The Vulnerable Patient
Posted by Dr. Vollmer on January 29, 2015
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.