Shirah Vollmer MD

The Musings of Dr. Vollmer

Why I Blog? The List

Posted by Dr. Vollmer on January 16, 2017

Image result for blog1. I am overwhelmingly sad by what I see as the death of my profession, and the transformation of psychiatry into a specialty that has more similarities to Neurology than it does to Psychology.

2. As a result of number 1, I see patient care being compromised significantly, and as such, many vulnerable people are being mis-labeled and “educated” to see themselves as ill, as opposed to experiencing human suffering.

3. Also as a result of number 1, those attracted to the field of psychiatry are not necessarily interested in the human mind and the various nuances and uncertainties which flow from this immensely fascinating organ.

4. Although I have a passion for psychoanalysis, I am also concerned that psychoanalysts are trying to “justify” their position by developing outcome measures, when in fact, human beings, at least in terms of their mental state, are not measurable. I think we have to come to accept that if insurance companies what outcome measures for our work, then we cannot accept insurance.

5. Further from number 1 are patient expectations that human suffering can be significantly alleviated with a medication, which although sometimes that is true, for the vast majority of people, it is not true.

6. Psychiatrists, by my way of thinking, jumped on the ship of “medication management” and in so doing, committed professional suicide for all of us. The result is less job satisfaction, less patient satisfaction, and poor patient care.

7. The “is bad care better than no care question” plagues all of health care, and in particular mental health care. I blog to struggle with those issues.

8. I blog to focus my teaching, to learn to make my points concisely and directly.

9. I blog to think clearly about hypothetical, or fictionalized patient scenarios. It is a “consultation,” if you will.

10. I blog to describe the thoughtfulness that goes into listening; to review the lost art.

 

Posted in Musings, Psychiatry in Transition | 4 Comments »

Can A Patient Have A Bad Attitude?

Posted by Dr. Vollmer on December 14, 2016

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A bad attitude can be a symptom of depression. Depression is a mood state we psychiatrists treat. So, is it possible that a psychiatrist says to a patient “the reason you are not getting better is that you have a bad attitude,”? As the story relates to me, I have no way of knowing the validity of that tale, but I want to take a moment to consider the notion of a psychiatric patient with a “bad attitude”. The idea feels so shaming and so blaming to me, I can hardly believe a psychiatrist could express this notion, and yet, at the same time, as more psychiatrists are “pill-mills” and as we know that our pills have limited efficacy, the frustration from the psychiatrist could translate to blaming the patient. Maybe we do not understand our tools, or for that matter, the human mind, enough to understand why people either get better or do not get better. Can we accept that amount of humility in our profession, or do we need to assume that a poor outcome has to do with the patient? The absurdity makes me laugh. If the patient had a “good attitude” what is he doing in our office? We treat “bad attitudes,” not by being accusatory, but by trying to understand the underpinnings of this “attitude,” or to put it another way, we try to understand it in historical context. Of course, historical context takes time and energy, along with carefully honed listening skills, a set of strengths that are no longer taught in Psychiatry Residencies, leading, to what I see, as professional suicide for all of us. The hard truth is that when our pills fail, which they often do, we must be able to use listening skills to help patients sort out their mental suffering so that they can have a narrative which helps them navigate their life, both past and present. If we lose these skills, the job satisfaction will be poor, and patient satisfaction will also be poor. The result, as I see it, will be a complete disillusionment with the field. There, I have ranted again. I just cannot say this too many times or too many ways. The state of my profession is dire, and we need to have an open discussion before we die completely. That is my hope, that these posts will stimulate a forum to push back and encourage psychiatrists to listen deeply, to learn how to listen in a therapeutic manner. The “good ol days” were indeed better than our present. I maintain that point of view and I am open to talking about that further. The gauntlet has been laid. I wait.

 

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

Marketing Psychoanalysis

Posted by Dr. Vollmer on December 13, 2016

Marketing psychoanalysis used to be an unspoken taboo, meaning that patients were supposed to come and seek our intensive help, rather than clinicians seeking patients to treat. This worked well when the supply of psychoanalysts outstripped the demand. In the 60’s and 70’s, and even in the 80’s most analytic institutes did not allow non-MDs to enter training, thereby limiting the available psychoanalysts. Further, in the 60’s psychoanalysis was a popular treatment modality, particularly in big cities in which it was fashionable to say, “my analyst says….” There was status to having an analyst and there was a sense that as a result of being in analysis, deeper creativity and deeper meaning in life could be obtained. Further, many insurance companies paid for the treatment, so the cost was not a big issue for some, leaving only the large time commitment the major barrier to care. As time marched on, the 90s brought us SSRIs and with that limited insurance coverage for psychotherapy. In the 80s, non-MDs sued the American Psychoanalytic Association for discrimination, and they won, opening the doors to non-MD therapists to enter in psychoanalytic training. Now, we have many more providers and much less demand, creating a situation in which marketing is essential to prevent professional death. Yet, how do we teach marketing when our senior colleagues find marketing offensive, in that it might diminish the élite aspect to the field? Marketing gives up the notion that we are a sought after commodity. It makes us be more honest with our environment, which of course, is what psychoanalysis claims to do to help patients. This massive shift in supply and demand is the subject of my class entitled “Building A Psychoanalytic Practice.” As I come to the end of my seminar, I hope to convey that our hard-earned psychoanalytic skills cannot be honed unless we have patients, and we can’t have patients unless we announce to the world what we do. Supply and demand has flipped since psychoanalysis came to America. We either adapt or die. It is that simple.

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

Analysis as Apprenticeship

Posted by Dr. Vollmer on December 8, 2016

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How do you make a psychoanalyst? No one knows, is the short answer. The tradition has relied on a tripartite model in which the student, a licensed clinician, enters into a personal analysis, attends four years of classes which are four hours a week, associated with one-hundred pages of reading per week, and has three psychoanalytic case control patients, which means three patients come four times a week, and each of those patients is associated with a supervisor who discusses the clinical work. This is a daunting task for most students who have loans to pay and children to raise, and yet, year after year, the five psychoanalytic institutes in town, get students, and every year there are students who graduate, now thinking of themselves as psychoanalysts. To paraphrase Mark Twain, the reports of the death of psychoanalysis are premature. Having said that, there is no agreement about how to develop a psychoanalyst, or how to develop a psychoanalytic practice, and yet, my task is to teach this subject to first-year students. As you could predict, I pull the curtain back and expose the fact that we do not know precise definitions of a psychoanalyst or psychoanalytic treatment, but we accept that we work in a fuzzy field, in which we cannot scientifically prove that we offer help, and yet, we have the conviction that we do. To work with conviction sounds awfully like a religion, and so we discuss that too. In essence, we have, what amounts to apprenticeships, where students find mentors who guide them through their work, and so traditions are passed down, which may or may not be helpful. The student, I emphasize, must find the path that makes sense for them. This provides little comfort, as the mandate is purposefully vague. I have one more class to teach. My students are enthusiastic and confused. I think I did my job.

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

The Shame of Ambivalence

Posted by Dr. Vollmer on December 6, 2016

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The grey areas of life tend to be the most anxiety provoking. The desire for a black and white world is universal, and this desire increases under stress. Tolerating mixed feelings, as a parent, as a spouse, as a professional, is the challenge of deepening one’s psychic existence. Tomorrow, as we explore the prospect of building a psychoanalytic practice with new students in the profession, we will discuss how, just like with our patients, the biggest obstacle may not be the fees requested from patients, the time required from the patient, but rather self-sabotage, the reluctance in these students to push forward with their stated goal for career development. Clearly, the patient has fears about deepening psychic work in that the digging up of past experiences can be fraught with pain and anxiety, but perhaps less well known, is the fear in the analyst which makes the psychoanalyst half-halfheartedly promote intense psychological discoveries. According to Roy Schafer, becoming an analyst entails an unending effort that includes tolerating confusing uncertainties about our understanding of our patients and our role in effecting therapeutic change. In other words, the psychoanalyst, but first accept a lack of understanding of his patient, and second accept that if he does understand his patient, he may not be able to bring about symptom relief, or psychic growth. According to RS Wille, the analyst must trust in the relationship between patient and analyst and in the analytic setting as sources of meaning. He suggests that in varying degrees, all analysts struggle to maintain their analytic identity. Lena Ehrlich says we, as psychoanalysts have a reluctance “to recognize the limitations of our influence and how, despite our best efforts, our patients are ultimately responsible for how they lead their lives.” This is challenging work because the psychic arena, the material in the office, as described by Parsons is make up of “symbolism, fantasy, transference and unconscious meaning.” As such, psychic reality becomes the domain, a reality that cannot be proven by fact, but rather can feel right, or resonate with the patient. It is this search for resonance which guides the work, but this search comes with great humility, that resonance may or may not reflect deep meaning. In essence, working as a psychoanalyst stems from a conviction, not a science, not a religion, but a conviction, that engaging with people in a deep way, keeping the patient’s interest in the foreground, allows for psychic growth. This conviction is shake-able, and so we, as psychoanalysts, must allow ourselves to question and consider alternatives, while at the same time, remind ourselves that all intense relationships are ambivalent, even therapeutic ones.

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

Analytic Stance

Posted by Dr. Vollmer on November 30, 2016

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The patient comes in with a stomach-ache, many things could explain it, but the psychoanalyst wonders about the psychology, the historical roots, and the meaning of the  stomach-ache, while the patient wants her stomach to feel better. This cross-purposes describes the “analytic stance” where the therapist is thinking on multiple levels, even if the patient is not. The stomach ache could be present as a way to communicate that she needs nurturing, but rather than asking for nurturing, or saying she needs nurturing, she presents with a stomach-ache because as a child she learned that the only way she could get attention was by being physically sick. So now, as an adult, she experiences psychological distress through her body. In other words, her psychological stress transforms into a bodily complaint, because talking about how her body is betraying her is a comfortable way for her to communicate with a doctor, even if that doctor is a psychiatrist. To say, that she is lonely or scared, or at loose ends, are feelings that she is not at ease to discuss. By contrast, complaining about her stomach is familiar and, in the past, has rewarded her with attention which helps her feel cared for. To understand her stomach ache in context, as code language for asking for emotional support, is the beginning of a psychoanalytic process which might grow into a deep treatment, that is, a deep understanding of her distress. The patient may walk out with the same stomach-ache she walked in with, but at the same time, she is stimulated to consider her distress in different ways, and in so doing, the stomach-ache could gradually recede, and with further work to understand her issues, her stomach-ache may not  come back.  She will discover more direct ways of communicating her feelings and in so doing, her relationships with others, and with herself will feel fulfilling. The psychoanalytic process will pay off, but not in the immediate way of relieving her chief complaint.

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

Affective Intensity

Posted by Dr. Vollmer on November 29, 2016

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And so begins again my class entitled “Building A Psychoanalytic Practice”. Some might call this a marketing class, in that the class is designed to help students deepen their work by transitioning some of their patients from once a week to multiple times a week. In so doing, an analysis, or deep psychological work, can occur. The focus of the class is to help students see the barriers, both conscious and unconscious, to working analytically, on both sides of the proverbial couch. One of these barriers is that more frequent visits invite an affective intensity which can be frightening to both the patient and the therapist.  Feeling shame or guilt, for example, can be deeply painful and de-stabilizing, and so there is often a strong desire to paper over these feelings with directives, platitudes and a lot of time between sessions. Increasing frequency makes the sessions less of a “dear diary” and more about “what is really going on here?” Looking down into the bowels of the mind, ultimately results in a more mature view of the world, but in the short-term increases anxiety and causes psychological discomfort. Dealing with difficult feelings, even if it is for the greater good, is the challenge of analytic work. Hence, as I said in my last post, this work is not a “lifestyle specialty,” but rather it demands the capacity to handle so many different types of feelings, the ability to listen and feel, in a way which is both empathic and thought-provoking. The therapist, the psychoanalyst, must facilitate the exploration, the archaeological dig, as Freud called it, in a way which titrates the associated feelings such that the patient is  stimulated to reflect on himself, but not overwhelmed and paralyzed by the experience. At the same time, the analyst needs to use his intuition to comment on how seemingly unrelated events, may, in fact, be related on a psychological level. It is this weaving of the affective domain with the cognitive domain which makes the work of the psychoanalyst challenging on many levels. Like starting chemotherapy, both the patient and the physician might be frightened about what untoward effects might happen, and yet, there are few other choices, for some, if they want to rid themselves of their poor judgment and self-sabotaging behaviors.

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

Psychiatry as a “Lifestyle Specialty”

Posted by Dr. Vollmer on November 23, 2016

With Thanksgiving approaching, I want to publicly thank my patients for giving me the privilege of entering their interior, knowing the courage and strength it takes to expose one’s deepest thoughts and feelings, both conscious and unconscious. My inner world is deeper and richer as a result of my work, and for that, I am eternally grateful. Having said that, I now return to my rant about the changing nature of my profession. Psychiatry is becoming a more popular specialty choice for medical students. The word on the street is that these students classify career choices based on how lucrative they are, and/or how “sensible” they are, meaning that certain specialties, are what they call “lifestyle specialties” in that the profession offers the opportunity to spend time doing other things, which usually means spending time with family. These “lifestyle specialties” contrast with surgical specialties, or life and death professions, like cardiology, where the commitment to one’s career has to trump other activities. Psychiatry, as a “lifestyle specialty” sends me flying with outrage and confusion. How does listening to physical and sexual abuse, deeply traumatic losses, and terribly self-destructive thoughts, create a “good lifestyle”? The emotional toll of getting down deep with patients is significant, thereby decreasing the bandwidth for listening to other important people in your life. This is a major occupational hazard, and as such, the “lifestyle” is compromised. When I challenge medical students with this notion, the feedback is the following: “I plan on just doing medications, so it won’t be so bad.” Oh my, I say to myself. How do I respond to that? First, I want to say that I do not understand what “just doing medication” means. I understand that they think they will be doing 15 minute visits in which they will be tweaking medications, for the most part. So, they are creating a superficial interaction, on purpose? They are signing up for boredom, in exchange for leaving the office by 6 pm? I am horrified. They, these students who claim that psychiatry is a “lifestyle specialty” are embracing the dullness of the work, when, in fact, by my way of thinking, psychiatry is the most stimulating field, in that one has no algorithms. The psychiatrist, at least in my day, must constantly be thinking on his feet. These “med checks” involve little thought, in that the medication is either increased, decreased, or stays the same, and in so doing, no deep conversation is had or sought after. And this is OK because the hours are good? I continue to be beside myself with a deep sense of grief, that the profession I entered is not the profession that exists today.  I know that with technology, with global trade and with clean energy, many professions of yesterday are gone forever. I am slowly accepting that mine is too.

Posted in Psychiatry in Transition | 4 Comments »

Psychiatric Identity: What Does It Mean To Be A Psychiatrist?

Posted by Dr. Vollmer on October 13, 2016

What does it mean to be a psychiatrist in 2016? As I teach many UCLA Psychiatry Residents, this question comes up on a weekly basis. My identity, feeling not much older, but in fact being twenty years older, is vastly different from their budding professionalism. I see myself as someone who listens, someone who privileges past experience as causing current symptoms, as someone who deeply feels that developing in-depth narratives is a healing process. I see myself as someone who has a toolbox which includes medication, but I do not privilege that over my other tools. They see themselves as someone skilled at “psychopharmacology,” a word I have come to despise, as that word has justified the development of pill-mills, doctors who have an assembly-line of patients, lined up to get a prescription, as if it is some sort of food line. I see myself as developing long-term relationships with patients, not that patients will see me for their whole lives, but rather patients will see me as a resource for their whole lives. They see themselves as not knowing their patients, not recognizing them on the street, or knowing their major milestones. Their identity makes me wonder two things. First, how do they not burn out? If they don’t develop relationships with their patients, how do they get up every morning and do their job? Where is the passion, the life-force, which makes them feel fulfilled? “It is not enough to help someone,” I say, “but it is important, for your own satisfaction, to know who you helped.” Second, and similar to my first question, how do they feel stimulation? Our medications have stagnated since the 90s. Our new treatments are expensive, and not necessarily robust. Understanding and listening is a stimulating and constantly changing experience. There is novelty on an hourly basis, and yet, prescribing medication can become painfully routine.

One resident, quoting another resident, said that they did not want to learn psychotherapy because it is “boring”. I was quite shocked by the comment, but my response was “of course it is boring, if you don’t have the skills to know how to listen, then it is boring.” Mastery is very important to self-esteem. Learning a new skill is both humiliating and time-consuming. “Psychopharmacology” is a relatively quick learning-curve, leading to a short-time to mastery, which I understand is seductive. Yet, what about the long haul? How do these residents do in twenty, thirty years? My hunch is that their passion goes elsewhere. They develop intense hobbies, and have intense relationships outside of work, while being a psychiatrist is their “day job”. I can see how this gives them a nice life, a comfortable salary, and time to themselves and to their families. At the same time, I am overwhelmed with sadness that the passion in psychiatry seems to be dying. Whereas when I trained, my colleagues and I spent countless hours trying to understand a patient’s dynamics, while we were doing patient care,  the younger residents, by and large, are more eager to “get out of the hospital” so that they can have “a life”. For us, our profession, caring for patients, was our “life”. It is not that we did not have other relationships, but it was that the priorities were closely aligned, meaning that professional and personal work mattered, if not equally, close to equally. One could argue the value of that lifestyle, but from my point of view, my generation, and those that came before me, were blessed with the privilege of work that felt passionate. My students, although, for the most part,  are not interested in that “passion,” they remain curious, as those who are curious about history, as to how I think, and at least in that way, I still have a place in their education.

Posted in Psychiatry in Transition | 2 Comments »

What Does It Mean To Be Spiritual?

Posted by Dr. Vollmer on September 29, 2016

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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 | 2 Comments »

 
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