Shirah Vollmer MD

The Musings of Dr. Vollmer

Therapeutic Process

Posted by Dr. Vollmer on January 14, 2015


“Freud demonstrated that the subjective sense of self as an omnipotent agent over one’s experience and actions is an illusion…..One often does not, in fact, know what one is really doing. ”

“Contemporary psychoanalytic commentators tend to make more modest claims for psychoanalysis, as one way to tell the story of human experience, as one way through which the meanings that are generated in the lives of individual and cultures can be traced, understood and appreciated.”

Stephen Mitchell and Margaret Black in  ‘Freud and Beyond’.


Teaching time. Yes, it is time to talk about what I do every day and why I do it. How do I think about what I do? How can my students, licensed clinicians dedicated to expanding their understanding of motivation, deepen their work with patients who come seeking relief, but often staying for a more fundamental understanding of themselves? This is the “big picture” discussion of how we look at the human psyche and thereby understand human suffering. What exactly did Freud teach us and should we move on from him or build from his iceberg description of the human mind? What about other writers, such as Otto Kernberg, Roy Schaefer, Hans Loewald and Jacques Lacan? Have they changed the field or merely layered over the understanding that the underpinnings of behavior are largely unknowable, but allow for a theoretical discussion of possibilities which include psychic structures such as id, ego and superego, along with instinctual drives of sexuality and aggression. How central is the oedipal conflict, where the little boy so desires his mother but must compromise his love for her by identifying with his father, and through this inherently frustration situation the boy grows up to navigate his world and mature into a man that handles frustration with grace, while maintaining the ability to love and work; the definition of mental health, according to Freud.

Case example. Lucia, fifty-three, female, wants to feel “important”. She does not feel valued by her husband or her three children. At work, where she is the office manager for a large law firm, she feels valued, but she does not value her work. In essence, her activities do not give her the pleasure, the fulfillment, she had imagined she would feel at this age. The lay person might say she is having a mid-life crisis. She has achieved her dreams, but they give her little satisfaction. Her narrative suggests a tone of “is this it?” How did Lucia get here, I wonder. Is this the result of living her parents’ dream but not hers. Does she lack, what Kohut would say, is a sense of agency or ownership over her life? Does she feel like the classic marionette, with strings pulled by imaginary figures, with little sense of her own power over her destiny? What changed for Lucia? Why now is she struggling with fulfillment? After the first child, the second, the third, did she suddenly experience the weight or responsibility for these three lives, whereas before she was not conscious of what it meant to have one child, never mind three? Her three children are all boys. Is the feeling the grief of not having a girl? What about her marriage? When did that seem empty to her? Or, maybe it is not empty, but just not right in the moment? Again, I say none of these things, I only ponder ideas about how a seemingly high-functioning person leads a double life, one with an external sense of being together and an internal sense of despair. What is my tool for understanding? Free association. How is Lucia going to tell her story? Is she going to reveal her early relationships or will she focus on the here and now. Is she focused on her symptoms or is she focused on her narrative? How does she imagine I will help her? Is she determined to get medication or is she open to exploration and further understanding of her mental interior?

Therapeutic process is the belief that together, Lucia and I, with the shared goal of understanding her mental state, can uncover unconscious contributions to her behavior, and in so doing, she can make decisions which have more meaning for her. “Is the upshot that Lucia will take an art class, something she has put off for twenty years, and now she is happy?” I imagine that question tinged with a cynical tone associated with the quick-fix solution of  “just tell her to get a dog” so that she can feel appreciated. Maybe that is the upshot that her loved ones see, but the path to her taking an art class is one in which Lucia understands her self-deprivation, how she has expected love and devotion from her children and her husband, because she never received that kind of love from her parents. The journey through this therapeutic process is one in which Lucia comes to see how her expectations, based on very early needs, were placed on her family, somewhat unfairly. Her husband, in this fictional example, is a ‘good enough’ husband, and her kids are thriving, but the problem is that Lucia is suddenly aware of her early deprivation and she is now looking at her current family in disappointment and despair. The understanding of this displacement helps Lucia keep her family together and enables her to nurture herself. Will my students understand this journey from blame to grief? I will let you know.



2 Responses to “Therapeutic Process”

  1. Shelly said

    How can you help Lucia if you ponder and let Lucia come to these realizations on her own? “Is she determined to get medication or is she open to exploration and further understanding of her mental interior?” Why are the two mutually exclusive? Is medication simply a quick fix and does that mean that once medicated, she will not be open to further exploration and a deeper understanding of her mental interior? What were Lucia’s parents’ dreams for her? Does Lucia have dreams for her children and does she put her own dreams on them, thereby living vicariously through them?

    • No, medication and psychotherapy are not mutually exclusive. The openness to internal exploration waxes and wanes, so the answer is nonlinear. Exploring Lucia’s parents dreams for her is a very fruitful endeavor, as is exploring her dreams for her children. The intergenerational boundaries which you are suggesting are critical to good mental health, throughout one’s lifetime. Having concern is different than living vicariously and that difference can feel very confusing. Thanks.

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