john s. smolowe, m.d.

panic attacks

in his book of case studies,  the search for existential identity, psychologist jim bugental describes the treatment of a businessman whose life is filled with efficient action but short of inner experience: “those panics just might be the only real touch he has right now with his inner aliveness. those panics are the frantic signals of his lost subjective center.”

a college student has a panic attack on an airplane. are you generally afraid of flying? “no, that’s the funny thing. i’ve flown before. and i’m usually fine. well, maybe a little nervous, but nothing big.” what was going on in the hours or days before the plane flight? “about flying?” about anything in your life. "well, i’d just been staying with my dad, and we didn’t get along at all. every time i’d get ready to go out and see friends, he’d go, ‘who are you going to see? what are you going to do? when are you going to come back?' he has this idea that my friends at home are slackers, and they’re somehow going to bring me down. so i thought maybe he’s right, and i stayed home. but then he and my mom are fighting all the time. and he takes it out on me…"

we start out with a problem of severe anxiety or panic. after some investigation, we end up with  a different problem: anger or sadness or embarrassment. what’s the advantage? one is that the uncovered situation is more primary, therefore, more real.

echidna dream

in my dream, i am walking across my front lawn on the grass. motion in the planting bed on my left catches my attention. i stop to look, move closer. the dirt shifts, rises. something is emerging from below. i walk closer, stoop, and my dream perspective zooms in. a spiny animal pushes rocks out of the way, then lies in the dirt hollow between them. it turns onto its back. basking in the afternoon sun, it holds a baby, nestled in one arm, on its pale, unarmored belly. whoa. this is cool! i have to tell the family!

as i hurry towards the house, joey walks from the driveway onto the lawn, fresh from a swim in the pool, carrying her bathing suit to hang on the line. head bowed, lost in thought, she doesn’t see me. afraid to shout lest i  disturb the animals, i hurry towards her, not running, but walking as fast i can. before i can catch her gaze, i see kitty, my old nanny, (who until her death, lived into her 90’s in the granny unit behind our house). she is shuffling along, singing cheerfully to herself. oh, no! don’t scare them away! i turn my attention from joey to kitty and walk fast towards her. just before i get there, my kids, jake and laura, walk out bickering. oh no! i hurry (quietly) toward the kids. when i reach them, i try to explain that i have something special they’ve just got to see but please be quiet while i explain. jake isn’t buying it: “why are you interrupting? can’t you stay out of it?” but but but... “you always…” please please you have to be quiet... “just because you say so doesn’t…” i give him a backhand slap across the face. i wake up, alarmed, thinking, oh no, i didn’t want to hit him! then i think, that animal was an echidna.

instrumental relationships

a colleague refers a graduate student for psychotherapy. carlos, he says, has been anxious since some legal difficulties, but he’s bright, articulate, and eager for help. legal difficulties? my friend says he’ll let carlos explain them, but don’t worry; he’s not dangerous.

in my office, i take a broad history, then i ask his main concerns. carlos speaks of his alienation from friends. he hesitates to tell them all of his difficulties. why? he doesn’t want to burden them; he’s not sure how they will react. finally, i check if i'm being asked for something different from (or in addition to) therapy: one more thing, carlos, before we decide whether to work together, i want us to be clear. are you here for therapy or do you need some kind of evaluation from me (some kind of letter for the court or for school) or both? “no, thanks for asking,” he responds, “just therapy. i’ve got the other covered with the deans and the attorneys.”

we meet for about 10 weeks. he is punctual, cordial, and respectful, but very limited in what he will talk about. he starts off abstract: “i think what’s going on is…” often he is also speculative: “i think maybe what’s going on is…” i ask for concrete anecdotes; if i am persistent, he obliges... a bit. every few weeks, i ask if he’ll tell me what happened to get him in trouble with the law. at first he is evasive, “well, that’s a tough question.” when he finally says, “i’m not ready yet for that question,” i’m thankful for small favors.

compassion

buddhist vipassana meditation combines 2 practices: cultivation of mindfulness and and cultivation of compassion. here, compassion is in the foreground.

andy and his wife, leslie, have a 2-month-old baby. today andy asks for help: his wife has complained that he fusses too much about the nursing. he basically agrees. their son is gaining weight, so there is really no need for him to track precisely how often and how long she breastfeeds.

i think about my son, jake. at his request, i am helping him choose an audio-video system for his new apartment in san franciso. i email url’s of brands and models (thanks), or ebay and audiogon auctions of used units (thanks), and suggestions for placement of the tv and speakers (uh, dad, i think I can do that myself). to andy, i say, “i know what you mean. it’s your wife now, but as your son gets older, there are going to be so many times you have to restrain yourself from helping him out.

under the gun

a dream with linguistic ambiguity

she’s weeks behind at work. her manager hasn’t noticed yet, but may any day soon. her dining room table is piled high with 3 years of papers. she’s lucky the electricity hasn’t been turned off yet. but today she’s a bit optimistic. her old, second car – that she’s never gotten around to selling - was towed because the registration is expired and the storage fees are so in-her-face high that she’s registered the car, retrieved it and, riding the enthusiasm, caught up with her most important bills. “it helped that i felt under the gun,” she says.

under the gun? i remember a dream. it is the mid-70s, and i have recently begun interpersonal (sullivanian) psychoanalysis 3 times per week. this is the first dream i bring to the therapy:

it is evening, dark out. i am in an multifloor apartment building , on the run through different flats, down the stairs, through the lobby, up another set of stairs. pursuing me is…(oh dear) my therapist. like a 40s detective, he wears a trenchcoat. eventually he corners me and holds a gun on me. i wake up frightened.

relax - or not

in 1977, i attend my first vipassana retreat, for 14 days, in julian, california. i am brave enough to get on the plane from san jose only because i am surrounded by my encouraging friends joan, roger, maureen, and jerry.

we are instructed to focus our attention on the breath – either the rising and falling of the abdomen or the in and out sensation at the nostrils. when we discover the the mind has strayed, we are to return to the focal point. on the second day, we start with the breath, then add body sensations. then, on successive days, we add sights and visual images, sounds, emotions and subtle feeling states, thoughts, and intentions.

each night at 7 pm one of the teachers gives an hour-long dharma talk. tonite is good friday, and the retreat leaders, jack and joseph introduce guest speaker, christopher titmus who, in respect to the holiday, speaks on suffering. i sit facing the dais in the third row of meditators, stage right. the retreat is by convention silent except for the brief question-and-answer period at the end of the talk. i pose a question: “you tell us to be mindful of our thoughts, to watch them as they arise, play out and pass away. i don’t seem to be able to do that. when i notice a thought, it disappears. there is nothing to watch. it’s as if i hit each thought with a baseball bat and knock it out of the park, out of my mind.” the teachers answer, continue to allow your thoughts, neither avoiding nor prolonging. yeah, i puzzle, good idea but how exactly do you do that?

social anxiety (and guilt) vs concern

"i was at this table in the bar," says the 20-something computer programmer. "there was this cute girl, and i think she might have been interested in me. my friend introduced us. but i was so self-conscious. i didn't know what to say. i talked about my work and where i live. i made some jokes, but i couldn't get them to come out right. and i'm not sure i like what i was wearing. i mean it was ok, but my shirt was kind of dorky. anyway, i need your help. how do i make sure i'm coming across well?"

how much of the time did you spend talking about her? "she talked some." what about? "she talked about work, too. maybe about her family." what did you find most interesting about what she said? "interesting? what do you mean?" just what i said, what was intriguing or impressive or fascinating about her? "i can't remember." i have a friend who likes to say, you'll never get laid that way. the young man laughs: "well, your friend is right about that night."

are we there yet?

accusations are so often hidden in questions that we come to mistrust a genuine question. in these postings to a webforum on the exotic bulb, worsleya rayneri, b has grown 100 seedlings and will ship them from australia; g will receive the seedlings in the u.s., repackage them, and mail them out in ones or twos to individual collectors in the u.s. jeff and i (john) are two of the individuals who paid about 6 weeks ago and are eager to hear news of the seedlings.

hi g ...i have paid and am wondering when i can expect to take delivery of my bulbs.  thanks,  jeff

hi all, we have reservations unconfirmed and money requests unpaid for and people who wanted a bulb turned away because I thought we were over-sold.  so......send a request for one bulb with your name, address, ph # and email. first come first served. Hurry it is getting cold for our little one year olds down under!!!!  b

hi jeff - b  has pretty much answered this from his end. b's tidying up stragglers and also a few people who've had problems. there are a few steps involved.  but other people are doing the work (b and me unpaid), so sit back and relax till they are there. generally, please don't muck b around!  If you have ordered, then finalise.   i suspect it will be 2 years before this happens again with bulbs.  g

hi g - actually, i have the same question as jeff - roughly when to expect the bulbs - and no, unless i missed something, b didn't answer it. rather, he described the hard work he's been doing.

prufrock

when i prescribe medication, i refer to the psychiatric literature. when i do psychotherapy, i want to understand another's experience. to do so, i draw first on my own experience or that of my family, close friends, and former patients. when i look for outside references, i look to the experts on psychology and relationships: the novelists, poets, playwrights and screenwriters.

a young man is depressed. he asks for medication and psychotherapy. we address medication first, discuss the benefits and risks of various possibilities, and agree on a common ssri antidepressant, starting with a low dose that he will raise every 4 days toward a therapeutic level, unless side-effects limit us first.

then we move to the psychotherapy. i ask him to feel his mood right now in the office; can he find some aspect of feeling down? yes, he feels sad, discouraged. i ask if any stories come to mind that go with the mood. yes, he recalls a time just before he dropped out of school. can he take us to a specific moment from that time? yes, he is sitting in his apartment. it's dark; the only light comes from his computer screen and from the "on" l.e.d.'s of his synthesizer and amplifier. what else does he see? dirty oatmeal bowls. what's sad? "i just finished working 36 hours straight on a composition. i'm like that. i get obsessed and jump in and can't think about anything else til i finish. especially with my music. anyway, i gave it to my roommate bill (he's not just my roommate, he's my best friend, he's the reason i moved off-campus. i was a lot more social when i lived at school, but when the chance came up to share the apartment with bill, i jumped at it). so i ask bill what he thinks, and he says, 'it's great,' but i can tell when someone really cares and when they're just being kind; and i can tell he's just being kind."