Holiday Time

 

Grateful? Yes, this is a time to take stock of good things; things being relationships and health. Simple, sweet, and always true. 

Hopin’ to Move Up!

Associate Clinical Professor of Psychiatry sounds pretty good, I think, but apparently, I am eligible to apply to become a Clinical Professor of Psychiatry (voluntary), and so I did. I wrote about my various and sundry teaching experiences, supervising, case conferences, journal clubs, along with my administrative work of representing the sole female on the Voluntary Clinical Faculty Board of Directors. Most uncomfortably, I listed ten folks who could affirm my work, and yet, I was told I was not to give them a heads up. Now, I wait many months as the committee forms an ad hoc committee to decide whether I qualify for a new title, which, in point of fact, means a lot and a little at the same time. It means a lot in that my peers will be evaluating me, and I would like to think that they think highly of me. It means a little in that my daily life remains. I see patients and I teach. That combination is independent of my title, for the good and bad of that. Many of my posts have my rant about the lack of transparency in mental health. The public does not know what they get when they walk into psychotherapy. That I am affiliated with UCLA may impress some, but the exact nature of that affiliation hardly seems to matter, as the nuances of my title are not relevant. In a way, that makes sense. Patients and students should evaluate me based on how I make them feel, and not necessarily where I went to school or whether I got honors or not. On the other hand, my academic record demonstrates a hard-working value which has lasted over many decades. This potential advancement is further evidence of my commitment to teaching, to giving my time, to help the next generation of psychiatrists hold on to the old notion of the value of history-taking and the doctor-patient relationship. I want to pass this on, both with my blog postings and my face to face contact with my students. Luckily, this is not threatened by this application. Volunteering seems to be an open position, at least for now. Still, I hope I pass.

Projection

When Marty speaks, the feeling of ennui pops up for me, but not for him. How do I understand that?  Shelly asks. I think about how that happens. How, I do not begin our conversation feeling a sense of boredom, but upon reflection, that feeling bubbles up. Am I feeling that because I have somehow lost interest, or am I feeling a feeling that he is having, but he is not aware.? This question prompts the hypothesis testing in the clinical interview. “I wonder if you are feeling ennui,” I say, as a way to test out my speculation. I shoot my idea over the bow, watching and thinking carefully about how it lands. If Marty supports this idea, then together we can conclude that the process of projection has occurred, whereby his feelings are somehow transmitted to me, and then I feel his unconscious experience of his life. If, however, Marty categorically denies a sense of ennui, then it could still be deep in his unconscious, or I could be completely, or partly off-base. Either way, my experience of being with Marty is critical information to my work in trying to understand his subjectivity. In a similar way, Connor, thirty-two, always makes me feel anxious in his presence. He makes me wonder if he experiences anxiety, on a deep level, despite his protest, that he is feeling in control and does not experience internal discomfort. “Somehow when we are together, I begin to feel uncertain about what I am saying, in a way that is not typical for me, so I am wondering if, perhaps, I am picking up on your distress.” I say to Connor, again, launching over the bow, a hypothesis based on my subjectivity. Paying attention to my internal process is an obvious, and yet fairly new, area of inquiry in psychoanalytic studies. The area known as “Intersubjectivity” speaks to this to and fro of thought from imagining the patient’s experience, to examining my experience, all going on simultaneously, to come to a question about deeply held, although perhaps shameful, feelings. This multiple layers of thinking and feeling, occurring all invisibly to the naked eye, is the challenge of both my work with patients and my teaching, as there are no right or wrongs, but only ideas which make more or less sense.

NYer Cartoon Entry: The Anal Phase

If you don’t mind acting like sh–, I think I can pipe you in.

Ennui

After writing about Marty, https://shirahvollmermd.wordpress.com/2013/11/21/spice-it-up/, I began to think about ennui, the feeling of having a perfectly fine life, and yet, lacking excitement. Is ennui or  boredom a euphemism for depression? I wonder. Is boredom a shameful feeling for the affluent, who often say “I have nothing to complain about,” suggesting that they have a lot to complain about, but they are ashamed. The protest suggests the difficulty with the topic of complaining, rather than the lack of difficulties in life. In the cartoon above, the little boy wants to blame, or project his ennui as someone else’s fault, which is funny, but often true, both in childhood and in adulthood.

“I think you are bored,” I tell Marty, as he agonizes over his next camera purchase. My hunch is that the agony over the camera serves to create an arc of excitement, where there is build-up, followed by the purchase, thereby leading to a sense of relief that the task is complete. This arc production makes me think that he is searching for other, perhaps more stimulating arcs, where he needs to anticipate and get excited, followed by an action, followed by relief. This is the arc which often draws folks to marathons and triathlons. The focal point of the arc serves to combat ennui. Marty does not have a subjective experience of ennui, and yet his language and his sense of frustration makes me think about ennui. Boredom, like all difficult feelings, are an opportunity for growth and exploration. If Marty could connect with feelings of ennui, then he would have a more direct solution to his feelings. He would be charged to find new, and as per Jon, deeper ways of connecting with his life. However, if Marty denies feeling of boredom, because that feels shameful or not how he wants to see himself, then he is left with feelings which remain vague and confusing for him. The boring patient, which Marty is not, is often bored himself, and so my boredom is a hint to this feeling. In Marty’s case, his words do not seem to match his feelings, and so he invites an exploration as to what those feelings are. Ennui is just a guess, but one worth playing with.

“Spice It Up”

Marty, sixty-two, retired, has a routine which he has adhered to for the last ten years. On Mondays, he plays bridge. On Tuesdays, he plays scrabble. On Wednesdays, he bikes with a senior pack. On Thursdays, he visits his elderly mom and on Fridays he spends the day with his wife of forty years. Marty says he like his life, but at the same time, he is dissatisfied in ways which feels vague to him, but he still wanted “to explore this uncomfortable feeling.” “Maybe you need to spice it up,” I say, wondering if his routine serves as an obsessional or rigid way of not exploring new avenues of interest. “Routines are great, but like everything else, there is a need for moderation. Too much of a routine can feel confining, whereas too little of a routine can feel unsettling and confusing.” I say, wondering aloud if whether his regimented life has put him into a nice, and sometimes enjoyable, prison. Repetition, although comforting at times, at other times, can feel dull and almost lifeless. “Routines are good to have and they are good to break,” I say, thinking about how hard it can be to fluidly go from knowing what to do every day to wondering about how to have new experiences and new forms of mastery. “Like a long marriage, there is both the possibility of  comfort and boredom, if you are not mindful to continually challenge your relationship.” I say, pushing the point, even further. “I am confused,” Marty says in protest. “I like my life. I am healthy. I am retired. I do what I want. I have nice friends. There is nothing wrong with my life.” He says firmly and definitively. I look at him, and without words, convey the question of, well then, why are we having this discussion? His quick disavowal of dissatisfaction appears to be fear that he could fall into mild, moderate or severe despair about uncomfortable feelings like boredom and monotony. He opens the conversation, but then quickly shuts it down, as unpleasant feelings seem to hit the surface. We do our dance such that the to and fro motion becomes obvious to both of us. “What did you mean by spice?” Marty returns to his dilemma. “I think you know what I mean, but you did not want to go there,” I said, “at least not right now.”

Self-Imposed Prison

 

Time, intensity of mutual effort and courage are the major ingredients in getting out of self-imposed prison. Roony, thirty-three, female, is “never satisfied with the therapy,” as she likes to tell me. “Maybe this dissatisfaction hearkens back to a life-long frustration that you could never feel free to do what made sense to you, but rather you had to care for your five younger sisters,” I say, feeling Roony’s endless sense of not getting what she needs. “You have put yourself in a box, and now you are mad that you can’t get out,” I say, again shifting the notion that she is not a victim, but rather a perpetrator of her own unhappiness. “I can imagine that you were in a tight corner growing up, with few choices, but now that you are an adult, you have many choices, but you are carrying forward the drudgery of your past.” This well-worn concept that the past invades the present speaks to my therapy with Roony. The feeling from the past, her frustration with her life, is carried forward into my office. Yes, my critics would say, that I am getting myself off the hook, that I am not looking at how I could make the therapy more satisfying for Roony, but to that, I would say, that this is not a binary experience. I am focusing on one plausible aspect of her unhappiness. Albert Mason MD calls this the “pathological superego” where Roony’s rules for her life give her misery and bitterness, but she disavows that the superego is within, so she experiences it as an unhappy situation, which is “put upon her”. This “pathological superego” is a model for depression, where the individual feels despairing, but does not see that the despair stems from negative self-assessments. Roony is unemployed, which she could see as an opportunity for new experiences, but instead, she feels her unemployment as a validation of her sense of failure. Sure, there is a dance between external limitations and internal feelings, but with Roony, her internal feelings dominates her external world. In other words, she feels life to be limited, and then it is. Working from within, her understanding of her opportunities, her ability to make herself a better life, her ability to be free of her past burdens, gives us hope that with our work together, Roony will find the key to get her out of her box.

Sleeping Your Way To Health

 

http://www.nytimes.com/2013/11/19/health/treating-insomnia-to-heal-depression.html?hpw&rref=health&_r=0

 

“Curing insomnia in people with depression could double their chance of a full recovery, scientists are reporting. The findings, based on an insomnia treatment that uses talk therapy rather than drugs, are the first to emerge from a series of closely watched studies of sleep and depression to be released in the coming year.”

 

Sleep is important. Yep! Sleep can help mood. Yep! “Insomnia treatment that uses talk therapy,” Nope! “The therapy that Dr. Manber, Dr. Carney and the other researchers are using is called cognitive behavior therapy for insomnia, or CBT-I for short. The therapist teaches people to establish a regular wake-up time and stick to it; get out of bed during waking periods; avoid eating, reading, watching TV or similar activities in bed; and eliminate daytime napping.” CBT-I, a “T” therapy is NOT “talk therapy”. The patient is taught life skills, which help with depression. That is fine! Being taught is not the same as talking, as a form of therapy. This is more aptly described as “listening therapy,” as the patient is told how to change their habits. I could write a letter to the New York Times, but I decided to rant here instead. Helping people to sleep is a worthwhile endeavor, but to compare this intervention to the Prozac revolution is absurd. “In the four larger trials expected to be published in 2014, researchers had participants keep sleep journals to track the effect of the CBT-I therapy, writing down what time they went to bed every night, what time they tried to fall asleep, how long it took, how many awakenings they had and what time they woke up.” Many depressed patients cannot follow-though with sleep journals or any tracking measure, for that matter. The severely depressed often have psychomotor retardation which makes doing tasks, including tracking, overwhelming and anxiety-producing. Again, I am all for tools to help healthful living, but the marketing and the limitations of these tools needs to be clear. need to be understood.

NYer Cartoon Entry

It is the Turkey in the room.

Addiction Therapy: Let’s Think About This

How do we treat addiction? Psychotherapy? Psychopharmacology? Rehabilitation Facilities? Yoga? Meditation? Twelve Step Programs? All of the above? None of the above? There are no answers to these questions, yet with the Affordable Care Act, every plan must include addiction treatment. We, taxpayers, will support treatment for which there are very few outcome measures of success. Am I saying that people with addiction should not get treatment? No, addiction is a symptom of an underlying disorder in one’s mental state, in which one sabotages oneself, and one’s family, and as such, treatment is indicated. At the same time, we need to be honest that although treatment is indicated, the field is in its infancy, and as such, the appropriate intervention is not known. Scientific studies are in progress, but we need to deal with the state of the art, at the moment. My solution is that every patient with self-sabotaging behavior, including addictions, should be evaluated by a psychiatrist and then the psychiatrist can determine the best plan of action. I do not think patients should self-refer to a rehabilitation facility, as this is an intervention that makes sense for some, but not all addicts. I return to the  building blocks of good medical care. A good history, an experienced and well-trained clinician, yields our best bet, given the limited science. The term “addiction treatment” should be re-framed to go under general psychiatric care, where patients are evaluated for mental distress and then referred on to a treatment program. “Addiction treatment” should not be separated from psychiatric care, in general. This division takes away from patient’s understanding of themselves, which is critical to their recovery. The psychiatrist needs to explain to patients, after the evaluation, his/her best guess as to the nature of his illness and the most appropriate intervention. Calling it “addiction coverage” is like saying all insurance plans should have “chemotherapy coverage”. Addiction coverage should be implied in mental health care. I state the obvious, but apparently, it needs to be said.

http://www.whitehouse.gov/ondcp/healthcare