“My Mother is an Orange Rind”

    Tom, twenty-four, an artist, struggles with his relationship with his fifty-two year old mom. Tom turns to her for comfort, inevitably feeling disappointed. “She is an orange rind,” he says. “What do you mean?” I ask. “She is very tough. I can never get to the soft parts.” Tom says with overwhelming sadness. “That really hurts you. You so wish that you could have a more tender relationship with her.” I say, repeating his idea. “Yes,” Tom cries, “I have given up.” “Not quite,” I say. “It seems like you still wish for a mother you do not have,” I reply. “Yes, but I know her, and I know she is not capable of understanding my emotions,” Tom says. “Yes, but each time you feel the need you turn to her and then you are disappointed,” I say. “Yes, but I am less disappointed each time because I am learning what to expect,” Tom says in a way which changes his tone from sadness to resignation. “An orange rind,” I repeat. “That is an interesting way of putting it.” Tom’s creative abilities percolate through his pain. He gave me an image which helped me understand his experience. I hope he experiences me as the inside of that orange. I should  ask him about that.  

Idle Mind…’Default Mode Network’

    This wonderful article describes the power of the human mind to examine itself.

http://www.latimes.com/health/la-he-brain-20100830,0,479095.story?

“The idea that there may be a physical structure in the brain in which we unconsciously define who we are ‘would warm Freud’s heart,’ says Dr. Marcus E. Raichle, a neurologist at Washington University in St. Louis who has pioneered work in this fledgling field. Sigmund Freud, the Austrian father of modern psychiatry, spoke exhaustively of the power of the unconscious mind in shaping our behavior and often surmised that the workings of that force would someday be revealed by scientists.”

Preschool Depression: NYTimes Style

 

http://www.nytimes.com/2010/08/29/magazine/29preschool-t.html?pagewanted=1&emc=eta1

   Old wine, new bottles. Kids have mental anguish. Child psychiatrists can help, with and without medication. It is important for parents and teachers to pay attention to the mental state of their children. If the article drives this point home, I am happy.

Staying Together For the Kids

    “We can’t break-up, it would ruin our kids’ lives,” Randolph and Judy tell me repeatedly. “What makes you say that?” I ask, feeling like I probably know the answer, but I am still curious as to what they will say. “A broken home is such a terrible thing,” Judy answers in a vague way. “And living with marital discord is not a terrible thing,” I respond, trying to be gentle, but realizing that this could sound sarcastic. So often I find myself wanting to expand thinking, knowing that stress narrows the mind. Children are hurt by the actions of their parents; that is a given. Most parents do not want to hurt their children. Finding the narrow path between protecting the children and living an authentic life is the challenge. The answers are not one-size fits all, nor are they necessarily clear from one moment to the next. However, the extreme situations open the discussion. There are situations where it is better for the children when the parents divorce. Domestic violence is the obvious example. Having said that, most of the time the issue is not the gross issue of physical violence, but the more subtle issues of self-esteem, both in the parents and the children. Children suffer when their parents suffer. Parents suffer when their children suffer. Selfish behavior causes suffering; so does martyrdom. Compromise is the challenge; compromise is the goal. How can parents find a way to live a life they enjoy, while at the same time protecting their children from unnecessary trauma and disappointment? These questions are tortuous; the process of sorting it out is troubling. Yet, without a deep thoughtful process, quick and shallow judgments flow rapidly. Words are important. Divorce is not always bad for kids. Kids lives are not necessarily “ruined”. Rather, there are times in life, like with this family now, where there are rough patches. These rough patches are opportunities for the family to re-examine their earlier assumption of family harmony. Randolph and Judy have hit a reflective time in their lives. My hope is that they stick with the reflection so that they can go ahead with a careful examination of the consequences, for themselves and for their children. The outcome is hard to say; the process is key.

Monte and Marla: At it Again

  Two o’ clock in the morning  Monte  https://shirahvollmermd.wordpress.com/2010/07/05/supervision-ii/ , wakes up, as if invaded by aliens, knows what he wants to do about his troubles with Marla; call Beatrice, Marla’s supervisor. The thought, mysteriously enters Monte’s mind,  seems like such a sensible thing to do. Maybe if Beatrice knew that Marla’s behavior was defensive, inappropriate, and hurtful, then maybe Beatrice could help Marla regain some traction with Monte. Oh, Monte thinks more deeply. By calling Beatrice, he is making  some assumptions. Monte knows that Marla goes to Beatrice for consultation, but he cannot assume that he is the topic of conversation. On the other hand, maybe he is. Monte goes back to sleep. A few days pass, Monte leaps forward; he emails Beatrice, sheepishly, but he does it. Beatrice responds in a kind and sensitive manner saying “I acknowledge receipt of your email. I hope you are well.” Wow, Monte thinks, that went well. Monte breathes relief.

     Monte, a middle-aged psychoanalyst similar to Aaron Green https://shirahvollmermd.wordpress.com/2010/07/20/book-review-psychoanalysis-the-impossible-profession/, has looked to Marla for help with his practice, his interpersonal struggles, and his existential questions. The complicated nature of working in a helping field makes getting help from a therapist/colleague different from it is for lay folks. Monte envies his non-therapist friends who can go to a therapist and then not see them again at a professional meeting or seminar. The overlapping roles of patient and colleague can deepen a relationship, but it can also create a crevice of unsettling feelings. Monte has a large crevice. Calling Beatrice settled Monte down for a bit; momentarily Monte could feel hope that this crevice might shrink.

    Weeks pass, Monte calls Marla. They agree to talk at 3:00 pm that day. An hour after they make that arrangement, Marla calls and said she made a mistake; she has a client at 3:00 pm. Monte is aware, yet again, there is no apology; just a statement of  fact. Marla has no time to talk about it. In an angry voice, she says “gotta go”. Monte is brought back to that feeling of being an open wound. Marla lets Monte down, but somehow Marla is the one expressing anger. Monte decides to let it go; he is not going to talk to Marla. Thirty minutes later, Marla calls apologizing for not being able to talk at 3:00 pm and apologizing for being hasty on the telephone. Monte’s unsettled feelings are now making a bigger crevice. He could attempt to call Marla again, or he could let it go. Either way feels bad.

Dynamite Couple

    Mark and Daniella, both in their fifties, have been married for thirty years; most of that time  they have been on the edge of divorce. Both deny extramarital relationships. They have a daughter,  with oppositional behavior, who has been challenging, but their marital issues preceded her birth. They have been in couples therapy with five different therapists over twenty years. Previous therapists have been helpful, but ultimately both felt that the relationship remained tortuous and destructive to their self-esteem. Neither party ever ventured out, yet each one said their lives were “miserable”. When I first starting seeing them, I thought that they were a “dynamite couple” in that only a drastic intervention could ever change their tightly wound interpersonal system.

    I really like Daniella and Mark. I want to say that since hearing about their relationship makes them sound like miserable people. In fact, each one is highly successful in his/her  career, and each one is a caring and generous person; just not to each other. Over the five years of our working together, the relationship has gotten substantially better in that there is less blame; there is less sadism. How did this happen? I held up a painful mirror to their behavior and they felt miserable about themselves. They each began to take back the projections of hurtful  behaviors and they each began to see  their own  aggressive behaviors as coming from a sad and lonely place. Each one wanted to be loved; each one was afraid the other could not give that to them. Out of that fear came aggression and hostility. Neither one left the relationship because each one saw himself/herself as unloveable. At the same time, each one felt that if by small chance they could experience love, then their current partner would be the most likely person to love them. This dynamic created a strong bond of togetherness, while at the same time, created an interchange which was degrading and primitive.

    Daniella and Mark now describe their relationship as “not as terrible”. I would say that each one is moving forward in seeing their own flaws and as such, they are becoming more tolerant of the other. Seeing their own flaws is painful, so neither one is in a joyful state, but when they see the flaw as internal, as opposed to external, then they can begin the work of healing themselves. Wounded souls can come together; particularly, when they can see their own wounds as clearly as they can see their spouse’s. Daniella and Mark were never at risk for divorce-just chronic unhappiness. At times, dynamite seemed like the only answer. Now, baby steps appears to be a better path.

Oppositional Defiant Disorder: I am Opposed

      Johnny is five years old, with verbal skills of a typical ten-year old. His confidence with his words is mind-blowing. Whereas most kids his age hardly speak to adults, Johnny quickly remembers your name, uses your name and tells you how pleased he is to meet you. Consequently, adults love him. His parents, however, are ready to put him up for sale. He is uncooperative with dressing himself and putting his toys away. His friends have trouble with him too. He tends to be bossy. His focus is impressive, although he is having trouble learning to read. His math skills are consistent with his age. Johnny’s parents were fighting with each other over how to deal with Johnny’s oppositional behavior. They consult a child psychiatrist who then diagnose Johnny with oppositional defiant disorder. The psychiatrist prescribes Ritalin; Johnny becomes more cooperative. The parents, Sienna and Clive, come to me for a second opinion.

     Oppositional Defiant Disorder is a mental disorder according to DSM-IV, not in my opinion, I explain. Johnny’s temperament is one of independence and strong will. He is hard to raise; I can see that, I share. The Ritalin makes him softer around the edges, but I do not think it is a good idea, I explain to them. Helping Johnny become more cooperative is the challenge. Sienna and Clive can do this with parent training. Johnny needs help understanding that his independence is helpful in certain situations, but not in others. Johnny’s young age is an opportunity to begin Johnny’s path of self-understanding. Ritalin could cloud these issues. “Don’t get me wrong,” I caution them. “Ritalin, as with all stimulants, are very helpful for children with ADHD in that it helps them focus and it helps them with their hyperactivity, but for oppositional behavior, I prefer to try parent training before jumping to medication.” Sienna and Clive look at me with wonder and fear. “He is so much easier to live with,” Sienna explains. “A good result does not necessarily justify the means,” I respond.

    Oppositional Defiant Disorder, or ODD, which, like the word ‘odd’ is an odd diagnosis. It applies to children, but not adults. What happens to a child with ODD when they turn 18? I do not know the answer to that. By definition, the child grows out of this diagnosis. I have trouble making sense of this, except to say the diagnosis is another example of psychiatrists, in this case child psychiatrists, pathologizing a variant of temperament. We need to understand children and we need a language to convey this understanding to parents. We do not need diagnoses which label children as ‘disturbed’ . Understanding a child is not the same as diagnosing a child. Strengths and weaknesses, that is where clinicians should begin their assessment. Behavioral interventions are almost always a good beginning. Usually, a diagnosis can wait a few weeks as the clinician works to  understand the child at home, at school, and with his friends. 

    Perhaps I am the one with Oppositional Defiant Disorder. I oppose the diagnosis. I oppose the apparent rush to medicate young children with this diagnosis. Am I an advocate for these kids or an adversary? Like the diagnosis, it depends on your perspective.

Freudian Flip: WSJ Follow-Up

http://online.wsj.com/article/SB10001424052748704868604575433240679742412.html. It is August 18, 2010 and here I sit in my office, waiting for my next client. In California, most therapists work in August, at least part of it. The East coast August tradition of folding up the practice and heading to Cape Cod, Long Island, Martha’s Vineyard, or Europe, does not have a parallel process on this coast. Some say that is a function of our weather. It is so pleasant here, we have no compelling reason to escape. We can choose our time off when it suits us, rather than having the climate dictate our time away. Others say it is a tradition, that in light of other traditions, Californians push away; nonconformists that we are. Still others, as in the reversing trend stated in the WSJ, are concerned about the economy, so staying around in August, keeps the ship sailing. Regardless the reason, psychoanalysis in August, psychotherapy in August, psychopharmacology in August, is alive and well in Los Angeles; it always has been.

Cleaning the Office

     Seven years from the last visit, the time charts have to be stored, except when it is a child, in which case it is seven years after the client turns eighteen. So, chart thinning is a yearly ritual. New psychiatry  graduates have a different plan. Many are paperless. There are no charts; patient information is digital. This means no file cabinet. All papers are scanned into an electric file; then the paper is shredded. Back-ups are digital as well. Space requirements go way down. Security issues change. Whereas I worry about a fire, my newly minted colleagues need to be concerned about an electromagnetic pulse which can wipe out electronic data. I peruse old files, looking through pictures, hand-drawn,  as well as photographs. I touch them. I turn them over. I feel nostalgia, remembering when a patient handed me something they wanted me to keep. I am no technophobe, but I  appreciate touching documents; turning pages stimulates reverie. Maybe sitting at my computer, reviewing old files would do the same thing, but I don’t think so. There is something nice, almost sweet, about holding a paper, seeing the writing, in assorted colors, pop out, as I sort through old charts. I embrace the digital age, but not for everything.

The Cancellation

      Ruthie, thirty-three, has not seen me in over a year. At that time, she cancelled her last appointment saying she was “better” and she no longer needed my services. She came to me through her psychologist who felt that her medications could be managed better by me than by her primary care doctor. I prescribed psychotropics which by her account “changed her life.” I connected with her internist who felt that the psychotropics he was prescribing seemed to “do the trick” such that he did not understand why she was being referred to me. I explained to him that certain medications change how people feel such that even though she was stable, the patient felt better on different medications. The internist, Dr. Yee, said, “yes, but couldn’t that be a placebo effect?” “Of course,” I say, “that is always possible.”

   Recently, Ruthie called me on a Friday afternoon, saying that although she has not seen me in a “long time” and she is no longer seeing her previous therapist, she has a new psychotherapist, and she has changed back to her psychotropics prescribed by Dr. Yee, she wants to come back and see me. . Now she says “it is time for a change.” I remember Ruthie well and I look forward to seeing her again, although from our conversation, I am not sure what “time for a change” means. I offer her appointments for the following week, but she says “oh, no I cannot do those times, I have a busy week, how about the next week?” she asks. “Monday,” I say; she enthusiastically accepts. Nine days later, on Sunday, I pick up my messages. “Hi, it’s Ruthie, I need to cancel my appointment for tomorrow since my new therapist sent me to a psychiatrist and I think we are on the right track. If things don’t work out, I will call you back.”

     When did she see the psychiatrist? I wonder. When did she decide not to keep her appointment with me on Monday? I wonder still. Why did she not cancel with me the moment she finished with seeing her new psychiatrist? Maybe she was ambivalent about changing psychiatrists. Maybe on Sunday,  she looked at her calendar for Monday and realized that she no longer needed to see me and she should let me know. I think back to my conversation with Dr. Yee. Maybe he was on to something when he mentioned the placebo effect. Maybe Ruthie is the kind of patient that is vulnerable to placing halos over new doctors. For many people, new represents improved, even though cognitively that makes no sense. New could be improved, but new could  be a lateral move, or a downward step.

     Cancellations, generally speaking, are stimulating. Some colleagues consider cancellations to be aggressive acts against the therapist. Other colleagues spell out cancellation policies which do not allow for personal emergencies. Psychoanalysts, historically speaking, consider their time “leased” meaning that holding the time, whether the patient uses it or not, warrants a fee; it makes therapy  similar to an apartment.

    In Ruthie’s case, I doubt she thinks that I am think about the underpinnings of her cancellation. Ruthie sees me as a psychopharmacologist who at one time in her life helped her, but at this time, maybe another psychiatrist can do even better. Ruthie is not thinking about the relationship she has with me; she is thinking about my psychopharmacological skills. As such, another psychiatrist might have a different skill set which can help her in a new way. By contrast, I am wondering about Ruthie. How has her life changed in the past year? Why now did she decide to make a change? I will miss seeing her.