Shirah Vollmer MD

The Musings of Dr. Vollmer

Therapeutic Ambivalence

Posted by Dr. Vollmer on October 27, 2011

  Maria,, thirty-three, comes to her monthly appointments “confessing” how she changed her dosages of medication. Her sister is a primary care physician, so she often “consults” with her and then changes her pharmacology accordingly. “You have problems trusting me,” I say, making her instantly uncomfortable. “I come here for a long time. I could get my medications from my internist, but I choose to come to you,” Maria says, bringing up some good points. “Yes, but at the same time, you feel the need to make your own decisions about medications, rather than discuss the issues with me. Both are true: you put a lot of faith in me, and you don’t want to be dependent on me, so you work independently.” I say, showing her the layers of her mind. “I guess I should go back up on the medication,” Maria says, as if I am concretely telling her to return to the dosage I prescribed. “The dose is not the important thing here at this moment. The important aspect of our conversation is your ambivalence in our relationship, which might reflect on how you have ambivalence in other relationships as well.” I say, trying to highlight the underlying issue of communication versus unilateral decision-making. I am trying to talk about her mixed feelings in our relationship which manifest themselves by her adjusting her dosage,  independent of my opinion. Maria looks like she wants to think about what I am saying. She leaves with some agitation, but she also looks like she appreciated the challenge to her thinking. Doing psychopharmacology, like in all doctor-patient interactions, bring up the issue of relationships, bringing to the forefront issues of communication and trust. Once again, the notion that a psychiatrist can “just do meds” is ill-founded. Understanding dynamics is critical to all relationships which are so loaded with deep underlying issues. Maria and I have work to do-psychodynamic work, that is.

4 Responses to “Therapeutic Ambivalence”

  1. Shelly said

    Did Maria ever talk to you about the effects the dose of medications she was on made her feel? Or did she only talk to her sister about it? Sometimes we feel that our physicians aren’t really listening to what we are saying and so we speak to members of our family about things, moreso if they are physicians. Did Maria feel that the medications were right for her but that the doses were not? I can see how this interaction affected the both of you. How do psychiatrists deal with a lack of trust?

    • Shirah said

      No. Maria has issues of trust, as manifested by her seeking advice and then acting on the advice and then telling me after the fact. I don’t think Maria would tell you that I don’t listen. I think she would say that it is hard to know what to do. Dealing with lack of trust is the mainstay of my work. Building trust is key to therapeutic change. The process of buiding trust consists of time spent together along with looking at the obstacles to trust, which often come from historical events. Thanks, as always, for your comments.

  2. danny said

    Dr. Shirah You brought the conversation back to the ‘layers of her mind’ and to the trust , and the relationship issues, since you’re a analyst, most straight forward psychiatrists who basically do medications only , wouldnt know much about these other issues, as you know. And these issues of trust and the relationship as subtle as they seem are the foundations of the therapeutic work that then lead to progress and therapeutic change. Thanks for the blog.

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