.
No spam. Unsubscribe anytime.
What you'll learn
- 1 (00:13) **Introduction & Episode Overview** - Host Dr. David Puder introduces returning guest Nancy McWilliams and the topics to be covered: shame, personality styles, countertransference, projective identification, and boundary violations.
- 2 (02:20) **Working with Shame: From Self-Knowledge to Self-Acceptance** - Nancy McWilliams explains how to help patients talk about deeply shameful parts of themselves.
- 3 (11:01) **The Therapist’s Countertransference to Being "Taken Care Of"** - McWilliams describes her own reactive countertransference when patients try to protect her from negative feelings.
- 4 (19:56) **Strengths & Vulnerabilities of Different Therapist Personalities** - McWilliams provides a detailed breakdown of how various personality styles affect therapeutic work.
- 5 (32:49) **Working with Dissociative Transference and Zoning Out** - McWilliams discusses how to handle patients who dissociate or "space out" during sessions.
- 6 (37:06) **Intense Projective Identification: A Case of Being Certain You Hate Them** - McWilliams shares her most memorable experience of projective identification and overwhelming countertransference.
- 7 (43:15) **Another "Outside the Book" Breakthrough: The Pregnant Therapist** - A second story about a narcissistic patient who insisted he knew McWilliams' internal state better than she did.
+ Full timestamped outline available in the app
Show Notes
In this in-depth interview, Dr. David Puder welcomes renowned psychoanalyst and author Dr. Nancy McWilliams to discuss essential clinical topics from her seminal books Psychoanalytic Diagnosis and Psychoanalytic Psychotherapy. Dr. McWilliams shares practical wisdom on working with shame in therapy by emphasizing self-acceptance over mere self-knowledge, along with powerful insights into transference, countertransference, and projective identification. The conversation explores how different therapist personality styles influence clinical work, strengths, and vulnerabilities. Additional highlights include building love and trust in the therapeutic relationship, protecting the therapeutic frame, setting early boundaries, and real-world guidance on handling stalking and boundary violations.
By listening to this episode, you can earn 1.5 Psychiatry CME Credits.
More from this podcast
Psychiatry & Psychotherapy Podcast →