Automated Medicine Versus Personalized Medicine…Narcissism Versus Self-Care

 

Financing health care fascinates me. So many folks who have private physicians resist changing to a health maintenance organization because they will lose the “personal touch”. I, who have advocated for the value of the physician/patient relationship, am always shocked by this choice. Sally, fifty-one, for example, spends $1500.00/month for her and her husband to maintain their physicians. This number represents their premiums, not their co-pays, or deductibles. The could spend half if they switched to an HMO, and finances are really tight for them. Plus, she and her husband are healthy, and rely on their physicians only for yearly check-ups. Still, the notion that they can call Dr. Lee, and Dr. Lee knows them, means so much to Sally, that she steadfastly refuses to change carriers. “What if the quality of health care was the same at an HMO, perhaps even better, would you still consider switching?” I ask, Sally, curious by what might be a sense of narcissistic pleasing, which comes with more personalized medicine, as is the difference between levels of service at three star versus five star hotels. “I don’t know. It just feels bad for me to switch, so I cannot think of it.” Sally says in a dismissive way, although I am also aware that her initial reaction to my comment is one of negativity, she often gives it deep thought. We, as a society, get used to a certain level of service, making it very difficult, even in the face of financial hardship, to go down to a system which meets the goal of good health care, without the special treatment of someone knowing your name and your family circumstances.  Personalized care is often mistaken for better care. Automated care might not appeal to one’s narcissism, but it might get the job done. The rules of business prevail. Making people feel good sells. Outcome measures, or hard data, does not sell as well. Concierge medicine works on this principle. Business minded folks understand the rules. The public, unless mindful, are vulnerable to financial hardship as a result. The Affordable Care Act will bring these notions into the foreground. The change in level of service will be interesting to observe. The doctor/patient relationship will still be there, but it will be expensive. Service costs money.

Narcissistic Injuries

Enlightened Self-Interest

When do we take care of others for the sake of ourselves? Jolie, fifty-four was about to lose battery power on her iphone5. Her husband, Shawn started to get anxious on Jolie’s behalf? “Why do you care about my battery?” Jolie asks Shawn. “Because I don’t want to deal with your tantrum when you can’t use your cell phone,” Shawn answers, startling Jolie. One could say it is sweet that Shawn is looking after Jolie, but one could also say that Shawn is looking after Shawn. In fact, Shawn could say he is caring for his wife, and/or he could say that he is protecting himself from future harm. Of course, Shawn is doing both, such that to say that Shawn is being selfish is not completely true, nor is it true that he is being altruistic. One could argue that enlightened self-interest is the best kind of love, since Shawn is caring for himself and Jolie at the same time. Too much selfishness, like too much altruism is a set-up for an unbalanced, and hence an unstable relationship. Having said that, should Shawn be honest about his consciousness that he is acting in his own self-interest, or should he emphasize the caring nature of his behavior? Perhaps Shawn could learn to say both parts to initiate a deeper understanding of their relationship. The most enduring kind of caring involves self-care, as well as care for others. As in my previous post about volunteering, one gives of oneself, as a way of getting back self-esteem-another form of enlightened self-interest. The narrow path resumes. Like the diagram above, the challenge in life is that very narrow, middle path.

Arrogance or Confidence?

Arrogance or confidence-what’s the difference? “All the other doctors released the medical records,” the trustee of a patient’s estate told me. “Yes, but that does not mean that all the other doctors did the right thing,” I respond. “Releasing medical records after someone passes away requires a court order,” I point out the law. I have confidence in knowing this fact, but to an untrained ear, I might sound arrogant and stubborn. As a psychiatrist, I have more medical training than non-medical therapists. This is true, but to some, this would also sound arrogant. As a psychoanalyst, I have more psychotherapy training than my non-analytic colleagues. Again, true, but potentially misconstrued, if spoken aloud. As a teacher of psychoanalysis, I convey psychoanalytic ideas, in a way which I hope enlightens my students, but I travel a fine line of sounding over-confident, as opposed to relative certainty. Is it that my confident colleagues can view alternative points of view with curiosity, whereas insecure folks view differences of opinion with contempt? The issue here is that the arrogant person, rarely, sees him/herself as arrogant. He/she sees him/herself as confident. Arrogance is a judgment laid on others, sometimes out of envy, and sometimes out of a certain tone, and sometimes out of experiencing a feeling of inferiority. At the same time, arrogance can be attractive when it is viewed as confidence. So many folks lack certainty, that when they are in the presence of one with certainty they are drawn into their presence. This may, in part, explain charisma, another challenging quality to articulate. Relationships often flip over, when it begins by admiring confidence, but over time, becomes a hatred for arrogance. I struggle with these ideas. Help!

The Narcissistic Pat

“Look at my Lego,” a seven-year old says to his mom, clearly asking for enthusiastic praise. “Wouldn’t it be wonderful if we could all ask for narcissistic pats, like children so easily do from their parents?” I pose to my ‘play class’. “Why do we lose our ability to get our needs met so simply?” I continue to ask my students, thinking about how children seem biologically programmed to demand praise, and parents, in turn, seem biologically programmed to understand the necessity for a passioned response. Somewhere, around puberty, getting affirmations become much more difficult. The relationship with parents are now more ambivalent. The praise has to come from peers, but the request for positive responsiveness is indirect and unclear. Competition sets in, meaning that friends hurt each other and help each other, at the same time. I wanted to say to my students today, “look at me, I am such a great teacher,” but somehow that did not feel right, so as a grown-up, I taught my class, hoping quietly that maybe, just maybe, a student would offer up some praise. I was having a day where I was needing a narcissistic pat, but asking for it, and knowing who to ask it from, seemed humiliating and inappropriate. The desire to have the excitement of showing off an accomplishment, knowing with almost certainty, that enthusiasm would flow readily, is still there. Some childhood wishes never go away. Wanting a narcissistic pat is one of them. Some days they are more important than others.

 

See also….http://shirahvollmermd.wordpress.com/2011/01/25/parenting-narcissism/

Medical Issues As A Narcissitic Injury

Xavier, sixty-four, has a sister with Multiple Sclerosis, another sister with Scleroderma, but he has always considered himself the “healthy one”. “Out of the blue, I started having pains in my chest, and now I discovered I have cardiovascular disease. I had no idea. How can this happen? What did I do?” Xavier communicates with a deep sense of wonder and shock about his newly discovered medical issues. I am aware how abruptly he must change the way he thinks of himself, yet I am also aware that cardiovascular issues are common medical problems, so I am a bit taken by his sense of immunity to the medical issues of aging. “This diagnosis has really gotten to your core,” I say, highlighting that  the meaning of these medical problems for him, run deep. “I know they do,” Xavier says with good humor, acknowledging that there are narcissistic issues at play. His sense of being “better” than his sisters because he was healthy is a longstanding mantra for him, which his family supported. Now, that he has joined the ranks of those with chronic medical illnesses, he is no longer special. “I have to say that this diagnosis is really making me look at myself and how I see the world. I really did not know how important it was to me, psychologically speaking, to know that I was healthy. Now, I feel that my core sense of myself has been shattered, but of course, I know that makes no sense. I am still Xavier, and yet, now I feel like a different person.” Xavier says with an openness and curiosity that begins to explain his powerful shock over this news. “That makes sense, given that your identity was built on your health, so now that your health is in question, your identity is too.” I say, reviewing our understanding of his mental state. As Jon said in his comment to the previous post, it is a universal truth that people both want to fit in and feel special. Xavier felt special because he did not have medical problems, and hence this fragile basis for his uniqueness was likely to shatter as he aged. Fortunately, his curiosity about this shift in his mental state, allows us to explore the inner workings of his mind, allowing for a more solid reconfiguration of how he both fits in to his world and how he is special.

The Analytic Separation

Seeing a therapist/analyst multiple times a week arises the incisive question of separations, be that from death, disease, retirement or vacation. How does that kind of emotional dependency play out when faced with an interruption of the routine? This is perhaps the hardest and most challenging aspect of analytic work, both for the patient and the therapist. If the therapist talks too much about an impending separation then he/she risks seeming to have an elevated sense of self-importance. On the other hand, if no mention is made of an upcoming separation, then the insensitivity of the analyst is both painful and revealing of an avoidant pattern in the analyst. Should the thought of this dependency, played out in the anticipation and then actual distance make potential patients flee the scene? Clearly, I think not, as this separation is ripe with windows into previous dependencies, both for the patient and the analyst. The art of psychoanalysis is to deal with these separations both in a sensitive way, but also in a way which might, with some patients, heal previous wounds of callous departures.

Although I intend this post to be the beginning of a long discussion-intermittent, as most of my discussions tend to be-I would like to begin by citing an example of Dr. Mor, a psychoanalyst, many people joke about being “less and not more”. Dr. Mor appears to feel overwhelming guilt when he goes on vacation, yet at the same time, he takes on average of eight weeks per year, sometimes divided over two-week vacations, and sometimes a month-long. Ernie, a long-term patient of Dr. Mor’s, explains to him that his apparent  guilt for going on vacation, as evidenced by the awkward and uncomfortable way in which he (Dr. Mor) announces his upcoming separation,  mandates him (Ernie) to soothe Dr. Mor’s ill-feeling. Ernie is not left with any space to experience his feelings as he feels compelled to make sure that Dr. Mor does not “fall apart” from his guilt.

Ernie comes to me for consultation with regards to his relationship with Dr. Mor. “It sounds like, as with so many relationships, the more narcissistic person in the couple mandates all the attention, since his fragility makes you behave in a way in which you cannot be authentic.” I say, highlighting that although we all have narcissistic needs, if these needs enter into the forefront of a relationship in a large way, then these needs crowd out the narcissistic needs of the other.  In essence, the more narcissistic person in the relationship is the more domineering. This domineering quality often leaves the other person feeling stifled and constricted.

Ernie is mesmerized by my understanding, but still stuck in a tremendous amount of pain and anguish. He now understands that Dr. Mor has “crowded him out,” leaving Ernie to feel compelled to shore up Dr. Mor, at Ernie’s personal expense. Yet, Ernie has grown under Dr. Mor’s care and so he has a very painful dilemma. “Why don’t you see how you feel during this upcoming separation?” I ask Ernie. “That’s a good idea.” Ernie replies. “Dr. Mor has helped me reflect on my internal process, so in a weird way, he has helped me see how he hurts me.” Ernie replies both grateful and aggravated with Dr. Mor at the same time “Mixed feelings,” I say, highlighting the layered and deeply conflicted feelings that Ernie is feeling. “Let the dimension of time, see how these feelings play out for you,” I say, thinking of my previous post about the “Etch-A-Sketch Brain”. “Time is a wonderful opportunity to see how your internal workings play out for you. ” I say, trying not to say the platitude that time heals all wounds, but to say that time is an added benefit for reflection. “You can both reflect in the moment and over time, and see how that goes for you,” I say, emphasizing that being mindful of one’s own mind, not just during meditation, but over time, is both fascinating and useful to making good decisions. “The separation might be good for you,” I say. “Yep, surprisingly so,” Ernie replies.

Narcissistic Obstacle

   Jamie, sixty-one, wants special treatment. I suppose one could say, we all went special treatment. It makes us feel good, and it reminds us of our childhood, when we were the center of attention. Giving up that demand for special treatment is a maturing process. It may also be genetically mediated in that I imagine that certain people are born to be more thoughtful of others. Jamie’s desire for special treatment is manifested in my cancellation policy, forty-eight hours notice. He believes that for him, it should be twenty-four hours notice because he has trouble planning his life, such that he is more vulnerable to calendar issues than other people. As such, I should be, according to him, “more understanding” and change my policy just for him. After all, individual psychotherapy, is individual, and I am able to cater to special needs. On the other hand, the desire to have special treatment, may come from a deep-seated personality issue in which Jamie fears he is ordinary, and as such, he needs special treatment in order to feel some self-esteem. If this is the case, which seems likely to me, then I need to help Jamie understand his need for special treatment. Granted, I could do both. I could change my cancellation policy just for him and help him to see the underlying dynamics behind this request. However, by not granting him special treatment, I then see how he responds to limits and what these limits mean to him. It is a tough call. For now, I am going to keep my policy. It is going to be a bumpy road.

Narcissism: ‘Ha, You Don’t Understand’

“Ha, you don’t understand,” Evie, sixty-three, an attorney,  says to me with a joking, supercilious and hostile tone. She is referring to her background of “white trash,” as she says, assuming that I come from privilege. “Maybe you don’t want me to understand so that you can feel unique in that you have grown up in a culture that you feel only you can understand,” I say, responding to her continual feeling that unlike her professional peers, she has “overcome” more economic and social obstacles.

It seems to me that the way she has dealt with what has felt to her to be an uphill road, is by convincing herself that she, alone, has traveled this path. The sentiment that “no one understands” could be a cover for a narcissistic streak which enables her to feel special. The hostility in her tone, as she tells me that I don’t understand, seems to convey a long-standing feeling that her childhood wounds are so deep, that she cannot imagine the feeling of sharing them with anyone. In other words, her arrogance seems to be a defense against getting close, feeling understood, by others.

I find myself feeling bad for Evie, on the one hand, since she her tone is so off-putting, but on the other hand, I feel like I have been knocked down, and so I must reconstitute my  internal self before I can respond in a professional way. “It must be hard to feel like no one can possibly understand  you,” I say, trying to soothe her, while being aware that I should not get defensive. “No one can understand,” Evie says with conviction, continuing to wall herself off from me. “Maybe if we keep talking about where you come from, I can get a better idea.” I say, trying to pull one brick off her wall. “I doubt that,” Evie says, returning to her hostile tone. “Maybe it is important to you,  to feel that your pain is special in some way.” I say, highlighting the narcissistic aspect of her statement. “I think you miss my point,” she says, unsatisfied by my response. Our work continues.

Narcissistic Begging

  Admiration, we all need it. We all seek it. The issue becomes what we want to be admired for, and who we want to admire us. Irene, twenty-five, is a musician, as is her father. She has “made it” in that she supports herself with her music, but she feels like a failure because in her mind, her dad sees her as “B-level musician”. Irene’s narcissism, her sense of herself, is defined by how her father, the man she has been trying to impress over the many years of her development, appreciates her accomplishments. Irene sends her father her music. She gives him posters that invite him to her upcoming performances, but her dad has no visible response. He responds flatly to her overtures, causing Irene to try harder to get his attention. Irene has many fans, but the fan she wants the most, her dad, remains passive and flat. Irene’s self-image in inextricably tied to her dad’s opinion of her. She cannot seem to understand why this is so, but she feels it to be so, and as a result, she continues to “beg” for admiration. Consequently, she continues to feel bad about herself; she feels hopeless. Our job together is to unwind this narcissistic begging so she can see why she needs his admiration so much. We are on the journey.