Quilt of Guilt

Guilt, that feeling of having done something terribly wrong, an agony, so hard to explain, and yet so powerfully dominating one’s mental existence, is often the essence of mental paralysis and psychic pain. Guilt, the longstanding feeling, often beginning with the failure to make your parents happy, resulting in a longstanding, chronic sense of “being bad” without a narrative to understand this feeling. The lack of a narrative often suggests a preverbal experience in which the person felt frustrated before they developed language and hence it is almost impossible to develop words to describe the feeling. This nonlinear aspect of development, where feelings precede language, is one way of understanding why some people struggle terribly with expressing their feelings, and why some of those who have trouble are mislabeled as autistic, where the more accurate understanding of their limited language is a result of very early trauma.

Conscious and unconscious guilt are the plague of our existence in that the ‘quilt of guilt’ as I like to call it, is woven with both past and present, real and perceived, transgressions. Tyler, twenty-two, comes to mind. He married a woman who his mother disapproves of, and although he loves his wife, he is “massively depressed” because “life never feels right.” His narrative begins with his current symptoms. He does not connect his current discomfort to the agony of being unable to please his wife and his mother, at the same time. By his way of thinking, he has “to live his own life, and it does not matter that his mother is upset with me,” he says, with a tone which suggests he does not quite believe what he is saying. “It seems like your mood tanked right after your marriage,” I say, trying to create a timeline to help us understand the trigger for his mood state. “It is true that I wish I could make my mom happy,” he says, sadly and reluctantly. And so we begin an inquiry into his past relationship with his mom, and how that may or not be connected to his current choice in his wife. We talk about how he negotiated internally that his mate gave his mother grief, and that a part of him did not want to care about that, and yet another part of him, felt deeply troubled by that. The guilt that he feels for making his mom unhappy, reminds him of the guilt he felt when his parents divorced, when he felt that he caused their separation and hence he caused her mom to be deeply unhappy during that time in her life. Tyler begins to wonder if getting married to a woman his mom did not think was good for her, was a repetition of him, in his mind, causing his mother grief, by not keeping his father in the home. Perhaps, Tyler wonders, if he developed the identity of a boy who just cannot please his mother, and in fact, adds to his mother’s stress, and as such, he found a woman who would reinforce this dynamic with his mother.

As we speculate together, we see that his parents’ divorce, in his mind, was a pivotal developmental point which diminished his self-esteem considerably, giving him a sea of guilt which has landed deep in his psychic apparatus. Further life choices are woven into this guilt, creating, what I see, as a quilt, in which each developmental period, another patch of guilt is added on. Our work is to take off patch by patch, to help Tyler see that the divorce of his parents was not his fault, and hence although he might have felt guilty as a child, as an adult, he needs to see their marriage from a different perspective. This new perspective needs to see Tyler as a child who was a victim and not a cause of their divorce, thereby slowly giving Tyler the opportunity to rebuild his self-esteem, with much less guilt left so far down in his psyche.

Dazed and Confused

 

It is so hard to not know, to not feel certain, to wonder or question decisions, big or little. This uncertainty often floats downstream and manifests as anxiety. Sometimes, it floats to a search for certainty, with a powerful search for people, or ideas, who seem to “know”. Other times, the “not knowing” floats towards organizations in which lives are tied to, giving the person a feeling of belonging, and hence a feeling of greater certainty. To stay in the island of wonder requires a psychic maturity in which life can still go on, despite the constant threat of unforeseeable change. This, one might, or I might say, is the art of living. In deeply uncertain times, are people mentally ill? Again, I say they are dazed, confused and psychically uncomfortable, but that does not define an illness, only a psychic bruise which offers up a range of painful feelings. Behavioral therapies offer certainty, which on the one hand, can give the patient comfort, but on the other hand, does not help with the maturational process of coping with uncertainty. It is not that behavioral interventions are problematic, it is only that their offer of relief is short-term, whereas helping someone mature offers long-term benefit.

“I really do not know what I want to do with my life,” Calla, twenty-eight says, with fear and panic in her voice. “Do you have to decide today?” I ask, wondering why there is such acute panic. “I feel a pressure to answer that question, and yet my mind goes totally blank,” Calla says while she sits and stares at me with a painful look of confusion. “If your mind goes blank, then I wonder whether you are too frightened right now to consider possibilities, and so maybe you need to think about why your mind goes blank? Perhaps you are so afraid of making a bad decision, or you are afraid of disappointing your parents, then instead of thinking about those ideas out loud, you shut down the engine so you cannot move forward?” I say, suggesting that the “blank mind” is a symptom of competing ideas which she does not allow to see the light of day. She is running away from herself, a psychic retreat, by not accessing her mental processes, and hence she experiences a “blankness.” “The circuits have shut down, so now we need to think about why that might have happened.” I say, opening up the idea that her mind is rich, but she has shut off access, for fear of what she might find.

Calla is not mentally ill, and nor does she suffer from an anxiety disorder, but she is paralyzed in her life right now, and medication might help her move forward in tolerating difficult mental states such as uncertainty and fear. Behavioral techniques such as deep breathing might help her feel more in control and this could help her reflection. Ultimately though, Calla’s task is to get to know herself. To find out what makes her happy and to leverage that in a way such that she can be financially independent from her parents. Calla, in essence, needs to grow up. She knows that. She wants that. She is working on it.

Hollywood Shows Empathy

Mental Health Became Behavioral Health: We Lost Our Mind!

 

Changing terminology with the hopes of changing expectations is an old trick. If we use the word “behavior” we think of quick fixes of change, of making new, healthier habits. If we use the word “mental” then we acknowledge the vast uncertainty and confusion involved in understanding a human being. The small name change in my field from mental health care to behavioral health care parallels the changing intervention from exploring with a deep respect for uncertainty to the more concrete, more certain intervention of behavioral training. Certainty feels better on the one hand, but on the other hand, it does not mirror the patients who are fearful, vulnerable and/or traumatized  and who want to be understood, even if understanding means there is a shared confusion about their mental state. The love of certainty is a sucker’s game in that certainty implies knowledge, and since there is no way to understand the deep workings of the human brain, then the one who screams the loudest, who promotes the most certainty will have temporary appeal, until the glow of idealization wears off and the feeling change to despair and hopelessness. By contrast, beginning with humility, with a position of uncertainty, gives way to healthy exploration and thoughtfulness which downstream results in a more stable, considered, examined existence. In other words, behavioral health promises short-term gains, but it does not account for the long-term disappointment and despair which may follow from the unfulfilled expectations. Mental health, by contrast suggests that there is a vague notion of mental balance and that through much hard work and contemplation, mental health can slowly improve, to create more lasting change and maturity. As parents, we want our children to grow slowly, to have baby steps of change to cement a solid adulthood, and so too with mental health, we want our patients to slowly step up their frustration tolerance in order to build a solid foundation to weather future storms. Mental health suggests a slow and deliberate intervention, whereas behavioral health suggests short-term habit change. I do not know how this change in terminology happened, but I can’t help but wonder whether a marketing genius changed the name to create a new brand of health care. If my theory is correct, I do think it is marketing genius, but at the expense of human suffering and low professional morale.

 

See Also…https://www.psychologytoday.com/blog/promoting-hope-preventing-suicide/200911/behavioral-health-vs-mental-health-battle-conformity

Mental Health is Lost

What does being a mental health provider mean? Does it mean that we help people breathe, eat right and exercise? Does it mean that we tell primary care doctors which drug to prescribe, after a two question or nine question paper and pencil test? Does it mean that we point people towards groups, where the individual can share their story with other folks who after a fifteen minute assessment seem to struggle from the same issues? Do we help people by stating the obvious? If we do not understand psychic pain, if we think that a quick appraisal of the person’s mental state can tell the practitioner what to do next, then there are two main problems as a result. First, patients will not get better and they will need to seek help from other sources who may prey on the vulnerable. Second, practitioners will not learn the language of deep mental processes which sabotage and destroy otherwise healthy people and healthy relationships. As a result, if the delivery system ever changed back to an in-depth approach to mental health, there would be no practitioners skilled in drilling down to the root cause of mental suffering.

Yaddy, ya, ya….same ole….rant, but today I add a new issue. As mental health care delivery transitions away from mental health providers giving direct patient care, and serving more as a consultant to primary care, then we will see two problems. One is that the practitioner caught in the midst of this change is going to be very unhappy because that is not the work they signed up to do. It would be as if you told an internist that now all they could do would be to work in the Emergency Room. They would lose their opportunity for long-term relationships because their skill set is needed for triage. This might serve the needs of the population, but for the physician, this is a low blow. If they wanted to be an ER doctor, they would have chosen that in the first place, so the ground under the feet has been ripped. Second, those choosing to enter the mental health field are choosing a career of triage, and not long-term relationships, and as such, a different type of person will enter the field. Triage is a different skill set from long-term care, and hence the mental health provider will shift from a person who enjoys relationships with patients to a person who enjoys shift work. Again, the ER doctor has a different personality than the internist, and so this is true for the changing mental health delivery system.

Words like “integration” and “patient centered medical home” speak to a primary care physician who handles the ‘big picture’ meaning that mental health is being renamed “behavioral health” to suggest that changing behaviors can change mental pain, which although sometimes true, is usually not a sustainable change. The MD  is being reserved for “prescriptions” as this is the one activity in mental health that cannot be done by another provider. As such, diagnosis and all other interventions, are being done by master level clinicians and ‘case managers’ who have less training and have a variable skill set. On the one hand, everyone would agree that the brain is a marvelous and complex organ, yet, on the other hand, helping the brain seems to be the work of simple interventions. That makes no sense.

Treating Confusion

 

Struggling to define what I do, to describe who I treat, and whether I see my patients as mentally ill, I have come to see that mostly, by no means everyone, I work with confusion and psychic pain. Do I think that everyone with psychic pain is mentally ill? No. Do I think that confusion can be measured, such that Big Data can monitor my “progress”? Of course not. Do I think that confusion is deeply personal and layered deeply with both conscious and unconscious layers? Of course, I do. Does medication help with psychic pain? Yep. Does putting someone one medication mean they are mentally ill? Of course not. Being psychically bruised is not the same as mental illness. Taking medication for a bruise makes sense. Labeling someone as mentally ill does not.

On another level, my field is also confused, just like my patients. We cannot define our terms, and we cannot establish indications for treatment, or modalities of treatment which create lasting change. We are desperate to measure something, even if what we measure has no inherent value. We hold hope for neuroimaging studies and pharmacogenomics to give us more objective evidence of what we are treating, and we seemed shame to say that we are as confused as our patients.

I advocate for embracing our confusion as a way of coping through life’s challenges. Confusion, although psychically painful, also leads to exploration and discovery, as Freud taught us years ago. He described understanding the mental apparatus like an archeological dig. We do not know what we will find, but the fun is in the adventure of not knowing, and being open to seeing things. Yes, inquiry into the workings of the mind is fun, while at the same time, it is layered with challenging feelings of guilt and shame.

Finding a path in life which feels fulfilling, connected and warm is a never-ending challenge, as one cycles through the stages of development, both one’s own development and those they love. The dynamics of aging, combined with the dynamics of mental processes create a constantly changing landscape in which to make meaning and happiness. Like all other endeavors, there are times when one’s personal navigation tools fail, and so this presents  an opportunity for new tools and new ways of understanding the world.  I help with that. That is what I do.

 

Life Cycle

Carey, fifty-three, male, was sharing his recent life events with me, catching me up, so to speak, as I have not seen him in a few years. His eighty-six year old father passed away, after a long and chronic journey of debilitating heart disease. He has been to many weddings of his friend’s children, and most recently, he attended a baby naming for the baby girl born to his niece. Of all these events, he said, “the most meaningful, by far, was the death of my father.” The weddings, the baby namings, the marking of life events, “it is hard to know” he says, just how important they are to him, but marking the death of his father, to him, felt meaningful and significant.

I am curious about the meanings, the way he integrates these life cycle events into his mental framework. From what I have gathered initially, I understand him to be saying that sometimes he phones it in, and sometimes he draws from the gathering a certain strength and gratitude for the people who showed up. However, he continues to explain to me the “politics” of these various gatherings. There are those who speak to each other, and those who do not. There are those who used to be very close, but after some bad blood, they barely tolerate one another. There are those who had bad blood, but act as if nothing happened, and yet, there was no repair ever attempted. There are warm feelings and there are cold feelings.

For Carey, a sensitive person, he feels all of it, leading to him feeling uneasy and uncomfortable. And yet, he struggles with the gratitude he feels around the support with regards to  his dad’s death. He does not want to shun community, but at the same time, he feels the lack of authenticity and the pain that often looms large during these “festivities”. He struggles with the opposing pushes and pulls of joining versus holing up. “It is hard for you to experience the group dynamics without letting the challenges penetrate your insides,” I say, helping him to understand his temptation to withdraw, to have a psychic retreat, as John Steiner would say. “On the other hand” I say, “when you do sense authenticity and genuine concern, then you are grateful that you did not withdraw, so that you could feel the human compassion of another.” highlighting this dialectic. “Yes, ” that is right Carey says, crying as he thinks about the pain, the long history with people, and the subsequent disappointments, along with the deep tenacity and concern in some of these relationships. “It is hard for me to maintain equilibrium,” he says, suggesting that he feels all of these contradictions at the same time, causing him both gratitude and despair. “At the moment, I am feeling more despair than gratitude. I don’t know why, but I am. I just want to cry.” Carey says with uncharacteristic emotion, and deep feeling, bringing tears to my eyes. “And so despair dominates right now,” I echo. “The sands are shifting, but I understand where you are right now,” I say, reminding Carey of the dynamics of feelings, which parallels the dynamics of life.

NYer Cartoon Contest

Valentine’s Day means different things to different people.

Movin’ On Up

DEPARTMENT OF PSYCHIATRY AND BIOBEHAVIORAL SCIENCES THE DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA 760 WESTWOOD PLAZA LOS ANGELES, CA 90024-1759

 

February 13, 2015

 

 

 

Shirah Vollmer, M.D.

941 Westwood Boulevard

Suite 204

Los Angeles, California 90024

 

Dear Dr. Vollmer:

 

Your advancement to Clinical Professor (voluntary) has been approved by the Faculty Executive Committee effective July 1, 2015. Over the years, contributions from our clinical faculty have been acknowledged and celebrated in the School of Medicine and throughout the world which validates our commitment to excellence.

 

In the future, you may contact our Voluntary Clinical Faculty Coordinator, Sabrina Sterrett at (310) 825-0125, if you have any questions or need to make updates to your personnel file.

 

After July 1, 2015, you will be eligible to obtain a new ID badge bearing your new title from the Security Office located at B8-153 Semel Institute. The form will be mailed to you during the first week of July.  Their hours of operation are Monday through Thursday, from 8:30 a.m. to 11:30 a.m., 1:00 p.m. to 4:00 p.m., and Fridayfrom 8:30 to 11:30 a.m.  You may also stop by the Psychiatry Academic Personnel Office,  B7-405 Semel Institute, to retrieve the form in person.

 

The Department and I are very appreciative of the intricate role that Voluntary Clinical Faculty members fulfill in our teaching programs.  Thank you for assisting us to validate our commitment to excellence.

 

Sincerely,

 

 

Peter C. Whybrow, M.D.

Judson Braun Professor and Executive Chair

 

 

Intersubjectivity

 

There are two people in the psychotherapist’s office. This means that there are two subjectivities, two impressions of what is the meaning of the interaction. Understanding this dynamic, that two subjectivities merge to create an “analytic third” was the subject of my class last evening. The concept that distortions happen on both sides of the couch imply the fallibility of the analyst, along with the opportunity to repair, which some, such as Jessica Benjamin say is an important opportunity to repair the damage done by not listening to the music of the psychotherapy. Capturing the main idea, being present while someone is talking, is an art which fluctuates based on the amount of sleep, the diet, and the activity level of both parties. Moods, in other words, change the ability to listen, and hence opens both parties up for self-examination about what went wrong, when either party feels they have lost the flow of the session.

 

Noel, seventy-one, comes to mind. She went to a party for New Year’s and she was quite critical of the party, including the food, the company, and the general atmosphere. I was confused by her criticism, and I wondered why she felt so strongly that the hosts did a very poor job. Noel, suddenly felt criticized by me, and felt that I was not empathic with her need to vent about this “awful party”. “How do you understand my confusion?” I asked her. “I think you judged me for being so judgmental about this party,” Noel says, striking me as a very accurate statement. “Yes, I can see that, and that was wrong of me,” I quickly replied, understanding that my tone sounded critical of Noel, and I inadvertently hurt her feelings. It is this apology, that Jessica Benjamin, sees as the key elements to a therapeutic cure. Noel was able to tell me that my tone hurt her feelings, and rather than me, making her feel “too sensitive,” which has happened throughout her past relationships, I owned my tone, thereby validating her feelings, and reminding her that my hurting her feelings, made me feel bad. Together, Noel and I could see that in those brief moments, I lost empathy with her, and so there was a need to repair that moment. The repair allowed for the acceptance, not just of my fallibility, but for hers as well. It was a modeling that empathy fails, but repairs can fix them. The empathy failing is a repetitive experience for her, but the repair represents a new way of being in the world, which allows for growth and development, as opposed to more hurt feelings and more self-loathing. This is a more contemporary model of psychotherapy, one that is harder to teach new students, as there is more subtlety, and there is the need for more seasoning in practicing psychotherapy,  that lets you appreciate the need for authenticity on both sides of the couch.