Shirah Vollmer MD

The Musings of Dr. Vollmer

Staying Curious

Posted by Dr. Vollmer on November 16, 2017

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Stay curious. This is my message for my current class, “Building A Psychoanalytic Practice”. To stay curious, I say, is to wonder how what you, the therapist says, impacts the patient, and how what the patient says impacts  you. “Find your voice of curiosity” I say, encouraging them to see psychotherapy/psychoanalysis as an art, in which each moment is unique, and each reaction to each moment is also unique. This moment by moment analysis of the session is the complexity of psychotherapeutic work. The therapist is challenged to think on multiple levels at the same time, and in so doing, there are many options about what to say and when to say it. Finding your voice means making informed choices about what to say, when to say it, and how to say it. With professional growth comes a shared interest, between the therapist and the patient about being curious, and how that curiosity can lead to compassion and understanding of deep suffering. With that curiosity comes a passion and with that passion, a practice is built, most often slowly, and with that slowness, nerves of steel help tremendously. There is both anxiety and shame in building a practice which makes staying curious quite challenging. No one wants to admit that they are skill-building, while at the same time, taking on the responsibility of a patient’s mental health. And yet, that is how we grow. We build skills the hard way, by watching people suffer, and at times, inadvertently adding to their suffering, and then we try to walk it back, and grow again. Again, it helps to be curious both about how we help people and also about how we don’t. Being curious means not having answers, but generating more questions? Why did that patient not come back to psychotherapy? What do you think happened? Those are the questions we need to ask, along with the opposite question of why did the patient come back and why do they keep coming back? Being curious makes it fun, but at the same time, allowing one’s mind to open to multiple answers, can be unpleasant and painful. That is why both therapist and patient often resist curiosity and that is why my class presents to me a welcome challenge.

Posted in Teaching Psychoanalysis | Leave a Comment »

Neural Networks

Posted by Dr. Vollmer on November 15, 2017

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The chemical imbalance theory is out. Neural networks are in. That is what I learned yesterday. With the introduction of Transcranial Magnetic Stimulation (TMS), a neuromodulation therapy for major depression and post-traumatic stress disorder, there is now the theory that mood disorders, and anxiety disorders are a result of a neural network failure and as such, therapies which jolt neural networks help patients feel better. Further, by examining EEGs and looking at brain electrical activity, clinicians might be able to predict who can benefit from TMS therapy. As I understand from Noah Phillips MD, a professor at the VA affiliated with Brown University, we, as psychiatrists, are exploring the notion that patients get better by changing the electrical activity in the brain, a re-boot, so to speak. At the same time, TMS, although FDA approved (it should be now called Food, Drug, and Device Administration), TMS is costly, time-consuming and not paid for by insurance. It is done at tertiary medical centers and in private practice. As with the use of psychopharmacology,  I am of two-minds about this technology. On the one hand I am excited about the new way we understand mood and anxiety, and the expansion beyond neuro-chemicals into neural networks makes a lot of sense to me. The brain is a complicated machine, and like a machine, things can go wrong, and re-setting it is very exciting. On the other hand, this technology supports the loss of a narrative. Patient is sick. Patient gets fixed. Next Patient. The medical model of human suffering dominates the clinical picture, and the individuality of the patient is lost to the physician, leaving the narrative to “lower-level” professionals. Clearly both can operate in harmony. Doctors could administer TMS and do psychotherapy, except that the model of care does not support combining these modalities using the physician as the deep listener. I am grateful to be so close to UCLA so that I can be exposed to the latest and greatest in psychiatric health-care. At the same time, I will always have a sadness when I go to lectures, that there is such little interest in the human component of mental health care. To put it another way, as psychiatry focuses on the brain, it has lost its mind.

 

https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation

Posted in neuromodulation, Psychiatry in Transition | 4 Comments »

Building A Practice: Let’s Talk About It

Posted by Dr. Vollmer on November 13, 2017

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Wednesday begins my fall teaching activity which is entitled “Building A Psychoanalytic Practice”. In this class/seminar we talk about what goes into a private practice. In medicine, private practice is all but extinct. The vast majority of physicians work for big employers such as UCLA, Kaiser, Cedars-Sinai and USC. Electronic medical records has made it such that payment is based on clicks, and so the emphasis is on checking off boxes, meaning there is little room for a narrative, at least with a physician. The narrative, if it happens at all, is delegated to what they call “lower-level licensed professionals” such as nurse practitioners and physician assistants. The distinction between those two “lower-level” professionals is not clear to me, but I digress. What is clear to me is that the story the patient wants to tell, putting symptoms in context, is falling to people with less training and that deeply concerns me. I digress further. In my lonely world of being a private practice physician/psychiatrist/psychoanalyst, there are few comrades, particularly few younger comrades. So I teach to foster a community of professionals who want to struggle with that narrative, who want to hear patient’s stories and understand symptoms in context. Without context there is an over-prescribing of medications, resulting in the patient having a deep sense of pathology with regards to their behavior, as opposed to understanding that self-destructive, or avoidant behaviors may have a historical context. Understanding can lead to compassion and empathy  and in so doing psychopharmacology can be less relevant. To be clear, I do not advocate an either/or, psychotherapy or psychopharmacology, as both can be used in harmony, but I do think that psychopharmacology without psychotherapy takes away from the attempt to understand the human suffering, and in so doing, denies the complexity of the mind. My class will focus on deep listening, and how deep listening requires time, both time to learn how to listen, and time spent actually listening. In other words, the training required to build a practice is intensive, and in parallel, the work we are asking from our patients is also intense. The upshot of the class is the more time you have with patients, the deeper your work can be, and so when we market our practice, we market our time. We do not advertise quick fixes, or a limited number of sessions. In contrast to insurance-based work, where a limited number of sessions are given, we promote the opposite idea, that the work is open-ended, and it is done when it makes sense to be done, not when an external entity says it should be done. This is a very unpopular notion. It is why I began this post with my loneliness. Patients and insurance companies want to hear that there is an end in sight. I say we can’t promise that, and that honesty is what we are selling. Such controversial ideas, when stated out loud, in the past, has created a polarized class. Some students feel relief to have these ideas verbalized, while others feel despair, that they will not build a practice if they can’t propose a time-frame. I am a provocative teacher, or so I have discovered. Wish me luck.

Posted in Teaching, Teaching Psychoanalysis | 4 Comments »

Teaching, Teaching and More Teaching

Posted by Dr. Vollmer on August 23, 2017

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So, where, whom and why do I teach? The where is easy: UCLA, New Center for Psychoanalysis and LMU (sometimes). The whom, is also easy. I teach psychiatry residents, child psychiatry fellows and psychotherapists. The why is the challenging question. It keeps me stimulated mentally and it keeps me feeling young and in touch with the next generation. That is the short answer. The longer answer is more complicated. Do I like the admiration that sometimes results from a teacher/student relationship? Yes, and no, is my answer. Yes, it sometimes feels good, but no, with that admiration comes the flip side of “falling down” at times, as the student matures professionally. The teacher/student relationship, like the parent/child relationship is fraught with both idealization and devaluation. Like raising a child, in the beginning, there is a feeling of deep love, on both sides, but as the relationship develops over time, the dynamics get more nuanced, more layered with good and bad feelings. To teach is to grow, I would like to say, and I believe that to be true. Yet, with all growth, comes pain, and struggle, and so the challenges are large. I see myself as a life-long student, and as such, I have signed up for the life-long struggle of learning, growing, and expanding, which can feel exciting, but it can also feel  remarkably humbling. No one said growing is easy, and so it is not.

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

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

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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

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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 »

 
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