Shirah Vollmer MD

The Musings of Dr. Vollmer

What Is Insight?

Posted by Dr. Vollmer on October 30, 2014

 

 

Psychotherapy and psychoanalysis aim to help the patient develop insight into his problems, such that with understanding comes incremental, and at times, transformational change. This is what we, in the psychoanalytic world, term “therapeutic action”. However, there is much debate about what exactly is meant by “insight”. Generally speaking, this is the understanding of the underpinnings, the back story of unpleasant, or self-sabotaging behaviors. The patient who discovers that he screams at his wife, mostly because he remembers his father screaming at this mother, and so he feels that is how relationships work. With this discovery, the patient garners greater control the next time he is about to scream at his spouse. His ego is expanded such that he begins to think of other options in which he can communicate his disappointment or his frustration.

Luca, fifty-two, comes to mind. He repeatedly tells me how ashamed he is of his behavior towards his teenage sons. He yells at them for getting Bs on examinations because he is fearful this will hurt their chances for an ivy league school. At the same time, Luca understands that shaming his boys could lead to psychological damage, which, even if it caused better grades, his verbal abuse  is more harmful than helpful. Yet, when he sees grades which are not As, he “goes off the handle,” to use his words. Months of talking about this problem has taken us to his deeply fearful place that his sons will not be self-sufficient. In Luca’s mind, the only path to self-sufficiency is an ivy league education. As he says this out loud, he sees the absurdity. We talk more. Luca feels his own disappointment about not going to a “good college” and how in his mind, that his hurt his entire career path. Again, he recognizes that absurdity as well. We talk about how different paths lead to different places, but that his disappointment in himself goes deeper than not getting into the college of his choice. Luca is developing insight into his deep sense of personal failure, manifests by his “need” to shame his boys, for their academic performance. Understanding that his disappointment with them, is a displacement from his disappointment with himself, allows Luca to be more respectful of his son’s school work, such that he accepts their grades as representations of their current performance, and not a source of deep fear for their future. Insight gave Luca perspective, which was lost due to his compelling need to transfer his disgust with himself on to his children.

 

 

 

Posted in Psychoanalysis, Psychotherapy | 1 Comment »

Listening As Mothering

Posted by Dr. Vollmer on October 29, 2014

The mother listens and the father guides. This gender stereotype is a way to describe that listening is a way of holding the patient, caring about what is on their mind, which is followed by fathering which is giving them ideas about their mind, that perhaps are unconscious thought processes. The latter intervention is termed an “interpretation,” which by this way of thinking is a more masculine behavior than listening. The oscillation between listening, holding, and offering ideas, intervening, is the dance of psychotherapy. Patients who have had early traumatic experiences, and/or who suffer from tremendous anxiety. often need to be listened to, but they cannot tolerate new ideas about their thoughts. The challenge to their thinking is met with defensiveness and more anxiety, as their mental fragility becomes more apparent.

Elie, thirty, male, comes to mind. I have worked with him for many years, and yet, each time I have an idea, he quickly, before I finish my sentence, says “I know, I know.” When I ask him what I am going to say, he says, “oh something about my anxiety.” “Why is it so hard for me to finish my sentence?” I ask, trying to work with his defensiveness. “I just do not want to be told that I screwed up my life,” Elie says, with sadness and despair. “Is that what you think I am trying to tell you?” I ask, understanding that for Elie to change his life, he has to mourn his previous decisions which landed him unhappy with his work and his relationships.  “Of course, you want me to fix things. I know that, but I just cannot deal with feeling so bad about my choices,” Elie says, moving me to feel a lot of compassion for him. “And yet, you come and you want to struggle with me about how to move forward,” I say, highlighting his ambivalence about change. “Oh, yes. I look forward to coming, and I look forward to telling you what is going on with me, but it is hard for me to hear your thoughts.” Elie says, illustrating this dance between listening and thinking. He is comfortable and soothed by my listening, and challenged, threatened, by my talking. In this way, he is a textbook example of a man who needs “mothering” but is not quite ready for “fathering”.

Posted in Listening | 1 Comment »

What Are We Listening For?

Posted by Dr. Vollmer on October 28, 2014

 

The fundamental rule, Freud stated, was free association. The patient is mandated to say whatever comes to mind, like he is on a train and describing the scenery as the train rolls on. There is an inherent contradiction to mandating free association, as the mandate makes it “unfree”. Having said that, the notion that the freedom to speak in a consultation room, with the promise of privacy and time, opens the speaker and the listener to a unique view of the mental state in that moment, and perhaps, many previous moments. The production of a story requires creativity and imagination which lends itself to interpretation, both by the storyteller and the listener. Both parties have now experienced the narrative, and it is the therapeutic challenge to work with the words to make meaning out of both the current story, as well as the underpinnings to the story, which might, in turn,  be contributing factors to the patient’s  mental suffering and distortions. So, we, as therapists, listen for both what is said, when it is said, and what is not said. Ezra, twenty-three, comes in each session, which is almost daily, by saying “well, not much to report.” This opening line, as we have discussed, is so rich with meanings. He is telling me, I hypothesize, that he wishes there was something to report, but he is very stuck in his life, and in turn, he is very frustrated. This speculation is derived both from his tone, and from the repetitive nature of this comment. “Not much to report,” is also, it seems to me, his way of easing into our session. He is unfamiliar with the therapeutic process, so he assumes that his job is to report to me, as if I am his boss. Ezra, as he has explained to me, comes from a family of business people, and so many interchanges are filled with, what feels to him, are  “reports”. Finally, “not much to report” is a way in which Ezra preempts, what he perceives, is my disappointment with him, for not doing more with his life. “Not much to report,” stops me, by his way of thinking, from asking him, or pressuring him, to account for his time. Ezra and I bat around these ideas, with a playful tone, one that allows for reflection, with minimal defensiveness. The persistence of his comment. That is what I listened for.

Posted in Listening | 2 Comments »

Why We Listen

Posted by Dr. Vollmer on October 27, 2014

We, the psychotherapeutic community, particularly the psychoanalytic community, listen to patients because we understand that to create a narrative, a deep understanding of oneself, someone else needs to listen and provide feedback. Children grow up dependent on their parents to interpret their world, and so adults and children in crisis, struggling with conflicting feelings, need to have someone listen to this conflict and help them sort out deeply rooted dilemmas. Listening, time, and privacy, are the three legs or our stool, all of which are threatened in today’s age of electronic records, hasty clinical contact and limited number of sessions. This change in the delivery of mental health care contradicts the fundamental principles of how mental health intervention becomes mental health. I am not tired of saying this, because not enough people have heard me yet. So, I will continue to teach and  to blog in order to advocate for in-depth listening as a means to promote well-being.

Posted in Psychoanalysis, Psychotherapy, Teaching Psychoanalysis | 6 Comments »

NYer Cartoon Contest

Posted by Dr. Vollmer on October 27, 2014

 

You are violating your restraining order.

Posted in Cartoons | Leave a Comment »

Amae

Posted by Dr. Vollmer on October 23, 2014

 

 

http://www.kirainet.com/english/amae-%E7%94%98%E3%81%88/

 

The Japanese language gives us a word to describe how a person, often a child, demands that he be loved and admired, not just to feel good, but in order to grow up and flourish. When I child says “mom, look what I have done,” they are seeking Amae, affirmation and recognition for their accomplishments. This need never changes, but hopefully, with maturity it evolves into a conscious need, such that the person can find constructive outlet for this need, such as running marathons, or producing art.

Psychotherapy, through transference and countertransference, helps to make this need for Amae, conscious, as the patient often pleads with the therapist for attention, which often highlights significant areas of emotional neglect in his past. continuing with the Edna and James dynamic, Edna needs to understand she needs to feel affirmed, not just sexually, but emotionally and intellectually as well. Likewise, James needs to feel like the rescuer, bringing him into a helping profession, but without full consciousness of his need to rescue, to feel affirmed. Amae is not shameful, especially once it is recognized and made conscious. The universality of psychoanalytic principles lives on. Language gives us a way to explore these concepts, and sometimes we need to shift to other cultures and other languages, to convey the many ways in which relationships promote growth.

Posted in Mother/Child Relationships, Psychoanalysis, Psychotherapy, Relationships | 6 Comments »

Boundary Check: No No…

Posted by Dr. Vollmer on October 22, 2014

 

All interactions have both conscious and unconscious layers. This is the premise of psychoanalytic theory and treatment. As such, fantasies, erotic and otherwise, are likely to grow in both directions, with the major vulnerability and hence, safety valve, is that fantasies led themselves to words and not actions. In other words,  fantasies must mutate into a narrative, but not into an action.

The cartoon above illustrates the point. That Dr. James (fictional, of course), wants to jump on the couch with Edna, is a rich area for exploration, but jumping on the couch is the source of cartoon and mockery. The caption illustrates that Edna, the patient, might indeed fantasize about James jumping on the couch, but narration in replace of action, leads to understanding and healing, as opposed to repetition and re-traumatizing.

This, again, is the fundamental principle of therapeutic action. Patients get better because unspeakable fantasies are speakable, and in so doing, analyzable, and in so doing, amenable to forgiveness and mourning. Edna, in this example, needs to mourn the loss of a parent who saw her as a sexual object and not a child that needed love and nurturing to grow up and flourish in the world.   This is not the loss of the death of a parent, but rather the loss of a parent she never had. Only through fantasy, both in patient and analyst, can these traumatic pasts be explored and worked through.

Fantasy, as opposed to  check-lists must be open to exploration and hence must not be limited by time. The open-ended nature of this exploration is critical to getting at deep unconscious material which troubles and disturbs functioning. These are the basic tenets of psychoanalytic psychotherapy. We must cherish these techniques and not abandon them for what sounds like a faster cure, but in fact, is a quick change to the check-list.

 

 

Posted in Countertransference | 2 Comments »

Countering Transference or Just Havin’ Feelings?

Posted by Dr. Vollmer on October 21, 2014

 

As I re-enter into the blogging world, I am reminded that one purpose of this blog is to focus my attention towards teaching about psychoanalytic concepts. In this way, this blog serves as my notepad, my preparation to stimulate a dialogue about the human condition in a psychotherapeutic setting. In that light, I want to focus on the notion of countertransference; a notion which is vague but generally means the unconscious and conscious feelings that the therapist has towards his patient. Edna and James, the therapeutic dyad, struggle together to make sense of Edna’s past and present anxieties. Edna, seen four times a week, for many years, is often angry and frustrated with James. She feels stuck and guilty, for no apparent reason, except she thinks that James could be doing a better job. At the same time, she comes regularly and reliably to her appointments and it never occurs to her to switch psychoanalysts.

James likes Edna, looks forward to seeing her, but feels that his feelings towards her are shallow, despite the many hours they have spent together. He assumes these shallow feelings are a result of both Edna keeping her emotional distance and James, not wanting to be drained at the end of each day. Still, of all of James’ patients, Edna, he would say is the one he feels the least connected to. James come to me for consultation about this troubling realization. “Maybe you have just not gotten close to her because she is so defended? And/or maybe she reminds you of people from your past who you spent a lot of time with, but who really never had emotional meaning for you?” I say, expressing layers of understanding to begin a discussion with James as to why he is seeking consultation with me, with regards to his therapeutic relationship with Edna.

The parallel process between trying to draw James out, via free association, follows James attempt to understand Edna, by the same means. Yet, my relationship with James is a teacher, or  a supervisor, as the psychoanalytic world likes to call me. My job is to help with his concern, not about his life, or his personal relationships, but with his psychotherapeutic dilemmas. At the same time, I teach a class, struggling with the idea of countertransference, and in particular, struggling with the word “counter.” This, as I will talk about in class, is a major misnomer. There is nothing “counter” in countertransference, but rather, feelings go both ways, and the dyad changes over time-both sides, of course.  This changing dyad is a result of the struggle to understand what happens when two people come together, hour after hour,  trying to heal, trying to understand, with an attempt to offer up many answers, to seemingly unanswerable questions. These answers, are ideas, not definitive conclusions, and yet ideas help soothe anxiety, and create forward momentum,  given the limitations of our own biology and the stressors in the world around us.

Posted in Countertransference | 4 Comments »

NYer Cartoon Contest

Posted by Dr. Vollmer on October 20, 2014

 

                                  I think he moved to the unconscious.

Posted in Cartoons | 2 Comments »

Doctor/Nurse Communication: The System Breaks Down…Old Fashoioned Medicine Prevails!

Posted by Dr. Vollmer on October 20, 2014

Ebola hospital

 

 

 

“The diagnostic team that treated Duncan — who had symptoms of headache, abdominal pain and fever consistent with the Ebola virus — did not know he told a receiving nurse that he had traveled from Africa. On that day, Duncan was sent home with antibiotics. He returned to the hospital by ambulance two days later.”

 

http://www.latimes.com/nation/nationnow/la-na-ebola-hospital-20141003-story.html

 

As the Ebola virus continues to make world news, I am struck that one important aspect of this story is not getting enough press. The nurse got the history of possible Ebola exposure, but the doctor did not. Nor did the nurse adequately communicate this VITAL piece of information to the doctor. This viral scare, from my point of view, highlights the prime importance, once enforced in medical training, and now less so, that a doctor MUST always take his/her own history. The idea of relying on other professionals for a history of present illness, as in this tragic case of Thomas Duncan, can cause fatal mistakes, History taking is/was the foundation of good medical care. This was the most important thing I learned in medical school, in rotation after rotation. Yet, today, there is a notion that professionals should work to the highest aspect of their license, meaning that one does not need an MD to take a history. Physicians are needed to prescribe, to order tests, but not to get background information. This background can be obtained by medical assistants and nurse practitioners.

Oh, no no, I say, learning of this paradigm change in health care delivery. With all due respect to nurses, there is the art to history taking with leads to accurate diagnosis and treatment. My professors, rightly, and repeatedly, taught me this. 80% of the diagnostic information is from the history, they would say, which became the often mocked mantra. Yet, almost thirty years later, those words come painfully alive, as we discover that the doctor did not do a “travel history” on Mr. Duncan. This pertinent omission of the history has sent this country into anxiety, reaching near panic levels in some. The focus has been on politics, on travel bans, on protective gear training, and yet, where are the doctors yelling about the need to reinstitute history taking as the vital art in medicine? Yes,in  most cases, the history is less critical and symptoms can point the physician in the right direction. However, once in a while, a critical case will come in the Emergency Room, and like Chelsey  Sullenberger,  the pilot who landed the plane in the Hudson, with  rarely used, but critical skills, doctors need to have history training for that, perhaps one time in their career, where it really matters.

Posted in Ebola, Health Care Delivery | 4 Comments »

 
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