The Kleenex Box

    As Julie was crying, taking an extraordinary amount of tissues, she says “it is part of the fee, right?” Twenty-one  years ago she made that comment;  I still laugh when I think about it. The meaning of my kleenex (or more accurately tissues) is constructed with each patient, at each visit. Even though my tissue box is there, some people prefer to reach into their purse or backpack for their own supply. Others do not want to use it, even though it looks to me like they might feel better with a tissue. Heinz Kohut saw the tissue box as a way of expressing empathy for his patients. He stated that if analysts were to be neutral, and not intrude into the patient’s line of thinking, then they should not “give” patients any relief for their pain; rather, they should watch how the patient deals with his teary eyes.  In other words, the tissues are one way in which we “serve” our patients, rather than allowing them to wrestle with their emotions. Kohut argued that coming to a place that understands pain, as evidence by the tissue box, is healing in and of itself. Empathy, or vicarious introspection as he called it, was the first step towards healing. I agree. My tissues are part of the fee.

Mother Figure

   Jennifer, twenty-four, comes in describing her fertile experiences with internet dating. There is Jeremy, the twenty-seven year old artist, Stanley, the thirty-two year old with a “boring 9-5,” Casper, the twenty-six year old “who is really cool.” As I try to keep these guys straight, I get the feeling that she is monitoring my reaction as she describes each one. I say to her “it seems like you are looking at me to help you decide who you should pursue.” She responds “well, I do care what you think.” I pause and then say “gee, why do you care what I think?” “I know you want the best for me, so I figure that what you think is going to help me,” she responds.

   Transference comes to my mind. https://shirahvollmermd.wordpress.com/2010/01/24/transference/. Jennifer has assigned me the role of the benevolent mom who wants the best for her child. By monitoring my reaction to her dating stories she is sorting through her feelings. She is using me as a tool to help her find her way through a series of dating relationships. This process is unconscious since in the moment she is only aware that she is telling me about her life since I have last seen her. When I point out to her that she is monitoring my reaction, she quickly agrees. She appreciates the opportunity  to think about her love life with me. She values  her perception of my reactions. Our relationship has meaning.

Feeling Bad About A Sandwich

    Leo, a ten old boy, came in pouting. Lidia, his mom, explained to me that they had just come from a restaurant, Leo ordered a corned-beef sandwich, but they were out of corned-beef. In response, Leo said “I am not hungry” and he sat in the booth appearing angry. His mom began to explain to him that “sometimes in life we don’t get what we want.” This comment made Leo even more upset. “You don’t understand,” he said to her. Lidia continued to plead with him to order another meal, but Leo refused. By the time they got to my office they were both angry at one another. “What am I doing wrong?” Lidia asks.

     “Leo is entitled to his feelings,” I say. “If he is mad about not getting corned-beef, so be it.” I am sure there are underlying feelings to Leo’s anger, but my focus in this moment is to help Lidia help Leo. Lidia responds “but Leo needs to learn that life is not perfect.” “I know that,” Leo responds. I say, ” the fact that Leo got angry over this disappointment does not mean that he cannot cope with imperfections in our world. It just means that it made him angry.” “What should I do?” Lidia asks. “Let him have his feelings, ” I say.  Lidia seemed taken aback and grateful for the advice at the same time.

   When people  respond negatively to a situation, in a way in which we imagine ourselves responding differently, we often get critical, and not accepting. This is a narcissistic form of criticism in that one is criticizing the other person for having different feelings. In other words, Lidia is looking at Leo and saying to herself “why are you not more like ME?” When I gently confronted Lidia about this, at a time when she seemed sure that I was going to talk to Leo about being more flexible, Lidia seemed surprised and then appreciative of a new perspective on her heated interaction with her son. It is hard for people to see outside of themselves. Lidia allowed for that and so she brought me into her thought processes. Allowing Leo to feel bad made him feel good. Feelings, good or bad, make us feel alive. Leo wanted affirmation for his feelings. Lidia, in the end, gave that to him. Their relationship mended. The missed sandwich proved helpful.

Family Vacations: Who Decides?

   Jessica, fifty-five, mother of three, comes in and says “I am going to Hawaii for spring break.” I say, “that’s wonderful.” Her facial expression communicates agony. I say “you don’t look so happy.” “Well, my husband (George)  thought it was a good idea so he booked the tickets. He called me, but before I had a chance to call him back, he had already decided that our family needed to get away” she says.

     As nice as Hawaii sounds, control sounds even nicer to Jessica. Once again, as she so often feels  in her marriage, she feels invisible. She has no ability to exercise her wants, her desires, her passions. She must follow along and then be grateful for the experience. Some people might experience rage in this circumstance, but Jessica experiences “deadness”. The air is out of the tires. I am reminded of Tim, https://shirahvollmermd.wordpress.com/2010/01/29/i-feel-like-a-corpse/, who responded to his wife’s criticism by feeling like a corpse.

     I think about life’s struggles. Many of us long for the closeness of a family, but at the same time, we long to have control over our lives. These two yearnings are contradictory. A family demands negotiation. If one gets control over one’s life, sometimes that comes with a cost of painful loneliness. The art of living is having some domains of control, while having other domains of compromise. The challenge is balance.

    Jessica’s balance is off and she is suffering. Going to Hawaii exacerbates her sense of deadness. She feels stuck because she loves her family, but she wants to be able to make decisions, and not be told what to do. I feel for her. I understand her plight. I think about her childhood and about how that might be related to her current frustration. I think about how having a man who makes decisions could have been desirable at one time of her life, but over the years, she  has begun to experience his decisiveness as if she is living in a dictatorship.  I think about her husband; about his point of view. By Jessica’s report,  he is feeling like  a good family man,  yet from Jessica’s point of view he is sucking the joy out of her life.

     I suggest that perhaps she can make some decisions about how they can spend their time once they are there. Jessica understands my comment. She knows that the more she can be involved with the decisions, the better she will feel. However, she fears that her husband will get angry if he does not get his way. Jessica has a challenging dilemma. She can go along with her husband and keep the peace, while at the same time, feeling no zest, or she can challenge George, and risk creating an environment of anger and criticism.  I hope she has a good time.

Siblings

  In my post about Dan Jansen https://shirahvollmermd.wordpress.com/2010/02/26/dan-jansen/ I spoke about enviable sibling love. Arthur wanted to feel important to his siblings as Dan’s sister felt to him. Arthur reminded me that in previous discussions we had talked about how his sister, Nicole,  being the first-born, likely felt annoyed by Arthur’s birth, since she was taken off her perch. In an opposite way, Arthur wanted Nicole’s love, almost as much as he wanted his parents affection. This collision between Nicole feeling annoyed and Arthur cloying for Nicole’s attention creates sibling rivalry.

    Caitlin, the youngest of three children where the first two are two years apart, and then she was born seven years later, talks about how her siblings treat her “like she does not really exist.” She describes  feeling as though she showed up at a party, but she was not invited. Caitlin feels like she “intrudes” in every new situation.  Her core belief is that she does not belong anywhere. She attributes this feeling to how her siblings treated her while she was growing up.

    Adam, the oldest of three boys, all born close together, talks about how he was “taken from my mother’s knee when I was not ready.” Adam feels that because his brother was born 18 months later, Adam had to “grow up” and so he “missed out” on his childhood.

   Arthur, Caitlin and Adam, like all of us, want to feel love from people they respect. Feeling loved, feeling lovable fuels our lives. Siblings can give that fuel and they can take it away. Fighting for love, sibling rivalry, is a  fight for survival. The intensity matches that.

“The Girls Turned Purple”

 

   Tanya, https://shirahvollmermd.wordpress.com/2010/03/23/female-friendship/, shy at first, did not want to come to today’s appointment, looks at the floor, and then says “well, we went on a trip with the boys school and the girls turned purple.” Once again, Tanya immediately transported me back to my own teenage years.  I was brought back to those times when looking at boys and having boys look back was scary and exciting at the same time. I repeated those words back to her. “The girls turned purple,” I said. “Yes” she says.

     Puberty, those years where girls transform to young women, where boys transform to young men, is such an interesting time. The multiple forces of  hormones, culture, and the formation of a new identity come together to give birth to a new personality. The body changes; the brain changes. The little girl  and the little boy become  sexual beings. Friendships deepen. The relationship with parents sometimes transform from open admiration to hotly contentious. It can be a rough ride on both ends.

     I look at Tanya and I am impressed at how well she expresses herself; she captures the dawning of adolescence with her words, her tone and her varying eye contact. In those few words, “the girls turned purple” she conveyed the sexual feelings of wanting to be seen, admired and sought after. Elementary school girls do not turn “purple” when they see boys, but twelve-year-old girls do. After just a few (ten or so) years of development,  sexual longings begin to dominate the mind.  

    Tanya continues, “I am like a Tom-boy.”  “Where did that phrase comes from?” she asks. “I don’t know, but that is an interesting question” I respond. “What makes you say you are a Tom-boy?” I wonder. Tanya says “well, I just don’t spend as much time in the mirror as other girls do.” I say “I understand that, but it seems like you turned purple too?” “Well, yea” she responds. Tanya expresses the freshness of her feelings. She is not used to thinking about “boys” in this way. Fear and excitement run through her veins. Her choice of the color purple nails it.

Food Religion

   Sherry and Damian, parents of seven-year old Bruce,  came in to talk about their tortured family dinners. Bruce is on stimulants, so he has no appetite for lunch. At dinner, he is hungry, but very picky. Sherry prepares gourmet family meals every night. Often, Bruce refuses to eat them. Sherry gets angry and says if he does not eat, he goes to bed hungry. Damian says “the poor guy is hungry, why can’t he eat some peanut butter and jelly?” In talking about this issue further, as we have done multiple times in the past, both Sherry and Damian are adamant that their point of view is right; their partner is wrong. When I suggest they try Damian’s plan, Sherry starts to yell at me, telling me that that is a terrible idea. When I suggest that Damian try Sherry’s plan, Damian starts to cry saying “I just can’t put my kid to bed hungry.”

      I feel as though both Sherry and Damian are from different religious backgrounds and they are fighting about how to raise their child. Both parents, out of love for their child, feel as though catastrophe will ensue if they bend on this issue. I am struck by how much these dietary rules mean to each parent. Compromise is not easy or clear. Bruce responds to the conflict by attempting to split his parents further. He knows that if he does not eat his dinner, his dad will come to his defense. Bruce makes his mom angry, but he also makes his dad feel like his hero.

    We talk about how important it is to get on the same page. Unified parenting is important so that Bruce can learn the rules of the road. A small divide in their parenting styles will enable Bruce to divide them further.  They understand that, but they cannot find agreement. We will keep working.

Female Friendship

   Tanya, a twelve-year old religious Catholic, attends an all girls Catholic school, describes her relationship with her girlfriend Jane. “I tell her things that I don’t tell anyone.” Tanya’s tone implied that as she said that, she was  surprised to appreciate that her best friend, a girl she has known since she was six, had such a unique role in her mental life. My reaction was strong. Instantly, I was brought back to that tender time in my life where I realized that I  could decide who I wanted to share my intimate thoughts.  I identified with Tanya. I could feel how Tanya was just beginning to appreciate the joys of female friendship. I could see how she felt that sharing her feelings with Jane made it so that her parents were receding in importance. Friends could now help her decide how to navigate her life.  The possibilities were endless. The world opened up. I was privileged to bear witness.

“I Feel Like I Got My Ass Kicked”

    Elizabeth at  forty-two was a  healthy, outgoing, upbeat person who was seeing me over the past ten years to help her with her ADHD. Over the years, I have seen how  Elizabeth loves her job, her husband, her kids and her cats. She has good relationships with her family of origin, and generally speaking,  she has felt  internally well-organized. Over the years, I saw her stay slim, while she reports to me that she eats wells, sleeps well and exercises regularly.

    Almost overnight, right in front of my eyes, she transformed into a woman with chronic bodily complaints. She developed paresthesia,  an unusual sensation, in her hands, which are chronic and unrelenting. She has headaches which she describes as an ice pick through her skull. Her hip hurts her so much she can hardly walk. Multiple specialists evaluated Elizabeth. By her report, all of her doctors appeared “anxious”. Ultimately, Elizabeth was diagnosed with a rare endocrine disease. The treatment is not clear; nor is the prognosis.

     Elizabeth does not complain of being depressed. She still appreciates the  facets of her life. She  does not feel well physically and for her, this means that her mental state is less enthusiastic, but still optimistic. My impression of Elizabeth is that her personality has changed, slightly, but perceptibly. She used to have a wonderful sense of humor. I hope that comes back. She used to transmit  a sense of enormous personal power, without being arrogant or grandiose. Now, she expresses a sense that she has significant limitations. I feel sad when I see her, but she is not a sad person. She is coping in an admirable way.

    Once again, I begin to think of the mind-body connection. Elizabeth’s mind seemed well constructed, yet, with the randomness of disease, her body got whipped, and now her mind has changed. She is not bitter or angry or depressed;  just more mellow.   I think about her future, as does she. She is not frightened, but she is mindful that her condition could worsen. She is trying to plan for that. I admire her ability to see the future, strategize if  her condition deteriorates,  and still  remain optimistic.

   I wish I knew the recipe for Elizabeth’s positive coping skills. She had a good childhood, but she also had significant challenges. She is smart and successful and she has a good marriage. These things help, but I am not sure that is the key to her equanimity. Her genetically endowed temperament is such that, even though she has ADHD,  she does not get frustrated easily. I think that has a lot to do with her good coping skills. Despite her rare illness, Elizabeth is fortunate to have a history of good nature and good nurture. Still, her life is forever changed. I think she described it well. ” I got my ass kicked.”

“You Mean My Kid Does Not Have To Go To College?”

    Stacy, a 19 year-old patient, went to college for one semester, came home and decided college was not for her. Her parents, both physicians, both from families where no one else went to college, verbally exploded. Stacy is an only child, loved dearly by both her parents, was raised with the idea that she would one day go to a university and from there, decide on a career path.

  We have a family meeting. Stacy’s mother Lori, cries in my office saying, “I don’t want her to worry every time she has to spend five dollars.” Stacy’s father  James  says “today, one has to go to college to be successful” then, he starts to cry.  Stacy tearfully says  “I don’t want to hurt my parents.” I say “Stacy is not being rebellious.” With a stunned look on his face James says “she’s not?” “No” I say, “Stacy is trying to be true to herself.” I explain to James and Lori that Stacy is caught in a bind because she wants to please you, but at the same time, she does not feel like she wants to go to college. Stacy wants to design clothes. “Fine” James says, “then she should go to art school.” Stacy speaks up, “I don’t want to go to art school either, I want to be an apprentice and work my way up.” James begins to yell at her “well, what have you been doing; why have you not started doing that?” I offer an answer, partly to protect Stacy from her father’s wrath, and partly because I think I can explain to James something that he is not seeing. “Stacy feels bad that she is disappointing you. Her bad feelings make it hard for her to be motivated to pursue her passion. Maybe, if she felt your support, then she could move on with her life.” Immediately, James begins to cry loudly. “I do not want to stand in her way. I feel terrible. I did not know I was doing that.” Stacy is visibly moved by her father’s love.  The theme has shifted from anger towards Stacy to feeling bad for James since he is beginning to understand how he has made Stacy’s life emotionally difficult.

     I see how difficult it is to be Lori and James. I understand why sending Stacy to college has been a long-held dream. No one dreamed of sending Lori or James to college, so when they met each other in medical school, they swore that they would provide their child with the infrastructure to go to college. They never imagined that their child would not be grateful for the opportunity.

   I see how difficult it is to be Stacy. She loves her parents, but at the same time, she feels that she will not benefit from the college experience. She is smart, but she does not love learning. She is social, but she enjoys her friends who live here and she does not want to leave them. She loves fashion; she wants to work in the industry. She feels her parents look down on her for that, so she is paralyzed. She wants their support, but she feels like that is impossible, given where they came from.

    My job is to help this family understand each other and to  help them understand themselves. “Stacy is not Lori or James” I say. “She is Stacy.” I try to explain that all of us hope when we have children to correct the ills of our childhoods, but the problem with that is that what served us poorly, may not serve another child  poorly in the same way. I think about narcissism. Every parent wants their child to reflect well on them; there is something very fundamental about that wish. At the same time, parents need to be open to the idea that their child has an independent mind and their wishes and desires need to be understood as a separate entity. Lori and James understand that. Lori says to me “it is not like I think Stacy should go to medical school; I just want her to go to college.” I think to myself that although I relate to Lori, she still needs to understand that college is not for everyone, and it may not be for Stacy. I say “yes, you have a wide view for how Stacy can live her life, but maybe it needs to be wider still.”

    Lori, James and Stacy leave looking as though they have been through a deep experience. Mom and dad left looking at me as though  I could not possibly have said what I said.  Stacy looked at me with some relief that she has an ally and some skepticism that this discussion did anything to help her at home. As they left, I thought about how hard it is to have a family; about how hard it is to have long-held expectations not met.  A child is an extension of his parents and an independent being, at the same time. This apparent contradiction creates challenges for both the parents and the child.  I am eager to see  this family next week.