Downstream

Laurie, twenty-seven, makes decisions which at first glance seems questionable, but the effects are most pronounced “downstream,” as I see it. She dates men who ultimately disappoint her, but initially give her excitement and hope. If she thought more long-term she would imagine the pain and suffering she is subjecting herself to, but instead, she thinks in the moment and she cherishes the happiness that the initial enthusiasm of a possible new relationship brings her. “It is really hard to take your imagination downwards to see how you might feel a few months from now,” I say, trying to help her see that decisions made now have an effect on her mood in a few months. She begins to get upset with me. “You just don’t want me to be happy. I really enjoy the moment and you want to take that away from me,” Laurie says with intense feeling and hurt. “You know that I don’t want to take any happiness away from you. You also know that I am trying to forecast your moods in the future and we can do that by examining the decisions you are making today.” I say, pointing out to her that on a deeper level she understands that I am trying to help her, but in the moment of our session she is feeling frustrated and perplexed by my challenging her about who she is choosing to date. “Looking downstream can be very important,” I say, helping her to live in the present and the future at the same time. “I guess,” she says, with reluctant agreement.

Starting The Session

Lee, a fifty-six year old female patient, comes twice a week for psychotherapy, walks in with “nothing to say.” We wait. She stares at me with frustration and anger. “Why are you so irritated with me?” I ask, feeling the nonverbal communication. “I just had a large argument with my twenty-four year old daughter and I guess you are feeling the downstream effects from that,” Lee says bringing together her emotional trouble from the morning into our session. Previously, Lee might not have been aware of how her interaction with her daughter spilled over into subsequent interpersonal interactions. “She just keeps telling me that I am incompetent, that I am stupid and that I am wasting my time in psychotherapy,” Lee continues to detail the argument. “She really gets to you,” I say, opening the question as to why she takes her daughter’s ideas so seriously. “Of course, she gets to me. I wonder if she has a point.” Lee says with directness and acceptance that she may indeed be stupid and exercising poor judgment, particularly with regards to coming to psychotherapy. “She may also be trying to tug at you so that you become more insecure because, maybe, she is feeling insecure and so she wants you to feel that way in solidarity,” I say, trying to point out that her daughter may have another agenda. “That is a good point,” Lee says, “but I just don’t know.” The window into Lee’s emotional state all started in the first few moments of our session. No words had to be exchanged-just a feeling of anger and frustration.

“I Really Look Forward To Therapy”

Can psychotherapy be exciting? Laura, forty-nine, has come to psychotherapy for two years. By her report, each visit gives her a sense of hope and enthusiasm. This feeling is particularly remarkable given that Laura is late over fifty percent of the time, added on to the fact that Laura constantly states “I have no idea what I am supposed to say in here.” Yet, she also repeatedly states “I really look forward to therapy.” The complicated nature of our relationship is apparent, but what is most notable is the opportunity Laura has for self-expression. This opportunity is unique in her world of feeling looked over and dismissed. One might wonder that given her enthusiasm for this process, why is she consistently late. The lateness, is multi-determined, but suffice it to say that it represents her self-sabotage-evidence that she is not worthy of undivided attention and care. Yet, at the same time, she deeply appreciates this opportunity because she recognizes how important it is to her self-confidence and engagement in life. Anecdotally speaking, therapy works-at least for Laura.

‘First Position’ Is In First Position

Following six kids, 9-19, as they prepare for the Youth America Grand Prix, one of the most prestigious ballet competitions in the world, is moving, touching and fascinating. This is a documentary that has no surprises, except to say that how are some children so focused, so talented and so inspired to become professional ballet dancers. This question looms over the movie, as we watch boys and girls prepare unbelievable physical feats, with grace and poise which is so beyond their years. Then, they compete in what appears to be the Olympics for ballet dancers, except that for the older kids, it also means a literal ticket into a prestigious dance company. This payoff is life-changing in a way that reminds us that hard work, along with unwavering determination, along with good genetics, can, sometimes, maybe rarely, change one’s life, allowing one to live their dream. The odds are stacked against each individual, and each one knows that, but they still put themselves out there, with a hope and a prayer, that they just might be the one chosen for stardom. The kids and their families create awe in the audience. Parents may want this for their kids, but with ballet, there is no way that they can force their child to maintain that level of skill and focus. Of course, unconsciously, parents can demand their kids shine, and kids, with some genetic talent, can feel the pressure to succeed from their parents, but this movie gave compelling evidence that for these six children, their determination was mostly internal, as opposed to external. Again, with more understanding of these family dynamics, that analysis could change, but on the surface of things, it seemed like each one of these children wanted to succeed for their own sense of purpose in this world, and not for the sense of purpose driven by an external force. It was feeling this genuine desire to shine, at such young and tender years,  which made the movie so interesting,  The music and the dancing were nice too.

Gender Gap

Psychiatry, particularly child psychiatry, is a female-dominated profession. Although I don’t have statistics handy, over the last twenty years, more than 50% of the trainees have been women. In this year’s fellowship program at UCLA there are six women and one man. In the incoming class at UCLA the gender distribution is the same. Yet, when I go to administrative meetings of the voluntary clinical faculty, I am the only female in the room, besides the administrative assistant. “The women have kids,” the chair of the committee says glibly, as if that explains why the women do not attend. I have a different take. Men feel more of a fellowship at these leadership meetings, whereas women might feel them to be cold and empty, especially when compared to chatting with a girlfriend, or hanging out with a dear family member. It seems to me that as men and women have different brains, they have different signals of pleasure. Going up a professional ladder might be more inherently rewarding for most men, but not for most women. Of course, there are outliers, but I am speaking about the folks under the large part of the bell curve. Regardless, I am lonely at these meetings because I feel like an outlier. Any time one’s brain does not match one’s peers, isolation ensues. The gender gap is yet one more example of the importance of neurobiology. That is what makes sense to me.

The Marionette

John, fifty-three, made all of his decisions based on his mother’s ideas of what was best for him. He “decided” to be a physician, but then he says that his mother told him that was the only “real” job for him. He had partial awareness of his mom’s role in his life’s goals, but most of the time, he felt that he was at the center of his agency. His wife, Janey, grew tired of living with a man who exerted little control over his own life. “Janey thinks you are a marionette,” I say, highlighting this issue that although it might appear to him that he makes his own decisions, in reality, his mom is pulling those strings, making him move in the direction that the mom wants him to move to. “So, what if I am a marionette,” John says to me in a defensive manner. “Well, it might be helpful to understand the center of your decision-making.” I say, not wanting to pass judgment, but wanting to help John be more aware of his existence. John could be more conscious of his thoughts, I think to myself. “Well, it is a pretty depressing idea to think that I am not pulling my own strings.” John says with more defensiveness and seemingly little interest in self-awareness. “Depressing is one thing,” I say, “but clueless is another.” I say, trying to point out that his choice is to understand and then feel the understanding, or to remain in his fog. “I am going to have to think about what you are telling me, but I can tell you right now, I don’t like this discussion,” John says with hostility towards me. “Not liking this discussion is different than not agreeing to the merit of these ideas.” I say, pointing out to John that he is not telling me that I don’t make sense, but rather he is saying that he does not want to hear what I am saying. “Understanding one’s self can be a struggle,” I say, repeating the idea that soul-searching can be a troublesome, although ultimately helpful, experience. “I am not enjoying this,” John repeats in his characteristic way in which he partially resists self-understanding, but at the same time, allows himself to digest the ideas over time. “Maybe you could cut the strings and make different decisions for yourself,” I say, shedding hope on top of understanding. “Maybe,” John says loudly, with a big grin, as if to say, “so now you want to get positive.” “See ya tomorrow,” I say, appreciative that we have another opportunity to explore these ideas further. “Yep, you will,” John says as he seems excited to leave.

Re-Posting for Mother’s Day” Mothers and Mothering

Cheryl, forty-nine, mother of two adult children, called her mother Maureen, eighty, to tell her that her dog Candy passed away suddenly. Maureen said, according to Cheryl, “well, honey, you can’t get so upset about every little thing.” Cheryl reported to me that she was “flattened”. I responded “you have a mother, but you don’t have mothering,” trying to express to Cheryl that not all mothers are nurturing, even though one often hopes for that. It seems true that  a nurturing mother helps a child to grow up with good self-esteem. “Yes, but I always thought that I was doing something wrong such that my mother could not nurture me. She seemed to nurture my four siblings, but not me,” Cheryl says with great sadness. “What do you think you did wrong?” I ask, hoping that Cheryl will come to see that as with most children, she is blaming herself for her mother’s foibles. “I think I am too intense. I think I am a hard person to soothe. I am never satisfied.” Cheryl says, as if ready for my question. “Even if that were true, it still seems that your mother did not try to empathize with your pain, either now, or in your past.” I say, trying to stress that mothering implies working with the temperament of your child in order to find ways to nurture and support them. “I am just going to stop speaking to her,” Cheryl says, trying so hard to stop the pain. “Well, you could do that, but you could also change your expectations,” I say, stating the clear point that Cheryl can learn not to be “flattened” by the insensitivities of her mom. “Needing mothering is different than needing your mom to give you that mothering,” I say, trying to parse out the need for nurturing from the person one expects to provide it. “I am sorry Candy passed away,” I say, knowing that I may sound as if I can be a substitute for Cheryl’s mom. Cheryl looks at me knowingly. “Thanks,” she says, “but it is not the same.”

Case Closed

“Case closed” I say to Barbara,  sixty-four, who is struggling with issues surrounding her relationship with her ninety-six year old mother. “How much evidence do you need to understand that your relationship with her has caused you tremendous distress?” I say, trying to demonstrate that after all these years she is still hoping her mother will change in such a way that her mother will show appreciation and admiration for Barbara. “You mean she will never be the mother that I think she should have been?” Barbara responds with some understanding, but also some disbelief that it is not too late to keep trying to achieve motherly love. “I think you need to come to see the kind of person she is, independent of you, and in so doing, you will come to see how she was not, and is not,  able to give you the attention that you felt you needed.” I say, reviewing the sadness of a life lived in search of a kind of affection that will never happen. “Case closed,” Barbara repeats with a touch of sarcasm and wonder as to how I can be so certain. “When do you let it go?” I say, again reminding her of how many times she has tried and failed to feel “whole” with regards to her mom. “That is a good question,” Barbara responds, “but I am not sure the case is closed.”

Medication Meaning

Donny, forty-three, fights with himself over taking psychotropic medications to help his mood. He feels his medication symbolizes his “weakness,” his inability to help himself. His shame around his medication is projected outwards such that he feels that I am “forcing” him to be on medication. By making me the parent, he takes on the role of the child who is helpless and resentful. Over the years we have discussed this dynamic at great length. “I see your point,” Donny says, “but I have to say it is hard to hear that I am acting like a child.” “Yes, I know it is hard to hear that, but maybe if we can think about this together we can come to understand how hard it is for you to take responsibility for your decisions.” I say, trying to help Donny take more ownership over his life. “I just wish I were not on medications.” Donny repeats. “It is really your decision. Again, this is an example of how you are able to choose being on medications or not, and yet your words make it sound as if I am forcing you to take psychotropics.” I say, rounding this bend. “I am going to think about what you are saying without feeling hurt by it. I think you are saying something important, but I am not sure I can hear it right now.” Donny says with his characteristic sweetness.

The Anxious Husband

Karen, fifty, married to Kip, fifty-five, for thirty years, says “I just realized that my husband is so anxious.” “After thirty years you realize this?” I ask, wondering how this happens that decades into a relationship new ideas are formed. “Well, yes, I know it sounds ridiculous, but last night as I was talking to him, I realized that the expression on his face was anxiety and not ‘spacing out’ like I used to believe.” “Tell me more,” I say, so curious about this pivotal moment. “We were talking about our financial situation and I was saying that I was worried about our retirement and he just went mute and in the past I thought he did not like to talk about this subject, but suddenly, I realized that it makes him anxious and that is why he does not like to talk about it. I never saw it as anxiety. I just saw it as avoidance. Now, I see that the avoidance is because of anxiety. Maybe I got this idea from reading your blog, but when I thought about it, his behavior made so much sense to me.” Karen says with the excitement of figuring out a puzzle.

“Did you tell Kip about your insight?” I ask, wondering if she had the courage to share her idea with Kip and wondering if he had the courage to consider this notion. “Yes, I did and he said he would think about it, so I was pleased with that.” “Is he anxious about other things?” I ask, wondering if there is a bigger theme in their relationship. “Yes, anything that has to do with losing control he gets anxious about. He seems anxious that I am going to gain a lot of weight and that really bothers me too.” Karen says with a feeling of irritability that his anxiety is infectious. “Maybe if he understands his anxiety then he can at least identify his feelings and communicate on that level and not on the level of the number on a scale.” I say, highlighting that this insight, if it fits Kip, could cause a major change in their communication style. “That would be interesting, after all these years.” Karen says, losing her irritable tone and regaining her enthusiasm.

“Anxiety is certainly a complicated feeling. You are right that so much of the time, the person does not even know they are experiencing it, but the people around them know.” I say, repeating a point I make in so many of my lectures. “Yea, but I did not know until now,” Karen repeats with the awe of reflecting over thirty years. “This is what is called the depth of a relationship. New things appear as time marches on.” I say, hoping not to speak in platitudes, but to emphasize that relationships deepen over time such that Karen should not be so mad at herself for not understanding this earlier. “I guess so,” Karen responds with some dismay. “I am glad you found my blog to be useful,” I say, reflecting on her comment and feeling cosy about it at the same time. Maybe the internet has helped Karen and Kip. Maybe I contributed to that through my work with Karen and through my blog. Maybe.