Shirah Vollmer MD

The Musings of Dr. Vollmer

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.

4 Responses to “The Vulnerable Patient”

  1. Shelly said

    Trevor feels very familiar to me. Do you think his personality was shaped by parents who had no rules? Is Trevor very tentative, disconnected from his inner self and cannot make decisions? Were his parents the type who never said “no?” It must be very difficult to be married to someone like Trevor because he never has an opinion, and always lays the burdens of life on his spouse. On the other hand, one has to wonder why Trevor’s spouse would have married someone like Trevor……?

    • Yes, Trevor’s spouse probably has her own dynamics which makes the “fit” happen. Yes, Trevor’s parents had no rules, and for Trevor this has meant a life which feels unformed and with little meaning. He cannot seem to get traction or connect to his world. Thanks.

  2. Eleanor said

    Yes…I remember free association being one of the hallmarks of the psychodynamic approaches….a complete freedom from any “planned agenda”… And this Is where the “art” you spoke of Shirah comes into play….the back and fourth verbal interaction and exploratory thinking becomes key to bringing deeper levels of unspoken shame, guilt and negative thinking into consciousness. One of Einstein’s famous quotes always reminds me of this process….” Education is not the learning of facts but the training of the mind to think”. Your work with Trevor never tells him what he should think, believe, do, feel, learn, etc. but in the process of free association and your listening with ever hovering attention, he will learn to “think” like he never has before and in doing so he can begin to truly understand himself as an individual in his own right. This is the “art”….something one can never see on medical records or lab results. And this takes time.

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