The longstanding debate in the psychotherapy world centers around the issue that we, the providers, do not understand how we heal. At first pass, it might seem that this field is so uncertain, why would a person devote his/her life to work in which outcomes are vague, and mechanisms of therapeutic action are subject to deep speculation? As with all issues involving uncertainty, the management of “not knowing” involves “pretend knowing” meaning certainty when there is none, and/or embracing the opaqueness of what we do. These two camps, those who feel certain, without science to back them up, and those who coexist with the uncertainty, are antagonistic to one another. I tilt towards embracing complexity and “not knowing” and I begin to tremble at the sound of pseudoscience presenting as science. Having said that, it has felt intuitive to me that people get better through relationships, be that marriages, friendships and/or psychotherapy. Feeling understood and cared about provides the soil in which growth can take place. Yet, one can challenge me and ask that if the most important aspect of psychotherapy is the relationship, than why do I teach “technique” in that most relationships evolve over time without structure or rules. Technique, by my way of thinking, is a litany of structure and rules which is woven together with a therapeutic relationship, resulting in a thoughtfulness about applying or not applying the rules. In other words, there needs to be guidelines in psychotherapy which stimulate the therapist to decide if and when to deviate from those suggestions. Issues such as self-disclosure, doing a home visit, working from home, are all issues which question orthodox views of psychotherapy, and yet with thoughtfulness these rules can be broken with great therapeutic success. The rules promote thinking about thinking and in so doing, therapists need to be taught about how to think about the patient and him/herself at the same time. Two minds engage together, a relationship forms, but the patient is focused on his/her mind, while the therapist is focused on both minds. The asymmetry follows from this thinking pattern, and with this asymmetry the patient learns to trust his/her therapist as someone who is mindful to take care of himself (the therapist) and the patient. This trust that the therapist will neither be a martyr or self-centered allows the patient to explore his/her mind. The relationship, the feeling of mutual caring, with these assigned roles, gives way to introspection and mastery over unconscious motivations. The work is hard because generally speaking, the relationship is necessary but not sufficient for growth. For growth, learning technique is essential. And still, at the end of the day, there is a lot we do not know.
Posted by Dr. Vollmer on April 23, 2015
Posted by Dr. Vollmer on April 20, 2015
Imagine an application in which you want to reach out to a physician, and like searching for a ride on uber, you press on your phone, you pay $45.00 and you ask the doctor a question. The doctor, like the Uber driver, responds promptly, and the application and the doctor make a small amount of money, for a small amount of time, and little by little, there is money to be made, and health care to be delivered. The word delivered is key, as the changing face of medicine is changing what health care delivery means. This is our new world of “population health” where for most people, their questions can be answered and the “patient” or “user” feels reassured and can lower his/her anxiety, but very occasionally, a serious health problem will be trivialized and catastrophe will ensue. Those of us trained before Electronic Medical Records were trained to search for the serious problem, so as never to miss the rare, but serious, disorder. More recently trained physicians are taught how to make most people well and stay well, with much less concern for the “zebras” as we used to call them. This major shift from thinking about population to thinking about zebras allows health care applications to provide an Uber-like service, of almost instant gratification, for a relatively nominal fee. I can imagine that insurance companies would buy these applications and direct patients to an email conversation before making an appointment. I can imagine that most of the time that works extremely well, both cost efficiently, and time efficiently. Yet, some “users” will not be able to convey the seriousness of their symptoms, and in those time urgent medical situations, irreversible damage can happen, tragically, and preventable if the patient had been in an emergency room. The future of telemedicine has arrived with the introduction of the Apple watch on 4/24. Health care is a major selling point to the accessibility of the internet on one’s wrist. The watch will be able to transmit medical data to physicians electronically. Our society will slowly be trained that medicine can be done remotely and, again, most of the time this is true. I worry about the times which are not most.
Posted by Dr. Vollmer on April 17, 2015
“Introspection is always retrospection.” One cannot think unless one reflects on previous experiences and hidden pathways to current feelings and motivations. Trauma and Evie come to mind. Evie witnessed her brother get shot in the back by a policemen. Since that fateful day, when she was thirty-two, Evie was a changed person. At first she was numb and went through the motions of life, caring for her young children. Then, what seemed suddenly, she became depressed and suicidal. Suddenly after that, she bounced into an enthusiastic and highly creative and energetic behaviors. Did Evie, at the age of thirty-two have an onset of Bipolar Disorder or is all of her behavior explained by trauma, or is there some combination? If one just looks at current behaviors, then Bipolar Disorder might make sense, but in the context of a major trauma, PTSD might also make sense. How much retrospection is necessary to diagnose psychiatric illness? Can symptoms be taken out of context to give someone a life long diagnosis? Is the only reason moods change suddenly is secondary to a bipolar disorder? Can sudden mood shifts represent an instability of personality due to either recent or past trauma to the soul? The value of retrospection, searching for past clues, to explain current behavior cannot be overstated. Triggers of abnormal behaviors can be recent or buried in the past, arising in one’s mind as a painful memory, long suppressed, but now coming to light. Do we need to bring Philosophy into psychiatric training to remind trainees that the mind is more than a series of chemicals which can be altered by medication? Do we need to bring Humanism, the concept of the everyday struggle for meaning, and importance, into the mind of the psychiatrist who may be very trigger happy to diagnose and treat, before carefully considering the landscape? Just as the police officer pulled that trigger way too soon on Evie’s brother, maybe psychiatrists, in a similar fashion, are too quick to judgment. With time and careful thought, understanding can happen. People, like Evie’s brother, and Evie, can be humanely treated and brought to a place of compassion and growth.
Posted by Dr. Vollmer on April 16, 2015
Irving Yalom MD, http://en.wikipedia.org/wiki/Irvin_D._Yalom, states that psychotherapists are “fellow travelers” with their patients on the journey of self-discovery, as the patient struggles with the existential issues of death, meaning, isolation and freedom. This is a wonderful characterization of the intimacy in psychotherapy, as, despite the asymmetry in the doctor/patient relationship, there is still a sense of sharing the road together. This is the contradiction in therapy, which is to say that on the one hand the patient travels alone in that only he is sharing is the intimate details of his inner world, and yet on the other hand there is a joining together of the experience as the patient narrates his tale. Leon, sixty-four, comes to mind, as I work with him around the slow decline of his ninety-seven year old father, whom I only imagine, having never met him. Yet, through Leon, through a son’s perspective. I come to understand his father. In that way Leon and I are fellow travelers on the journey which witnesses the slow exit of his father. This sense of joining between patient and therapist, the sharing of interest in the changing emotional landscape, gives way to a unique relationship in which the external world, the decline of his father does not change, but the internal world, the world of sharing feelings does change. Feelings, once shared, become owned, and in so doing, define the person who has those feelings. A deepening of the self ensues, as feelings are expressed in psychotherapy, as, at times in friendship, both travelers have a greater connection to each other, and to themselves. Giving the patient permission to express feelings opens the path towards traveling together, which for some people, is virgin territory. The “fellow travelers” notion gives the imagery of journeys, and sites, yet to be seen, with a sense of discovery and wonder. This contrasts with the T therapies (CBT, DBT, FFT), in which the answers are given, sometimes even before the questions are asked, and hence there is no discovery and hence there is no excitement. Dr. Yalom speaks to this old-fashioned notion of “letting the patient matter,” meaning developing a doctor/patient relationship, or more specifically a doctor/patient traveling relationship. I join hands with him with the hope of creating a chain of physicians who want to be “fellow travelers” with their patients.
Posted by Dr. Vollmer on April 15, 2015
TMS, transcranial magnetic stimulation, is an FDA approved treatment for Major Depression, but insurance does not pay, and fees are in the 5 digits. As the rate in which new psychotropics appears diminishes, the rate of neuromodulation treatment increases, in a similar way that technology is on such a rapid rate of change, that treating psychiatric diseases with drugs could become a “so yesterday” phenomena. Of course, this could be another tool in the box, an additive treatment, rather than a substitute, but my fear continues to be that newly minted psychiatrists will trust devices more than they trust their ability to use their words, their feelings, and their imagination to help people. Is this large sum of money better spent on intensive psychotherapy? I wonder. Psychotherapy takes longer, a lot longer, and hence one could argue that this is a “quick fix” in that it is usually administered over a period of one month, instead of many years. Like with the promise of the SSRIs, the hope is that we will find some external treatment to fix the complexities of mood and motivation. My bet, as my readers could predict, is that TMS may significantly help a lot of people, but it will very rarely be a substitute for a deeply analytic experience of understanding oneself. Most people restrict themselves from having a richer experience in life, usually due to unconscious forces which lie deep in the psyche. TMS may provide temporary relief to the human suffering of misery, but it will not substitute for the long road of building self-esteem and self-empowerment. There, I have said it again.
Posted by Dr. Vollmer on April 9, 2015
The trainees, those committed to a career in Psychiatry , at UCLA, have organized themselves to learn more about psychotherapy. Yes, I am clicking my heels with joy and excitement. Finally! The pendulum of biological psychiatry dominating my field is pushing back to regain the mind, the human kindness involved in healing. At least, that is my hope, as evidenced by this year’s intern class, the class that graduated medical school in 2014, coming together to ask the UCLA Psychiatry Faculty for a Spring retreat in which they have protected time (no on-call duties) in which to get to know each other, and to be introduced to the concepts of psychotherapy. First, in preparation we will read this book, “The Gift of Therapy” and discuss what it meant to them. This book focuses on how psychotherapy provides the unique experience of listening, a gift that few people ever receive in their lives. Learning to listen and valuing listening are essential components that contribute to emotional growth. Then, we will watch together a few episodes of “In Treatment” and we will discuss how this fictional psychotherapy show illustrates the complexities of listening. Together, we will free associate to the book and to the episodes in ways in which we will come to appreciate that thinking about thinking is a stimulating and curative endeavor. I am glad I am around to see this change. The hope is that as very young psychiatrists they will “grow up” appreciating the value of the personal narrative, and in so doing, they will resist being pill mills. There is a smile on my face, with a certain guardedness at the same time. This is a positive baby step and we will see if it grows into a new world, which, of course, would be the old world of psychiatry.
Posted by Dr. Vollmer on April 8, 2015
Another rant about how the world of medicine has changed. In my era, we saw inpatients, which meant that we saw the same patient every day. That patient expected Shirah to show up, and not the “doctor.” Some patients would track when I was on call (sleeping in the hospital, resulting in a 36 hour shift) and they would have the nurses page me in the wee hours, because they wanted to talk to ME, not the doctor on call. I would have seen that patient hours early, during “business hours” but as we developed a bond, he began to see how talking to me relieved his anxiety, as we developed a trust which grew out of spending many daylight and nighttime hours together. Seeing these patients was more than my job, it felt crucial to the well-being of these hospitalized patients. I, like my colleagues at the time, would never think of “leaving early” or “coming late” as we understood that specific patients were counting on us to be there. It was as much my personal integrity, as it was my professional duty to show up and work my grueling hours. Fast forward thirty years and inpatient psychiatry has dwindled, making the Resident’s experience, mostly outpatient. As a result, the Psychiatry Resident never sees the same patient every day, nor does he/she see them every week. Patients are shuffled like cards and they may or may not see the same doctor, at a frequency of once a month or longer. Consequently, Psychiatry Residents do not have the same work ethic, as it is not as critical that they be on time, or show up for a particular patient. The environment changed, and so did the working style. I do not blame the Residents, as I would be just like them, if I were working in today’s environment. Patients depending on you is different than a clinic depending on you. The problem is not that millennials were raised with entitlement, although that may also be at play. Rather, the problem is that the work is no longer personal. If you change the game, then you change both the people who want to play, and how the players approach the interaction. Duh?
Posted by Dr. Vollmer on April 7, 2015
We have a new sleeper on the market which antagonizes a chemical called Orexin. Orexin is a wake promoting chemical which is stimulated by the drugs Provigil and Nuvigil. Nope. I have not used it yet. Yep. I am excited to have a new tool for those sometimes stubborn symptoms of initial, middle and late insomnia, meaning the type of sleeplessness which could be trouble initiating or maintaining sleep. Provigil and Nuvigil I do use and really appreciate. Those two drugs increase wakefulness which is handy for those with chronic fatigue from a variety of sources. It is exciting to prescribe medication and watch people get better. It is even more exciting to bear witness to a new generation of medication which helps people who could never be helped before. Prozac did that for some individuals with irritable dysthymia and severe OCD. Belsomra could also be revolutionary. We will see.
Posted by Dr. Vollmer on April 6, 2015
Ordering laboratory tests is an important part of my work as a physician. I prescribe drugs which require laboratory monitoring and as such, blood work is important for some of my patients. I write an order. The patient takes it to their lab of choice and results are sent to me. When it is urgent, I tell the lab, and results are given to me promptly. Sounds simple? Well, not so much. As the wheels of payment changes, as patients and physicians are being forced into specific ecosystems, the flexibility is lacking if a patient or a physician is not part of a larger group. Like a PC user who feels foreign in an IOS environment, so a patient that gets most of his healthcare at UCLA will have trouble integrating his medical record if he also goes to Cedars. Example. A patient needed a stat or urgent lab. I called the lab and they said that since I did not have a physician member number, they could do the lab, but they could not do it stat. “Isn’t that unethical?” I asked, wondering how the laboratory has the right to refuse a physician’s order. I got the repetitive answer that I had to sign up with that lab in order to get the blood result quickly. There are politics here, and payment streams and consumer manipulation, all of which I am not clear about, but a laboratory telling me that they refuse to do a stat lab because I am not a frequent flier, just seems wrong. Rant complete.
Posted by Dr. Vollmer on April 3, 2015
27 years old. Premeditated murder/suicide. 149 innocent victims. h/o depression with suicidal ideation. What of it? How do we make sense of these facts? As a psychiatrist, what are my thoughts on the matter? For a week I have thought about my perspective, wondering how I reconstruct this story which has no answers and only questions. As this is also the eve of holidays in which many family and friends get together, Mr. Lubitz might make it into dinner table conversations. For the families of the victims, there are simply no words. For the world, there is fascination and quick answers, hoping that the next plane we step on, or the plane our loved ones step on, does not suffer this tragic fate. My first point is that I want to rid the world of the shock value of these tragedies. Like school shootings, or suicide bombers in the middle east, there is a small group of people, who will take harmless victims with them to the next world. This will always happen, and there is no way for psychiatrists, or anyone else to fully prevent these tragedies. For a variety of reasons the perpetrator of these crimes believes that this murder-suicide is justified, and as the human brain can convince oneself of almost anything, once the brain is convinced, the behavior follows and terrible consequences ensue. To be shocked by this behavior is to be naive to human nature. Most humans want to help others, but a minority of humans do terrible destruction. This is our landscape. To pretend that is not true, is denial. The shock of Andreas Lubitz behavior is evidence of this denial. My second point is more difficult to articulate. Mr. Lubitz has a history of depression with suicidal ideation and he sought medical care immediately prior to this event. Does this mean he was mentally ill? Probably, but we will never know, unless the physicians who evaluated him can disclose their findings. Assuming he was depressed and a danger to others, then he should not have been allowed on that plane. However, it is rarely that clear. He may have been vague in his description of his mental state, and he may not have mentioned that in his suicidal ideation he was contemplating taking down innocent people. A psychiatric assessment includes asking about homicidal ideation, but his answer could range from “sometimes I hate people” to “I can understand the man who did Sandy Hook.” The privacy laws in Germany are not clear to me, and so I can only imagine if Mr. Lubitz walked into my office in California. If he specifically stated that he was going to take the plane down, then I would call Lufthansa immediately. However, the likelihood is that he hinted at his plan without being explicit, leaving, I imagine, the five doctors he saw prior to the plane crash in terrible despair, desperately trying to remember exactly what he said. Unfortunately, the relationship of mental illness to violence is not clear. Our most clear understanding of behavior comes from the past and from family history. The adage that past behavior predicts future behavior holds true. I do not know what is in Mr. Lubitz’s past, but I suspect he had no violent history, making this event even more difficult to predict. My final point is that as awful as this tragedy is, we need to acknowledge that we are terribly inadequate at predicting these events, and hence having two people in the cockpit at all times is a good intervention. Trusting passengers to one pilot will ensure that this tragedy will repeat.