“I take futility to a new level.”
Posted by Dr. Vollmer on May 13, 2013
“I take futility to a new level.”
Posted by Dr. Vollmer on May 6, 2013
Posted by Dr. Vollmer on March 28, 2013
Posted by Dr. Vollmer on March 21, 2013
Posted by Dr. Vollmer on March 20, 2013
Posted by Dr. Vollmer on March 13, 2013
Carrey, thirty-two is not so happily pregnant. She is married. She planned this baby, but her mood is low and she is wondering about antidepressants. “Are they safe in pregnancy?” She asks me, hoping that this is a yes or no question. “It is really a nuanced question.” I say, beginning an educational moment that medications cross the placenta and can impact the development and the delivery of the fetus, so we look to the literature to help us out. The literature tells us about studies which describes what happens most of the time, but there can be exceptions and new information that develops over time. “One question is whether there are other options for intervention, while you are pregnant, which pose a lower risk to the fetus,” I say, highlighting that part of the decision about psychotropics during pregnancy is whether or not other modalities of treatment can be tried and could be useful. Experts in the field come to the conclusion that the decision to treat a pregnant woman with medications comes down to a risk/benefit ratio, which means that each individual patient needs to be evaluated to determine if the risk of treatment exceeds the risk of not treating, with psychopharmacology. First and second trimester exposure appears to cause no organ malformation, but third trimester exposure can cause the baby to be born irritable, perhaps to the point of requiring the baby to stay one extra day in the hospital, and thereby increasing the risk for hospital-acquired infections. Some psychiatrists interpret this data to give them a low threshold to treat pregnant women with psychotropics, whereas other psychiatrists take this data to suggest that non-pharmacological interventions should be tried intensively before jumping to medication. There is no agreement, and there are no specific guidelines. This uncertainty in the field causes patients to be confused and, sometimes angry, at physicians who do not share their point of view. With this grey area of treatment, comes a lot of subjectivity about how to proceed which leads to professionals being judgmental with each other, and patients looking to professionals who lean in the direction they are looking for. Carrey is confused, seeking other opinions. I respect that.
Posted by Dr. Vollmer on November 29, 2012
“I want you to know we have a normal family,” Maureen says to me, as she admits her twelve-year old to the psychiatric hospital for serious substance abuse issues. I did not ask her about her family, so her comment made me pause. You mean, you feel very guilty, I wanted to say, but I did not have the history with Maureen which would have enabled me to speak my mind. “Parental guilt is overwhelming,” I say to my students, thinking about Maureen. “Parents feel guilty, generally speaking, no matter what happens to their children, and when this guilt is added on to things they really feel they did wrong, then they have guilt squared,” I say, trying to explain that a part of parental guilt is about understanding the enormous responsibility of another human being, whereas another part of guilt could be a knowing negligence when it comes to parenting. “When the guilt can come to the light of day, parents often feel uniquely understood,” I say to my students. “No one wants to talk to them about their guilt. Most well-meaning friends and family want to jump in and quickly reassure the mom that she did the best she could.” I say, emphasizing that the role of a mental health professional who works with children and families, is to demonstrate the understanding of the really difficult feelings which can bubble up during a mental health crises. Reassurance does not help because the parent often feels like their friends do not really understand how deeply bad they feel. Further, the loved ones often do not want to acknowledge the depth of the guilt because it can trigger in the listener their own sense of guilt towards their children. “The default assumption, until you get more information, is that the parent is feeling guilty when they see you.” I say to my students who are rookie child psychiatrists. ”Probing for that guilt is the art of our profession,” I say, thinking to myself that in some ways, this is a lost art, but also hoping that maybe, I and many of my colleagues, are slowly bringing this art back to the field. “No one wants to feel guilty, but worse than that, no one wants to feel alone in their guilt.” I say, pointing out that feeling misunderstood is worse than feeling guilty. “Understanding guilt is tricky, because you need to empathize without agreeing or disagreeing with their own sense of negligence.” I say, emphasizing that understanding guilt is a challenge. “I hear you,” I respond to Maureen, acknowledging that I hear her statement about her family, but I am also hinting that I understand that there could be a subtext.
Posted by Dr. Vollmer on November 28, 2012
Tomorrow, in my “Play Class” we will talk about Winnicott’s paper (1963) about emotional growth in “terms of the journey from dependence to independence”. In this essay he coins his famous phrase “primary maternal preoccupation,” the time in a mother’s life, third trimester pregnancy along with the first few months of infancy, where the mother can think of little else besides her baby. The significance of this concept is that a mother has the challenge to follow a parallel journey with her child; a journey which begins with a merger, and ends with separateness. This parenting process is hard because it is overwhelming to feel responsible for another human being, and then it is overwhelming again, to let go of that responsibility so that the child can develop his/her own ego. A mother/caretaker has to have the emotional sophistication to know when to be hovering and when to let go. This, the lay public might say, is a “mother’s instinct”. Winnicott teaches us that without a mature mother, a child is psychologically damaged because he/she does not have the opportunity for ego development, for coping skills. For example, if a mother is afraid of their child’s upset, then she might feed them continuously. If the child never gets hungry, then the child does not know how to cope with the need for self-care, possibly leading to an eating disorder. The process of development, of maturation, demands that the child experience frustration followed by gratification. Optimal frustration is the key to healthy growth, as the child learns that needs can be met with thought and patience. Without optimal frustration the child is vulnerable to feeling omnipotent, where every need is immediately met, and hence arrogance ensues. The proof of healthy development, Winnicott would say, is quality interpersonal relationships, where quality is defined by mutual satisfaction. In other words, the metric of good mental health, is socialization. The ability to cultivate relationships requires flexibility and compromise. This has to be learned in the tender developmental years, and then again, throughout life. Winnicott’s theory still holds true, fifty years later. Let’s see if my students feel the same way.
Posted by Dr. Vollmer on November 20, 2012
Betsy, age ten, a patient of mine since she was six years old, comes into my office with her mom, Gloria. Betsy and I play catch and talk about her summer. She tells me about the books she is reading, her friends, shesays that she hates camp, and she is nervous about going back to school next month. Given Betsy’s long history of anxiety, poor eye contact, poor social relationships, poor behavior at school, I am pleased at our relaxed interchange. The appointment winds up with our usual routine. Gloria and I make the next appointment. Gloria reaches into her purse, and says “here is Betsy’s report card. It is really good.” Gloria has handed me Betsy’s report cards for years, but this is the first time she announced it in front of Betsy. Dramatically, Betsy became irritable, angry, and rude. She grabbed the envelope out of my hand and said “this is none of your business.” Gloria says, “Betsy, I have given her report cards for years.” Betsy gets more upset. “She is not related to me, so she should not see my report card,” Betsy screams. Gloria responds “but it is a really good report card, what is the problem?” “It is just none of her business,” Betsy screams louder. “Just pay her and let’s go,” Betsy says.
Why did Betsy get so mad about me seeing her report card? I speculated to myself that this is an issue of intimacy. Betsy and I, although we have known each other for many years, is not comfortable sharing herself with me in that way. As such, she felt violated that her mom exposed a part of herself, her report card, that she was not ready to share. I understood Betsy’s discomfort and I felt bad that I was a party to it. At the same time, at the time of the interaction, I was surprised by her strong reaction. Betsy’s sensitivity helped me understand her relationships. She enjoys interacting with others, but she is also afraid that getting too close to people could result in painful humiliation. Even though her report card was good, she seemed afraid that my reaction would make her feel bad. Betsy’s anger might have protected her from having to suffer from my unsatisfactory response to her school evaluation. In another context, Betsy might be seen as bipolar, or quick to anger, but had this happened, Betsy would have been misunderstood. Her hair-trigger response was not a “manic” experience; rather it was a response which protected her ego. In the end, Gloria and I felt sad that Betsy was so upset; it was a hard learning experience.
Posted by Dr. Vollmer on September 20, 2012
Unconscious agendas, the need to rescue, found in so many therapists, so many relationships, and so many seemingly altruistic acts, like saving a dog from the pound, results in anger when the object of the rescue does not comply with the hopes and dreams of the rescuer. So says, one of my students, Frank (not his real name) in today’s ‘Play Class’ where we discussed the dynamics in the story of a fictional seven-year old child, Sam, both parents unable to take care of him, leading a very distant relative, Gerard, to step in and provide parenting, but over time, Gerard has shown an edge of anger and disappointment that this child is not showing the world the benefits of his deeply devoted caretaking. Frank nailed it. The unconscious need to rescue, often results in anger and disappointment because there is an unspoken agenda, in which the dependent soul is vulnerable to not fulfilling, causing despair and agitation in the rescuer. The rescuer, in this case Gerard, seems to be hoping that taking care of Sam is going to make Gerard feel good about his core self. If Gerard’s core self is poorly formed, then Sam will feel the pressure to take care of Gerard, and thus Sam is not able to grow and develop with the freedom to find his core self. Sam, as a sensitive child, perceives this, and then resents Gerard for putting pressure on him to “show off” Gerard’s altruism. Gerard feels this resentment from Sam and then becomes even more angry, that not only is Sam not grateful for his intervention, he is angry at Gerard. This negative dynamic leads both parties feeling unappreciated. If, on the other hand, Gerard did not need Sam to prove that he was a good person, Sam would be free to express himself, and then in that case, he would more likely grow up to be grateful for Gerard’s intervention. In essence, primitive personalities, like Gerard, in this fictional case, begets more primitive personalities, like Sam, since his development is obstructed by Gerard’s unconscious demands. Relationships do best when people appreciate each other, without being too dependent on one another for a sense of confidence and well-being. This applies not only to friendships, romantic relationships and to parenting relationships, but to therapeutic relationships as well.