Team Building

   In the last few weeks, what made you feel successful? Why did that make you feel successful? What made you feel moved? Why did you feel moved? Asking “what” questions, followed by “why” questions, probes the brain to explore the nature of feelings. Exploring the nature of feelings shapes behaviors, since a person will want to repeat experiences which yield positive emotions. This exploration, when shared in a group setting, also creates intimacy in the group which allows the employees to work together more effectively as a team. Further, understanding how others process feelings gives the team  leader important clues about how  to manage their workers in the most sensitive way, thereby having their team be highly productive. In other words, psychological interviewing skills are useful for management.  Shamelessly, I want to say one thing: organization consultation, I am open for business.

Contracts

       Edgar, twenty, lies around the house all day. He was going to college, but he dropped out. His parents, both successful professional, do not know what to do with him. They come to me for advice; they come to me to let off steam. “He sleeps until 3:00 pm. I know it is hard to find a job, but how are we going to get him to do something?” Edgar’s mother, Joy, asks me with utter desperation. “What is important to him?” I ask, knowing that his social life is the focus of his life. “He texts all the time,” Jeff, his father tells me. “Who pays for his phone?” I ask, again knowing that his parents do. Jeff says, “he is on our plan.” “Maybe he has to earn his phone,” I say, directly. I suggest they make a contract, where Edgar has to get a job so that he can pay for his phone so that he can connect with his friends. Joy looks at me, and says what her face expresses so clearly. “Has our life really come to this? Has he no internal motivation? Do we really have to make a contract, like he is an employee?” “Yes,” I answer emphatically. “We all work for positive reinforcement,” I say, knowing that Joy wants Edgar to have internal motivation, not external. Jeff and Joy look discouraged. Joy says “thank you for your expertise,” with a slight edge of sarcasm. I chuckle, letting her know that I know that on first pass, she does not appreciate my advice. At the same time, I know she will think about it.

Idealization…..

 

To be great is to be misunderstood.
  – Ralph Waldo Emerson

Munchausen By Proxy

Some folks lie about their symptoms. Since all psychiatric diagnoses are based on historical information, along with a mental status examination, a patient can skillfully convince a doctor that he/she has a particular syndrome. When this process is done to obtain a secondary gain such as federal disability or an insurance settlement, we call this Malingering. When a person does it for unconscious reasons, then we call it factitious disorder. When a parent creates an illness in a child,  and then denies that she does this, we call this Munchausen by Proxy; I call it heart-stopping child abuse.

Anna’s eight year old son, Don, has ADHD. Although all psychiatric diagnoses are open to suspicion, Don has problems focusing, problems sitting still, and problems with impulsivity, in all settings: home, friends and school. Anna did not cause Don’s ADHD, but she acts as if Don’s disability has given her a focus (pun intended) that has long been missing in her life. Anna worked as a corporate attorney for ten years before she had Don and her second son Anthony. Her husband, also an attorney, suggested that she stop working to take care of her kids. She, without much thought, agreed. Anna works out, she has friends, but ever since she stopped working, she has felt that a gaping hole in her mental well-being. She had a hard time explaining this feeling to her husband, to her friends and to her family, since to them, Anna’s life was the dream life. She had time to herself; she had time to be there for her kids, her husband and her friends. Anna’s quiet sense of emptiness persisted until Don started having behavior problems at school. Suddenly, Anna was mobilized into action. She needed to mobilize a team to help Don. She needed to investigate the best schools, the best professionals, the best doctors. This “project” as she called it, quickly made her feel like she was using her research skills, her interviewing skills and her management skills.

Anna is not abusing Don; she is helping him. At the same time, she is exhibiting the same characteristics of mothers who are guilty of Munchausen by Proxy. These mothers go from what they perceive to be a mundane existence, to one where they have to deal with doctors, physical therapists, occupational therapists and nurses. Their child is “sick” and no one knows what is wrong with him/her. This puzzle creates a challenge; a secretly needed challenge.

Maybe if we, as a society, recognized the challenges of parenting, the need in some parents, to explore many aspects of their brain in parallel, the need to multi-task, then perhaps we could help parents accept that raising children may not feel like “enough” to keep them satisfied. I wonder if accepting how brains need to be satisfied, mother’s brain and baby’s brain, then maybe we could decrease child abuse. I wonder.

It is Time to Stop…..

                 “Two-minute warning.”

What is Therapy Worth?

    Priceless and too expensive, that is what psychotherapy is worth. Geraldine received a large inheritance, a windfall for her, yet paying money to see a therapist feels “extravagant” to her. Harold, age twenty-three, desperately wants to change his life; he is willing to pay a large percentage of his income for psychological help. How do people place a dollar amount on an experience which may be their life boat, but could be part of their sinking ship. Cultural acceptance-is this the answer? Geraldine comes from a family where there is a strong value on “independence”. Geraldine’s parents came through the Depression of the 1930′s, and through that, Geraldine says, they instilled in her a strong belief that one has to handle their own problems; others will not be there for them. Harold, by contrast, comes from a family where having what he calls a “staff” of people to help is the way of life. Depending on others for advice, counsel, support is commonplace among his relatives and his friends.

     Understanding the meaning of paying for therapy for each person, and for each family, in the case of a child patient, is my job. The nature/nurture understanding applies here. Sure, I can see that family values have a lot of weight when people decide about psychotherapy, but so do genes. Some people seem to feel more free to spend money than others; regardless of their economic circumstance. Money, like time, is measurable, and as such, some people like to control it, whereas others like to lose track of it. My impression is that the need to control, as with most behaviors, is in part a biologically based. The control of money often binds anxiety, which is also partly biologically based. In other words, Geraldine has anxieties about aging, about getting sick, about dying. She binds her anxiety by controlling her money. It reassures her to know that she will have more than enough money for her old age. The more she can hold on to her money, the better she seems to feel about the uncertainties of aging.

   What is therapy worth? The answer stymies everyone. Nature and nurture help navigate these waters. Understanding how one approaches this question leads to a rich understanding of  an individual’s psyche. There is no simple answer. In fact, there may not be any answer.

45 Year Old Female, Single, Never Married: Is Something Wrong?

       Marjorie, forty-five, pretty, financially successful, smart, from a stable family, never married, often encounters “you are so lovely, why are you not married?” Together, we dissect this comment as both an insult and a compliment.  “Why do I have to be married?” Marjorie wonders aloud. “Why does that prove to people that I am normal?” Again, Marjorie ponders the assumptions that her friends and family make when they offer up their thoughts about her life. “Is marriage somehow the crown jewel?” She asks. I began to think about gender, knowing that many people in Marjorie’s world would probably say the same thing to a man, so this issue of marriage as the stamp of “normal” does not seem to be gender specific. At the same time, a single woman experiences a certain prejudice; a feeling that she is defective because she does not have a husband. Marjorie explains to me that if a woman is married, friends and family do not need to “worry”. The quality of the marriage seems to be less important  then the fact of the marriage. Similarly, a single woman might have a great support system, but this issue does not fall in the radar of being “OK”. I tend to think that Marjorie’s well meaning friends and family want her to be happy; in their worlds,  happiness comes with a family. A family begins with a marriage. I can see that, but I can also see that there are other ways to find happiness in the world. Marjorie is not so sure.

Passive Agressive

     Blake, thirty-two year old female, married for ten years with two grown step-children, complains of persistent body aches and pains, such that she never wants to leave the house. She has seen many types of doctors, both traditional and nontraditional healers. “Nothing has helped me,” she reports dryly. “What do you think is going on with you?” I ask, curious about her intuitive understanding of her symptoms. “I am just very weak. I am fragile,” she says, without much feeling. “Tell me more,” I ask, wanting her to explore her sense of herself in more depth. “I just feel like I cannot do anything and this makes my husband really angry,” she says, with the same monotone. “You must have some feelings that your husband is getting angry at you when you do not feel well.” I ask, knowing that I am speculating that she cares that her husband is upset with her. “What can I do?” She says,  as if she has no personal agency.

  Blake returns the next day. “What are we doing in here?” She asks, bluntly. “That is an interesting question,” I respond, but since I realize that my answer might make her angry, I continue. “We are exploring your inner world so that maybe we can understand why your body is betraying you.” I say, noticing that as soon as I mention her body, she seems to pay more attention to what I am saying. “Yes, but there is nothing I can do about that,” she says,  in a matter of fact tone. “I am not so sure about that,” I respond. “It is possible that your inner world is expressing itself through your aches and pains. It is possible that you are communicating with your husband some dissatisfaction in your marriage, by retreating into your body and in so doing you are not able to take part in activities with him. Could you be expressing anger by having your body shut down; maybe your aches and pains are a passive aggressive way of telling your husband you are unhappy.” Blake looks at me with a face that makes me think she is feeling uncomfortable and thoughtful at the same time. “Maybe,” she says. “What do you want me to think about for next time?” she asks directly. “I want you to think about that question; that you are asking me to structure your psychotherapy rather than taking charge of our time together. Maybe that question speaks further about your passive-aggressive tendencies,” I respond, determined to make my point. “Maybe,” she repeats. “See you next week,” she says as she leaves, looking as though she enjoyed the challenge of our session, but at the same time, not sure what to make of it. “Oh, and I am sorry,” she says as she is leaving. “Nothing to apologize for,” I say, “but it is interesting that you felt the need to say that.”

       Blake’s challenge with owning her anger is palpable. The mind/body connection seemed linear. If she could not express her anger with her words, she could express it through her “weak” body. Maybe she apologized when in fact she was angry with me for not being more understanding. Rather than getting angry with me, she retreated. I foresee a few rounds with Blake,where I feel her anger and then she recoils. Her anger will be like the sand falling through my fingers; as soon as I think I have a grip, it will fall out. I see how I can help Blake develop more control, more ego. My job is to help her take charge of  the horse, her body in this case, rather than have the horse control her. I want to see her take the reigns-from passive aggressive to assertive, from fallen victim to jockey.

Borderline Personality Disorder: Misogyny?

     Jolie, a mother of three, thirty-five, a full-time hospital administrator, divorced from the father of her children, breaking up from her boyfriend of two years, calls her psychiatrist on a daily basis because she is not sure if her antidepressants are helping her. The psychiatrist, Dr. K  communicates to her that she has Borderline Personality Disorder because she is not able to contain her anxiety and because she is acting in a chaotic fashion. By chaotic fashion, Dr. K explains that Jolie is “all over the place. One minute she is calm, the next minute she is crying hysterically, the next minute she is yelling at her kids.” I think about Jolie as a woman under stress and as such her emotional life is rapidly shifting.

       The diagnosis of Borderline Personality Disorder is rarely used to describe men. Dr. K and I discuss the possibility that this diagnosis may in fact be a way to demean women; a diagnosis which demonstrates that psychiatrists do not understand how a woman’s life is qualitatively different than a man’s in that the biology of female hormones combined with societal expectations of women, even in this era, makes the multiple demands on women challenging. Consequently, women are more likely to express emotions more openly, to reach out for help, which to some, could seem to be chaotic, but to others, understandable in light of the stressors. Maybe  the description of Borderline Personality Disorder is a variant of personality, but not a disorder. Perhaps it is the kind of personality which is more expressive of emotion; for the good and bad of that.

Facebook Friending My Patients: Good Idea or Unethical?

     Tom,
http://shirahvollmermd.wordpress.com/2010/09/15/success-rebellion/
, says “I would hate for you to be my Facebook friend. You would not approve of what I have up there.” Howard, the father of a five-year old patient, asked to be my Facebook friend. Tracy,  
http://shirahvollmermd.wordpress.com/2010/02/07/the-artist/
, wanted me to join her Facebook group so that I could have a deeper understanding of her art. Jessica,
http://shirahvollmermd.wordpress.com/2010/04/01/brain-fear
, wanted me to follow her on twitter. She also wanted to follow me.

    What are the rules of the road here? Is connecting with my patients through social media a boundary violation? Or, is it a tool to help me understand the world my patients travel in? Maybe it makes sense for me to be Facebook friends with parents of my child patients, since I am not directly treating them? Maybe not. Is this a case by case basis-a clinical judgment? Is this going to be yet another generational issue? An issue similar to using psychotropic medications to treat problems of daily living where many of those trained before the 80s feel that psychotropics are over-prescribed, whereas more recently trained colleagues accept the wide use of psychotropics as the norm. My older colleagues shutter at the thought of the transparency inherent in social media. Patients will no longer be able to project their ideas on to a blank screen, resulting in greater inhibitions in psychotherapy. My younger colleagues accept the new reality of our lives; social media means we lose privacy but gain connection. It is a net positive. My generation is caught in the middle; both sides make good points.

     I tilt towards accepting our new media as an opportunity for exploring new boundaries in psychotherapy. This is a new frontier for my field-an opportunity to open discussions about the psychotherapeutic frame. Is this a rigid frame or a shifting frame? Maybe after a certain time period, being Facebook friends makes sense, but if it happens too soon in the psychotherapeutic relationships, then there could be painful misunderstandings. On the other hand, painful misunderstandings are the grist for that therapeutic mill. We, my colleagues and I, need to explore the meanings of this new technological world. We adapt or we die-that makes sense to me. How we adapt is the question. I welcome your answers.