Shirah Vollmer MD

The Musings of Dr. Vollmer

Twice A Week!

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.

8 Responses to “Twice A Week!”

  1. Jon said

    Frequency and choice. How to spend one’s time, and what is missed by how one spends one’s time. Opportunity costs and the choice of not choosing. Tardiness and timeliness. These are the surface discussions that you seem to be having with Leigh.

    However, as you note, the subsurface is really about anger and latent self-hatred. Working through the surface to get to the more fundamental subsurface seems to be the medium to long term goal. Whatever the frequency and whatever the cost, this appears to be the necessary trip that Leigh must take, hopefully with you along as a companion. A good traveling companion enhances the trip, and, with luck, this will be Leigh’s experience as well.

    • Thanks, Jon. Yes, this is a journey of reflection and pain. The pain, at times, can be so intense, that the source of pain, whether from within or without is often confused and confusing. Thanks Again.

  2. Shelly said

    Is it forbidden for you, as a therapist, to give concrete answers to your patients that your patients are looking for? For you to give them the reassurances that they so crave? It seems so simple to say, “It is absolutely and utterly ok for you to cut back your sessions with me to once a week, if that is how you feel you would like to spend your time. Don’t feel badly about changing your scheduled time with me.” Instead of giving your patients vague answers about making them rethink about their answers, why not be clear? Does it not seem to you that Leigh has been thinking of cutting back before she ever set foot in your office and that she had been dreading bringing up the subject to you because she didn’t want to hurt your livelihood? Perhaps it had nothing to do with self-hatred at all.

    • I can give concrete answers, but sometimes they do not suffice. The subtext is where the juice is, and in this fictional case of Leigh, the subtext was this never-ending need for reassurance which seemed to stem from a deeply rooted insecurity. This was a feeling, which by your response, was not communicated well in this post. I need to think more about how to describe this experience. Thanks.

  3. ashanam said

    What’s interesting is that even if you were mad at her, it doesn’t matter. It is her therapy, not yours.

    Is she afraid you’ll be mad at her for needing you less? Some of us are used to people who help because it makes them feel good about themselves, not because they genuinely care or even just because it is their profession. People who help for that reason don’t really want the people they are helping to get better, because then they lose a source of supply. If she constructs this as an “attack” for you, that seems like the kind of person she is imagining you to be. I wonder…

    • Hi Ashanam,
      Your insights are very interesting and on point. I agree that the motivation of therapists vary tremendously and this has huge ramifications for the course of the therapy. The complicated nature of psychotherapy, as you note, is that the therapist may have an unconscious wish for the patient to stay sick, and likewise, the patient may project on to the therapist this motivation. It can be very challenging to determine how much is projection and how much is the unconscious of the therapist limiting the progress of the treatment. Thank you for adding to this discussion.

      • ashanam said

        Thank you. I wasn’t actually thinking of you or even of a past therapist, but perhaps of other people in “helping” positions in her life who may have thought and behaved that way–even “helpful” friends, or an AA mentor, a parent, or a coach. It isn’t uncommon. If there have been enough of them it can become a part of one’s assumptions about how people in “helping” positions generally act and feel.

        That came to mind because for someone who avoids speaking up about what she wants for fear of your anger, saying 2 sessions a week is too tiring and she wants to cut back sounds like it could be progress. She may have always felt that way and only now been able to tell you.

        Therapists and even laypeople with an interest in psychology sometimes express aggression indirectly, by doubting someone’s motivations or transparency, so in asking, “Why now?” that whole set of past experiences about angry and resentful “helpers” may have been triggered, even though that wasn’t your intention.

        Or not. It’s just a thought.

        • Interesting thoughts. I agree that the assertion of once a week, could indeed, be a sign of forward movement in self-assertion and authenticity. That is an excellent point.

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