Posted by Dr. Vollmer on September 29, 2016
Spiritual is a word that confuses me. It is not that I do not appreciate the right-brain and all of the fantasies and creative thinking that results, but the word “spiritual” makes me wonder what the patient means when he says it. Do they mean that there is more to life than the mundane aspects of showering, eating and sleeping? Do they mean that the word “religious” troubles them, and so they compromise by using the word “spiritual”? Jay, seventy-one, comes to mind. He was brought up in a devoutly religious home, in which he feels did not “suit him”. He raised his children without any religion, and by his account, he suffers “tremendous regret” about that. In the last decade, he has become “obsessed” with yoga, which he feels to be very “spiritual”. My hunch with Jay is that yoga has allowed him to access the part of his brain which is non-linear, the part which is not focused on competition or comparisons. The “spirituality” of yoga seems to have given Jay the ability to relax, to not worry about his future, to not worry if he will be the next one of his friends to get a cancer diagnosis. It allows him to be “present” as he would say. How do I, as Jay’s psychiatrist, work with his “spirituality”? First, I try to understand the meaning it has for him, and how he integrates this word into his mental space. In other words, I try to understand how he connects this word to other ideas and fantasies in his mind. Second, I try to see how his “spiritual” side might help, and might hinder, his personal growth. This new-found love of yoga might open mental doors for him and allow him to get access to parts of his mind which were previously shut off, but it also might serve as a protective shield, in which he goes to yoga seven times a week as a way of avoiding having relationships with those he cares about. It is our job to explore this together, to try to add historical context to his newly discovered passion. The ambiguity inherent in the word spiritual is our open window into his mind. “Tell me more,” I like to say, truly curious about what it means to him.
Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 1 Comment »
Posted by Dr. Vollmer on September 26, 2016
What happens when a therapist needs to be liked, needs to feel like they matter, and/or needs to feel like they are nurturing and the patient does not meet the therapist’s need for such gratification? Often, the work grinds to a halt. The patient gets “busy” with other things. The therapist, suddenly, must cancel multiple appointments. These unconscious resistances on both sides of the couch is the meat of psychoanalytic teaching, and yet, the most challenging concept to grasp in psycho therapeutic work. In other words, the beginning therapist must put aside the layman’s notion that “this work is so gratifying” as the need for that gratification can impose a burden on the patient to say they are well, when, in fact, they are still suffering quietly. The therapist’s unconscious need for affirmation can replicate the patient’s role in his/her family to make sure that their parent is happy, at the expense of knowing their own true self. In this scenario, the patient is not only not getting better, but in fact, is being re-traumatized by the alleged therapeutic situation.
Ty, a forty-year old female patient, and Tro, a forty-four year old female beginning therapist start to work together. Ty keeps telling Tro how much she is helping her. Tro reports the gratification is seeing Ty develop and suddenly, after 6 weeks, Ty drops out of therapy, while Tro is aware that Ty remains in a difficult relationship and she has occasional substance abuse issues. Tro is bewildered. On the one hand Ty expressed gratitude at every session, and on the other hand, Ty stopped the work prematurely, according to Tro. “Could it be that Ty unconsciously had to tell you how much you were helping her, because she sensed your need for affirmation, but that deep down, Ty knew that she was not finding her sense of agency, her sense of her own voice?” I say, to my student, to her amazement and somewhat alarm. “You mean that I am letting my own stuff get in the way?” She asks, astutely. “If by stuff, you mean, your need to feel validated by others, then yes, that could be getting in the way of Ty being more authentic. She may feel she has to care for you and make sure that your ego is intact, as she had to do that with her mom.” I respond, pleased that Tro is quickly grasping the concept of counter-transference. “It is hard to be in a field, where positive reinforcement can be a defense,” I say, trying to make light of this challenging topic. “The holy grail of reward is seeing a patient become less defensive, which does not necessarily translate into holiday cards, or presents. In fact, gifts become a complicated subject, layered with meaning, and sometimes, “you guessed it” I say, a defensive act.
Posted in Psychotherapy, Psychoanalysis, Teaching Psychoanalysis, Countertransference | 2 Comments »
Posted by Dr. Vollmer on September 19, 2016
Primitive mental state-that is what I strongly prefer to say when my students tell me that their patient, or their patient’s mother has “Borderline Personality Disorder.” My reasons are many, which begin with I find this diagnosis misogynistic, given to women who exhibit colorful or spirited emotional responses to stress, thereby imposing a judgment in which emotional reactions are somehow pathological. I accept that women and men, as a general rule, express themselves differently, but to say that a woman who describes dark moments in her feelings a “borderline” is to inhibit the facilitation of emotional expression. Second, I find this diagnosis a way of saying that the doctor does not like the patient, and finds the patient’s emotional experience objectionable. It is as if the doctor perceives the patient in a compassionate way, then the doctor diagnoses Major Depression, but if the doctor starts to feel uncomfortable with a patient, then he/she is more likely to throw the personality disorder label on the patient. Third, the terminology “Borderline Personality Disorder” does not convey the process in which the personality needs help. I prefer the developmental model of personality in which some of us fail to develop, or we develop and then we regress to more primitive expressions of our feelings which often involve rage and bodily and/or property destruction. If we were to use the term “primitive mental state” then we convey a certain hopefulness, that with all states of mind, they are fluid and subject to maturity and emotional growth, whereas “Borderline Personality Disorder” implies a life-long struggle which borders, pun intended, on hopelessness.
My students, taught this diagnostic system, are almost always taken aback by my objection to our language, which shapes our thinking, and hence our interventions. The advantage of a big institution, like UCLA, for example, is that students are exposed to multiple ways of approaching this complicated organ, we refer to as the brain. This seems to give little comfort, when I encourage them to challenge their rock stars. Students, like patients, have a transference to their teachers, and so learning new information, in such an intimate setting, is not an emotionally neutral experience, but rather it is an experience filled with identifications and defensiveness. Therein lies my challenge. I need to work with both the conscious and unconscious aspects of my student’s brain, while at the same time, not go too deeply into their own personal dynamics. Like psychotherapy, this is a delicate dance, which most of the time goes well, but occasionally I need to be mindful, not only the layers in treatment, but the layers in teaching as well.
Posted in Borderline Personality Disorder, Psychiatry in Transition, Psychoanalysis, Psychotherapy, Teaching Psychoanalysis | 5 Comments »
Posted by Dr. Vollmer on September 1, 2016
Many people ask me whether I exaggerate the issues in my profession, so I am always glad to read works from psychiatrists who have similar concerns. In this article, Nathaniel Morris MD, a psychiatry resident at Stanford outlines similar concerns of how we sabotaged ourselves by getting greedy with regards to “medication management” and in so doing we have lost the trust of our patients. Can we turn ourselves around, he ponders. I hope so, because if we don’t we will get folded into Neurology, and the curiosity about the unconscious might get lost in the profession.
Posted in Psychiatry in Transition | 2 Comments »
Posted by Dr. Vollmer on August 31, 2016
Posted in Asperger's Disorder | 1 Comment »
Posted by Dr. Vollmer on August 8, 2016
We prescribe antipsychotic medications which cause weight gain and serious metabolic side effects. Why don’t we weigh patients at every appointment to monitor the impact of our medications? It seems obvious that we should, but changing the model of care is slow and out of step with our shift towards a more medical model of treatment, and away from the more psychological, or history-driven emphasis of care. Psychiatrists were quick to embrace becoming “pill-mills” which meant shortening appointment times, lengthening the time between visits, and relying on non-MDs for the patient’s history, and yet, we, as a group, are slow to embrace the “data” available to us, which in this case means weight. Although it is a simple point, I think it speaks volumes about the inconsistencies in my profession. If we are to align ourselves with our internal medicine colleagues, then we should follow their lead in collecting as much patient data as we can. At the same time, we can maintain the strong principle of listening, allowing ourselves time to understand, as a means of healing. As I have posted previously, I take issue with our new model of care in which the psychiatrist prescribes in the dark, without understanding the meaning of the patient’s symptoms in the larger context of his history and his associations to his struggles. I now also go on record as objecting to the lack of data mining to monitor the impact of our prescribed medication. It is time to weigh our patients.
Posted in Psychiatry in Transition, Psychopharmacology | 2 Comments »
Posted by Dr. Vollmer on August 1, 2016
“Gallegos was caught in a historic transition in housing policy as the federal government wrestled with how to parcel out inadequate resources to the most needy. It’s a shift away from waiting lists toward what is essentially a homelessness grading system.”
The most vulnerable population gets hurt over and over again. Without advocacy, the mentally ill are often falling through the proverbial crack. In my experience, those well enough to “work the system” often get tremendous benefits, but those who have little insight into how a city distributes funding, or those who do not have loved ones who can help them, suffer the most. Systems can be “gamed” and those savvy enough to understand that get to the top of the line. Cynical, you say? Maybe, but maybe also true. The issue with mental illness is that, by definition, the illness impairs their ability to navigate systems of care and as such, they often lack the mental tools necessary to deal with changing rules, and as such, homelessness often results. The homeless mentally ill, by and large, do not vote, and as such they lack political power. Having said that, there are wonderful advocacy groups such as NAMI, http://www.nami.org/ which make a large impact on helping the helpless. Still, there is work to be done. This LA Times story of Rory brought tears to my eyes. How he could fall down on the list because the rules changed on him is simply tragic. This new system is based on a paper and pencil test, which more insightful folks, will fill out to gain priority, rather than honestly answering the questions, thereby tilting the program to the less-needy.
We know that “Housing First” programs work. http://www.endhomelessness.org/pages/housing_first . The lower the threshold to get housing, the faster people, including people with mental illness, will function independently. If we know that, why don’t we act on that? The answer is that there a huge housing shortage in LA County. Too many developers are gaining from building new apartments and homes for paying customers. They often create low-income housing along with new housing, but not enough to meet the growing need to house this population. Government must intervene to care for our most needy. As a psychiatrist, I want to shout about it. It is a baby step.
Posted in Chronic Mental Illness | 2 Comments »
Posted by Dr. Vollmer on June 29, 2016
If child psychiatrists spend their time prescribing medication, and if foster children are over medicated, then it stands to reason that child psychiatrists are exacerbating the problem and then the so-called shortage of child psychiatrists, might, in fact, be a good thing. It is true that foster children are not only treated by child psychiatrists, as these medications may be prescribed by pediatricians, neurologists, primary care physicians or nurse practitioners, it is still true, that if child psychiatrists stop prescribing these medications, then these other providers would not feel comfortable prescribing them. The use of these medications for behavioral management is simply inhumane because of the metabolic and cognitive side effects. There, I have said it again, as I will again, as this has got to stop.
Posted in Child Psychiatry | 4 Comments »
Posted by Dr. Vollmer on June 28, 2016
“There are only about 8,500 child psychiatrists in America, not nearly enough for the estimated 15 million kids who need one, the American Academy of Child and Adolescent Psychiatry says. On the local level, the shortfall becomes more pronounced. No individual state meets the AACAP’s standard of 47 child psychiatrists for every 100,000 children 17 or younger — or one for every 2,127 kids. In Wyoming, there is one child psychiatrist for 22,960 children, and in Texas the ratio is one per 12,122. Only Washington D.C., enjoys what the group calls “sufficient supply,” with one child psychiatrist for every 1,797 children.”
The mantra that there are not enough child psychiatrists in the US, as stated above, comes from the American Academy of Child and Adolescent Psychiatry. A group that I respect and often attend their professional meetings. Yet, I question this assertion. Child Psychiatrists, by and large, prescribe medication, and as such, they help some children, while, at the same time, they, as a profession, are guilty of over-prescribing medication to children who could benefit more from behavioral and/or psychological interventions. So, it is not clear to me that the problem is physician supply, but rather I see the problem as the need to re-define the job of the child psychiatrist. If the child psychiatrist were in charge of systems of care for children, we would not need more child psychiatrists, but rather we would need to change the training of child psychiatrists to include leadership skills to improve the health and welfare of children and their families. If we do not train child psychiatrists to take the aerial view of the profession, and we continue to train them to take a piecemeal view of children, then training more child psychiatrists will not help. We need to learn how to be thought leaders, and as such, we need to learn how to execute our ideas into a major overhaul of mental health for children which includes wellness centers, home visits, and family interventions. Medication can be a piece of this, but, it is only one of many pieces. This is the message that we need to get out to policy makers. Incentivizing child psychiatry by loan repayment programs or higher salaries are not the answer. The field needs to change its focus. There, I have said it again.
Posted in Child Psychiatry | 2 Comments »
Posted by Dr. Vollmer on June 23, 2016
White privilege, in academic measures, leads to higher school performance than minority children, creating, what experts call the “achievement gap.” Although many factors contribute to this gap, the increase in stressors, be it poverty, domestic violence, childhood neglect and abuse, make it difficult for children to learn, and to have a supportive learning environment. Further, minorities tend to go to schools with fewer resources to support their education. Given that, what is the role of the child psychiatrist? How can he/she advocate for these kids? Providing mental health care at these schools is one answer. If these schools were staffed with mental health professionals who were trained to help children cope with their environments, could their school performance improve? I bet so, but studies are needed to prove this hypothesis. Plus, what about the funding? Well, if we assume that kids with lower achievement are more likely to drop out, and therefore have fewer employment opportunities, and be more likely to end up in the correctional system, then keeping these kids in school could pay off in the long run. My solution: have every parent sign a consent for mental health treatment, at school, if the need arises and is deemed necessary by school personnel. That way, as soon as symptoms are identified, intervention could be immediate. There, I have solved the problem. Of course not, but I think that is a good first step.
Posted in Child Psychiatry, school visit, school refusal | 4 Comments »