More Betrayal

    Monte, betrayed by Marla, https://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/,        Tom, my twenty-four year old patient betrayed by his mother https://shirahvollmermd.wordpress.com/2010/01/24/betrayal/, Christopher, betrayed by his boss,  https://shirahvollmermd.wordpress.com/2010/03/07/unemployment-a-betrayal/, Teri betrayed by her psychiatrist, https://shirahvollmermd.wordpress.com/2010/02/11/youre-fired/, all came to mind as Al described his feelings about his children. Fifty-five years old, three grown children, married for thirty years, Al was relatively content with his life. His oldest son got married a year ago. He and his wife danced at the wedding; “the happiest they have ever been” he says. On Father’s Day, 2009, his wife announced she had a lover, she was leaving him, the kids have known this for the last eighteen months and “they agree it is a good idea” his wife tells him.

     Al came to me with excruciating back pain which followed this news. He was seeing a wise psychologist who felt that since Al had body pain and mind pain, then he needed someone who could work with both. Sure enough, the pain of his separation from his wife exacerbated his underlying pain in his back. Sure enough, as we uncovered the psychological issues, his back pain improved, without medications. Together, Al and I came to understand that although he was upset that his wife left him for another man, the most wounding part was that his kids knew, but they did not tell him; they kept the secret. Al loves his children. He thought he had a great relationship with all of them, but this episode made him seriously question his beliefs. “Why did they not tell me?”  He asked repeatedly. “Why do they not apologize?” He quickly says. The pain in these questions is intense.

    Like Monte, Tom, Christopher and Teri, Al feels that the people he loved, the people he counted on to “watch his back” seriously let him down. An apology could mend the wound, but in all these cases, the apology does not capture the pain inflicted. In Al’s case, the pain was both physical and psychological. Many months later, Al’s kids came around. Each one asked for forgiveness. Al was living alone in the family home. He was working at his job, lonely at night, suffering with chronic back pain,  yet these apologies brightened his mood considerably and diminished his backache. Al feels renewed. He is looking forward to the next chapter in his life. He looks back on his marriage and he now realizes that there was a lot missing. He accepts his divorce; he has understood that for a while. He could not accept his children’s behavior. Fortunately, he does not have to. Al is a new man; up from the despair that he felt when he thought he lost his whole family. Happy ending.

Women, Moods and Their ObGYNs

     Heidi, twenty-nine, suffered painful feelings of guilt and inadequacy after the birth of her first child. Eventually, she felt more confident, but then after the birth of her second child, she had a recurrent postpartum depression. On a routine postpartum visit to Dr. Little,  her obstetrician, she explains her mental difficulties of handling her two children. By Heidi’s report, Dr. Little hands her a prescription for Zoloft 50 mg, a one-month supply with three refills. “Time to blog” I immediately think to myself. “Should I call Dr. Little?” I wonder. “What would I say?” I could try to get more history on Heidi. Maybe I should educate her about prescribing psychotropic medications and the importance of good follow-up. Perhaps I should say that medication, especially in the post-partum period needs to be given along with psychotherapy. Then, I think, maybe I could give a Grand Rounds presentation to the OBGYN departments at local hospitals, entitled “Medicines for the Female Mind.”

     As I learn more about Heidi’s history, I continue to wonder about Dr. Little. How did she learn how to prescribe SSRIs? Was she trained by a psychiatrist? How does she think they help her patients? Why would she give Heidi so many refills? Why would she, (again, according to Heidi) not refer her for psychotherapy? Did she get any training on the importance of the mother-child relationship? Does she appreciate the value of a good attachment in terms of primary prevention of mental health issues in the child? Is she open to learning more about maternal bonding?

    I wondered what Heidi thought about receiving a mood altering medication from her obstetrician. “She is a great doctor” Heidi tells me. Heidi appreciates that she can receive Zoloft from Dr. Little since she does not have to have the “shame” of seeing a psychiatrist. “If it were up to me I would not take any medication,” she tells me. “Who is it up to?” I ask. “Well, that is not what I meant. I meant that I wish I did not have these problems.” “I can understand that” I reply.

    I wondered if Dr. Little colluded with Heidi’s wish to minimize her psychological pain by “medicalizing” her suffering such that, as with hypertension,  the doctor prescribes a medication, gives multiple refills, and then briefly checks on the condition many months out.   Mental suffering is hard to contend with, both by the sufferer and the observer. Women who struggle after they give birth are doubly stigmatized. Society looks at all women as if they are made to have babies, and hence a newborn should make the mother happier than she has ever been. When a mom feels depressed after giving birth, the shame of depression is compounded by the shame of not enjoying her child. The depth of this shame, layered over the depth of despair, layered over multiple hormonal changes, layered over changes to the family structure, can be profound. Psychotherapy, along with medications, are the mainstay of treatment for these complex feeling states. Dr. Little, I hope you are reading this.

Anger

   Marla,  https://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/, https://shirahvollmermd.wordpress.com/2010/06/21/withholding-information/, told Monte ” you get so angry that I just can’t deal with you.” Monte paused. Anger is a complicated feeling, yet so often, it is an outgrowth of feeling misunderstood, deprived of attention. Marla, although a psychotherapist, feels this anger to be assaulting and unacceptable. Monte, in direct contrast, feels justified in feeling upset that he cannot trust someone he thought he could. This clash results in Marla’s contradiction; at first she insists they are “breaking-up,”  and then she says “let’s meet face to face to discuss this.” The ambivalence dominates their relationship because if Marla could stand back and look at Monte as a separate person who has hopes and expectations which were unfulfilled, then Marla could be helpful.  Marla’s low self-image makes it impossible for her to analyze her feelings. She has to react to her emotions, not think about them.

     Heinz Kohut pioneered the concept that anger is an aggression which is self-defense against the destruction of one’s sense of self. In other words, anger is a way that one maintains his dignity when he feels he was mistreated. This is a healthy anger which maintains one sense of power in their world. When one views anger as a way of protecting the “self” then one can be understanding and less reactive. Anger is a signal which should prompt curiosity and understanding, similar to a child who screams after a fall, a parent wonders what happens;  he does not get mad at the child for screaming.

   Marla is blaming Monte for reacting to his disappointment. Monte understands this, but at the same time, he feels cornered that if he cannot make peace with Marla, he must find a new professional outlet; a new teaching opportunity. Monte could make this whole episode blow over by colluding with Marla’s revised history https://shirahvollmermd.wordpress.com/2010/06/27/rewriting-history/. If Monte does not show his anger towards Marla, their relationship could be repaired. The farce, the make-believe relationship would help Monte stay involved professionally, but personally, he would feel like a fraud. The irony; the psychoanalytic field which theoretically promotes authenticity,  in Monte’s case is promoting pandering to people in power. Not surprising, Monte thinks, an organization is an organization. Power struggles often dominate the direction. Monte accepts that. He is still angry at Marla.

Rewriting History

Friday afternoon, after a long and grueling week, Monte reads his email, as he is about to settle into a relaxing weekend. Graham, Marla’s co-chair of the committee sends a group email reminding him of a meeting the following Sunday. Given Monte’s history with Marla,  https://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/ https://shirahvollmermd.wordpress.com/2010/06/21/withholding-information/, Monte is rattled. Marla, his previous therapist, uttered the reverberating line “we’re breaking up” so why is he getting this email, he wondered. Monte, with some hesitation, calls Marla. Marla answers, hears the anger in Monte’s voice and begins to say “this is why we are not talking.” Yet, the conversation continues. Monte wonders about this email from Graham. Marla explains that she took him off her email list, but she had a hard time explaining the situation to Graham, so Monte remained on Graham’s email. Hence, Monte received this email reminding him of a meeting that he did not know was happening. Monte is not pleased. “What do you want from me?” Marla asks. “An apology” Monte responds. “OK, I apologize” Marla responds robotically.

Marla, as if amnesic, says “why don’t you come on Sunday?” Monte, stunned, says “you know why.” Marla continues “you needed our help, we were there for you, things got better, and then we moved on. What was the problem?” Monte, with a surprising presence of mind, calmly responds “gee, you just re-wrote a lot of history. Yes, I needed your help. Yes, you helped, but then you threw me under the bus.” https://shirahvollmermd.wordpress.com/2010/01/24/betrayal/. Monte continues matter-of-factly, “I wanted a face to face meeting, but you refused.” Marla, as if not hearing the previous statement responds “that’s a great idea, let’s have a face to face meeting.” Monte, head-spinning, says “no, I wanted a face to face meeting when I trusted that you wanted to help and support me, but now I realize that you manipulate information in a self-serving way, so meeting now is pointless. Further, you only hear what you want to hear, so I have no faith that you would understand me. Finally, you always need to believe that you are a good person, so you will never get your head around the idea that you abandoned me. You will constantly re-work the story such that you were the hero.” “OK, well, if you change your mind, let me know,” Marla responds, again, as if the content of Monte’s words had no impact.

Monte was shaken. The long saga of Monte trying to get Marla’s attention, leading to frustration and despair, was now twisted in Marla’s mind, as a tale where Marla saved Monte. “Is it as simple as saying that Marla creates the history that she wishes were true? ” Monte wonders. Monte has known Marla for over two decades. He has never seen her distort reality so much. Monte, a psychotherapist, understands the power of self-deception, but knowing Marla, also a psychotherapist, makes him wonder about the underpinnings of Marla’s thought process. He speculates that Marla, suffering from a low self-image, rescues herself by creating wild tales of heroism, while deleting the hurt and despair she has caused. Monte believes that Marla, at some level, understands the lies she is weaving, and as such, suffers from tremendous guilt and remorse, but that these negative feelings are covered up by creating an exterior image of helpfulness and generosity.

Friday night, Monte cannot sleep. It is one thing to have a difference of opinion, but it is another thing not to agree on the facts of the story. Marla’s story was one of half-truths. Monte realized that when one changes the sequence of events, one can make a different chapter, even though each event is true.  The power of the human brain for self-deception hits Monte deeply. “How do you trust people who can deceive themselves?” He wonders, knowing that the obvious answer is that you cannot trust people who deceive themselves. Despite years of working with Marla, Monte has discovered a new layer to her personality; the layer of lies and manipulation. This layer, Monte imagines, only comes out under stress, when no other option exists for Marla to recover from feeling like a disappointment. Monte feels, as he has felt before, that he has gained a deeper understanding into Marla’s dynamics. He still cannot sleep. The weekend was more grueling than his week.

Family Anxiety

     Seventy-year old Eric, retired engineer, married for forty-five years, four children, two biological, two adopted, one biological grandson, is referred to me by his primary care physician five years ago. He complains of irritability, impatience, and overwhelming anxiety with regards to his ninety-two year old mother who is in a nursing home. He comes in with his wife who Eric says can “say how I am feeling a lot better than I can.” Susan, his wife, appears to really enjoy talking about Eric. Their loving relationship is quite touching. Susan describes the family history of anxiety. Eric’s mother was an alcoholic, but since she had her stroke five years ago, she has not been drinking. Eric’s brother Eugene committed suicide ten years ago. Susan says that Eugene was always anxious and “he never seemed comfortable in his skin.” Their biological children and their biological grandchild suffer from “terrible anxiety.” All three of them take selective serotonin reuptake inhibitors (SSRIs). Their two adopted children are doing well; they have never been on psychotropic medication.

     Although Eric has never been treated for his anxiety in the past, he has suffered with it for many years. The tipping point, according to Susan, was that Eric’s mother began to deteriorate and this exacerbated Eric’s baseline state of tension. After a very pleasant interchange between myself, Susan and Eric, I gave Eric Zoloft 25 mg and told him that I needed to follow-up with him in one week. A week later, Eric felt “like a new person.” I then saw him two weeks after that, and he maintained his stance that he was a “new person.” Now, I see him once every three months, the medication remains the same, and he continues to remind me how much the Zoloft helps him enjoy his life. He says he is more patient, and “little things just don’t bother me as much. ”

    Eric, the poster child for SSRIs, seems to show the biological basis of anxiety in that the anxiety  runs in his family, he  responds to medication, and his anxiety gets worse under stress. Over the years, his mother passed away; his life has become simpler. He is enjoying his retirement. He enjoys his wife. He enjoys his kids and his grandchild. He appreciates the Zoloft such that as far as he is concerned he is quite content to keep taking it as long as he lives. He has no side effects. Eric does not see any reason to go to psychotherapy, but he tells me how much he enjoys coming to see me, with his wife, every three months. He appreciates having me “look in” on his life.

    Many people in Eric’s situation would be reluctant to take medication, as it might make them feel “weak”. Eric might have felt this way, but he has seen how this class of medication helped his children and his grandson. Further, Eugene’s suicide made him realize how black life can get, so for Eric, if the Zoloft can make the “sun shine” then that is a “blessing.” Eric then tells me a story about his  ten-year old  grandson, Craig. Craig got up in front of his fifth grade class to talk  about how much Prozac helped him cope with his life. Eric then said matter-of-factly, “I guess this problem is in our genes. Thank goodness there is treatment.” I agree.

Toy Story 3

      The empty nest: that is the theme of Toy Story 3. The toys have to cope with Andy leaving for college. Now, all they have is each other. They will miss being played with, being the subject of Andy’s wonderful imagination. Andy is going on to a new world, leaving his toys, and most of his imaginative play behind. The tear-jerking story of loss through development is poignantly told in this Pixar sequel to a story of toys, used as symbols for the wonders of a child’s brain. This is the child’s brain that creates stories out of inanimate objects. The objects, called toys, serve to trigger entertaining tales. Alas, this developmental phase is transient. The brain matures and the child becomes an adolescent wherein he changes his focus to  sexuality and independence. And what about the parents? I mean the toys. The parents and the toys “suffer” in the same way. Their utility for Andy has forever changed. Sure, they can stick around as a support system; for when Andy wants to play with little kids or for when he wants to look at them and remember his childhood play. Yet, on a day-to-day basis, they no longer have a function. Bittersweet. The toys, the parents, helped Andy launch. Now, the toys, the parents, have to change their focus. It is a sad, I mean a happy, ending.

Feeling Stuffing

   Peter, https://shirahvollmermd.wordpress.com/2010/02/28/seeming-sad/http:/ /shirahvollmermd.wordpress.com/2010/03/09/seeming-scared/, a sixty-four year teacher, with chronic weight issues returns to his weekly appointment. “You know, you said something last week which was so obvious, and yet for the first time in my life, I really began to understand what it meant.” I look at him, not sure what he is referring to. He continues. “You told me that I stuff my feelings, quite literally. I use food to avoid my feelings. I know that, but somehow last week that really began to mean something to me.” I feel good that my words had an impact, but I am also confused about exactly what made my words stick like that.

    Peter has multiple health problems, many weight-related. To be a healthy weight, Peter needs to lose about forty pounds. Yet, talking about weight is very delicate. The edge of shame is close to the surface. I have tried behavioral recommendations such as weight watchers or consulting with a nutritionist  but Peter says “I know all that.” Looking for the underlying dynamics of eating seems ripe for a deep understanding of Peter’s mind, if we can find a way to think about his eating together without increasing his defensiveness.

    We talk about his childhood as a military brat, moving around a great deal; always having to make new friends. “When you moved, did you tell anyone how hard that was for you?” I wonder aloud. Peter looks at me, as if surely I have no idea where he comes from, and says “are you kidding, it was hard on all of us, but we could never talk about it.” “I suppose your family was concerned that talking about losing relationships would make people sad or lonely and so in your family, as in many military families, the general belief is that if you don’t talk about it, then you won’t feel it.” “Yes,” Peter says “we had to stuff our feelings.”

    “‘ When you say ‘stuff’ your feelings, that  reminds me of stuffing food down, where eventually you just feel physically sick,” I say. “You go from feeling emotionally ill-at-ease to physically ill,” I continue. Peter stares at me, as if I had said something interesting, but he is not sure how to respond. “I will see you next week” I say. The mind/body connection strikes me. Eating issues is the arena where this connection is so obvious. Hunger changes our mental state, as does eating. Our mental state influences our eating behaviors. The bidirectionality is clear, and yet, easy to forget.

      For Peter, connecting his overeating with his history of multiple losses associated with his family moves, along with his inability to express his feelings to his family of origin, seemed to lead to a pattern of behavior where difficult feelings had to be “stuffed.” In this context, Peter was not ashamed of his weight; rather, he could understand how despite his good judgment in most areas of his life, when it comes to eating, he was responding to his emotional state and not to his frontal lobes; the area of the brain responsible for thought and executive decision making. Harnessing his frontal lobes in his food choices is his goal. Understanding his emotional state, not “stuffing”,  is the first step.

Barren

    Monte, https://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/ and https://shirahvollmermd.wordpress.com/2010/06/21/withholding-information/, filled with pain from his “break-up” with Marla goes into once weekly psychotherapy with Jared. Jared is an eighty-five year old seasoned psychoanalyst who has been in practice for over fifty years. Monte describes the agony that he experiences when he thinks about his twenty year relationship with Marla. Jared asks Monte to talk about his other relationships; to talk about his family and friends. Monte describes the variety of his relationships, thinking that he is impressing Jared with his ability to connect to so many different types of people. Monte mentions how his support system has been there for him in times of crises, but at the same time he often felt profoundly alone. Jared responds “it sounds so barren”. Monte left fixated on that word, barren.

    Monte felt he knew what Jared meant. Monte expressed a coldness in his relationships, by saying that his friends and family were there for him, but they were also not there for him. Although pleased with himself that he had many relationships, Monte was critical of his support system in that he felt that in times of crises they could have gone further. Monte understood that there was a certain coldness within him that created a  cold aspect to his relationship with his loved ones. More specifically, Monte felt quite self-centered at times, and although he wanted to be there when his friends needed him, he also felt overburdened by work and so he felt himself to be somewhat withholding with his friends. In kind, he felt this sense of withholding from them. Monte was impressed with how Jared could summarize this experience with that one word: barren.

    Monte went for help with his relationship with Marla, and instead he learned more about his other relationships. He connected the idea that his barren relationships reflected the fact that he is likely to seek a psychotherapist who could be withholding at critical times in Monte’s life. In essence, his relationship with Marla was a repetition of his previous relationships; both with his family and his friends. Monte knows that all relationships are repetitions of previous relationships, at least in some ways, but a psychotherapist is supposed to take that repetition and help his patient, not repeat the trauma. As Monte thinks about it, he realizes that this is an ideal, which sometimes happens, but it is also true that therapists can repeat past traumas without helping the patient understand that that is what is happening.

    Monte begins to wonder if he is repeating without gaining understanding, yet again, with Jared. He does not think so, but then, how would he know? The word barren continues to stick in Monte’s mind. Monte was so impressed by that word, that he is going to stay with Jared. One word. Deep meaning. A cause for reflection. Monte is engaged; for better or worse or both.

Hypoactive Sexual Desire Disorder: Am I Missing Something?

       ‘ Hypoactive sexual desire disorder’, I  pause. Now, it is a disorder, not clear where it is written as such, for a woman not to want to have sex, at the same time that DSM-5 is floating the possibility of a hypersexuality disorder https://shirahvollmermd.wordpress.com/2010/02/15/hypersexuality-another-are-you-kidding-dsm-5/ . Is there some meter for sexual desire? Is sexual desire directly linked to the chemicals of our brain? What ever happened to the connection between a satisfying interpersonal relationship leading to sexual desire and the converse also true? Perhaps the disorder is not in the woman, but in the relationship. Duh.

    Now, let us suppose that a woman, no matter what relationship she is in complains of a low libido. One could argue that chemical assistance might be in order.  Boehringer Ingelheim, a German pharmaceutical company, has a medication (flibanserin) which although originally designed as an antidepressant, is now geared to elevate sexual desire in premenopausal women who are distressed by diminished libidos. http://www.nytimes.com/2010/06/19/business/19sexpill.html?scp=1&sq=boehringer%20fda&st=cse

       I would happily prescribe a drug to a woman who could experience more sexual pleasure, given that the benefits outweigh the risks. I salute any pharmaceutical company that is focused on improving women’s mental and physical health. I support their efforts and I look forward to the FDA approval. My issue is not with the medication or with the drug company, but with the diagnosis. If the medication enhances the quality of life for a woman,  why do we, as a society, need to link a drug to a diagnosis? Maybe the drug, like caffeine, helps people by altering the chemicals in their brain; the fact that the drug helps does not necessarily mean there is a disorder.

     Insurance companies require a diagnosis for reimbursement. Is this the problem? Perhaps, but not the only problem. Doctors tend to want to treat disease. As a group they are not comfortable with promoting wellness, either through education or through pharmaceuticals. The culture of medicine needs to change. Baldness is not a disease, and yet doctors prescribe medications to help. Treatment must have a broader meaning beyond treating disease. As physicians, we need to treat discomfort; we need to openly accept that we want to help people enjoy more pleasure from their lives. A woman who has a low libido is not ill, but with some help, she could have a lot more fun.

    

‘We’re Breaking Up’

Monte, a psychotherapist, went into psychoanalysis at age twenty-eight, when he was getting divorced from his wife of eight years. Marla, the psychoanalyst, had a wonderful reputation in the community. She was known as smart, compassionate, seasoned and dedicated. Monte thought that was exactly what he needed given the pain of his break-up (see also https://shirahvollmermd.wordpress.com/2010/04/20/the-break-up/). Monte, after much drama, divorced his wife, and then he fell in love with Marla, the psychonalyst. Marla was thirty years older than Monte, happily married with three grown children. Monte and Marla met a few times a week, during which time, Marla appeared quite flattered that Monte was so fond of her. As the years went by, Monte grew more and more attached to Marla. Marla continued to foster the dependency. Ten years into the treatment, Monte’s mother passed away after a long illness. Marla was supportive. Five years after that, Monte finished his psychoanalytic training and he finished his psychoanalysis.  At this point,  Monte and Marla became psychoanalytic colleagues.

As professional colleagues, Monte and Marla are on committees together, plan conferences together, and support the community of psychoanalysts by going to the same parties, the same funerals, the same graduations. The boundaries seem clear. Monte found a new romantic relationship; he is getting married again. Marla has become a grandmother. Marla asks Monte to teach a class at the psychoanalytic institute. Monte is excited to be asked and eagerly says yes. Monte begins to teach the class, realizing something is terribly wrong. The students are not engaged. He cannot seem to grab the students to think about the articles. He turns to Marla for support. Marla, at first, seems eager to help Monte, but over time, Marla stops returning Monte’s phone calls. Monte is flattened. He seeks help from others to improve his teaching style, and his class improves, yet, his disappointment with Marla feels massive.

Monte tries to help Marla understand his disappointment. Marla becomes defensive and angry. Monte keeps pleading for understanding and open communication. Marla, rather suddenly, or so it seems to Monte, says “that’s it, we’re breaking up.” Similar to earlier posts https://shirahvollmermd.wordpress.com/2010/02/11/youre-fired/,  https://shirahvollmermd.wordpress.com/2010/01/24/betrayal/,  https://shirahvollmermd.wordpress.com/2010/02/12/youre-fired-ii/, Monte is stunned. The words echoed  in his mind. The phrasing made sense. He felt that he had a very meaningful relationship with Marla, and if Marla wants to change that connection, it did feel like a “break-up”. The shocking part was that  Marla used the words “break-up,” implying that it was a large emotional upheaval for Marla as well.  Monte was confused as to how wanting support over teaching the class led to the “break-up.” Monte felt there was more to it; the uncertainty was painful.

Relationships with therapists, even without an erotic component, can be intense. When the patient is also a therapist, the situation is ripe to morph into a deeply meaningful mentoring relationship or a deeply painful split. In Monte’s case, the split seemed unbearable. For years, Monte had looked up to Marla; admiring her career, her personality, her charm. Monte counted on Marla to be there for major life events, as she was there for him when his mother passed away. Now, Monte felt rejected and confused. At the same time, Monte and Marla are still colleagues so Monte has to interact with Marla at professional meetings.

Time passed. Monte came to a point of acceptance, although he was still confused. He hoped that none of his patients would  experience disappointment in him, as he felt in Marla, but he also knew that it could happen. Long-term relationships are hard to predict. Working through conflicts and misunderstandings requires patience, attention and humility. Those qualities are rare, particularly as one ages and one has more life stressors. Monte has a lot to think about. Being a psychotherapist helps him think, but it does not take away his pain. He is going back to therapy.