Past Present Puzzle

 

“The most remarkable thing is this. The patient is not satisfied with regarding the analyst in the light of reality as a helper and advisor who, moreover, is remunerated for the trouble he takes and who whold himself be content with some such role as that of a guide on a difficult mountain climb. On the contrary, the patient sees in him the return, the reincarnation, of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions which undoubtedly applied to this prototype. This fact of transference soon proves to be a factor of undreamt of importance, on the one hand an instrument of irreplaceable value and on the other hand a source of serious dangers……The analyst may shamefacedly admit to himself that he set out on a difficult undertaking without any suspicion of the extraordinary powers that would be at his command…

Another advantage of transference, too, is that in it the patient produces before us with plastic clarity an important part of his life story, of which he would otherwise have probably given us only an insufficient account. He acts it before us, as it were, instead of reporting it to us.”

S. Freud, “An Outline of Psychoanalysis” 1940, published posthumously.

Monte and Marla come to mind. https://shirahvollmermd.wordpress.com/2011/08/10/monte-and-marla-on-the-rise-again/ . Monte, a psychiatrist, comes to me concerned about his troubling relationship with his mentor Marla. Monte’s mother, ninety-two, just passed away, after a long illness, but Monte wants to focus on his trouble with Marla. Suddenly, Monte begins to have a strange look on his face, as if something really significant has floated into his head, and after a long and confusing pause, he says, “you know, having gotten together with my siblings when my mom passed away this past week, I began to think that Marla was shockingly similar to my sister Lianna. In all these years, I never put that together,” Monte says, as if his mother’s passing has opened up a closet in his brain, and he finally found his old shoe. “For a long time I told myself that Marla was a ‘new relationship’ for me, a bond which was unique in my life and not a repetition of my previous relationships where I felt so used and not seen. It is true that Marla does not resemble my mother or my father, and so I thought I was breaking the mold, but I also realize that Lianna, ten years older than I am, also had a huge influence on my life, and I idealized her in a very similar way that I idealized Marla. I cannot tell you how haunted I am by this thought, this idea, which seems so obvious now, but was hidden from me for  decades.” I begin to think about the transference that Monte is describing towards Marla, thinking about the article by Arnold Cooper MD that I just read,which reminds me that there is a “release of memories” meaning that as defenses diminish, thoughts can be connected in new ways. The ability to think is clouded by anxiety and fear, and so I imagine that Monte was too fearful to connect Marla with Lianna for fear that he would have to give up the notion that Marla was going to mentor him towards a successful career. Monte held on to Marla as “the shepherd of his future” only to be come away feeling that Marla threw him under the bus when there was a political battle during a committee meeting. This reversal of his fantasy devastated Monte such that it was very hard for him to think clearly about Marla, about his poor judgment of her character. Years after he severed ties with her, he allows himself to consider that he plunged into disaster, in part, because as he trusted Lianna to watch his back as he was growing up, only to find out that Lianna intensely wished he was never born, so too, he wished that Marla could secure his future, only to find out that Marla treated him like a competitor and not a protegé. This epiphany gave Monte a calmness which he had never experienced before. Suddenly, this part of his life made sense, whereas before, he cringed at the thought of his investment with Marla. Transference, in this case, outside of the transference to me, was, as Freud said, the holy grail of therapeutic action.

Blind Spots In Psychotherapy

 

A good therapist fails. How do we understand this? What, anyway, is a “good therapist”? Is there a “good therapist” or a “good therapist-patient fit”? These are the questions which have no answers, but generate more questions. Often, when I am asked for a referral, I think about “fit” but I recognize that this is largely an intuitive process which involves educated guessing. The dyad brings up issues for both the patient and the therapist, and if the injuries in the patient hit close to injuries in the therapist, this can cause a “blind spot” as James McLaughlin has described. Monte and Marla come to mind. https://shirahvollmermd.wordpress.com/2011/08/10/monte-and-marla-on-the-rise-again/. Monte and Marla, both psychiatrists have been working together for many decades. By working together I mean that Monte has sought guidance from Marla for his career, but the relationship has bled into personal matters as well. Monte grew up in a family where he felt he had to please his parents. So did Marla. When Monte spoke about his narcissistic parents, Marla defended his parents by saying “they did the best they could,” thereby making Monte feel dismissed. Monte came to see me, and in our work together we postulated that perhaps Marla could not help Monte cope with being unseen by his parents because Marla has never resolved this very same issue with her parents. The collision of these two traumatic experiences created a blind spot in Marla which caused Monte considerable distress. Unresolved traumas create a defensiveness when a similar situation is described, either in film, in literature or in person. So too, with psychotherapy, unresolved issues in the therapist, can lead to a coldness when these same issues are presented by the patient. This coldness is a way for the therapist to avoid the deep pain associated with her past. It is a wish to think that therapists have resolved all of their issues such these blind spots never happen. They do happen, making the  hope in the ability of the therapist to come to recognize the deficit and try to move the therapy forward. Like my last cartoon post, like life, we want the path of psychotherapy to be linear, but in fact, it goes up and down.

The Psychiatrist Seeks A Consultation

Monte, the middle-age psychiatrist, continues to seek Marla, the elderly psychiatrist for consultation about his work. In so doing he presents his therapeutic dilemmas and Marla sheds her words of wisdom. Sometimes the “session” goes smoothly, and other times, as previously reported in this blog, Monte and Marla get entangled in personal issues which leaves Monte feeling disappointed that Marla, although sometimes wise, is not always a good mentor, meaning that she does not always seem to want Monte to succeed professionally. This is manifested by Marla giving helpful work opportunities to other psychiatrists. Monte comes to me, wondering about how to handle Marla. “Variable reinforcement is really tough, since sometimes you get a lot out of her, and sometimes you feel that she does not have your back. It must be hard to weigh these competing feelings.” I say, outlining the equation where Monte has to come up with a summation of his relationship with Marla in order to decide whether to continue to see her. Like all relationship dilemmas, the challenge lies in trying to weigh the good with the bad, given that different times yield different experiences, and given that the twenty-five year history with one another cannot be duplicated. The length of their drama speaks to the depth of the good and the bad. I hope Monte can navigate his way through to find peace with that relationship. A deeper consciousness about their dynamics will help him. In that, I can be helpful.

The Horror Of Your Own Words

Monte and Marla, https://shirahvollmermd.wordpress.com/2012/05/06/i-am-willing-to-talk-to-you/ return, much to Jon’s dismay. Jon has consistently commented to these posts that Marla is one of Monte’s toxic relationship, and as such, he should move on so that Monte can develop self-esteem without the inevitable setbacks that his relationship with Marla encourages. The fictional Monte sees me, where we discuss his relationship with Marla to examine how this serves Monte on an unconscious level. At times, Monte sides with Jon, feeling like distance is the answer. Other times, Monte seeks Marla’s professional consultation for work-related dilemmas. Still other times, Marla solicits Monte’s advice about teaching opportunities and teaching experiences. Recently, Marla contacted Monte, leading Monte to remind Marla of her last interchange in which Marla said “I am willing to talk to you,” much to the horror of Monte. Marla, upon hearing her words reflected back at her, begins to understand the arrogance of her words. She is not exactly remorseful, but she is aware of the haughty nature of that comment. Marla, somehow seeming that she wants to apologize, but never quite saying that, suggests that they meet to talk about that some more. Monte comes to me with the dilemma. “She seemed upset by her words, but I know we are in a cycle of hurt followed by reconciliation followed by hurt again.” Monte says with understanding, along with wishing that their relationship could reach equanimity.  “Why do you think it is so important that you get peace with Marla?” I ask, knowing that I have inquired about this repeatedly, but also knowing that each time I ask I get a slightly different answer. “Two of my mentors have passed away recently, and so there are so few people in my life who have seen me grow professionally, that I want to hold on to Marla because of our long history.” Monte says in a way which makes me understand his yearning, but also in a way which makes me think that he is living in wishes. He seems to be yearning for a parental figure who will nurture him through his career, but he and I both know that Marla cannot be that person. “Sometimes you have to go around the block a few times with people before you really understand how they impact you,” I say, pointing Monte to the idea that we know how this tale ends. We know that Monte will get hurt again. “Yea, I do know how this tale ends, yet for reasons I don’t understand, I want to go around the block again. I am sure I will end up saying you told me so, but I still need to give Marla another chance.” Monte says to me, with both cognitive understanding and deep emotional yearning for a connection with Marla, for reasons we have yet to explore.

Feeling Used

Monte felt used by Marla again, only this time, the drama unfolded years after the event. Marla, the senior mentor/advisor encouraged Monte to pursue medical student education to encourage more medical students to go into psychoanalysis. Years later, Monte finds out that Marla received funding from a benefactor which was going to support medical student interest in psychoanalysis, such that Marla then received an award for spearheading a medical student program. In essence, Monte feels that his work was used to give Marla recognition. “It is the old story,” Monte tells me. “The old story where the little guy does all the work and the big guy gets all the credit, but in this case, I was unaware of Marla’s motivation until now, which is years later.” Monte tells me with both understanding and dismay. “You use Marla as a way to beat yourself up,” I repeat, over the years that for Monte, Marla has become the relationship in which Monte continually feels bad about himself. “Yes, I can see that,” Monte says, without a sense of relief, but with a sense of cognitive understanding. “I can see how my trust in Marla has led to one betrayal after another, but that I keep going back for more.” Monte says, again showing an intellectual understanding without the emotional understanding which would make Monte separate from Marla. “It takes time for you to feel that you deserve relationships which are more respectful of your time and energy.” I remind Monte, to help him see that he cultivates relationships in which the other person treats him how he feels he deserves to be treated. “Yes, it takes so much time that I think I will be dead by the time I figure it out.” Monte says in despair. “I hope not,” I remind him, but I also appreciate how long Monte’s painful  journey with Marla has been. “Moving forward is painful because you have to look back and feel your mistakes.” I say, trying to convey this understanding of how challenging personal growth can be. “I resist that,” Monte says. “I don’t want to look back, so maybe I can’t move forward.” “Sometimes you can and sometimes you can’t,” I say, reminding him about the changing nature of his mental state.

‘I Am Willing To Talk To You’

“I am willing to talk to you,” Marla responds to Monte upon his request for supervision. The arrogance overwhelms Monte. The words reverberate in his head. Monte, disturbed by this interaction seeks help from me in psychotherapy. “Yep, it sounds like arrogance,” I affirm. “Why does the grandiosity bother you so much?” I ask Monte. “We are colleagues. I am asking for help, but she treats me like she is doing me a favor.” Monte says with internal turmoil which appears to exceed the current interchange. “You are so disappointed with Marla, over and over again. Why do you keep going back for more disappointment?” I ask, thinking that Monte might be replaying an experience in his life where he gets his hopes up, only to be met by crashing devastation. “I really don’t know,” Monte says, almost pleading with himself to come up with an answer. “Maybe you feel you deserve to be disappointed.” I say, trying to gently suggest that he set himself up for this by calling her up. “Maybe,” Monte tentatively says, with a sense of personal disgust in his voice. “I am willing to talk to you too,” I say, trying to make light of this situation as the time comes to an end. We laugh, but we know the pain is still there.

Re-Posting Since I Am Wonderin’ When Is It Witholding and When Is It Lying?

Monte, https://shirahvollmermd.wordpress.com/2010/06/18/were-breaking-up/, dismayed over Marla’s lack of support for his teaching, wonders with Marla, before they “broke up” how he will ever be able to take part in teaching so long as Marla is the person he is supposed to turn to for help. After all, Marla is the head of the faculty committee.  Marla agrees that this is an “issue”. Monte and Marla then sever their relationship, leaving Monte adrift. Eventually, Monte finds other avenues to direct his professional energies and he settles into a new routine.

Buying tomatoes at the local Farmer’s Market, Monte runs into Gigi, a colleague, who tells Monte that Marla has retired and now she  is going to be taking over the leadership  in the next academic year . Monte, stunned, says “when did this come down?” Gigi says, “oh, we got together and we decided this about a year ago.” Monte, still almost speechless says “has this been announced?” Gigi says “well, at a meeting, I told people.” “So, there was no email announcement?” Monte asks. “Right, it was not handled well” Gigi agrees.

Monte goes back in time in his mind and determines that Marla could have told him that there would be a regime change, thereby allowing  Monte  to  have the option to stay involved on the committee. “Why didn’t Marla tell me that?” he asks himself.  As in, https://shirahvollmermd.wordpress.com/2010/06/15/communication-pain/, Monte realizes that information is power. So long as Marla has knowledge that Monte does not have, Marla can feel in control. To let Monte know that there is going to be a regime change, weakens Marla’s place of authority. Monte understands that Marla, for her own reasons, needed to hold on to the power of knowing something that other people did not know. Monte believed that Marla had a hard time giving up the power and so to say it aloud was difficult for Marla. Still, Monte felt that Marla was being cruel to let Monte suffer in this way.

Personality, the way a person interfaces with his world, is often learned in layers. Even though Monte had known Marla for years, this aspect of  Marla’s personality where she used  information as a source of power, was new to Monte. However, in thinking over their relationship, Monte began to realize that there had been other sensitive times when Marla was withholding. He remembered that sometimes Marla would have a long vacation planned and “forget” to tell him well in advance. Monte began to reframe this “forgetting” as yet another example of Marla withholding. Monte wonders whether Marla’s need to exercise power in this way is a reflection of Marla’s overwhelming sense of impotence. In thinking about it, Monte began to have some sympathy for Marla, but at the same time, he was angry and hurt over her behavior. Despite years of an intense relationship with Marla, Monte felt that this chance encounter at the Farmer’s Market added yet another dimension. Despite Monte’s pain, Monte could stand back and see the layers to the deceit and the cruelty. Maybe Marla helped him after all.

Finding Validation

 Charlotte returns to Roger, https://shirahvollmermd.wordpress.com/2011/08/16/unloveable-loneliness-turns/, in a similar way that Monte and Marla continue their drama https://shirahvollmermd.wordpress.com/2011/08/10/monte-and-marla-on-the-rise-again/. Some relationships persist because each person assign the other person a great deal of power over their self-esteem. Roger believes that Charlotte’s love and attention, despite her on-again, off-again behavior, is the only attention which makes him feel whole. Likewise, Monte craves attention from Marla, even though she has been very hurtful to him in the past. For Monte, Marla’s attention enables him to feel like his world is stable, secure. Charlotte and Rogera must also have very important reasons for persisting in their relationship, which to an outsider seems self-destructive.

   “I just did not want to come in today to tell you that Charlotte and I are back together,” Roger says. “Since you think I am going to look down on that decision,” I say, explaining that he is externalizing his ambivalence towards Charlotte, and assuming that I hold the negativity about their relationship. “I don’t know, we could break-up again, but I really missed her and it is nice to have her back in my life.” Roger continues to sound defensive and confused. His agony feels palpable. “Charlotte has a lot of insecurities,” I remind him. “Yes, but so do I,” he responds quickly. “I remember that it is hard for you to reassure her that you care about her.” I say, trying to integrate the good and bad aspects of their relationship into one coherent narrative. “Yes, but it makes me feel good when I can make her feel good, so it is worth the effort,” Roger says, explaining that he gets pleasure out of quieting Charlotte’s anxieties. Relationships are so interesting, I think to myself. Roger has suffered with Charlotte, but he has also felt better than he has ever felt in his life with her. How he balances out these conflicting forces is fascinating.

    Like the Monte and Marla drama, the experience is so different looking in, as opposed to being a character in the story. As I look in on Roger’s life, I see the pain that he and Charlotte have  had together. The happy times, we only discuss in passing. Hence, my vision can be colored, and I have to keep that in mind. Although it is tempting to tell Roger what to do with Charlotte, my job is to help Roger look at his relationship in-depth, and from there he can make a good decision. Respecting the inner world is key. Only Roger knows how he feels.

What’s Up With Marla?

“What’s up with Marla?” Monte asks. https://shirahvollmermd.wordpress.com/2011/08/10/monte-and-marla-on-the-rise-again/. Of course, I have never met Marla, so I enjoy the speculative nature of our discussion, but first I want to know what Monte is trying to get at. “What do you mean?” I ask right back. “Why does she want to have a relationship with me? I understand why I want to keep this tortuous relationship going. I mean I sort of understand that, but I can’t get my head around why she continues to engage with me. She could just go completely silent and never return my phone calls. Instead, she only goes silent intermittently.” I am wondering why Monte cares about Marla’s motivations. Maybe he feels that if he understood her motivation then he could make a better decision about whether to continue this twenty plus year relationship. “What are your ideas about that?” I ask, before venturing with my associations to his question. “I think that she is trying to work something out with me. I think she feels guilty for how she has treated me and so by continuing the relationship with me, she tries to assuage her guilt. Severing the connection, it seems to me, would make her have to face her own cruelty. This way, she can reassure herself that she has been forgiven for her dismissiveness and her rage.” Monte explains this to me as if he has given this really deep thought and although he opened the session with this question, he appears at this moment to be more interested in his ideas than mine. “So, does your theory about Marla trying to cope with her guilt, change anything about the way you think of her? I ask. “A little,” he says, “in that, I know she does not have my best interest in mine, but then again all relationships are selfish when it comes down to it.” Monte returns to his tortured state. His body language changes, he appears frustrated and confused. As he explained how he sees Marla as selfish, and then quickly protects her by saying we are all selfish, his mixed feelings about Marla quickly resurface. “Marla means a lot to you, but exactly what she means to you is my question,” I respond. “I would like to know why you spend so much time thinking about this relationship when you have so many other things going on in your life.” I say, trying to be compassionate, but wanting to challenge him at the same time. “I lost my best friend when I started my psychoanalytic training, which is also when I first met Marla. I think that has something to do with it.” Monte says with tears in his eyes. “You mean that somehow Marla has become the continuation of your best friend. She has somehow eased the pain of that loss.” I say, surprised that I had never known this fact before. “Of course, I am just guessing, but I have been thinking about that recently.” Monte says, crying heavily. “That is very moving,” I say, taken by the change in affect, and struck by the new understanding of the meaning that Marla might be playing in his life. “It is really too bad we have to stop now,” I say, struggling with how to close this moving session. “Yea, I left the major punch for the end. I hate it when I do that,” Monte says, trying to make light in the midst of a heavy session.

Monte and Marla: On The Rise Again

    Monte, the male psychiatrist in his 50s, has this twenty plus year relationship with Marla, a female psychiatrist in her seventies. https://shirahvollmermd.wordpress.com/2011/08/04/monte-and-marla-oh-not-again/ . As previously chronicled, this relationship, although platonic, has had the ups and downs of an intense love affair, flowing from intensely satisfying to painfully disturbing and destructive. Their relationship is professional and personal at the same time. Both are married with children. Marla has grandchildren. Both are successful in their careers. Both are satisfied with their professional and personal lives. Yet, together they have created a dynamic which is characterized by primitive sadistic impulses along with loving support. The relationship is asymmetrical. Monte talks about his professional misgivings and insecurities. Marla listens and offers advice and support, sometimes. Other times, she is deeply critical or surprisingly unavailable. Both of them work on their relationship. When Monte stops calling Marla, Marla will call Monte to “check in”. When Monte has not heard from Marla for a while, he will call under the guise of “needing to discuss a case,” but really wanting to know that Marla still cares about him. As with so many long-term relationships, there have been times when they do not speak to each other: anywhere from months to years. Likewise, there are times when they speak multiple times a week.

  Monte chronicles his relationship with Marla by talking to me and seeking guidance for the “hard times” but not wanting to hear about what I call the “warning signs” during good times. In other words, Monte’s focus in psychotherapy is the feelings that Marla stirs up in him. Today, Monte went to visit Marla; a face to face meeting instead of their usual phone contact. Marla continued to apologize for her “rage” as Monte reports. “She has apologized many times before, so it does not mean anything,” Monte tells me, as if to say ‘don’t get too excited’. Monte is depressed after his meeting with her, he tells me, but at the same time, they have scheduled another face to face meeting next week. “Why did you agree to continue the discussion?” I ask, knowing that  Monte cares so deeply about Marla that he jumps at the chance to spend time with her. “Well, I was going to refuse, but then she said, ‘hey, we are talking about what went wrong between us. Don’t you think we should continue that discussion?’ I just crumbled when she said that because she had a point. Marla explained to me that although so many people think that Marla is so loving and so giving, I am one of the few people in her life who have seen her rage and as such, she is trying to understand what that is about for her. I was moved by the fact that I was in such a small compartment in her life that I said ‘well, that explains why I have had a hard time finding a support group.’ She laughed. On the one hand I think that Marla lives in a dream world where she thinks that everyone loves her and so she cannot embrace her negativity and then apologize for it. On the other hand, I think there is something very powerful about our dynamic that thinking about our to and fro always draws me in.”

I am left with the same dilemma that Monte carries so deeply. Marla is one of the best things in his life and one of the worst as well. Giving up Marla, to Monte, means  a void in his internal world. Keeping Marla means opening himself to deep pain and rejection. Monte keeps Marla in his life, at least for now, because Marla makes him curious and interested in her, and in so doing, Monte stays curious and interested in his world, in general. Monte has made Marla into a parental figure; a flawed parent who one cannot imagine living without. Although Monte was in his thirties when he began his relationship with Marla, Monte feels that Marla has helped him “grow up” and as such, Marla is irreplaceable. My role then becomes helping Monte learn to cope with Marla’s seemingly erratic and hurtful behavior. Maybe if Monte could develop a thicker membrane, then he can keep Marla in his life without being so flattened by her rejecting and withholding behaviors. For now, Monte feels the relationship is mending, yet again.