Shirah Vollmer MD

The Musings of Dr. Vollmer

Amae

Posted by Dr. Vollmer on October 23, 2014

 

 

http://www.kirainet.com/english/amae-%E7%94%98%E3%81%88/

 

The Japanese language gives us a word to describe how a person, often a child, demands that he be loved and admired, not just to feel good, but in order to grow up and flourish. When I child says “mom, look what I have done,” they are seeking Amae, affirmation and recognition for their accomplishments. This need never changes, but hopefully, with maturity it evolves into a conscious need, such that the person can find constructive outlet for this need, such as running marathons, or producing art.

Psychotherapy, through transference and countertransference, helps to make this need for Amae, conscious, as the patient often pleads with the therapist for attention, which often highlights significant areas of emotional neglect in his past. continuing with the Edna and James dynamic, Edna needs to understand she needs to feel affirmed, not just sexually, but emotionally and intellectually as well. Likewise, James needs to feel like the rescuer, bringing him into a helping profession, but without full consciousness of his need to rescue, to feel affirmed. Amae is not shameful, especially once it is recognized and made conscious. The universality of psychoanalytic principles lives on. Language gives us a way to explore these concepts, and sometimes we need to shift to other cultures and other languages, to convey the many ways in which relationships promote growth.

Posted in Mother/Child Relationships, Psychoanalysis, Psychotherapy, Relationships | 4 Comments »

Boundary Check: No No…

Posted by Dr. Vollmer on October 22, 2014

 

All interactions have both conscious and unconscious layers. This is the premise of psychoanalytic theory and treatment. As such, fantasies, erotic and otherwise, are likely to grow in both directions, with the major vulnerability and hence, safety valve, is that fantasies led themselves to words and not actions. In other words,  fantasies must mutate into a narrative, but not into an action.

The cartoon above illustrates the point. That Dr. James (fictional, of course), wants to jump on the couch with Edna, is a rich area for exploration, but jumping on the couch is the source of cartoon and mockery. The caption illustrates that Edna, the patient, might indeed fantasize about James jumping on the couch, but narration in replace of action, leads to understanding and healing, as opposed to repetition and re-traumatizing.

This, again, is the fundamental principle of therapeutic action. Patients get better because unspeakable fantasies are speakable, and in so doing, analyzable, and in so doing, amenable to forgiveness and mourning. Edna, in this example, needs to mourn the loss of a parent who saw her as a sexual object and not a child that needed love and nurturing to grow up and flourish in the world.   This is not the loss of the death of a parent, but rather the loss of a parent she never had. Only through fantasy, both in patient and analyst, can these traumatic pasts be explored and worked through.

Fantasy, as opposed to  check-lists must be open to exploration and hence must not be limited by time. The open-ended nature of this exploration is critical to getting at deep unconscious material which troubles and disturbs functioning. These are the basic tenets of psychoanalytic psychotherapy. We must cherish these techniques and not abandon them for what sounds like a faster cure, but in fact, is a quick change to the check-list.

 

 

Posted in Countertransference | 2 Comments »

Countering Transference or Just Havin’ Feelings?

Posted by Dr. Vollmer on October 21, 2014

 

As I re-enter into the blogging world, I am reminded that one purpose of this blog is to focus my attention towards teaching about psychoanalytic concepts. In this way, this blog serves as my notepad, my preparation to stimulate a dialogue about the human condition in a psychotherapeutic setting. In that light, I want to focus on the notion of countertransference; a notion which is vague but generally means the unconscious and conscious feelings that the therapist has towards his patient. Edna and James, the therapeutic dyad, struggle together to make sense of Edna’s past and present anxieties. Edna, seen four times a week, for many years, is often angry and frustrated with James. She feels stuck and guilty, for no apparent reason, except she thinks that James could be doing a better job. At the same time, she comes regularly and reliably to her appointments and it never occurs to her to switch psychoanalysts.

James likes Edna, looks forward to seeing her, but feels that his feelings towards her are shallow, despite the many hours they have spent together. He assumes these shallow feelings are a result of both Edna keeping her emotional distance and James, not wanting to be drained at the end of each day. Still, of all of James’ patients, Edna, he would say is the one he feels the least connected to. James come to me for consultation about this troubling realization. “Maybe you have just not gotten close to her because she is so defended? And/or maybe she reminds you of people from your past who you spent a lot of time with, but who really never had emotional meaning for you?” I say, expressing layers of understanding to begin a discussion with James as to why he is seeking consultation with me, with regards to his therapeutic relationship with Edna.

The parallel process between trying to draw James out, via free association, follows James attempt to understand Edna, by the same means. Yet, my relationship with James is a teacher, or  a supervisor, as the psychoanalytic world likes to call me. My job is to help with his concern, not about his life, or his personal relationships, but with his psychotherapeutic dilemmas. At the same time, I teach a class, struggling with the idea of countertransference, and in particular, struggling with the word “counter.” This, as I will talk about in class, is a major misnomer. There is nothing “counter” in countertransference, but rather, feelings go both ways, and the dyad changes over time-both sides, of course.  This changing dyad is a result of the struggle to understand what happens when two people come together, hour after hour,  trying to heal, trying to understand, with an attempt to offer up many answers, to seemingly unanswerable questions. These answers, are ideas, not definitive conclusions, and yet ideas help soothe anxiety, and create forward momentum,  given the limitations of our own biology and the stressors in the world around us.

Posted in Countertransference | 4 Comments »

NYer Cartoon Contest

Posted by Dr. Vollmer on October 20, 2014

 

                                  I think he moved to the unconscious.

Posted in Cartoons | 2 Comments »

Doctor/Nurse Communication: The System Breaks Down…Old Fashoioned Medicine Prevails!

Posted by Dr. Vollmer on October 20, 2014

Ebola hospital

 

 

 

“The diagnostic team that treated Duncan — who had symptoms of headache, abdominal pain and fever consistent with the Ebola virus — did not know he told a receiving nurse that he had traveled from Africa. On that day, Duncan was sent home with antibiotics. He returned to the hospital by ambulance two days later.”

 

http://www.latimes.com/nation/nationnow/la-na-ebola-hospital-20141003-story.html

 

As the Ebola virus continues to make world news, I am struck that one important aspect of this story is not getting enough press. The nurse got the history of possible Ebola exposure, but the doctor did not. Nor did the nurse adequately communicate this VITAL piece of information to the doctor. This viral scare, from my point of view, highlights the prime importance, once enforced in medical training, and now less so, that a doctor MUST always take his/her own history. The idea of relying on other professionals for a history of present illness, as in this tragic case of Thomas Duncan, can cause fatal mistakes, History taking is/was the foundation of good medical care. This was the most important thing I learned in medical school, in rotation after rotation. Yet, today, there is a notion that professionals should work to the highest aspect of their license, meaning that one does not need an MD to take a history. Physicians are needed to prescribe, to order tests, but not to get background information. This background can be obtained by medical assistants and nurse practitioners.

Oh, no no, I say, learning of this paradigm change in health care delivery. With all due respect to nurses, there is the art to history taking with leads to accurate diagnosis and treatment. My professors, rightly, and repeatedly, taught me this. 80% of the diagnostic information is from the history, they would say, which became the often mocked mantra. Yet, almost thirty years later, those words come painfully alive, as we discover that the doctor did not do a “travel history” on Mr. Duncan. This pertinent omission of the history has sent this country into anxiety, reaching near panic levels in some. The focus has been on politics, on travel bans, on protective gear training, and yet, where are the doctors yelling about the need to reinstitute history taking as the vital art in medicine? Yes,in  most cases, the history is less critical and symptoms can point the physician in the right direction. However, once in a while, a critical case will come in the Emergency Room, and like Chelsey  Sullenberger,  the pilot who landed the plane in the Hudson, with  rarely used, but critical skills, doctors need to have history training for that, perhaps one time in their career, where it really matters.

Posted in Ebola, Health Care Delivery | 4 Comments »

Announcing…..My New Twitter Life!!!! @svollmer

Posted by Dr. Vollmer on October 20, 2014

 

After a long hiatus, with much time to think, I have decided not just to return to blogging, but to add onto  my media presence by also tweeting. As with this blog, tweeting now represents to me an experiment in mass (35 followers) communication. I would like to use it to point to interesting news articles which relate to my point of view about the changing nature of psychiatry, in particular, and medicine, in general. In my next post, I will specifically comment on the Ebola virus and how I see it as a prime example of how the practice of medicine is changing, and in this particular instance, leading to some scary times. I have long avoided twitter as I had thought that it was redundant to this blog, but now I hope to expand my voice by using it to supplement, and not repeat my ideas. Out of media darkness comes a flurry of media activities, perhaps in a bipolar way, but hopefully with thought and concern for public information, while at the same time, maintaining the foundation of my work, privacy. Do I hope to get more followers? Sure. Do I know that to get more followers I would need a supplementary media angle such as a book, a speaker series or a new health care application? Yes, I know that. Despite this knowledge, I charge on. Putting my narcissism, my ego, on the line, fodder for commentary, judgment and affirmation. I assume civility in social media, perhaps naïvely. Wish me luck.

Posted in social media, twitter | 3 Comments »

Coming Back….

Posted by Dr. Vollmer on October 16, 2014

 

My hiatus is officially over and now I am returning to my blog, perhaps with less intensity in terms of the number of posts, but not with less intensity in terms of my deep concerns for the movement of psychiatry towards quick assessments and hence hasty diagnosis and treatments.

 

One might wonder why I was on hiatus, and why I am back. One might also wonder what I have been up to professionally. Let me begin there. I was honored to speak at the UCLA Child Psychiatry graduation. This was a special honor as it was my students who wanted me to wish them on their way to what I hope to be a very rewarding career. So, here is my speech…

 

 

Graduation
Thank you- the graduates if 2014- for asking me to speak at this- momentous occasion- marking you as newly minted child psychiatrists. Your class is very important to me as you provided me the opportunity to teach the clinical practicum- the class that formally introduces you to child psychotherapy . It was an honor and a privilege to teach you – as it is an honor to stand here tonight.

As I think about you- the graduates-I am reminded of my mentors who very sadly are no longer here- Denny Cantwell, Chris Heinicke and Ken Silvers-  three UCLA professors who each gave me the courage to launch a very rewarding career.

Tonight…

I would like to speak to you about those rewards- as you are about to embark in the next chapter of your life!

The parent calls confused and bewildered as to how to help their child. We listen to their confusion and we think about the neurobiology, the possible psychopharmacology and the issues of child development. Through these multiple lenses we can analyze the situation with empathy and compassion to help this family get back on track .

That first call may be because someone told them their child might need  medication, but the family stays in treatment- not just for their prescription- but also to help their child grow up and navigate their worlds through the foibles of their parents and the challenges of their own biology.

Nature and nurture come alive for a child psychiatrist. Like no other specialty in medicine, we have the privilege of a cradle to grave specialty because our toolbox is wider and deeper than our colleagues! We can see how their birth and subsequent development landed them in our offices and then we can help them understand how to cope with their circumstances.

As Denny said you have to pick your parents carefully if you want to do well in the world and this motto has helped me help my patients understand that there is not just a brain lottery but there is a parent lottery as well.

To be a child psychiatrist- as you- the 2014 graduates will learn more and more- is to feel the heartbreak of both children and parents. The art in this field is to walk a fine line between empathizing with the child and the parent at the same time.  It is both sad to watch a child be abused by his parent and it is also sad to watch a parent being tortured by a difficult child. This ability to see multiple points of view is the excitement of this field.

To be a child psychiatrist also means feeling the reward of helping kids mature. I am reminded of
of male teenager I see who is now 18 but I have worked with him since he was 12.  I will call him Tom. Tom came to me against his will. He was having severe substance abuse issues and conduct problems. He was failing at school and was disrespectful to his parents. I worked with him and his parents over the years . I gave him an SSRI briefly but it did not have a big impact on his mood so we decided to do intensive psychotherapy to help him through his issues. He reluctantly agreed. Now he is off to an Ivy League college, he has nice friends and he enjoys his life . This past week in one of our sessions-he completely surprised me as he reflected on our work. “You know,” Tom said sweetly, ” I think we have a good relationship and I think you have really helped me grow up and see the world in a very different way then I did a few years ago.” I could feel my ego swell as those words came out of his mouth. The gratitude from a g adolescent is a particularly special experience.

Being a child psychiatrist is in one way like going to the movies every day- seeing a tale unfold in unique ways – but- perhaps more like  a videogame- we get to attempt to change the ending. I just cannot imagine a more rewarding career. Good luck to all of you and most importantly-stay in touch!

 

Another important professional development is that I am now on faculty at LMU. I will be teaching psychopharmacology to first year art therapy students.

 

Meanwhile, I continue to teach at Los Angeles Institute for Psychoanalytic Studies, where I am now teaching the first year class about basic psychoanalytic concepts.

 

 

In November, I will begin teaching Psychoanalytic Understanding of Mood Disorders at the New Center for Psychoanalysis and in January, I will teach basic clinical concepts to their evening psychodyanmic psychotherapy program.

 

I continue to teach at UCLA where I supervise both an adult psychiatry resident and a child psychiatry  fellow. I also remain active there on the board of the Volunteer Clinical Faculty Association.

Finally, I continue to teach and serve on the board at the Venice Family Clinic.

 

In returning to my blog, I plan on posting about psychiatry, psychoanalysis, child psychiatry and the changing of the profession, given the presence of electronic medical records. I want this blog to be a place where ideas are shared with thoughtfulness and consideration for the writer (me) and the audience. Of utmost importance to me is maintaining the privacy of my patients. Keeping this in the front of my mind, I want to use  small moments, without identifying information, to illustrate important clinical concepts. I am happy to receive comments, either personally or publicly.

 

Thank you readers who have waited patiently for me to return. I appreciate all of your support during my hiatus.

 

 

 

 

Posted in Psychoanalysis, Psychopathology, Psychopharmacology | 3 Comments »

Publishin’

Posted by Dr. Vollmer on April 22, 2014

I am still on hiatus, but check out my panic attacks commentary…

 

 

http://www.hcplive.com/publications/family-practice-recertification/2014/April2014/How-to-Distinguish-Panic-Disorder-from-Panic-Attacks

Posted in Anxiety, Panic Attacks | Leave a Comment »

Injustice

Posted by Dr. Vollmer on March 26, 2014

 

Also….http://onpoint.wbur.org/2014/03/20/prison-reform-america-holder-obama

 

“We have a system of justice in this country that treats you much better if you’re rich and guilty than if you’re poor and innocent. Wealth, not culpability, shapes outcomes. And yet, we seem to be very comfortable. The politics of fear and anger have made us believe that these are problems that are not our problems. We’ve been disconnected.”

 

Bryan Stevenson is my hero today. http://en.wikipedia.org/wiki/Bryan_Stevenson ” He spoke at TED2012 in Long Beach, California, and received the strongest standing ovation ever seen at TED.[3] Following his presentation, over $1 million was raised by attendees to fund a campaign run by Stevenson to end the practice of putting children in adult jails and prisons. [4]” 

 

He is a new hero for me, as I was not familiar with him until I popped into the TED radio hour, leaving his presentation with such sadness about our, the United States, society. “We love innovation. We love technology. We love creativity. We love entertainment. But ultimately, those realities are shadowed by suffering,abuse, degradation, marginalization. And for me, it becomes necessary to integrate the two. Because ultimately we are talking about a need to be more hopeful, more committed, more dedicated to the basic challenges of living in a complex world. And for me that means spending time thinking and talking about the poor, the disadvantaged, those who will never get to TED. But thinking about them in a way that is integrated in our own lives.”

“And as I was walking up the steps of this courthouse, there was an older black man who was the janitor in this courthouse. When this man saw me, he came over to me and he said, “Who are you?” I said, “I’m a lawyer.” He said, “You’re a lawyer?” I said, “Yes, sir.” And this man came over to me and he hugged me. And he whispered in my ear. He said, “I’m so proud of you.” And I have to tell you, it was energizing. It connected deeply with something in me about identity, about the capacity of every person to contribute to a community, to a perspective that is hopeful.”

It is so easy to deny the suffering of others, or to think that those who suffer deserve their pain. The higher road is to feel that vulnerability, that sense that we share a civilization that without the privilege of love, education, support and the absence of trauma, we can easily slip into despair and aggression, both outward and inward. This message hearkens back to my post about Adam Lanza. His aggression is not surprising, but rather it reminds us of how tragedy begets tragedy. His personal tragedy of not being able to find mental peace spilled over into the tragedy of his father, Peter Lanza, who has to live with his son’s notorious legacy, and the tragedy in each family who suffered the shocking loss of their innocent loved one. Suffering is our common bond. It reminds us that the world needs to help one another diminish suffering, rather than separate ourselves from the pain of others. This separation creates the inequality gap, the opportunity gap, and most importantly the emotional gap because we lose touch with our own layers of despair and hopelessness which creep in from time to time. Understanding these common feelings brings us together as a society. Splitting off these feelings creates a shallow existence, where, as Bryan Stevenson says, “that we cannot be full evolved human beings until we care about human rights and basic dignity. That all of our survival is tied to the survival of everyone. ” No wonder he got the largest standing ovation in TED history. He needed to remind us that we easily go into denial, to our own detriment.

Posted in Criminal Justice, Musings | 1 Comment »

NYer Cartoon

Posted by Dr. Vollmer on March 24, 2014

 

Starbucks is changing its demographic.

Posted in Cartoons | Leave a Comment »

 
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