Psychotherapy: Push/Pull

“You seemed to be afraid to cry,” I say to a fictional seventy-three year old lady patient, Courtney,  who looks so sad and yet so restrained, at the same time. “I have never cried in front of anyone” she says, almost with pride. “You mean you have never allowed yourself to cry in front of anyone,” I say, underscoring her agency and her need for control. “Crying seems to represent for you an opening of a sphincter which, for you, feels very distasteful, almost like diarrhea. You do not see crying as a means of communicating your feelings.” I say, showing her that she has tied together tears with disgust, rather than intimacy. Courtney reminds me that she is in my office because she wants to change her emotional interior, while at the same time, her fear of change inhibits her from experiencing life in a new way. This battle, this conflict, creates the uphill feeling in psychotherapy. A deep appreciation for this approach/avoidance, I tell my students, is the key to developing patience and understanding in the midst of what might seem like stagnation. Helping Courtney move from a fixed place in which she rigidly refuses to cry in front of anyone, to a play space, a more flexible mental space, where she can consider that crying in front of others may not only be acceptable, it could also help her feel more connected to her world, more accepted for who she is and how she feels. This “play space” is the area where patients can contemplate another way to interact in the world. This contemplation, this imaginative experience, expands the emotional landscape,  happens with a sense of safety and security that Courtney and I have developed with time and repetition. In essence, psychotherapy is a simple idea with a difficult implementation.

“Object Usage”

Phillip Bromberg in his book, “Standing in the Spaces” (1998)  quotes a dream from a patient to illustrate Winnicott’s concept of “object usage”.

“I was leaning out of a window on the top floor of a tall building that was in flames. A fireman was climbing up a ladder to rescue me and I was throwing rocks at him.”

Bromberg explains the dream. “A person may feel himself so psychologically incapacitated and at risk in the world of people, that it is indeed similar to living alone in a burning building from which he needs to be rescued. But that particular burning building is the only one that exists as a self, and one’s individual selfhood, no matter how painful or unadaptive, must be protected at all cost as part of any rescue operation.” Hence, Winnicott’s “object usage” means that the therapist must respect the patient’s need to “throw rocks”. Some psychoanalysts call this phenomena “resistance,” but Bromberg prefers “object usage”.

A fictional patient comes to my mind.  Louise, fifty-five, lesbian, mother of two, professional comes in describing her relationship to Harry, sixty-four, single, never married, a plumber. “Harry treats me like I am his mother. He acts like I am extremely interested in everything that happens to him, but he hardly ever listens to me, and he hardly ever seems to care what is going on in my life. The relationship is so one-sided that I feel so angry when I am around him.” Louise says, clearly caring for Harry, but also really frustrated with the relationship. “It sounds like Harry is using you as a caring bosom, because he must need that, but he does not have insight into the fact that you may not want to be that for him.” I say, thinking about Winnicott’s concept of “object usage.” As with Harry and Louise, all relationships, to some extent, involve using the other person to get our personal needs met and thereby not seeing the other person as a unique individual. The more one can gain insight into their “object usage,” the more their relationships can deepen into a process of interpersonal exploration. “Do you think if you confronted Harry that the relationship is feeling lopsided, that maybe then things could get better?” I ask, wondering if Louise can help Harry get some insight into how the relationship feels to her. “I have tried that, and it helps for a short time, but then things go back to this mother/child dynamic.” Louise says, with obvious anger in her voice. “You are in a tough spot, because it sounds like the relationship has hit a wall,” I say, mirroring her frustration. “Relationships work better when ‘objects’ are appreciated and not ‘used’ ” I say, throwing in some jargon about their dynamic. “Yep,” Louise says, with the joy of feeling understood.

 

 

 

Resistance

Martha Stark MD says “the pioneers of psychotherapy quickly learned that an unconscious psychological force worked against a patient’s conscious desire for cure. This impediment to change was captured in the term resistance. Each new understanding of resistance opened a door to fresh clinical challenges.” Sheldon Roth MD wrote in his Foreword to Dr. Stark’s book, “success in working through resistance reawakens the dormant possibility of that frail, but intensely human quality-choice.” Dr. Stark continues, “my contention is that the resistant patient is, ultimately, someone who has not yet grieved, has not yet confronted certain intolerably painful realities about his past and present objects.”

A fictional patient comes to mind. Becky, fifty-one, went to visit her father, eighty-five, in his assisted living facility. “My dad told me that my mom would not let him hold me on his lap when I was little because my mom was afraid he would sexually abuse me, but then again, he changed all of my diapers. I just got sick listening to this.” Becky says, with the disbelief that new family dysfunction can be uncovered all these years into her adulthood. “It is hard for you to fathom how your mom prevented your dad from showing love to you,” I say, to which Becky quickly changes the subject. Becky’s resistance in that moment was a clear indication that at that moment, she could not emotionally process the fact that her mom consciously made her life more difficult by telling her father not to be loving towards her. She also could not begin to process that her dad accepted her mom’s distorted reality. He could have insisted on having his children on his lap. Becky moved on to talking about her problems at work. This was not the time to unpack her experience visiting her dad that day. Her resistance was too great. It seemed that she was not ready to grieve the absence of a loving father figure from a very early age. She also was not ready to grieve the loss of a mother who wanted her child to grow up with two loving and caring parents. We will come back to these issues, but now she wants to focus on the lighter issues of work stress. Dr. Stark notes that anxiety must be “titrated”. Becky did this for herself by changing the subject. She wanted to preserve her status quo with her dad. Later on, I suspect, she wil be at a point where she wants to understand her family history, so she can stop being disappointed with what she did not get. As Jon pointed out, time is necessary for this resistance to fade. Patience, as he also says, is key.

 

 

 

Do Therapists Really Care? A Commenter Responds…My First Guest Blogger!

I suppose every Zach has his own reasons, but I can say for myself that the idea that a therapist cared about me in a personal way came to me only with profound astonishment.  It is, after all, your job to help your clients.  It isn’t your job to care.  That’s a bonus I don’t ask for or expect, and you give it to your patients only because that’s the kind of person you are.

Understanding that people care just because they do is such a difficult idea for me, if I really think about it, my head hurts a little at the strangeness of it–like how my students feel when they are exposed to a very advanced type of math. Because it is not quite solidly in my mind that other people have the capacity to care in a sustained way. I grew up surrounded by people who interacted with others solely to use them, and who mimicked an appearance of care for personal gain or just to look good to themselves.

It isn’t that I think people can’t care about me, but that I’m not clear that others can care about anyone.  My model of normal human behavior and thinking continues to be, to some extent, grossly pathological–I still assume people’s insides to be vast emotional wastelands, although I do know better.

If the issue for Zach in your mind is about care, then I would guess some element of that may be at play: he grew up with profoundly selfish people, and still assumes emotional callousness and disengagement are what he can expect from others.  If you disrupt that view by being caring, it may even frighten him, as that means he lives in a world he now does not understand and cannot trust himself to be able to navigate  safely or successfully.

A world in which people care is not necessarily a safer world to Zach.  It can seem dangerous.  Selfish people have flattened inner worlds, and less complex desires and responses.  They may be violent and homicidal, but they will be predictably violent.  They can be managed with a little attention and skill.  Caring people are complex.  There’s no telling what they will do.

To see the fictional Zach narrative, check out…https://shirahvollmermd.wordpress.com/2011/09/13/the-no-show-returns/

Does Therapy Ruin A Marriage?

Ten students, two absent, made for a vibrant class discussion last evening. My class is titled  “Psychoanalytic Technique”. My students have engaged in a two-year Psychoanalytic Psychotherapy program, in which they attend class from 5:30 pm to 10:00 pm every Wednesday night for two years, with a two month break in the summer.  There are psychiatrists, social workers, MFTs and psychologists, all together with a common purpose: trying to understand how to help folks who suffer. As per my previous posts, our class began with understanding Transference. Yet, as the conversation unfolded, in ways that are interesting to reconstruct, we went down a path in which we outlined how if one person in a couple goes into treatment, that it could, cause significant relationship tension for a variety of reasons. If, for example, there is a ‘idealizing transference’ then the partner in the relationship could begin to feel competitive with the therapist. Alternatively, if the patient experiences significant personal growth, then he/she may turn to his/her partner and feel a large emotional disparity in terms of their maturity levels. Of course, this change in maturity level can happen in any relationship, but psychotherapy is one way in which that can happen. “Should the therapist feel good or feel bad if patients who come to therapy without conscious issues with their life-partner, but over time, develop these issues?” One student asks, highlighting the dilemma, that therapy, as the movie suggests is a “Dangerous Method”. “Therapy is a journey,” I say, “and so we never quite know where we are headed. As Freud instructed his patients, therapy is like a train ride where we narrate what we see out the window, not knowing what is coming next.” My students were sophisticated and intelligent, and clearly dedicated to their work. These classes don’t increase their prestige or their fees. This is a labor of love, for all involved. Yet, at the same time, all of us in the room are aware that our good intentions sometimes cause others, either in the consultation room, and/or their collaterals, significant distress. “Personal growth is a challenging experience,” I say, “and next week we will talk about ‘resistance,’ the unconscious fight against such a challenge.” I do learn by teaching. The adage holds up.

Idealizing Transference

 

“This (idealizing) transference expresses the need for a calm, strong, wise and reliable therapist whose ‘properties’ and presence can be made use of by the patient in order to foster of sense of safety, self-esteem, and well being; self-worth and value are enhanced in the glow of the idealizing transference,” says Mark Thompson MD and Candace Cotlove MD in their book entitled “The Therapeutic Process”.   Becky, forty-four, a psychiatrist, glows when she speaks about her therapist, Doctor Holzberg. Her tone makes me think that she is speaking of a passionate love relationship, but she will tell you that she loves her husband and her three children very much and she did not seek psychotherapy because she was feeling unloved or unloveable. Becky, also known as Dr. S. has seen Dr. H. for over three years and she has yet to feel she has had a difficult session or a disappointment. “Could you be idealizing him?” I ask Becky, in casual conversation, as it is hard for me to believe that any psychiatrist, any psychotherapist,  does not present frustrations and grievances during the course of a treatment.  Becky is not sure, but she responds astutely. “Idealization prevents further growth, so if I am, then I have a pretty shallow relationship with him,” she says, hitting my point head on. Glowing reports about a psychotherapist are always suspect, given that too positive a point of view might suggest that the narcissism in the therapist does not allow for the relationship to have its fair share of interpersonal struggles and minor ruptures. It is through these struggles that relationships deepen and people grow internally. The trained ear tries to separate the need for the “perfect therapist” from the “good enough” therapist who provides support and trust, within the framework of divergent points of view. The “perfect therapist” may have too high of a need to be loved to allow for enough discourse. Given that, it is hard to plunge into therapy, as too great an endorsement may suggest a very self-centered therapist. The layers of meaning are endless. Diving in takes great courage.

Feeling Soup

Glen Gabbard, a noted psychoanalyst, likes to say that “there are two patients in the consulting room. The two complex human beings who are interacting in the course of psychotherapy are mutually influencing one another all the time and evoking a varied of feelings toward one another.” Now, a case example, you, the reader, I can hear, is asking and so a fictional case pops to mind. Patient A makes Doctor B bored. Doctor B wants to “leave the room” in his fantasy life when Patient A enters. Patient A talks about his writing career, but Doctor B does not feel engaged. Doctor B, before medical school, wanted to be a writer. His envy of Patient A makes him “tune out” to tales of his writing career. Doctor B goes to therapy with Doctor C. Together Doctor B and C begin to unravel the complex feelings that Doctor B has in regards to deciding to go to medical school. Doctor B begins to see, in his mind, that patient A, is not only a writer, which Doctor B dreamed of being, but also that patient A reminds him of his demanding mother who insisted that Doctor B become Doctor B. Doctor B’s newly discovered understanding of how patient A has triggered so many negative feelings helps Doctor B become more engaged with patient A and kicks Doctor B into his second psychoanalysis. As Daniel Stern taught us, the famous infant/mother researcher, not only does the mother influence the baby, but the baby influences the mother. So, the obvious is stated, but the complexities are uniquely compelling.

See Also…https://shirahvollmermd.wordpress.com/2012/11/01/countertransference-come-on/

Teaching Transference

So, it is time again for me to embark on another psychotherapy class that is interested in learning about transference. We will discuss how the therapeutic relationship leads to change in personality structure. This is the fundamental principle of in-depth psychoanalytically oriented work. The notion of transference separates out the therapies which focus on behavior from the therapies which focus in on deeper issues of unconscious self-sabotage and deeply rooted pain. “New brain” therapies, I like to call it, in which by understanding transference, a new brain can be formed, whereas with behavior oriented therapies, limited improvement is inevitable, since only the surface is being addressed. As always, I eagerly anticipate how this class will feel, their transference to me, in other words. We will talk about transference and experience transference, all at the same time. The parallel process will give us a way to make the subject come alive.  It should be interesting. Stay tuned.

 

Vulnerability

Annie, fifty-one, had her purse stolen from her office downtown. She did not lock it up, as her colleagues usually do, but she felt like she worked in a safe environment. She works for an architecture firm, and so clients come in and out, which she assumed, were honest folk. “On the one hand I want to hate humanity, but on the other hand, I know that most people are kind and generous,” Annie explains to me her perspective, as she is obviously shaken, but not flattened. “The next day,” she continues, “I got a call from an employee at Subway who said she found my purse,” and I was like wait, I was just hating the world, and now there is this really good person, a stranger, who wants to help me out. I am confused, but relieved,” she explains. “In the meantime, I cancelled all my cards, so I still feel naked,” she says, using a sexual term to describe vulnerability. “Somehow those cards protect you,” I say, going with her naked image. “Yes, if I have trouble, I can use my credit card, or my ATM card, or my AAA card or my insurance cards to help me out. Without those, if I needed help, I would have to call a family member.” Annie says, stating the obvious, but also reminding me that our world is so electronic that without those magnetic strips in hand, it is hard for us to function. “Maybe you learn who your friends are,” I say, pointing out that vulnerability could be an opportunity for closeness, an opportunity for others to show they care. “That is true. I need to remember that guy from Subway. He could have taken my purse and done all sorts of terrible things, but he wanted to help me out. He had a soul.” Annie says, marveling at the kindness of strangers, in the midst of being victimized by the unkindness of a stranger. “I know this is a major inconvenience, but it hits me in a deep place of insecurity. I know I have to be more careful, but I don’t like feeling how uncertain the world can be.” Annie says, as if she is thinking about the Sandy Hook shooting, or at least making me think of that. “Yes, when the wheels turn, when you feel clothed, you forget about the anxieties of living.” I say, highlighting how this episode jolted her out of her comfortable routine, causing her to pause and reflect on the dangers of the world, and the cruelty of others. “You saw the gamut of human nature in a short period. Both sides exist, but usually we don’t see them so close together,” I say, remarking on how evil was so quickly followed by kindness. “Yes, it has been quite a few days, but now I would like to return to denial.” Annie says, trying to end on a light and humorous note.

The Cost of Therapy

Alexander, seventy-two is spending his retirement money on therapy. His friends and family tell him he is “crazy”. “They don’t understand that I have very strange and bothersome thoughts and I have no one to talk to about that.” Alex explains to me, even though I know that. He is feeling defensive and misunderstood by his village. “On the one hand I know these people care and they are trying to help me so that I don’t run out of money, but on the other hand, they have no idea what I struggle with internally.” He tells me, again, even though we have discussed this many times. I hear the loneliness of someone who has such invisible suffering that no one, other than a mental health professional, can understand. The torture of brain suffering is beyond the comprehension of most people, even beyond some trained in the helping profession. Plus, friends and family presume to know his financial situation and this presumption hurts Alex’s feelings since he feels demeaned that they do not respect his decision-making. “Maybe you have lead them to believe that you have financial problems so they are confused why you invest so much of your resources into psychotherapy.” I say, knowing that he does need to be careful with his money, but at the same time, therapy, for Alex, is a life-line. “Yes, I do complain about money, but this expense is not optional for me. At least it does not feel that way.” Alex explains, mostly to himself. I am left feeling privileged with my medical training. Years of seeing how the brain can cause so much invisible misery has sensitized me to Alex’s issue. He suffers in ways, if he were to explain to his loved ones, would only alienate them and scare them away. Understanding goes a really long way, particularly for Alex.