A Psychoanalytic Rant

1993-2001 were the years that I did psychoanalytic training at an institution then called Los Angeles Psychoanalytic Institute (LAPSI), and now called the New Center for Psychoanalysis (NCP). This training involved 200 hours of supervision to discuss 800 hours of patient care activities. Plus, I had four hours of seminars a week for four years, that came along with four hours of reading each week, to prepare. At the end, I had to pass an oral examination, write-up four cases, and go before a committee to qualify for graduation. This work, done in the midst of  my development of a psychiatric practice, was a questionable activity, according to those who followed me through my path. “Would it earn me more money?” Some folks would ask. “Nope” I replied proudly. This education was not intended to pad my income. Clearly it was a financial sacrifice, given the many hours of dedicated time to understanding psychoanalytic thought. Given the paradox of this educational activity, I was rather closed-mouth about it. Psychoanalysis, at the time, was thought to be “going out of business”. I understood that, but I maintained the conviction that deep understanding of the human mind is valuable to any kind of interpersonal activity, be if professional or personal. Over a decade after graduating, I am immensely proud of this accomplishment, and deeply connected to my work. I now teach at psychoanalytic institutes with the notion that the torch carries on, despite insurance pressures to the contrary.

My current rant centers around the notion that this eight year journey of mine is not always clear to those in educational institutions. More specifically, when volunteer teachers are sought, there is no targeted search for those with psychoanalytic training. This catches me by surprise, because although one could argue that the business of psychoanalysis might be fading, the need to teach in-depth psychotherapy skills is still a valuable entity. As such, the more depth one has as a clinician, the better the teaching could be. As a psychiatry resident in the 1980s, I made sure that all of my teachers/mentors were psychoanalytically trained, because this background enhanced their ability to articulate the ideas of the human mind. Without this training, I experienced teachers who, although bright, were often at a loss as to how to explain human motivation. One needs to cite  the literature, a skill developed over years of instruction, not given in psychiatry residencies that do not have a psychoanalytic bent.

The internet, however, gives me some hope.   This post, along with others, allows people from all over the world to chime in about their psychoanalytic journey, thereby reassuring all of us, that psychoanalysis is alive, making the need to teach deep thinking, alive as well. Perhaps this teaching will not go on at universities, but rather in free-standing institutions of psychoanalytic thought. This thought, likely to be true, gives me pause. Without the backing of a university, psychoanalytic thought will lose its intellectual rigor. A university needs to ponder the many ways of thinking about human behavior. Likewise, psychoanalysis needs the university to fertilize the thoughts that are in parallel with our explosion in understanding the mapping of the human brain. This divorce of in-depth psychology from universities is the basis of this rant. Some might say that the humanities keeps psychoanalytic thought alive, as many people who study literature and anthropology are concerned with human motivation. Although that may be true, it is still sad to me that psychoanalytic thought is being divorced from neuroscience. These two disciplines can learn from one another.

Am I Bad And/Or Did I Have Bad Parents?

 

“Outer security is thus purchased at the price of inner security,” so says Ronald Fairbairn about a child who protects his parents, defends them, at the expense of his self-esteem and intuition. In other words, when one senses that one’s parents are malicious, then one can protect them, and discard one’s sense of right and wrong, outer security, and thereby dismissing one’s internal sense of ethics, inner security. “It is better to be a sinner in a world ruled by G-d, than to live in a world ruled by the Devil,” Fairbairn continues. To be in a world ruled by the devil, “he can have no sense of security and no hope of redemption,” he elaborates. Fairbairn is famous for his example of the boy faced with poisonous chocolate pudding, as a symbol of difficult parents. He can either eat the poison and die, or starve and die. Inevitably, the boy will eat the poison, as this wins over starvation. This example is meant to illustrate how paranoid thinking can come into existence, if one grows up needing to trust people, who ultimately betray them. In essence, unwinding  from bad parenting is a long journey of self-reflection, requiring a separation from parental figures which is both agonizing and destabilizing.

 

 

 

 

See also…http://shirahvollmermd.wordpress.com/2012/08/06/relationships-heal-fairbairn-comes-alive/

Why Psychotherapy?

http://www.apsa.org/

Check out the animated video on the home page of APSA (link above), which I think is a great explanation of why psychotherapy is so important to build quality of life, in ways that medication management is severely limited. With the movement of psychiatry away from psychotherapy, we are limiting ourselves to a limited treatment, and hence we are leaving to non-MDs the treatment of very complicated mental states with means other than medication. I hope, with some technical assistance to be able to embed that video into my post, but for now, this will be a two step process. I think Dr. Norman Kohn did an excellent job illustrating why the narrative is critical to healing. In the second video, the one that I could embed in my post, there is a tutorial on Freud’s model of the mind. The illustration that we have behaviors which we are ashamed of, or not proud of, or that make us feel guilt, helps us to understand that guilt is the point of inquiry into the recesses of our minds. Understanding this guilt, in addition to minimizing the anxiety which arouses around the guilt, is key to promoting mature and sophisticated human beings. Psychopharmacology, although useful, does not take away guilt and it is this guilt, which is often the key to understanding inconsistent, or neurotic, behavior. More than any other reason, promoting this cause, psychiatrists doing psychotherapy along with psychopharmacology, is a major motivation for this blog. For reasons that seem to be unconscious, at the moment, I felt like I  just had to write this today.

Hedda Bolgar PhD: A Life Well Lived!

Hedda Bolgar 1909-2013 (via http://psychoanalyticpost.com)

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My colleague, Hedda Bolgar PhD, practicing psychoanalyst for 80 years, passed away yesterday at age 103. Her mind was vibrant. Her compassion was enormous. Her vision for the future was spot on. She taught, she saw patients, she started a free-standing psychology graduate school and a psychoanalytic institute. Los Angeles Institute for Psychoanalytic Studies (LAISPS), an institute that I am on faculty, came to life because Hedda recognized that psychologists, social workers and MFTs, needed a place to explore psychoanalysis. This was at a time when the American Psychoanalytic did not admit non-MDs (other than academics) into their training programs. LAISPS carries Hedda’s tradition of understanding that although the world is changing rapidly, what does not change is an individual’s need to share their stories, to be listened to, to be understood. No medication, no neuromodulation device, no psychosurgery, will ever change this. She was a wise woman because she realized man’s evil, as she lived through and protested against the Nazis, yet at the same time, she loved life and she loved people. Her home was a constant place for get-togethers to share stories, do book signings, and plan conferences. She was warm, intelligent and caring. She often voiced how she understood that working into her sunset years meant that she would inevitably abandon those who depended on her. She was open and honest about her impending departure from this material world. Her strength of character came through with this brutal honesty and integrity. She was both ambitious and nurturing, a combination that is rarely seen. She wanted to make a mark on the world, while at the same time, helping her colleagues and her patients strive to be the best that they could envision for themselves. She was a visionary, both for herself, and for psychoanalysis, but for those who came in her path. I was fortunate to be in her path, although in a small way, allowing me to feel her goodness, her reliability and her strength. Her loss is huge, but so is her legacy.

See also….http://www.latimes.com/news/obituaries/la-me-hedda-bolgar-20130519,0,2504238.story

Emotional Vacancy

Stuart, sixty-three, a beloved teacher, psychiatrist, mentor, creates feelings in his students, which Jerry, forty-four, also a psychiatrist, leaves him feeling “vacant.” “I do not think there is a there, there,” Jerry explains to me. By that he means that Stuart, although enthusiastic, clear-thinking, and an excellent teacher, does not appear to have a deep sense of himself. Although this is a vague concept, Jerry is trying to describe the feeling of Stuart as a shell of a human being, a person who says the right things, but in his core, he appears to feel insecure and as a result, uncaring of others. I begin to think about the “no there, there” feeling that sometimes happens in the presence of others, which is so hard to pin down, yet manifests in a feeling of emptiness. “It feels like you are sensing that Stuart is detached from himself in certain ways, and as a result, you have a sense that he is not capable of deeply caring for others.” Jerry gets excited by my comment. “Yes, that is how I feel.” “Authenticity of feeling is quite the personality challenge.” I say, elaborating on the notion that for someone to feel authentic, one must accept the entirety of feelings which include both positive and negative life forces. One imagines that Stuart has to shut off a part of himself which is unsavory, and in so doing, he makes himself more shallow, and hence less emotionally available to others.

Transitioning From Therapy To Life

 

Whitney, sixty-one, long-time patient, ends each session with “so, what should I do?” Over the years, I have come to hear that question as a signal which tells me that transitioning from therapy back to life is challenging for her, as well as for many patients. The comfort of getting honest with one’s feelings makes it hard to leave, and go into a life in which social graces demand a certain amount of deception. The relief of authenticity is palpable for some, and especially for Whitney. The question she asks, feels to me, to be “how can I feel good when I leave here?” I hear the pain of the uncertainties in her life. Her son is getting divorced. She has a health scare. Her finances are rocky. In my office, we share the anxieties, whereas with her friends and family, she maintains good cheer. Some colleagues call this transition the “insult” of psychotherapy, because telling patients they have to stop talking can feel assaultive. The notion that time is up, potentially narcissistically injures a deep unconscious which needs to feel endlessly fascinating and engaging. Whitney deals with this “insult” by hoping to take away a concrete notion, while at the same time, knowing that I am not going to answer her question directly. Sometimes I say, “you should make sure that you are taking care of yourself,” knowing that this is a very general comment, and not what she is looking for from me, but also knowing that she appreciates the reminder. Maybe I should respond “it is really hard to leave,” with the understanding that although it does not answer her question, it addresses a possible underlying motivation to her inquiry.  We know each other well enough to engage in this kind of  indirect conversation. I will try that.

Success Metric

 

How do you know when you are successful? Your bank account, your house size or your job title speaks to an “accomplishment”. Is the measurement external, such as buying a fancy car, and/or is it internal like feeling good about what you are doing? I maintain that for so many of us, the success metric is unconscious. meaning that we are trying to please our parents, our siblings, or those who early in our lives were very important to our growth and development. Elaine, fifty-one, went to a prestigious law school, graduated with a great job, made boat loads of money, quit her job and decided, at the age of forty, to settle down and have a family. Neil, a high school classmate of Elaine, also went to a prestigious law school, graduated with what he called a “mediocre” job, and he has felt like a failure, ever since. Elaine thought that having a successful professional practice would make her happy and when she realized she felt lonely, she  turned her life in a different direction. Neil, imagining a financially secure life, now faced with some significant financial hardships brought on by raising his family in the way he wished he had been raised, now looks at himself with disgust and disappointment. Elaine never felt that her bank account had any reflection on her sense of success. She was looking to feel good about her life. Neil, by contrast, believed for many years, that financial success, would prove that his hard efforts paid off, and so without a sense of financial security, he has let himself down, and I suspect his  parents, as well. Both Neil and Elaine grew up lower middle class, but Elaine’s family never encouraged her to “change her life,” whereas Neil’s family saw Neil as “breaking through the barriers into economic freedom.” If life is all about expectations, I would add that it is the expectations of our caretakers, that most of us, without examining our life, are slaves to. In other words, our default motivation is to fulfill the expectations of our parents. Only with deep introspection can we begin to change that.

“I Can’t Complain:” Shorthand For Guilt

 

Carrie, fifty-seven, comes to therapy and says, “I can’t complain,” implying that she feels too guilty to acknowledge the burdens she feels. Her internal script, one that goes back to her early childhood, is that she is born into a “fortunate” family, and all those who were born into other families suffer in ways that she does not, and hence, she has no right to express heaviness or disappointments. Of course, the word “fortunate” is a code word for financial privilege, which, of course, is not a privilege if Carrie is constricted emotionally. “Since when does having money mean that you cannot have negative feelings?” I ask, in order to challenge this family narrative that if one does not have financial woes, then one has no woes. This narrative is mirrored by many impoverished families who recite “well, if we had money, all our problems could be solved.” Superficially, this is obviously a weak thesis. Financial comfort does not save one from the hurt of relationships, or the threat of health problems. Sure, money does ease a lot of burdens, but at the same time, without the appreciation for friendship, for interpersonal connections, and for good health, then money serves families in very limited ways. Since Carrie cannot acknowledge her struggles to herself, she is unable to metabolize them in a way which leads to deeper understanding and compassion. As little compassion was shown to her as a young child, so she exhibits little connection to her emotional interior, and subsequently, her relationships feel shallow to her. Pushing through that guilt is my challenge. This is the guilt in which Carrie feels she is betraying her family story if she “complains,” as she was taught that she could not complain, and even worse, that she was a bad child if she attempted to voice any negativity. I need to slowly and gently unhinge her from this confining notion. The goal-some good complainin’.

The Forgotten Aunt

 

Zoe, from my previous post about siblings, gets the sudden, although not surprising news that her father is in the hospital. Sean, eighty-six, has multiple medical problems, but still, it always catches Zoe by surprise when there is a medical incident. This time, Sean had pneumonia, requiring an inpatient stay. Zoe goes to visit and she begins to wonder about her dad’s sister, an aunt, that she has no memory of ever meeting. Sean tells Zoe to call Aunt Fay, and so within minutes, both Zoe and Fay are crying on the telephone. Fay, ninety-two, tells Zoe that she thinks about her every day and that she has kept up on Zoe’s life by her daily phone calls to Sean. Upon hearing about Sean’s pneumonia, Fay immediately says “it is because he is with all  those women. You have to tell him to slow down.” Fay tells Zoe, as if the two of them are close. Zoe leaves from seeing her dad deteriorate suddenly, with sadness, along with the odd happiness of “meeting” her 92-year-old aunt. Zoe talks to me about her mixed feelings with a heavy heart, both in terms of her dad’s deterioration and in terms of her yearning for a part of her family she never met. Zoe explains to me that her mother, Claudia, did not like Fay. Claudia never allowed her children to spend time with her, and Sean, although very close to Fay, agreed. Zoe, still recovering from her emotional wounds from Berkeley, is further faced with her family dynamics in which there were deep divides. Suddenly Zoe has another memory from her conversation with Fay. “You know she said that my mom never let us meet because we looked alike and we are both really pretty. It was such a strange comment, but I do look like my dad’s side of the family, and that could have something to do with why my mom treated me poorly.” Zoe says, with wonder, as if she does not quite believe her own words. Zoe is now immersed in more family dynamics because she cares for her dad, but this forces her to interact with her siblings. I listen and I imagine Zoe’s subjectivity. I imagine Zoe, with her dad’s illness, thrown back to her childhood memories, which bring up lies, betrayals, and heartless attempts to create children who reflect well on their parents. Once again, listening is a deep experience, like reading a good novel, takes me to a deep place, filled with my thoughts and associations to Zoe, both the Zoe of the present and the Zoe of the past.

Understanding Subjectivity

 

Understanding subjectivity is the essence of good listening. Zoe and Berkeley illustrate this point well. http://shirahvollmermd.wordpress.com/2013/03/27/disappointing-siblings/

Many of my readers commented that Zoe was being “too sensitive”. This “too sensitive” remark often strikes me with the wish to respond “on what scale?” Who owns the sensitivity meter between nicely sensitive where one is sympathetic to others, to ‘too sensitive” where one is considered a “drama queen”? I often think of a dog who hears sounds that humans cannot detect. Are dogs “too sensitive”? Or, do they have powers of perception which exceed humans, and therefore we are baffled by their abilities? Sure, one could say that Zoe should not “make such a big deal” about Berkeley interrupting a yoga session, and that Zoe, clearly, to some, is either unforgiving in general, or specifically, with her sister Berkeley. On the other hand, Zoe’s reaction to Berkeley could be a detection of underlying hostility that Berkeley feels for Zoe, and as such, Zoe is wise to pay attention to her feelings, such that she understands the dynamics of her relationship with her sister. Suppose Zoe were to brush off the yoga experience, only for it to happen again, leading to more ‘sensitivity” and pain. This minimization of her feelings could lead her to a larger problem of repeated exposures to situations where she ultimately feels deeply devalued. Similarly, Zoe’s attention to her feelings could lead her to protect herself from people who do not appreciate her, thereby protecting her self-esteem. As Zoe’s therapist, it is my job to understand her subjective experience, and in so doing, help Zoe deepen her understanding of how she is feeling in the moment. I encourage her “sensitivity” such that she has a language for her emotional interior in which she can describe her  experience of a deeply wounding experience. This language of feelings can be scary to some ears, leading some listeners to want to dismiss her and say “get over it”. It does not matter whether the listener, in Zoe’s yoga experience, would have had the same reaction. What matters is that Zoe experienced hurt feelings, and like a person who takes a tumble, the friend asks  ’how can I  help?’ and not ‘why are you moaning?’