Quoted!

Nagging Worries?
Take a bird’s-eye vieW
Despite resolving to set financial concerns aside until after the holi- days, fears of overspending keep gnawing at your mind. (I’ ll never pay off my credit card; I can’t afford the gifts my family wants.) “If you stuff a feeling down long enough, it’s going to come out—either in an explosion where you say or
do something you’ll regret, or an implosion of depression and feel- ing stuck,” says Gilbertson.
To get ahead of the worry, try describing the situation from the perspective of a third-person nar- rator like, Pressure to spend is forcing her to reexamine budget constraints. According to Shirah Vollmer, M.D., a psychiatrist in
Los Angeles, this prevents knee- jerk emotional reactions. “You’re ‘metabolizing’ the feeling. It starts off huge and looming, but narrat- ing helps break it down into small pieces that are easier to deal with.” From there, you can use this objec- tive mind-set to seek solutions.

1449-StressSOS.pdf

Depression or Misery?

“Depression as a feature of mental illness is the misery of childhood translated into the present….” Charles Brenner MD

 

As we enter into the Thanksgiving holiday and remind ourselves of what we are grateful for, I am also reminded that relieving human suffering is the goal of my work as a clinician, and my work as a teacher. As such, understanding suffering is critical to a meaningful intervention. Children who suffer in childhood are likely to suffer as adults because those are the limited tools they are given to cope with a challenging and uncertain world. This understanding has multiple layers. One obvious layer is that we, as a society, need to do what we can to make sure that childhoods are supported by a rich infrastructure of nuturance, through schools, community clubs and religious organizations. Second, those who did suffer greatly as children, who grow to adulthood, need intensive intervention and understanding to create a new, more optimistic schema of their world. Third, mental health practitioners need to understand the connection from past to present in order to help the depressed adult. One cannot just look at the here and now, without thinking about what this current suffering hearkens back to.

Robyn, fifty-five, male, comes to mind. He dreads the Thanksgiving Holiday and so this time of year he retreats into his apartment and does not go out much, except for work. “What was Thanksgiving like as a kid?” I ask, trying to tie past with present. “Oh, I hated it. My family would get together and they would be mean to each other. My mother would tell my father that he was lazy and did not do any of the work. My brother and sister would fight, leading my brother to make holes in the wall, as that is how he discharged his anger. My mother would then praise my brother for hitting the wall and not a person. The more I think about those days, the more sad I am about the family I grew up in,” Robyn says, with deep feelings which make me feel both sad and interested in his past. “Do you think those memories have carried forward such that you are re-living them every year around this time?” I ask, wondering if he sees the connection between past and present. “Actually, I did not think about that, but as you say it, it sounds so obvious,” Robyn says with obvious excitement over this understanding. “Maybe you can layer over those memories by creating happy times for yourself around the holidays. Maybe you need to make an extra effort to do that, as a way of pushing down further the memories of your Thanksgiving table.” I say, not encouraging repression of memories, but layering over them, consciously, with times which create very different associations to the holiday. “Maybe you need to ask your friends for an invitation, so you won’t be alone?” I say, encouraging him to reach out to those who care about him. “Yes, of course that is what I should do, but I need to think about it, as I am afraid I will be a downer.” “Maybe if you are around people you care about, your mood will lift and people will enjoy your company,” I say, pushing him to interact over this sensitive time of year. “Maybe,” Robyn says, with extreme hesitation.

Medication Transference

 

http://slideplayer.us/slide/219857/

“There is only so much you can say about Prozac,” one of my students says and makes me chuckle. “Yes, but there is a lot to talk about the meaning that Prozac has to that person.” I say, highlighting that themes in a person’s  life come alive when you ask them what the medication means for them. Without this discussion, the physician is at a loss as to how the patient integrates psychiatric medication into their schema of their world. This issue of what the diagnosis and/or the treatment means to that individual patient is what drew me into the world of medicine. Yes, diagnosing can be fun, and watching people get better by using your intervention is fulfilling, but for me, the excitement comes from understanding how the person is thinking about their circumstance, in this case the agreement to begin a psychotropic medication.

 

Clarissa, sixty-one, comes to mind. She feels that she needs medication “to function”. Sometimes this “medication” is Xanax, and sometimes it is alcohol, and sometimes she takes Zoloft. In her mind, each of these mind-altering agents serve the same purpose. They make her feel rewarded and worthy of enjoying her life. Without these substances, Clarissa feels lost, anxious, and unloveable. Yes, these medications help her feel loveable because they shut off the voice which speaks to her and tells her what a bad person she is. Her superego is very mean and loud, I say, explaining that the medications turn down the volume of her superego, thereby allowing her pleasure. “Wouldn’t it be nice if you could tame your superego without medication?” I propose, hoping that she will work with me to taper her Zoloft. “I am just not sure I can do that. I am an old lady and I have been this way for a long time,” she says, giving me hope that although we both agree that things get harder with age, slowly, change can happen.

 

Clarissa illustrates the weaving together of medication and psychotherapy which can only be done with time and focus. A “med check” visit could not explore these meanings. A therapist visit could explore these meanings but they would not likely tie the exploration to the discontinuation of the medication. Being able to use medications to launch into a discovery of the internal mind is what I call “integrative care,” as distinct from that term which is now used to suggest that psychiatrists can do chart review while another clinician implements the treatment. Psychiatrists, as prescribers of medication, need to understand how these prescriptions are integrated into the mental interior, through Freud’s famous adage of “free association”. To do this, psychiatrists need to reflect on our history of understanding that meaning is derived from the past, influenced by the present.

Marital Ambivalence

 

This describes my parents’ marriage.

The Adam Lanza Story

 

http://www.latimes.com/nation/la-na-adam-lanza-20141121-story.html#page=1

The article referenced above exposes the details of Adam Lanza’s forays in the mental health assessment world, with all of the issues of parental push back, deep speculation, but a strong inclination, by trusted clinicians that he needed more mental health intervention. As the article states….

 

” ‘I told Adam he has a biological disorder that can be helped with medication. I told him what the medicines are and why they can work. I told him he’s living in a box right now and the box will only get smaller over time if he doesn’t get some treatment.’

Nancy Lanza rejected the Yale doctors’ plan. Adam was 14.”

 

It is easy to take away that Nancy Lanza should not have rejected the Yale doctors’ plan, but that is way too simple. Yes, the Yale Child Study Center is an impressive diagnostic and treatment institution, and yes, it makes sense to me that Adam needed mental health intervention, but we have no way of knowing if anything would have been different had Nancy Lanza followed through with the recommendations. That is the problem. It is tempting to demonize the parent who did not want to see the depth of her child’s illness, and indeed, that is often an issue, in my experience, but at the same time, there have been so many school shootings lately that we have come to see that there is no discernible pattern. Sure, in Adam’s case he was lonely and isolated and preoccupied with guns. That is a dangerous combination, but how do we know that treatment would have helped? I know that treatment does help some times, and hence I go to work daily, but I am also aware that bad outcomes happen when patients do stick with treatment. There are no easy answers.

 

 

 

See also…https://shirahvollmermd.wordpress.com/2014/03/14/adam-lanza/

Punching Out

Jorge, from my previous post, likes to use the expression “punching out” to describe his sensation of leaving where he came from and starting new. By “new” he means creating a new set of values which differs from focusing on material gain. It is not that money is not important to Jorge, but rather, he would hate to think that financial gain and prestige rules his life. This tension between the reality of financial responsibilities versus enjoying his life is a constant struggle for him. His family of origin led him to believe that financial gain was the route to great happiness, but as he has matured he has felt that dictum to be empty and shallow. Relationships yield great happiness, he says in a matter of fact way, but relationships can also yield great pain. It is about finding good relationships that matter, relationships which nurture and promote growth, rather than relationships which are dominated by competition and envy. Jorge almost begins to sound like a self-help book, but I can see that he is struggling with how to “punch out”. He has not just been hurt by his family, but by many romantic and platonic relationships as well. Jorge gets intimate quickly, only to discover, at times, that his chosen “friends” are “just as bad as my family. Actually, not that bad, but close,” he says, expressing massive disappointment. “I guess that sometimes I am so desperate for connection that I pick people who let me down,” Jorge says, struggling with what went wrong. “Punching out is not easy,” he says, as if he is talking to himself, because he knows I am aware of that. “Thinking and learning from your mistakes will help you,” I say, trying to encourage his continual reflection on his behavior. “Yes, it already has, but I still pick people who hurt me,” he says, acknowledging growth, but frustrated at the slow pace. “Humans have a long incubation period, so I am afraid that slow growth is inevitable,” I say, venturing a guess that our long development to adulthood means that change in adulthood is often painfully slow. “You can punch out,” I say, but you need to build a lot of muscles first to make those punches mean something.” I say, using his metaphor to expand his idea.

The Upsetting Email

Continuing with Jorge, https://shirahvollmermd.wordpress.com/2014/11/14/the-lying-relative/ , he gets an email from one of his siblings who is one of the two executors of the estate. The executor/sibling expresses terrible disappointment in the lack of responsiveness from the “grandchildren” after having received funds from the estate. Apparently, there was an open request to send memories about their parents/grandparents, in order to make a book, but no one stepped up. Jorge’s brother tied the issue of receiving money with the unspoken mandate to exchange a tale. Jorge was cc’d on the email, making him “squirrelly” in that the email was addressed to his one adult son, who was perfectly capable of managing the email as he saw fit. On the other hand, Jorge explains to me, “my brother just disgusted me with that email. There should be no quid pro quo when it comes to an inheritance. However, I do know that money is really the religion in my family and it is used as a source of competition and control,” Jorge says as he begins to cry. “What’s going on?” I ask, not sure how his rage became sadness. “There is just no love in my family,” Jorge says. “If the grandchildren wanted to express themselves in writing that would be nice, but how can feelings be mandated to go public. Maybe some people want to keep their thoughts private? It is as if the money is payment for them to do a job, but of course that was never stated, so there is massive confusion, but clarity in the sense that the money must come with an exchange.” Jorge continues to cry. “What do I do? Do I write back and say this is not OK, or do I stay out of it?” Jorge asks, not really wanting my advice, but wanting me to understand that his family of origin just puts him in one bind after another. “There is an amazing lack of compassion in my family, and even though I have been on this planet for quite some time now, this always seems like new information to me. I guess I am in denial.” Jorge says, allowing me to sit back and watch him struggle with his defenses. “Yes, you keep hoping with each major family milestone that there will be love and peace and harmony, and with each marriage, each birth and each death, nothing changes.” I say, watching Jorge suffer disappointment after disappointment. “It is really hard to give up the notion that you got love as a child, that you were welcomed and wanted in this world.” I say, returning to the theme of our work, about how Jorge goes in and out of knowing that he grew up in an emotionally hostile and unloving household. Now, he has added on the feeling of “disgust” by this email. He hates to think of where he came from, but at the same time, it helps him to understand the battles he had to take to break out of the mold of his family. One email, one trigger, made for a very very bad day.

Psychoanalysis: What Is That?

 

“Clinical psychoanalysis is most fundamentally about people and their difficulties in living, about a relationship that is committed to deeper self-understanding, a richer sense of personal meaning and a greater degree of freedom.” Stephen Mitchell

 

“If treatment as written seems so discursive and intellectual and neat and cool, perhaps treatment as it happens really works on the basis of what every psychotherapist feels daily: personal push and pull; nameless, theory-less, shapeless, swarming interaction.” Lawrence Friedman

 

 

Shark Bait

Ever feel like shark bait? That, no matter what you say, or how you say it, the person on the receiving end is going to become antagonistic and aggressive? This was our discussion today, or more specifically, how one feels like a victim, in situations which feel perplexing. “The moment I started teaching,” one student says, “I knew that I was in for trouble.” “Does this represent the student’s persecutory internal world, or is there more context to the situation?” another student asks. “It is hard to know what sets people off, sometimes, and it is also hard to say what feels disproportionate, but this is the realm of our work, ” I say, highlighting this never-ending struggle to understand human behavior. “Persecutory feelings,” a student says, “come up for people and then they can become aggressive.” Yes, that is one way of thinking about it.” I say, reminding them that we are merely speculating, but with the background of reading great thinkers like Melanie Klein and Albert Mason. “How do you explain that feeling when you just want to vomit after speaking to someone?” I say, thinking of times where I am feeling lied to, but I can’t be sure that is happening. “Feelings of internal persecution can make the other person uncomfortable,” explaining that moods happen within the interchange of ideas, and as such, when we pay attention to those feelings, we can gather ideas about how the other person is feeling.

 

Edna, fifty-five, comes to mind. At the beginning, at each session I felt angry and uncomfortable, and I worried about being personally attacked. Over time, I have ventured comments which describe my experience of her, and with many therapy sessions under our belt, she has come to see how her anger has been unconscious, but that it stems from her perceived rejection from her parents. “My mom told me she was not proud of anything I have done, and I have just not recovered from that body blow,” Edna says, with me now not feeling angry and uncomfortable, but rather sympathetic and compassionate. As we explore the roots of her negative feelings, there is a bonding and deepening of the relationship, that in previous sessions had seemed impossible. I no longer felt like shark bait.

 

 

Marital Therapy

He says I drive him up the wall, but I did not know how concrete he is.