Focusing The Patient’s Attention

One of the goals of analytic work is to extend the province of the ego, and more specifically, to make the patient more aware of his distortions. With Lynda, from my previous post, with her unrelenting selflessness, I could say “you are determined to do for others and then resent your friends for not appreciating  you.” The words “you are determined” changes her from a victim to the author of her own experience. In this new narrative, she is now able to contemplate that this dynamic which she resents is of her own creation, and hence subject to change. These simple words, “you are determined” is the basis for therapeutic intervention which empowers the patient to take more control over his life. So, I am off to teach these concepts. This will be my last class for these ten engaged and enthusiastic students. I will miss them, as teaching is one way I express my agency, my desire to do what makes me happy.

“Understanding and Being Understood”

Does the patient want to be understood, or rather, to understand? So, Martha Stark MD poses the question. Helping the patient be curious about his internal world is the job of the therapist, yet, at the same time, there needs to be a sensitivity to the patient in so much internal crisis that understanding is too large in the moment. In those moments, being understood trumps understanding. Self-psychologists frame this issue as gratifying a need versus helping a patient understand the need. The classic example being the therapist leaving for vacation. The therapist has two choices. He can tell the patient where he is going, which is gratifying the patient’s curiosity, or he can explore why the patient cares where he is going on break,  as a way of stimulating the  patient’s understanding of his  need to stay connected with the therapist despite their physical separation from one another. Of course, this is a fake choice, as the therapist could say “I am going to tell you where I am going on vacation, but before I do that, I am wondering why that is important to you.” Such a two-part answer addresses both the requested gratification, the ‘being understood,’ as well as helping the patient with ‘understanding’ of his emotional interior. Hence the patient can be gratified and stimulated, at the same time.

Lynda, fifty-four, consistently puts her needs behind others. She is always helping her friends, her family and even people she meets once or twice. Inevitably, she is resentful of the “other” for not recognizing her sacrifice. “On the one hand, you want me to be sympathetic to your good nature in which you are a very giving person, and yet, on the other hand, you want me to help you be more protective of yourself and you want me to help you understand why it is hard for you to assert your own needs.” In this compound statement, I am both gratifying her need to be seen as a ‘nice person’ as well as understanding her unconscious plea to help her be a more ‘self-protective’ person. As with all of therapy, there is a constant duality. There is the duality of change versus stability and now we add on, by saying that one facet of this duality is the need to be  understood, which is part of maintaining stability, and the other part of duality, which is helping the patient understand himself,  the first step towards changing. It is this dance between support and challenge, which is the to and fro of psychotherapy. Nonlinear is the modern word for such a dance. The tension which ensues creates the dynamics of the experience. The wrong call, the wrong dance move, creates pain and suffering. The margins are narrow. The work is hard.

“The Price You Pay”

Martha Stark MD talks about helping patients understand the “price” of their conscious and unconscious choices in life. Megan, fifty-nine, constantly complains that she is always there for her friends, but her friends are never there for her. “You chose friends who are not as reliable or devoted as you are. That is very interesting.” I say, thinking about Dr. Stark’s point of view that  choosing relationships which lead to disappointments is the “price” paid for finding people who you otherwise find to be good reflections of your internal state. Megan, for example, seems to be pick friends that her mother, age eighty-six, would approve of. Megan thinks about re-creating her mother’s life which includes re-creating a friendship circle like her mother has. This desire to emulate her mom, comes with the “price” of picking folks who do not value loyalty or devotion in a friendship. Creating a consciousness about this “price” allows Megan, in this case, to see how she engineered her own unhappiness and she is not the victim of horrible people in the world who just “don’t care about anyone but themselves.” Every decision, every turn of events in life, is a constant weighing of pros and cons, a constant evaluation of “price”. Megan can see that she can compromise on her car, by buying a car which is not her ideal, but which fits her budget, and yet this concept, when it comes to relationships, is more elusive. Every relationship, in fact, does involve such a compromise. We never get all of what we want, and hence our job is to choose what is most important, to prioritize. Simple and complicated, at the same time, since so much of this “prioritization” is outside of our awareness. When a great deal of our decisions are based on keeping our parents happy, then we need to take a closer look. Again, that is obvious and not obvious. We will grow to resent our relationships if they were not what we wanted in the first place. Once again, the problem is almost always within and not without.

 

Scary Feelings

“How are you?” I ask, Whitney, fifty-seven. “I don’t know,” she responds, as she says each time I see her. “You need not to know your feelings,” I say, changing her words slightly to give her more of a sense of agency. It is not that she does not know her feelings, as she believes, as she takes a passive stance, but rather, it is more that she NEEDS not to know her feelings, since she is scared by them. Whitney’s husband of twenty-two years passed away two years ago. Her kids are grown and independent. She has a boyfriend. She works as a therapist. Yet, her feelings remain “not knowable” to her as she walks in my office. She then agrees. “Of course, I need not to know my feelings. I miss my husband terribly and so if I get too close to those feelings, I will hurt my boyfriend’s feelings, and my kids think I should be over that by now.” She says, defending her position of detaching from her feelings. “Yes, but you can feel them in here,” I say, pointing out the obvious, that my office, this play space, enables her to be free to talk about her feelings without fear of judgment or hurt feelings. “Yes, but then I have to leave, and my feelings do not just zip up as soon as I leave your office,” she reminds me that the transition out of my office can be quite challenging and she has to be mindful of that. “Yes, I understand that, but the price you pay for being detached from your feeling is also a large one.” I say, pointing out that there is a challenge in  both feeling and not feeling her inner world. “What do you mean about the price?” she asks, wondering about my choice of words. “The price of not experiencing the texture of life.” I say, even though I know she knows that. “I think it is worth the price,” she responds, keeping my choice of words. “Well that is where you are today, but you might not feel that way tomorrow.’ I say, pointing out that the ‘price’ might change for her with time and distance from her husband’s passing. Making her aware of the “price” is making her more conscious of her unconscious decision not to feel her feelings. The word price is carefully chosen to suggest that she is deciding how she interfaces with her world. Agency is established. Victim-hood recedes.

“Resistance As A Failure to Grieve:” So Says, Martha Stark

“Genuine grief is the sobbing and wailing which express the acceptance of our helplessness to do anything about losses. If instead, we whine and complain, insist that this cannot be, or demand to be compensated for our pain, then we are forever stuck with trying to redeem the past.”  Sheldon Kopp, “The Refusal to Mourn”

Martha Stark MD argues that the challenge of living is understanding our losses. In trying to avoid the pain of loss, be it the loss of a nurturing mother to alcoholism, or the loss of an attentive father due to workaholism, one develops, unconsciously, techniques to distract ourselves from this understanding, and hence from this pain. These techniques include anger, intellectualization, isolation of affect, reaction formation and denial. We employ these defenses which “defend” us from feeling distraught and hence they have a utility. On the other hand, as Dr. Stark says, “there is a price to pay.” This price is often one of feeling empty or unsatisfied. It is as if our brain is deciding that it would rather feel empty than helpless. Another way of looking at this is that the defenses were helpful at one point in our lives, such as childhood, when there were few other options available to us, but as we enter into adulthood, we need to shed our defenses and develop a maturity which allows us to look at our lives as they have been, rather than how we wished they were. This realistic appraisal of our life is one of the “goals” of psychotherapy, because it is in this understanding that we can accept ourselves, and hence accept others. When we live in a world of wishes, then it is very challenging to find people who can fulfill our fantasies. Crushing disappointment is inevitable and hence the loneliness is profound.

Courtney, fifty, very attractive, very intelligent,  is single, never married, never had a relationship longer than one year, never lived with a loving partner. She has lived alone for twenty-five years. By her account, she “has not found the right person, despite multiple approaches to meeting people and dating. She is placing the problem externally. She does not ponder if she is pushing people away. She would get angry if you suggested that. Her anger is clearly a defense against feeling like her neediness is so great that no one can possibly satisfy her. She avoids this notion because she would need to reflect on her childhood, which although was one of affluence, was also one where she was not “seen” as a separate developing being. As such, she felt the need for affirmation, but since that need was never gratified, she was left to feel, as a child,  deeply isolated and alone. She has carried that isolation feeling into adulthood where she now feels, unconsciously, that she should continue in this lonely way, since, she behaves as if she believes that since her mom could not “see her,” so no one else can either. In order for Courtney to find a relationship, she would need to grieve the mother she wished she had; the mother who took pride in her accomplishments and understood her in an empathic way. Instead, Courtney defends her mother by saying “no one is perfect, and I had it pretty good.” Courtney’s problem is not that she is single, but that she has not formed a narrative of her life which is consistent with how she has felt throughout the years. Her narrative is a way in which she “lies” to herself and hence she remains confused as to why, as she says “I am fifty and I am not married. I just can’t believe that.” In the honesty of one’s feelings is the experience of  clarity and the hope to move forward.  This is what grief does. There is the painful “missing” followed by carrying the memory as a building block to a deeper existence. Without this grief there is a shallowness and a confusion. Understanding is often grieving. This is one of the many challenges in the work.

Push/Pull: The Compromise in Psychotherapy

1912 Freud said “Resistance represents a compromise between the forces that are striving toward recovery and the opposing ones.” Glen Gabbard MD added on to say “the way the patient opposes a therapist provides valuable information about the patient’s intrapsychic life.” He continues “circling the wagons against the potential intrusion of the therapist may seem like the safest course of action.” Returning to Freud, he found that what often inhibited free association was the feelings about the analyst. Thus, the notion of transference as resistance. At the same time, transference revealed how the past repeated itself in the present. As Friedman says transference is the “necessary (and troublesome) vehicle conveying unconscious material into the field of analytic operations.” The task, Freud came to state, is not to get rid of the resistance but to help patients develop a divided consciousness so that they could observe and reflect on their minds. In this divided consciousness there is permission to have wishes, fantasies, conflicts and desires.

Marissa, sixty-four, excitedly talks about her visit with her son and then suddenly she falls silent. “I noticed that you stopped talking right after you mentioned his girlfriend. Any thoughts about that?” I say, seeing her silence as a resistance which was triggered by her uncomfortable feelings with her potential future daughter in law. In making this comment I am encouraging Marissa to be curious about the occurrence of the silence/resistance right after a specific event that is being recounted to me. If I had a deeper relationship with Marissa I might suggest that her silence is related to her fear that I am being judgmental. If I made such a comment, then I would be working in the transference. The compromise here is that her silence when she brought up her son’s girlfriend was a hint, if you will, that this was a subject that has deep meaning for her. She wanted me to know this was a sensitive topic, but the way she let me know was by going mute; it was indirect. In the same way an “exit line” is a compromise between opening a discussion of an important topic and then not having the opportunity to explore it in that moment. The therapist’s  understanding of the challenge of being a patient, allows for patience with the “chosen” compromise.

Talking Back To The Talkback

 

So, I studied CS Lewis. I reviewed Freud’s life. I watch the PBS Special entitled “The Question of G-d.” When it came down to the last few days, I mostly worried about my hair. This was a new and exciting experience for me, and as such, I felt like I had to narrow the field into one particular anxiety. In an odd way, that seemed to calm me down. Speaking to professionals is comfortable for me. I have a sense of why they come and what they want to hear to make their time feel well spent. This opportunity presented different challenges. I did not have a grasp as to who was in this audience. Some, a few, came to support me, and for that I was very grateful. Yet, the majority, I assume, were West Los Angeles theater goers who came to be entertained, but their idea of enjoyment was not so clear to me. How much did they know about Sigmund Freud or CS Lewis before they entered into this ninety minute sword fight? I made my best guess, as I approached the play as a drama which illustrated the conflict of ideas, as opposed to action. The mental game, if you will, provided the action in the mind. My five minutes on stage before the actors came on, felt long and short at the same time. I had a lot of ideas, but I also felt braced for the transition from speaker to moderator. The actors did arrive on stage, and I reminded myself that my job is to repeat the question, which sounds much easier than it actually is. No worries though, since the actors repeated the question they wanted to answer, and so I was left to hold my tongue from my urge to make the discussion linear. The actors exerted their charm. I was, as I expected, mostly a tree at this point. The evening concluded and then I could relax. Yet, like ending a good book, or leaving a good movie, I was left bereft. I so enjoyed the intense focus of trying to understand the life and work of two great thinkers in the twentieth century. Of course, I could continue my quest, but without the thought of standing up in front of five hundred strangers, the push to learn more has dissipated. My début is complete. I am open to more opportunities…..hint, hint!

 

CS Lewis: Known as “Jack”

 

According to Wikipedia, “at the age of four, shortly after his dog Jacksie was killed by a car, he (CS Lewis) announced that his name was now Jacksie. At first, he would answer to no other name, but later accepted Jack, the name by which he was known to friends and family for the rest of his life.” This vignette intrigues me, as I continue to prepare for my upcoming Talkback. My contention is that CS Lewis and Freud are each representing different aspects of their own belief systems. In essence, they agree with each other, they maintain conflicting opinions, but, for the purposes of a writing career, for the purpose of establishing a place in history,  they articulate only one side of the argument about G-d, sexuality and the meaning of life. Given that point of view, I take from CS Lewis, insisting on being called the name of his suddenly deceased dog, is a way in which he lives out  his belief that death is not permanent, so long as someone keeps your memory alive. So much of the discussion about the meaning of life, stems from one’s view of death. If death is final, then fear might ensue. If death is one step on a longer journey, then perhaps one can relax into life. If CS Lewis could think about his dog every day, as he is called by his dog’s name every day, then Jacksie is still alive, yet in a different way then before he was hit by a car. As February represents a month of memories for me, of a particular person that I was close to, who is no longer with us (or me), I, too, am aware of how important it is to keep the discussion, and hence the person, long away from our living world, alive in a way which still has meaning for me. I imagine telling others to now call me by the deceased person’s name. I can feel how special this would make me feel. I can feel that I was not just living my life, but theirs as well. The name would represent a “containment” as Winnicott  would say. In this “containment” there is peace. CS Lewis, Jack, was on to something psychoanalytic; a fact he may take issue with. May he rest in peace.

“Exit Lines”

“Exit lines” as Glen Gabbard MD likes to say, or “doorknob comments” are another “royal road” to the unconscious. The comments as one leaves the therapy office are often so revealing, as this is the opportunity for the patient to get the last word, without time for challenge or deeper thought. “You got up early this morning,” one fictional patient says at the end of our 7:00 am appointment, making me think that in her mind, it was hard for her to come today. Maybe she wanted me to appreciate that she made a large effort to make this early time. Alternatively, maybe she wanted to show appreciation for me making time for her. There is always the question of bringing up the “exit line” at a future session, but by that time, the feeling in the room is gone. There is power in the “exit line” as it resembles getting the “last word” in on an argument. It is the final punch at the end of a long fight. It leaves me with wonder and curiosity. Sometimes it leaves me with difficult feelings which I am not able to discuss with the patient until the next session so I am left to stew. Universally, it helps me understand a very important  dynamic in the relationship.

See also….http://shirahvollmermd.wordpress.com/2011/07/11/the-doorknob-comment/

Wanting Change/Wanting Stability: Push/Pull Continued

As Bromberg says, every patient enters into the consultation room with the internal dialogue saying “I’m here because I’m in trouble, but the trouble I’m in is not something I need rescuing from, even though it may look that way. However, I fully expect you to try to cure me and I’m prepared to defeat you. I don’t have an illness; I am my illness and I won’t let you cure me of being who I am.” In other words, the patient comes, as Phillip Bromberg PhD continues, “for a secure nest in which to stay safe and accepted forever, not having to bear the discomfort of the new and unfamiliar, while at the same time, looking for metamorphosis (growth, movement, transition).” Bromberg continues to describe this paradox by suggesting that the fear of therapy is represented by Prometheus, the Titan who in trying to create a better civilization, ultimately was punished and tormented. Bromberg says that therapy moves along by “enhancing the patient’s perceptual capacity….creating a change in the structure of his personality organization.”

Clarissa, fifty-five, an endocrinologist, wants to retire. She has plenty of financial resources, so that is not the issue. What stops her is her perception that her parents will disapprove of that decision. “My parents immigrated from India so that I could be a doctor. They would be devastated if I stopped working. They would feel that they wasted their life supporting my education, only to see it used for such a brief period of time.” Clarissa says, clinging to her need to please her parents, while at the same time, hoping that our work together will free her from the shackles of parental affirmations. “You have quite the dilemma on your hands,” I say. “You can please yourself or you can please your parents, but in this moment, it feels impossible to do both, or even to reach a compromise.” “There is no way I am going to upset my folks,” she insists, as if I have just told her to disregard their opinion. “I can see that option feels very uncomfortable for you,” I say, again, highlighting her conflict. Clarissa’s inner tension has come to light in my office. She is at war with herself. I am not championing her to retire, nor am I supporting her belief that she needs to keep her parents content, but I am listening to her struggle and helping her consciously make decisions which will impact her future. Her dynamics with her parents have been life-long. Changing those relationships are really scary. At the same time, Clarissa is flirting with the option to have a life of flexibility and relaxation which she has longed for, for many years. I do not know how she will sort out her conflict, but I am interested in helping her explore this internal process.

 

See also…

 

http://shirahvollmermd.wordpress.com/2013/01/31/psychotherapy-pushpull/