The Angry Friend: Continued

See….http://shirahvollmermd.wordpress.com/2011/07/22/the-angry-friend-2/

 

Shai and Claire, girlfriends for forty years, now in their sixties, just “broke up” Shai tells me with sorrow. “Claire is just angry all the time. It is not my fault that her life did not turn out the way she wanted it to, but she seems to take that out on me and I can’t take it any more. ” I think about unconscious anger, the anger that comes out with the smallest frustration. The anger that seems so disproportionate to the situation. This is the anger that Shai describes in Claire. “Has it gotten worse over the years?” I ask Shai. “Well, it seems to. It actually got worse when I stopped being so accomodating. I used to dance around her anger and try to do things that made her happy so she would not get angry, but it turns out that I always felt like I was disappointing her no matter how hard I tried. ” Shai describes the frustration of what felt like to her to be a one-sided relationship which now she seems to have reached her limit. “It sounds like you feel like you made the right decision about ending the relationship.” I say, detecting Shai’s resolution that she had lost her patience with Claire. “Oh, absolutely, I feel like I made a good decision, but I am still sad about it,” Shai says. “It is like a break up of a romantic relationship. You may have decided to end it, but that does not mean that you are not suffering terribly.” I say, highlighting that friendships can be more intense than long term sexual relationships. “Yea, I feel like I am suffering quite a bit. I am angry with myself for not ending it sooner. I put up with her anger for years.” Shai says, reflecting back on her tolerance for hostility, which she believes decreased the quality of her life. “Why do you think you put up with it?” I ask, wondering about her perception that this was a masochistic relationship for her. “I think that I felt close to her for so many years that I did not want to lose the relationship, so I tried to tell myself that her anger was not so bad, but it was. She sucked me dry. Every time I was with her, I just felt her anger so strongly that it made me really unhappy to be with her. At the same time, we are fond of one another, so it was hard to balance out these conflicting factors. Nevertheless, I feel like life is too short to feel that anger, so I want to move on.” Shai says, with torture in her voice, since she sounds less certain that she is making the right decision. “Why don’t you see how it feels to not talk to her for a while, and then decide if you want to get back together or not?” I say, trying to help her see that time may or may not change her opinion, but she should stay open to that. “I don’t know. At this moment I know that her anger just grates at me, so I can’t take it.” Shai repeats, with the gravity of knowing that long-term friendships cannot be replaced.

Metabolizing Anger

Larissa, fifty-eight, got angry at her son for not telling her that he was engaged. Paulene, thirty-three, got angry with her best friend for not calling her back. Luke, sixty-two, got angry with his wife for “never being home.” Each one had a similar philosophy, which was, in essence, “what can I do?” To which, I respond, “you can metabolize your anger. You can see your feeling state as a journey in which if you focus on your feelings you can then understand what it is that upsets you, such that over time, you can make a good decision about whether to confront the other person or not.” I say, with each one looking at me as if the word “metabolize” does not belong next to anger. I strive to describe a process in which there is an internal path which is set off by a hurt feeling. This path gives one information about oneself as well as about the “other.” If one begins this contemplation, with the understanding that over time, new ideas, new feelings, will rise to the surface, then one begins a journey of curiosity and exploration. By contrast, feeling helpless, feeling like one has to accept the hurt, pushes one’s internal state out of awareness, making one vulnerable to unconscious acts of hostility and revenge. Larissa refused to contribute to her son’s wedding, although she denied that her withholding of money was related to her hurt feelings. Paulene did not go to her friend’s birthday party, but again, denied that her absence was related to her friend’s unresponsiveness. Luke “forgets” his anniversary. Understanding feelings, allowing  time and reflection to attempt to sort out internal and external factors, deepens one’s sense of oneself, and thereby humanity. Like food going down the esophagus, and  ultimately, in a different form, coming out the anus, feelings need to be digested and the toxins need to be expelled.

Re-Posting Because of Today’s LA Times: Father Boyle

Today’s LA Times….http://www.latimes.com/news/opinion/commentary/la-oe-newton-column-homeboy-industries-greg-boyle-20120423,0,5754852.column

Father Gregory Boyle, a jesuit priest,http://www.npr.org/templates/story/story.php?storyId=3911907 , and http://latimesblogs.latimes.com/jacketcopy/2010/06/father-boyle-la-times-bestsellers.html reminds me of my earlier post  http://shirahvollmermd.wordpress.com/page/16/. Father Boyle knew intuitively that when gang members can find an alternative sense of belonging they can find a new way to be in the world. He proves, through his life’s work, the value of attachment. He invests emotional energy in “kids” who have never ”experienced dignity before.” By dignity, he means that when one begins to respect the individuality of these gang members, then the adolescent can change their lives and contribute to society. He gives them work skills and in so doing he proves to the ex-gang members that they have hope to make their lives better. In my mind, he re-parents these young adults such that these youngsters can “navigate the treacherous waters of their lives.” As Father Boyle says “people say I give them a second chance, but I say, it is really a first chance.” “Gang members are coming from a place of despair” he says. Without formal mental health training, Father Boyle recognizes the essential need to have a family that instills hope in the future. He teaches coping skills, parenting skills, and responsibility such that they can deal with the challenges of their world. His work inspires therapists to work on a one on one basis to change lives, by believing in their client, such that the client can eventually change course and live in the world in a new way. Inspiring.

Nature or Nurture: Will The Debate Ever End?

   Daniel http://shirahvollmermd.wordpress.com/2012/02/07/the-aggressive-child/ is out of control in that he throws chairs when he gets frustrated with his video games. He punches his mother when she asks him to do homework. Is the problem a parenting issue or a mental health problem or both? Although seemingly complex, the issues become straightforward. All children, especially aggressive children, need to have very clear limits: a “holding environment” as Winnicott has taught us. By clear limits, I mean that Daniel has to be told that hitting is not acceptable. He needs help to use his words when he gets frustrated. He needs to be exposed to video games which are age-appropriate. He needs to have guidance with self-regulation when it comes to eating and sleeping. The parents need to make sure that he eats well and has a regular bedtime. They also need to make sure that the school is attending to his academic and emotional needs. Finally, they need to make sure that Daniel is exposed to playdates so that he has the opportunity to learn social behaviors from his peers. When all of this is in place, and Daniel still has problems with frustration and aggression, then the discussion about diagnosis and medication management needs to begin. It is not that Daniel’s parents are responsible for Daniel’s aggression, it is that Daniel’s parents can provide the basic nurturing environment such that we can see that even with a clear “holding environment” whether Daniel can control his impulses. It is hard to know if Daniel can control his impulses when the environment is chaotic and unpredictable. In this latter circumstance, many kids, with or without a mental illness, become anxious and physical. I think I am stating the obvious, and yet controversy ensues. What am I missing?

Relationship Drama

      Joe, twenty-two, Jaclyn, also twenty-two,  just had a big fight in their apartment in New York. Jaclyn was throwing dishes at him. Joe was telling her she is “crazy.” Jaclyn, by her report, goes to see a psychiatrist shortly thereafter and she is diagnosed with bipolar disorder and placed on the mood stabilizer Lamictal. She calls her parents who are “very uncomfortable with mental health care,” as Jaclyn reports, and they begin to embrace this diagnosis. They read about it. They tell their friends. They give her a lot of support now that they see her issues as “medical.”  A few months later, Joe and Jaclyn go at it again. This time, Jaclyn wants to come home to Calabassas. I see Jaclyn and I question her bipolar diagnosis. “It seems to me that you had stress in your relationship and you became violent. I am not hearing any other history of bipolar symptoms,” I say, thinking that this is a common problem, where heated emotional moments in a young person get characterized quickly as bipolar disorder; at least that is the way it seems to me, of late. ”I am hearing that you and Joe were hurting each other feelings, and one time you responded to those hurt feelings with violent behavior.” I say, trying to show Jaclyn that her behavior might be a result of her pain in the relationship, and not necessarily a chronic mental illness.

     Serena and Enzo, also both twenty-two, also just got in a big argument, where Serena was physically attacking Enzo while he was driving. ”It was dangerous and scary,” Serena reports to me. “I just lost it with him. I was so mad. I asked him to take me home, but he wouldn’t so I started to hit him. I just could not control myself.” Serena tells me with some regret, but also with a sense of justification. In the past, Serena has been diagnosed with Borderline Personality Disorder, but I did not agree.  As such, I said,  ”it sounds like you were so disappointed that you needed Enzo to see how you were feeling, and that you wanted to go home, such that when he ignored your plea, you became very frustrated. That frustration, led to violence, which you used to do as a small child towards your siblings, and now you are doing it with Enzo.” I say, trying to help Serena understand that she was in pain because of Enzo’s poor responsiveness, but her tendency towards violence, seems to stem from patterned behaviors which she did as a child. ”In other words,” I continue, “this episode with Enzo, where he did not listen to you, reminded you of so many times when your mom did not listen to you, such that in the past you would have taken that frustration out on your little brothers, here you took it out on Enzo.”   

   The quick trigger to diagnosing bipolar disorder, or personality disorder in young adults often stems from the heated nature of their relationships. Both Jaclyn and Serena acted strongly to hurt feelings within the context of disappointments with their boyfriends. This strong reaction does not give evidence of a psychiatric diagnosis, but rather the reaction sheds light into the psychodynamics of Jaclyn and Serena. They are each acting out the past and the present, within the framework of a loving relationship. Their behavior helps me to understand how their minds work in the event of stress and disappointment. It does not give me reason to think that they are mentally ill. Young people are new to relationships, and as such, they bring an intensity which often leads to the roller coaster quality of their dynamics. Time, experience and maturity tend to mellow them out with age. The diagnoses do not disappear as they enter the next developmental phase; this is the value of waiting to see how the next chapter plays out before placing a diagnostic label on an emerging adult. My hunch is that both Jaclyn and Serena will be fine. They are struggling with how to maintain love in their lives, while still feeling strong and valued. I admire their energy in defending their sense of themselves, even though this energy may be misplaced at times. These tender relationships will shape their emotional lives; it is my privilege to be on the sidelines.

The Tardy Patient

   Lateness is an interesting phenomena. Some folks are chronically late, whereas others are always on time. Typically, patients are one or the other. Few people in my experience are occasionally late. Of course, there are issues of traffic and parking, but prompt folks allow space for that, and tardy folks always feel surprised by those factors. Talking to tardy patients about their tardiness usually makes them defensive. I often hear “well, you get paid the same, why do you care?” My response is often, “no one likes to be kept waiting,” although I say that, knowing that this is not new information. I am also aware that the hostility in the comment might need to be addressed.

    Cynthia, sixty-four, is consistently twenty minutes late. She is neither hostile or apologetic, but rather she laughs at herself as she walks in, while she says, “I think of your start-time as a suggested time, rather than an actual time.” She then launches into her concerns about her marriage, and how troubled she is by her relationship. I think about addressing her lateness, or dealing with the issue that she presents to me. Most of the time, I dealt with the subject that she presented, but after ten years, I wanted to discuss her time management issues, even though she did not seem particularly concerned about her use of our time together. As I suggested that her tardiness affected our ability to talk about her problems, since we have less time to do that, she responded with intense anger. “You know that I am always late. You know there is nothing I can do about that. You have known this for ten years. Why are you picking on me now? Do you want to get rid of me as a patient?” Cynthia says, looking deeply hurt that I confronted her. “I do feel that our relationship can handle this confrontation. I wanted to talk about your tardiness for a long time, and I thought that since your life was relatively stable, this would be a good time to talk about that.” I say, knowing that Cynthia is feeling fragile since I held up a mirror to her tardiness.

   ”If I came on time, would things be better?” Cynthia says with hostility and sarcasm. She is implying that more time with me would not be more helpful. “I don’t know, but we could try that out.” I say, trying to explore her ambivalence towards me. “I am not happy with how our relationship has changed.” Cynthia says, referring to my confrontation about her time management. “I can see that,” I say, wondering how this chapter in our long relationship will play out. My inserting this agenda into our session had a bigger impact than I had imagined. Upon reflection though, I can see that Cynthia’s chronic tardiness must be deeply rooted in chronic pain which causes her to avoid getting help from her therapist. Her defensiveness supports that conclusion. I hope we can work our way through this. Time can be a sensitive subject.

The Angry Friend

Claire, sixty, calls her girlfriend Shai, opening the conversation with ”you didn’t call me back.” Shai did not know that she owed Claire a phone call and besides that, she was annoyed at the hostility directed at her. They had a short conversation, followed by Shai calling Claire back and opened the conversation with  “I felt like you scolded me.” Claire, completely taken aback, says “what are you talking about? I thought you were going to call me back and you did not and so I called you.” Shai, knowing that she did not say she would call Claire back said “well, first of all you did not listen to me when I told you I was not going to call you back. Second, it is hard on me when you start a conversation in such a hostile tone.” Claire, again, shocked by this discussion continues to be defensive, “gee, I don’t know how else to put it. You did not call me back and I thought you would.” Shai, amazed at Claire’s lack of social skills, says “the problem is your tone is very hostile.” The conversation took a major shift. Claire replied, “I do feel angry that people don’t respond to me, but I did not know I was expressing that in the phone conversation.” Shai, immediately warmed up to Claire. “I can certainly understand how bad it feels not to be responded to.” Shai has now changed from feeling contempt for Claire, to very bonded with her feeling that she is dangling in the world without a feeling of being important to someone. By the end of the conversation, Shai and Claire were really glad they were friends. Shai ended the conversation by saying “it is so nice to be able to be real with someone. Most of the time, I just suck it up when someone hurts me, but you and I have been friends so long, I did not want to carry around this resentment. I am really glad I called you back.” Claire agreed heartily. Once again, anger was a passing stage from a bond almost breaking to a bond deepening.

Angry Patients

 

 
   Karen, sixty-two, sees me twice a week, like clockwork. Recently, I had to change one of her times, an action I resist, but I had no choice. “That’s OK, I will just come one time next week. It does not matter.” Karen says, with hostility that hits me in a way that is consistent with her quiet way of being angry. The following session she says “I don’t know what to talk about,” again, I am feeling a passive-aggressive feeling where she resigns from initiating a discussion, but she is mad that not more happens in psychotherapy.

      ”I have been thinking about our last session,” I say, making her look surprised. “When I was sorry to have to change our schedule, you said it did not matter and that made me think that you were angry.” I said, expecting her to be taken aback by my comment, but instead she said “of course, I am angry. Wouldn’t you be?” “I am not sure what you mean,” I say, knowing that Karen’s style is to obscure what she is talking about by not telling me her entire thought. “My life is ruined. My husband walked out on me. My kids are doing their own things. I am old. I am fat. I am lonely. Of course, I am angry.” Karen says, with tears running down her face. The tone changed dramatically. Her sadness came through after her anger subsided. Instead of feeling devalued by Karen, I began to feel her pain. She was struggling and her anger was her defense.

   ”I can see why you are angry,” I said. “It seems like your life is not what you expected it to be; not what you want it to be.It also seems like you don’t feel much hope that you can make it better.” I said, feeling like I was understanding her feeling state. I began to learn more about her childhood, as she told me how she felt her life was going to turn out when she was growing up. She wanted to share with me how she felt about her mom and dad. I felt like we surprisingly opened up a new chapter in our relationship. She did not seem angry. She was comfortable sharing her history. Anger is pretty interesting; there is always some deeply meaningful material behind it. Anger, to me, feels like a door. Sometimes they are hard to open, sometimes pretty easy, but either way, when you can get in, there are rooms to explore.