The First Date

     Geraldine, seventy, really wants a boyfriend. She has not had one in maybe thirty years, maybe forty. When she turned sixty-five, she decided that “it was time to start looking more seriously.” She bought a series of tickets to a local theatre; she decided to go alone hoping to meet someone else who was going alone. In her mind, this was the perfect strategy to meet someone who is likely to be compatible. Sure enough, she meets someone while she is waiting for them to open the doors for the show to begin. She encourages him to continue the conversation at intermission. He does. After the show, they chat again. She asks him for his phone number and his email address and she gives him her contact information. Geraldine felt like she scored. She, not wanting to wait around, called him the next day and left a message. A few hours later she received an email from him informing her that he wants no more contact with her. “Did I miss all the social cues?” Geraldine asks me, befuddled. “Maybe,” I said. “It is also possible that he had some sort of internal dialogue which you had no way of knowing,” I continued. “It is hard to live with the uncertainty of not knowing, because your mind goes to a place which explains the situation, even though when it comes right down to it, you have to accept that you will never know for sure.” “I go to a place where I blame myself.” Geraldine says. “Yes, you feel bad about yourself most of the time, so it is not surprising that when you have no other explanation, you assume you did something wrong. It is like a child who blames herself for her parents’ divorce.” I say, trying to point out that she is projecting her bad feelings on to this stranger, and that is one reason dating is so challenging. “Maybe I will figure it out when I am a hundred,” she says, lightening up the tone, but with a touch of fear about her age.

Unloveable Loneliness

    Roger, thirty, is terribly afraid to break up with his girlfriend, Charlotte, also thirty. His emotional life feels very black and white. When he talks to Charlotte and they have a good conversation, he likes his life, he likes his family, he likes his friends. On the other hand, when they have a disagreement, he gets scared they will break-up, and then he imagines a loneliness which is unspeakable. On those days, he does not want to get out of bed; he does not want to go to work and he does not want to talk to his friends. As he puts it, “I just want to cry all day long.”

   Roger is a strikingly handsome, wildly successful man who comes from a stable and loving family. From the outside, it is hard to imagine that his internal world is so dark. “My family loves me. I have no doubt about that,” he says, in a way that makes it sound like he is so puzzled that he is going through such a hard time. “I can feel that your family loved you, but what is interesting is that somehow you do not feel loveable,” I say, trying to explain that his fear of breaking-up with Charlotte, is based on a primitive fear that he will never find anyone to love him; that he is essentially not worthy of love. “Maybe that is why I drink too much,” he says, looking at me with deep understanding about what I am saying. “Numbing the pain only goes so far,” I say.

   Roger, despite his good looks, and despite his material success, he  has not had many girlfriends, nor has he had many “hook-ups.” It seems, from the outside, that he has been reluctant to share his heart with anyone. Charlotte won him over by pursuing him aggressively, he explained to me. “She would not stop bugging me,” he said, with deep admiration and gratitude for her persistence. “So now, when you worry that she could pull the plug, you see that she can go after what she wants, but you are more hesitant to do that,” I say, stating how passive he has been with romantic relationships. I was trying to tie his passivity to his fear that if they part ways, he will feel unable to reconnect with someone else. “I have no confidence,” Roger says, with a sad and moving expression. “I am insecure,” he repeats. “It is really good you can see that,” I respond, saying that his insight allows us to probe deeper. “This is going to take forever,” he says with impatience, touched with a bit of humor. “We will see,” I say, closing the session on a note which felt both deep and hopeful.

Conversation Challenge

   Mortie, seventy-two, likes to come in and report to me how her week has been. She does not seem terribly interested in my thoughts, but she does seem to be interested in her stories, which I find interesting, most of the time.  My dilemma is how much I should listen, and how much I should interrupt and make a comment, either in the form of a question or an idea about why she is telling me this particular story. My timing is critical in that if I say something too soon, she will feel she is not being heard, and if I wait too long, we won’t have enough time to work together to explore a new way of seeing things. One session, I did interrupt early on, to which her rapid response was “I am paying you to listen to me.” I knew as soon as she said that, that we were now in a world of pain and struggle. In that moment, she exposed her vulnerability in a way which I felt was going to take a lot of time to mend. I could challenge her statement by explaining that she does not pay me to listen, but rather, she pays me to help her understand how her mind is working. I did not think it was a good idea for me to say that, because the emotional temperature was too high. Then, I thought I could continue to listen, but I did not want to do that, since I did not think it was helpful to continue on the train where she relates her stories and I passively listen. So, I chose a third option, and I said “wow, that must be hard for you to feel that you have to pay someone to listen to you.” She calmed down and said “you know what I mean. I come here and I expect you to listen.” “Well, I do listen, most of the time, but maybe there are other times, when I feel it is more appropriate for me to say something rather than to continue to  listen.” I said, hoping to keep the calmness, since the raw feelings a minute ago had been so palpable. Mortie begins to cry. She says,  “I just want to disappear from the planet. I don’t like myself. I can see why people don’t want to be my friend.” ” Wow, we went from talking about conversation skills to suicide, awfully quickly. How did we get there so fast?” I asked. “I just don’t like myself sometimes,” Mortie says, “and I am too old to change.” As hard as it was to hear her say that, I felt the hope that we could now enter into territory that was more meaningful; she presented her feelings which could lead to some internal change. “I can see how badly you feel about yourself and I am sorry you feel that way. I think we can work on those feelings in a way which might help,” I say, with confidence that a positive shift has taken place. We are on our journey.

Health Care Disparities

Rant alert-I am angry! In teaching my Family Medicine Residents about the delicate and complex role of benzodiazepines in the treatment of anxiety, one of my students informed me that at the low-income clinic where many of my students work, they have eliminated this class of drugs from their formulary. I could hardly contain my rage. In fact, I did not contain it and I began to try to turn my rage into an important teaching point. That is, regardless of income level, patients are entitled to have access to medication which can make their lives significantly better. Instead, this policy has made it so getting treated for anxiety is now a middle to upper middle class possibility, but lower-income folks have to find other means of dealing with anxiety. The unfairness of this discrepancy is hard to understand. The medications are cheap. There is no cost barrier.

  I do see how prescribing benzodiazepines are time intensive and therefore costly in that way. The medications need to be monitored. As with prescribing any medication, there is a risk of liability. Yet, it is a clinic, and the mission of the clinic is to help low-income people receive health care. Treating anxiety with available medications is part of that mission-I would think. Second, and terribly obvious, how are my residents supposed to learn how to prescribe these anti-anxiety agents if where they work does not allow them to use these agents? Yes, they do get experience with the likes of Xanax, Klonopin and Ativan on their other rotations, but they should also be able to learn to see how these medications impact people who are struggling with unemployment, foreclosures, and high intensity exposure to violence and substance abuse. Helping someone with anxiety, whether with medication and/or behavioral techniques, enables the patient to cope with what might otherwise feel like impossible situations. Further, anxiety causes medical problems to get worse, so if the doctors can’t treat their anxiety with psychotropics then they will be treating their medical problems, such as their increased blood pressure, their increased sugars, and their irritable bowel disorder. Treating the mind, helps the body, and treating the body helps the mind. Why is that not clear to policy makers?

Fear

     Buck, the focus of the documentary, knew one thing. Fear inhibits coöperation, often resulting in aggression. By contrast, trust creates team work and serenity. This is as true for people as it is for animals. Paige, a fictional patient, reports to me that our relationship has taken a turn for the worse. She feels I am critical and judgmental of her. As she continues to describe her negative feelings, she is clear that she has come to fear my commentary such that it is very hard to work with me. Her trust that I will say things in a gentle way has been threatened. Sure, her fear could come from her childhood, which is now transferred on to me. Sure, I could have changed in a way that made her substantially more fearful. Either way, Buck’s point is still valid. Fear could destroy our working relationship. To build it back up, trust needs to be re-established. Buck shows in the film that creating trust involves patience, understanding, and calmness. As he worked with the horses, Buck reminded me of my work as a psychotherapist. He gives the horse a space to be so that he can develop an understanding of that particular horse, in the same way that I try to give patients a space to unfold in order for me to really understand their mental processes. Intruding into that space too soon can create fear. Waiting too long can cause the person, the horse, to feel abandoned. The art of knowing when to introduce a new way of behaving is the challenge.

The Angry Friend

Claire, sixty, calls her girlfriend Shai, opening the conversation with “you didn’t call me back.” Shai did not know that she owed Claire a phone call and besides that, she was annoyed at the hostility directed at her. They had a short conversation, followed by Shai calling Claire back and opened the conversation with  “I felt like you scolded me.” Claire, completely taken aback, says “what are you talking about? I thought you were going to call me back and you did not and so I called you.” Shai, knowing that she did not say she would call Claire back said “well, first of all you did not listen to me when I told you I was not going to call you back. Second, it is hard on me when you start a conversation in such a hostile tone.” Claire, again, shocked by this discussion continues to be defensive, “gee, I don’t know how else to put it. You did not call me back and I thought you would.” Shai, amazed at Claire’s lack of social skills, says “the problem is your tone is very hostile.” The conversation took a major shift. Claire replied, “I do feel angry that people don’t respond to me, but I did not know I was expressing that in the phone conversation.” Shai, immediately warmed up to Claire. “I can certainly understand how bad it feels not to be responded to.” Shai has now changed from feeling contempt for Claire, to very bonded with her feeling that she is dangling in the world without a feeling of being important to someone. By the end of the conversation, Shai and Claire were really glad they were friends. Shai ended the conversation by saying “it is so nice to be able to be real with someone. Most of the time, I just suck it up when someone hurts me, but you and I have been friends so long, I did not want to carry around this resentment. I am really glad I called you back.” Claire agreed heartily. Once again, anger was a passing stage from a bond almost breaking to a bond deepening.

Angry Patients

 

 
   Karen, sixty-two, sees me twice a week, like clockwork. Recently, I had to change one of her times, an action I resist, but I had no choice. “That’s OK, I will just come one time next week. It does not matter.” Karen says, with hostility that hits me in a way that is consistent with her quiet way of being angry. The following session she says “I don’t know what to talk about,” again, I am feeling a passive-aggressive feeling where she resigns from initiating a discussion, but she is mad that not more happens in psychotherapy.

      “I have been thinking about our last session,” I say, making her look surprised. “When I was sorry to have to change our schedule, you said it did not matter and that made me think that you were angry.” I said, expecting her to be taken aback by my comment, but instead she said “of course, I am angry. Wouldn’t you be?” “I am not sure what you mean,” I say, knowing that Karen’s style is to obscure what she is talking about by not telling me her entire thought. “My life is ruined. My husband walked out on me. My kids are doing their own things. I am old. I am fat. I am lonely. Of course, I am angry.” Karen says, with tears running down her face. The tone changed dramatically. Her sadness came through after her anger subsided. Instead of feeling devalued by Karen, I began to feel her pain. She was struggling and her anger was her defense.

   “I can see why you are angry,” I said. “It seems like your life is not what you expected it to be; not what you want it to be.It also seems like you don’t feel much hope that you can make it better.” I said, feeling like I was understanding her feeling state. I began to learn more about her childhood, as she told me how she felt her life was going to turn out when she was growing up. She wanted to share with me how she felt about her mom and dad. I felt like we surprisingly opened up a new chapter in our relationship. She did not seem angry. She was comfortable sharing her history. Anger is pretty interesting; there is always some deeply meaningful material behind it. Anger, to me, feels like a door. Sometimes they are hard to open, sometimes pretty easy, but either way, when you can get in, there are rooms to explore.

Angry

 

 

 

 Angry is one of the most common search words that people use to find my blog. I did not know that I spoke about being angry so much, but now that I think about it, anger is certainly one of the negative feelings which propel folks into psychotherapy. Like all pain, anger is a clue to internal distress, sometimes rising to the point of needing medical attention. Betrayal makes people angry as I spoke about in my previous posts involving the Monte/Marla drama: https://shirahvollmermd.wordpress.com/2010/01/24/betrayal/   https://shirahvollmermd.wordpress.com/2010/06/30/more-betrayal/. Susie, sixty-one, was angry today when she came in, not at me, but at her employee, Tony. Tony did not do his work, and when confronted, he took the opportunity of this negative exchange to attack Susie on a personal level. Susie handled it professionally, but internally, she felt dismantled. “It seems that Tony honed in your vulnerability; on the parts of yourself that you do not feel sure about.” I said. “Well, obviously,” Susie replied. “So that is helpful to us to understand what this vulnerability is all about.” I say, highlighting that getting hurt, although painful, is also an opportunity for self-exploration. “I guess,” Susie says, dismissing the opportunity, but at the same time, understanding that maybe when the pain subsides, she might be able to examine her sensitivity. Susie was angry when she walked in; she was calm when she walked out. Sharing the experience, thinking about her feelings, seems to have diffused them. Immediate gratification happens in psychotherapy, along with the long-term kind. Being angry can be part of a helpful internal journey. Susie reminded me of that.

Prozac Cartoons Never Get Old

Dual Relationships

   July kicks off my month of meeting new Family Medicine Residents, Child Psychiatry Fellows and Adult Psychiatry Residents. My role differs in these three arenas, yet I feel similarly in that I have this sense that we are creating new bonds. Sure, I am their “teacher” and sure, there are boundaries that I must be very conscious about, but they are no where near the boundaries involved in a therapeutic relationship. I have reporting responsibilities with my students such that they know that I am letting their program director know if I encounter any problems or concerns. Still, as a psychiatrist-teacher, I feel it is important to get to know my students. Part of this desire is selfish. My job is more fun when I know who I am teaching. Part of this desire is also helpful. If they trust me as a person, they are more likely to be interested in what I have to say.

    Jerry, twenty-eight, fresh out of medical school, comes to my office to learn about psychopharmacology. As we begin to chat, he tells me, with tears in his eyes, that his mom passed away two years ago in a car accident. “You know, I don’t know how to deal with it. It is just too hard for me.” He says, not really asking for my help, but wanting me to know that he is suffering terribly. “Have you thought about going to therapy?” I ask, knowing that he knew that I was going to inquire about that. “Oh yea. I have been to therapy but it did not help.” Jerry says, looking at me as if to say, my mom died and therapy can’t make that better. We continue to talk about what his mom was like. As we do that, we move into the details of her death: how he found out, what the funeral was like, how his friends rallied around him. I feel very sad for him, but I also need to teach him about medicines for the mind. Of course, I am thinking that psychotropics might help Jerry, but since I am not his doctor, it is not really my place to say that. Perhaps he will think about it as we discuss the indications for the SSRIs. We slowly transition to the didactic part of our time together, but it seems clear to both of us that we are really sad.  Yet, as the time went on, and it was time to go, Jerry perked up. He seemed relieved to get his feelings out. We had a good connection, I felt. We will see how it goes next week. I am optimistic and sad at the same time.