Screen Memories

“Screen-memories,” Freud, 1914 said has important elements of childhood experiences. Freud said that recalling childhood is like talking about a dream. There are memory fragments, which when unpacked, yield volumes of insights into past experience. Troy, sixty-three, spoke about how he always loved chocolate, always! Yet, every birthday, his mother would buy him a vanilla cake. This could be seen as a “screen” for all the times when Troy’s mom was unresponsive to his needs and desires. A lack of responsiveness, Peter Fonagy MD from Baylor College of Medicine, would say contributes to abnormal brain development such that the individual no longer understands how his own brain works. In other words, we only know how we think if there is another person who guides us through the path of understanding our own minds. “I am good at thinking,” five-year old Armada, says with the self-assurance of a confident child. She knows she is good “at thinking” because adults in her life have told her so. Indeed, Armada is a bright child, so she, in all likelihood, will be able to develop a coherent narrative about her mental processes. If, on the other hand, when Armada came up with a new idea, she was shamed, told that her ideas are “stupid,” then Armada would have a hard time understanding the power of her brain. In other words, without the appropriate positive reinforcement, we, as humans, are left in a painful state of confusion and insecurity. We may not remember all of the times we were shamed, but we will have certain memories which stand out, and thus provide a window, or a screen, into more experience. “But you are guessing,” Mila, forty-two, tells me, as I float hypotheses about her childhood experiences. “Absolutely,” I say, “our work is about speculation. There are no definite answers, only ideas for us to play with.” I emphasize that we are trying to construct a narrative, but at the same time, we are humbled by the idea that we cannot go back in time. No one who does not have a conflicting internal agenda, can report on our childhood experience. We must work with what we got-just like a dream.

Dissociation or Forgetting?

Memory, Freud said, was crucial to mental healing. That which we can remember, we can then “work through” so as to be more realistic in our expectations of others. How then, do we encourage memory in our patients? Originally, hypnosis was designed to pull out repressed memories, like a blunt instrument carving out repressed images, hopefully leading to a catharsis, or a discharge of deeply rooted emotions which could not make their way to the surface without a psychotherapeutic intervention. Freud was unsatisfied with this technique of hypnosis, so he turned to free association as a means of discovering what the person “failed to remember.” Freud said “the forgetting of impressions, scenes, events, nearly always reduces itself to ‘dissociation’ of them. To the lay public, the word ‘dissociation’ implies deep pathology where one has to split off any memory so as to not cope with the emotional sequelae. Child sexual abuse is the common trigger for dissociation, yet here (1914 Freud) is saying that any emotion which overwhelms the ego will be dissociated, and hence separated from conscious thought. Bringing these dissociated thoughts back to consciousness, through the work of therapy which triggers long-repressed memories, allow for the healing between pain and circumstance; this allows for a more meaningful catharsis than one brought about by hypnosis. In other words, integration is the cure for dissociation, since dissociation takes up large amounts of mental energy, thereby hijacking the brain, leading to an obstruction to creative output. With the value on integration, it is no wonder that patients sometimes get worse before they get better. Yet, in today’s society of quick-fixes, it is hard to get patients to tolerate this journey. Herein lies the art of psychotherapy. Sometimes muscles hurt in an effort to get stronger. The brain is no different.

 

See also…https://shirahvollmermd.wordpress.com/2012/06/07/dissociation/

“Recollection, Repetition, and Working Through,” Freud-1914

Teaching technique, my first time, is a wonderfully challenging experience. This week we read Freud’s original technique papers which he wrote before he wrote about the structural model (id, ego and superego). The major premise of this paper is that we use our behavior to prevent us from remembering painful experiences. In essence, we do not change our relationships with our parents, for fear that if we were to examine the relationships then we would have to mourn the parent we wished we had, rather than pretend we have the parent we wished we did. Living in wishes, Freud’s version of neurosis, was postulated on the idea that if we could “remember” then we could “work through,” but our behaviors serve as a barrier to recollection and hence a “resistance”to further emotional growth. For example, some people become very obsessional, or focused on one part of human existence, such as food. This obsessional preoccupation serves as protection from feeling the pain of deprivation, but at the same time, turns other people off in that the obsessional neurotic tends to be a fairly boring individual. By contrast, hysterical folks, those who create a lot of drama in their lives, may be more lively, but they too are acting instead of remembering, so that they are not coping with their disappointments and failures, leading them to live in wishes. The expectation of being treated as if one is stupid, for example, is repeated in the therapeutic relationship as a way not to remember that one was demeaned as a child. One comes to see themselves as one with diminished capacity, rather than see that their family members were cruel to them. These notions of transference as a repetition to prevent memory, was started by Freud in this 1914 paper. Almost one hundred years later, I, as a clinician, still deeply appreciate this notion. Repeating is easier than remembering-simple and elegant.

Arrogance or Confidence?

Arrogance or confidence-what’s the difference? “All the other doctors released the medical records,” the trustee of a patient’s estate told me. “Yes, but that does not mean that all the other doctors did the right thing,” I respond. “Releasing medical records after someone passes away requires a court order,” I point out the law. I have confidence in knowing this fact, but to an untrained ear, I might sound arrogant and stubborn. As a psychiatrist, I have more medical training than non-medical therapists. This is true, but to some, this would also sound arrogant. As a psychoanalyst, I have more psychotherapy training than my non-analytic colleagues. Again, true, but potentially misconstrued, if spoken aloud. As a teacher of psychoanalysis, I convey psychoanalytic ideas, in a way which I hope enlightens my students, but I travel a fine line of sounding over-confident, as opposed to relative certainty. Is it that my confident colleagues can view alternative points of view with curiosity, whereas insecure folks view differences of opinion with contempt? The issue here is that the arrogant person, rarely, sees him/herself as arrogant. He/she sees him/herself as confident. Arrogance is a judgment laid on others, sometimes out of envy, and sometimes out of a certain tone, and sometimes out of experiencing a feeling of inferiority. At the same time, arrogance can be attractive when it is viewed as confidence. So many folks lack certainty, that when they are in the presence of one with certainty they are drawn into their presence. This may, in part, explain charisma, another challenging quality to articulate. Relationships often flip over, when it begins by admiring confidence, but over time, becomes a hatred for arrogance. I struggle with these ideas. Help!

Doctor, Patient and Pharmacies: An Oedipal Triangle

 

For years, pharmacies call me “demanding” a refill for a patient. Sometimes I have never heard of the patient. Other times, I just saw the patient and handed them a prescription. Still, other times, I have not seen the patient in quite some time. Without knowing the circumstances, pharmacists leave messages like “this is our third call,” as if, I have been a “bad girl” and not responded, as if I need to respond to a message that does not make sense. Today’s LA Times, exposes a practice that I have long suspected. Pharmacies call for refills, even when the patient does not ask for a refill, so that they can bill the insurance company. “That is why I don’t call back pharmacies unless the patient tells me ahead of time that I will get a call,” I want to scream to all who will hear. As I see it, the pharmacy represents an intrusion into my relationship with my patient. I work to help my patients, not the pharmacy. The pharmacy enters into my relationship with “demands” which I find out of place. One of the many advantages I have, by not having a staff, is that I am on the front lines with all of the administrative details of practice. My ship is small, but it sails. No intrusions allowed.

 

http://www.latimes.com/business/la-fi-cvs-caremark-20121024,0,6138463.story

Hostility As A Search For Love

Brooklyn, twenty-six, was always mad at me. She felt I was harsh with her and unsympathetic to her struggle with her divorced parents. “Maybe you are hostile towards me because you are afraid that I don’t care about you, so you deal with that fear by being angry,” I say, after knowing Brooklyn for many years. “Yes, I am afraid of that, but I am not sure that explains my anger. I feel so alone in the world. My mom only cares about her boyfriend. I am an only child. My dad has a new family, so to see me represents his past mistake and I feel that every time I am with him. You are all I have, but you are my therapist, so of course I am angry with you. I know that you are trying to help me, but I also know that you expose my defects and I don’t like that. I know that I have to learn about who I am, but sometimes I wish that we could talk about nicer things.” Brooklyn articulates her struggle in a calm and meaningful way, which is  uncharacteristic, given that in previous sessions she is often  violently upset with me, her parents or her employer. “Anger seems to be more comfortable than trust,” I say, “probably because your trust has been violated so many times.” I expand on why it is hard for her to love others given the betrayal she feels from both of her parents. “On the one hand, after all these years, you know you can trust me, but on the other hand, you feel so scared of depending on anyone, that you lapse into anger, which is a more comfortable, more familiar place for you.” I say, thinking that she will agree with me, as she has acknowledged that this concept resonates for her. “I have come a long way in seeing that,” Brooklyn says with appreciation for her journey.

“The Sessions”

“The Sessions” is a movie worth seeing, perhaps at home, with friends on a cool winter night. It is a “feel-good, feel-bad” movie, with good actors, but not good acting. As a Psychiatrist, it brings me back to the days where sex therapy was an acceptable intervention in which therapists helped their patients with their intimacy issues, by being intimate with them. Today, of course, we would consider this a boundary violation, but at the time, the field accepted this practice as a helpful tool for some patients. As a person, the movie brought me to a place of compassion for those with disabilities, reminding me, yet again, how we able-bodied folks take so much for granted. The story is a true one; a story I have followed over the years, as the details grab me. Mark O’Brien, a healthy child until age six when he was stricken by polio. This meant that his brain was fully functioning, but his body was paralyzed and he depended, mostly, on an iron lung. He went to college at UC Berkeley, followed by Journalism school there as well. I get emotional thinking about his struggles, and yet, the movie did not tug there. The movie tugged at his sexual frustrations, no doubt a large part of his mental existence. The movie, missed, from my perspective, a more comprehensive understanding of his relationship with his body. Sure, we felt his frustrations, his utter dependency on a machine which required electricity, and his keen sense of understanding his situation. However, we did not, to my satisfaction, probe into how he discovered joy and satisfaction in the midst of overwhelming helplessness. Most striking, was the lack of interaction with any biological relatives. No relatives ever came to visit. He was not just portrayed as alone in his body, but alone in the outer universe as well. This part disturbed me. It is hard for me to imagine that no family member was checking in on him, but maybe that was the case. My hunch is that some family members served as a lifeline to his emotional being. Surely, the church did that, and so that part of the movie, with the wonderful Willam H Macy, was delightful. Is this a comedy? I wondered. No, I would say not. I was not amused, nor made sad. My emotions stayed flat, but I enjoyed the story. Home theatre seemed more appropriate, given the linear nature of the experience.

 

See also…http://www.nytimes.com/1999/07/11/us/mark-o-brien-49-journalist-and-poet-in-iron-lung-is-dead.html

Oh, If Relationships Could Be Honest…

Women Doctors

Last night I had the privilege of speaking to a group of women physicians, mostly psychiatrists, leading to the inevitable topic of how quickly the field of medicine is changing in that it is unrecognizable from our field twenty years ago. We were middle-aged women who remember when it was a big deal for a woman to become a physician; gender atypical, one might say. Now, over half of most medical students are women. As a group, our daughters, not our sons, are entering medical training. “What does this mean?” one woman asked. “Women will earn the money and men will take care of the household,” one woman answered. “Or women will do both, like they have been doing for generations,” another woman said. “Women are twice as likely to get depressed as men,” I say, adding in a well-established psychiatric statistic. “Is this related?” I ask out loud. “Yes, but women are twice as likely to get depressed from menarche to menopause, so that makes it seem hormonal,” one knowledgeable woman answered. “Yes, but those are also the years where women have to juggle a lot of competing responsibilities,” another well-informed woman chimed in. “Men are more likely to be alcoholics,” another woman said, implying that maybe men deal with their psychological issues through substances and not through talking about their mental state. As usual, we had no answers, but many questions. Our worlds,  the world of knowing a “woman’s role” and the world of medical practice, is confusing to us. We want to help people, but how best to do this, is not completely clear. We want to be role models to our younger colleagues, but we do not understand their world and they do not understand ours. All in all, it was nice to be together to chat about common concerns. My job was to keep the conversation going. They did not need me for that. The passion for this topic generated the energy in the room.

The Ugly Interior

Fear, aggression, envy, are all part of mental existence, yet, we as a society, seem to condemn these feelings to only belonging to those individuals who are deemed “not nice” human beings. This was the discussion in my “Psychoanalytic Technique” class where we tried to understand how we can help people embrace their minds without guilt or shame. “To understand negativity is to understand our patients, and this is one way to model relationships, where both good and bad is embraced and accepted. ” I say, trying to promote the concept that seeing the landscape is the goal, with a large push to eliminate judgment. Neutrality, as Freud advocated, meant understanding in a way which does not impose values.  This “neutrality” is one of the large challenges of our work, a skill which takes a lifetime to develop. “This is one of our tools,” I say to a student. “Yes, but I am not liking this tool box,” he responds. “Because the tools are never certain to work,” I respond. “Yes, I hate that,” he says, articulating the issue in our field that we try hard to help people, but we do not always feel like we are on the right track. “We need not just to be neutral, but to help our patients attend to their minds in a neutral way,” I say, again talking about giving people the freedom to examine their own minds. “The Dark Knight incident was a tragedy, but we should not be surprised that people have murderous rage,” I say. “Acceptance of this will be the first step towards helping people separate thought from action.” I say firmly, reminding my students that dangerous behaviors come from dangerous thoughts, particularly unexamined dangerous thoughts. “Talking about dangerous thoughts usually stops them from turning into behaviors, because the verbalization serves to release the tension, most of the time.” I say, wanting to carefully say that words often, but not always, discharge the tension which drives the behavior. “The mind may not be pretty, but it allows us to enjoy horror films for a reason,” I comment, trying to lighten the discussion as we all say goodnight.