Shirah Vollmer MD

The Musings of Dr. Vollmer

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 »

Working With Perception: Learning Counter-Transference

Posted by Dr. Vollmer on September 26, 2016

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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 Countertransference, Psychoanalysis, Psychotherapy, Teaching Psychoanalysis | 2 Comments »

Borderline Personality Disorder: Bah

Posted by Dr. Vollmer on September 19, 2016

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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 »

Psychiatry In Transition

Posted by Dr. Vollmer on September 1, 2016

 

 

 

 

http://blogs.scientificamerican.com/mind-guest-blog/can-psychiatry-turn-itself-around/

 

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 »

Special Needs Trust: A Public Service Announcement

Posted by Dr. Vollmer on August 31, 2016

Posted in Asperger's Disorder | 1 Comment »

Should Psychiatrists Weigh Their Patients?

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 »

 
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