Shirah Vollmer MD

The Musings of Dr. Vollmer

Growth Vs. Anxiety

Posted by Dr. Vollmer on February 9, 2016

Anxiety is often a stimulus for growth, but when it becomes paralyzing, it is termed a “disorder”. On the other hand, no anxiety can mean mental “deadness” and that may represent developmental stagnation. The sweet spot of anxiety is the discomfort on the journey to new challenges, and yet to get to this “sweet spot” is a non-linear path. Medicating anxiety is often helpful, but at the same time, it side-steps the notion that anxiety which is overwhelming is often more a reflection of self-esteem than a problem with “anxiety”. Psychic withdrawals often produce calm states of mind, but at the price of developmental growth. Similarly, addiction is a form of psychic withdrawal, which temporarily relieves anxiety, but long-term causes immaturity and bodily destruction. With this conundrum I am left wondering about our diagnostic system which classifies “Anxiety Disorders” as a condition warranting treatment, as opposed to an “immaturity disorder” which is a condition warranting psychic growth. It is politically incorrect to term those with “Anxiety Disorders” immature, and yet, for the moment, I would like to entertain that notion. Perhaps maturity means a certain calmness in handling life’s irregularities. Perhaps anxiety is a signal to promote growth and development, to help the patient “grow up” and manage life. Perhaps it is wrong to give these folks a medical diagnosis which promotes the sick role, as opposed to a psychological diagnosis which mandates them to develop coping skills.

Chad, fifty-four year old male, comes to mind. He quit his executive job because he was having panic attacks. He now stays home and reads books, while his wife and three children leave the house to go to work and school. He says he is “disabled” by his anxiety, and that “no one” can help him. His “panic disorder” qualifies him for disability, so he receives a monthly check. I wonder what would happen if his panic attacks did not qualify him for disability. I wonder if he would then feel the need to re-boot his life to a job that gave him more satisfaction. Chad is not anxious now and he is not on medication, but then again, he hardly leaves his house on weekdays and his weekends are spent driving his kids around. Is Chad immature by my account? Yes and no. Chad had a good job for many years but when he was passed over for a promotion he felt humiliated and started having panic attacks. He left his job and his symptoms immediately went away. Chad needs to take this humiliation as a step towards finding a new way to be in the world, rather than retreating to a safe, but stifling existence. We, as physicians, should not encourage him to take on the sick-role, but rather we should facilitate him in finding his next career move, by exploring different areas of satisfaction for him. A more positive psychology, one based on the notion that humans want to live in deeper and more meaningful way, would be far superior to a medical model which promotes disability and stagnation.

Posted in Anxiety, Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 1 Comment »

To Understand Or To Ameliorate?

Posted by Dr. Vollmer on February 3, 2016

How does the mind work? More specifically, how does your mind work? That is what I am curious about. Does that mean I do not care about my patients and that I am only on a journey of understanding? Of course not. This struggle between the therapeutic basis of the relationship versus the need to understand unconscious motivations seems to be a weak fight in that they are complimentary. The central question is what is the agent of change. Is it the bond the patient forms with his therapist or is it the patient  “learning” the secrets and lies which underlie his “analytic surface”?  How about, both are true? Or, why do we care as long as the patient gets better? We care because we aim to help people and we aim to teach new therapists how to help people. If the relationship heals then the content of the therapy is not relevant. On the other hand, if the understanding is key, then maybe we won’t wish the patient a happy birthday. I find this discussion tiresome and yet my job tonight is to review these ideas with bright and eager students. I will take the unpopular stance and say that we do not know the agent of change, ever. In fact, it is a surprise when patients get better, not because we don’t have a lot of training or experience, but because the one thing that seems certain is that patient, no matter how much they consciously express a desire to change their way of being in the world, the pull towards sameness is very strong. Hence, when a person grows and sees himself as a third person in order to understand his own struggles, the work is both rewarding and astonishing. What distinguishes psychoanalytically trained therapists from cognitively oriented therapists is that we accept that change is not going to come easily, if at all. Through this understanding we have joined the patient in his rigidity and we propose an opportunity to loosen up the joints in that box the patient has put himself into. Like Houdini’s work, the escape is crafty and creative, and not linear or easy to see. Knowing the dark halls of interior mental life, we tread slowly and gently, with great respect for what is around the next corner. We take time and patience as we are wary of what we will uncover with even gentle probing. We imagine the challenges their life presented to them and this helps the patient feel less alone, but it may not help the patient cope with his circumstances. Coping skills developed over many years. Adding new coping skills and/or getting rid of old ones is not a linear process. So, what is the technique? I imagine a student will ask. To which I will respond, you imagine the life of your patient, both past and present, and from there, the narrative begins.

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

Understanding One’s Own Mind: The Work Of Mental Well-Being

Posted by Dr. Vollmer on February 1, 2016

The mind both inhibits and punishes. To quote Fred Busch http://drfredbusch.com/ “unless the analyst is willing to make some attempt to understand the patient’s mind, and comes reasonably close to doing so (especially with regard to those ways of thinking that brought the person into treatment), a primary component of what has led to the patient’s unhappiness will be ignored.” To continue, “Within the areas of conflict that bring the patient to treatment we see an ego frozen into rigid, repetitious ways of seeing and living within the world based on ancient but still active fears.” The goal then of treatment is an expansion, or de-icing of the ego, rather than  symptom relief, which is the goal of third-party reimbursement. With the expansion of the ego there is reflection instead of action. With reflection comes compassion and peace.

My “Technique” class begins this week and so I will start the discussion about what happens in the office? What does it mean to think “analytically”? What are the tools of our trade? Bianca, fifty-four, will be my imaginative case example. She is a successful attorney. She likes her job. Happily married, she is  the mother of adult children, who are doing well, by her report. Yet, Bianca constantly thinks about how pointless life is. She is not suicidal, but nor does she embrace life. She denies feeling depressed in that she says “I don’t feel anything but anger.” With time, Bianca has come to understand that her “anger” follows the path of her mother’s anger, in that her mother raised five children with a husband who was often gone and not available. Bianca being the oldest child felt her mother’s anger and felt helpless in that she could not make her mother happy. Bianca identified with her mother’s anger such that all these years later Bianca still carries the negative feelings which she says are often directed to my husband, which “sometimes he deserves, but most of the time, I am being unfair and then I feel horribly guilty.” In helping Bianca to see how her mind is still punishing her for not being able to make her mom happy she can reflect on how her past is influencing her present. This reflection replaces the tantrums she used to throw when her husband did not put his socks in the hamper. Her ego expands. Her coping skills improve not because we talk about coping skills, but because she can see that the intensity of her disappointment with her husband stems from her mother’s disappointment in her life. From the “analytic surface” of “persistent anger,” together, Bianca and I can explore the repetitions in her life which leave her feeling either dead or guilty inside. Her ego does not have to punish her.

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

The Analytic Surface

Posted by Dr. Vollmer on January 25, 2016

“Tell me your story,” I like to say, which leads to a confused look. “The whole story?” A 20-year-old patient named Libby responds. I think 20 years is not that much, but to her, she thinks the summary of her life is an impossible task. The open-ended question is designed to see where the patient will begin. Will she tell me where she was born, whether her parents stayed married, or will she focus on her friends or her academic life. As she constructs a narrative, it is my job to formulate hypotheses about why she is in my office. Of course there is the stated reason she came, but there are many unstated, and unknown reasons she is there as well. I am looking for, what some authors would term, “the analytic surface,” which means where to take her narrative and go deeper. Libby spent a great deal of time talking about her mom leading me to think her parents were divorced, but in fact they were not. This confusion of mine leads me to wonder if perhaps Libby wished they were divorced, and/or felt neglected by her dad and controlled by her mom. “What about your dad?” I ask, intruding into her narrative since my sense was that the absence of hearing about her dad was meaningful. “He was there and he was not there. He did not seem to care about us,” she says with tears in her eyes. The analytic surface in this case was a large and lengthy discussion of her relationship with her mom, moving us to the seemingly more painful relationship with her dad. Struggling to work with this analytic surface is the art of psychotherapy in that from this surface I try to look for meaningful experiences which are harder for us both to see, at first glance. This digging, if you will, needs to be gentle so as not to overwhelm the patient, but it also needs to penetrate the conscious experiences so the patient can experience her life in a deeper and more liberating way. Going below the analytic surface helps  the patient understand the inhibitions and constrictions which prevent her from embracing her life.

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | Leave a Comment »

Is Therapy Work?

Posted by Dr. Vollmer on January 21, 2016

Talking about oneself brings relief and a struggle. The thrill of being listened to is counterbalanced by the shame of sounding “silly, inappropriate, consumed with minutia,” my fictional patient Adie reports. Psychotherapy as an opportunity to expose past experiences continues to stimulate me. I have never thought that Adie was inarticulate and yet, in her mind, she deeply fears that she cannot put words together in an interesting way. Hence she often sits in silence, with a pained look on her face. She often leaves sessions exhausted, even when she begins with high energy. “Today seems like it has exhausted you,” I say, and she quickly responds, “this is a lot of work for me.” I feel for Adie that she cannot see psychotherapy as a release, but rather she sees it as a medicine she has to take to get better, but the journey is one of endurance. Adie has never been listened to. No one in her life, by her report, has ever taken a keen interest in her thoughts, and so the opportunity for that interest makes her anxious and uncomfortable. We talk a lot about how traumatic it has been for her to want to be listened to but at the same time, she is too fearful to talk. She is caught in a never-ending bind, which, together we are slowly trying to unwind. Some days are better than others. Today was hard. Work for both of us.

Posted in Psychotherapy | 7 Comments »

A Gene For Depression?

Posted by Dr. Vollmer on January 20, 2016

 

http://www.nature.com/news/first-robust-genetic-links-to-depression-emerge-1.17979

 

Jonathan Flint MD http://grandchallenges.ucla.edu/depression/team/ presented his work today in which he gave a compelling talk demonstrating that he has found possible two genetic links to depression. He is a recent UCLA hire in which he joins the UCLA Grand Depression Challenge in which there is a multidisciplinary team working on understanding depression. He began with the familiar statistic that women are twice as likely to get depressed as men, and within that, women have a 20 percent chance of having a depression during their lifetime. He did not quite define depression but in the Q and A, he said that he was using the PHQ-9 which are nine questions to determine the diagnosis, which, of course, makes me suspect. Then he said it causes tremendous disability throughout the world and as such costs the world a lot of money in terms of lost labor. So, he summarizes that depression is common, causes disability and is costly and yet research on depression is minimally funded compared to diseases such as cancer or heart disease. He proceeds to show a negative  study by  his colleague Ken Kendler which did not demonstrate a gene for depression and so from that he concluded that depression is a heterogeneous disease. Well, that cannot be new information, I think to myself. He went to China where he studied only women, who apparently do not smoke or drink, and through looking at their DNA in their saliva, he could demonstrate that the women with depression had a different genetic makeup than did the controls. At this point I was beginning to be interested. The gene, he continues, impacts the mitochondrial DNA, which is the engine of the cell. He was a wonderful speaker and he did fascinating work, all as a result of new technology that makes sequencing DNA cheap and easy. Like the internet, UCLA could lead the world in this work. I am proud to be a Bruin today!

 

 

Posted in depression, genetics | 4 Comments »

Substance Abuse, Dependence Becomes Substance Use Disorder

Posted by Dr. Vollmer on January 19, 2016

Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impairment or distress. Although the termsubstance can refer to any physical matter, ‘substance‘ in this context is limited to psychoactive drugs.

 

 

DSM 5 changed our language from substance abuse to substance use disorder. Further, the diagnostic system requires that the substances be specified such that the DSM IV diagnosis of “poly substance abuse” has become “opiate use disorder, methamphetamine use disorder, tobacco use disorder and cannabis use disorder.”  More specificity in the diagnosis will help big data analyze “population health,” the new buzzword for focusing on trends and not on individuals. I wonder if there is a difference between “heroin use” and “heroin use disorder”.  Clearly, outlining the nature of the substances that the patient uses helps us understand the chemical feeling they are seeking. Yet, my experience in working in drug rehabilitation centers is that the majority of patients use all substances available to them including opiates, cannabis, alcohol, meth amphetamines and tobacco. I salute Lance Dodes MD http://www.lancedodes.com/ who says that substance abuse, like so many behaviors, are about self-sabotage, and not so much about the exact chemical that the patient is drawn to. He states, rightly so, that alcohol abuse is not qualitatively different from opiate abuse, but rather they are the result of self-hatred.This matches my clinical experience. If a patient goes from an alcohol use disorder to a gambling disorder, he does not have a new diagnosis, only a new symptom of an old diagnosis, which, in my mind would be a lost self. Rehabilitation centers need to help people love themselves, and how to do this is up for debate. Being tough, setting limits, or giving them understanding and compassion. Both approaches have successes and failures and both approaches do not know who to target and so most programs use a one-size fits all approach to a problem which uniquely develops in each person. In my mind, the diagnoses should be “escape disorder,” to group people together who need to escape from themselves, such that the major challenge is to find out what they are escaping. If they no longer have to escape, the substance will recede in importance. Is this oversimplifying a complex disorder? I do not think so. It is a hard job to find out what the patient is scared to face, and, of course, the pain they are avoiding is layered and often not obvious. Still, if the focus was on the escape and not the drug, there would be more hope. Our diagnostic system is important since it helps patients understand themselves and their family members. To speak in terms of “use disorders” misses the point.

 

 

Posted in Substance Abuse | 4 Comments »

Ferenczi, An Attitude, So says Andre Haynal: A European Analyst Hits the LA Scene

Posted by Dr. Vollmer on January 11, 2016

How do I come back to my blog in 2016? How do I not repeat my plea that psychiatrists need to return to history-taking, active listening, and thoughtful consideration of diagnoses, before plunging into the psychopharmacological rabbit hole, where patients do not know who they are or what their problem is, but they are stuck on medications which make them wonder if they, or the person who encouraged them into the mental health office, are “losing their mind.” How do I express my passion for pharmacology which sits next to my passion for understanding and explaining the inner workings of a complex mental apparatus, shaped by years of experiences, and in particular, early vulnerable experiences which lay down a foundation of neural networks which can be re-wired with monumental effort, but there are no short-cuts.

I return to my psychoanalytic roots, my training which promotes the dyad, the relationship between doctor and patient, hoping to return to the comfort of the womb, only to be reminded that my imaginary “womb” is also troubled. The doctor/patient relationship is essential for healing, any healing, but at the same time, the power differential in that relationship needs to be understood and appreciated. Patients are vulnerable, as is the physician, but there is an important asymmetry here. Patients can be persuaded to harm themselves, so often evidenced by the seduction of the patient, leading to the patient as re-victimized as a sexual object.

Once again, I find myself in this middle band, the band in which the 15 minute psychopharmacological appointment seems greedy and inappropriate to me, while at the same time, the intense psychoanalytic relationship can be used to feed the narcissism of the analyst at the expense of the patient. There is a middle band, but it is lonely and thinly available to me, in terms of like-minded colleagues. This has been my challenge, my point, in post after post.

Sunday, I immersed myself, or re-immersed myself, I should say in a psychoanalytic historical lecture about Sandor Ferenczi MD, the Hungarian psychoanalyst who was one of the many proteges of Freud, before he was ex-communicated. In the early 1900s Ferenczi promoted the idea that the doctor and patient are both flowers, sitting together trying to understand one another. There is free association on both sides, he would say. André Haynal MD, a swiss psychiatrist/psychoanalyst explained Ferenczi in historical context, allowing me to propose that while Ferenczi thought he encouraged free association, perhaps he encouraged the patient to feed Ferenczi’s narcissism, to make the analyst feel good, and in so doing, the patient repeated early trauma of sacrificing oneself for the other. Dr. Haynal appreciated the discourse, and a lively discussion ensued. I found myself pathologizing a great forefather in my field, knowing the possibility that one person’s great psychoanalytic treatment could be another person’s narcissistic feeding frenzy. In other words, treatment is not measurable, but ideas are worth struggling with, to deepen understanding.

With age, I see the multiplicity of ways in which scenes can be interpreted. One person’s mental illness is another person’s creative expression. The lines are blurry. I embrace that uncertainty. Now, I need to find peers.

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

2016

Posted by Dr. Vollmer on December 17, 2015

 

We turn over the calendar with hopes and dreams of turning over into a new and better self. We promise to exercise and eat better, pay more attention to our friends and family, and we hope to work either more or less, depending on our self-perception of the role that work should play in our lives. Inevitably, by mid-January, old habits return and the glow of new year’s resolutions dim. This return to ourselves, the part of ourselves which we find troublesome, or self-sabotaging, is so disturbing and yet so predictable because fundamental change requires a fundamental overhaul of the psyche. Hoping that a change in the calendar will somehow undo the bad habits that we have accumulated over decades is naïve, at best, and misguided, at worst. We can’t tell our addict loved ones to stop using drugs, nor can we tell our obese loved ones to eat less, since they both already know this. On the other hand, we can be sympathetic to how hard change is, any change for that matter. Most of us bumble along by inertia, doing what we did yesterday, not creating a lot of surprising behaviors. That is because habits are hard to break, even bad habits, because the familiarity of the habit may override the desire to stop it. The hope for a new beginning is endless. Each new week, each new month, and each new year can give us the notion that things can be different, because, after all, the calendar changed. Can we use the calendar change to cause internal change? Sure, but the effort is monumental, and without being braced for the intensity of change, relapse is bound to happen. We are creatures of habit, and with age, habits are more deeply entrenched. So we return to the importance of childhood, the importance of setting up good habits, both in terms of behaviors like diet and exercise, but also in terms of expectations for a relationship, the expectation of giving and taking and treating others with respect. The sooner we can lay down these neural pathways, the better each individual, and hence society will be. There is a critical period for the developing brain to learn how to take care of himself. As a society, nothing is more important than respecting that. Happy 2016! May all your wishes come true, with the associated effort required, of course.

Posted in Musings, Psychotherapy | 2 Comments »

Can Depression Be Taught?

Posted by Dr. Vollmer on December 10, 2015

Depression Class: check! I just had a wonderful and stimulating time teaching depression at the psychoanalytic institute and yet I am left feeling that this is a class which should not be taught. The word is simply meaningless. Psychic pain is my replacement. Pain is a symptom. Depression is a diagnosis. We need to be clear about the distinction. Symptoms trigger deep inquiry into the origin, the pathophysiology and the underlying issue. A diagnosis closes the discussion, as if there is nothing more to be said. “He is depressed,” the physician says, as if the next step is clear, when in fact, so much more needs to be done to investigate what that means. So, maybe I do need to teach this class to convey this point of view, spread the word, as they say. Yet, I am left feeling part of the problem and not part of the solution. I will lobby to rename this class “Psychic Pain” because this gets at the issue of how people suffer, and as with all of psychiatry, there are more differences than similarities between patients, making this the most interesting field in medicine from my point of view. Pattern recognition, the job of a good internist, to determine how symptoms present the clue to disease processes, gets old and routine, whereas the individuality of psychiatry, the unique stories of the patient, create an atmosphere of intense curiosity and openness to new perspectives. Looking at suffering as the end-product of years of life experience helps the patient understand how the past influences the present. It is not that the patient is “depressed,” but rather that the patient has hit a time in his life, both because of current and historical issues, along with their biology, making the patient lose the joy, the happiness, the fulfillment, in his life. There are contributing factors, but never a “good explanation” for why the patient is suffering. The quest of understanding is infinite and hence digging into suffering is a deep and moving experience. “Thank you for making me think about something I did not want to think about,” my patient expressed today, causing me to laugh and feel her gratitude, at the same time. That is what I want to teach. The way in which suffering has a language, which, when shared, creates an intimacy, a healing feeling, which cannot be quantified or predicted, and yet, is very meaningful when it happens. Psychic pain, that is what I am going to propose. That sounds right.

Posted in Psychotherapy, Teaching Psychoanalysis | 11 Comments »

 
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