The Nightmares

Madeline, fifty-two, a psychotherapist, comes in after having a “terrible night.” “I just had one nightmare after another,” she reports with utter helplessness. “Tell me about it,” I say, knowing that she was going to, but also wanting her to know that I was curious about the content. “I dreamt I got my period and then I was bleeding non-stop. I think it was like I was having a miscarriage, which I have had in the past. It was like I was reliving that horrible experience, even though that was thirty years ago.” Madeline says, offering up an interpretation of her nightmare. “Do you have any idea why it came to your mind last night?” I ask, wondering if something had triggered her. “Yes, my son is leaving for his semester abroad and I think that is triggering feelings of loss inside of me.” Madeline says, clarifying the connection between her dream and her present state of mind. “Dreams are powerful tools that remind us what we are dealing with internally.” I say, stating what she already knows, but still feeling compelled to say it. “Yes, but I did not like waking up so upset,” Madeline says, as if reminding me not to intellectualize her distress. “Of course not. I am sorry about that.” I say, reminding her that I feel for her. “And what were your other nightmares?” I ask, reminding her that I was thinking about her opening remark. “I also dreamt that I had sexual intercourse with one of my former patients and I was horrified at my behavior.” Madeline says, with some shame, but also knowing that this was a dream, and hence she has no conscious control over the content. “Again, I wonder if you have an idea about what that was about.” I say, knowing that she is aware that I want her to take her dream one step further. “Yes, I think that my eating is out of control and I am mad at myself for gaining weight, so  this dream was in line with that.” Madeline says stringing her anger at herself for her eating together with her anger at herself in the dream. “Your self-hatred came out at night.” I say, repeating her idea, to let her know that I am thinking about what she is saying. “Your internal world is pretty black right now,” I say, ending our session with a summary comment. “You got that right,” she says, leaving a little bit less distressed, compared to the beginning of our session.

Feral Cat

Ursula, forty-one, has been orphaned since she was sixteen. Both her parents were killed in a car accident, leaving her to the care of her not-so maternal grandmother, who then passed away when Ursula was twenty-one. For the last twenty years, Ursula has had menial jobs, “getting by” as she says. Ursula, to her surprise, met Patrick, forty-five, ten years ago and now they have been happily married for ten years. Ursula’s issue is with Patrick’s parents. She feels them to be ”abusive” to Patrick, since they sometimes comment on his life’s choices. “I feel like a feral cat,” she says, “since I can’t really remember having parents, I am not sure what role they play in adult children’s lives.” I begin to think about her “feral cat” comment. When are parents helpful and nurturing and when do they become intrusive?  How does an adult child take in the advice of parents without feeling shamed and bewildered? Is the issue one of self-confidence? If Ursula were more internally secure, then maybe she would be more appreciative of the support offered by Patrick’s parents? Or, are Patrick’s parents trying to ground themselves by latching on to the lives of Ursula and Patrick? “Tell me more” I say, in characteristic fashion. “They think that Patrick should shoot for a better job and I think it is not their business.” Ursula says with a tone of self-doubt. “I mean, I agree that Patrick could do better, but that is for Patrick to decide,” Ursula says, almost inviting me to argue with her. “What if we entertained the thought that Patrick’s parents have a point. Maybe they see a problem and they want to prod Patrick into a more challenging job.” I say, trying to examine this issue from all sides. “That is what confuses me. Maybe that is true, but I just don’t understand parents. I am not a parent, so I do not understand that relationship.” Ursula says, with humility and confusion. She also points to her own sadness for her losses. “Maybe, you feel envious that Patrick have parents who think about his life, and maybe it is just so painful for you to think about what you don’t have.” I say, treading lightly on a profoundly difficult subject. “Maybe,” Ursula says, as she cries deeply.

Re-Posting: Mom’s Birthday

Today is my mom’s birthday. It is hard to think about a birthday when the person who was born is no longer with us. Normally, I would wake up and call my mom and I would wish her a happy birthday and for many years she would say “well, it is better than the alternative”. Even though my mom passed away in 2008, I am still thinking about calling her.

My mom was born in 1925. She often told me that she was a depression baby. By that she meant that she grew up in the Great Depression. As we all know, the Great Depression was a severe worldwide economic depression in the decade preceding World War II. In most countries it started in about 1929 and lasted until the late 1930s or early 1940s. In 1933 the unemployment in the United States rose to 25% and in some countries rose as high as 33%.  The depression originated in the United States, starting with the stock market crash of October 29, 1929, but then spread to almost every country in the world. In today’s terms, we would say “it went global”.

The cause of the Great Depression is not clear, but two economists of the 1920s, Waddill Catchings and William Trufant stated that since the economy produced more than it consumed, there was an unequal distribution of wealth throughout the 1920s, causing the Great Depression. The end of this economic downturn seems more straight forward. Most people think that the Great Depression ended with the advent of World War II. America’s late entry into the war in 1941, when my mom was 16, finally eliminated the last effects from the Great Depression. Unemployment rate went below 10%.

For years, when my mom described herself as a “depression baby” I had no idea what she meant. I knew that she grew up in poverty. I knew that when I went to visit my grandparents, her parents, I slept at night with my hands over my ears so that I would not hear the gunshots in the neighborhood. I understood that her childhood was rough. I also understood that she attributed her challenges to the economic conditions of the country. However, what I did not understand is whether other people, born in her era, saw themselves in the same way.

My dad, born in 1927 into a poor family, had a very different outlook. He saw himself as a very lucky young man. He served in World War II, went to college on the GI Bill, and poof, his life changed. My dad’s focus has been, and continues to this day, to be on how fortunate he was to be able to take advantage of this government program. My father often tells me how college was amongst the best years of his life.

So, as a psychiatrist I wonder how two people, born into similar economic circumstances, grew up to review their early years so differently. Clearly, there are many many factors which determine one’s formative experiences. My question though is why my mom attributed her challenges to the economy. My mom spoke about how poor people suffer in ways that affluent people do not understand. It is not that rich people do not have their challenges, it is only that people in different economic classes cannot really understand each other, even if they think they can.

I remember when I was little and the Pritikin diet had just hit the public’s eye. The diet promoted grains, with some, but not much protein. My mom laughed, saying that when the food is associated with poverty, no one wants any part of it, but now that some fancy doctor is saying it is good for you, everyone wants to eat like poor people.

My mom never wanted any presents for her birthday, but she did want me to call her. She wanted me to remind her that I was happy she was still here. At the same time, even though in her adult years, her economic life was characterized by booms and busts, her birthday seemed to be a painful reminder of her adversities. She understood that her childhood was challenging on many levels. Eventually, I began to understand that when she said she was a “depression baby” she was saying that the challenges of the country were woven together with her personal challenges of her family dynamics. I came to appreciate the wonders of the double meaning of depression: psychological and economic. This is no coincidence.

My mom taught me a lot. Today I appreciate her wisdom. In particular, I embrace her point that people in different economic circumstances do not really understand each other. The longer I live, and the longer I work with people who are suffering, the more I understand that she was right. Happy birthday mom

http://shirahvollmermd.wordpress.com/2010/01/24/moms-birthday/

Harsh Superego: Inability To Forgive Yourself

     Sherry, recently turned fifty, spends her internal life being mad at herself. She hates her body, and she is mad that she is overweight, even though she is not. She wishes she had more money, even though she pays off her bills every month. She wishes she had better friendships, even though she is beloved my many. In essence, Sherry never lives up to her own expectations and so she lives with a chronic anger inside of her. To meet Sherry, one sees an exuberant, curious and engaged person. Her exterior is both charming and attentive to others. Yet, her interior is tortured “beyond belief,” as she says.

   Sherry’s sister, Ruby,  died when she was four years old and her sister  was eighteen months. Ruby tragically died suddenly as she choked on a walnut at the dinner table, surrounded by her helpless sister (Sherry) and their mom, Rosemarie. Sherry, although she understands she was four years old at the time, never recovered from that fateful day. Rosemarie did not either, according to Sherry. Sherry feels close to Rosemarie, now seventy-three, but they stopped talking about Ruby years ago, knowing that when they did talk about Ruby, they both got upset and so it was not comforting. Sherry believes that this traumatic event, even though decades have past, has created an indelible internal experience of guilt and bad feelings which she cannot describe or resolve.

     ”Gee, you must not come to therapy to deal with those bad feelings, as it seems like you feel pretty confident that that area is untouchable for you.” I say, with some compassion and some confusion. “Yes, I come to therapy to deal with more superficial experiences, like my frustrations at work, or trouble with my husband.” Sherry explains with a sense of painful resignation. “The part of your personality which is punishing, your superego, has a loud and chronic roar,” I say, bringing in Freud’s useful concept of a layer to our brain which judges ourselves and others. “You could say that,” Sherry says as she starts to cry. “I just don’t like myself,” she says as she cries more deeply. “I am sorry,” I respond, knowing that in this moment I cannot help her like herself, but I can join her in feeling bad that she carries this weight of self-hate. “Maybe turning fifty has made you realize that this feeling is not going away and maybe you hoped it would have disappeared by now,” I say, postulating that her birthday was a disappointment to her in that her dark interior world still persists. “Yea, it was a hard birthday,” Sherry says with the tone of recognition along with a feeling that she was relieved to say that aloud. “Maybe fifty-one will be better,” I say, pointing out that fifty is just an arbitrary number. “Maybe” she says, as if to please me, but not convincing me that she has any hope.

Missing

   Leslie, twenty-four, “misses” her parents being married to each other, even though she was two years old when they split up. Susan, sixty, “misses” her husband who died from cancer ten years ago, even though she reports that she had a terrible marriage, and they would have gotten divorced if he did not pass away. Rachel, fifty, “misses” her adult children who live far away from home. She can’t seem to focus on anything else. Sharene, fifty-five, “misses” the way her marriage was before she had children. She muses about “the good ole days” with a feeling of loss and cherished memories. For each of these women, I think about their inner hole, along with ways in which they can partly, although never completely, fill that hole back up.

     The passage of time creates change in ourselves and in those we love. Change creates loss and so it is hard to ride the wave of loss while appreciating the inevitability of change. Holding on to memories, while at the same time, allowing the feelings to percolate while accessing those memories is a challenge. Some folks, like Rachel, become obsessed with their past. Their memories become a preoccupation. Other folks, like Leslie, hone in on one aspect of her past, in a way which seems to oversimplify why she suffers the way she does now. Still other folks, like Susan, deal with their ambivalent feelings by taking the loss of her husband as an opportunity to deny her negative feelings. Sharene uses the past as a way to avoid making her life better now. She can never go back to a marriage without children; a metaphor for how life changes and how some decisions become one-way streets.

   Sharing the “missing” feeling helps, since a lonely “missing” is infinitely more painful than a bonded “missing.” Friends who can relate over aging, growing children, losing friends, through interpersonal problems, geographical change or through death, can deepen their friendship over sharing these feelings. At the same time, relationships often break when there cannot be a shared feeling of loss. Therapists help both broaden and deepen the understanding of the “missing” both in terms of the present and the past. For this to happen, the patient/therapist dyad needs to enter the zone of feeling the inner hole. The zone can be very dark, but exploring the zone, like going in a cave, is both fascinating and enhancing.

“Dad, I Have A Stomachache”

    Milly, fourteen, just lost her mother, Penny,  to metastatic melanoma. Penny had been sick for five years, on and off. When Penny passed, it seemed sudden, despite her poor prognosis. There was a memorial service; three hundred people attended, told Milly how sorry they were. Milly went to school the next day. She continued participating on the dance team, hanging out with her friends, and doing well in school. Brad, Milly’s father asked me “what should I be worried about with Milly?” “Keep an eye out for signs of distress. It may happen soon, but it also may happen weeks or months from now,” I said, trying to explain that reactions to death have no precise time frame. Brad leaves with a feeling of uncertainty, trying to deal with his grief and Milly’s grief at the same time.

      Three months later, Brad calls me and says “Milly is having stomach-ache.” “You should take her to her pediatrician to rule out any gastrointestinal illness, but at the same time, I am wondering if she is now expressing her feelings about Penny’s passing.” I say, thinking that Milly’s stomach-ache may be her ticket to discuss her internal distress about losing her mom. Brad, somewhat robotic, says “OK, I will call her pediatrician and then I will take her into see you.” “I could see her before you take her to her pediatrician,” I respond, emphasizing the time urgency of the situation, since Milly seems ripe to talk about her feelings. Brad agrees, again in a robotic fashion. Brad sounds scared and overwhelmed by Milly’s stomach-ache. “It is just a lot for me to handle,” Brad says, implying that dealing with Penny’s death has been overwhelming. “Well, maybe if we can help Milly feel better, that will help you feel better too,” I say, trying to say how his whole family is hurting, so dealing with one part will help the other parts. I also think that Brad could benefit from psychotherapy, but I don’t feel it is the right time to bring this up. “Thanks for seeing her,” Brad says to me in a kind and grateful tone. “Your welcome,” I respond, thinking back to our earlier conversation when he asked me when Milly was going to express her grief. Brad seemed to feel reassured that my prediction that Milly will react to Penny’s passing at a time when Brad least expects it, came true. Some things are obvious to outsiders and mysterious to those living through it; Brad and Milly were such a case.