Working and Meaning

How do people feel meaning from work? Are they doing something they love? Do they feel they are servicing their family? Are they feeling respected by their colleagues, appreciated for what they do? Do they feel like they are part of a major contribution to society? Or, do they, what I call, butt-drag their way out of bed every day, because after all, that is what is expected of them. The relationship to work, like all relationships, gives me a window into how the person embraces or avoids his life. The view of their day, not their external or perceived impression by others, but the associations people make to their job intrigues me. As with all of life, there is not necessarily a correlation between a “cool job” and a happy employee.

Lester, forty, comes to mind. He always wanted a corporate job with stock options, and now he has his dream job, enabling him to buy his dream house and take his dream vacations with his family of three children. Lester, although envied by his siblings for his financial success, is miserable on a daily basis. He feels his job contributed very little to society, and only makes he, and the other executives, have more money in his pocket. Although that sounded good to him when he was out of college, not it feels empty, leading him to feel painfully trapped. What went wrong for Lester, I wonder to myself. Did he not understand what was really important to him? Was he trying to please and impress his parents, to his own detriment? Has his wife become a stand-in for his mom, and now he lives in fear of letting her down? My head is filled with hypothesis, but my technique, if you will, is to let Lester speak, to encourage free association. His narrative is one of emptiness and despair, making me wonder about his early childhood, which I know little about.

“Is this an old feeling?” I ask, wondering about the context of his stew of bad feelings. “Yes and no,” Lester says. “I was poor growing up and my mom always said people with money are much happier and they have much easier lives, so I fought and fought to get more and more money. When I was climbing ladders I did not think about my mood or the meaning of what I was doing, I was just thinking about how I could get ahead. Now, that I am where I dreamed to be, I have time to think about how I am spending my time, and I am slowly seeing that my mother’s narrative was only half-true. Money does make life easier, but for me there is a very big cost to pay. For my wife, well that is a different story. ” Lester explains, letting me know he has given this issue a lot of thought. He implies that his wife has the life he wishes he had; a life with financial comfort, but not a life in which she exchanges time for money.

“So you are in a terrible bind.” I say, highlighting my understanding that for him to go to a more meaningful job might make his wife unhappy, as she is quite content with their lifestyle and it would be heartbreaking to her, he says, if they were to downsize their life. “Oh, the worst,” he emphasizes. “I am really stuck.” He says, with despair and hopelessness. “And so you come here with some hope that you can get unstuck,” I say, reminding him that our job together is to help him have meaning in his life, to help him find a way out of a situation, which, at the moment, feels like he cannot navigate. “Yes and no,” he says again. “I need to do something, but I don’t know what, so I am trying this, but frankly, I do not see how you can help me with this,” as he outlines his ambivalence, or as Freud would say, his resistance to opening himself up to new ways of seeing the world. “If you could change what is important to you, you could make different decisions, ” I remind him, meaning that he does not have to assume that his wife would be intolerant of change, because perhaps, just perhaps, this is a projection on his part. “Let’s see where this goes,” he says, jumping to the other side of his ambivalence and propelling us forward.

 

The Vulnerable Patient

 

We ask patients to free associate, to let go of their conscious mind, and tell us, like they are on a train, what comes into their mind, as the moments fly by. We assume they can bypass feelings of shame and guilt, which may be associated with some of their thoughts. We understand that shame and guilt inhibit, and so free association is never free, but only a goal post, an ideal to strive for. We flow with ideas as a sense of pride, and we avoid and retreat, to lick our wounds and reboot. As a psychiatrist/psychoanalyst, I am aware of the sensitivity that arises with this shame and guilt, and hence my plea for free association requires great courage from my patients. They are scared of judgment, both mine and their own. They do not know where this journey ends, but they do know that where they are right now is not good. They give me enormous trust as they place their precious thoughts into my brain. It is no wonder that when things go wrong in treatment, they can go very wrong. The shame and guilt, if exacerbated, can lead to rage and retaliation. Words of shame and guilt are rarely uttered by patients, and so it is the therapist’s job to gently guide the patient into understanding how these negative feelings contribute to their behavior.

Trevor, fifty-four, comes to mind. He is silent for most of our sessions, holding in, what feels to me, to be tremendous rage, guilt, and shame. Over time, we have come to understand that his parents had no rules. He never felt contained, and hence he always felt confused; confused about his life, his relationships, who he was as a person. He became a dentist, like his father, but that had no meaning for him. He married and had three kids, but those relationships also were without form, in his mind. He missed appointments frequently, “because after all I had nothing to say,” he told me, when he finally surfaced. “You really do not think that what is in your brain has any importance to you?” I say, struggling with him to understand his profound need to retreat, along with his profound sense of detachment from himself and others. “I just did not want to come in if I had nothing to say,” Trevor insisted. “How can you have NOTHING to say?” I respond. “I just wanted to figure things out,” he replied. “Isn’t that what I am here for, to help you with that?” I replied quickly. “Well, I needed to think by myself,” he said. “And so you did not tell me you were not going to come?” I say. “I know, that was rude,” he said, unapologetically. I could try to explain to him what it is like waiting and not knowing, but I decided to say, “I guess you needed me to share your confusion, as I, too, was confused when you did not show up.” “Maybe” he said, in his characteristic hesitancy. His formlessness in his thoughts, his lack of connection to himself is palpable and painful. He is vulnerable, I suspect, covering up guilt, shame and rage, for never feeling entitled to have his own way of thinking, and for feeling like he could never make an impact on his world. That is my formulation, at least so far.

Is Bad Care Better Than No Care?

 

If the choice is bad care or no care, what do we choose? This sums up my current focus on the changing nature of mental health delivery. Today I am reminded that psychiatrists are asked to do paper reviews of prescribing practices. This means that there will be psychiatrists employed to review charts to determine the kind of care the patient needs. Whatever is documented is valued as being “true” since the psychiatrists will never interview the patient, and in terms of children, he/she will not interview the parents either. Like teachers who are forced to teach to a test, rather than help each child learn to the best of his ability, physicians are now looking at data, and this data is what is entered into the computer, and this data is used to evaluate the appropriateness of the care. Garbage in, garbage out, as computer engineers would say. We rely on the input to make determinations, but we are not questioning the input. This results in big data which is determining reimbursement and program development. Measuring cholesterol may help determine the overall health of a population, but there is no corresponding measure in psychiatry. There is no short-cut for assessing mental health. The long-cut is a trained professional doing a painstaking interview, along with review of previous evaluations, talking to collateral historians and then formulating a hypothesis which is tested over time, through interventions such as psychopharmacology, psychotherapy, and environmental manipulations. This is my rant. I will keep saying it, as long as I keep hearing about the future of medical care, and in particular, the future of mental health intervention. Bad care is not necessarily better than no care, but bad care breeds statistics and big data. No care seems like neglect, but picking an option which only gives data, but does not address the state of mental health assessment is not wise.  “There is no money” I keep hearing as to why the system is stuck. “You mean that it is not a priority,”  I reply. And so the dilemma continues.

Psychotherapy As Art

“On the day, some decades ago, that I sent off the manuscript of what would become my sixth published book, I was suddenly possessed — there is no other word — by the desire to leave this world, and to do so by stepping in front of an oncoming bus. I walked to the edge of the sidewalk, stepped down, hesitated, let the bus go by, and decided to go home, where, if one of my children, then ages 4, 2 and 1, defied me in any way, I imagined picking that child up and throwing the child against a wall or through a window.”

“I came, slowly, not merely to remember experiences and feelings, but to relive them. And this turned out to be not unlike what I did while writing fiction: I gave myself up to my own life and feelings in the same way that, when inventing characters, I gave myself up to what my characters felt and experienced. By imagining an experience back into existence I came closer not only to what had happened and what I’d felt, but to what I’d forgotten, or had not felt, or not seen, or might have felt. I became lost and frightened the way characters in my novels became lost and frightened, and I found ways of surviving in ways my characters did. Like my writing, psychotherapy enabled me to make sense of a world that often seemed senseless.”

 

 

http://nyti.ms/1yXZ7KV

 

These are quotes from the article for the New York Times blog, entitled the couch. The author, Jay Neugeboren describes the process of psychotherapy as similar to writing fiction. By imagining himself as a character in his book, he could then develop sympathy and empathy for himself. With these feelings comes the ability to feel sad for what he did and did not get throughout his life. This sadness is the journey of mourning, and like mourning the death of a loved one, it is a journey of fits and starts, a journey of waves coming in and then receding, but ultimately with an acceptance of the loss and an ability to re-invest in new relationships. Psychotherapists, psychoanalysts, help people imagine themselves in the third person, and in so doing, the patient can begin to feel his experiences with consciousness and depth, rather than lapse into denial and superficial thinking. The art in the work is that the journey is not mapped out. The journey evolves over time.

 

This critical distinction is why I rail at time-limited therapies, since one cannot put a time on personal exploration, because, as the word implies, it is personal. If we then accept psychotherapy as an art, then we have to accept that there needs to be an open-ended approach in order for it to be deeply helpful. At the very least we should acknowledge that open-ended therapies are the gold standard, and so when modifications need to happen, we need to modify with the understanding of what is useful, is the ability to go on that journey of self-exploration, with a concerned professional, is useful. We cannot prescribe the journey, we must let it unfold. Thank you Jay Neugeboren for articulating my point.

 

Unwanted Mental Contents

Receptivity is mental sophistication. The ability to listen to a new idea without the need to dismiss it, or to change the subject back to a more comfortable zone, is yet another hallmark of mental health. The ability to say “that’s interesting” relaxes the mind, as opposed to feeling that you must fight with the idea being proposed. New ideas makes one think, challenges one’s preconceptions, and hence, for most of us, when presented with an idea that alters our way of thinking, we recoil back to our original thought, with very little interest or desire to expand our mental universe. We see this with Republicans versus Democrats. We have come to a period in which neither side listens to the other. Neither side seems to want to know what the other is thinking, and so each side reinforces itself by surrounding themselves with like-minded folks. Perhaps the internet has made this parochial-minded approach more prominent, since we can pick and choose our news and how we receive media, such that we can fall back on our childlike tendency to “dig our heels in” and stick with our original way of thinking. The media then, is used to reinforce our views, rather than challenge them.

Psychotherapy and psychoanalysis is yet another opportunity for mental expansion, but this presupposes that the patient is capable of piecing together a new narrative. The fight against this new narrative is called resistance, since Freud liked to use machine metaphors. If the therapist is not capable of coping with this resistance, then there is a therapeutic impasse. The treatment is stuck. On the other hand, pulling at the resistance could increase the fight, and the treatment could be stuck in that direction as well. The art of psychoanalytic psychotherapy is to learn to dance around this resistance through dreams and free association, such that the patient can learn to play with ideas without threatening his narrative. In other words, the mandate to say what is on your mind, without trying to create a coherent narrative allows the patient a play space to see what his mind produces, without the immediate pressure of making meaning out of his thoughts. The meaning may come later, much later in fact, and this is yet one more reason why unlimited time in psychotherapy is critical to its success.

John Steiner http://en.wikipedia.org/wiki/John_Steiner_%28psychoanalyst%29 makes the distinction about understanding versus the need to be understood. The latter is about empathy, whereas the former is about growth. To make the patient feel understood is the first step towards understanding, or making a new narrative. Being understood does not create a new narrative, but understanding does. Travis, forty-one, comes to mind. He has a very close relationship with his mother and a very contentious relationship with his wife. In psychotherapy, with a female therapist, he never wants to talk about his wife or his mother. He is terribly afraid that the therapist will tell him that his relationship with his mom is “sick” and that is why he cannot connect with his wife. The therapist has never said this, but Travis “knows that is what she is thinking,” in all likelihood because that is what Travis is thinking. Travis becomes angry at his therapist for “not listening.” His therapist, feeling this to be resistance, as opposed to a legitimate criticism, says “maybe you are afraid that I will listen, and that would be hard for you, so you need to see me as ‘not listening’ in order to cope with your terrible dilemma of wanting help and being afraid of help at the same time.” The therapist attempts to help Travis be understood, but she perceives that he is not emotionally ready to handle the idea that when Travis says his therapist is ‘not listening’ that this is a projection in that Travis is ‘not listening’ to himself. To create an understanding of projection, Travis would need to see himself as the author of his struggles, and not a victim of them. This transition can take a lot of patience and time. Unwanted mental contents are unwanted for good reason. They hurt.

Unbearable Reality

Unbearable reality, that sensation of trauma, when an experience, or a relationship, or a part of the self is defeated or not attended to, then mental distortions often occur, particularly in young children, and particularly in adults who struggle to cope with challenging situations. Janet, thirty, comes to mind. She has just discovered that her husband of five years was having an affair with his co-worker. Her immediate attention is drawn to her weight. She is convinced that if she had just lost those ten pounds that she has struggled to lose since her last child was born two years ago, then her life would have been just fine. She is seeking a clear target, a reductionistic point of view, in order to cope with, what she perceives, as devastating news. She is not ready or able to think about the complexities of her marriage, her developmental issues, or the impact of having children on her marriage. She is driven to stop eating, see a nutritionist and begin an exercise program. In her mind, this will solve her problems. Psychoanalysts would term Janet’s thinking and behavior as resistance. She is avoiding seeing the multiplicity of factors which impinge on this potentially catastrophic moment in her marriage. It is not that there is anything wrong with her desire to gain control of her health, including a good diet and exercise program, but her limited thinking that all of her emotional struggles stem from poor eating is upside down. Her poor eating stems from emotional troubles. With time, Janet will likely come to see the factors which have brought her into this threat with despair, but for now, as she tries to maintain her ability to maintain her job and take care of her kids, she feels certain that diet and exercise will put her marriage back on course. This certainty is how she is coping. Threatening that certainty could cause her anxiety to skyrocket, and so she avoids any threat to that certainty. The time is not right for her to examine her situation, like a novel, with thoughts, ideas and formulations, but with no certainty.

What Is Your Narrative?

How do we tell our story? Do we start with where we are born, the type of parents who raised us, our siblings, or do we start in the present and work our way backwards? Do we speak about our jobs, our kids, our friends, our hobbies? Do we spill the traumatic aspects first, or do we withhold them for fear of the listener’s reaction? Does our story depend on who is listening? Do we change narratives based on our audience or do we drone on regardless of the feedback we are getting? This was our discussion last night with my students, who, as I have been blogging about previously, mostly work in agencies which demand EBPs, or evidenced based therapies http://en.wikipedia.org/wiki/Evidence-based_practice which deny the possibility of a narrative. This is the tragedy of our time, that newly trained therapists are not learning to appreciate the patient’s narrative as a window into understanding their mental distress. Yet, I preach to the converted as my class is 8 students who are committing themselves to learning how to understand the narrative. Still, there is a collective sigh of familiarity when I remind them that EBPs not only superficially help patients, but they create superficial therapists as well. The depth of our work comes from listening to how the patient constructs his world, to listening to the meaning associated with his behaviors and his interactions.

Isabelle, fifty-five, comes to mind. She was an attorney, but hated her job. She developed fatigue, headaches, and joint pains, all non-specific symptoms which prompted her to believe that she had a fatal illness and that she must retire instantly because her days were numbered. She sought endless medical consultations and had expensive medical tests and procedures to prove her point, and yet all of the results turned out to be negative. Still, she could not take ownership of her desire to retire, but rather she had to construct a story in which she was on her death-bed, in order to give herself permission to start a new chapter. Money was not an issue, as she had saved enough over the years to comfortably retire, and her husband was still enjoying his work. Still, the guilt that she experienced when thinking about quitting work was enormous, but also unconscious. It was through our work together that she could come to associate that her guilt was transferred into somatic symptoms, resulting in her need to create a narrative of death in order to make the changes in her life that she felt to be necessary. She was raised to believe that work was the only meaningful way to contribute to the world. It took us a long time to see that that was a very limited world view which she adopted, unconsciously. Eventually, Isabelle was able to create a new narrative where she embraced life and developed insight into her previous behavior, such that going forward she could make decisions which were more linear, more in line with her passions, and so she gave herself permission not to work and to be healthy.

“That is how new narratives lead to mental health,” I explain to my students. “We do not have to tell people what to eat or when to exercise, but we do have to help them want to be healthy so they can figure that out. ” I continue with my mantra. We give people the opportunity to metabolize their childhood experiences and in so doing they are free to make new choices for themselves. With this freedom comes the birth of a human being, the birth of a person who wants to make a mark in the world, and with this desire, will come the behaviors of healthy living.

Analytic Narrative

The mind is generated by and organized according to narratives, Roy Schaefer proposed. We tell ourselves stories about ourselves in order to have a sense of cohesion, a sense of self, and a sense of continuity. The fluidity of this narrative is often a sign of mental health. The more rigidly a person adheres to one narrative of himself,  the more difficulty that person has adapting and coping with the changing tides of life’s stressors.

Money, an interesting name for a person obsessed with financial sucess,  (his birth name was Monroe, but he goes by Money) age fifty-six, comes to mind. He is the youngest of two children, growing up in affluence, surrounded by very financially and educationally successful relatives. Money too has achieved a modicum of success. He received a degree in Business Administration and he works as a mid-level executive. However, by his narrative he is the “black sheep” of his family, since his house is only of modest size, and he feels limited about the types of vacations he can take with his family. Money’s narrative is that he is not “as good” as his sister, his parents or his cousins. He describes himself as a “blob”. As Money and I begin to explore his meaning of the word “blob” we come to see that Money’s competitive family, are by his account, all “blobs,” meaning that no one has created a life that feels meaningful, but rather his family dynamics have given birth to lives which feel competitive and empty. These “blobs” as Money described were shapeless, formless and menacing experiences, with little feeling of significant impact on the world. Together, Money and I came up with a modified narrative where he was no longer the “black sheep,” but he was yet another family member who feels inferior in a world which seemed to offer little meaning. It was only through feeling more successful than his relatives that he thought meaning could be obtained, but through our work together, he has come to see that that narrative is flawed, and that he needs to create a new narrative where he acts to create meaning and not “superiority”.

Changing, or expanding our narrative, is what Roy Schaefer taught us is therapeutic action. In other words, deeper self-understanding, with a continual search for a broader narrative, is how we can help our patients and ourselves live in a world with satisfaction and fulfillment; to love and work, as Freud would say.

NYer Cartoon Contest

 

I was framed.

Generational Strife

The struggle for power and sexuality, the acceptance of one’s decline, and the acknowledgement of the up and coming generation are the universal struggles of mankind, as Freud liked to teach us. “How does the increasingly vital younger generation appropriate the power of the decreasingly vital older generation?” Stephen Mitchell and Margaret Black ask us in the book ‘Freud and Beyond’. On the one hand the younger generation wants to kill off the older generation so that there is room for them to grow, and on the other hand, the guilt and fear associated with this wish can be paralyzing. This is the fundamental paradigm of the oedipal conflict. The little boy’s fantasy of marrying his mother, ridding himself of his father, is associated with guilt which is tempered by his acknowledgment that his father loves his mother and hence he must make peace with being left out of their dyad. This struggle, followed by compromise, is the paradigm for negotiating frustration throughout life. As the boy matures, he can become competitive with his father, and for some fathers this is a challenging situation to the father’s ego, and as such, generational strife can take on massive proportions. In essence, not all fathers want to see their sons be more successful than they are. In fact, some father’s sabotage their children so as not to be faced with this perceived humiliation.

Bart and Brad come to mind. Bart is in his sixties, working hard as an attorney. Brad, in this thirties, is working hard in investment banking. Brad has surpassed Bart’s earning power my many magnitudes. Bart is not happy and continually criticizes Brad for his choice of girlfriends, his wardrobe, his financial expenditures. Through my work with Bart, we have come to understand that this criticism of Brad is based on Bart’s weak ego in which he feels “upstaged” by his son. He understands that most people expect him to be proud of Brad, but he feels very threatened by him. He feels that Brad has made him look inferior to his friends and extended family and he does not know how to cope with those feelings. He has come to see that his competition with his son has caused him to be mean and judgmental of him. “It is not easy getting old and feeling like I am not going to make any great career moves now and so this is it, for me financially speaking.” Bart says with sadness that he has reached a plateau. “Maybe you need to grieve the loss of your upward mobility,” I say, suggesting that maybe he needs to accept his stage in life. “That’s tough, but I can see how threatened I feel by my son’s success and I can see that I have treated him poorly, as a result. I guess I just do not have the daddy gene which says that if your kids do well, you should be happy. I just do not feel that, at all,” Bart says with uncharacteristic frankness. “It is great that you know how you feel and it is curious why you do not have a sense of pride,” I say, wondering aloud as to what this missing “daddy gene” is about.

I imagine that Brad wants to please Bart and wants to compete with him, at the same time. The dilemma that Brad is in makes me wonder how he copes with, what Freud would term, his aggressive drive. Does Brad feel the guilt of making his father feel small, and is this played out in his trouble in finding a life partner? I have never met Brad, but I imagine that hypothesis. Playing with ideas is my business. Having theoretically underpinnings to forming these ideas is useful, not as declarations, but as a framework on which to build a theory. This delicate balance between floating a theory and making a declaration is the art in the work. And so, this will be the opening for my upcoming class.