Time to Face the Change

I have decided to make some changes to my practice. I am no longer accepting new medication management patients. This means seeing myself as a psychotherapist. I worked hard to become a doctor and letting go of that identity isn’t easy for me. Of course I am still a doctor, but I will  be practicing  very little Psychiatry now. I used to think primary care wasn’t the place for psychotropic medication prescribing, but I now see it as the right place. Many primary practices are moving toward a model of Integrated Behavioral Healthcare. This model is supposed to help de-stigmatize patients seeking mental health services. I think it may help with that. I think where it makes the most sense is for someone who strictly wants medication management. I know there is a place for Psychiatry and when I went into this field 27 years ago I had planned to do psychotherapy and medication management.

Finding Eros

As I have reflected on the direction my professional life should go, it has become clear to me my true passion lies in practicing psychotherapy. Someone might say it is where my eros lies.  It is a  question I frequently ask my patients. What is their eros?  Eros was the Greek God of love  and sexual desire.  I see eros as that intense feeling of desire.  It can be in the form of making music, cooking good food  or writing. It is crucial that we have it.  Finding eros can bring change.   As we all know change can sometime bring on anxiety. It can also be marked with astounding beauty.

  

I Missed Again

Sometimes I can miss things my patient is trying to tell me. I know I can’t be perfect but I do get upset with myself when I felt I may have missed something important in my patient’s session. I generally will feel uneasy after the session ends which is a signal to me that something didn’t feel quite right. I have to watch my own anxiety that wants to make it better quickly. Therapists are not perfect either. We do our bests but contrary to what our patients may think we are not immortal and we make mistakes.

I’m all Ears

I have been trained to listen with a “third” ear. It is my job to connect what my patient is telling me during those precious 50 minutes. Sometimes because I am tired or maybe not wanting to see something in one of my patients I may miss it. I don’t stop thinking about my patient until she comes back for her next weekly session. Sometimes something will naw at me. I will do some writing about it to see if something comes. Sometimes I might have a dream. Or something I read triggers me to think about the session again. If I am really struck by something I might bring it to supervision. Supervision is what we therapist use to discuss cases that bring us difficulty. I don’t usually use supervision for cases I am doing well with. It helps to have an objective ear listening with me as well. Part of residency training is weekly supervision. I have found it helpful throughout my career.

The Clue Phone is Ringing

If my patient becomes emotional during a session or their body has a sensation they bring up it can help guide us. But sometimes they have neither experience. I work hard to bring a session’s ideas together but even sometimes I cannot. Luckily if it is left unresolved my patient will bring it up again. Sometimes it takes more than one or two sessions for me to make the connection to what is going on. Maybe a similar dream gets brought up at the next few sessions or more symptoms of anxiety are developing around a certain issue in my patient’s life. Whatever it may be it is my job to listen and be aware something is not yet conscious or resolved. Sometimes patients will avoid going deeper so they might keep the conversations light. I also have to use that as a signal something is being avoided.

Weekly is the right dose

Whatever is going on between my patient and myself will hopefully get resolved. This is why anything other than weekly psychotherapy doesn’t work when the inner emotional work needs to get done.  I continue to pay attention when a session doesn’t feel right to me. I also have to consider it is my own feeling and that it needs addressing, but usually it is what has gone on (or not) in the session that signals me to listen up.

 

My New Blue Door

Yesterday I finally painted my office front door a vibrant blue. It had been the black I painted it a few years ago because I thought that went better with the yellow siding. I think my contractor had suggested it and I went along with it thinking he knew better than me about what I wanted. I have never liked the black but it was “ok.” I discussed colors with my teenage son who has a very good eye for this and we decided on Benjamin Moore’s Pacific Palisades Blue. I didn’t realize it at the time we picked but I needed a change that this door would come to symbolize. Without getting into details I knew that something needed to shift inside of me. That I needed to start seeing myself differently in order to move on from something. In essence I had been stuck in one facet of my life. Yes, even us immortal therapists struggle with being stuck sometimes. I needed a new door to open and I had to have the courage to walk through it. So I did. It was quite liberating and freeing. It feels great!

Stuck feels like a four letter word

Frequently I deal with my patients who are stuck. Sometimes, but rarely it unsticks quickly. Other times it can go on for a very long time. I find it mostly in the stories they have told themselves. It usually involves their self worth. That my patient  believes she deserves far less than than she does. That she must settle for crumbs. I can’t tell her she deserves more and expect she will instantly  believe it. She must do the inner work and determine this for herself. I do of course tell her that she deserves everything she wants. It will require going deep inside to figure out why she doesn’t believe this in the first place. It can be a long and painful process, but the only way through it is through it.

It takes as long as it takes!

Sometimes it can take years to get unstuck and walk through the a new door. It can be terrifying.  We can imagine all kinds of bad things happening.  So rather than risk it we stay stuck.  Getting unstuck can be a lengthy process. The insurance companies would have us believing it’s a matter of weeks , maybe a few months to unstick. I don’t agree. I also know   it doesn’t matter how long it takes. In my supervision with a Jungian analyst I used to wonder how long it would take my patient to become unstuck? This particular supervisor always said “it takes as long as it takes”! He was so right. I must be patient with my patient and stick with her through her difficulties imagining a different life for herself. One where she has what she wants instead of struggling to have it. One that lets her walk through the new door and into the life she deserves. My job is to simply walk along side her while she is finding that door.

What new door do you imagine opening for yourself? What in your self proclaimed story needs to change?

Happy Thanksgiving!

‘Til the Cows Come Home

Children need to grow up and become separate from their parents. It is how “normal” development happens, but what happens when children are unable to separate? It can create a very anxious child or an adult who is unable to take care of herself. Separation can be made more difficult if the parent struggles to let the child move away from them. This happens physically and emotionally. The first time it may show up is when it is time to go to school. The child is so anxious they might cry and beg to stay home with “mommy.” The truth is the child senses “mommy” is actually afraid to let the child go. The child feels it unconsciously. They sense somehow the parent won’t be OK without them home. The parent’s anxiety fills the child with anxiety and so the protest to leave begins. Sometimes we see it earlier now that more children go to daycare at a  younger age.

Don’t give yourself a kinehora

It shows up later in life as the adult child who can’t seem to stay at college. Or calls the parent every day while away. The parent will sometimes frantically call the child at college “just to make sure they are ok.” They may have seen something on the news like a fire in a neighboring town that sets the anxiety in motion. The adult child is fine. It is the parent who is terrified of losing them. It can also show up when an adult child struggles to move away emotionally even after they are married. The spouse might feel second to the parent’s demands for constant contact. It also shows up when a parent continues to bail an adult child out financially. It creates an unhealthy dependency. The child may then feel obligated to the parent. Jews have an expression about giving themselves a “kinehora”  which is the equivalent of bad luck. The actual translation is an evil eye. It again is a way to create anxiety in the adult child. After the child says something about an accomplishment the parent will say, “you will give yourself a  kinehora,” which implies bad luck. Ahh, anxiety the gift that keeps on giving.

Stop! You might leave me and I’ll die (of loneliness)

Therapy helps identify the separation problem. It does cause anxiety to move away especially after the patterns have long been established. It can take years to do this. The problem is when the adult child tries to have a life of their own the parent may attempt to undermine it. It can be as small as making the adult child anxious about purchasing their own first car. It is my job to ask my patient what she fears most about saying no to her mother. I am not here to judge or give advice. I am here to explore what drives the fear. The hope is talking about it helps my patient work through her fears. To see if they are grounded in reality which most of the time they are not.

Mother cows are very protective of their calves.  It is what makes them good mothers.  We non-cows  also need to protect our children  but only until the time comes when they can do it for themselves.  It is our job as mothers to release our children. They don’t belong to us. They were just passing through on the way to adulthood.

We Are Really All Alone

Many times I will see a patient who is afraid to be alone. It can become difficult to spend time alone following a divorce or a breakup. It’s not unusual for my patient to stay in a long term marriage or relationship because the fear of being alone becomes too much to bear. So she stays rather than leave and experience the pain of the breakup. As we get older we also see our chances of meeting new partners or friends as less likely and so we may also stay out of fear of being alone. The feeling of “not being alone” is kind of an illusion. For example “being in a relationship” with someone who is drinking too much is actually pretty close to being alone. The drinker is not emotionally available. So in essence we are alone. It goes for any situation in which the other person is addicted to a substance whether it be work, alcohol or exercise to name a few.

Do not enter

Being alone has shown up markedly since the pandemic started. I recently had to have a medical procedure in the hospital. I was not allowed to bring anyone with me. I had my “driver” bring me and pick me up. I sat by myself in the procedure area. After the nurse finished up her part with me I sat for the entire time alone. The whole thing took two hours, but it was very different from years past when I have had other procedures. I had come all prepared with a book and my ear buds but I found myself thinking about how alone we really are in this world.

Only Ticketed Passengers May Enter the Boarding area

The first time I really knew we are alone was after my father’s death as I watched them carry him out from the synagogue in his pine casket. Observant Jews, which my parent’s were emphasize modesty and simplicity. Rabbi Simeon ben Gamliel II started the tradition in the second century C.E. I realized in that moment , as he was being carried to his resting place, that he was leaving by himself. It was then I knew that we are all really alone. We come into this world alone and we leave the same way. 

Leaving on  a jet Plane

I always think of the song by the Peter, Paul and Mary., “Leaving On a Jet Plane.” For some reason the lyrics seem to fit. She sings of having to go.  She knows she must leave. She hasn’t left yet but she already feels alone.  It’s also about letting go.  We have to let go to move forward. There really is no other way.  Sometimes it means being alone for a while.  But the real growth can only happen when we embrace our fears rather than avoid them.

Swimming in the Deep End takes Courage

So how does  my patient get over her fear of being afraid to be alone? We must  look together and be curious about why this particular fear has become so embedded in her psyche. I tell my patient she must go deep inside and she will find her answer. I usually get back, “what do you mean go deep inside?” I mean go as far as you can with writing, visual imagery, paint or whatever else creatively will help her find the answer.

Thin Privilege

In recent times we are learning how certain groups are afforded more rights or privilege than others. As someone who grew up fat most of my life except for about ten years in medical school and residency, I know what it is like to be treated differently from thin people. I was also not a fat child or teen, but I ALWAYS felt like I could be thinner. I don’t think I know any women in or out of my practice that at sometime was not unhappy with her body. I see more women than men in my practice who are dieting or using extreme forms of exercise to maintain thinness. However, lately I see more men trying for that twenty something body well into midlife. Today’s discussion is not about trying to convince you that diets fail in 98% of people.  It is about how badly fat people are treated. It is also about the privilege I see afforded to thin people.

Seatbelt extenders are shameful

On airplanes seats are designed for thin people. At one time a major airline was requiring fat people to purchase two seats. I thought this was odd because up until age two a child can sit in a seat with the parent for free. Yet if you have an extra 20 pounds of fat you will need to purchase the extra room. What’s even more humiliating is having to ask for the seatbelt extender. You might fit in the seat but to safely sit there you will have to ask the flight attendant for the seatbelt extender. Why would anyone design a seat like that? Cars are not designed for seatbelt extenders. If you are a woman shopping for clothing in the plus size category, you will also  know that ten dollars gets added on for those sizes. As someone who sews, I highly doubt an additional ten dollars worth of fabric was used to make the garment and sewing a seam is sewing a seam.

Dieting makes us feel bad

Some of the most accomplished women in my practice “feel like failures” if their bodies have gained back the weight they worked so hard to lose. It is usually a repetitive cycle, they lose, they gain, they lose and gain time and time again. They only see that failure rather than their accomplishments as good friends, mother’s, doctors, lawyers, nurses etc. My job is not to stand in their way if they truly wish to diet to try to be thin. I am there to understand it with them. Why do they hate their bodies so much? What started the war with their bodies? Was it a mother who was always dieting? Was it something they learned?  Did a doctor tell them to lose weight?

It’s time stop hating Fat people

I am learning more about white privilege these days. I will admit I was unaware of how lucky I was to be afforded things others were not. I am now far more conscious of what I need to do to stop it in myself and my community. I know the time is also here to stop thin privilege as well. I am tired of seeing fat people ridiculed, passed over for jobs, labeled as lazy or unfit. It’s time to stop hating fat people.

Fat women hate Fat women too

I know I have had patients leave my practice because of my being overweight. Oddly the women who seemed upset with me were not the thin ones. It was the women who had body’s similar to mine. They wanted to see me as bad because I wouldn’t join them in hating their bodies. Thankfully through my own therapy I found a therapist who helped me stop the war with my own body. Each day I am grateful this body lets me dance, ride a bike, garden or walk. We must stop giving so much privilege to any group. For today I will think about ways I  might still conform to thin privilege, to be “the good fat person.” I would ask you to think about it too.

Mad feels better than Sad, but does it?

Yesterday I lost one of the my first chickens. She was my Buff Orpington known affectionately as Nancy Drew. On Wednesday I saw that she was not doing well. In chicken farming, that usually means the end is near. Chickens do not let you know they are sick until it is too late. They hide their illness. I have learned not to feel bad anymore and that by the time I know, there is little I can do. I let myself feel sad rather than avoid the feelings. She was a good chicken who provided me with hours of joy and many, many eggs  Although she stopped laying a few years ago I felt she earned the right to stay for the duration of her life. I do not enjoy the painful feelings that come when we lose an animal, but it is inevitable as we usually outlive them. I also know that we humans as a group tend to hide or mask feelings a lot of the time.  For example, it is far more ladylike to look anxious than angry.

Therapists make mistakes too

 

Last week I continued to listen to a podcast of three jungian analysts. It is called “This Jungian Life.”  It helped me personally get through the pandemic. I would listen to them pretty much every night. I found myself feeling connected to them. It was very comforting.  Last week they spoke of all the anger around the country and that they felt that it was more related to how sad everyone is actually feeling about the current state of affairs. I felt they were exactly right about what is going on.  That is that “we would rather feel mad than sad.” Feeling mad is so much easier than allowing ourselves to feel sad.  Like when we leave a job or relationship, it’s easier to go when we feel mad vs. sad.  When I have a patient who is angry at me or  seems  mad, I will often ask to see if something I did made them feel upset. I make mistakes all the time.I am human. I readily own that I will NEVER be a perfect therapist. However, therapy is a relationship that is to be learned from. It is not only my patient who learns. I try not to beat myself up when I make mistakes, but I know I can feel badly when they happen. A mistake could mean me not offering empathy at the right moment, or letting my own feelings into the session.

Mean is the new normal

Outside my office I am disheartened to see the personal attacks on people for having differing opinions than one’s own. I have made a conscious choice to leave some forms of social media when it seems too personal. I wish we could all be kinder to one another and allow for differing opinions. Yesterday I was watching a conversation on social media. There were differing opinions. I watched one poster start a personal attack on the other poster for simply having a different view. I understand this comes from fear and sadness, but it seems endemic. That it seems to have become acceptable to lash out at people with differing views. I think the lack of dealing with that which makes us sad has infected social media. It has become a platform of meanness and “having to be right.” What might happen if we dealt with the sadness? I suspect those angry misguided feelings would evaporate. 

I will leave you today with a picture of Nancy Drew. She is the yellow one. She will always live on in my heart.

It Wasn’t The Fish

“One thing about which fish know exactly nothing is water, since they have no anti-environment which would enable them to perceive the element they live in.” ― Marshall McLuhan, War & Peace in the Global Village (1968)

Many times in life we can be so heavily immersed in something that we miss what is actually happening around us. What I mean by this is if I am so involved in a movement or cause that I may fail to see my own short comings or how I too am like what I seem to be fighting for or against. The bigger question is “what is it I am fighting against inside of me?” “What am I afraid I might be?” Sometimes those short comings can look opposite of what I am fighting for but in essence opposites are just different sides of the same coin. For example, the opposite of love is not hate. It is indifference. Hate is a very strong attachment to the previous loved object. So instead of actually letting go of the relationship or person, I am still holding on very tightly but in a negative way. This happens frequently in contentious divorces. If one or both parties “hate” each other they may fight for years in court. This does nothing more than keep the two very negatively attached. Or years later one or both parties is still unwilling to let go by keeping past grievances alive.

Can I get a side of Masochism, please?

So if I am a fish swimming in the water and I have nothing to compare the water to, I don’t really know that I am swimming in water. When my patient grows up in a family where she is told she is loved but family members are also mean to her, this becomes her “normal.” My patient then learns love comes with pain. Going forward, her adult relationships resemble this family pattern  She becomes masochistic.  Unbeknownst to her she picks very sadistic partners. That being loved in such a painful way is the norm. Ah, if someone really loves her then of course they would treat her badly!

Therapy is deeper work

Therapy is not to make us feel better and to have the therapist cheerlead away the problems. It is a process of discovery. It is learning to immerse ourselves in a discovery process. Lawyers use discovery to get at the truth. In therapy it’s kind of the same thing. Finding our truth is the way out of the dark and frequently murky water.

Fat Phobia

I am fat. I have been fat since I was in fourth grade. I got very thin in medical school mostly from not eating and dieting. The trouble was I could not keep the weight off. I felt like a failure when I gained back the weight. I weighed a whopping 142 pounds! Over the years and through my own therapy I realized I had to love the body that I had. That I was never going to be thin and that my constant rejection of my body would show up in other ways.

Weight Loss Rarely Lasts

What didn’t help was when my doctors would ask me, “have you ever thought about losing weight?” Are you kidding me?! I don’t know any overweight woman who has not thought about losing weight! Even the thin ones want to be thinner! I don’t know any woman who is truly in love with her body. In my practice so many women reject themselves and their bodies. I am also seeing it more now with men than I had in the past. There seems to be an association with thinness and happiness. Most of the doctors I see for any thing will typically counsel me at the end about weight loss. Thankfully, I have learned to tune it out. I know that weight loss only leads to weight gain and usually we add more back each time. I also know that after five years only 2% can keep the weight off. That is the same statistic as surviving pancreatic cancer. Why would I accept a prescription that has a 98% failure rate? A few years ago I had foot pain from what was diagnosed as a “stress reaction.”. The orthopedist told me I would likely improve if I lost weight. Well, that didn’t happen and HUZZAH my foot got better on it’s own. Guess that blew his theory out of the water.

Attacking our bodies is bad for our health

I am not going to pretend that my own negative feelings never come up now and again. What I must do is take on the battle of rejecting myself. This is what I teach my patients. It’s more about attacking myself rather than the actual struggle. When we reject our bodies it can show up as physical illness. It may show up as Lupus or another autoimmune disorder. Which by definition is the body attacking itself. I will teach my patient not to reject herself. Hopefully she will listen rather than believe I am “not on her side.”

Chickens are the best

This is a picture I would have hesitated to post many years ago because it does not depict a flattering image of myself, BUT this is who I am. I am fat and I love my chickens!  

Face to Face, the Sequel

online counseling session

I haven’t written in a while and I know it is long overdue. I am feeling back to my “new normal.” I play my flute, exercise, garden when the weather permits and talk virtually or by phone with friends. During this time it is important to maintain some sense of structure and connectedness. My practice is entirely Telehealth. I have even met with new patients that way which is quite different than I would have ever done it in the past. Most of my patients are finding it OK. Only a handful have not.

 

Psychotherapy is not Crisis Management

This morning I read an article in the local paper. It is not my first source of daily news but it gets delivered online so I took a look. There, on the front page was an article about therapy. I read it and I found don’t agree with much of what was being said. Sure there was an occasional valid point being made, but my practice is much different from the ones’ being described in the article. I have always felt I practice quite differently from my peers. I believe in depth psychotherapy and my work is not crisis or symptom management driven. My practice certainly has seen an uptick but not due to the pandemic. Talking about the pandemic was surely on the agenda in the beginning of all this but most of my psychotherapy patients continue to work on the very issues that brought them in the first place.

Feelings, whoa Whoa Feelings

One question that is now coming up for some and also for me is when do we go back to face to face meetings? The simple answer is I don’t know. But if I look more deeply at that question, it can mean my patient is missing seeing me.  It can mean she wants to feel more connected in my office space.  I will explore her feelings around this and see if we can get to the heart of what she is feeling. The work I do is always about  feelings.

The Ugly Duckling Strikes Again

I have always felt I was a bit different from my Psychiatrist peers. I used to wonder if that was a bad thing not quite fitting in. When Psychiatrists wanted to become more biological, I was still more in favor of psychotherapy over prescribing. In the fairy tale, The Ugly Ducking, the beautiful swan just needs to grow into herself and find her truth. My truth has always stayed the same. My new truth is Telehealth works. I will stay with this as long as I need to to keep myself and my patients safe. I will deal with my patient’s feelings as they arise the same as I would doing face to face. I do believe we will be back working physically  face to face again. I just don’t know when.

online counseling session