Shirah Vollmer MD

The Musings of Dr. Vollmer

Gender Health?

Posted by Dr. Vollmer on January 11, 2018

https://www.uclahealth.org/med-peds-care/gender-health-program

 

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With deep respect for UCLA as an institution, and with deep respect for my training which has entirely occurred at UCLA, and with deep respect for the many departments within UCLA that I have been affiliated, I am quite curious and, dare I say, skeptical, about a “gender health program”. Reflecting back on my training in the 1980s (yea, I am getting old, I know), UCLA was doing transgender surgery, mostly in the department of urology. Mostly they were turning male genitalia into female genitalia. Other tertiary care medical centers were doing this too, and so this was a “standard of care” a phrase which has now been replaced by “evidenced-based medicine”. In the early 90s they stopped doing this surgery and so patients seeking a change in genitalia sought private practice doctors, both here in LA and around the world. Medical tourism was a popular notion among male-female transgender folks as they could pay out of pocket a fraction of the cost in another country, and that would include their airfare, a fancy hotel, and an American trained physician working in another country (usually their birth country). Somewhere around 2010, the “medicalization” of transgender patients took off, with the example being in LA, that children’s hospital started a clinic…

http://www.chla.org/the-center-transyouth-health-and-development and then pediatricians throughout LA, when faced with a patient who expressed discomfort with their gender, would be sent to Children’s Hospital. The assumption is that CHLA is a good hospital and so, therefore, they must appropriately deal with transgender issues, since most pediatricians have no training in this area. Somehow, UCLA seems to want to join the party, and so the Gender Health Program is born. I say this, with the complete disclosure that I am not aware of the politics, or the motivation behind opening this clinic, but I do enjoy speculating publicly (to my 50 or so readers), as to how transgender issues seem to come and go within the medical profession. Having Gender Dysphoria..as opposed to Gender Identity Disorder (GID)..see below

 

GID was reclassified to gender dysphoria by the DSM5. … The American Psychiatric Association, publisher of the DSM5, states that “gender nonconformity is not in itself a mental disorder. The critical element ofgender dysphoria is the presence of clinically significant distress associated with the condition.

 

…is a mental disorder. I am not sure that I agree that those who have distress over their gender are mentally ill. Sure, they need a prescription for hormones, and possibly surgery, to change their gender, so they do need medical care, but whether they need mental health care has more to do with individual preference. A patient, for example, might have extreme distress over the size of their nose, but they don’t need to see a psychiatrist if they opt for rhinoplasty to attempt to minimize their distress. I know this statement is very controversial when it comes to gender, but I think this argument is worth consideration. If the patient is curious as to why their nose distresses them so much, then mental health intervention makes sense, but if there is no curiosity, then mental health care is harder to execute. In the 70s being gay meant you had a mental illness. That quickly got fixed when psychiatrists realized the absurdity of that notion. Being bisexual, or uncertain of your sexuality, is also not a mental illness. So, I would say that being uncertain about your gender is not a diagnosis, but only a nodal point, which suggests thinking about how to proceed. As with all big decisions, we, as psychiatrists, can help people through them, but it is also true that people make big decisions without our help and do just fine.

Returning to the Gender Health Program, I can see the advantage of pooling patient populations in order to develop an expertise. I can also see the marketing advantage that the program makes people feel like they will have a place of understanding. My issue is that Gender Health is a made-up term. I wish they would call it a Gender Program. I am not sure what Health has to do with it, as the patient may not be sick to begin with.

 

 

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Patient Sculpting

Posted by Dr. Vollmer on December 19, 2017

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Hans Loewald  discusses the idea of patient sculpting, meaning that the therapist imagines the patient without his neurosis, and in so doing, imagines the patient having a more fulfilling life. What would the patient be like if he did not live out the guilt of his parents, for example. Lewis, sixty-six comes to mind. He is the son of holocaust survivors. Parents who instilled in him a sense that the world is a frightening place and he must be suspicious at all times. Lewis has embraced this philosophy unwittingly, living his life in constant fear, but not exactly understanding what he is afraid of. Imagining Lewis without anxiety is what some theoreticians call an “analytic stance”. If Lewis could come to understand that he “inherited” this fear from the trauma his parents experienced, then he could begin to separate out his reality from theirs. In so doing, Lewis could come to experience life in a more relaxed and engaging manner. Moreover, his physical symptoms of irritable bowel and intermittent headaches might improve substantially. A patient without anxiety uncovers the goodness of his soul, as anxiety can obscure that. Keeping the vision provides hope for patients. All of this is not spoken, and yet, magically transmitted between therapist and patient. How to teach these concepts is challenging and yet also very fulfilling. As with sculpture, each student has to find his method. The art of psychotherapy lies in its creativity and in its uniqueness with each therapist/patient dyad. There, I have said it again.

 

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

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 4 Comments »

Why Is It Hard To Stay Curious?

Posted by Dr. Vollmer on December 5, 2017

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The therapist, as Hans Loewald says, holds in mind an image of the patient without neurotic distortions. In other words, the therapist can see how the patient mis-perceives his universe, and in so doing, causes himself to suffer, and so it stands to reason that if perceptions could be more accurate, or less historical, then the patient would suffer a lot less. In other words, we, as humans, unconsciously feel that current situations are triggering past situations, and so we react as we did in the past, without the benefit of a more mature mind. The therapist, mindful of this distortion, envisions the patient with a more mature mind, and thereby imagines a patient with a more fulfilling life. This imagination creates therapeutic zeal, which in the right amount, can carry the therapist and the patient through hard therapeutic times, but if the therapeutic zeal tilts to a more self-centered approach by the therapist than that zeal can kill the treatment. This brings me to my class tomorrow. We will discuss how to imagine patients without symptoms, without being overbearing or inserting one’s own agenda. The sweet spot of curiosity without a specific agenda is the gift we give to our patients. Yet, it is hard to stay curious. Maybe we didn’t sleep well. Maybe we are burnt out. Maybe the patient is boring. Maybe we have too many acute issues on our plate and there is not enough bandwidth to think about someone else’s problems. Maybe we are  hungry. My class is designed to talk about ways in which we mess ourselves up, and by we I mean we therapists. That perhaps building a psychoanalytic practice, or a psychotherapy practice is not what we want to be doing. Can we express that out loud? Maybe we have serious ambivalence. Here, we as therapists, believe that talking about ambivalence is the key to bringing authenticity and depth to one’s inner life, and yet, at the same time, we feel shame in talking about our own ambivalence towards the profession. This ambivalence changes every moment, with every patient, and with the maturing practice and yet, how do we talk about that without feeling shame and without worrying about getting referrals. Do we pretend to always be curious, when, in fact, there are times when we lose our curiosity, when we just want to go home or we just do not want to get out of bed? If authenticity is our holy grail, then we need to be authentic with ourselves, and our trusted colleagues. We have to hold in mind ourselves, with the humanity to know that we do not always show up for patients in the way that we might hope we do. Despite many hours of training, and despite many hours of reading theory, and despite our own treatment, we fail patients, or we are less than optimum, at times. Psychoanalytic work helps us with the concept of repair. We try to repair, knowing that we are flawed. That repair can be a healing process does not justify the fact that we let people down, in subtle ways, in every hour, and with every patient. This is a field of humility. I like to say. We know we do not know what we are doing, and yet, we are motivated to keep trying to do things better and better. We are motivated to stay curious, and then to be curious as to why we lose curiosity. That’s what we do, and for that, patients are helped through the human suffering that brought them to our offices. Or, I should say, we hope for that.

Posted in Teaching, Teaching Psychoanalysis | 2 Comments »

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 | 2 Comments »

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 | 8 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 | 8 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

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 »

 
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