Raphael is a thirty year old hispanic male, working hard as an internal medicine resident. He is the first person in his family of ten siblings to graduate high school. His father washed dishes for a high-end restaurant. His mother took care of the family. His siblings have had many social problems including drug abuse, teenage pregnancies, and truancy. Raphael has persisted in school despite the odds against him. His father passed away when he was sixteen. His mother has chronic medical problems. Raphael began residency as a strong resident, but along the way, he stopped showing up for work. He got depressed. He did not know how to reach out for help. The residency directors worried about him, but he did not respond to emails or phone calls. Eventually Raphael surfaced and he agreed to get help. He consulted with prominent mental health experts and to his surprise, they told him he had a substance abuse problem, even though he said that he drank “like every other college student.” Raphael was sent to a rehabilitation program for substance abusers, even though he, and many other professionals did not agree with the diagnosis. Raphael was then ready to return to work, but at the same time, he was applying for his medical license. The board that issues the licenses became concerned about his “substance abuse” history and so then refused to issue him a medical license, even though he met all the other qualifications. Now, Raphael cannot go back to work. At the moment, he cannot learn to practice medicine, despite his ten years of diligent work preparing for his career. Raphael needed help to get back on track, but he did not need a substance abuse rehabilitation program. Raphael has the potential to serve the community in a unique way because his background is unusual for physicians. Is it too naïve to think that if he had a little mental health support during his rough patch, and not a formal substance abuse rehabilitation program, that maybe, just maybe, this mess that he is now in could have been avoided? I do not think so. Tragic.
Archive for February, 2011
Posted by Dr. Vollmer on February 28, 2011
Posted by Dr. Vollmer on February 25, 2011
Monte returns to Marla, http://shirahvollmermd.wordpress.com/2010/08/26/monte-and-marla-at-it-again/, partly for that sense of continuity, partly for a strong desire for rapprochement, partly because Monte’s therapist took ill. Monte craves for some affirmations, some loving feelings and some mentorship. Marla craves admiration. Predictably, there was an emotional collision. Monte suddenly was confronted with Marla’s insensitivity to his struggles in his practice. Likewise, Marla was suddenly confronted with her angry feelings, stemming from not feeling appreciated. Yet, both acknowledged that there were good feelings between them and that the relationship, however one might characterize this atypical union, is worth maintaining. Monte expresses his disappointment in her. Marla expresses her inability to tolerate his disappointment in her. At the end, they set up another meeting. Both parties are confused. Yes, both are therapists/psychoanalysts with a lot of clinical experience. Some relationships defy explanation.
Posted by Dr. Vollmer on February 24, 2011
“Do you charge when someone calls you to ask for a refill?” a colleague asks me. Once again, I feel the contradictory pulls of my older colleagues who would say “no way” and my younger colleagues who would say “time is time”. Do I bill like a lawyer or an accountant who charges for their time or do I bill like an old-time physician who charges for a service? Or, as one would imagine, is there some combination of service and time which goes into this fuzzy world of billing? Emails take time. Phone calls take time. Faxes take time. Prior authorizations, letters for insurance, letters for school, they all take time too. Sure, billing for my time makes sense. Time is limited. I have to figure out a way to use it most efficiently and effectively. On the other hand, there is a service aspect to what I do, which would get lost if every minute was “on the clock”. It is a tough question. I have to think about it.
Posted by Dr. Vollmer on February 23, 2011
“When is she ever going to grow up?” Arline, the mother of Jolie, age eighteen, asks me, with a tone of frustration, impatience and anger. “ADHD tends to cause a three-year lag in emotional development,” I try to explain to her in a flat tone to say that Jolie is going through a slower developmental trajectory than the average child her age. “Yea, but look at her,” Arline continues, “she is not motivated to do her homework. She is texting all the time. I mean all the time.” Arline continues with her frustrated tone. “I think you should use an incentive program for her to do her work, but at the same time, I think you need to understand that she is a late bloomer, so you need to have some patience with her development.” I try to explain in a way which is supportive to Arline and Jolie at the same time.
Developmental change, the rate of development, is a variable in personality which is hard to contemplate because we cannot measure it. I imagine that the brain is developing, along with the other organs in the body, and as such, the DNA instructs this rate of development, as it does for height. Everyone grows at different rates, but most people stop growing around twenty. The rate at which people achieve their final height varies. Some people are done at twelve, whereas others are still growing in college. Girls tend to start their growth spurt before boys, and they tend to stop growing before boys as well. Brain development is probably similar. Girls mature before boys. In general, they reach their developmental milestones earlier. They develop speech sooner. Girls, in general, are not smarter than boys, but a three-year old girl who has sophisticated speech seems smarter than a three-year old boy who is still speaking like a telegraph. Understanding that the brain is also developing at a rate which we cannot measure, but we can infer from the type of decisions the person makes, helps us understand that growth is in progress. With this understanding, intervention can be tailored to the person’s developmental, not chronological age.
Arline looks at me and says “do you have children?” She seems to be trying to figure out if I have any idea about her parental frustrations, her worries, and her guilt. “I am happy to answer that question,” I say, “but tell me why you are curious. Do you think that if I have children, then I have a better idea of what it might be like to be concerned about how a child is eventually going to be independent, whereas if I don’t have children, then I would not be clued in to the feelings associated with having a child who is not responsible.” I ask, trying to guess why she is feeling so alone in our session. “Yea, I am not sure you understand how worried I am.” Arline says with deep feeling. “I am sorry if I have not conveyed my understanding, but I feel as if I do understand,” I say, trying to state that although she feels alone, I can feel, at least in part, her trembling anxiety over Jolie’s future. “I am going to think about this slowly developing brain idea, but right now, I don’t get it,” Arline says in a calmer voice. “Think about it,” I say, feeling like Arline is a bit more open, and perhaps more able to accept Jolie’s biology. “It is not easy being a mom,” Arline says with lightness. “Yep, I get that,” I say, mirroring her easy going tone. “There is a lot at play in helping a human being develop,” I say, stating the obvious, but feeling like I need to express the complexity of parenting. “More than I ever thought,” Arline says, allowing us to connect in a warm way.
Posted by Dr. Vollmer on February 22, 2011
Tim Lippe (Ed Helms) is a man who has a painfully undeveloped superego. As Wikipedia says http://en.wikipedia.org/wiki/Cedar_Rapids_(film) “To call insurance agent Tim Lippe (Ed Helms) ‘naive’ is a gross understatement.” As I learned , in bits, about his childhood history, Tim’s character becomes pathetic, sad, and funny, all at the same time. He appears to have no judgment, which made me feel annoyed at him, but then other times, his innocence was both refreshing and charming. He was painfully looking for love and acceptance, which he tried to get by loving and accepting others, in a way which made him look desperate, not in a way that made him generous of spirit and kindness. Tim was a frustrating character, because I felt that if only he had a little more guidance in life, he could have made better decisions for himself. Yet, if he had a more protective shepherd, then this would not be a comedy. The humor, the pleasure in the film, is looking at someone’s life, but not living it. We can see Tim’s collision course; it is obvious and almost amusing to the outsider, yet so dark to the insider. ‘Cedar Rapids’ reminds us why we have such a dark pleasure in making fun of other people’s lack of sophistication. We want to see our own innocence as cute, but the innocence of others as “immature.” This split between the beauty of childhood thought and its subsequent liabilities is a great diversion from one’s own attempt at personal integration. The movie is fun, mostly, stupid sometimes. That’s OK. Better to laugh and cry with Tim, then to look inward and feel one’s own pain, to look at one’s own bad decisions, at least for a while.
Posted by Dr. Vollmer on February 18, 2011
Lilith, twenty, starts to cry. “I wish my brother Xavier (age twenty-two) would stop defending our parents. I know that he has a better relationship with them, but he could be more sympathetic to what I am going through. He just tells me how spoiled I am and I don’t appreciate them, but he knows that they favor him and he knows that when I ask for things, I am not being ungrateful, but they give me a hard time.” “What do you think is going on?” I ask, curious about her perspective. “I think he is mean to me because he has always been mean to me. He has never accepted me in his life.” Lilith says, as if to say that no one ever asked Xavier if he wanted a sibling and so he has punished Lilith ever since she was born. “Do you think you could talk to him about it?” I ask, knowing that she has probably tried many times. “I think he should come in here with me,” Lilith says, almost as if she was reading words out of my mind. “Maybe if the two of you came in together, you could learn to see each other’s point of view, and in so doing, forge a lifelong relationship which is mutually rewarding.” I say, trying not to sound trite, but at the same time, expressing a deep appreciation for the importance of sibling love. “That would be so nice,” Lilith says with tears running down her face. “We have never had a good relationship, but maybe there is still hope.” Lilith says, again, as if she is reading the words straight from my brain. The meaning of this sibling relationship to Lilith seems clear to me. Lilith wants Xavier to validate her perspective that her parents treat them differently. Only Xavier can give her that affirmation, as Lilith believes her parents will never acknowledge the asymmetry. Maybe he will not go there with her, but she certainly wants to try. It means a lot to her. It means her mental health, or so she believes in this moment.
Posted by Dr. Vollmer on February 18, 2011
Posted by Dr. Vollmer on February 17, 2011
Tom, http://shirahvollmermd.wordpress.com/2011/02/16/mobilize/, twenty-four, told me about his new class entitled “The History of the Sixties.” “How old is your teacher?” I wondered, since for some, the sixties does not feel like history. “Oh, he is old, maybe early fifties,” Tom says, oblivious to how I might feel about such a comment. I was suddenly struck that in Tom’s eyes, I must be ’old’. I understand that I am a parental figure in his eyes, and therefore, he sees me as a lot older than he is, but that he might see me as ‘old’ shocked me. My narcissism penetrated my thoughts. I wanted to stop his train of thought and remind him that I am not old, but of course, the conversation was not about me, or my age, but about how Tom is adjusting to being back in school. We returned to his life, his feelings about where he is going, and how he feels he does not measure up to the expectations of his parents. I thought about how Tom might perceive himself as younger than his stated age, given his feelings of inadequacies, and how he might perceive those who have a direction in life to be ‘older’. At the same time, I am aware that age, and feeling a certain age, is so subjective, so fascinating.
Posted by Dr. Vollmer on February 16, 2011
Tom http://shirahvollmermd.wordpress.com/2010/09/15/success-rebellion/ describes painful loneliness and sadness. “You know, sometimes I wonder if your loneliness and sadness are a way for you to get back at your mom to show her what a lousy job she did raising you. I wonder that, unconsciously speaking, you want to maintain your inner pain in order to prove to her that she was an inadequate mom.” Tom looks at me with wonder and some anger over suggesting that he is causing his own pain. “What am I supposed to do Dr. Vollmer? I had a difficult childhood. I had no friends. I had an isolated life. That was my mom’s fault. It is not easy for me to make friends now and I blame her for that.” Tom says through his tears. “I understand that, and I feel for you around that, but at the same time, you are an adult now and you are capable of creating a meaningful social network.” I say, hoping that I am not sounding too harsh, but at the same time, wanting to empower him to change his life. “That is really hard for me,” Tom says with more intense anger. “Yes, I understand it is hard and I understand that your past experience might make it harder, but you are still a bright, engaging young man and you have the capacity to have really good friends.” I say, both reminding him of his strengths and reminding him that he is not using his skills to make his life better. “I will have to think about that Dr. Vollmer, but my mom really did screw up my life.” Tom says, as if trying to convince me. “Yes, I understand that is how you feel, but hopefully she did not paralyze you. You can mobilize yourself into actions which will help you feel less lonely.” I say, not thinking too much about my choice of words. “Mobilize,” Tom says, “that is an interesting choice of words. It makes it sound like I have to prepare for a fight, like in the army.” Tom says, free associating to my comment. “I guess that is what it feels like for you,” I say, implying that although it was my choice of words, he took the word ‘mobilize’ in a direction that I did not expect. “Let the battle begin,” Tom says with good humor and calmness.
Posted by Dr. Vollmer on February 15, 2011
Susie, forty-one, feels abused and persecuted by Zane, forty-eight. Zane tells Susie that she is “stupid” and “slow”. Susie does not respond. “What am I supposed to do?” Susie asks me. I love Zane but I hate the way he treats me. “Maybe you can do some pushback,” I say, wondering if she has ever considered that. “Well, yes, I know I need to set limits on him,” Susie says as if she has talked about this issue with a previous therapist. “So, what gets in your way?” I ask, thinking about what she is going through. “I just retreat,” she says with a great deal of sadness. “You retreat because you feel helpless and ineffective,” I say, gently reminding her that she is not helpless, but that she feels helpless. “What if you said that words like ‘stupid’ and ‘slow’ are unfair fighting words and that if Zane wants to help you understand your behavior you are willing to listen, but if he is going to use nasty words, then you are going to walk away.” I say, trying to help Susie have words to set limits with Zane, but at the same time, remind him that she is willing to engage in a constructive discussion about their relationship. “When you say it, it makes so much sense, but how am I going to be able to say that in the heat of the argument.” Susie says, reminding me that rational behavior often gets cast aside when a deep relationship is threatened. “Write it down and keep it in your pocket,” I say, trying to lighten up our discussion, but also being somewhat serious at the same time. “Well, I like the word pushback, so that part I can remember,” Susie says, feeling somewhat encouraged and empowered by our discussion. “Communication involves strategy, so keep that in mind,” I say, thinking about the executive functioning of the brain and how important it is to use higher level thinking when engaged in important conversations. “Easy for you to say,” Susie says as she leaves, half smiling, half serious.