Time

      I have been taking time to think about time. In my work, being on time is critical. To show up on time is to show respect. There are many aspects to why people show up on time, and why people are chronically late. Here, I want to focus on my timeliness. In general, I run on time. I try to get to my office with time to spare, but like everyone else, there are times when this is not possible. The meaning of my being on time, or of my being late is always different. That is, sometimes I have an understanding why I am late. Other times, my patient “reads” into why I am late. This “reading” becomes grist for that therapeutic mill, but it does not excuse me for being late.

    I understand that it is a large effort for my patients to come to me. They have to leave what they are doing, they have to battle traffic,  find parking, and then they have to negotiate what feels like two flights of stairs. For me to be late, knowing the effort they make to come, feels horrible. So, I work to be on time. Yet, I am aware that the majority of physicians run late. I recently went to a doctor where there was a pre-printed sign in the waiting room which said “the doctor runs 60-90 minutes late, please be patient.” I said to myself “why is it OK that he routinely runs late, and I, as a psychiatrist,  have to be on time?” I thought further, and I said to myself “I am in the business of building self-esteem, being on time is one way to show respect, respect builds self-confidence, so I cannot run late.”   

    Once again, I am left to reflect why I am a physician, and yet, my “rules” are not the “rules” of my medical colleagues. I would think that all doctors need to show respect for their patients. People come in pain and they want help. To keep people waiting, adds to their pain. How can that be OK? It is not. On the other hand, I know that for a doctor to run an efficient practice, he should schedule his patients for one of two times, 8:00 am or 1:00 pm. This way, all the morning patients come at once, and he can,  like working on an assembly line, see patients rapidly with no down time in between visits. One might say that this “assembly line” mentality is a function of greed. In private practice, the more patients one sees, the more money one generates.  I would argue that although that might be a factor, it is also easier to work without a break. One gets into a certain patient-seeing zone and it helps if one can stay in that zone for the morning without having to transition to another mode.  Still, does efficiency,  staying in the zone, justify keeping patients waiting while they worry about what is wrong with them?

   I waited for my doctor for an hour. The sign prepared me. The person who referred me also warned me. I did not like it, but I trusted that I would get good medical care, and that is what I wanted most. Yet, I sat there thinking that I could never feel OK letting my patients wait for me for 60-90 minutes. Managing expectations is important. Clearly, if one expects to wait, then one does not get as angry. However, there is a certain message  in waiting that the doctors’ time is more important than mine. That does not feel good. I run on time, so if I am a few minutes late, my patients will get concerned. They are not used to that. But, it is not all about expectations,  and it is not all about respect either. Timeliness  is also about a certain mutuality in our relationship. My time is important, and so is theirs. There is something nice about that kind of reciprocity. The effort to be on time is worth it. My medical colleagues have a lot to learn.

“I Feel Like A Corpse”

 

      Tim, a 44-year-old, long-term patient (identity disguised), said “I feel like a corpse”. I was speechless. I wanted time to ponder what he meant, but at the same time, I know that  it can be painful if I allow for a long silence after that disclosure.  Is this depression? I wonder. Do I have to call it anything? Should I start thinking about medication? Should I wait to see what he says next? I am flooded with unsettling feelings. I want to help, but I am not sure what to do. 

   On the surface of things, Tim has a good life. He is healthy, his family is healthy, and he does not have financial woes. The most difficult part of Tim’s life is his marriage. He feels demeaned and dismissed by his wife. For the past five years that I have known him, he has had overwhelming fatigue. Numerous physicians have ruled out cancer, autoimmune diseases and organ failure. I understand this lethargy to be a result of the verbal abuse that he experiences from his wife. The constant criticisms seem to literally suck the life out of him. As I think about this, I understand that a feeling of fatigue would progress to feeling like a corpse. His life has gotten worse, but the nature of his distress is the same. He is living in a verbally abusive environment, such that he no longer feels any sense of vitality. 

    How can I help? I want to remind him that he does not deserve to be treated this way, yet I know that saying this, might help for a few moments, but  his involvement in this relationship runs deep and as such, my words will be superficial. I want to make him feel powerful. He does not have to stay with his wife. This is tough though because they have little children. How can I advocate for him to break up his family? I do not want to do that. At the same time, I want him to feel better . I also know that, his feeling like a corpse is not good for his kids. Ultimately, he needs to make big decisions for himself and his children.  My job is to help him untangle  these issues, but if he feels like a corpse, he does not have the capacity to untangle them now. So, my first task is to help him feel more energetic. How do I do that? Medication might help, but is that a good tool? I am not sure yet. 

    I continue to listen, and reflect. I begin to feel as helpless and powerless as my patient. There does not seem to be a way out of this dreadful feeling. I begin to think about practical solutions. I wonder if he had some time to himself , then maybe he could regain a sense of energy and enthusiasm for life. He says he has thought of that, but that his wife will be very angry if he does that. Maybe he has to cope with her anger, I say, but he responds that no, this will only make him feel worse. We are both back to feeling lost. 

    The session ends. He says thank you. I am not sure if he was being polite, or if he felt grateful for my understanding. I felt worried. I am not sure what I was worrying about, but the word corpse stuck with me. He had never said that before. No, I was not thinking that he would hurt himself, but I was thinking that he was trying to tell me just how bad things feel to him. He did not cry when he said it, but rather, he was flat, like a corpse, when he uttered those words. He did not just say he felt like a corpse, he acted like a corpse. I think of my cardiologist colleagues who put paddles on patient’s chests’ when their heart stops beating. Where are my paddles? How do I bring Tim back to life? I do not know, but I wonder.

Blogging: The Narcissism Of Our Time

“Do I need to remind you that I have a large internet following?”

My Audience

    Many people ask me who is the audience for my blog. My internal reaction is one of utter distress. I want to scream and say “I don’t know and don’t ask me”. However, I realize that this is the most important question for me to answer and as such, I am grateful for the inquiry. Over the past two and a half months, I have dwelled on that question,  getting stomach pains as the thought bubbles up in my mind. Today, the answer to the question is that I would like to target this blog to those who are curious about how I think about my work. I want to continue to take vignettes, based on real experiences in my office, and describe how these tales have deeper meaning, both for the person telling the story and for me personally. I want to talk about struggle and personal growth. I want to talk about the doctor-patient relationship, and in particular, I want to talk about how that relationship can help with the struggle. I want to weave in the role of psychotropic medications, when that comes into play. I want to expand my work beyond my office such that my friends, my past patients, my current patients,  my future patients, and those interested in psychotherapy and psychoanalysis,  can get to know how I conceptualize my work.  My hope is that these blogs will be illuminating and thought provoking. I also hope that, at times, my readers will experience some comfort in reading these posts in that the themes of human suffering are universal, and understanding the underpinnings of an emotional struggle can occasionally make it feel better. 

      I consider this blogging exercise to be an experiment. I want to see what happens. If, as I noted in my earlier blog entitled “Blogging: Changing Course,” I feel that my blog causes harm, then I will once again review this hobby. Of course, my concern is that by the time I see the harm it has done, the world of the internet will have created far too much exposure  for me to quickly fix the problem. As a result, I am mindful of the power of the internet, and I will try to be very careful with my subject. Once again, I rely on my readers to keep me in check. As I said, I am interested in the doctor-patient relationship. This blog has  made me also interested in the blogger-reader relationship, but writing about that relationship is for another time. Suffice it to say, my readers are very important to me. Thank you for being my audience.

Narcissistic Bubble

      I have thought about relationships as I work with a number of couples in my practice.  I have noticed  that when two people form a narcissistic bubble, then the relationship seems to have better fiber. What do I mean by a narcissistic bubble? Did I not say that I would use less jargon? Sometimes, jargon is helpful. Jargon gives us language to express an idea concisely. In fact, in this blog, I hope to create new jargon. I want to take the psychoanalytic concept of narcissism and extend it to couples work. In this way, I am still trying to focus my blog.

    Narcissism is love of oneself. The name “narcissism” is derived from Greek mythology. Narcissus was a handsome Greek youth who rejected the desperate advances of the nymph Echo. As punishment, he was doomed to fall in love with his own reflection in a pool of water. Unable to consummate his love, Narcissus pined away and changed into the flower that bears his name, the narcissus.

   I would argue that when one views another person, their significant other, or in the new lingo their “plus one,”  as a part of themselves then they take pride in their accomplishments, feel pain when the other feels pain, and watches their back.  One could call this love. Others call this attachment. I call it the creation of a narcissistic bubble. As I write this, I hear people telling me that sometimes these bubbles can be harmful. The boundaries could be blurred. The relationship could be unhealthy. To that I say, of course. Still, a couple has to form a narcissistic bubble to create a team. Each one has to see the other as extensions of themselves. This bubble formation creates a union which has strength and durability. The resistance to forming this bubble creates relationship tension and deeply hurt feelings.

     In further thinking about this, I see that a family, as I define it, is a narcissistic bubble as well. By that I mean that to take care of another human being, one has to feel personally invested. I would argue that all investments are narcissistic in that each person expends energy to see reflections of  himself. Some people call this enlightened self-interest, in that if one takes care of their children, then one is consciously or unconsciously hoping  that one day those children will take care of them. Although that may be true, , that is not the dimension that I am talking about here. I am highlighting the point that love involves a narcissistic attachment where one has to view the other person as an extension of themselves to form a connection. Another way of saying this is that all love is self-love. The problem comes in when the other person does not act in a way which is line with one’s view of oneself. When this happens, tensions ensue and there is a struggle to re-define the relationship and there is a struggle to redefine one’s self.

    The trite saying that one has to love oneself to love another, holds true. However, I am expanding this idea so that we can talk about loving another as a reflection of ourselves in the healthy sense of that love. Most people assume that when one views another as an extension of themselves, then that is unhealthy. Although it can be pathological, as with most things, it is all a matter of degree. When there is  a broad idea of this extension of oneself, then the attachment can be quite positive. On the other hand, when the extension is a very narrow concept, then the relationship can be quite stifling.

    We are born alone and we die alone and the world is a large and scary place. Bubbles provide a clear demarcation. Narcissistic bubbles help us cope.

Terminating Treatment

    This week, I have had two patients terminate, both suddenly, but not unexpectedly. I experience loss, fulfillment and wonder. The loss is obvious. Sitting with a patient, feeling what he is feeling, is an intimate experience. Having patients say goodbye is similar to kids going off to college. I hope that my patients have benefited from our work together. I imagine that they will think about what we talked about, although I am not sure. Mostly, I wish that their inner fiber firmed up such that they can weather the inevitable storms which lie ahead. Of course, I am still here for them, if they choose to come back. I also know that if they come back, the circumstances will not be good, so I do not wish for that. I want to stay in touch, but how this comes about is up to them. It is their decision whether to email me, call me or come in again for an appointment. I wait. I am in the passive place. I cannot talk about them, but they are free to talk about me. They can sing my praises or they can feel critical of our work together, or they can experience many contradictory feelings. Often times, I never know what goes on for them after they leave treatment.

    The fulfillment is vague. I feel like I have tried my best, and I want to believe that goes a long way. On the other hand, I am never sure how much of my feeling fulfilled is my projection. The messiness of my field makes it so that even if patients leave satisfied, that does not mean that five, ten, or fifteen years later, that they will reflect on their experience with me in a positive way. I live with uncertainty.

  The wonder is perhaps the most difficult feeling. I think about what happens to my patients in their lives, in their fantasies, and in their relationships. Once in a while, I call or email them to check in. I always do this with tremendous trepidation. I am not sure they want to hear from me. I wonder if they feel that my contact is one of interest or one of intrusion. My experience with calling old patients has been mixed and unpredictable. Some folks appreciate my call “out of the blue”. Others, through their tone, tell me that they feel odd and uncomfortable about it. For now, I have stopped doing that and I have returned to wonder. Sometimes, I hear follow-up of my patients in unexpected ways. Someone will mention an old patient in the course of a random discussion. Of course, I do not acknowledge my recognition, but I am always uneasy that my body language might give some clues. At the same time, I am curious,  so my ears perk up.

    I think about being a surgeon. I could say I did 500 knee replacements. I could measure my performance. I could then talk about the number of complications, and if my statistics were better than average, I could feel proud. Unfortunately, I do not have that pleasure. In this way, I feel more like an artist. I have done work, some of which is appreciated, some of which is dismissed, but each time, my creative juices have flowed and I have tried. I never set out to be an artist. I always thought of myself as someone who needs quantifiable goals. I do need that, but at the same time, I imagine that over time, that might feel unsatisfying to me. For now, I live with the messiness, wondering about a life with more certainty, but embracing the art form. Loss is never easy. Today, I mourn.

Blogging: Changing Course

    Welcome to my new WordPress blog. I hope you like my new  format. I am also going to change the content. Read on to understand my new course.  

      Since November, 2009, I have wandered into this blogosphere, not knowing what to expect. I became a movie critic, a book critic, a psychotherapy observer, a commentator on the state of psychiatry, a blogger on child development and parenting,  and I tentatively entered into the world of personal memories. I am now trying to develop more of a focus.  When I ask myself what I most like writing about, the answer is that I would like to continue to write about my interesting moments in psychotherapy. This answer, however,  leads me to the dilemma that although I want my blog to enrich my life and my readers’ life,   and sometimes that has happened,  it is also true that my blog has created some distress. Writing is a vulnerable process. I have  intense feelings about  being seen. This is a new and interesting experience for me and I welcome that. However, what I have also discovered is that my patients are also feeling more vulnerable. This is an unintended consequence. One that gives me pause.

     None of my psychotherapy blogs give identifying information.  Still, my patients reading my blog have very strong ideas and feelings as to whether I am talking about them or not. Sometimes, I tell my patients that something they said has inspired me to write a blog and I point them where they can read about it. Is this a problem?  Is this bad technique?  I ask myself. Should I seek consultation? Who would I ask? Would I find someone to answer my question in a way that would support me, without challenging my ideas? Who has experience with these issues? I do not know.

     Some of my patients have found my blogs helpful in that they feel like they have gained greater insight into me, and into themselves. This cannot be bad, I say to myself. However, as I feared, these same patients, at other times,  feel agitated by my blogs. They read what I have to say and they feel like I am putting them down, or worse yet, that I do not understand them at all. When they tell me that, I want to stop blogging. I do not want to create an environment which promotes more dis-ease. On the other hand, I think that maybe this is grist for the therapeutic mill. No. I do not like that argument. I feel bad upsetting my patients. I do not want my blog to do that, and to the extent that it contributes to suffering, I should stop blogging about my patients. Is it that simple? If one patient tells me that my blog was upsetting, does that mean that  I cannot blog any more? Yes, maybe that makes sense. Patient care is my first priority. There is no question about that.

     So, I say to myself, I can blog about other things. I can return to being a movie critic, or a book critic. That could be fun, but I do not think that is my passion, at least not now.  I do want to write about psychotherapy, and when it is woven together with psychopharmacology, I want to write about that too.  Perhaps I will start by writing stories. My hope is that these stories will be less controversial, but still illuminating. My critics tell me that I use too much jargon, so I am going to focus on telling my stories in a way which is user-friendly. I am going to try to change from a  teacher to a storyteller. I believe that stories help us grow. They can inspire us to take chances, to involve ourselves in life, and they can challenge our world view. I want to share the meaningful stories that I hear every day. This will be my new path. You, my readers, will help me out. Wish me luck!

Techie Changes

We just completed moving from Serendipity to WordPress, hopefully everything went successfully.

Unfortunately, it will appear that all of the previous blogs have created at once — oh well.  The software package has changed, the contents and the address will remain the same. To repeat, the URL of this blog will remain http://blog.shirahvollmermd.com.

In the language of committee meetings, here is the ACTION ITEM. If you tried to come to the blog via RSS, you will probably need to reestablish the RSS connection. If you have links directly to blog content, you will need to reestablish those links.

In the short-term, I am on a blogging break. Please stay tuned. As always, I welcome your comments.

“I Can’t Sleep:” Saying No to Prescription Hypnotics

This blog is part of my series on sleep pathology.

Today I saw my nine year old girl who was featured in my previous blog entitled “I Can’t Sleep“. Her mom informs me that she has been diagnosed with Period Limb Movement Disorder. This is new information. I think to myself, Periodic Limb Movement Disorder, what is that? After she left I did some research. It turns out that PLMD used to be called nocturnal myoclonus. Sigh! I knew what that was, but I never got the memo that they changed the name. I suppose that since I am a psychiatrist and not a neurologist that this name change never hit Psychiatric Times. Thank goodness for the internet.  I think they, whoever they are who change the name of neurological diagnoses, wanted to confuse me, but I know that is silly, so I return to trying to understand what is going on. Here is what I learned.

Periodic Limb Movement Disorder (PLMD) is repetitive cramping or jerking of the legs during sleep. The movements often disrupt sleep and they can lead to daytime sleepiness. PLMD is often linked with Restless Legs Syndrome (RLS). RLS is a condition involving strange sensations in the legs while awake and an irresistible urge to move the limbs to relieve the sensation. At least 80% of people with restless legs syndrome have PLMD, but the reverse is not true.

If PLMD is not associated with another disease or medication it is called primary PLMD and it has no known cause. On the other hand, if PLMD is linked to another problem it is called secondary PLMD. Secondary PLMD has many different causes such as diabetes mellitus and medications such as Haldol or L-dopa. Most people with PLMD are unaware of their leg movements unless their bed partner tells them. Typically, the knee, ankle and big toe joints all bend as part of the movements. The movements vary from slight to strenuous and wild kicking and thrashing. The movements last about 2 seconds and thus are much slower than the leg jerks of myoclonus. The movements are rhythmic and repetitive and occur every 2-40 seconds. Sleep lab testing is necessary to confirm PLMD. Treatment does not cure it, but medications can help.

So, now I am up to speed about what my patient suffers from. I review her sleep study, I speak with her pediatric neurologist. Often times, when I consult with other physicians, I find them to be hard to reach, dismissive and hurried. In this case, I was pleasantly surprised. We spoke for fifteen minutes and we ended our conversation because I had to see another patient. He was warm, informative, interested in what I had to say, and most surprisingly, insightful about this young girl and her family dynamics. He also said that there may be a relationship between PLMD and ADHD, but he was not sure. I felt encouraged to have such a positive collegial interaction. He explained to me that there are no medications which are FDA approved to help children sleep. There are also no FDA approved medications to treat PLMD in children. Nevertheless, he has had great success giving children the same medications which are approved for adult PLMD.

Even though this young girl was treated for her PLMD, by her mother’s report, she was still not sleeping well. After the initial appointment, I was hesitant to treat her sleep problem with medication. Her mom decided to give her Benadryl, an over-the-counter medication which is used for allergies, but it can also be used as a sleep aid. It worked. The mom was very happy. The sleep problem has been solved. Now, I could focus on her other issue, anxiety. She complains of getting worried to the point where it is sometimes hard to breathe. We talk about this symptom at great length. I discover that she has half-siblings I did not know about, even though I inquired during the initial three hour consultation. As with learning about PLMD, I am once again reminded that time is important in an evaluation because there is an unfolding of information.

Unlike in our previous appointment, this time the mom was relaxed. To an outside observer, there would be no hint of previous tension. I did not understand what changed, but I was relieved. Clearly, she was sleeping better and this put the mom at ease, but I sensed there was more to it than that. I had a hunch that the mom had appreciated that I was not quick on the trigger to prescribe medication to help her daughter sleep and this helped to build her trust in me. Again, I am speculating.

There was a strong family history of anxiety. This little girl had frequent, indeed almost daily, episodes of feeling like she could not breathe. Consequently, I prescribed a medication that other family members had taken. We all agreed that we would see how things go. There was a good feeling in the room.  I felt like I could breathe better as well.

When I do not prescribe a medication, usually a hypnotic or an anti-anxiety medication, patients often get very angry. When the patient is the child and the parent has an idea of what I should prescribe, the disappointment is exponentially worse. After all these years, saying no to patients in distress is still quite challenging. The last visit with this mom and child was tough. Today, the tides turned. Although I have my theory that because I stood my ground, I earned some respect, it is just a theory, and once again, I am not sure why things are so much better. I know the Benadryl is a key factor, but I ask myself why the mom stayed with me. Why did she not seek care elsewhere? I return to my theory that although she was disappointed, she was also relieved that she could not push me into doing what she wanted. Like a parent with a child, sometimes saying no contains the person asking for something such that although they experience disappointment, they also experience comfort. This is the comfort in knowing that someone else is taking responsibility. I think this mom needed that. I think she ended up appreciating that. When dealing with children, I am not given permission to talk to the parent about the dynamics of my relationship with them. In other words, I cannot explicitly float the idea that I think things got better in our relationship because I said no to her. After all, she is not my patient. I am left back in my own head. Luckily, this time, that is not a bad place to be.

Indiana Jones: The Franchise

This blog is part of my series on the media.

Some stories live through the ages. Some characters become the center of a franchise. Indiana Jones, the fictional adventurer does both. Henry Walton “Indiana” Jones Jr. lacks a proper father figure because of his strained relationship with his father, Henry Senior. Because of Indiana’s strained relationship with his father Indiana spent much of his youth searching for the Holy Grail.

In his role as a college professor of archeology, Henry Jones Jr is scholarly and learned in a tweed suit, lecturing on ancient civilizations. At the opportunity to recover important artifacts, he transforms into “Indiana,” a near superhero image he has concocted for himself. Mr. Jones is a fallible character. He makes mistakes and he gets hurt. Steven Spielberg said that “Indiana Jones is not a perfect hero, and his imperfections, I think, make the audience feel that, with a little more exercise and a little more courage, they could be just like him.”

Alan Zients MD, wrote a paper entitled The Psychoanalytic Treatment of a Child with Deviational Development (1999) where he presents the treatment of a little boy he has named Peter. Peter was a nine year old boy who was very excited by “Indiana Jones and the Last Crusade.” At the same time, Peter’s father, having suffered the loss of his first child, dedicated himself to his work thereby having little face time with Peter. The search for the Holy Grail paralleled Peter’s search for his father. The hopeful obyssey in the Indiana Jones’ movies contributed to Peter’s hope in himself.

The Holy Grail is what I call the “if only,” meaning that so many people in pain come to the conclusion that if only one thing did or did not happen in their life, everything else would be better. A 55 year old man I saw last week, said if “only I did not get a diagnosis of prostate cancer” everything else would be fine. His prostate cancer was cured with surgery. His prognosis is excellent. He is likely to die from another problem. Yet, he believes that this one event in his life was pivotal. By his account, the diagnosis changed him from a happy person to a scared person.

The human brain tries to simplify a complicated life.  This effort at simplification leads to spurious conclusions. Yet, one often holds on to these summations as if they are facts. Psychologists call this a false attribution. Dr. Robert Stolorow called it an organizing principle. By that he means that people try to organize their lives around a center. For some, this center is religion. For others, it is a traumatic event in their lives. Peter’s organizing principle was around the wish that if he could just find the Holy Grail, his difficult life would transform into a contented life.

Many movies, comic books, graphic novels, cartoons and fiction allow us to escape to a world where an organizing principle is a superhero, an individual who can beat the odds. Peter had a difficult relationship with his father and he wanted to make that better. Indiana Jones gave him hope.

Indiana Jones became a franchise. George Lucas created the character in homage to the action heroes of the 1930s film serials. The character first appeared in the 1981 film Raiders of the Lost Ark, to be followed by Indiana Jones and the Temple of Doom in 1984, The Last Crusade in 1989, The Young Indiana Jones Chronicles from 1992 to 1996, and Kingdom of the Crystal Skull in 2008. Alongside the more widely known films and television programs, novels, comics, video games, and other media also feature the character.

Identification is a psychological process whereby the subject assimilates an aspect or attribute of the  other and is transformed, wholly or partially, after the model the other provides. Multiple identifications create personality. Superheroes, such as Indiana Jones provide an opportunity for identification and personal growth. If Peter can feel that he can be like Indiana Jones then Peter can feel hope in the face of a disappointing father who Peter feels does not protect him.  In this case, the media is a tool promoting development. If Indiana Jones can survive not having a proper father figure, so can Peter. The franchise works.