Posted by Dr. Vollmer on February 3, 2014
“You have an empty life and that is why you are in this field,” an angry female patient, age fifty-four, says to me, causing me to pause and reflect about both how I feel and how I want to respond. “What gives you the idea that I have an empty life?” I ask with a calm tone, wondering what might have happened in the previous session that led her to that conclusion. “It seems like you are always working. I know you have early morning appointments, weekend appointments, evening appointments, so I was thinking that the reason you must do that is because you have no one you want to go home to,” Marni says with a degree of certainty that gives me deep pause. “It is interesting that you jump from the time of our appointments to the fact that I am working all the time, to the fact that I have no one I want to go home to,” I say, highlighting her assumptions which begin in the present, but maybe bring up her past important relationships. It is in these assumptions where I begin to wonder if Marni is confusing past from present. Whether I do work too hard, or whether I have someone to look forward to see when I go home, is not as critical as to how Marni created that narrative and why, at that moment, she wanted to share that story with me, as opposed to maintaining a private fantasy life about my non-working existence. The technique issue in the moment, is that Marni is so certain of her conclusion, that any pushback, might be heard by her to be defensiveness, such that we may not have the opportunity to pause and reflect over her narrative.
Now, I begin to think about the second half of her sentence. My motivation for being a psychiatrist stems from my “empty life”. How does having an “empty life” encourage someone to pursue undergraduate, medical school and residency? Does Marni think that the time commitment of medical training suited me perfectly because, after all, I had nothing else to do? I had a strong internal urge to point her to my last post where I confessed to watching, and loving, ‘Breaking Bad’. Although this line of thinking was riveting for me, I thought it was wiser to focus on her anger. “Why do you think you have to put me down?” I say, thinking about the enormous hostility and meanness, I felt from her tone. In the moments before Marni answered, I thought about her relationship with her younger sister, and how she explained to me, that whenever Marni had a bad or difficult day, she came home and tortured her sister, leaving Marni to feel tremendous guilt and confusion as to why Lissa, her sister, was the object of her venom.
Marni began to cry. “I guess I feel empty. My kids have grown up and they are doing well, with little need for my attention, but the truth is, I hated being a mom, so I am not sure I can say that is the central issue. I had a career as an attorney, but my husband makes enough money that I quit my job two years ago, and so I thought that would give me relief, but I have not found anything to fill that void, even though I am happy not to be a lawyer any more.” Marni’s tears are painful and not surprising. Her anger towards me was quickly transformed into her own despair. “I wonder if your despair begins as anger, since that is how you lived your life as a child, when you came home and beat up on Lissa, when life presented unbearable challenges. It seems like you transfer your sadness, your fear, into a more active stance of aggression, and in the past it was towards Lissa, and today, it was towards me, but just for a few moments.” I say, reminding both of us that her anger was her first step on her journey towards sadness and fear. To put it in Freudian terms, her anger and aggression were her defense against despair. Uncovering her defense, put her in a sympathetic place that allowed both Marni and I to feel her pain, in a way which began a process of thinking together, how she can restore meaning in her life. Her word “empty” was the key to understanding that she feels a desperate need to “fill up” and yet she is painfully confused as to how to begin. By putting me off my center, Marni could feel the power that is so sorely lacking in her life in which she feels impotent and lost. Understanding transference allows us to work with her initial venom as the manifest content, covering up the latent material of uncertainty, with subsequent anxiety. Thinking in terms of layers is the difference between the beginning therapist who is unable to think, when attacked, and the more mature therapist who can feel the attack, but still think about the multiple meanings, both in the present and the past.