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.

Relationships Heal: Fairbairn Comes Alive

“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.

Re-Posting Since I Am Wonderin’ When Is It Witholding and When Is It Lying?

Monte, http://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/, dismayed over Marla’s lack of support for his teaching, wonders with Marla, before they “broke up” how he will ever be able to take part in teaching so long as Marla is the person he is supposed to turn to for help. After all, Marla is the head of the faculty committee.  Marla agrees that this is an “issue”. Monte and Marla then sever their relationship, leaving Monte adrift. Eventually, Monte finds other avenues to direct his professional energies and he settles into a new routine.

Buying tomatoes at the local Farmer’s Market, Monte runs into Gigi, a colleague, who tells Monte that Marla has retired and now she  is going to be taking over the leadership  in the next academic year . Monte, stunned, says “when did this come down?” Gigi says, “oh, we got together and we decided this about a year ago.” Monte, still almost speechless says “has this been announced?” Gigi says “well, at a meeting, I told people.” “So, there was no email announcement?” Monte asks. “Right, it was not handled well” Gigi agrees.

Monte goes back in time in his mind and determines that Marla could have told him that there would be a regime change, thereby allowing  Monte  to  have the option to stay involved on the committee. “Why didn’t Marla tell me that?” he asks himself.  As in, http://shirahvollmermd.wordpress.com/2010/06/15/communication-pain/, Monte realizes that information is power. So long as Marla has knowledge that Monte does not have, Marla can feel in control. To let Monte know that there is going to be a regime change, weakens Marla’s place of authority. Monte understands that Marla, for her own reasons, needed to hold on to the power of knowing something that other people did not know. Monte believed that Marla had a hard time giving up the power and so to say it aloud was difficult for Marla. Still, Monte felt that Marla was being cruel to let Monte suffer in this way.

Personality, the way a person interfaces with his world, is often learned in layers. Even though Monte had known Marla for years, this aspect of  Marla’s personality where she used  information as a source of power, was new to Monte. However, in thinking over their relationship, Monte began to realize that there had been other sensitive times when Marla was withholding. He remembered that sometimes Marla would have a long vacation planned and “forget” to tell him well in advance. Monte began to reframe this “forgetting” as yet another example of Marla withholding. Monte wonders whether Marla’s need to exercise power in this way is a reflection of Marla’s overwhelming sense of impotence. In thinking about it, Monte began to have some sympathy for Marla, but at the same time, he was angry and hurt over her behavior. Despite years of an intense relationship with Marla, Monte felt that this chance encounter at the Farmer’s Market added yet another dimension. Despite Monte’s pain, Monte could stand back and see the layers to the deceit and the cruelty. Maybe Marla helped him after all.

Passive Aggressive

  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.

Personality: Scab-Picking

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.