Posted by Dr. Vollmer on December 19, 2012
Posted by Dr. Vollmer on December 18, 2012
Wishing all of my readers a strong internal compass for 2013.
Thank you for reading my blog.
I will be back in January, and I will look forward to your input.
Posted by Dr. Vollmer on December 14, 2012
Themes go round and round until they sink in. So goes the mid-phase of psychotherapy. “When is the midphase?” One of my students asks me, reminding me that the fuzzy lines of my work are hard to explain. “This is the time in a therapeutic relationship where there is stability. The trust has deepened to the point where tender issues can be explored over and over, with slightly new insights each time. Like yoga, where postures are repeated and yet each time, each moment, is a different experience. Within the framework of repetition, there is greater depth. Many analysts call this phase “working through” to imply that rolling around each corner there are paths to enlightenment and deeper understanding, even though the surface issues are repetitive. It may be a troubled marriage, or a troubled friendship, but with each anecdote there develops a different facet of the dynamics. Within these facets there is self-understanding. With self-knowledge comes better decision-making. The process is challenging to do, but simple to explain. The mid-phase involves deepening issues which might feel tired or worn out. Keeping these issues alive, without experiences tedium, is the art in the work. Fictional cases will follow this discussion, later.
Posted by Dr. Vollmer on December 13, 2012
Brit, sixty-five, decided to end 2012 with the monumental step of stopping her twenty-year long weekly psychotherapy. “I will talk to you constantly,” she tells me, explaining that she will keep our conversations alive and she will wonder what I would say as she navigates her world. “I am sad,” she says, knowing that she is making this decision, which is, of course, layered with feelings of strength and autonomy, as well as deep sorrow for the change in our routine. “You know how to find me,” I say, understanding that on the one hand, I am still in practice and happy to see her, but on the other hand, I respect her decision to leap forward into the world in a new way. “It is sad for me too,” I say, gently reminding her that our relationship is a steady part of my mental existence as well. I tread lightly, knowing that I want to communicate both that she is important to me, but at the same time, she should not come to therapy to make me feel needed. We reflect back over our twenty years together. Her children have grown up. I feel, in some small, but meaningful way, that I have helped raise them. She agrees. “You are one of my longest relationships,” she tells me, reminding me that she has been married multiple times, and that both of her parents passed away when she was in her twenties. I think about that. I am not sure I appreciated that before. Wow. This is the privilege of my work. Brit and I have been on a long journey together, and in different ways, we are both very appreciative. “Happy Holidays,” I say, ending our last session, feeling deeply that I hope things continue to go well for Brit. I also know she wishes me well. “I will think about you and I hope you keep me posted,” I say, reminding her that my curiosity continues after our official relationship ends. “Oh, I will,” she reassures me. Happy endings, I think to myself.
Posted by Dr. Vollmer on December 12, 2012
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Posted by Dr. Vollmer on December 11, 2012
“I talked to some people, about some things,”Whit, fifty-five, says to his wife after they gave a big holiday party. “Could you be more vague?” she responds with complete frustration, as Whit relates this interaction to me. “Communication is so important to relationships, that vague communication can feel like a distancing move,” I say, sympathizing with Whit’s wife’s point. ” I just do not think in specific terms,” Whit explains to me. “I could tell you all about the food at the party, but I don’t remember people’s names, and I don’t always remember what we talk about.” Whit says, showing me that his brain works very differently than his wife’s brain, in that she remembers conversation and people, but not necessarily the specifics of the food or the wine. “Yes, but you need to be sensitive to your audience,” I say, reminding Whit that he should know his wife will get frustrated if he speaks in vague language. “Yes, my default position is to feel like a ghost, even at my own parties,” Whit explains to me. “So the vagueness mirrors your feeling that you are not a part of things.” I say, deepening my understanding of Whit’s struggles with fitting in. Suddenly I feel for Whit. I imagine what it is like to throw a party and not feel like a valued participant. I switch from empathizing with his wife, to feeling for Whit and his lifelong experience of being on the periphery. “Learning communication skills is valuable, but perhaps the bigger issue for you Whit, is to enhance your sense of confidence and value. Maybe this will improve your relationship with your wife.” I say, pointing out that confidence will not only help Whit individually, but it will help his relationship, and in turn, that will help Whit even further. “Language is the window to the soul.” I say, using a cliché, but at the same time, understanding how Whit’s vagueness spoke volumes about his emotional interior. Once again I am reminded of the importance of working both outside in, and inside out.
Posted by Dr. Vollmer on December 10, 2012
Romy, fifty-three does not sleep well the nights before her therapy sessions, she tells me. She is worried about how our sessions will go. She comes, always on time, settles into a meaningful discussion, and then, after about fifty minutes, with a panic in her voice, she says “so what should I be doing?” Through the years of seeing Romy, she continues to ask this question as the session closes, as if I am going to say something that I have never said before. Instead, as predicted, I say “we need to keep thinking about how you make decisions which trip you up,” knowing that she is looking for a directive and not a meta-analysis of her situation. I understand this panic question at the end as a way in which Romy communicates to me that she is having a hard time transitioning from the security to my office to the uncertainties of her world. Romy’s life is in transition, although as long as I have known her-ten years-her life has been in transition. She has been single, married, divorced, single again and then married again. Through each phase in her life, she has asked me for reassurance that she is making the right decision. Through each of these phases, I have reminded her that decisions come with risk, and so to move forward she has to tolerate the unknown. Yet, despite her need for me to be more directive, Romy is a faithful and reliable patient. Even though she knows that I emphasize the need to be thoughtful and reflective, she still presses me for specifics, is frustrated when I don’t give that to her, and still stays in our treatment. This phenomenon has always intrigued me. Outwardly, she appears dissatisfied with my belief that developing an observing ego is the key to her lifetime happiness. Inwardly, or privately, she appreciates our work and she sticks with it. I imagine that is why she persists in a treatment, which at times, has frustration. Her anxiety in coming and leaving, we both understand, to be her anxiety with herself. She is trying to find inner peace. She believes she will find this as she learns to soften her superego. Yet, the journey is long and hard.
Posted by Dr. Vollmer on December 6, 2012
Lori Gottlieb, the author of this NYTimes article talks about her experience transitioning from a journalist to a psychotherapist. She explains that “empty hours” are best met with marketing one’s practice to a specific need, as opposed to remaining generally interested in the internal psychic world. Have we arrived to a world where therapists need publicists? I wonder. Do we need to search for niche markets? I also wonder. This is a stimulating article which poses the question of supply and demand. Is there a demand for insight-oriented psychotherapy, or is the demand for a relatively quick-fix to a very specific problem? Does marketing one’s practice create a harvest from which to pick out more long-term patients? Does the publicity serve to overcome the inhibitions of psychotherapy, such that once the patient gets comfortable, a deeper experience can be had? In other words, does the promise of seeing a “specialist” give the patient permission to unleash one’s fantasy world? As usual, I have no answers, but only ideas and possibilities. As Ms. Gottlieb states, as our antidepressants go generic, there is much less direct to consumer advertising for medication, which may mean that there are less patients seeking mental health assistance. This, combined, with a variety of both licensed and unlicensed professionals seeking to help people guide their way through the messiness of adult life. The patient, suffering from ill-defined issues, is at a loss as to where to turn. The media, friends, relatives, and their primary care physicians, serve as referrals. The patient in pain trusts their referral source and then they land in an office, of which they do not know what will happen next. They could end up on medication, engage in long-term psychotherapy, engage in short-term behavioral techniques, or a combination of the above. There is no good algorithm. I am glad Lori Gottlieb brought this issue to her readers. I am left stimulated and confused.
Posted by Dr. Vollmer on December 5, 2012
Once versus twice a week: how does one decide? Psychotherapy, exercise, piano lessons, all of these are more intensive experiences, the more one commits to them. This is obvious, yet potentially agonizing at the same time. The opportunity cost is clear. The deeper the involvement, the less there is time for other activities. Priorities have to be set. A trial run has to be done to determine the relative cost versus benefit. “I don’t want to come twice a week,” Leigh tells me, having seen her twice a week for many years. “What makes you say that?” I ask, not sure what has changed for her. “I am tired. It takes a lot of energy.” She replies, with profound sadness and ambivalence. “Yes, it does, but what has changed for you?” I ask, the always interesting “why now” question. “I don’t know. I just feel like it is time,” Leigh remains vague. She looks worried about what I am thinking. As with one theme of our work, I know she is worried that this ‘attack’ will make me angry with her. I see this as her projection that she is a bad person and this manifests in her constantly feeling that she is disappointing me. My work is to help her see her projection, such that it is not that I feel disappointed in her, but rather that she feels disappointed in herself. “I am always late, anyways.” Leigh says, as if her being late is a reason to cut back to once a week. “Yes, but your lateness is, yet again, another way for you to feel bad about yourself, but you feel that your lateness makes me mad at you.” I say, helping her see that by coming late, she is giving herself reason to feel the disappointment which dominates her mental existence. “I may want to continue to come twice a week, but I need to think about it,”Leigh says, as if I am forcing her to decide instantly. “Of course, you should think about it,” I say, reminding her that the core of our work is thoughtfulness, so I encourage her to reflect on her decision-making. “You won’t be mad at me,” Leigh repeats her fear, which again, I hear as her constant feeling of being mad at herself. “The more time we have to understand what is going on with you, the better,” I say, “but I also know that therapy has to fit into the rest of the demands of your life.” She does not feel reassured. “I just have to think about it,” Leigh says with irritation. “Yes,” I repeat, puzzled by her reaction, although thinking that she is irritated with herself.
Posted by Dr. Vollmer on December 4, 2012
Tony, forty-one, smashed his car. “What does an accident mean?” He asks, saying that on the one hand, he did not mean to crash, but on the other hand, he could have been more careful. “Accident is a relative term,” he continues. “Yes, it is a gray area, in which you did not have intention, but that does not mean that you were not responsible,” I say, creating a spectrum of feelings. “I just feel so guilty,” Tony says, which strikes me as both logical and puzzling at the same time. “You feel guilty because you feel like you did a bad thing,” I say, trying to understand the nature of his bad internal state. “Yea, I am having trouble forgiving myself.” Tony says in a particularly harsh way. “Do you think you should be punished?” I ask, probing for greater understanding of his superego. “Well, I think I am punishing myself. I just feel uptight since it happened.” Tony says that he takes it upon himself to feel tense as a form of retribution for his behavior. “Where does this harshness come from?” I ask, thinking that he has internalized a harsh superego from his childhood. “Yes, my parents were very hard on me when I messed up, but I also think that I would be hard on myself anyway since I do not understand forgiveness.” Tony explains a nature/nurture argument in which he explains that, by his account, he was hit twice. “Forgiveness is a wonderful skill,” I say, helping him entertain this notion as something that he can work on. “Our insurance will go up. We have to get a new car. We are inconvenienced and that creates stress in my family. Forgiveness is not coming easily.” Tony says, outlining his subsequent struggles. “Those are all good opportunities to practice,” I say, trying to help him begin with a baby step. “When you can forgive yourself, you will be better at forgiving others, and that will help you feel more relaxed in relationships.” I say, emphasizing how importance forgiveness is to both self-esteem and interpersonal relationships. “You smashed your call, but you do not have to smash your soul.” I say, highlighting that he is making the experience of his accident much worse by imposing hard negative judgments on himself. “That is a challenge,” Tony looks at me with hopelessness, bordering on despair. “You are up for it,” I say, using words of encouragement, but also understanding how hard forgiveness will be for him.