Confronting Avoidance: Not So Easy

 

 

 

The art of psychotherapy, the sense, the intuitive sense, that a patient’s chief complaint, may in fact be a diversion away from a more touching issue, comes from years of practice deciphering whether there is congruence between content and affect. Then, even if one accurately detects avoidance, the question arises as to how best to talk about something that is not on the surface. Patients have taught me to say “hmmm….” in a way which suggests suspicion, without directly saying that it feels like something really important is not being talked about. There is Jerry, the fifty-two year old massively unhappily married man, who never talks about his marriage, but mentions at the end of every session how he is going to leave his wife. There is Susan, thirty-six, who appears deeply concerned about her sixteen-year old son, but she dominates our time with issues regarding her fourteen-year daughter who is doing very well. There is Larry, sixty, who consistently comes twenty minutes late to every appointment, but insists that traffic was “particularly bad today.” My sense of this form of denial is that these folks carry a tremendous amount of internal pain, which one day, hopefully soon, will come to the surface, so that we can process it together. It seems that the longer the pain is pushed away, the harder it will be to wrestle with it. The harder one tries to keep these demons in the closet, the more forcefully they will pour out, when the time comes. This time will usually be at a point where the person can no longer hold that door shut. Jerry’s wife will likely one day leave him. Susan’s son will collide into trouble at school or with the law, or both. Larry will ultimately come to understand that he is wasting his time in psychotherapy if he comes twenty minutes late. At these points, the flow of emotions will be massive. As with so many things in life, I can see the pain coming, but I don’t know when the patient will be able to feel it. It is like seeing cracks in the earth and knowing there will be an earthquake, but not knowing when. There is controversy in the field, whether a clinician should wait for the person to experience pain, such that the pain is a springboard to exploration, or whether the clinician should point to the avoidance before the patient has conscious awareness of his behavior. My solution is to decide this issue while I sit with a patient. As I said, this is the art of psychotherapy.

 

 

See also….https://shirahvollmermd.wordpress.com/2010/02/10/avoidance

Wishful Talking

“I am going to move to the Bay Area,” Noah, age sixty-two, has been saying for at least forty years. My sense is that Noah is saying “I wish that I had the courage to move to the Bay Area because I would be happier there.” He makes a declarative statement, when his behavior suggests that he wishes he could, but something, likely his fears, prevent him. When faced with this contradiction, Noah maintains that one day he will move up there, as if the fact that he has been saying this for many decades without taking action, makes sense. Noah, in this moment, is unable to appreciate that he is talking in wishes, and at the same time, paralyzed by fear.

Clarissa, forty-nine, Noah’s platonic friend, experiences exasperation every time Noah talks about moving. Clarissa fails to see that Noah is speaking in wishes, so she gets angry with him for what she calls “speaking nonsense.” “What if you thought of his statement as a wish?” I pose to her. “Well, are you saying that I need to remind myself that this is a wish, so that I don’t feel so violent towards him?” Clarissa asks. “Yes, understanding that people sometimes speak from their deep unconscious processes without any awareness that they are doing that. The Freudian slip is the prime example of such a phenomena.” I say, highlighting the idea that from time to time, we all reveal our underlying dynamics. The issue with Noah is that he reveals the inner workings of his mind to others, but he does not take stock of that for himself. In essence, his insight into himself  is limited and that disturbs Clarissa. “Talking in wishes. You should blog about that,” Clarissa says. So, I did.

‘Too Sick For Therapy’

Meital, twenty-year old female, long-standing issue with drug and alcohol abuse, with long-standing history of psychotherapy, along with a history of intermittent psychosis, which could be drug-induced or it could be a primary psychotic process.  She goes out of state for an upscale rehabilitation center at which time she is forced to develop a new relationship with a psychiatrist because her new facility insists that she use their staff psychiatrist as her treating physician. Dr. Luigi, her new psychiatrist, reviews the records of her psychiatric hospitalizations, but he does not talk to her previous treating psychiatrist, me. Meital, anxious to be in a new setting, is guarded and reluctant to engage in a new relationship with Dr. Luigi. Dr. Luigi, basing his opinion on hospital records and not outpatient treatment experiences, views Meital as “psychotically withdrawn” and therefore not amenable to psychotherapy. “Maybe she is frightened and therefore she needs the time and patience of a good and attentive listener before she will express herself,” I say to the staff at her treatment center. As I say that, I am once again feeling like I hearken back to an age where listening was so valued. Instead, Dr. Luigi maintains Meital on high doses of antipsychotic medication because it is his professional opinion that she is “very ill.” I, in contradiction, think that the medication is hindering her recovery because she is overly sedated and more withdrawn on the medication, making her appear more ill than she is when she is unmedicated. Dr. Luigi and I discuss this, but no meeting of the mind happens. We agree to disagree. There are no objective tests to settle the score. I worry for Meital, but I also worry for my field, where medications not only mask underlying issues, they also cause people to misunderstand what is going on in their internal world. Maybe Meital will never have the opportunity for personal exploration. Maybe Meital will come to see herself as mentally impaired, and as a result, she will not strive to build a life for herself. The downstream of these decisions could be grave. There are people who are “too sick for therapy.” I just think Meital is not one of them. The weight of this decision point is huge. I can only hope the tides will turn.

Do Child Psychiatrists Still Play With Kids?

I have a new job-a volunteer job, that is! On July 12, 2012, I will begin teaching “Clinical Practicum,” which is a six month child psychotherapy course to first year child psychiatry fellows at UCLA. I will have seven students with varying degrees of interest in doing child psychotherapy. “Can I give my students articles to read?” I ask, my new boss. “You can do whatever you want,” she tells me with a smile. I am excited to walk into an environment in which psychopharmacology is the dominant modality, with the hope, that maybe, just maybe, I can remind my students, budding professionals, that listening and explaining are still valuable skills. Maybe, I can encourage play. By that I mean, maybe I can inspire them to play with their patients as a way of getting to know them.

I have a goal, but my question to myself is how best to achieve that goal. We can read and discuss articles. I can talk about my clinical experience, by disguising identifying features in order to preserve privacy.  If I choose that path, should I pick one patient and go into depth about his treatment, or should I discuss vignettes of multiple patients? I can have them bring in their clinical experience, and we can have a group supervision group where we share ideas about how to get into the inner workings of both the child and his/her family. If I have the child psychiatry fellow bring in a case, then should I divide up the 26 weeks among seven fellows so that everyone has an equal opportunity? Should I limit the class to the treatment of pre-pubertal kids, since treating adolescence is a very different skill set? The best path is not clear to me.

I need to connect with them in a way which expands their experience, but does not seem “outdated.”  I fear that they will see the idea that one must  spend a lot of time with a child and his family before plunking down a diagnosis  as “unrealistic.” To help them see that understanding and explaining is a journey contradicts the notion that parents need immediate answers to their concerns about their child. On the other hand, this is a University, so a multiplicity of ideas should be embraced by both students and faculty. I hope that my exploration of different ways to approach this class will be in line with my goal that different approaches all have value. The more one learns, the more tools one can draw upon. This is a simple notion, but even in the most open minded families, I mean institutions, this idea gets lost. Am I too grandiose to think that I can bring back a discussion of family dynamics to a scene which is so heavily based in neurobiology? Or, do I need that grandiosity to enter into this adventure? As always, I welcome your thoughts.

Guilt

Lea, astonished me, when she says “I just feel very guilty for how I have behaved towards you,” as she refers to her incessant curiosity about my life. The surprise is not that she feels badly about her behavior, but the surprise is that she chose the word “guilt,” as if she has committed a crime. For the first time, in ten years of seeing her, I began to understand that she grew up feeling guilty about her behavior. Her mother, Carolyn,  was very jealous that Lea was the focus of her husband, Joe’s, Lea’s father’s,  affection. Consequently, it seems that Carolyn made Lea feel guilty for taking Joe away from her. All of these dynamics were subtle on one level and not so subtle on another. Through our work together, this feeling of guilt was reactivated in our relationship, in the transference, thereby illuminating a longstanding feeling which she has absorbed into every fiber of her being. To talk about the guilt she felt as a child is one avenue into this pain, but to reactivate this feeling with me, makes the work feel so much more alive and interesting. It also gives Lea tremendous pain, which we work with in a patient way in which we  peel away the agony in order for us to look at Lea’s history in a more detached way. The emotional pain is important to process, but so is her family dynamics. Lea is beginning to see how she fit into her parents’ marriage in a way in which she was robbed of certain aspects of her childhood. Living with guilt on a daily basis and not understanding the source, was a cause of huge confusion for Lea. Almost within an instance, clarity came.

Self-Deception: Psychoanalytic Principles in Action

Leo, fifty-two, says he is happily married, even though he spends every weekend with his guy friends from his childhood. Bo, seventy-three, says he loves his wife and kids, but he tells them they have ruined his life in that they have financially drained him of his resources. Marcy, sixty, says she comes from a wonderful family, even though her father beat her frequently when he drank too much. These examples of how people create narratives which involve what they wish to be true, rather than what they actually feel to be true, is where psychoanalysis enters as a helpful discipline. We embrace contradiction, as we understand the layers of the mind. We understand that wishes can seem like truths, until a point in time, where reality collides with the wish, and crisis ensues. Leo thought he was happily married, until his wife of thirty years told him she was leaving the marriage because she felt lonely. This crisis led to couples therapy which eventually led to Leo going into his own intensive therapy, such that Leo could begin to see his disappointments in the marriage. He would come to understand that he was avoiding his marriage by “hanging out” with his “buddies.” Ultimately, he could see how he was lying to himself-the worst kind of lie. Yet, if he could lie to himself, he could also learn to be honest with himself, and so he could learn to forgive himself and appreciate his personal growth. He came to embrace his more authentic life. He saved his marriage. The ability to deceive ourselves is uniquely human. This brain complexity demands a highly skilled and highly intensive intervention. Fortunately, we have tools for such complexity.

Where In The World?

All Time

Country	Views
United States	9,416
Canada	725
United Kingdom	692
Australia	533
India	415
Israel	284
Philippines	235
Netherlands	151
Turkey	148
Ireland	137
Portugal	111
Brazil	94
Germany	94
Indonesia	91
Mexico	87
Greece	82
Malaysia	73
Singapore	64
Pakistan	61
South Africa	58

‘Thanks For Reminding Me Not To Get Binary’

“Mixed feelings” I say to one of my students to explain the back and forth nature of a patient’s decision-making process. “One minute he wants to divorce his wife and the next minute they are planning to have a baby,” my student says in utter disbelief. “I just can’t stand Jessica,” my twenty-year old male patient says to me about his current girlfriend. “I think you have a lot of feelings about her,” I say, reminding him that there is an array of internal experiences going on in this moment. Immediately, he responds, “thanks for reminding me not to get binary,” he says, bringing in the computer age of ones or zeroes. Kleinian therapists call this splitting, when a person goes to extreme reactions without being able to experience the gray area. Tolerating confusion, this gray area, is psychologically challenging and uncomfortable, making it such that one has a tendency to think and/or act in a binary fashion, as if there are only two options. Idealization and devaluing are another example of this phenomena. “My mom is loved by all,” Bethany, fifty-two tells me, wanting me to understand what an amazing mother she has, despite the fact that I am aware how much Bethany’s mother fails to be sensitive to Bethany’s feelings. Creating a more nuanced narrative is the challenge of a deeper existence. Psychotherapy, like many art forms,  is one way to go there.

Mind Music

http://perfoundation.org/

Richard Kogan MD, a psychiatrist, Julliard-trained pianist, helped fundraise for PER (see above link), by describing how Beethoven’s inner landscape contributed to his composition. In the above YouTube we see him playing Tchaikovsky, but we saw him playing Beethoven. We learned that his alcoholic father might have made Ludwig feel unloved, and hence unloveable, perhaps explaining why Beethoven never had a serious relationship. With such painful loneliness he composed music which seemed to correspond to his mood during that period in his life. Yet, the most fascinating part of the evening was when Dr. Kogan spoke of his own personal challenge of going from playing Beethoven to describing Beethoven. The transition between being immersed in the mind to being immersed in the music was something that Dr. Kogan had to work at. That amazed me given his talent for music, along with his medical credentials. Some people amaze. Beethoven and Kogan are both such people.

‘Bully’: Such An Important Movie

‘Bully’ makes us aware that “boys will be boys” is a lazy excuse for allowing psychological and physical torture to occur at school. The movie also reminds us that the “victim” is not just the child who is isolated and picked on, but their family who feel helpless and inadequate to cope with the issues. As one father who lost his son to suicide, presumably secondary to bullying, says “I am nobody. I love my wife, and I loved my son, but I am nobody.” That sentiment, perhaps because it was expressed by a father and not a mother, was so moving, because he conveyed how helpless he felt, thereby suggesting how helpless his son felt. How do some people feel like “somebodies” and others feel like “nobodies,” I began to wonder. Does the social dynamics of elementary, middle and high school, set down the identity of nobodies versus somebodies? The film made me think.

The administrators in this film were portrayed as shockingly insensitive, perhaps as the result of their defensiveness. They were confronted with kids who felt victimized by bullies, and hence by the school system who did not protect them. Predictably, the administrators gave the first shot at parental responsibility-an old trick. In the movie, this was so obviously a cheap shot. The parents cannot control what happens at school. They can help their child defend themselves, but that presumes that the child conveys to the parent what is going on, and as one very insightful mother said in this movie, it is humiliating for a child to confess to what they perceive to be a strong parent, that they are the target of human cruelty. Then, the administrators tried to deal with it on a case by case basis, and not as a systemwide problem. That also, came across as lame. The problem is not that one child is being bullied, the problem is the lack of adult supervision in hallways, school buses and recess yards. More staff, along with a more highly trained personnel, would help, but the cost implications seem to be the clear barrier to intervention. I surmise.

To see a movie where you see the parents who have not only had the unspeakable tragedy of losing their child, but they have had this tragedy as a result of suicide, is to see massive suffering and sadness. One might think that to see this kind of suffering would make this movie unbearable. I thought that. Surprisingly, the movie pointed our attention towards the children, who were so neglected at school that I actually felt positive that when we expose the playground, we can make an argument for highly trained people to monitor these kids so that when they grow up they learn to be respectful and kind human beings. I am reminded of a time when a young child was learning to ice skate and he accidentally hit me. His skating teacher told him “you go apologize to that nice lady,” and so he did. Such simple interventions, I feel, are going to create a respectful society. Watching the movie drove that point home. If the bus driver, as one articulate mom said, could pull over and talk to those kids and set out her expectations for a respectful and cooperative bus ride, then most of those kids would behave nicely. The problem, as this movie so clearly shows, is that no one is paying attention and if they are paying attention, no one is talking to the kids in a meaningful and kind way. Most kids listen to adults. In this film, the adults either were not intervening or they would say things which revealed their lack of understanding of the dynamics on that playground. Psychological sophistication could have made a huge difference in those kids’ lives. Knowing that, I felt hope.

 

 

See also…http://movies.nytimes.com/2012/03/30/movies/bully-a-documentary-by-lee-hirsch.html?ref=movies