Posted by Dr. Vollmer on September 26, 2013
23 years in practice and I still struggle with this diagnosis of a borderline personality disorder. I tell my students that I have never seen one, meaning that what they see, I do not. Brianna, twenty-five, has had multiple suicide attempts. She is the product of an Italian immigrant father and an African-American mother. She complains that she cannot fit in anywhere, because of her mixed heritage, and as a result, she often feels like killing herself. My students, who have seen Brianna, say she is borderline or Asperger’s. I propose that she is lost, searching for meaning in her life. Once again, I find myself using lay terminology to express the desperate feelings that lead to self-injurious thoughts and behaviors, in preference to the jargon in psychiatry, which I find to be unhelpful in terms of thinking about how to help patients like Brianna. Once again, I feel the laziness of using diagnoses like Bipolar, Asperger’s (now Autistic Spectrum), or Borderline, as a way of NOT thinking about the struggles of living in this world. Psychiatric diagnosis, sometimes, skims over the complexity of mental existence, leading to yet another irony, where on the one hand, in the neurobiological world, the brain is seen as complex, but in the clinical world, there is a push towards simplicity. Self-injurious thoughts do not necessarily imply a DSM 5 mental illness, but often implies, psychological pain, which is not an illness, but a symptom of a deeper problem of struggling to latch on to the beauty of the world, and the beauty of oneself. All of this dispute, my plea to get away from jargon, makes me scared that psychiatry will bury itself. Brianna, and so many people like her, need understanding and listening; they do not need a label. Other mental health professionals (non-MDs), and clergy, understand this, but psychiatry, at least a large part of psychiatry, pushes away from the value of embracing the complexity involved in finding meaning in life. Labeling patients Borderline often embodies this issue. It is as if the label stops the psychiatrist from probing deeper into the personal struggles of Brianna. She is Borderline, implying that she needs medication to control her impulses. I do not have an issue with giving Brianna medication to control her impulses, but I do have a problem if the intervention stops there. Controlling her impulses allows Brianna to become more contemplative, and hence more reflective on what is important to her. Medication in this light, opens the door to an internal journey which is messy and complicated, but ultimately helpful to Brianna becoming an authentic, and hence beautiful human being. I repeat. She is not Borderline. She is lost . So is psychiatry.
Posted in Borderline Personality Disorder, personal growth, Personality | 16 Comments »
Posted by Dr. Vollmer on July 29, 2013
Martha, forty-one, always allows her husband to make their major life decisions: what house to buy, where to send the kids to school, how to incorporate religion into raising their children. For years, working with Martha has made me reflect on this sense of deference. Is it respect for her husband? Is it a lack of faith in her own decision-making ability? is it fear of confrontation? Of course, these are not exclusive and so at different times, different factors may be at play. Consciously, Martha is not aware that she defers to her husband. Her narrative is that they have thought things through together, but upon deeper exploration, it is clear that her husband always steers the family ship. Suddenly, Martha, unrelated to our present discussion states “how do I know what is the right thing to do?” The moment of clarity arrived. Deep insecurity and a lack of trust in her ego, not believing in her sense of right and wrong, has led to a marriage in which she is the more passive participant. Sometimes these marriages work well, but Martha is now suffering from questioning why she cannot form her own opinion. Forming opinions, thinking, deciding, are actions that many of us take for granted because we have to navigate through life. Yet, Martha is now in a period of reflection where she is confused as to why she is never certain, or even reasonably sure, so that she can then decide what is best for herself, and what is best for her children. She is no longer comfortable being passive, but nor is she content with offering an alternative point of view. She is stuck by the constraints of her ego which, at this moment, is unable to guide her towards changing her life. Her paralysis is painful as she does not want to stay the same, and yet, she is frightened to change her interface with the world. This is our work together-building a sense of self that can go forward with her own decisions, and not be inhibited by the overwhelming fear of making a mistake. A strong self knows that bad decisions will be made, but that the “self” can then make another decision which will put the person back on track. In other words, the stronger person can see the arc which includes both good and bad decisions, and with the ability to reflect, a better course can come out of wrong turn. The more vulnerable ego stays in place, so as not to experience regret. Accepting regret is personal growth. Martha and I are working on this big picture, the picture of building a new self, a new brain, which steers her in a way where she can feel proud.
Posted in personal growth, Personality, Psychotherapy | 9 Comments »
Posted by Dr. Vollmer on May 2, 2013
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.
Posted in Personality, Psychoanalysis, Psychotherapy | 4 Comments »
Posted by Dr. Vollmer on August 6, 2012
“My dependence on my mother is so great, and she is so privileged in my eyes that it makes my rage more acute and more forbidden. Mommy is someone I cannot attack….My position with her is so precarious that I don’t risk upsetting the balance.” Karl, the name given to W. Ronald Fairbairn’s patient that he writes about in 1958 in his article entitled ‘Nature and Aims of Treatment’. Karl continues with a dream. As Fairbairn describes the dream, “he was starving in the dream and there was no food available apart from the pudding. He knew, therefore, that if he did not partake of the pudding, he would die of starvation; but he also knew that the pudding was poisoned and that, if he ate it, he would likewise die. It goes without saying, of course, that the poisoned pudding symbolized his relationship with his mother.” Fairbairn used Karl as an example that not only does he need to understand his sense of deprivation from his mother, but he also needs to develop a therapeutic relationship with his therapist so that he can see that not all deep relationships consist of poisoned pudding. This notion was then re-branded by Kohut as Self-Psychology, where the theory purports the same therapeutic action.
W. Ronald Fairbairn (1889-1964) studied divinity and then served in the British Army in Palestine before returning to his native Scotland and becoming a physician. He spent most of his professional career in Edinburgh, which was quite peripheral culturally and politically to London, with the result that much of his work was not appreciated by the larger psychiatric and psychoanalytic community until late in his career.
Re-reading Fairbairn for my upcoming Journal Club with the Psychiatric Residents, I am once again struck by how his ideas, although poorly written, were not brought to the light of day until, thanks to Kohut, we could now begin to tolerate the notion that relationships are therapeutic, even without the attainment of insight. Sure, my issue with Kohut is that he writes as though Fairbairn did not state this years before, but at the same time, I credit Kohut for having the charisma to take these ideas to a broader audience. In essence, the packaging is almost as important as the product. Kohut was a better salesman. Fairbairn’s ideas kick started our movement towards understanding the importance of the two people in the consultation room: their relationship matters.
Posted in Fairbairn, Kohut, Personality, Psychoanalysis, Psychotherapy, Self-Psychology, Teaching Psychoanalysis, Winnicott | 2 Comments »
Posted by Dr. Vollmer on December 15, 2011
Lola, forty, tells me how much she loves her husband, Harry, even though she knows that Harry is very frustrated with her and they live very separate lives. Lola reports that this does not bother her because she knows Harry loves her too and she does not want to give that up. Lola does not understand why Harry never wants to spend time with her, even though Lola and Harry have been in couples therapy for the last ten years of their fifteen-year marriage. Lola does not believe that she has done anything in particular to irritate Harry. By Lola’s account she has been a very devoted wife, mother to their children and wage-earner.
Lola comes to therapy without an agenda. She has “no idea” why she comes, other than that “Harry thought that it might be a good idea.” Lola does not know what she wants to talk about, but when she misses a few weeks, she reports that she misses talking to me. Yet, when she comes in, she says she has no complaints and that her life is “very good.” “How can I help you?” I ask, directly to see how she thinks of her treatment. “I don’t know,” she responds flatly. I find myself feeling irritated at Lola’s passivity and from that I guess that maybe Harry feels the same way. “Does Harry ever get mad at you for not being more engaged in the marriage?” I ask. “Oh, yes!” Lola perks up with a tone of surprise that I asked that. “Well, that makes sense to me, since your passivity can be irritating. Your lack of initiative could create irritation in the people close to you and in so doing, there is aggression in your passivity.” I say, explaining passive-aggressive behavior, which she understands but she did not see this in herself. “I have never thought of that before. If what you are saying is true, that is very interesting,” Lola says with authenticity and openness. Her willingness to examine this passivity deepened our work. Hope ensues.
Posted in Personality, Psychotherapy | 4 Comments »
Posted by Dr. Vollmer on August 30, 2011
Kim, forty-five, a friend of my patient Rebecca, also forty-five, is getting under Rebecca’s skin. By Rebecca’s account, Kim is always telling her to change her life in some way, like changing her clothing style, changing her relationships, changing how she spends her time. Rebecca keeps at it, Kim says, as she describes this relentless bossiness. “She sounds like a scab-picker,” I say, trying to explain that some people, likely based on their experience as children, take a weak point in someone they are close to, and then they keep bringing the conversation back to that issue. Sometimes it is subtle, and sometimes it only happens when the person, Kim in this case, is under stress. “I can’t confront her,” Rebecca says, “because she thinks she is being a good friend.” “Maybe you can gently change the subject,” I suggest, encouraging the art of conversation which can protect the friendship, without the adverse consequences of direct confrontation. “I can do that,” Rebecca says, but she still really gets on my nerves. “Well, then, maybe you do have to gently confront her, and tell her that you appreciate her concern, but that you are fine with the way things are for now,” I say, trying to be directive so that she has the words to use with Kim. “Understanding that this scab-picking trait is really about Kim, and that it is likely to be about how Kim was treated by her mom, might help,” I say. “No, that does not really help,” Rebecca says immediately. “She still hurts me when she picks at my scab,” Rebecca says, taking my metaphor and running with it.
Posted in Friendship, Personality | 2 Comments »