Borderline Rant

 

 

http://en.wikipedia.org/wiki/Borderline_personality_disorder

 

23 years in practice and I still struggle with this diagnosis of a borderline personality disorder. I tell my students that I have never seen one, meaning that what they see, I do not. Brianna, twenty-five, has had multiple suicide attempts. She is the product of an Italian immigrant father and an African-American mother. She complains that she cannot fit in anywhere, because of her mixed heritage, and as a result, she often feels like killing herself. My students, who have seen Brianna, say she is borderline or Asperger’s. I propose that she is lost, searching for meaning in her life. Once again, I find myself using lay terminology to express the desperate feelings that lead to self-injurious thoughts and behaviors, in preference to the jargon in psychiatry, which I find to be unhelpful in terms of thinking about how to help patients like Brianna. Once again, I feel the laziness of using diagnoses like Bipolar, Asperger’s (now Autistic Spectrum), or Borderline, as a way of NOT thinking about the struggles of living in this world. Psychiatric diagnosis, sometimes, skims over the complexity of mental existence, leading to yet another irony, where on the one hand, in the neurobiological world, the brain is seen as complex, but in the clinical world, there is a push towards simplicity. Self-injurious thoughts do not necessarily imply a DSM 5 mental illness, but often implies, psychological pain, which is not an illness, but a symptom of a deeper problem of struggling to latch on to the beauty of the world, and the  beauty of oneself. All of this dispute, my plea to get away from jargon, makes me scared that psychiatry will bury itself. Brianna, and so many people like her, need understanding and listening; they do not need a label. Other mental health professionals (non-MDs), and clergy, understand this, but psychiatry, at least a large part of psychiatry, pushes away from the value of embracing the complexity involved in finding meaning in life. Labeling patients Borderline often embodies this issue. It is as if the label stops the psychiatrist from probing deeper into the personal struggles of Brianna. She is Borderline, implying that she needs medication to control her impulses. I do not have an issue with giving Brianna medication to control her impulses, but I do have a problem if the intervention stops there. Controlling her impulses allows Brianna to become more contemplative, and hence more reflective on what is important to her. Medication in this light, opens the door to an internal journey which is messy and complicated, but ultimately helpful to Brianna becoming an authentic, and hence beautiful human being. I repeat. She is not Borderline. She is lost . So is psychiatry.

Decision Making: What’s Your Style?

 

Martha, forty-one, always allows her husband to make their major life decisions: what house to buy, where to send the kids to school, how to incorporate religion into raising their children. For years, working with Martha has made me reflect on this sense of deference. Is it respect for her husband? Is it a lack of faith in her own decision-making ability? is it fear of confrontation? Of course, these are not exclusive and so at different times, different factors may be at play. Consciously, Martha is not aware that she defers to her husband. Her narrative is that they have thought things through together, but upon deeper exploration, it is clear that her husband always steers the family ship. Suddenly, Martha, unrelated to our present discussion states “how do I know what is the right thing to do?” The moment of clarity arrived. Deep insecurity and a lack of trust in her ego, not believing in her sense of right and wrong, has led to a marriage in which she is the more passive participant. Sometimes these marriages work well, but Martha is now suffering from questioning why she cannot form her own opinion. Forming opinions, thinking, deciding, are actions that many of us take for granted because we have to navigate through life. Yet, Martha is now in a period of reflection where she is confused as to why she is never certain, or even reasonably sure, so that she can then decide what is best for herself, and what is best for her children. She is no longer comfortable being passive, but nor is she content with offering an alternative point of view. She is stuck by the constraints of her ego which, at this moment, is unable to guide her towards changing her life. Her paralysis is painful as she does not want to stay the same, and yet, she is frightened to change her interface with the world. This is our work together-building a sense of self that can go forward with her own decisions, and not be inhibited by the overwhelming fear of making a mistake. A strong self knows that bad decisions will be made, but that the “self” can then make another decision which will put the person back on track. In other words, the stronger person can see the arc which includes both good and bad decisions, and with the ability to reflect, a better course can come out of wrong turn. The more vulnerable ego stays in place, so as not to experience regret. Accepting regret is personal growth. Martha and I are working on this big picture, the picture of building a new self, a new brain, which steers her in a way where she can feel proud.

Should I Tweet?

“You should tweet,” a colleague tells me. “Why?” I ask. “People wonder what you think,” she says. Do I want to be an internet personality? I ask myself. What is the difference between my blog and tweeting? Yes, I know that tweeting is “microblogging” and so they are different beasts, but do I have something to say in a limited number of characters? I suppose I could try tweeting and see what happens. I did not think I would post four days a week, but as it turns out. I do. I often do not know what I want to say until I sit down and say it. Before I started blogging, I could not imagine the pleasure in having a forum in which I could express ideas which have buzzed around in my head for over two decades. Indeed, there is often a sense of relief after I post. I have written something that I have wanted to express for so many years, but I had no audience. Now, the thought of my audience inspires me to discharge thoughts, agonies and concerns regarding the state of psychiatry, medicine, and psychoanalysis. So, how does tweeting add-on to this mission? I could comment on mental health tragedies that hit the news. I would enjoy that. My mind thinks in tweets, so I like the limitation in characters. On the other hand, would this blog suffer if I added tweeting to my working life? Maybe. I am surprised how much energy goes into posting, such that tweeting would also be consuming, despite the brief nature of the result. As we all know, it sometimes takes longer to be brief. Then, there is the issue of my narcissism. How will I feel if I have few followers? Do I want to subject myself to unpopularity? I think I can handle that. This blog has taught me that there is pleasure in writing, even if only one person reads it. As a person who came of age before the internet, few followers still amaze me, so my bar is low. Have I reached a conclusion? Nope. It is summer and so I will give myself time to contemplate.

Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

Leadership

Health Care Apps

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In the “adapt or die” mode, part of moving into the next wave of health care changes is using applications to help patients understand and treat their ailments. Knowing which application to recommend to patients will be an important tool in the ever-expanding toolbox of treatment modalities. This application, pictured above, helps patients learn diaphragmatic breathing by showing a man lying on the ground with a book on his stomach, demonstrating that the book rises and falls with each deep breath, but not with shallow breathing. Deep breathing soothes anxiety, and is a relatively simple means of coping with stress in very powerful moments, such as learning about the Boston Marathon. Teaching people to breathe is that simple, elegant, intervention in which there are no negative effects. The smart phone allows people to teach themselves deep breathing in the privacy of their own space, along with the value of repetition, if need be. There is no doubt, that the smart phone will serve as both a health care passport, in which patients travel with vital medical information, along with serving as a  treatment tool, particularly for stress-related disorders such as anxiety or insomnia. This advanced technology thrills me beyond words. Only in my wildest dreams did I imagine such useful patient information to be so incredibly handy and useful. In this way, medicine is in an exciting era.

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.

Lost Years Stimulated By Turning 50

Tea, turned 50 in December, but she is still fixated on this number. “I finally figured it out,” she tells me with great enthusiasm. “Yes,” I say, nodding that she has built up suspense. “Well, as you know, my son died twenty years ago and for me, the world just stopped. I was in a grief period, of course I still am, but I was really in another world for so many years, that turning 50 does not seem real to me. Everyone looks at me with a sense of recognition about how hard it is to turn 50, but I know that I am experiencing something that they do not connect to. I feel the loss of so many years where all I could think about was my son. That distortion, if you will, made me lose the normal tracking of time, such that I cannot latch on to my age. Sure, I have the other issues of aging, both body and brain, but that is not what is getting to me.” Tea relates this to me, as if she has solved a challenging puzzle. She is enthusiastic and not sad about her disclosure. “You know, it makes me sad to hear you talk about your son and particularly sad to hear how you feel you have so many lost years because of it. I am a bit perplexed as to why you don’t sound sad as you talk about it. At the same time, I can understand that you had an itch, which was the mystery of the meaning of turning 50, and now you have scratched it.” I say, knowing that we have discussed on numerous occasions how talking about her son is sad for both of us, but that does not mean we should not talk about him. “Yes, I do feel like I scratched an itch. That nails it. Before, I just felt so uneasy about my age, but it did not make sense to me, because normally I am not sensitive in that way. Now, it makes sense to me, so I feel better.” Tea, has done self-analysis, in a way in which she is communicating to me that the tools from our work together have helped her dig into her mind and test out hypotheses, until she lands on a concept that feels satisfying to her. “It must be so hard to ‘lose’ so many years, and have the people in your world not appreciate your feelings. I mean, I can connect with what you are saying, but it still must feel lonely.” I say, highlighting an old discussion about how Tea feels so alone in her grief. “Maybe you lost many years, but now that you have turned 50, you will be starting to appreciate time in a different way.” I say, highlighting that maybe this self-discovery will yield a deeper presence for her. “I can only  hope,” Tea says, now looking sad, but appreciative of our discussion.

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.

How Many Patients Should Residents See? The Confusion Of Medical Training

When I was in training, I had six or seven outpatients, three clinical supervisors, along with the responsibility of doing inpatient psychiatry work. In this pre-Prozac era, there were not very many “outpatient clinics” since there was very little that we could do for patients on an outpatient basis, other than psychotherapy. Today’s resident spends his time in a series of clinics in which he prescribes medication to patients in a medical model which resembles a primary care visit. In programs that I am familiar with, the requirement to do long-term psychotherapy work is usually one or two cases a year, during his last two years of training. Once again, I must ask myself if I am resistant to change or if this change is harmful to our future generation of psychiatrists. The training programs are focused on the brain and not the mind. Hence, the medical student drawn to psychiatry is a different student than in my day when the common thread in going into psychiatry was the passion to mine the mind. The sadness I feel about this cannot be overstated. I am not saying that every psychiatrist trained today does not appreciate the depth of meaning which is learned from deep listening. However, I am saying that the priorities have shifted such that a “clinic” model of psychiatry is overtaking the long-term psychotherapy model of psychiatry. This shift causes most psychiatry residents to feel most comfortable with a prescription pad and less comfortable with formulating psychodynamic understandings of how a patient’s mind has come to give that patient deep suffering. I am left to hope the pendulum will swing back to prioritizing intense listening. This skill is what so many patients need to heal. Have I said this loudly or too many times? I don’t think that is possible. This series of posts will continue until training programs turn back the clock, just a little, in order to bring back psychotherapy training. Change is good, sometimes. This change was too far.