Unpacking An Obsession

Abie, fifty, stopped obsessing over me, her therapist, but remained in twice weekly psychotherapy. “I feel so empty now that I don’t think about you all the time,” she reports. “So, the obsession was masking an emptiness,” I said, repeating her idea, but giving it to her in the reverse way. “I don’t think the obsession was masking an emptiness, but when I was obsessed with you my head was busy with happy thoughts, and now I just feel nothing.” Abie says, as if we are trying to figure out a puzzle. “So, what stopped the obsession?” I ask, wondering if I should already know the answer to that question. “You know, ” she responds, reminding me that she has mentioned this before, but also reminding me that her answer has never held together for me. “You hurt my feelings when I confessed my obsession because you told me that I was obsessed with you and in that moment I was humiliated so I stopped obsessing, but I still enjoy coming to see you.” “So, even though you agreed with the word ‘obsessed,’ it still hurt you deeply that I used that word.” I said, understanding why her explanation was so hard for me to remember. “Yes, I know it does not make sense, but that is how I felt.” Abie says, reminding me that constant humiliation was a theme of her childhood. “So, the obsession made you happy, but calling it obsession stopped the spell.” I said, trying to understand this dynamic. “Yes, that is exactly right.” Abie replies with enthusiasm. “And you have not found a replacement obsession?” I ask, thinking that she might have transferred that energy on to another person. “Right, I am looking, but I have not found it. However, I do obsessively record every movie I see, but of course, that is not the same thing. Still, I started doing that after I stopped being so focused on you.” Abie says, again, struggling to understand how her brain travels through time. “I know I have to go, but I have to say that although I am not obsessed with you, I still think about you from time to time,” as if to reassure me that I am still important to her. “Vice versa,” I reply.

Therapy Fear

“I am afraid to go to therapy. I am afraid you are going to make me feel so bad about myself. I am afraid I will lose all of my confidence if I start seeing you on a regular basis,” Zoey, thirty-three says as we discuss that psychotherapy may be an important addition to her psychopharmacology for her treatment of her mood disorder. “It is that fear that makes me think that psychotherapy makes sense. Confidence, that quality in which you feel good about yourself, is what is missing from your life. Your fear that psychotherapy could diminish your sense of yourself speaks to the fragility of your self-esteem.” I say, knowing that Zoey will click in to what I am saying. “Yes, that’s true. I see that.” Zoey says with her typical candor and openness. “Still, I don’t want to think I need that.” She says, implying that she is able to accept that she needs medication, but that her associations to psychotherapy are negative and scary. “Sometimes things have to get worse, before they get better,” I say, knowing that I am stating the obvious, but also knowing that the obvious helps us lay out the psychological barriers to treatment. Zoey changes the subject, or so it seems. She talks about how she is getting involved with a new political passion. “Maybe you have transitioned to talking about your new politics as a way of reassuring me that you are engaged with life and thereby not needing psychotherapy.” I say, thinking about how our conversation shifted. “Yea, you are right,” Zoey readily agrees. “I do need therapy. I just don’t want to think about that right now.” “I love your candor,” I respond, feeling a fresh breeze in the air.

Mockery

Brenda, forty-three, mocks my behavior, with a tinge of aggression, mixed with a tinge of humor. I put my feet up, so she does in an exaggerated way. I scratch my head. She copies me. Understanding this mockery is my challenge. The asymmetry of our relationship challenges her to try to feel important, and not so vulnerable. Mocking me is one way in which she can feel more in control. “Sometimes I think you mimic me because you feel so much smaller than I am.” I say, using the word smaller to imply a feeling of being psychologically little, or immature. “I just think it is funny to copy you,” Brenda insists. “Yea, but you are so keyed into my every movement that it seems to me that you are trying so hard to feel good, yet in here, you feel like you are so exposed, causing you to counter that vulnerable feeling with a feeling of mastery.” I say, repeating how hard it can be to talk about one’s misgivings about oneself. This time, Brenda begins to reflect on my comment, because now she is no longer fixated on my movements, but rather, she becomes overwhelmingly sad. “I just feel like I am never going to get out of this mess,” she says with profound despair. “What do you mean by this mess?” I ask, curious about her choice of words. “The mess of my internal world,” she says, as if it is obvious what she meant. “You mean the bad feelings that you carry around with you each and every minute which makes you feel confused and judged all of the time.” I respond, bringing back previous discussions of her emotional interior. “Yes, that mess,” she says with hostility, as if she desperately wants to eradicate her internal self. “So sometimes you feel aggressive towards yourself, and sometimes you take that aggression and turn that into mocking me,” I say, bringing the concept of aggression and mockery back to our initial discussion. “Yes, I suppose,” Brenda says as if she has just begun to see how feelings can manifest in words such as “this mess” as well as actions such as mockery. “So I will see you tomorrow at 9,” mocking my habit of restating our next appointment at the end of the current appointment, even though we are both very aware of our schedule. “Very funny,” I reply, with a nod of recognition of the thread to our session.

Feeling Used

Monte felt used by Marla again, only this time, the drama unfolded years after the event. Marla, the senior mentor/advisor encouraged Monte to pursue medical student education to encourage more medical students to go into psychoanalysis. Years later, Monte finds out that Marla received funding from a benefactor which was going to support medical student interest in psychoanalysis, such that Marla then received an award for spearheading a medical student program. In essence, Monte feels that his work was used to give Marla recognition. “It is the old story,” Monte tells me. “The old story where the little guy does all the work and the big guy gets all the credit, but in this case, I was unaware of Marla’s motivation until now, which is years later.” Monte tells me with both understanding and dismay. “You use Marla as a way to beat yourself up,” I repeat, over the years that for Monte, Marla has become the relationship in which Monte continually feels bad about himself. “Yes, I can see that,” Monte says, without a sense of relief, but with a sense of cognitive understanding. “I can see how my trust in Marla has led to one betrayal after another, but that I keep going back for more.” Monte says, again showing an intellectual understanding without the emotional understanding which would make Monte separate from Marla. “It takes time for you to feel that you deserve relationships which are more respectful of your time and energy.” I remind Monte, to help him see that he cultivates relationships in which the other person treats him how he feels he deserves to be treated. “Yes, it takes so much time that I think I will be dead by the time I figure it out.” Monte says in despair. “I hope not,” I remind him, but I also appreciate how long Monte’s painful  journey with Marla has been. “Moving forward is painful because you have to look back and feel your mistakes.” I say, trying to convey this understanding of how challenging personal growth can be. “I resist that,” Monte says. “I don’t want to look back, so maybe I can’t move forward.” “Sometimes you can and sometimes you can’t,” I say, reminding him about the changing nature of his mental state.

Living With Depression

Neha, sixty-one, female, says “I can’t stand going home. I hate being there because my husband of forty years just sort of creeps around the house. The vibe is really bad. The feeling is so empty.” “Is this a new problem?” I ask, thinking that the chances are high that over such a long-term marriage, Neha has faced this issue before. “Well, for years, we were busy raising children and then our parents became ill, but now that we don’t have so much stress in our lives, I really feel the emptiness.” Neha explains in a narrative which conveys that the problem has always been there, but now it is unmasked because there are no pressing responsibilities on them. “What happens when you confront Jason, your husband,” I ask. “He gets a down look on his face and so he makes me feel like I just ruined his day, but on the other hand, I don’t know how things will get better unless we talk about it.” “Is he open to treatment,” I ask, wondering if psychotherapy and/or psychopharmacology would help. “Yes, he is open, but frankly, I don’t know how optimistic I am that it will help.” Neha tells me, with despair. “It must be so hard to live with him,” I say, bouncing a way for a moment from a practical recommendation to a sense of empathy for Neha. “Oh yes. I don’t know what to do,” Neha repeats her sense of hopelessness and fear that things will never get better. “Getting him into treatment might help,” I repeat, giving her the reminder that depression is a condition which is treatable and there is a way out of her current situation. Neha looks at me with skepticism, along with a willingness to discuss intervention with Jason. “I think we are going to have a tough evening.” Neha says, knowing that sometimes things have to get worse, before they get better. “Yes, change, of any sort, but particularly changing a mental state, is a daunting prospect. “I guess it has helped me,” Neha says, recalling the hard times she has had in her own life. “Yes, remember that, as you discuss it with him.” I say, relieved that Neha has connected her journey with that of her husband’s, thereby developing more patience with him.

Re-Posting From “Shrink Things,” Since He Calls Me A “Shrink Blogger”-Posting From WG-Wounded Genius

Weekly Psych Rounds 22-06-12

http://shrinkthings.wordpress.com/2012/06/22/weekly-psych-rounds-22-06-12/

The Animal Story

Toobie, a seventy-year old female, saw a dog lying on the street. In her attempt to rescue the dog, the dog died at the scene. Toobie narrated this sad tale adding in personal responsibility and overwhelming guilt. She was sure that if someone else had tried to rescue the dog, the dog would have survived, even though she called for help, which is what anyone else would have done. “You know, I have never gotten over watching helplessly as my mother died from Huntington’s Disease thirty years ago, and I think seeing this dog die brought back all of those horrible feelings. “Maybe it is a really good thing that you saw the dog in distress, because maybe finally, that gives you an opportunity to work through the overwhelming guilt that you feel over your mom’s passing,” I say, feeling so positive that she could connect the dying dog to her dying mother without me having to make that link. Toobie looked at me with palpable relief. “You get it. You really get it.” Toobie says, expressing her trepidation over telling me the story. “Everyone else tries to reassure me that I did everything I could for that dog, but I know that is not the point. I take every opportunity to feel bad about myself.” “Yes, you are very good at that,” I say, chuckling together. “Maybe it is time to become less good at that,” I say, again seeing the relief in her eyes as we discuss this very painful event. Tears flow rapidly now. Toobie says, “you know I just can’t forgive myself for what happened with my mom.” She has already told me that her mom was dying and even though her mom insisted on no heroic measures, Toobie feels horrible that she did not disobey her mom’s wishes. “Further,” Toobie continues, “my brother is angry at me over my mom’s death, as well.” “I know,” I remind her, “he has never coped with her passing and so he takes his bad feelings out on you,” I say, reviewing previous painful conversations. “You see, that dog on the street has really helped our work. We have this opportunity to explore these bad feelings which stay so alive for you, all these many years.” I repeat, wanting to emphasize that sometimes triggers can be very helpful. “I hope so.” Toobie says as she leaves.

Love and Aggression

 

 

Billie, fifty-nine and female, was brought up in a strictly religious household where girls were supposed to be nice and boys were supposed to be wild and aggressive. Billie’s desire to be a tomboy, perhaps fitting her name, did not go over well with her mom. She was constantly told that getting angry was not “nice” and that she needed to be ”nice.” Consequently, when Billie gets angry at her friends, she is filled with guilt and despair. Internal feelings of aggression are so uncomfortable for Billie that she never outwardly experiences a sensation of anger or frustration. Yet, at the same time, she has many sleepless nights where she experiences fantasies of killing her friends, yet she denies any conscious disappointment with them. “It is really hard for you to deal with aggression,” I say, using the word aggression as a short-hand for all of the negative feelings that arise in close relationships. “I suspect that you were never given permission to experience hostility and so now that you are an adult, you are confused by your feelings.” I say, thinking about just as children need to learn to read as youngsters, so also, they need to learn to begin to understand their emotional interior. Without a space to learn feelings, children grow up without the tools to deal with a range of emotional experiences. This lack of exposure to feelings is one kind of emotional deprivation which can have life-long consequences. In other words, trusted adults need to help children translate their behavior into feeling states. For example, I explain to Billie that if a child hits a parent, the parent can say  “you are angry and that is why you are trying to hit me, and it is not OK to hit me, and yet I can understand your anger.”  These kinds of narratives begin to help a child understand that his desire to hit the mother he cares deeply about,  is a function of an angry feeling state. The feeling is understandable, but the behavior is unacceptable. Without this narrative, a child may be confused as to why he feels like hitting his mother. The child knows he loves his mother, but he also wants to hit his mother. This juxtaposition of love and hate needs to be sorted out, with help from the parent. Billie, it seems, never had an explanation for why she wanted, at times,  to hurt the person she cared most about. As such, she is haunted in the evenings with disturbing fantasies that confuse and disturb her. “I hope I can get over this,” she says, with despair. “I hope so too,” I say, mirroring her wish to have a better state of mind.

Stuck

Getting stuck in treatment presents the question of who is stuck. Clearly, both the patient and the therapist are in a box, as all of the treatment is dependent on this dyadic interchange. The valence around this stalemate is often frustration, but it can be boredom or despair.  Frank, a fifty-three year old patient, started each session by saying “I don’t know what to say.” The therapist, Fred, reacted differently each time. Sometimes he would wait. Other times he would bring something up that came to his mind. Still, other times, he would say “that is interesting.” Each comment was met with silence. In a psychoanalytic sense, this reluctance to engage, and yet still show up for psychotherapy, is the classical approach/avoidance in which someone has mixed feelings about entering into a psychologically vulnerable state. Fred’s job is to try to understand both the need to approach and avoid the psychotherapy at the same time. In this endeavor, both Fred and Frank are going to develop feelings about the process. A “stuck” feeling is a challenge to move the understanding of the conflicting forces of engagement to a deeper level. Eventually, Fred decided to say “you know, I am really stuck. I don’t know how to go further in our relationship.” Frank, relieved at Fred’s willingness to be so honest said, “yea, I know I am a lot to deal with, and I have been waiting for you to fire me.” This disclosure of Fred’s painful belief that he is “a lot to deal with,” opened their relationship to explore Fred’s deeply rooted negativity about himself. The glue was dissolved, such that Fred now feels the relationship is more fluid. Frank feels better too.

The Cheap Friend

Maya comes in fuming about Lauren, age fifty-two. Lauren’s relationship to money, like her relationships to important people, speaks to a certain amount of withholding and selfishness. Maya, fifty-one, complains to me that her dear friend Lauren is “incredibly cheap.” “We go out to dinner and she always has to use a coupon, and then she never wants to contribute to the tip, and then, she thinks it is fun if we can go to an event, even one we don’t care about, if there is free food. I just hate it,” Maya continues. “I hate that each time we hang out, the focus becomes on how we can get something for free or for very low-cost. I just want to connect with her and have a really good conversation, whereas she is focused on having an evening where she can then brag about how she got something for a really good price.” “Is this a new problem?” I ask, knowing that Maya has been friends with Lauren for at least the last fifteen years. “No, but it is getting to me more. Now, I know you are going to ask me why I have become more sensitive to this, and of course, I have been thinking about that. My hunch is that as I get older, I am more and more focused on enjoying my relationships and so this makes me less patient with my friends and family who seem to be so neurotic that it detracts from our connection. Lauren may be having a good time, but I am not and Lauren knows that I don’t get pleasure out of getting something for half-price, so I see Lauren as being a bit selfish in those moments.” I pause to reflect on Maya’s analysis of her upset. “It sounds like you are saying that Lauren’s constant search for a bargain is a narcissistic act and as such, it takes away from the intimacy of your relationship.” ”Yep,” Maya enthusiastically agrees with my re-stating her understanding of the disappointment that she experiences when thinking about Lauren. “I suppose you could talk to Lauren about this, or you could assume that this is an irritant to you, but that you will put up with it, given all of the other goodness that she brings to your life.” “Yea, I know that, but I am not sure what to do,” Maya says, acknowledging that she has already thought about whether to confront Lauren or whether to suck up her discontent. “Friendship can be hard when narcissistic forces dominate the interaction.” I say, making an overarching comment, not specific to Maya and Lauren. “Yea, I don’t think her cheapness dominates our relationship, but it certainly gets to me,” Maya says, reminding me that she has maintained perspective with regards to this irritant. In this session,  Maya has done most of the psychoanalytic work, while I sit back and appreciate her reflecting on this important friendship.  I have a deep sense of pride that I have helped Maya analyze her dilemmas in a way which is both balanced and authentic. It was a good day.