Pre-existing Conditions

Pre-existing conditions are particularly important for people in psychotherapy. Before Obamacare when a patient changed jobs, he or she was ineligible for coverage of psychotherapy for 6 months or a year. For patients who were self-employed, changing health plans was also prohibitively expensive because of being in psychotherapy. If pre-existing conditions are not covered in the health plan that replaces Obamacare, we will return to that situation. For further discussion of this topic, CLICK HERE.

Pre-existing conditions.jpg

Getting Old Can be Depressing

Aging involves losses—loss of friends; loss of spouse; loss of siblings; loss of status; loss of hair; loss of physical mobility; loss of hearing; loss of eyesight; and sometimes loss of financial stability. So it is not surprising that aging and depression often go together. For more on this topic CLICK HERE.

Sick or Not Sick?

Suzanne O'Sullivan, a neurologist specializing in epilepsy who practices in London, has recently written a book about conversion disorders--somatic symptoms caused by psychological distress--Is It All in Your Head? True Stories of Imaginary Illness (Other Press, 2016). In his review of the book, Jerome Groopman (New York Review of Books, Feb. 9, 2017) points out that Freud believed that conversion disorders had an unconscious meaning that could only be understood through psychoanalysis. For a further discussion of hypochondria, CLICK HERE.

It's so hard to say you're sorry.

Intimacy, in friendships as well as romantic relationships, inevitably involves hurt feelings and disappointments. Those hurts can erode trust unless there are repairs along the way. For relationships to have the best chance of lasting, apologizing has to be part of the mix. But it is not easy. For more on saying your sorry, CLICK HERE.

Idealization as a defense

Idealization is the normal experience of a young child who puts his parents and himself on a pedestal, but in an adult it usually indicates a problem integrating good and bad aspects of self and others. My analyst had an ashtray in her office that said: "Things come in mixed packages." I haven't seen that ashtray in many years, but the message is still with me. To read the complete article below, CLICK HERE.

PT Idealization and Contempt.jpg

Narcissistic Injury

Does your entire sense of self collapse when someone hurts you? Narcissistic injuries do not feel like your feelings are hurt, they feel like your self is being attacked.  To read the complete article below, CLICK HERE.

Was Frida Kahlo a narcissist?

Everyone craves approval and attention—that’s healthy narcissism and an important ingredient in self-esteem. Unhealthy narcissism is when other people are only used to perform a function—to mirror the specialness of the narcissist. If the other people do not perform this function, they are discarded (usually with contempt). He is incapable of reciprocity in a relationship because of his lack of concern for the other as a separate person.

Intermittent Reinforcement

For more information on intermittent reinforcement and how it affects partner choice go to:

For more information on intermittent reinforcement and how it affects partner choice go to:

Apology and Forgiveness: Essentials of Intimacy

Last week I said the session was over 15 minutes before it was actually over! The patient said: "You want to get rid of me, don't you?" The truth was I did! She had been complaining about how victimized she was for the first 30 minutes of the session and I DID want to get rid of her--for the moment. I could have tried to wiggle out of it--"I got confused about when we started" or "I didn't sleep last night so..." But I knew I needed to be honest. "You're right, I think I did want to get rid of you for now because it's tiresome listening to you blame everyone else for not treating you as if you are the most important person in the world." I was holding my breath after that--not knowing what she would say or do. Would she walk out? Would she quit? No, she didn't do either of those things. To my astonishment and delight she was able to take responsibility for expecting people to treat her as special and feeling victimized by them if they didn't. I think she was able to take responsibility for her behavior because I had been able to take responsibility for mine.

Schizoid phenomena

Harry Guntrip in his groundbreaking book Schizoid Phenomena, Object-Relations and the Self (International Universities Press, May 2001) discussed the schizoid personality who presents in psychotherapy as withdrawn and detached. But he also discussed schizoid phenomena which can be present in a much wider range of people. The central dynamic is the oscillation between desperate hunger for a love object and the fear of being devoured, smothered or trapped. For more discussion on this topic:

Healthy Ambivalence

Llywelyn Nys/

Llywelyn Nys/

In common parlance “ambivalence” tends to have a pejorative connotation—as if it is a problem if you feel ambivalent. President Bush told the world: “You're either with us or against us in the fight against terror." President Bush’s stance allows no room for ambiguity or ambivalence. Similarly, Tom Ridge, the former homeland security secretary told Americans: “We can be afraid, or we can be ready.” Can’t we be both afraid and ready? President Reagan also had a penchant for reducing complexities to simple images of good and bad. Ambivalence isn’t American; America is the land of moral polarization. Cowboys wear white hats and black hats so that we know the good guys from the bad. And Americans love professional wrestling in which the good guy waves at the crowd and the bad guy usually has a grotesque appearance and makes threatening gestures to the crowd to elicit their booing. Yet, from a psychological point of view ambivalence is a healthy state and not being able to tolerate it is a problem. 

Setting Limits is Not Easy

If you don't want to feel angry about people taking advantage of you, you need to protect yourself by setting limits. That involves being able to say "no." Click here for more.

Beginning the session

Photo by Anna Vander Stel/

Photo by Anna Vander Stel/

Patients sometimes get annoyed at me because I wait for them to start the session. "Why don't you ask me how I'm feeling?" one patient asks. "Why don't you ask me questions?" another complains. I try to explain the importance of letting the patient start the session. The patient's first words of the session, the selection of topics and the order of topics is of major significance. And what they leave out is equally important! Some patients complain because they don't want to free associate; they are uncomfortable letting their minds wander. They don't want to see what might emerge. But sometimes a patient CANNOT start the session because they have so much anxiety or feel so empty that they cannot speak. That is important to find out, but it will not become known unless, at least for a while, I let the patient begin the session.

Unconscious Conflict

Unconscious Conflict

Unconscious conflict can be like an undertow--pulling you under and preventing you from accepting responsibility, producing creative work, taking in information, or completing tasks. For example, not being able to finish things can be an unconscious way of holding on to a depressed mother while finishing represents losing her. Conflicts get displaced onto situations or people that seem to have no relationship to the original source of the conflict and that makes it difficult to connect problems at work or school with the underlying issue.

Narcissism and disappointment

People with Narcissistic Personality Disorders attempt to fight off their fear of failure with grandiosity and contempt. They are usually oblivious to the impact they are having to people around them, but when negative reactions pierce their grandiose defense, their reaction can be intense shame.

Narcissistic Personality Disorder

Psychoanalysts do not make diagnoses based on symptoms, but rather psycho- dynamics which can only unfold in the office. In the most general terms, narcissism is a continuum that we all have to more or less degrees. But a narcissistic personality disorder is diagnosed when narcissism is a defense against loss of self-esteem. Patients alternate between grandiose conceptions of self and self-contempt OR grandiosity and raging at others for failure. 

Caregiving and Guilt

Caregivers often feel guilty for not rescuing their elderly parents. But rescue is not possible; we can only offerlove and support and hope they accept it. Many caregivers do offer that to their elderly parents and still feel guilty.  To hear my interview with Diane Rehm CLICK HERE.

The Empty Self


Sheldon Bach, et. al. in their article " The Empty Self and the Perils of Attachment," (Psychoanalytic Review, Volume 101, No. 3, June 2014) write about working with patients who feel empty, depleted and alone. They feel that "something is wrong with them," but they don't know what. For these patients, their early scaffolding (basic developmental functions) have never been provided or are distorted. They have difficulty feeling comfortable; they can be destabilized by noise, temperature, light or tone of voice. They have trouble sleeping and waking, eating regularly, drinking moderately. They often suffer from psychosomatic complaints such as gastrointestinal problems. These patients also have a difficult time deciding what to talk about in a session. Traditional psychoanalysts may fail with these patients because they hold to the view that the patient starts the session. But helping the patient discover what he or she wants to talk about and facilitating the patient's ability to use the interaction is actually a major part of helping the patient build a sense of self.

Adult Sibling Rivalry

A patient, Emily, is enraged at her brother for being the favorite of their parents. She has internalized a mental representation of her brother and it is unconsciously displaced onto friends, classmates, colleagues at work, etc. It is difficult for her to accept that her parents singled out her brother and treated him with obvious favoritism. He did not cause the rivalry; it was foisted upon both of them by their parents. Thus working out relationships between siblings involves working out feelings about parents as well. Sibling relationships take place in the context of a “family script” which involves a complex set of relationships between each child and each parent as well as between the children. The parents can be long gone, but the internalized relationship with siblings and parents is carried around with us--often unconsciously.