Hedda Bolgar PhD: A Life Well Lived!

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

Click Here to Read:  A Centenarian’s Retrospective on Psychoanalysis - An Interview with Hedda Bolgar Interviewed by Michael J. Diamond in Diamond, M. J. and Christian, C. (Eds., 2011) The Second Century of Psychoanalysis: Evolving Perspectives on Therapeutic Action. Dear LAISPS Colleagues, Dr.…

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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.

Volunteering? What Does That Mean?

 

http://shirahvollmermd.wordpress.com/2013/03/01/should-university-teachers-be-paid-to-teach/

 

I return to the issue of volunteer teaching, thinking about what the word volunteer, actually means. Clearly, working for no pay is the first association to the word ‘volunteer’. Yet, the second, and sometimes most important association to the word ‘volunteer’ is the notion that one is helping out those who cannot help themselves, like volunteering in an animal shelter, because the animals need the attention. Where is the line between ‘volunteer’ and ‘slave labor’? I wonder. Plus, one can volunteer their time, but expect to be ‘paid’ with appreciation and/or respect. If this ‘payment’ does not happen, resentment ensues. What about love of the work? One could volunteer because they love the task, but committing to a time and place could be a strain, no matter how much one loves one’s work. Then, there is the peer group. When one volunteers along with others, then the socialization is part of the “pay-off’. Many docents, for example, not only love the museum, but they also love their colleagues. So, how does one decide where to put their volunteer chips? Like any decision, it is a pro/con dilemma, along with the opportunity cost of being limited by time and energy. Teaching at a University on a voluntary basis is tricky. It could be a set-up for low-respect and hence high resentment. On the other hand, access to bright ‘young’ things is fun and interesting. Working in parallel with W-2 folks could also be the seeds of ill feelings, but on the other hand, it could give the  freedom of leaving at the end of every class. Volunteers need to be celebrated, both to encourage more people into the field, and to stroke those who choose to put their chips in that particular bucket. To volunteer is to expect to be celebrated, in one way or another. To ask someone to volunteer is to promise, directly or indirectly, to celebrate them. Missing that point hurts the institution asking for volunteers. Nothing is free in the world. That saying, although trite, fits. We give in one way, always with the expectation of reward, but in the case of volunteering, it is not a financial reward, but rather a narcissistic, or self-affirming one. I state the obvious, and yet, sometimes this is missed.

PMDD Walks Into DSM 5

 

PMDD, premenstrual dysphoric disorder is currently a diagnosis in the appendix of DSM IV, meaning that if a physician believes the patient has PMDD, then he/she must write Depression NOS (not otherwise specified). At the same time, there are currently drugs approved for PMDD, despite the fact that it has not achieved diagnostic status. Well, come May, 2013, after Bill Clinton speaks to the American Psychiatric Association in San Francisco, California, the DSM 5 will be announced and the criteria for mental illnesses, in the United States, at least, but probably around the world, will change, including more folks, causing a large stir about the wider scope of psychiatric disease.  DSM IV came out in 1994, making almost ten years of a classification system, which for the most part, has not matched the explosion in psychopharmacology. DSM 5 has taken a long time, mostly, as I can tell, because the debates over the diagnostic system were tense. So, it is very likely that PMDD will hit the light of day and now women who suffer from terrible irritability before their periods will merit a psychiatric diagnosis. The good news is that there will be more acceptance of the biology of mood swings, and then hopefully more acceptance of psychopharmacological interventions. The bad news is that some women, through no fault of their own, will be labeled, potentially increasing their premiums for health insurance, life insurance and disability insurance. The triad of emotional lability, irritability and anger, during the luteal, or last phase of the menstrual cycle, in about 2-5% of menstruating women, had been validated in the research over the past 20 years. This additional research, the DSM 5 committee argued, gave good reason for PMDD to be “promoted” to  a diagnosis and out of the appendix. PMDD now joins the ranks of a full blown mood disorder; it is in parallel with bipolar disorder, which also has prominent mood lability and irritability, but PMDD symptoms cease on the first or second day of menses. Plus, PMDD comes with physical symptoms of bloating and breast tenderness, making it easily distinguishable from bipolar disorder. What about heritability? You ask, knowing that most psychiatric diagnoses run in families. The heritability of PMDD ranges from 30-80% which is indeed, a wide range, but enough to merit a full diagnosis. What about treatment? PMDD is ameliorated with an SSRI (Prozac and his cousins), quickly, unlike when an SSRI is used to treat Major Depression. Also, intermittent or continuous treatment are both helpful, suggesting that a constant blood level is not necessary, but rather more serotonin in the premenstrual or late luteal phase, seems to do the trick. So, the world will change in May, 2013, the psychiatric world, that is, and hence all of us who work, love and/or experience others who suffer with negativity, irritability, and quickly shifting moods. Now, women who cycle in and out of these mind states will be legitimized on the one hand, and maybe, but hopefully not, stigmatized, on the other.

Should University Teachers Be Paid To Teach?

I grant you that at first glance, it seems obvious that Universities should pay folks to teach, since students are paying to learn. Yet, most of us are familiar with the fact that University Professors are paid to generate revenue, either through grants or, in the case of medical education, through patient care. Hence, teaching is really a “side business,” if you will; something University Professors do, either because it is part of their job description, and/or because they love it, but not for purposes of career or income advancement. Now, what happens if students need to learn, but the University has to hire outside people to teach? Then, the teacher could be a volunteer, or they could be paid a stipend. Let’s suppose the teacher volunteers. In this case, how do the students view this class? Does it get the same respect and attention as classes done by full-time faculty? Or, let’s suppose the teacher gets paid a “fair” salary. In this case, do the students come to appreciate the value since the University is putting down their chips on something they feel is important? Management flows downwards and students feel the difference. If teaching is valued, then the students and the professors are higher quality. When teaching is thought of in the second tier of priorities then the students are less interested and the teachers drag their feet. In the midst of these troubles, there are those gems of teachers who inspire students beyond what they might have dreamed about before entering the class. These folks give hope for all.

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.

 

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!

 

“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/