This is for my next and final class for this series. A countertransference discussion. Stay tuned.
Posted by Dr. Vollmer on February 23, 2017
This is for my next and final class for this series. A countertransference discussion. Stay tuned.
Posted by Dr. Vollmer on February 22, 2017
Freud initially thought that transference was an impediment to treatment, but as the years went by, he began to “discover” that understanding transference was the holy grail of treatment, meaning it is the part of psychotherapy which creates personality change. In other words, how we feel about ourselves, based on early relationships is often recreated in our meaningful relationships and if we form relationships which are harmful to our self-esteem, then we need to reformulate our opinion of ourselves, based on a new relationship. This new relationship, in the form of psychotherapy, allows the patient to examine how he projects on to others ideas from his past, and in so doing re-affirms his previous notion that the world is mean/cruel/withholding towards him. If the patient can see his own projections then he can open himself to new possibilities which includes relationships in which he feels valued/loved/cherished. This is a simple notion, which in practice, requires many hours, in fact, at times, many years of treatment to see how deeply held beliefs can be faulty and damaging.
Joe, thirty-two comes to mind. “I am going to disappoint you,” he tells me with great certainty. “Why do you say that?” I ask, thinking about his declaration. “I disappoint everyone in my life. I just do.” He says with little elaboration. “You mean you disappointed your mom,” I say, thinking that he is referring back to his earliest relationship in which he felt terrible sorrow for not making his mother happy, and in fact, disappointing her by not becoming a doctor or lawyer. “It must be terrible to feel that you disappoint people,” I say, thinking about what it is like to think that you will cause a significant other deep pain. Joe starts to cry. His tears speak volumes to his sense of inevitability that he disappoints; that is just what he does. “Maybe you disappointed your mom, but that does not mean you disappoint everyone,” I say, stating the obvious, but also knowing that it needs to be stated. “The issue is that you feel like a disappointment, and that is a terrible burden to bear,” I say, trying to help Joe understand that he carries around this painful feeling that he cannot shed, since he is so attached and identified with his mother. “I wasn’t abused,” Joe says protecting his mother. “Not in the traditional sense, “I say, “but you weren’t cherished for who you are, and that is a different kind of trauma,” I say, trying to help him understand the childhood feelings he carries forward into adulthood. “I don’t get it,” he responds impatiently. “Yes, we have more work to do,” I say, knowing that this is a painstaking process.
Posted by Dr. Vollmer on February 17, 2017
Distortion is another word for transference in that we mis-read social cues based on past experiences and not based on current interactions. Barb comes to mind again. She is the 50ish year old woman who suffers from always feeling persecuted and treated poorly. She tells me that I “make her go to her appointments with me,” as if somehow I have that power over her. Her issue is that she attributes to me, as an authority figure, the power to condemn her if she does not coöperate. She fails to see that it is her decision to be in treatment, and it is her decision to stop or decrease the number of our sessions. How she managed to recreate her experience of feeling persecuted with me, is how Freud described this phenomena called transference. At first, he saw it as an obstacle to treatment, but over time, he came to “discover” that understanding the transference was the holy grail of treatment. In other words, if I can help Barb see how she makes her world play out such that she always feels boxed in, then I can help expand her mind such that she can see the situation in new and meaningful ways. Eventually, I believe, Barb will see me as someone who offers her a safe space to examine the inner workings of her mind, but for now, I am another persecutory figure who makes her life feel frustrating and that results in chronic feelings of anger. As we examine this repetition of feeling which occurs in my office, we can begin to understand how she unconsciously makes her life such that she feels she is a slave to other people, a repetition of childhood feelings of being a slave to her mother. As Freud said, we repeat in order not to remember, and so with Barb, understanding this repetition will take a great deal of time, because remembering her childhood feelings is going to feel deeply sad and despairing. The safety of our relationship allows for those feelings to bubble up, but it will still take time and care, on both of our parts, for her to allow herself to get there. Transference is a simple concept, but in the therapy room, it is complicated by very challenging feelings. Still, privileging the transference as the key to therapeutic gain is the concept, we, as mental health professionals, must hold on to, as this is where we need to guide treatment for psychic pain. I never tire of saying this, as the importance cannot be overstated.
Posted by Dr. Vollmer on February 16, 2017
How do you teach this concept? I wonder. We repeat behaviors from the past and impose them in the present, and in so doing, our behavior is out of proportion to the present situation but our behavior makes sense in a historical context. In other words, all actions are reactions to past experiences as well as reactions to current experiences. So, if Barb feels that I am being mean to her in session, I may in fact be mean to her, and/or she may get triggered by something I said which reminds her when her mom was mean to her, and in that situation, I am the trigger, but she does not see that immediately, so she feels very hurt and disappointed by me. With time in psychotherapy, Barb and I can come to see how she felt my behavior was “mean” and she can also talk about how it reminded her of how her mother treated her when she had a boyfriend that her mom did not find suitable for her. As we unpack her feelings of hurt and disappointment, Barb comes to see how in other parts of her life, particularly in her close relationships, she often feels hurt and disappointed, and this may, in fact, be her carrying forward painful experiences she had with her mother. “Maybe I am too hard on my boyfriend,” Barb says with the suggestion that her insight into her behavior is slowly expanding. Helping Barb understand how she feels that everyone will treat her as her mom did, opens her eyes to the understanding that maybe she carries with her painful assumptions, which, when tested out, turn out not to be true, but without opening her mind to the fact that she is making assumptions, she then constantly feels hurt and disappointed. Through talking about the transference, Barb has the opportunity to grow emotionally, such that she can begin to understand how she can take a benign comment, such as “I wonder what you find attractive about your boyfriend,” and given her history with her mother, she hears “what on earth could you like about that man?” In her mind, she is prepared for a judgmental, critical attitude towards her boyfriend, such that she cannot entertain the possibility that my question is one of curiosity and not criticism. Clearly, tone is critical in this discussion, but even with a neutral tone, there is the sense that Barb is so convinced that the discussion is going to be antagonistic, and as such she must go on the defensive when talking about her boyfriend. This is a simple notion of transference, but one which I hope will illustrate the point. The point being that by reacting to our past and not our present, we, who have been hurt in childhood, continue to feel the pain and we do not open ourselves to feelings of acceptance and love. In essence, understanding transference can be transforming, creating a life-changing and maybe even a life-saving experience.
Posted by Dr. Vollmer on February 14, 2017
Tomorrow, in my Psychoanalytic Technique class, the topic is silence, and what to do about it. The meaning of silence, the challenge of silence, and the patience with silence will all be ripe for discussion. We will springboard from John Steiner’s work about psychic retreat, where he teaches us that patients often withdraw into silence as that is a safe space; safe from anxious and depressive feelings. More to the point, many people, particularly males, who withdraw in social circumstances, due to fear of having feelings, are often labeled as “on the spectrum” when in fact, they are using a defensive psychological organization to cope with psychic trauma. The misunderstanding between trauma symptoms and “spectrum” symptoms is particularly upsetting to me, because it is one thing to understand a patient as trying to cope via withdrawal as opposed to understanding a patient as incapable of nuanced feelings and social skills. This distinction is critical and it takes time with patients to really understand this difference. A severely traumatized individual will have no friends because he/she is frightened of the feelings generated by friendship, and this can seem identical to the “spectrum” individual who has no friends because he/she is not able to have the reciprocity required in relationships. Two fictional examples come to mind. One, a young male, isolated, lonely, and despairing, has never had friends because he is antagonistic and arrogant, by his report. In the intensive treatment he is often silent, requiring what I have called “hide and seek” such that he hides and I need to seek out his psychological state of being. Without my seeking, he remains hidden. The meaning of my seeking is that it serves to reassure him that I am indeed interested in his mental state. The issue of how long to remain silent as opposed to “seeking” him is the art of my work. The second fictional example is a fifty year old woman who often says, ten minutes into the session “that’s it. I have nothing more to say.” This seemingly abrupt ending to her thought process has puzzled me for many years. It is clearly defensive in that she protect herself from deeper intimacy with me, but at the same time, she is frustrated by her inability to deepen her treatment. Her psychic retreat would not be confused with “spectrum” issues and yet, she isolates herself in our sessions such that there is no reciprocity. She does not play “hide and seek” since she simply hides from me, in that “she is done”. She does not leave however, as she waits, perhaps with unconscious hope, that there is more to be said. Our work is focused on understanding these retreats and how historically speaking, these withdrawals saved her from feeling unloved in her family. Both these fictional examples illustrate how silence is as important as verbal output, as they both convey how the patient organizes his mental interior and as a result how the patient can share, or not share, those very private experiences. John Steiner has helped us a great deal with talking about the quiet, the dark space, if you will, within the psycho-therapeutic hour.
Posted by Dr. Vollmer on February 9, 2017
Still thinking about the analytic surface…just sayin’
“Tell me your story,” I like to say, which leads to a confused look. “The whole story?” A 20-year-old patient named Libby responds. I think 20 years is not that much, but to her, she thinks the summary of her life is an impossible task. The open-ended question is designed to see where the patient will begin. Will she tell me where she was born, whether her parents stayed married, or will she focus on her friends or her academic life. As she constructs a narrative, it is my job to formulate hypotheses about why she is in my office. Of course there is the stated reason she came, but there are many unstated, and unknown reasons she is there as well. I am looking for, what some authors would term, “the analytic surface,” which means where to take her narrative and go deeper. Libby spent a great deal of…
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Posted by Dr. Vollmer on February 8, 2017
Tonight I begin my new class in the psychoanalytic psychotherapy program at the New Center for Psychoanalysis. My class is on clinical technique, about what do you actually say when you are in the room with someone, if you are attempting unconscious exploration. In the past, this has been a stimulating class to teach with bright and interesting students and I have always felt that I got back more than I gave forward, and yet, many people have asked me why I don’t get paid for this activity. Tradition is the short answer. Those who taught me, whom I am eternally grateful to, were not paid, so I tell those interested that I am paying it forward. Upon further reflection, though, I wonder if the quality of teaching would improve if there was a stipend associated with the activity. Would market forces create a healthy competition where only the best teachers were asked back, and in turn, the teachers would have incentive to be on the top of their game? In the psychoanalytic community, this discussion is taboo. Like so many traditions, the “young” people are not supposed to question older, more established practices. Like the movie “Moneyball,” the senior members are quite certain they are making the best decisions, even though big data showed that, in fact, their “traditions” failed them. As a medical student, doing rotations in different clinical settings, I learned quickly that the practice of medicine was highly dependent on the reimbursement system, where, in the days before productivity measurements, doctors who were salaried tended to work less than doctors who were fee for service. This seems obvious in that if someone is paid the same whether they see ten patients or twenty patients, then they are going to argue to see ten patients, and vice versa. Reimbursement systems, like all behavioral systems, impact behavior, and physician behavior is included in this paradigm, of course. So, am I saying that I would be a better teacher if there was a salary associated with it? I think so, but I am not sure. It is an interesting question.
Posted by Dr. Vollmer on February 6, 2017
30 students, different backgrounds, all engaged in a lively discussion of what it means to have meaning, and how patient’s come to us (clinicians) in search of meaning because either they have lost meaning or they never felt they had any. The discussion was broken up into to parts. Part one involved the fictional tale of a middle-aged woman who could not find any inner peace. Externally her life seemed enviable, but internally she never felt any traction. To say that she is depressed misses the point, we discussed, as her disposition was cheery, and her self-care was excellent. Yet, she never felt that what she did really mattered, either to herself or to others. In this fictional case, we explored her childhood roots, her exposure to her parents and our presumption about their internal world. We talked about what it meant to her parents that she was born, and how downstream that caused her to feel unimportant and lost. The students asked lively questions about how to help someone have meaning, when no obvious intervention seems to take hold. The obstacles to having meaning were discussed, as in this tale, the obstacles had to do with her internal alliances to her family in which if she did not mirror the meaning her parents put on the world, then she felt a huge sense of unconscious betrayal and so she could not latch on to new passions. The second part of the morning involved another fictional case, this time of a young adult who was trying to find his way in the world and the obstacles he felt in doing so. Issues of gender, sexuality, professional identity were all mentioned, again in the context of trying to make his parents proud of him, while at the same time developing his own sense of meaning. The relationship between meaning and attachments were discussed in length, as most meaning is made through both conscious and unconscious attachments in that passion is derived from feeling like one key person in your life is going to be very proud of you and in that mental image, enthusiasm is born. The underpinnings of happiness were discussed in a positive psychology model as contrasted with the persistent focus on the underpinnings of distress. Meaning is made if the person can have his life make sense to him. That is, often, but not always, a tall order. And so, my next class is on my mind. How about Healthy Happiness? It is a thought.
Posted by Dr. Vollmer on February 2, 2017
How do you teach psychotherapy? What does it mean to supervise? Who should teach psychotherapy? I am involved with this question at both psychoanalytic institutes where psychoanalysis is taught and in psychiatric residencies where psychiatrists are taught. In both institutions, the teaching is done by those willing to teach, and not necessarily by the best teachers. Further, as with all work environments, friends are tapped first, again based on personal relationships and not necessarily based on what is best for students. And despite my continued plea for humility in this field, the sad truth is that we don’t know how to teach it, and student satisfaction is no proof of good teaching. Like psychotherapy itself, we have no clear guidelines about what to do and we have no clear guidelines about how to measure our effectiveness. My answer, not surprising to my readers, is to accept that psychotherapy is an art, and as such, those who choose to enhance themselves our signing up for art school, learning ideas and concepts, but no firm path to doing the work. Further, I value my credentials and I think those are important, and as such, those who teach, in my opinion, should have completed training programs which are recognized by the field, such that dynamic psychotherapy should be taught by graduates of psychoanalytic institutes since they have spent hours reading and discussing psychoanalytic concepts, and without this rigor, the depth of discussion is limited. Yet, since teaching is mostly a volunteer activity, few leaders want to impose restrictions, and so quality control is often sorely lacking. Politics is everywhere. Friends take care of their friends, and so opportunities are shared, sometimes to the detriment of students. Navigating around these waters is the art of life. Recognizing that merit based promotion is often rivaled by cronyism. We help our patients wrestle with these ideas, and so as therapists, we should understand it. I think we do, but it is still a challenge.