Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for May, 2010

Exciting Times

Posted by Dr. Vollmer on May 13, 2010


 Glen, twenty-one, comes in, and without a word spoken I feel him vibrating with excitement. I began to think of my previous post There was something about his facial expression, his body movements and his posture, that made me think about how happy he seemed to be feeling. I say “so you are done with school for this year.” He quickly responds “yea, and I am leaving in eleven days.” I suddenly remember that he has been talking about his summer plans to travel to Brazil with his friends. “Eleven days, wow you sound so excited,” I say. ” “Yea” he responds, with tremendous youthful enthusiasm. In Glen’s mind, he is leaving his troubles behind and he is going to a “stress-free” zone of hanging out and exploring new places. Glen has constructed his summer to be free of “parental nagging” as well as  free from studying for examinations. It is as if Glen feels like he is finally being let out of his cage and explore the world on his own terms. The trip is six weeks, so it is circumscribed play. He is not entering the adult world of responsibilities. He is still dependent on his parents for financial support, but he sees himself free from the phone calls from his mom reminding him what he has to do, either for school or for his family. Glen loves his mom dearly, but he also feels burdened by her prompting him to “call this relative, or buy this one a present.” Glen figured out that travel meant a temporary respite from responsibility. Glen knows that travel can be difficult. He could get sick. He could run into significant travel delays. He could have interpersonal issues with his friends. Knowing this, Glen still feels that the opportunity to explore a new culture, a new country, far outweighs the potential for adversity.

    I saw in Glen the power of his imagination for a positive experience. Even though Glen has never been to South America, he forecasts a fun time. These positive feelings stem from his sense in himself to become excited by new places. In essence, Glen is calling up his positive introjects. also loves his friends and as such, he is excited to share a new experience with them. He is confident that his friendships will deepen with this experience. Glen’s internal sense of security translates into excitement for adventure. He knows that he can rely on himself and his friends, in case trouble occurs. His youth means that he has not accumulated terrifying experiences which can damper a sense of excitement.

    Despite the popular belief that therapy is a place to “dump your problems,” therapy is actually a place to share many types of  feelings. Good feelings need to be shared, as do bad ones. As Glen and I talked about Brazil, I could see how he both grew more excited  and he  calmed down.  The excitment mounted as we spoke about the details of his trip. He calmed down as he was in such an up-regulated state that talking with me, brought him back to an equilibrium. The layers of his anticipation were displayed over our session. Once again, I was privileged, and in this case excited, to bear witness.

Posted in Musings, Play | 1 Comment »

Vanity in ‘Please Give’

Posted by Dr. Vollmer on May 12, 2010

    What happens when we look in the mirror? Do we see happiness? Beauty? Sexiness? Or, do we see age, burden, and/or loss? How does this impression change from minute to minute or from day to day? Do we look at our feeling state when we look in the mirror, or are we seeing the contours of our face? I thought about all these questions as I watched “Please Give”


Please Give 


Written and Directed by Nicole Holofcener

Catherine Keener, Amanda Peet, Oliver Platt, Rebecca Hall

Official Selection SUNDANCE Film Festival

Official Selection BERLIN Film Festival

Now Playing in New York and Los Angeles


      ‘Please Give,” a movie titled to suggest the guilt of the privileged (see, made me more aware of the never-ending vanity that strikes all of us, throughout our lives. The teenager, Abby (Sarah Steele) is preoccupied by her facial acne and looking good in a pair of jeans; fairly typical concerns of her age. Kate (Catherine Keener) wants to “help” others but at the same time she says “gee, my elbows are looking really old.” There is Alex (Oliver Platt), Kate’s husband who, in typical middle-age fashion, flirts with women half his age, as if to prove that he still “has it,” implying that he wants to feel attractive. Then, there are neighbors, two girls in their twenties caring for their ninety year old grandma. One sister, Rebecca (Rebecca Hall) is a radiology technician, and she seems to have little interest in her appearance, until she wants to meet a man, at which point, she begins to look more attractive. Mary (Amanda Peet), the other sister, is consumed with looking good, making her character  empty and shallow, apparently as a way of covering up more deeply seated pain.
     The intersection between the interior world and the exterior world gets played out in ‘Please Give’. The reality of aging is sometimes driven home by looking in the mirror. Sometimes, this creates anxiety and depression. Other times, feeling good about the world trumps the site of wrinkles and skin damage. In ‘Please Give’ there was a constant tension between looking good and feeling good. Mary’s character looked good, but felt angry.  She was tan (with tanning machines) well-dressed and she always looked attractive, while at the same time, she had  poor relationships and she was  yelling at those who were closest to her. Rebecca, by contrast  was cast in a role in which she was the “nice one” but not the “pretty one.” As such, she was the better caretaker of her grandmother;  the movie made it seem that because she did not focus on her appearance, she had a hard time finding a relationship. 
    Throughout the movie, how the characters felt about their appearance seemed to layer over how they felt about their lives. Mary was pretty, but empty. Rebecca was plain, and she struggled. Kate was struggling with middle-age; she hoped to use her age and stage in life to help others, but that failed. Alex sought young beauty, so that beauty would reflect back on himself,  but eventually, he found himself feeling guilty and uncertain. Abby was the only one who won the vanity struggle. She came to accept her acne and she came to love herself in her jeans. As such, Abby seemed both internally and externally gratified. Although a minor character, Abby became our role model for happiness. She moved through angst to acceptance. Exactly how she did that, the audience can only wonder. I suspect that Abby, having a good-enough relationship with her mom and her dad, had the safety and the security to move from the fear of an adolescent body, along with adolescent skin, to the excitement that she was entering into a new adult world filled with possibility. This excitement made Abby put her appearance in perspective. To me, Abby’s psychological growth made her the heroine of this character-driven movie.



Posted in Movie Review, Musings | 2 Comments »

Binge Eating: A Disorder? More DSM-5 Troubles

Posted by Dr. Vollmer on May 11, 2010

     Binge Eating Disorder is likely to hit DSM-5. Once again, psychiatry has lost its’ way. Since when does a symptom become a diagnosis? To say that binge-eating is a disorder is like saying a headache is a disorder. A headache, like binge-eating is a symptom of underlying distress in which the physician must explore the underlying cause. Is it a brain tumor? The sinuses? Stress? Neck problems? A migraine? The symptom of the headache is the jumping off point to curiosity and exploration. Binge eating is the same thing. Is it anxiety? Is it sexual discomfort? Is it depression? Is it bad habits? By making binge eating a “disorder” psychiatrists are discouraging the discovery of the person’s interior life.  HELP!

Posted in DSM 5, Musings | 4 Comments »

Blame Game

Posted by Dr. Vollmer on May 10, 2010

    A year ago, Mitchell, moved ninety minutes away. He still came once a month to see me, but recently, he had a setback. He stopped taking his medication and now he is massively depressed on top of his baseline of incoherent speech. He is not getting out of bed. He will not shower. He is eating too much food. Roxanna, his wife, is furious. She believes that Mitchell is deliberately making her life worse. Roxanna calls me to tell me “she is going to find a new doctor.” I respond “I can understand why you are upset, but changing doctors is a big decision. Maybe, I could see Mitchell and try to help him out. “No,” she says, “I think he needs a fresh look.” “I think a second opinion is helpful, but at the same time, I think I should see him because maybe I could help him get out of this crisis,” I respond. “No,” Roxanna  replies, “we don’t need your help.”

       I understand that without traffic, I am a ninety-minute drive, and now that Mitchell does not want to get out of bed, someone would have to drive him to my office. Since Roxanna works, she would have to take off a half a day. When Roxanna and Mitchell first moved, we discussed finding a doctor closer to their new home, but Mitchell insisted that he wanted to keep seeing me. When Mitchell is doing well, he enjoys the drive to my office; he enjoys seeing me. Now, the tides have turned, and Mitchell is no longer able to help himself. Roxanna has to take charge. Roxanna’s angry response is easy to understand. She is frustrated and confused by Mitchell’s situation. She would feel better if she could focus her anger. I am a temporary target.

    Mental illness is a heavy burden for the individual and his family. How does one get angry at your loved one’s  brain? How does one tease apart personal responsibility from a brain disease? How does one understand good medical care in the case of a challenging medical condition? How does one decide the importance of a longstanding physician-patient relationship versus the ease of proximity? Who does one turn to for advice? What about the shame? These waters are tough to navigate.

   I worry about Mitchell. I call Roxanna and say “can I help you find a second opinion?” “No” she says abruptly. “OK, let me know if there is anything I can do. I would be happy to speak with another psychiatrist about Mitchell.” “OK” she responds hastily. We end our conversation on a rough note. I feel for Roxanna. She needs to decide how to help Mitchell. I wish she would call Mitchell’s mom, Sherry, but Roxanna does not respect her. I move from feeling Sherry’s  gratitude to feeling Roxanna’s anger. Briefly, I feel the intensity of the ups and downs of Mitchell’s life.

Posted in Musings | 2 Comments »

Psychotherapy Package

Posted by Dr. Vollmer on May 9, 2010

     Ernest, thirty-three, has seen me over the past ten years, in spurts. He has a marital crisis; he comes in for a few sessions. He has panic attacks; the pattern repeats. He has problems with his daughter; the pattern repeats yet again. Recently, Ernest decided to “handle things” on his own. He went to his primary care doctor, received prescriptions for Restoril to help him sleep and Xanax to calm his nerves. Within about two months, Ernest could not sleep at all and he was “anxious all the time.” He called me in a panic; he needed to come in right away. It was Sunday. I saw him Monday. I gave him some medication to counteract the effects of  the Restoril and Xanax. He began to feel better. “You know what I am going to do,” he says. I am going to pay you ahead of time for twenty visits, so that I don’t “flake out this time.” “I am cheap,” he says, “so I know if I pay you in advance, then I will definitely come. ”

      I thought about Ernest’s amazing  initiative. I called it  “the psychotherapy package” similar to a package for a personal trainer, which both helps the person commit himself to his work-out and it gives the trainer some financial security. I was impressed with Ernest’s creative thinking to help himself. I was inspired by his determination to overcome his previous crisis oriented approach to psychotherapy; I was impressed by his wish  to create a deeper, more long-lasting experience. I wondered what would have happened if I suggested the package, rather than Ernest coming up with the idea on his own. I wondered if I should suggest this “package” to other patients. Of course, I also wondered what would happen if I blogged about this. Ernest gave me a lot to think about.

Posted in Musings | 2 Comments »

Picturing the Brain: Go UCLA!

Posted by Dr. Vollmer on May 7, 2010

May 05, 2010 // By Stuart Wolpert

New Staglin neuroscience center to probe how human mind works

Faculty campuswide will be participating in the new Staglin IMHRO (International Mental Health Research Organization ) Center for Cognitive Neuroscience to probe how the human mind works, using state-of-the-science imaging technology.

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Posted by Dr. Vollmer on May 7, 2010

      Sheldon, age thirty-four, came in saying “you know Dr. Vollmer, I am really mad at you. After our last session, I was in utter turmoil. I kept thinking about what you said and it really bothered me.” “What part of what I said?” I asked. “You know, when you were saying that I was picking girls that were not good for me.” I paused. “I remember that I was concerned about how you were choosing people from the internet to date. I was thinking about how you were thinking about your priorities, and I wanted to explore that with you. I did not say the girls were not good for you, but rather I was curious about your priorities.” Sheldon looks at me “well, I am still mad at you.” I offered an idea: “maybe there are two Sheldons. Sheldon-1 makes impulsive choices that feel good in the moment, but cause problems down the line, whereas Sheldon-2  knows that if he forecasts the future of a relationship, then maybe he will not begin one. Sheldon-1 and Sheldon-2 are at war with each other, so when you came in here yesterday, you were Sheldon-1 and I became Sheldon-2. You then were mad at me, rather than wrestling with the turmoil internally.” Sheldon responded “maybe”.

     Projection or projective identification, as Melanie Klein called it, is a psychological idea where the person splits their ego and then expels part of the ego  on to a significant other. Usually, either really good or really bad parts of the ego are projected outwards. A major consequence of such projections is that it gives rise to paranoid anxieties. People, such as myself in this case,  who are felt to have the negative parts of the self (Sheldon’s self in this example) become persecuting and are experienced by the patient as very dangerous and uncomfortable.

     Sheldon’s expression of his discomfort with me felt to me to be a projection, since I expressed to him concerns about his dating choices which had echoed his own concerns which he verbalized in the previous session. Sheldon seemed to “forget” that and then “assign” me the role of the “mean therapist” who was being “judgmental.” When I proposed that perhaps he was externalizing his internal conflict, he was willing to consider that concept. I admired Sheldon for that. Owning one’s projections is a sign of maturity. Sheldon is still mad at me, but he is also willing to see his anger from another point of view. I am sorry that Sheldon was in utter turmoil after our last session. At the same time, I was pleased he could come in and tell me that. I was also mindful  that we could look at his anger using therapeutic tools. Despite Sheldon’s anger at me,  I am hopeful.

See related post….

Posted in Musings | 4 Comments »

Mental Illness Gratitude

Posted by Dr. Vollmer on May 6, 2010

     Mitchell, forty-one, met me ten years ago after he received my name from someone in line at the pharmacy, while he was waiting to renew his psychiatric medications. When he started seeing me he had been three prior psychiatric hospitalizations for manic episodes. His brother has bipolar disorder also, although his three other siblings and his parents are free of psychiatric symptoms. I have seen Mitchell deteriorate over ten years; I have diagnosed him with schizoaffective disorder. He was gainfully employed as a software engineer for fifteen years after college, but now he is unable to hold a job. In talking to him, he is painfully incoherent. Roxanna, his wife of twenty years does not believe he has a mental illness. She calls him “lazy.” I have explained to her multiple times that Mitchell has a disease which does not allow his brain to work in the way that it used to. “Mitchell cannot think in a coherent fashion,” I say.  Roxanna says “I disagree.” As Roxanna and I discuss Mitchell’s brain, Mitchell sits there quietly and then returns to his incoherent conversation, this time about the Department of Water and Power and how high her bill is becoming.

    Recently, Sherry, Mitchell’s eighty-five year old mother came in with Mitchell to an appointment. Sherry walks with a cane, but otherwise, she appears quite healthy. She reminds me that she met me eight years ago and then she says “it is nice to see you again.” Sherry is down here from Montana, spending some “quality time” with her son. Sherry understands her son’s mental illness. After all, her other son suffers from very similar issues. Mitchell starts talking about his wife, but I am not sure what she is trying to tell me; Sherry is not clear either. At the end of the appointment, Sherry turns to me and says “thank you for taking such good care of my son for all these years.” I look at her with tears in my eyes and I say “your welcome. It is nice to see you too.”

     I prescribe Mitchell medication which Mitchell takes most of the time. I see him once a month for thirty minute visits. The psychotropic medication seems to keep Mitchell stable. Mitchell is very pleasant; he always has been. His wife encourages him to take his prescriptions, but she does not believe that he is “sick.” Mitchell seems to enjoy seeing me, but he cannot articulate why he comes to see me or why he needs to take medication. Sherry understands. Her comment made me think that she is grateful that Mitchell is still the loveable son she has always known.  I suspect that Sherry understands that some folks with schizoaffective disorder lose their sweetness.  Sherry appreciates that she can be with her son and she can hold on to the memories of him growing up; she can  see the twinkle in his eye; the sparkle he has had for his entire life. She gives me some credit for Mitchell’s twinkle. I accept that.  Sherry’s gratitude is touching.

Posted in Musings | 4 Comments »

The Guilty Road

Posted by Dr. Vollmer on May 5, 2010

     Liam, forty-six, the child of holocaust survivors,  tells me the following story about his trip with his wife and two small children to a plush resort. His wife, Nora,  took the car to visit a friend, so Liam and his kids went to grab a bite for lunch at the hotel, where he ended up paying sixty dollars for three hamburgers. Nora returns after a long day with her friend, wondering how Liam and her children spent their day. Liam said “the food here is so expensive.” Nora responded “oh my goodness. You are here with your children, in the midst of total luxury and all you can say is that the food is expensive. Where is your perspective? Why do you have to say that first? What is your problem?” After much discussion, Liam said to Nora “I feel guilty.”

    “What do you think was going on? I ask Liam. Liam said “I don’t know. I just felt guilty.” Liam’s mother survived Dachau, as did his mother’s brother. She married Liam’s father who escaped  Poland before the war. His mother never spoke about the holocaust.  His father could talk about his past, but he never expressed suffering. He spoke about how “lucky” he had been to get out before all the horror set in. “Do you think it could be related to your parent’s history from the war? I wonder. “I doubt it,” Liam replied.

       The intergenerational transmission of trauma may or may not be applicable to Liam, but I am thinking about it. When parents experience a life-threatening experience, the emotional associations, such as survival guilt, could get transmitted to the children, wherein the kids experience feelings which they cannot tie to anything in particular, since the feeling is an identification with the parents’ experience.  For Liam, this association to his “guilt” does not ring true.

     “Do you feel like you do not deserve to stay at such a nice resort?” I ask. “Maybe,” Liam replied. “So the guilt has to do with your sense of self-worth?” I say. “Yea, that sounds right,” he responds. “So, rather than saying that you do not feel that you should be at an expensive hotel, you express your discomfort over the price of the hamburger,” I say. “That’s messed up,” he responds. “Yes” I say, “that is messed up.” We laugh together.

    Guilt, as opposed to shame, is a feeling that one deserves punishment for an act that he has done. In this case, Liam was “confessing” to Nora his transgression of spending twenty dollars on a hamburger, even though Nora did not see that as a crime. It seems that Liam was hoping to rid himself of his guilt by “confessing” to Nora what he had done “wrong.” Nora, of course, did not understand that this was a confession, but rather she understood that Liam was being “negative” and as such, “ruining” her vacation. Since Liam did not connect his need to talk about the price of the hamburger with his feeling of guilt, Nora was left wondering why he was focused on the lunch bill. When Liam finally said he felt guilty, Nora said “well if you had just said that in the beginning, you could save a lot of money in therapy and that would have paid for your lunch.” Liam did not think that was funny, although he did think she was right.

     The invisibility of guilt, makes the destructive feeling all the more powerful. Liam could not enjoy himself, he could not enjoy his children, all because the hamburger cost twenty dollars. Further, he did not understand the connection between the price of lunch and feeling guilt until later in the day, thereby causing Liam to feel uncomfortable for a sustained period. On the other hand, that Liam could eventually name his discomfort with the feeling of guilt, speaks volumes to the progress that Liam has  made in psychotherapy. Once the feeling of guilt is identified, Liam can now wrestle with where that comes from. The guilty feelings, which have dominated Liam’s unconscious life, have now seen the light of day. Liam can now look forward to feeling less guilty in the future, as he  begins to understand where this feeling is coming from. Nora can look forward to enjoying  Liam’s company again as Liam becomes more at ease with himself. Their children will benefit by feeling  happiness and joy, rather than tension and marital discord.  I am proud of Liam for being able to name the feeling of guilt. We are on the right road.

Posted in Musings | 7 Comments »

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