See You in My Dreams

Lately I've been dreaming about my patients. I don't even want to tell you how many years I'm in practice. Let's just say a lot. And this has never happened, not ever, not that I remember, anyway.  

Dreaming in Living Color

Most therapists have an occasional dream about a patient, don’t they?  

 

 

It’s happened twice, each time the night after a visit. My subconscious apparently picked out these unsuspecting women to join in on whatever adventure it had scheduled for the night. 

 

My dreams are always adventure dreams, usually about getting lost and driving endlessly on a clover-leaf highway exit in an unfamiliar city. Or I’ll be on vacation with FD and we find ourselves in a house that is smelly and dilapidated with broken windows. It most likely has been hit by a bomb, and yet is huge, a city in itself. There’s no way out, no map, and no one cares about getting out—or so it feels, except for me.  

 

 

Reliably in my dreams I have no idea where I'm supposed to be, which isn't atypical, others tell me they have that, too. Those are bad, but I’ll take that confusion over the terror of those recurring home-invader dreams in my youth. Those are gone. Now I just live with the fear, lock constantly.

 

 

The most recent dream with a patient in a starring role had the feel of a chick flick. There’s no remembering the plot, but one thing for sure: she isn’t a patient but a girlfriend. We are doing friend things, shopping. My mind’s eye tells me however, that although she’s a patient I should carry on, keep dreaming. 

 We do not usually have this choice in that other reality, wakefulness, the choice to turn relationships into whatever we please, alternative genres. 

 

 

The plot of the flick, alas, is forgotten. I wake only with the sense of positive emotional engagement, the feel-good of the friendship bond. But it is laced with guilt about having breached a professional boundary. I attempt to rationalize away the guilt. As the dream fades away my brain says:   

 

 

Hey who cares, woman? This is a good dream. You like this dream. Here you are, the two of you, that person who sits across the invisible divide every week, and you . . . you’re girlfriends. 

 

 

Wait, I say. Isn’t everyone in my dream really me?

 

 

Well, technically, yes. Nobody else is there, after all, just the dreamer, just her, dreaming away.

 

 

Meaning both of us are me.  I’ve created a friend, projected from inside Me Myself, and I. Hal’vai  (Hebrew for “it should be so” rhymes with rah-l’-tie). Hali’vai we should all have friends who are the people we want them to be. Most of them are already, right? That’s why we pick ‘em. But sometimes they pick us, is the truth.

 

 

I’m not Freud, just making sense of dreams.  

 

 

We’re out somewhere, girlfriend and I, at a mall then a pool. Our roles as doctor-patient are no longer relevant, deliberately abandoned. Those roles that determine the dynamics of our usual interaction—gone! There’s no implied hierarchy or expectation of therapeutic appearances, no guise of being therapeutic.

 

 

Well, that could be nice. A wish dream!

 

 

If we look at dreams as emblematic of wishes, fears, or gas, then this dream for sure lands in the wish category. Sweet and happy, it gets 5 claps and 4 stars, maybe even 5! Except that threaded throughout the cognitive/emotional content is that disturbing certainty that this is a patient not a friend, and the dream is a warning: 

Be careful what you wish for, cross that boundary and you will regret it. Oh, and by the way. Haven’t you noticed? You have more friends than you even want.

 

 

The dual relationship is unethical, unbecoming of a professional. It takes advantage of the patient’s trust in us, that trust that we are there to help them  for one thing, not visa- versa, which is why upon waking I feel a bit disturbed, disoriented, and guilty, despite the 5 stars. 

 

 

The next movie is the usual Where am I? How did I get here? And what in the world is she doing in my dream?!  Not a nightmare so much as a bad dream. It is a different patient and we share a difficult circumstance. We are upset, lost, and dependent upon each other in some way that is out of the official context of our relationship. And we both need to find our way out of messy confusion. Messy and confused. A typical dream.

 

 

 

That’s all I remember. 

 

 

The interpretation of this dream could it be me unsure of the quality of my work, needing to tackle it at night to get a good grade. Or maybe my head is remarking on the complexity of the patient, that she isn’t progressing. Her dreamlike confusion is expected, mine is not.  There should be emotional spillover to me if there's a feeling incompetence, even if it is unconscious until now, and consequences for staying in denial 

It makes sense. She is complicated. And yet, we've been living together in all of her chaos for years and she’s doing so well! Still, the dream is talking to me. The other dream, too. 

 

  

What is going on here? Am I working out unresolved patient/therapist dynamics—a wish in the first dream, fear residing in the next? Are they warnings to resolve my feelings during waking hours to avoid doing it at night? 

Or could it be that because we only see one another on screen, that patients are externalized to the extent that they have simply become videos in the library of the therapist's subconscious. Choose one a week. The Blockbusters of therapy.

 

 

Maybe I just miss them. Maybe I simply miss being with people, any people, but these people in particular, having known both for some time. They are a part of my weekly groove. Maybe I miss the sensuousness of being together—the swish of their bodies as they pass me to enter the office; the whiff of cologne or perfume, a new hairstyle. I saw someone in the office this week and felt that. It was wonderful for both of us to be there, in real time, in real space.

We can't even be sure if anyone is grooming on Zoom. It doesn't look that way. It's so black and white, even though it isn’t, not really. Data of the senses, other than visual and hearing, is not communicated on digital media. We could say a dream is making up for that, but rarely does it feel that real.

 

 

Considering that dreams are legitimate ways to blur boundaries, if this is about wish fulfilment, then patients should always be in our dreams. If you eschews hierarchy (like me) there’s nothing keeping them out!  But to its credit, hierarchy is about who knows more about mental health, if not the person in the room doubting his-- and it helps keep emotional distance. Respecting them keeps patients out of our heads on off hours. The boundaries of therapy are wise indeed.   

 

 

PROBABLY. . . the problem is that I miss my friends! The ones who come over and have long Friday night dinners with us. The ones I go out with—remember going out?— to talk about our feelings, our histories, that trip we took together.  This is as close as it gets, hearing about the lives of the patients, about their histories. Because after seeing people on Zoom all day to work, it isn’t something some of us care to do in the evening with friends.  

In a sense therapy is the equivalent of lunch, except that we consume nothing but reality. So maybe I simply miss lunch. 

Oh, but now patients are in my living room. They see me a little too closely, frankly.

 

 

Let’s sum up: 

 

In pre- and post-corona times the relationship boundary is tight— therapists don’t socialize with patients. We refuse gifts (no thanks for the opera tickets); we don’t take a lesson from a tennis pro; and we make self-disclosure rare and relevant. In fact, if I am honest with myself, my self-disclosure with patients the past few months is off the charts. It isn’t me and it has to stop. 

 

 

It can be hard. There’s temptation to talk about ourselves with patients, our past experiences, which is probably why these dreams that blur the boundaries are so compelling. They speak to unconscious wishes of both therapists and also, patients. Keeping it professional is work. If dreams are another way to master our issues, than that’s what is going on here. 

 

 

There is some intimacy, too, in a dream. Therapeutic intimacy, meeting that projected need of the patient for a mother, a friend. When she cries in a digital visit I feel so powerless—not that I would hug anyone in the office. But it used to feel like all I had to do was move my chair closer and this helped.  

 

 

And yet, like I said, that online human, the one on screen—no matter how large or small our home theater—now has carte blanche to come into our homes, something they may have considered or alluded to —because don’t we all, at some point in therapy, want to be a fly on the wall of one another’s homes? We want to see what’s really up with the other. 

 

 

And if we’re using a tablet or a phone with the freedom to get up and walk around, we might even walk together into the kitchen for a cup of coffee, a piece of fruit. Once she has been in your living room and kitchen, what’s to stop the patient from having a visit in your dreams? 

 

 

Nothing apparently. Nothing.  

 

therapydoc

 

 

 

TAGS  #boundariesInTherapy, #telehealththerapy, #therapistPersonalBoundaries, #wishOrfearDreams, #dualRelationships, #Nightmares, #badDreams, #patientFriendRelationship, #consultationWithOtherTherapists, #therapysupervision

 

 

Schizoaffective Disorder, Ethics, and Brian Wilson of the Beach Boys

Love and Mercy

We’re in Miami, FD has a cardiology conference. 
Miami Beach is nice but it's not 

Bermuda, Jamaica, gee I wanna take ya’ to Key Largo, Montego, honey why don't we go.  .   .  to the Kokomo. 

It gets in my head (you're it) and wanting to know where exactly Kokomo might be, a little research yields the following.  

According to the band, the inspiration for the song (is) a pool-side bar at a hotel in Islamorada, one of the little island towns in the Florida Keys.  

So we’re not that far away. 

We saw the Brian Wilson- Beach Boys movie last week, Love and Mercy. If you haven't seen it, there will be spoilers. But most of today's story is from YouTube interviews and Rolling Stone.

There was a time when a certain brand of music summoned up barefoot on the beach, surfing, fast cars, and a paycheck lost to buying records at K-Mart; 45's or the long-playing 33’s. Some of us bought albums by the Beatles, but there was always a kid who loved the Beach Boys. Paul McCartney is quoted as saying that Pet Sounds, an innovative Beach Boy album, is his favorite of all time.* But the Beach Boys had so many hits.

Surfin', California Girls, Surfer Girl, Don't Worry Baby, Do You Wanna' Dance, Good Vibrations, Fun, Fun, Fun; God Only Knows, Caroline No; Help Me Rhonda, I Get Around, Wouldn't It Be Nice, Kokomo. To name a few.

Surfin' USA

And In My Room, a slow dance song that Brian Wilson, now 73, the primary writer, composer and musical director of the group, says expressed his inner feelings and thoughts. In My Room makes Brian's private world public, invites you inside, universalizes the need for safety. So many of us still do this, retreat to our rooms, or would if we had one, for personal space.

Mr. Wilson has an amazing recovery story, beginning with the decline to severe mental illness, a "nervous breakdown" in his twenties. He hears voices telling him he isn't as good as the public says he is, that he ruined the band; his orchestrations, far from brilliant. He rationalizes, in a psychotic but sensible way, that the voices aren't able to keep up with his success, that they are jealous, want him out of the way. It is likely they told him to self-harm.

After dropping out of sight in the seventies, a hermit due to mental illness and drug addiction, Mr. Wilson is in recovery by 1999, twenty years later, working again, producing records, even Smile, the long awaited unfinished album of 1965. "I'm anxious, depressed, I get scared a lot,"  he tells his fans. But he's out there, brilliant as ever.

In 2006 he tells a reporter that he still hears voices, every single day, that he has most of his life. A community of angry, critical people in his head.

His whole adult life he's been begging them to shut it up.

How does it present, an illness like this, Schizoaffective Disorder? There are two types, F25.0 bipolar, and F25.1 depressive. Voices in the head, delusions, can be features of either.

The DSM 5:

 In schizoaffective disorder, a mood episode and the active-phase symptoms of schizophrenia occur together and are preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms.

According to Mr. Wilson the voices started soon after his first LSD trip as a very young star.

This changes everything, as far as diagnosis goes, foils schizoaffective as the obvious choice, because if you read the criterion, you find the all important D.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Technically he couldn't have schizoaffective order because the effects of a substance triggered the illness. That being the case, the diagnosis has to be:

 Substance/Medication-Induced Psychotic Disorder (F16.959), without use. 

Without use means that he doesn't have to be using anymore to suffer the delusions, hear the voices of psychosis. He stops abusing drugs in treatment, but his disorder has its hold. Without use, still delusional, it is an F16.959.

Your mom was right when she said that drugs are dangerous. During the frolics of the sixties, the more anxious worried about friends who took LSD. We heard stories of people flying off rooftops. They needed designated watchers, really.

The most famous of the Beach Boys might not have suffered Schizoaffective Disorder, a combination of symptoms that present in both Major Affective Disorder and Schizophrenia. Had he not used LSD his bout with mental illness might have been much less horrific. But we really don't know.

And there is another theory, that children with a predisposition to major affective disorder or schizophrenia manifest their symptoms under stress. Brian undoubtedly had stress, beginning with a family group that depended upon him and a rabid desire to succeed, and a father who physically and mentally abused him, deliberately made him feel badly about himself, fed his self-doubt with critical, harsh words, and the fist. Wilson boxed Brian in the head, permanently knocked out the boy's hearing in one ear when Brian was little.

Murry is the voice behind the voices, cold and withholding, jealous, a spare the rod, spoil the child kind of father who strips a kid of his confidence.

The son still wants the father’s approval, plays down the abuse in interviews, although in the film it is the first thing he talks about with Melinda, the woman who tries to save him from an exploitative psychologist, Eugene Landy. He won't demonize Murry for traumatizing him, triggering his illness. He can't embarrass his father. It was the drugs, Brian insists.

He even credits his Murry with the success of the band. Murry is the one with connections, the one who arranges the initial recording contracts. When things sour financially and the band doesn't like his decisions, they fire him. Vengeful, he sells their songs for a fraction of their worth, keeps the whopping $700,000 for himself. Bermuda, Jamica, come on let me take ya'.

No picnic for our hero, the path to superstardom is disrupted, spotty, an illicit drug marathon. He hides in his room for two to three years (!), fears the shower (the shower-head is a spy), eats constantly (weighs over 300 pounds), and stays stoned 24-7. Tired of it, the family hires a psychologist to bring Brian back. 

Eugene Landy claims to have done it, but his methods? Full of textbook professional ethics violations. 

Landy marginalizes his patient, squirrels him away in a rented beach house, taking Brian’s home from him for himself, a house that is also on the beach. He renovates it on Brian’s nickel. We might call it messed up milieu therapy, Landy protecting the patient from family, denying all visitors. He snows Brian with psychotherapeutic drugs that he has no license to prescribe, and beats on him emotionally about his weight. All the while, Brian takes it on the chin, follows the doctor's orders, alternatively idolizes but fears him.

You don't have to be a professional to connect the dots when it comes to father figures.

The family has always known Brian to be fragile and afraid, but that the young man has plenty of confidence when the band is recording. He's on them for every sound, controls exactly what each musician plays, every note, each harmony. He arranges meetings in swimming pools, probably assuming that the voices can't spy on him there. Manic? Certainly, which is why the schizoaffective disorder, F25.0 bipolar is everyone’s first choice, as if it really matters, the diagnosis. 

But it does matter, at least for us mental health professionals. We have to get it right, think about what is really going on, assume nothing. If we think about the history we find that the triggers for schizoaffective disorder are rife in Brian’s world before the LSD.  

1.  He had a difficult young adulthood. Psychoses often present in the twenties or late teens

2.  He suffered extreme stress, had to produce the perfect record, face audiences of thousands.  

3. He surely suffered post traumatic stress, the negative, or “expressed emotion” inherent in child abuse. 

So maybe he had schizoaffective after all.

Looking back on how he cut off his wife Marilyn and his two daughters, Carlie and Wendy, in that stoned, depressed, psychotic two-year episode in his room, he regrets his decisions, his decent, especially listening to Eugene (Gene) Landy for prolonging the family abandonment another five years. He doesn't seem to care that Landy made millions off of him, but it infuriates the mental health community.  

See, most of us want a few well-off patients.  But we would never consider this kind of thing. 

Landy persuaded Brian (coerced, because Brian suffered a disorder) to become partners, a business collaboration, Brains and Genius (Brian and Gene). Landy takes half of Brian's earnings from investments contracts, books, and records in this great deal. If a sponsor gives Brian a sports car, Gene gets one. If Brian lands an upright piano in a deal, Gene gets a baby grand.

Sickening, taking advantage of a patient like that.

Marilyn Wilson ends the marriage, and his daughters grow up missing him, yearning for him. They team up with Chynna Phillips, daughter of John Phillips, another addicted, dysfunctional father (Mamas and the Papas). Wilson-Phillips will successfully produce and perform their own songs. You know the songs, they're that popular. Hold On, for example.

We want to give the father, the genius a big hug and say, It's not your fault.

As therapists, of course, we can’t hug him. We have our ethics and touching is touchy.  (See the new page on ethics on this blog).

Eugene Landy will lose his California license.

Later in life Brian will produce more records, and children all over the world will perform his songs in choirs. He and his wife Melinda establish a foundation for mental health awareness.

Watching the film isn't easy, but it is so well done. And hearing the rest of the story cleared my head, for I could hear Eugene Landy telling Brian Wilson, “They (his family) don't love you.  I do.“ This is what cult leaders tell their followers, young and old, who also pledge their allegiance and all of their money to an idealized father figure.

Ultimately Eugene Landy is listed as the sole beneficiary of Brian's will. You'll have to watch the movie to find out what happens with that, or read the biographies.  The Rolling Stone article is wonderful, too. 

Not surprisingly, Landy has other ethics violation accusations: one for rape, another for free-basing cocaine. We can diagnose him with an Antisocial Personality Disorder.

Because that's what he has.

therapydoc

*Brian refers to George Gershwin's Rhapsody in Blue, a masterpiece in his opinion, the great musical influence in his life. The seventeen minute composition is just shy of one side of a microgroove vinyl record album (bigger even than CD's) back in Wilson's day. Gershwin inspired Wilson, and Wilson inspired the Beatles.