More Adolescent Turmoil

Greta, sixteen, like Graham, twenty, https://shirahvollmermd.wordpress.com/2011/08/29/adolescent-turmoil/ is struggling with identity formation. “My parents are my whole problem. I don’t want to be anything like them. I hate them. Their lives seem so boring and mundane. I want to be creative. I don’t want to work in an office all day. I just hate living with my parents. I won’t have dinner with them. I hate taking vacations with them; I just hate them.” Greta says with great passion and hysterics. She cries as she tells me how much she dislikes her parents. “Maybe you are scared that you are going to have their lives and so to deal with that fear, you hate them, so as to remind yourself to take a different path.” I say, knowing that Greta’s parents are both attorneys, and imagining that Greta might worry that she will be trapped into going to law school, for fear that she will not figure out what else to do with her life. “I am not scared. I know myself very well and I am not scared. I am angry that I have to live in the same house with these people that I don’t like.” Greta says defiantly, but at the same time, I have a strong sense that she is thinking about what I said. “Also, maybe it is easier to identify your parents as your major problem, rather than working inwards to see how difficult it is for you to make decisions for both the present and the future.” I say, pointing out that it is always easier to blame others for one’s problems, rather than seeing how one’s choices create difficulties downstream. Again, she responds, “it is not difficult for me to make decisions for myself. I know what I want to be doing now and I am thinking about my future in a reasonable way.” Again, I see the two Gretas. The one that contradicts everything I say and the one that processes my comments privately, after our sessions. Over the fifty minutes, Greta calms down. It is almost as if she exhausted herself by complaining about her parents. As she begins to show signs of fatigue, I felt she transformed into a girl, seven years of age. I almost asked her if she wanted to play cards. It seemed like when she was done with her adolescent pushing away behavior, she wanted to be a latency age child who could play and accept the world for what it was. The shift in intensity from hatred to calmness is a wonderful part of working with adolescents. I feel for Greta in that her “hatred” of her parents is clearly an exhibition of her internal painful state. She has not found internal contentment and her parents, with all of their flaws, get the brunt of that, or so it seems to me. “Can I go now?” Greta asks, acting like every minute is now painful for her. “We have about five minutes left,” I say. Greta throws herself on to my couch, lies down, and says “I don’t know if I can survive that.” Then, after the five minutes, she is so comfortable, she does not want to get up to leave. Like infancy, adolescence is such a precious time.

Sticky Relationships

   Evelyn, fifty-two, worries about her twenty-five year old daughter, Eleanor, with regards to Eleanor’s relationship to Eli, Eleanor’s boyfriend. Eli wants to be with Eleanor. Eleanor is not sure she wants to be with Eli, but she has been with him for two years and despite her ambivalence, she does not want to end the relationship.  They both live in San Francisco. They both have good jobs. Evelyn explains to me that “Eli is very sticky. He clings to Eleanor and that bothers me. It does not seem like such a good relationship,” she says. “It sounds like you feel that Eli is holding on to Eleanor by the ankles,” I say, trying to create a visual image of Evelyn’s concern. “That is the perfect description. Eli seems so desperate to me. I think Eleanor cannot part with him because she is afraid of what that would do to Eli, not because she wants to be with him,” Evelyn says with deep concern and worry. “I suppose part of your issue is that you feel helpless to do anything about Eleanor’s choice in a mate,” I say, understanding the frustrations of parents of adult children. “Yes, I can talk to Eleanor, but of course, she won’t listen to me. Besides, if she does stick with him, I don’t want to create bad blood between me and Eli,” Evelyn says, explaining her helplessness and her fears.  “Maybe you need to trust that Eleanor will figure out her relationships, in the same way that you figured out yours,” I said, reminding Evelyn that she was once young, facing life-changing decisions. “Yes, but it is like watching a train crash. It is really hard to witness it, even if in the long-run everything turns out fine.” Evelyn explains that she feels so certain that Eleanor and Eli are a poor match. “Sometimes, as a parent of an adult child, you do have to watch the train crash,” I say, thinking of how many parents I see that are faced with similar feelings of helplessness and fear. It is hard to watch and adult child make decisions you don’t agree with. Likewise, it is hard to watch a parent watch a child make decision that the parent does not agree with. There must be an art to living with anxiety about one’s child, but I don’t think that art is ever mastered. I think we need people to share those anxieties with. I would like to think that Evelyn agrees with me. I am pretty sure she does.

Personality: Scab-Picking

Kim, forty-five, a friend of my patient Rebecca, also forty-five, is getting under Rebecca’s skin. By Rebecca’s account, Kim is always telling her to change her life in some way, like changing her clothing style, changing her relationships, changing how she spends her time. Rebecca keeps at it, Kim says, as she describes this relentless bossiness. “She sounds like a scab-picker,” I say, trying to explain that some people, likely based on their experience as children, take a weak point in someone they are close to, and then they keep bringing the conversation back to that issue. Sometimes it is subtle, and sometimes it only happens when the person, Kim in this case,  is under stress. “I can’t confront her,” Rebecca says, “because she thinks she is being a good friend.” “Maybe you can gently change the subject,” I suggest, encouraging the art of conversation which can protect the friendship, without the adverse consequences of direct confrontation. “I can do that,” Rebecca says, but she still really gets on my nerves. “Well, then, maybe you do have to gently confront her, and tell her that you appreciate her concern, but that you are fine with the way things are for now,” I say, trying to be directive so that she has the words to use with Kim. “Understanding that this scab-picking trait is really about Kim, and that it is likely to be about how Kim was treated by her mom, might help,” I say. “No, that does not really help,” Rebecca says immediately. “She still hurts me when she picks at my scab,” Rebecca says, taking my metaphor and running with it.

Adolescent Turmoil

   Graham, recently twenty,  says “it has been so long since I have partied, I am really worried I won’t like it.” Graham moved home from the dorms to save money and now he is going back to living on campus.  “I just don’t know how that lifestyle is going to be for me. I mean I did not like living with my parents, but I am worried what it will be like to be surrounded by people my age. I did not like it the first time I was there, so I don’t know how I am going to feel now.” “If you don’t want to party, are you afraid you will be lonely? Are you concerned that you won’t find like-minded folks who also don’t want to party?” I ask, thinking how prevalent alcohol is in this population, and concerned that for some kids this can be a major problem, but at the same time,I realize that parties are the social outlets for many college students. “I am just really anxious that I won’t make friends. I am sure I will, but I am still really anxious,” he says. “Coming home was a hard transition, and now moving back to school is also challenging. The change is so uncertain, so unsettling. ” I respond, trying to help him understand that his anxiety is understandable, although understanding it does not necessarily take the pain away.

  The social scene at college is so critical to Graham, like it is to so many people his age.  Fitting in, finding a peer group, seems to be a larger issue than the academic challenges that lie ahead. I wonder about college as a developmental milestone, and if it is, then what happens to kids who don’t go to college? Does college postpone maturity, promote it, or both? From patients like Graham, I see that college presents him a social opportunity that he hopes will compensate for his poor high school social life. At the same time, he knows that his lack of friends in high school, makes him insecure such that he might have a hard time making friends in college. So, university is both an arena of hope and despair for Graham. Maybe he can re-invent himself: hope. Maybe he will be that ‘weird kid’: despair. My job is to tie the past to the present, while at the same time helping him see hope in the future; hope in himself.

Psychopharmacology Excitement

   Don Levin, I knew that name was familiar. I met him today at a speaker training meeting for a new and potentially exciting psychopharmacological agent, Viibryd. I looked at him, like I knew him from somewhere, and over the course of about thirty seconds, I said “are you the New York Times guy?” When he said “yes” I  started stamping my feet with excitement. Sure enough, his side of the story is so different than the New York Times, http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=2&scp=1&sq=psychiatry&st=cse, that although I appreciated the opportunity to rant, https://shirahvollmermd.wordpress.com/2011/03/09/i-repeat-where-did-the-listening-go/, I felt bad for feeling so negative about him and the state of my profession. Although I did not get the opportunity to go into detail with him, the gist of his message was that he faced a career transition and he made his best judgment under those circumstances, which were not outlined in the article. Meanwhile, we were both excited to learn that maybe the stalled psychopharmacology world is beginning to start up again. Prozac came out in 1988 and the world changed. Since then, we have stalled, such that after twenty-one years, the wonders of Prozac have fallen like the wonders of antibiotics. The first few years were exciting, and then it became old news. Don’t get me wrong. It is still exciting to see people go from suffering to enjoyment, as a result of a multimodal intervention which includes psychotherapy and psychopharmacology. It is still exciting to teach primary care physicians how they can help people have a better quality of life. Yet, the learning curve in this psychopharmacology world came to a flat line. Almost all of the newer medicines on the market imitated the wonders of Prozac. The nuances were helpful, but not that thought-provoking. As a result, both the field of psychopharmacology and the psychiatrists who identified themselves as psychopharmacologists, were losing their luster. We, as a field, are ripe for a new paradigm to treat depression and anxiety. Viibryd might provide this, which means there is hope not just to treat patients who have not responded to our current armamentarian of drugs, but there is hope to reinvigorate my profession. Dr. Levin, I apologize for using you as the springboard to talk about listening. Having met you, I now respect your decision to take a turn in your career which made sense to you at the time. The complexities of that decision, which you only hinted at, changed the notion that you somehow wanted to stop listening. It was really nice to meet you.

Feeling Feelings

   “I only want to feel positively about things,” says Monique, a peruvian born sixty-two year old patient. “My daughter does not call me very often but I don’t feel bad about that,” Monique continues.  “How can you control your feelings?” I ask, wondering about the cultural understanding of feelings. “Well, when I was a little girl and my aunt told me that I had to change seats at the dinner table, I was so hurt that I went to bed without eating dinner. I just could not take the insult of having to move because someone was more important than I was. Ever since then, I realized that my feelings never helped me. They just hurt me. So, it was better not to feel my feelings and move on.” “Well, you can feel your feelings but not act on them,” I say, feeling like I am saying something very basic, but, it might be an important reminder. “You mean I could just come here and tell you how I am feeling,” Monique says with a childlike sense of wonder. “Yes, that is what I mean,” I respond, realizing that managing feelings is a new experience for Monique.

    “I feel very confused by this discussion. I feel like I should write it down so we can talk about it next time,” Monique says, surprising me with her confusion. “We were talking today about how you are trying to control how you feel, but at the same time, you were telling me things that were disturbing you,” I say, pointing out that her feelings do get hurt and she shares that with me to help her feel better. “I thought we were talking about those experiences so that I could get an American point of view. Maybe in the United States adult children don’t stay in touch with their parents as much as they do in Peru.” Monique explains why she mentioned her experience with her daughter. “I am not sure I represent the American point of view, but I can tell you that it felt to me that you are hurt by the emotional distance between you and your daughter.” I say, struggling to lay a landscape of feelings which do not result in any action, other than trying to understand them. “I hear what you are saying, but I am not sure I understand. I will think about it, but this feels very foreign to me.” Monique says with her heavy accent.  “Maybe there are some cultural issues here that I need to understand better, but I also wonder if you have spent so many years of your life trying to control your feelings that you have lost touch with yourself in the process.” I say, thinking back to her moving story of emotional pain at eight years old. “I did not like myself very much so I am not surprised I lost touch,” she says with a matter of fact tone. “I know that is a very painful comment, but I also think that is funny,” I respond. “Glad I could make you laugh,” Monique says, “it is good to be positive.”

Helping ‘The Help’: Psychoanalysis Comes Alive

         “The Help,” both the book and the movie are interesting, but not great works of art. However, they are great advertisements for why psychoanalysis and psychotherapy are so important. Aibileen captures this moment when she says to herself, with great wonder, that she can’t believe someone cares about how she feels about her life. Race relations are so painful, partly for this country’s history of cruelty towards African-Americans, but maybe more importantly because of the history of  how large segments of the population ignored their feelings. Psychoanalysis comes alive in these times because it is a field which validates this notion that people need to be heard and understood, as much as they need to have food and shelter. Skeeter, the main character of the story, took an interest in Aibileen’s point of view. Like a patient who enters into psychoanalysis, this interest, at first, made Aibileen anxious, but over time made Aibileen appreciate herself in ways that she had never experienced before. With Skeeter as an attentive audience, Aibileen had permission to reflect on her life; she had permission to think about how she was thinking. She had permission to feel her feelings.

    Prior to Skeeter wanting to interview Aibileen,  Aibileen’s major outlet for her emotional life took place in her relationship with the children she helped to raise. The movie and the book depicted just how important this attachment was, both for the white child and the African-American help. It was in this connection, that feelings could be expressed, and hope could be felt. Psychoanalysis comes alive yet again. Attachment theory supports the notion that this tender relationship between caretaker and developing child becomes the paradigm for important relationships downstream. Further, psychoanalysis gives credibility to the feeling that not only do children benefit from a loving caretaker, but the caretaker grows emotionally as well. Aibileen understood this. Her life was not all about prejudice and maltreatment. It was also about loving children and helping them grow up to be self-confident and loving adults. Aibileen knew that this pleasure far surpassed the materialism of her employers. 

   “The Help” is a sad book/movie. The themes of prejudice and hatred are hard to watch. Yet, like being a psychotherapist, one witnesses the ugly side of human nature, knowing that good things can grow out of seemingly endless cruelty and unfairness. Aibileen and Skeeter, like patient and therapist, both transformed in the course of the story. They did not transform because of their suffering, they transformed because they had each other. The attachment, the connection, the love, the relationship, whatever we call that, was the instrument of change. Psychotherapists know this. We just need to get that message out. Maybe “The Help” helped us.

Cynicism or Human Understanding?

“A gift is a form of coercion,” I say, trying to point out that human behavior is about multiple motivations, both conscious and unconscious. “You are cynical,” Stu says to me, with a tone of both surprise and contempt. “When I give a gift, it is because I feel good about a person,” Stu says, as if there is nothing more to talk about. His wife, Deirdre, also in my consultation room, chimes in, “I think she is trying to say that human behavior is complicated.” Stu responds rapidly, “yes, but to say that a gift is coercion seems to take the joy out of the process. I like giving people gifts.  I don’t care what they think of me.” “I understand that,” I respond, trying to point out the layers of meaning in every action, “at the same time, I can imagine that when you give someone a gift, you hope they appreciate the gift and you hope they appreciate the giver as well. There are expectations associated with gift-giving which can lead to loving feelings, but other times, it can lead to anger and disappointment,” I respond. “This is silly,” Stu says. Deirdre stays patient, but responds quietly, “this is not silly. We need to understand our expectations from one another so that we can get along. I do appreciate you when you get me gifts and I hope that you appreciate me when I do the same. I am not trying to manipulate you, but I am trying to generate some positive feelings when I get you presents.” “Now I think you are both cynical,” Stu says, “but I will think about what you are saying. Right now it sounds crazy to me.” “I am glad you are open to thinking about these ideas that on first pass sound absurd to you.” I say, feeling optimistic, but also concerned that Stu sees  motivation as purely altruistic and then he defends his thinking by attacking me. At the same time, I begin to think, where does understanding the selfish nature of human behavior end and cynicism begin? Stu does raise a good point. Human behavior, when thought about in stark terms, can sound cynical. The challenge is understanding layers, especially while under stress. “Gifts are also a really nice part of relationships,” I say, reminding Stu, Deirdre and myself that the nice layer is important too.

“You Were Right:” A Ten-Year Follow-Up

  Sando, sixty-three, male,  came back after ten years, having seen me for the ten years before that, saying “you were right. I should not have married her.” “I am sorry,” I said, thinking that I am not sure what I was right about, but whatever it was, I feel bad that he is going through more hard times. “What do you mean?” I ask, remembering how worried I was about his upcoming marriage all those years ago. “Well, as you said, she liked the idea of marriage, more than the reality of being married, so she was just very selfish. The irony though is that I was unhappy for a long time, but it was she who ended the marriage. She wanted to get back together with her ex-boyfriend from high school, so she left me.” Sando is flat while he is describing the painful relationship until the very end of our session, when he breaks down and says “I just don’t know why I pick such bad people. As you said, Sheila (his current wife, soon to be ex-wife) was just like Sandy (his ex-wife) except that Sheila was not as mean as Sandy.” I don’t remember saying that, although it sounds like something I could say.

      Sando comes back to me with tremendous ambivalence. On the one hand, he appreciates the history we had together, but on the other hand, he wonders if he will fall into the same trap, since he hoped that by seeing me he could pick relationships which made him feel more fulfilled. The fact that I was right did not help our relationship; it only made him mad at me, and mad at himself for repeating a bad pattern. Yet, despite these questions about our relationship, we are quite fond of each other, and so Sando feels drawn to the warmth and comfort of seeing me and being in my office. “I guess we could make another appointment,” Sando says, implying that he is not committing to psychotherapy, but he wants to continue to explore how the past relates to the present, at least for a few sessions. Surprised by his initiation of further contact with me, I said “sure, we can try to sort some things out. It is good to see you, but I am sorry about the circumstances.” I say, remembering the hard times we have been through together: the death of his father, then his mother, then his younger brother. “Well, it is not nice to be back,” he says, with some humor and some truth. Being “right” has little value in our relationship, I feel. The strength of our bond is in our emotional connection. I might tell him that next time, but then again, maybe he already knows that. Seeing Sando made ten years feel like one. Time is funny that way.

The Coach Mom: Transference In Action

     Murray, 37, wants to run a marathon so he hired, Millie, 62, a coach, to help him. Inevitably, Murray starts to treat Millie as a mother-figure. He rebels against practicing. He is fearful of letting her down. He wants her to be proud of his accomplishments. “She has become a stand-in for your mom.” I say, pointing to the transference that is occurring as their relationship deepens. “Well, sort of. She has other students that she coaches and they don’t seem to have a problem telling her that they did not practice, but I feel so guilty about it.” Murray reports with a sense of anxiety and tumult. “Exactly,” I say excitedly. “Everyone has a different relationship with authority figures based on their past experiences and for you, disappointing your authority figure gives you internal disruption, as it reminds you of the pain of disappointing your mom.” “Yea, I see that, but it is still really difficult. I emailed Millie to tell her I was not going to practice with her Sunday and now I am on pins and needles waiting for her response, ” Murray says, as if he just had to tell his mom that he was not going to study for his math test.  “Millie is bringing back a lot of old feelings for you. That is really hard.” I say, connecting the past to the present. “They don’t feel like old feelings, but I guess they are,” Millie says, somewhat confused by my line of thinking. “Your relationship with Millie is so intense that you bring past relationships into the present.” I say, trying to explain the universal nature of this experience. “Yea, but I wish it were not so intense,” Murray says. “Yet, at the same time, maybe you appreciate Millie as a mother-figure who can slowly change your relationships with authority figures. Maybe you are hoping that Millie will reshape your experience of trying to please someone.” I say, explaining that new relationships can sometimes mend the trauma of old relationships. “That is very interesting,” Murray says, as if the session was finally congealing for him.