Girls Need Girlfriends

 Samantha, twenty-one, explains her forays into dating. Five guys seem “really interesting” to her, she tells me. ” What about girlfriends?” I ask, wondering why her social life only involves boys. “Well, I don’t see that as so important right now. I am enjoying the attention from men.” Samantha says, as if the sexual tension is the most exciting part of a relationship, ignoring the intimacy that girlfriends can provide. “I understand the excitement of that sexual tension, but what about the continuity that platonic relationships can have.” I say, implying that as these boys settle into relationships then they will probably will not be paying too much attention to her. “I have never really had girlfriends.” Samantha says in a way which makes me feel sad for her. ” I know that your interaction with the world has always been through creating sexual tension, even when you were small.” I say, reminding her that she used to talk about how she felt that her relationships with both of her parents were sexually charged, even at a young age. “Yes, that is true. Maybe that is why I have never seen the value of girlfriends,” Samantha says in an intellectualized way, without much feeling about that. “I am really excited to have all these guys in my life,” she repeats in somewhat of a defensive way. “I am happy for you too,” I say, trying to say that she can have both male and female relationships, if she begins to value both forms of connections. For Samantha, relationships without sexual tension are foreign territory. Maybe she will begin to migrate away from her comfort zone. We will see.

Tardiness Tales

  Alana, thirty-three, comes routinely ten minutes late. Ordinarily she is a prompt person, but to our sessions she sheepishly apologizes for her tardiness. “I am going to do better next time,” she says, as if she can be more disciplined. “Maybe you are ambivalent about coming here and so you compromise with yourself by coming late,” I say, stating that her unconscious has a large contribution to her behavior. “I never thought of that,” she says, as if stunned by my comment. As the session proceeds, she begins to tell me how she is still having problems with her boss at work. She knows she needs to find a new job, and she knows that we have discussed this before. “You came late because you did not want to face me and tell me that you have not sent out your résumé.” I say, pointing out that she anticipates our conversation about how unhappy she is at work, so to avoid this uncomfortable conversation, she delays the experience. At the same time, she finds our time together valuable, so she has deeply mixed feelings which are exhibited by her consistent tardiness. The striking aspect to her lateness is that she has pushed out of her awareness her strong fear of talking about her work; this fear only surfaces as she begins to tread familiar ground. Now it suddenly makes sense to her why she is late. She fears, what she perceives, is my silent scolding for not pursuing new employment. The ah-ha moment happened. I suspect she will continue to be late since this ambivalence still needs to be processed. For now, we are both frustrated that we don’t have much time together. Still, we both see that this frustration is preferable to the unconscious fear of my disapproval. The human mind never fails to impress with the depth of its processing and the compromises it makes, whether we know it or not.

Insecurity

   William, sixty-two, wanted to know his diagnosis. “How would that change things for you?” I ask, wondering about why a psychiatric label is something that he is seeking. “I need to know I am not alone. I need to know that there are other people who suffer in the same way that I do,” he responds, tearfully and powerfully. “It sounds like you don’t trust your instincts. You know that you are suffering. You know something is not right in your head, and yet, if I were to give it a name, then you would not need to feel anxious that you are somehow imagining this condition.” I say, understanding that labels cut both ways: they help people looking for support in their condition and they hurt people who feel stigmatized by being part of the mentally ill. “Over time, I would hope that you could use your intuition to reassure yourself that something is wrong, rather than relying on outside sources to tell you that you could feel so much better.” I say, trying to explain that on top of his depressed feelings, he is also feeling insecure, or uneasy about the way he is feeling, because he has never learned to trust his intuition about himself. “That would be nice,” he says with recognition of what I am saying, “but I am not there yet,” he continues. “I am going to go to a support group. It will help me,” he says, listening to my point about his anxieties around his condition, but also saying that he is trusting his intuition in that he knows he does need reassurance so he is going to seek that out. “I am all for it,” I say, collaborating with his desire to help himself, while at the same time appreciating that it would be nice if he knew he was suffering without feeling anxious about that layer of it. The journey is just beginning.

‘I Am Making Better Friends, Thanks To You’

 

Jennifer, twenty-four, https://shirahvollmermd.wordpress.com/2010/03/30/mother-figure/, looks to me as a mother-figure. She reports to me about her daily life: school, friends, roommates, job. She tells me about the people she meets and we talk about the quality of her friendships. As a high-school student, this kind of discussion made her defensive. Her pot-smoking friends were “cool”, she would tell me, as if to ward off her assumption that I would be judgmental about them. Now, to my surprise, Jennifer says “I really want higher quality people in my life. I want people with some ambition, some sense of where they are going. I did not realize how important that was, but thanks to you, I do now.” I did not expect this expression of gratitude. I began to wonder, why now, after all these years together, is this coming up? I begin to see that Jennifer is now transitioning to an Occupational Therapy Program, where she is on her way to a career. This is a marked shift from the girl a few years ago who could not imagine herself deciding on a career path. Jennifer went from being aimless to being focused and in so doing, she wanted to shift her friends from drifters to future professionals. She gives me some of the credit for this shift since she assigned me the role of wanting to see her grow and develop into an independent adult. It is true that I wanted this for her, but it is also true that she allowed me to encourage her in that direction. She entered into the relationship with me, wanting a nurturing person in her life. Sure, her parents also want to see her succeed, but Jennifer felt she needed more support for her development. She initiated therapy as a teenager. This drive for development was impressive. Jennifer was likely to succeed; she was determined. I facilitated her, mostly by allowing her to have this mother-transference. The love of a mother figure facilitates growth. Jennifer proved the point.

The Fish Died

    Caroline, fifty-two, had major heart surgery last May. She approached her upcoming hospital stay and intervention with ease and grace. She was grateful for the attention from her loved ones, but she was neither needy or demanding. She appeared to have little stress. Recently, her doctor told her that she now had to have a pacemaker put in, a fairly minor procedure. Caroline now cannot sleep. Her appetite disappeared. She is angry that her husband is not more supportive around this upcoming procedure. “It sounds like the kid whose mother dies and then goes out and plays, but when he is told his fish died, he throws himself on the ground with terribly dismay.” I say, pointing out to her that one would have expected her to be stressed with open-heart surgery, whereas a placing a pacemaker is a relatively minor procedure. It seems clear to me that she is only upset about the pacemaker because she is having a delayed stress response to her surgery last May. Caroline agrees, although she still cannot stop worrying about this pacemaker. “It is so interesting to me that you are allowing yourself to worry about this procedure, whereas when you had open-heart surgery, you marched through it like a soldier, almost as if you did not allow yourself to have feelings about that.” I say, again reminding her that her feelings seem out of proportion to the current stressor, but they are in proportion if we consider the historical context.

Missing Appointments: What’s Up?

Diane, forty-four, like Zach, https://shirahvollmermd.wordpress.com/2011/09/13/the-no-show-returns/, “spaces out” on her monthly early morning appointment with me. I call her, fifteen minutes into our scheduled time and she is convinced that I have the wrong time. After a few minutes of discussion, she says “well, let’s schedule for next week.” I respond, with some irritation in my voice, and we make arrangements for our next visit. Diane comes in with obvious trepidation. She reports that her dating life is “messed up.” Her parents are “driving me crazy.” Work is good, “but way too busy.” Absent from this conversation is a recap of our last conversation where we both felt irritated with one another. “I notice that we are not talking about the missed appointment,” I say, wanting to discuss the large issue which seemed to be making us both uncomfortable. “Well, now that you mention it, I was quite irritated with you,” Diane reports, not surprisingly to me, as I could tell by the way she walked in that our relationship was bruised. “I know that I screwed up. I know that I did not look at my calendar. I accept that, but mistakes happen, and I did not understand why you were so irritated. Sure, it is your time, I understand that, but I am not perfect, and so it happened.” Diane reports in a defensive way, and yet she surprised me in that she took responsibility for the missed meeting. “That irritation with me must have made it hard to come in today,” I say, trying to talk about her body language of discomfort. “No, not at all. I am not married, so I am not used to talking about relationship issues, but I did figure that we would work it out.” She says, conveying a sense of hope in our relationship, but also conveying a sense of confusion about how to deal with her upset with my behavior. “I think we can work it out, also, but I know that we were both irritated when we spoke on the telephone, and so our relationship feels different to me than it used to.” I say, again trying to say how feelings impact  our interaction. “It sounds like you have had a hard few weeks,” I say, explaining to Diane that I understand that missing our appointment falls into a larger picture of stressful events in her life. Diane visibly relaxes after I say that. “Yes, it has been very hard for me,” Diane says, easing the initial tension, allowing us to return to feelings of mutual fondness.

ADHD:Who Should Treat It?

   Child psychiatrists, behavioral pediatricians, family physicians, child neurologists are all physicians who feel comfortable and confident in treating ADHD kids. Where should a family turn when their child begins to have behavioral problems at school? The path is not clear. Often, the family begins in primary care, either at a pediatrician’s office or a Family Medicine doctor. Then, depending on the comfort level of the provider, either they receive treatment in primary care, or they get referred. This referral can be to any of the above-named specialists, all of whom have a different idea about how to treat ADHD. The family is often unaware of the landscape, and hence they are blindly following the recommendations of their Primary Care Physician. Usually, the child ends up on stimulants, but the difference lies in the details. For example, child psychiatrists, as a group, are usually the only ones who insist on a two-parent consent process, whereas the other providers are satisfied with getting the history and the consent from one source. The other disparity is in how much attention is paid to the family dynamics. ADHD poses a severe risk to marriages, and neglect of other siblings. I contend that child psychiatrists are more attuned to those very important issues. ADHD kids often need an advocate at their school to make sure that their educational system is maximized given their disability. A child psychiatrist is more likely to emphasize the importance of altering a child’s education, given the diagnosis of ADHD.

  I am biased, I hear my readers saying. Of course. I speak from my point of view. Still, the medicalization of ADHD seems to narrow the scope of this large issue which occurs in a developing child, and hence impacts a family. Child psychiatrists are uniquely suited to understanding the need for medication, while at the same time, appreciate the need for multiple psychosocial interventions as well. Child neurologists tend to treat ADHD like seizures; they try to “get it under control” as if this is not a life-long struggle with many potential hazards downstream. Behavioral Pediatricians are well trained in the area of ADHD, but they hit their limits when the behavior becomes very aggressive and is unresponsive to psychotropic medication. I do not mean to disparage my medical colleagues. I would rather that we pool our expertise so that we can figure out how to refer to one another. I am not sure how to make that happen. My second wish is for the consumer (or the patient’s family, in these cases) to know the difference so that they can seek consultation in a place that makes sense to them. Medical care is in such high demand. It is too bad there is redundancy in our system, especially when healthcare workforce issues are coming to light. Clearing the road for consumers, such that there is greater clarity on who should treat ADHD,  might help patients streamline their efforts to help their child. I can hope.

 

See also…https://shirahvollmermd.wordpress.com/2010/04/25/is-it-severe-adhd-or-is-it-aspergers-the-case-for-a-good-assessment/

Ahhhh!!! Senior Year

    Carol, seventeen, is a changed person. At sixteen, her emotions were like winter; she had terrible anxiety which clouded her mental state. She could hardly sleep; her eating habits were poor. She did not get along with her parent. They were “stupid”. Her friends were fine, but her teachers “did not know what they were doing.” Life was no fun for Carol. She felt pressure from her family to “succeed,” whatever that meant to them. She felt she did not have autonomy; she had to follow her parents’ rules. A year later, with psychotherapy, psychotropic medication, time, maturation, and being closer to finishing high school, Carol is a more relaxed and sensible young lady. She now respects her parents and she feels confident about getting into a good college. Although she needs medication for her ADHD, she no longer needs anti-anxiety medication. She drives herself to her appointments with me, but unlike last year, she is prompt and organized. Sure, I would like to take credit for this transformation, but dealing with a developing mind is humbling on both ends. Adolescence grow, mature and transform into very likeable human beings. Likewise, they can grow, not mature, and engage in illegal activities. Both processes have happened on my watch, so I am weary of assuming powers to change developmental course. Clearly, working with adolescence is a team effort; the team of parents, school, psychotherapy, and medication. The rapid shift in prognosis is exciting. One minute, Carol seemed like she was going down the wrong path: bad test grades, too many parties, too much tension at home. What seemed like the next minute, Carol has become a model citizen. She looks back on her rebellious times as “something I had to go through.,” Asking Carol, what changed in her outlook on life, she says “well, I know I am leaving home soon, and then I will be able to do what I want.” Suddenly, Carol can see her future; a future that was invisible to her last year. It is nice when the fog lifts.

Relationship Drama

      Joe, twenty-two, Jaclyn, also twenty-two,  just had a big fight in their apartment in New York. Jaclyn was throwing dishes at him. Joe was telling her she is “crazy.” Jaclyn, by her report, goes to see a psychiatrist shortly thereafter and she is diagnosed with bipolar disorder and placed on the mood stabilizer Lamictal. She calls her parents who are “very uncomfortable with mental health care,” as Jaclyn reports, and they begin to embrace this diagnosis. They read about it. They tell their friends. They give her a lot of support now that they see her issues as “medical.”  A few months later, Joe and Jaclyn go at it again. This time, Jaclyn wants to come home to Calabassas. I see Jaclyn and I question her bipolar diagnosis. “It seems to me that you had stress in your relationship and you became violent. I am not hearing any other history of bipolar symptoms,” I say, thinking that this is a common problem, where heated emotional moments in a young person get characterized quickly as bipolar disorder; at least that is the way it seems to me, of late. “I am hearing that you and Joe were hurting each other feelings, and one time you responded to those hurt feelings with violent behavior.” I say, trying to show Jaclyn that her behavior might be a result of her pain in the relationship, and not necessarily a chronic mental illness.

     Serena and Enzo, also both twenty-two, also just got in a big argument, where Serena was physically attacking Enzo while he was driving. “It was dangerous and scary,” Serena reports to me. “I just lost it with him. I was so mad. I asked him to take me home, but he wouldn’t so I started to hit him. I just could not control myself.” Serena tells me with some regret, but also with a sense of justification. In the past, Serena has been diagnosed with Borderline Personality Disorder, but I did not agree.  As such, I said,  “it sounds like you were so disappointed that you needed Enzo to see how you were feeling, and that you wanted to go home, such that when he ignored your plea, you became very frustrated. That frustration, led to violence, which you used to do as a small child towards your siblings, and now you are doing it with Enzo.” I say, trying to help Serena understand that she was in pain because of Enzo’s poor responsiveness, but her tendency towards violence, seems to stem from patterned behaviors which she did as a child. “In other words,” I continue, “this episode with Enzo, where he did not listen to you, reminded you of so many times when your mom did not listen to you, such that in the past you would have taken that frustration out on your little brothers, here you took it out on Enzo.”   

   The quick trigger to diagnosing bipolar disorder, or personality disorder in young adults often stems from the heated nature of their relationships. Both Jaclyn and Serena acted strongly to hurt feelings within the context of disappointments with their boyfriends. This strong reaction does not give evidence of a psychiatric diagnosis, but rather the reaction sheds light into the psychodynamics of Jaclyn and Serena. They are each acting out the past and the present, within the framework of a loving relationship. Their behavior helps me to understand how their minds work in the event of stress and disappointment. It does not give me reason to think that they are mentally ill. Young people are new to relationships, and as such, they bring an intensity which often leads to the roller coaster quality of their dynamics. Time, experience and maturity tend to mellow them out with age. The diagnoses do not disappear as they enter the next developmental phase; this is the value of waiting to see how the next chapter plays out before placing a diagnostic label on an emerging adult. My hunch is that both Jaclyn and Serena will be fine. They are struggling with how to maintain love in their lives, while still feeling strong and valued. I admire their energy in defending their sense of themselves, even though this energy may be misplaced at times. These tender relationships will shape their emotional lives; it is my privilege to be on the sidelines.

Twice A Week?

    When should someone come twice a week for psychotherapy? Like so many questions in my field, there is no solid answer, only more questions. Candace, fifty-three, is in a lot of distress. She can hardly get motivated to do the things that in the past have given her enjoyment. She has withdrawn from her friends. She no longer gets pleasure out of reading. She feels like life is not “a lot of fun.” There are no obvious stressors in Candace’s life. She is married, and although she has issues with her marriage, that relationship is very stable. She has a good job which she says is “fine”. Her parents are healthy. Her adult children are doing well. Financially, she is comfortable, although occasionally she worries about having enough money to live on, once she retires. Candace sees me once a week, reluctantly. By her account, “who wants to spend their life in a psychiatrist’s office?” She says, as if there is no other way to view her visits to me, other than that they are unpleasant in the short-run, but maybe they will benefit her in the long-run. I countered. “Sometimes people feel relief in here. They are grateful for the opportunity to talk about things that they can’t talk about anywhere else, but I guess you do not experience that.” I say, trying to point out to her that she does not allow herself to settle into our relationship with comfort and ease, but rather she tortures herself for having to come to see me. “Well, yes, I can see that,” Candace says with deep thoughtfulness. “In fact, maybe if you came twice a week, we could understand better why the vitality in your life seems to have disappeared.” I say, thinking that I need a helmet to protect myself, given her reluctance to come once a week and now I am proposing that we double our time together. Candace looks at me stunned. “Well, I certainly will think about that, but my first reaction is no way,” she says reinforcing her previous statement that she can barely allow herself the time to come once a week. “Yes, think about it. I know the issue is not time or money, but rather whether you think it would be worthwhile.” I say, stating the issue in stark terms. “Yes, that is right,” Candace says with angst and sensitivity to my suggestion. She is caught with an internal struggle of seeing the benefit of coming, but judging that twice a week, implies to her, that she is more severely ill than she first thought. For Candace, the decision revolves around accepting the need to talk to someone about tender issues in her life.  This is hard for her. She wants to feel independent, that she can handle things on her own. At the same time, she is not handling things on her own well, since the pleasure in life has evaporated. She is stuck in the dilemma. We will keep talking about it, once a week.