Shirah Vollmer MD

The Musings of Dr. Vollmer

TalkSpace

Posted by Dr. Vollmer on July 19, 2017

Meaningful therapy from every device

It can be difficult to wait days or weeks until your next appointment. With Talkspace, you can send your therapist a message whenever you’re near a laptop, tablet, or smartphone. Your conversation carries over seamlessly across devices and uses banking-grade encryption to keep it safe and confidential.

How Therapy Works on Talkspace

Getting Started

During Therapy

Your Own Therapist

Once you’re matched, you’ll be working with the same licensed therapist every time.

Write When You Want

You can set aside some time every day, or write when the mood strikes you. Your room is always open.

Regular Responses

Therapists respond 1-2 times per day. If you need more, simply schedule a video chat.

Customer Support

Customer Support is available to help answer non-clinical questions about how Talkspace works.

https://www.talkspace.com/

 

 

Oh my, the world changed again, and I just woke up to text therapy. Talkspace is a company that offers packages for texting therapy. Do I text my patients, you wonder? Absolutely. I have embraced the technology early on, as I find texting a great way to communicate and keep in touch. Having said that, what do I think of therapy that is only done by texting. I am simply outraged. Free association is the mainstay of psychodynamic psychotherapy, and so the critical feature is to allow the patient an open space to understand how their mind works by listening to how they put ideas together. Texting, like tweeting, limits the amount of verbal output and as such, limits the depth of the experience. Plus, writing and speaking are two very different forms of communication, and there is something very valuable to a verbal exchange which happens like ping-pong, where ideas feed each other. This is the basis for the “good fit” in psychotherapy where the patient’s mind and the therapist’s mind need to be able to feed one another for the therapeutic process to get started. To only have text as a therapeutic tool is to me, yet another way, in which mental health is being diluted from a high quality profession, to one that can be done “easily” with a smart phone. The complexity of psychotherapy needs to be embraced and not denied. This Talkspace company, although perhaps profitable, strikes me as a very poor substitute for good treatment. Once again, the question arises about whether I am resisting new technology or whether new forms of treatment are not necessarily better forms of treatment. Both, of course, could be true. In this case, the latter seems clear to me. New is not better, it is just new.

Posted in Psychiatry in Transition | 7 Comments »

U Is Me!

Posted by Dr. Vollmer on May 5, 2017

Dr. Shirah Vollmer

 

 

 

http://magazine.uclahealth.org/body.cfm?id=6&action=detail&ref=1461

Posted in About Me | 3 Comments »

New Job: Editor of PCFA Newsletter!

Posted by Dr. Vollmer on April 6, 2017

PCFA Newsletter header

 

 

 

 

https://www.semel.ucla.edu/pcfa

 

In the continuing plea for a psychiatry of days gone by, I have accepted the job as Editor of the above Newsletter. I have been a member of the board of this organization since 1995 serving in various capacities including child psychiatry liaison, member of the retreat committee, member of the diversity committee, secretary and now Editor of this newsletter. This organization is a support to the psychiatry trainees in UCLA affiliated programs including the San Fernando Valley Program and the UCLA-Harbor program. We provide low-cost psychotherapy to trainees, along with supervision of trainees.  In addition we   provide many didactics. For example, in addition to my work on the board of the PCFA, I do individual supervision to four adult psychiatry residents, a shift for me, as I used to provide supervision for child psychiatry fellows.  In addition, I give the adult psychiatry residents lectures on childhood assessment, and in the past, I gave the child psychiatry fellows a class on child psychotherapy. Now, I am adding on by helping this newsletter publicize our work, as I feel the strong pull to remind psychiatrists, at all levels in their careers, that listening is an important art, which could sadly be lost, if we are focused on fifteen or thirty minute appointments, with infrequent follow-up. It is my hope that by carrying the torch of listening, both by teaching this art and by doing this art with trainees, then psychiatry will maintain one of its major therapeutic tools, that is, the talking cure.

Posted in About Me, Psychiatry in Transition | 2 Comments »

Primary Care Docs: I Am Looking At You!

Posted by Dr. Vollmer on March 10, 2017

Image result for pri-med

West Annual Conference

Anaheim, CA | May 10-13, 2017

Anaheim Convention Center

The Worried Well: Anxiety Disorders in Primary Care

Description

This talk will cover the assessment and treatment of anxiety disorders in a primary care setting, incorporating new diagnostic issues as a result of D5M5

Learning Objectives

The clinician will learn how to classify anxiety disorders

The clinician will learn how to choose a psychopharmacological agent to treat anxiety disorders

The clinician will learn how to manage patient anxiety in a busy clinical practice

The clinician will learn how to take patients off anti-anxiety medication


Speakers

Default Biography Avatar

Shirah Vollmer, MD

Shirah Vollmer, MD is a Clinical Professor of Psychiatry at the David Geffen UCLA School of Medicine. She is a board certified child and adult psychiatrist and she is a psychoanalyst. She is on faculty at Loyala Marymount University, The New Center f…

View Full Bio

I return to my mission of teaching primary care doctors about anxiety disorders, as a way of sensitizing them to the suffering of mental distress. Today, I spoke at the 44th Annual UCLA Family Medicine Refresher Course, a conference I have participated in for over 25 years. My slides have been updated to include DSM 5 diagnostic system. A few new medications, but not many, have been added to my presentation. Mostly, my talk has changed in form and not in substance, meaning that I make a deeper plea for taking time with patients to determine why they are anxious, along with a plea to give anti-anxiety medications with caution, but at the same time, not withhold them from those who are temporarily overwhelmed with their circumstances. In two months, I give a similar talk at Prime-Med, a larger audience of primary care, but my message will be the same. Anxiety is a starting point, not an end-point. Stay curious and help the patient understand himself and what meaning the anxiety has for his life. Yes, this takes time, I say, and yes, I know you are not reimbursed for that time, I say, but that time is essential to helping the patient cope with the stressors, both internal and external, that he faces. At the end of my presentation, the questions are predictable. “What do I do with a patient who won’t come in because he does not want to pay his co-pay?” An audience member asked, knowing that I had no answer for that. “Tell him that management of his issues requires time and patience, and that you cannot short-change him of that, while at the same time understanding that co-payments can be a burden”. I say, knowing that this will not convince the patient to come in, but it might help the physician stand her ground. As with all of my presentations, I review the history of psychiatry, those wonderful days before we had medications, where we offered deep listening and thoughtfulness, and I sadly state that those days created a field in which thinking was valued, and time with patients was essential. This contrasts with today, where algorithms rule the evaluation, and time is crunched for “efficiency” which in my mind means poor care. So, all you primary care docs out there, wanna come to the happiest place on earth on May 11, 2017 and hear me say this one more time? I would welcome your questions.

Posted in Anxiety, Teaching | 4 Comments »

Is Psychiatry As Bad Off As I Say It Is?

Posted by Dr. Vollmer on March 6, 2017

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Check out Kelly Brogan MD…http://kellybroganmd.com/, a psychiatrist, similar to my thinking, advocates for mental health without medication. Now, I do not completely agree that medications are hurting patients, although sometimes that is true, but I do agree that we as psychiatrists have gotten trigger happy, which means we are too eager to prescribe, and too reluctant to listen and put symptoms in context. I have recently taught second-year psychiatry residents (UCLA-15 total), psychodynamic psychotherapy students (New Center for Psychoanalysis-9 total) and I am about to teach primary care doctors .https://www.cme.ucla.edu/courses/event-description?registration_id=146702 about the diagnosis and treatment of anxiety disorders.  In each of these very different audiences I lament the loss of history taking in psychiatry, associated with the rush to prescribe and the consequences being unrealistic expectations and poor understanding of one’s personal dynamics. Associated with this are tremendous health care disparities in psychiatry where those without means are given care which is significantly lower quality than care given to those with discretionary income. Further associated with this are training programs where students learn to read checklists as opposed to asking and listening to open-ended questions. The patient’s narrative is lost and with that comes the loss of the excitement and joy of self-discovery; this loss being for both patient and provider. Burn-out seems like an inevitable consequence of our new model of care, but it will take many years to document this and so we must wait for evidence to validate our suspicions. Meanwhile patient care is suffering, and those with means can seek out care that makes sense, while those dependent on public funds are left to focus on symptom relief and not bigger picture understanding of what is killing their vitality. “I make students depressed” I say frequently, always to laughter, which goes with the grain of truth this gloomy picture represents. Exposing the problem remains the first step. Hence, I will repeat myself until this broken system starts to mend.

Posted in Psychiatry in Transition, Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 2 Comments »

Countertransference

Posted by Dr. Vollmer on February 28, 2017

Posted in Countertransference | Leave a Comment »

Did I Mention I Was Teaching Transference Tonight?

Posted by Dr. Vollmer on February 22, 2017

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Freud initially thought that transference was an impediment to treatment, but as the years went by, he began to “discover” that understanding transference was the holy grail of treatment, meaning it is the part of psychotherapy which creates personality change. In other words, how we feel about ourselves, based on early relationships is often recreated in our meaningful relationships and if we form relationships which are harmful to our self-esteem, then we need to reformulate our opinion of ourselves, based on a new relationship. This new relationship, in the form of psychotherapy, allows the patient to examine how he projects on to others ideas from his past, and in so doing re-affirms his previous notion that the world is mean/cruel/withholding towards him. If the patient can see his own projections then he can open himself to new possibilities which includes relationships in which he feels valued/loved/cherished. This is a simple notion, which in practice, requires many hours, in fact, at times, many years of treatment to see how deeply held beliefs can be faulty and damaging.

Joe, thirty-two comes to mind. “I am going to disappoint you,” he tells me with great certainty. “Why do you say that?” I ask, thinking about his declaration. “I disappoint everyone in my life. I just do.” He says with little elaboration. “You mean you disappointed your mom,” I say, thinking that he is referring back to his earliest relationship in which he felt terrible sorrow for not making his mother happy, and in fact, disappointing her by not becoming a doctor or lawyer. “It must be terrible to feel that you disappoint people,” I say, thinking about what it is like to think that you will cause a significant other deep pain. Joe starts to cry. His tears speak volumes to his sense of inevitability that he disappoints; that is just what he does. “Maybe you disappointed your mom, but that does not mean you disappoint everyone,” I say, stating the obvious, but also knowing that it needs to be stated. “The issue is that you feel like a disappointment, and that is a terrible burden to bear,” I say, trying to help Joe understand that he carries around this painful feeling that he cannot shed, since he is so attached and identified with his mother. “I wasn’t abused,” Joe says protecting his mother. “Not in the traditional sense, “I say, “but you weren’t cherished for who you are, and that is a different kind of trauma,” I say, trying to help him understand the childhood feelings he carries forward into adulthood. “I don’t get it,” he responds impatiently. “Yes, we have more work to do,” I say, knowing that this is a painstaking process.

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis, Transference | 2 Comments »

Transference: Continued

Posted by Dr. Vollmer on February 17, 2017

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Distortion is another word for transference in that we mis-read social cues based on past experiences and not based on current interactions. Barb comes to mind again. She is the 50ish year old woman who suffers from always feeling persecuted and treated poorly. She tells me that I “make her go to her appointments with me,” as if somehow I have that power over her. Her issue is that she attributes to me, as an authority figure, the power to condemn her if she does not coöperate. She fails to see that it is her decision to be in treatment, and it is her decision to stop or decrease the number of our sessions. How she managed to recreate her experience of feeling persecuted with me, is how Freud described this phenomena called transference. At first, he saw it as an obstacle to treatment, but over time, he came to “discover” that understanding the transference was the holy grail of treatment. In other words, if I can help Barb see how she makes her world play out such that she always feels boxed in, then I can help expand her mind such that she can see the situation  in new and meaningful ways. Eventually, I believe, Barb will see me as someone who offers her a safe space to examine the inner workings of her mind, but for now, I am another persecutory figure who makes her life feel frustrating and that results in chronic feelings of anger. As we examine this repetition of feeling which occurs in my office, we can begin to understand how she unconsciously makes her life such that she feels she is a slave to other people, a repetition of childhood feelings of being a slave to her mother. As Freud said, we repeat in order not to remember, and so with Barb, understanding this repetition will take a great deal of time, because remembering her childhood feelings is going to feel deeply sad and despairing. The safety of our relationship allows for those feelings to bubble up, but it will still take time and care, on both of our parts,  for her to allow herself to get there. Transference is a simple concept, but in the therapy room, it is complicated by very challenging feelings. Still, privileging the transference as the key to therapeutic gain is the concept, we, as mental health professionals, must hold on to, as this is where we need to guide treatment for psychic pain. I never tire of saying this, as the importance cannot be overstated.

 

See also…https://www.youtube.com/watch?v=PD5iyGBVASU

Posted in Transference | Tagged: | 2 Comments »

Teaching Transference

Posted by Dr. Vollmer on February 16, 2017

Trans·fer·ence
transˈfərəns,ˈtransfərəns/
noun
  1. the action of transferring something or the process of being transferred.
    “education involves the transference of knowledge”
    • PSYCHOANALYSIS
      the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis ).

    How do you teach this concept? I wonder. We repeat behaviors from the past and impose them in the present, and in so doing, our behavior is out of proportion to the present situation but our behavior makes sense in a historical context. In other words, all actions are reactions to past experiences as well as reactions to current experiences. So, if Barb feels that I am being mean to her in session, I may in fact be mean to her, and/or she may get triggered by something I said which reminds her when her mom was mean to her, and in that situation, I am the trigger, but she does not see that immediately, so she feels very hurt and disappointed by me. With time in psychotherapy, Barb and I can come to see how she felt my behavior was “mean” and she can also talk about how it reminded her of how her mother treated her when she had a boyfriend that her mom did not find suitable for her. As we unpack her feelings of hurt and disappointment, Barb comes to see how in other parts of her life, particularly in her close relationships, she often feels hurt and disappointed, and this may, in fact, be her carrying forward painful experiences she had with her mother. “Maybe I am too hard on my boyfriend,” Barb says with the suggestion that her insight into her behavior is slowly expanding. Helping Barb understand how she feels that everyone will treat her as her mom did, opens her eyes to the understanding that maybe she carries with her painful assumptions, which, when tested out, turn out not to be true, but without opening her mind to the fact that she is making assumptions, she then constantly feels hurt and disappointed. Through talking about the transference, Barb has the opportunity to grow emotionally, such that she can begin to understand how she can take a benign comment, such as “I wonder what you find attractive about your boyfriend,” and given her history with her mother, she hears “what on earth could you like about that man?” In her mind, she is prepared for a judgmental, critical attitude towards her boyfriend, such that she cannot entertain the possibility that my question is one of curiosity and not criticism. Clearly, tone is critical in this discussion, but even with a neutral tone, there is the sense that Barb is so convinced that the discussion is going to be antagonistic, and as such she must go on the defensive when talking about her boyfriend. This is a simple notion of transference, but one which I hope will illustrate the point. The point being that by reacting to our past and not our present, we, who have been hurt in childhood,  continue to feel the pain and we do not open ourselves to feelings of acceptance and love. In essence, understanding transference can  be transforming, creating a life-changing  and maybe even a life-saving experience.

     

See also…https://shirahvollmermd.wordpress.com/2014/02/03/teaching-transference-2/

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis, Transference | 2 Comments »

Psychic Retreats

Posted by Dr. Vollmer on February 14, 2017

Tomorrow, in my Psychoanalytic Technique class, the topic is silence, and what to do about it. The meaning of silence, the challenge of silence, and the patience with silence will all be ripe for discussion. We will springboard from John Steiner’s work about psychic retreat, where he teaches us that patients often withdraw into silence as that is a safe space; safe from anxious and depressive feelings. More to the point, many people, particularly males, who withdraw in social circumstances, due to fear of having feelings, are often labeled as “on the spectrum” when in fact, they are using a defensive psychological organization to cope with psychic trauma. The misunderstanding between trauma symptoms and “spectrum” symptoms is particularly upsetting to me, because it is one thing to understand a patient as trying to cope via withdrawal as opposed to understanding a patient as incapable of nuanced feelings and social skills. This distinction is critical and it takes time with patients to really understand this difference. A severely traumatized individual will have no friends because he/she is frightened of the feelings generated by friendship, and this can seem identical to the “spectrum” individual who has no friends because he/she is not able to have the reciprocity required in relationships. Two fictional examples come to mind. One, a young male, isolated, lonely, and despairing, has never had friends because he is antagonistic and arrogant, by his report. In the intensive treatment he is often silent, requiring what I have called “hide and seek” such that he hides and I need to seek out his psychological state of being. Without my seeking, he remains hidden. The meaning of my seeking is that it serves to reassure him that I am indeed interested in his mental state. The issue of how long to remain silent as opposed to “seeking” him is the art of my work. The second fictional example is a fifty year old woman who often says, ten minutes into the session “that’s it. I have nothing more to say.” This seemingly abrupt ending to her thought process has puzzled me for many years. It is clearly defensive in that she protect herself from deeper intimacy with me, but at the same time, she is frustrated by her inability to deepen her treatment. Her psychic retreat would not be confused with “spectrum” issues and yet, she isolates herself in our sessions such that there is no reciprocity. She does not play “hide and seek” since she simply hides from me, in that “she is done”. She does not leave however, as she waits, perhaps with unconscious hope, that there is more to be said. Our work is focused on understanding these retreats and how historically speaking, these withdrawals saved her from feeling unloved in her family. Both these fictional examples illustrate how silence is as important as verbal output, as they both convey how the patient organizes his mental interior and as a result how the patient can share, or not share, those very private experiences. John Steiner has helped us a great deal with talking about the quiet, the dark space, if you will, within the psycho-therapeutic hour.

Posted in psychic retreats, Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 2 Comments »

 
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