How do we talk about our work without worrying that we will be seen as fools? Do we only talk about the success stories, with a good dollop of embellishment about how we changed a patient’s life, or do we fall on our sword and admit defeat, that despite years and hours of treatment, the patient is not only not better, but worse? Hearing case presentations, then opening the discussion to feedback, there are two kinds of responses from the audience. There is the “you should have taken this approach” comment, or there is the “you really did and said everything right, but the patient just did not respond.” In the former, the presenter can say “thank you very much for that feedback,” and/or he can say, “you are not in the room with him, so you don’t know how hard it is to take that approach.” Learning psychotherapy is a constant dance of “showing off one’s skill set,” alternating with looking at therapeutic impasse with an open mind, which can easily lapse into a defensive posture. There are no rights and wrongs. There are two people in a room, and when this is discussed amongst professsionals, than there are many minds, but nothing can replicate that experience of the struggling dyad, trying to make sense of their therapeutic relationship, trying to find ways in which the pain and suffering can be alleviated. Teaching involves the same dance. Trying to give feedback without making the student feel humiliated and hence defensive. As a student, the challenge is to feel humiliated as a means to growing as a therapist. Running away from that humiliated feeling, like patients who want to grow emotionally but cannot take the pain of regret, stifles the learning curve. Teaching psychotherapy and doing psychotherapy are a parallel process. Both involve creating pain for the sake of a future gain. The challenge is both the need for diplomacy and emotional maturity. The margins are thin, and the feelings can be explosive. On the other hand, watching someone grow as a therapist, like watching a patient go through the journey of metabolizing their pain, is a fulfilling experience. Like hiking a steep mountain, the path is hard, but the end is glorious.
Posted by Dr. Vollmer on October 8, 2015
Posted by Dr. Vollmer on October 7, 2015
ICD-10 has arrived, October 1, 2015, changing our charting system, creating a much more detailed diagnostic system. Instead of saying, for example, that a patient has “polysubstance abuse,” I need to say they have “cocaine use disorder-severe, alcohol use disorder-severe, cannabis use disorder-severe, Tobacco use disorder-severe,” etc. Theoretically this new diagnostic system will create a more accurate database in which to do research studies on disease trends. I am excited by that prospect, but at the same time, this added detail adds inaccuracies. In the case of substance abuse, it is more accurate to say “polysubstance abuse,” as most drug addicts use a variety of drugs at different times during their years of addiction, and so to write each drug separately does not convey the narrative of their journey from prescription opiates to street heroin and back to prescription drugs. In general, more specificity is helpful, but people are not robots and being specific can come at the price of the nuances in their history. I return to the major thrust of this blog. The history remains the most important part of psychiatry and now with ICD-10, there will be more focus on a reductive approach to diagnosis and treatment. The narrative gets lost for the sake of big data. For other areas of medicine, where there are objective findings, more specificity makes sense. For psychiatry, it will be garbage in, garbage out, as computer programmers like to say. ICD-10 has a broad reach, and as such, psychiatry should not be included in this wide net. Our field remains in its infancy. We are not ready for the adult table. Once again, I think we should be honest about that.
Posted by Dr. Vollmer on October 5, 2015
There is a little LEGO man standing on one of my pictures in my waiting room. Yes, I have LEGOS in my waiting room and so, I can imagine, that some person, child, adolescent or adult, thought it would be fun, funny, cute, or something to deposit Mr. Lego man on my picture frame. The gauntlet is laid. Who did that? Do I ask my patients? Do I take it down? Do I smile when I see it? Yep, that is an easy question. I am reminded that so many things happen in my waiting room that I am not privy to. Patients can sit there before or after appointments. There are magazines to read, toys to play with, and yet, when I open the door, most of my patients, regardless of age, are on their phones. I joked with one patient that I can stop my subscriptions, and she said “no, I like to see the magazines, even if I don’t read them any more.” I suppose if I ever get a new office then perhaps the waiting room is unnecessary. I can just text my patients to come in, and then they can tell me their ETA, just like Uber, I suppose. I can give them a little warning, like I will be ready in 5 minutes and then they will show up exactly at that time, as their phone will them to do that. Yet, in this imaginary scenario of a waiting room-less office, I would miss out on seeing my little Lego so cutely sitting atop a picture. I would miss that.
Posted by Dr. Vollmer on September 22, 2015
May 6, 2016, I am booked. Geez, that is advanced planning. Three hours, I have, to discuss medicating kids to mental health professionals dedicated to working with children. As usual, I expect to gain far more than I give, as this audience are folks who have spent years fine-tuning their skills to work with disadvantaged youth who struggle with coping with their circumstances. Nature and nurture will be discussed heavily, as the decision to medicate a child is never easy, simple, or straight-forward. The decision is made after a thorough history, but whose history? The parents, the child, another clinician, or all of the above? Yet, my first order of business is generating a title. I have a series of lectures which begin with Medicines for the…fill in the blank. Originally, I kept a similar title for all of my talks as a way of picturing my book on psychopharmacology for the lay public. Each talk was a chapter in my book, such that “Medicines for the Mind” was the large title and then there was “Medicines for the Female Mind”, “Medicines for the Old Mind,” and “Medicines for the Child’s Mind.” Yet, as the book has receded in my task list, and, as a patient once said to me, “you want to know about my head meds,” I began to think about changing my title. My next lecture on adult psychopharmacology will be entitled “Head Meds” but for my “kiddy talk” I will stick with “Medicines for the Child’s Mind.” I want to emphasize that the complexity of working with children is that their minds evolve as time goes on, such that all practitioners are made humble in that we never know whether we had an impact or maturation finally kicked in. I suppose the same is true of parenting. Parents take credit for “how well their children turned out,” when, in fact, it could very well be that their brain was developing in a non-linear fashion such that the child surprisingly became a responsible adult. Oh, so we return to nature vs. nurture, in which I will say that if the child does well it is nurture, and if he does not, it is nature. I hope I will get a laugh.
Posted by Dr. Vollmer on September 21, 2015
7 hikers died suddenly. I knew some of them. Did they die doing what they love? I don’t think so. I think they died sad and scared. They left families and loved ones who might define their lives by this before and after moment. The question of “should they have known” will never be known, but many people have very strong opinions on both sides. Estimating risk is the discussion of every adventurer. Every step up a mountain could be one’s last, and yet the thrill of the adventure propels people forward. Most people do not die on adventures, and most people do not know people who have died on adventures, and yet, the risk still looms. There is no good way to think about this, except to say, that thinking about these seven people is how we remind ourselves that we matter, and our friends and buddies who share our passion matter too. Tragedy has no words, only feelings of pain and confusion. Adventure tragedy is no different. Movies are made, stories are told, but the pain does not change. There is no lesson learned. Yes, slot canyons are very dangerous. Yes, flash floods means there is no way out. Skill and experience matter little. Warnings come and go, and getting information out is not always easy given the limitations of cell coverage. The search for someone to be mad at comes up empty. We cannot funnel our feelings into rage and that makes it even harder. The shock and sadness keeps coming, in waves, which feel like an emotional tsunami, similar to the water which killed these hikers. They were trapped, as we are now, trapped in the mourning and bewilderment of sudden loss. There is one thing to do. Hold hands with people you care about, because you just never know when that won’t be possible. Yes, I have lapsed into cliché. Mourning has emptied out my language, perhaps explaining why clichés come in handy.
Posted by Dr. Vollmer on September 18, 2015
I am a child psychiatrist. I added two years of training, took both an oral and written examination, with the resulting distinction that I am a board certified child psychiatrist. I also did psychoanalytic training, a process which took me 8 years, involved 3 supervised psychoanalytic cases and 4 years of 4 hours per week of classes. Those are two recognized distinctions within the field of psychiatry. Yet, there is a push to specify a niche, perhaps to improve what advertisers call branding. Suppose, for example, that I “specialize” in divorce. Does this mean I only see divorced people? Does this mean I am divorced, so I have personal experience to bring to the table? Does this mean I attend a study group on divorce, and together we have discussed divorced cases in some depth? Or, does it mean that I think that focusing on divorce can increase my business, and in so doing, I need to carve out this corner of the market. The unaware consumer feels comforted by going to a person who “specializes” in their problem, even if drilling down, “specializing” has little practical meaning. Is the skill set different, treating people going through or suffering from divorce, or am I using my old skills, but applying them to a very particular stressor? This dilemma between accurate representation and marketing getting hazier as the world moves toward electronic searches which require key words, and tags which bring you to certain websites.
For years, I have taken the opposite approach. I have emphasized both my breath and depth, focusing on the notion that my training, rather than narrowing my focus, has allowed me to see people from a variety of vantage points, and as such, I am able to handle a variety of problems which present to me in my office. My “wider and deeper” tool box has been my signature, and yet, with the focusing of treatment programs, such as addiction and eating disorders, there is a push to find “addiction specialists,” eating disorder specialists,” etc. I still give push-back to this notion. Eating disorders, like all disorders, involve a person “with” an eating disorder, and it is the person who needs the attention, along with the symptoms, the eating, which accompany the individual who presents. In certain fields, such as oncology, I can certainly see how the patient is wise to want a “specialist,” someone who sees a lot of their particular kind of cancer, because the treatments are changing rapidly, and there is a need to be able to distinguish the nuances of treatment. However, to continue with the example of eating disorders, the patient needs someone who understand them, who can think like them, and feel like them, as all psychiatric patients need this. Through this understanding the patient will want to take better care of him or herself. Eating disorders, like addiction, and like the majority of psychiatric issues, are yet another example of self-sabotage. As such, patients need help understanding why they would ruin their own lives. The specialization should be in human motivation, not the symptoms which are downstream from that. I never tire from making this point, and so my blog continues.
Posted by Dr. Vollmer on September 17, 2015
Neuroscience is marrying psychoanalysis. For real? Yep. Mark Solms PhD https://en.wikipedia.org/wiki/Mark_Solms is spearheading this field, as he passionately pursues both worlds. In essence, his goal is to demonstrate that different parts of the brain light up when experiencing different kinds of feelings, such that the id, ego and superego, will, one day, be able to be localized in the complicated brain structure. In a primitive way, psychoanalysts have always thought of themselves as people who strengthen the prefrontal cortex, the part of the brain responsible for judgment and executive decision-making. Dr. Solms wants to go deeper with this notion to say that feelings of attachments, and primitive feelings of rage and aggression can also be located in deeper, more primitive structures of the brain. Casey Schwartz, http://www.theatlantic.com/author/casey-schwartz/, writes about Mark Solms and the converging worlds of neuroscience and psychoanalysis, and she has a new book, entitled “In The Mind Fields”. I heard her speak last night, along with a psychoanalytic candidate, Justin Shubert PsyD, about the ways in which psychoanalysts are beginning to care about neuroscience, and how equally surprising, neuroscientists care about psychoanalysis. Oliver Sacks did not get mentioned, but I felt his presence in the room, as they described stories of patients who had severe cognitive deficits, and yet, could still benefit from psychoanalytic inquiry. Not surprisingly, as I work with kids who are both verbal and non-verbal, the psychoanalytic method, although seemingly based on verbal exchange, is, in fact based on a relationship, and words can be substituted with action, and a psychoanalytic experience can still be had. So, a stroke patient with aphasia, can benefit from the intense curiosity that a psychoanalyst brings to the consultation room. I knew that. Now, I hope others do too.
Posted by Dr. Vollmer on September 16, 2015
We diagnose, and yet, our diagnostic system is flawed, and hurtful to some patients and their families. We treat with medication, and mostly that is helpful, but occasionally it is a means to enforce a misdiagnosis and a misunderstanding of the patient’s psyche. We also treat with machines such as ECT and TMS, and that is also mostly helpful, but without a theoretical basis for clinical improvement. I would like to think that what psychiatrists do, what I was trained to do, is listen. Yes, yes, I am on my soap box, talking about the complexity of listening, the use of listening as a healing device, and the respect we show to patients by listening deeply with a thoughtful and theoretical mind which gives us multiple models in which to listen. How do I market listening? How do I tell the world of drive-by health care that time and patience are the key ingredients to my work. Like cooking a brisket, there is no short-cut. Limiting time kills the value of the product, in that the product is open-ended. Giving the patient “goals” is also antithetical to my model, in that goals imply that the patient comes in knowing what the problem is, instead of my model which says that there is both a stated and unstated, or unconscious, agenda. Marital problems might bring someone to my door, but a hunger for understanding their childhood may keep them coming. If I stated the goal was “marital harmony” then I would miss the opportunity to explore deep-seated feelings which have manifested by displaced anger and aggression. If I shorten my sessions, then I would miss the unpeeling of the onion which only comes after many minutes spent together struggling to understand how the patient suffers. If I speak in terms of “tools” then I miss the point that the patient knows about these tools, but for complicated reasons does not avail himself to them. It is simplistic to expect that short sessions, limited visits and goal setting could overcome lifetime habits of poor decision-making and self-destructive behavior. Why would psychiatrists, those with more training than any other mental health professional, buy into this simplicity? This question represents my struggle. How did we get here? The greed of the 15 minute appointment is one answer, given that it is easy to do the math. Is the answer as simple as that? I think so.
Posted by Dr. Vollmer on September 10, 2015
Moments of decision-making in psychotherapy: how are decisions made? What do you comment on? What do you ignore? When do you interrupt? When do you listen? These are the daily questions which arise for a psychotherapist. The New Center for Psychoanalysis, under the brilliant leadership of Lynn Kuttnauer PhD has initiated these monthly meetings to talk openly about how to think about how to listen. I am honored to be invited to do the last one for the 2015 calendar year. Now, I need to think about how to shine a light on this question. I could illustrate a brilliant decision I made, or make it look that way, or I could present from a point of humility, where I am honestly not sure what to do. As Freud says about dreams, the telling of a dream is a secondary revision, as the dream is the first draft. So, too, in teaching, I am consciously and unconsciously framing my clinical vignettes with an agenda to make myself look both competent and questioning. This is a delicate balance, particularly in teaching psychotherapy where the road map is clouded with conflicting theories as to how the mind works. Candor has always been my strong suit. I have counted on authenticity as my strongest tool, both in the struggle of psychotherapy, and in the struggle to convey complicated ideas. Not knowing, I teach my students, is our strongest foundation. We know, we do not know, and as such, we can enter into contemplation and reflection without rigid ideas or preconceived outcomes. This humility is what distinguishes us from other practitioners, particularly the “T” therapies in which they convey a confidence about how to heal. I have no such confidence, only Irving Yalom’s notion of the “fellow traveler”. I can accompany you on the journey, but I can’t say I know where we are going. “Clinical Moments” gives me the opportunity to push this idea forward. I will take it.
Posted by Dr. Vollmer on September 9, 2015
Student mental health services have not kept up with the growing demand, brought on by our explosion in diagnosing ADHD, Asperger’s Disorder, Depression and Anxiety in adolescence. Consequently, kids who are properly and improperly labeled and/or medicated come to college without the mental health resources they had in high school. Plus, the availability of drugs and alcohol give way to an epidemic of untreated college students, occasionally with tragic outcomes of suicide, unintentional overdoses and mass shootings. I propose the following solution. Have psychiatrists run mental health clinics at colleges and university and in so doing, there could be a better triage system of care. Of course, not everyone with a mental health issue reaches out for services, but for those that do, they need to be reassessed and properly guided towards what they need. This is in contrast to the current system in which the college student goes to student health, has a limited number of visits, and medications are done on a “drive-by” basis. Yes, my proposal is more costly, but given the cost of both public and private universities, these days, the money for these resources must be there. Plus, college students can be on their parents’ insurance plans and as such, there is another revenue source (in addition to student fees) which can support this major overhaul. College is prime time for the onset of serious substance abuse, chronic mental illness such as schizophrenia and bipolar disorder, and eating disorders. It is also the time when coping skills can be severely challenged, and issues of feeling lost, hopeless, and unlovable can reach a fever pitch. Mental health services are critical to get these “kids” on a good life path. They need to put their interior life into perspective, and many need professional assistance to separate from their parents and develop their own identity. As the David Geffen School of Medicine at UCLA has initiated, there should be a dean of wellness on every campus. This dean needs to be a psychiatrist, given the complexity of mental states. Anyone want to hire me?