Posted by Dr. Vollmer on June 29, 2015
Mechanism of action (MOA) is the holy grail of psychopharmacology. How exactly do these drugs work? This is not the same question as which neurotransmitters are altered by the administration of this drug. How do we know that altering neurochemicals produces symptom relief? We do not. We practice “black box” medicine, meaning that a medicine is administered and for reasons which are unclear, the patient reports a change, either good or bad, in symptoms. Placebos can also alter neurochemicals, at least conceptually, they can. So, perhaps it is the anticipation of relief which creates new neurochemistry, and hence improvement. Nora Volkow MD, https://en.wikipedia.org/wiki/Nora_Volkow, the head of NIDA (National Institute of Drug and Alcohol Abuse) has pioneered the new theory that addicts remain addicts, not because of the drug’s influence of the brain, but because of the anticipation of the drug’s influence on the brain. Love, and hate, and stress, can all, theoretically change brain chemistry. Perhaps the doctor/patient relationship, the aspect of medicine I am most in fear of losing, is in fact, the agent of change for neurotransmitters, resulting in better self-care and more enjoyment. Transcranial Magnetic Stimulation, https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation, a novel way of altering brain chemistry, is yet another attempt to change the electrophysiology and thereby change the patient’s approach and outlook towards his life.
Am I taking the curtain off of psychiatric medicine, or psychopharmacology, that word I have come to despise because it has not particular meaning other than that psychiatrists, physicians, prescribe medications which change brain chemistry? Psychiatrists have been doing this for years before we re-packaged ourselves as “psychopharmacologists.” Maybe that veil needs to be lifted. Medications, like cooking, or any art for that matter, is a skill honed with years of experience, but at the end of the day, the choice of medication is an educated guess. There, I have said it. So, does a patient pick a psychiatrist because they guess well? I would hope not. I would hope that a patient picks a psychiatrist who understands the speculative nature of the work, and as such, is willing to be prepared for any eventuality, knowing that each medication, interacting with each patient, is a unique experience which therefore requires close monitoring and careful attention. That is the key to a good “psychopharmacologist.” It is not picking the drug off the shelf; it is what happens after that.
Posted in Psychopharmacology | 1 Comment »
Posted by Dr. Vollmer on June 24, 2015
Talking drugs, as I call it, is a favorite pastime of mine. By that I mean that I like to talk about psychopharmacology in the context of human suffering. This, one might say, is my dog and pony show. Usually my audience ranges from medical students, psychiatric residents, child psychiatry fellows, art therapy students, or master level clinicians. Each group brings a unique perspective to my talk. Today, I expanded further by talking to patients, a group of folks who are on psychotropics, prescribed by other clinicians. “I used to talk to my psychiatrist for an hour, but now I see him for fifteen minutes. I say a key word, and he jumps to a particular medication. I do not know what happened,” says an audience member, illustrating my persistent point that psychiatry has lost its way. To prescribe medications, the first order of business is to establish trust with the patient, I explain, articulating the physician’s side of the street. I continued with a frequent example. I see patients in a substance abuse rehabilitation facility. “How are you?” I ask, “Fine,” they respond. If I were to end the session at that point I would have documented that the patient is doing well. However, if I wait, and follow-up with a few probing questions, I learn a different story, often involving some major life event, like a relapse, or a break-up, or a family member with a new diagnosis of cancer. Time is critical to uncovering the details of the patient’s interior. I continue explaining my dismay over the fifteen minute appointment, and once again there is a sense of gratitude, that someone wants to listen and prescribe medication. So, if you readers want me to come to talk about psychotropic medications, I would be happy to. Just know that I maintain my stance that listening and prescribing are both critical to the experience. Anyone listening to that?
Posted in Psychiatry in Transition, Psychopharmacology, Teaching | 6 Comments »
Posted by Dr. Vollmer on June 19, 2015
It is the end of the academic year. My class called “conversion” which focused on transitioning patients from psychotherapy to psychoanalysis, thanks to my students, will be re-named, “Developing A Psychoanalytic Practice.” My “Psychopharmacology” class for my art therapy students is complete, papers read, and grades submitted. And so tonight, my student/child psychiatry fellow will graduate and launch into the world of private practice. She will prove all of my postings wrong in that there is still a minority of psychiatrists who want to develop relationships with patients which are both therapeutic and mutually rewarding. Medications are important too, but only in the context of mutual trust. Although I look forward to the time, which these endings give me, I am also my sad self, missing my students, while wondering what happens to them next. Like a parent who sends their child to college, with both strong feelings of loss and pride, I too feel that these transitions are vital to the developing autonomy of my students, but at the same time, I have a hole in my mental existence, realizing that their growth creates my challenge to embrace the necessary change that educational institutions promote. I like my teacher role, but I do not like this time of year. It is a “quality problem” as some would say, and indeed that is true, but it is a problem, nonetheless.
Posted in Teaching, Teaching Psychoanalysis | 2 Comments »
Posted by Dr. Vollmer on June 19, 2015
Posted in Cartoons | 4 Comments »
Posted by Dr. Vollmer on June 12, 2015
Well, today is my last class with these fascinating art therapy students. My job is to teach them psychopharmacology, yet I took this opportunity to talk about how the discovery of new psychotropic drugs in the early 1990s changed the physician-patient relationship, turning psychiatrists into pill mills and causing a great deal of confusion among therapists about when and how to talk to their patients about medication. Making a referral to a psychiatrist can be a daunting process, given the uncertainties in the field. Some of my colleagues say a referral for medication is a sign of failure of the treatment? Yes and no, I would say. The criteria for referral are not clear, and so how that referral is framed is often critical to the success of the medication. The therapist often sets the stage for hope, sometimes unrealistically, and sometimes with the proper amount of skepticism. The more a therapist can educate him/herself about psychotropic medication, the more they can help the patient navigate these murky waters. It is a simple message. Learning about the brain, includes learning about how medications changes the brain, facilitates the therapeutic relationship in which they also use art as yet another tool, for people to use their brains. These students draw people out of their inhibitions by introducing art as a medium for self-expression. Psychotropics partner in this goal in that, at times, they can help people feel less anxious, and thereby more free to express themselves. Psychiatrists and art therapists are on the same team, even if most of the time, we never speak to each other. Perhaps if I keep tooting the horn that we are on the same team, that psychopharmacology is not as complicated as it seems, then maybe we can open doors of communication, and in so doing, create a friendly working environment which increases job satisfaction and gives patients better care.
Posted in Psychiatry in Transition, Psychopharmacology, Teaching | 2 Comments »
Posted by Dr. Vollmer on June 11, 2015
Imagine a world where psychiatrists disappeared? Primary care physicians took over psychotropic prescribing, doctoral and masters level clinicians did psychotherapy and mental status assessments were done by neurologists. As Prozac was born in 1988, and psychiatrists quickly reinvented themselves as “psychopharmacologists” and no longer promoted the doctor-patient relationship, and diminished the importance of a good assessment, the field has narrowed itself so much that it could disappear. There is nothing that we do that can’t be replaced by a primary care physician or a nurse practitioner because we gave up our flag carrying notion that what we do is understand the whole patient. This is what no other physician has the time or inclination to do. By shortening the standard appointment to fifteen minutes, we gave up the uniqueness of our field, the quality of relationships with patients that no other doctor has the privilege of experiencing. We leverage this relationship to have the patient help himself. This, more than medication, is the fundamental healing power that we hold. Shame on us for letting that slip through our fingers. If psychiatry does die, we have only ourselves to blame.
Posted in Musings, Psychiatry in Transition, Psychotherapy | 7 Comments »
Posted by Dr. Vollmer on June 2, 2015
I return to blogging, filled with new tales from my latest endeavors including teaching art therapy students at Loyola Marymount University, drilling down into the world of substance abuse rehabilitation, and now adding on, teaching a new class to psychoanalytic candidates on “converting” patients from psychotherapy to psychoanalysis. This class, never taught before at the New Center for Psychoanalysis, is my current challenge. To begin, the name of this class escapes me. I am working on a catchy title. Then, the syllabus. What should we read? I chose Owen Renik’s book, “Practical Psychoanalysis for Therapists and Patients.” http://www.amazon.com/Owen-Renik/e/B001H6NDV4. Now, my task is to stimulate conversation, not so much to delineate the difference between psychotherapy and psychoanalysis, but more to help these clinicians transition patients from one kind of psychotherapy to another. This transition, in my mind, grows out of a strong pull to go deeper into the psyche, by having the time to explore associations and nuances of behavior, which can only be discussed when the relationship is intense, meaning a lot of time together. Weekly psychotherapy is often consumed with “dear diary” material, that there is little opportunity to interrupt and pursue choice of words, small changes in facial expression, or small changes in posture. It is the ability to take the small things, Freudian slips, if you will, and create narratives with deep meaning. These small behaviors, looking under a microscope, exposes a wealth of ideas about hidden assumptions and hidden agendas that lurk behind conscious motivation for action. The microscopic assessment lends the both viewers to examine a clearer picture into the behind the scenes examination of how the mind works. “Why did you choose that word,” is an example of pausing and reflecting about language as a royal road to the unconscious. That question is hard to ask in once a week psychotherapy, where that might be heard of as an interruption, rather than an opportunity to understand the layers of the mind. Like any skill, the more you do it, the better you get, and so it is for a psychoanalytic understanding of oneself.
Posted in Teaching Psychoanalysis | 4 Comments »
Posted by Dr. Vollmer on May 21, 2015
Why do we fear abandonment? How do we balance dependency with self-reliance? These are the core issues of happiness in that if we can feel both self-reliant and dependent then we have reached a sweet spot of confidence and pride. Psychotherapy promotes dependency on the therapist, while at the same time, stressing self-reliance as a goal post. This duality, by its nature, supports the notion that dependence and self-reliance are not mutually exclusive. The fluidity of self-reliance alternating with dependency is an art, which throughout life, and particularly through traumatic experiences is the challenge. Too much tilt in either direction leads to pathology and unhappiness.
Marnie, twenty-eight, comes to mind. She is very anxious to have relationships such that she creates fantasies in her mind which stem from brief “hook ups”. Each brief encounter with a man gives her a feeling of security, short-lived, leading to a persistent cycle of these very brief connections. She is aware that she feels desperate and this solves her problem, but like the alcoholic who knows that alcohol is a problem, this does not translate into a change in behavior. Marnie and I work together to help her see herself deserving more, more stability, more love, and more stimulation, while at the same time we work on her appreciating herself and all of the qualities that she brings into a relationship. The work involves both an in-depth approach to her judgment as well as an in-depth approach to her lack of self-esteem. The more she can appreciate herself, the more likely she will find someone who she can appreciate. The big picture is clear. The work involves helping her tolerate difficult feelings without acting them out, without seeking immediate gratification. Gaining frustration tolerance is the key towards her maturity. Marnie has a bright future, but she has to reflect and not act in order to reboot her emotional life.
Posted in Psychotherapy | 2 Comments »
Posted by Dr. Vollmer on May 7, 2015
Most psychiatrists leave academic medical centers and practice in the outpatient setting, and yet, many four-year training programs do not begin to expose residents to outpatients until year three. Medical education has typically been skewed towards the notion that if you can treat the sickest patients, then treating less acute folks will follow easily. This has never made sense to me, as although I think it is critical to see severely ill patients to learn the scope of illness, it is also critical to learn the skills of dealing with less intense, but still troubling symptoms. More specifically, in psychiatry, outpatient psychiatry is a very different skill set than inpatient psychiatry. With hospitalized patients, the goal is to stabilize them so they can leave the hospital, typically in three to five days. Stabilizing means getting symptoms under control. By contrast, with outpatients the goals are to improve functioning at work and at home. Here the skill set requires stimulating the patient to care about himself such that he makes good decisions which yield a sense of fulfillment, or “to love and to work,” as Freud would say. The goal post changes over time, as the patient gains greater self-esteem and confidence. To learn outpatient psychiatry one needs to take a longer view of health, and as such, continuity of care is critical for learning. If outpatient work began in year one, then the resident would have the opportunity to watch both patients grow, and watch themselves grow as a clinician. Utilizing time, the four years of training, as a way to emphasize that change takes time and as such, time is critical to professional development. Psychoanalytic training adds on, with a high-intensity clinical demand, but it is not a substitute for the challenging transition from medical student to psychotherapist. My rant continues. Psychotherapy needs to be a valuable part of psychiatric training and more pointedly, it needs to start when the student becomes responsible for patient care. I dream of this world where psychotherapy returns to psychiatric training in a way which builds confidence in the residents. I know it is a dream, but maybe, just maybe, it can get some traction.
Posted in Psychiatry in Transition, Psychotherapy, Teaching, Teaching Psychoanalysis | 2 Comments »
Posted by Dr. Vollmer on May 6, 2015
Drugs provide symptom relief, so a psychopharmacologist inquires about symptoms and provides medication. Yet, this makes no sense to me. Symptoms occur in a context, in a setting of relationships, childhood attachments and struggles of identity and meaning. If we, as psychiatrists, try to put symptoms in a framework with personal meaning to the patient, and provide medication which offers symptom relief then we are providing comprehensive care. We must also understand the meaning of the medication for the patient. On the other hand, if we only focus on symptom relief, we are making our profession narrow and limited. Yes, this is my rant. Yes, understanding context is time-consuming and expensive. And yet, if we do not attempt to help the patient have insight into his symptoms then we are colluding with the world of drive-through psychiatric care. We, as psychiatrists, must care about history, and we must encourage patients to care about that as well. I went into psychiatry because other specialists were too focused on disease and not the person with the disease. Psychiatry offered me a space to explore how the patient integrated his medical and psychiatric issues into the context of his personal story. Each symptom has a unique meaning to the patient, and inquiring about this meaning is the excitement and therapeutic aspect of my work. So, it is obvious why I am saddened that psychiatry, as a profession, has lost this curiosity. Symptoms, quite honestly, are not that interesting. How the patient manages with those symptoms never cease to be fascinating. Drugs are a great tool, as is good history taking. I am going to stick with that, while at the same time, mourn the change in my profession.
Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 2 Comments »