Shirah Vollmer MD

The Musings of Dr. Vollmer

Memory and Therapy

Posted by Dr. Vollmer on December 5, 2014


“Memory is so complicated,” a psychiatrist-in-training, said to me, in talking about the Ferguson case. “Oh yes, doesn’t that explain why cookbook therapies, which only address cognition and not the emotional component to symptom formation are of limited utility?” I say, to a student who looks back at me with shock and thoughtfulness. If we agree that memory is complicated by predispositions, the need to fill in gaps, and social pressures, then can’t we also agree that symptoms such as anxiety and depression are also complete with backstories and family context which make understanding the complexity of the symptom more important than proposing a quick treatment? This is my thesis and this is why I continue to blog. The contradiction between marveling at the many aspects of memory and, at the same time, proposing that deeply held symptoms are simply treated in 12 sessions seems outrageous to me. Having said that if 12 sessions brings relief, I have no issue, but what happens when the patient does not respond to 12 sessions? Do we say they are untreatable? Do we refer them to a higher level of care, such as medication management or hospitalization? No, I say. We should understand that for some people, given the complexity of their situation, more therapy is needed, not necessarily with medication, and not necessarily requiring hospitalization or intensive outpatient programs. Complex brains require complex treatment. At the very least, we should all agree to that.

4 Responses to “Memory and Therapy”

  1. Eleanor said

    Shirah, I feel, as you do, so strongly about the complexity of the mind…of the multiplicity of sources of symptoms, of all the gray areas in emotions and the many deeper layers in our cognition that I’ll leave it at that……. (or I’m at risk of getting on my soapbox 😉 !

    What I’d like to bring up here is the difficulty in obtaining psychodynamically oriented psychotherapy by those who would truly benefit from it but don’t have access to it because they honestly can’t begin to afford it. What is the answer for this group of the population??? Stick with short term limited “counseling” targeted perhaps at one specific life challenge when it’s obvious the difficulties go deep beginning with family disfunction? I don’t think there is an answer. I would like to hear what you suggest. Do psychoanalytic organizations have treatments offered on a significant sliding scale?

    • Shirah Vollmer said

      Hi Eleanor- thank you for spearheading this discussion. I think there are two issues here. First, therapists need to understand that 12 sessions may or may not help, given the multiplicity of factors which go into symptom formation. Given that, patients should not feel like they need a hospital when in fact they need intensive psychotherapy. Second, the issue of affordability and population health is the sticking point- meaning how do we get mental health care to all who need it? My answer is that, yes, psychoanalytic clinics and many training sites in LA offer low fee therapy. This probably does not meet the need- but funding these clinics should be our goal- instead of offering a therapy which reduces complex feelings and then gives hope for a quick fix. Thanks again!

  2. Shelly said

    What’s wrong with introducing medication earlier in the treatment? Why start only after the allotted 12 sessions? Couldn’t the patient have started to feel better almost immediately and you could have monitored the improvement over the course of the remaining sessions? I do realize that psychiatrists need time to treat their patients, but like Eleanor, know that patients cannot afford long-term treatment.

    • There is nothing wrong with introducing medication early on in the treatment. The issue is that mental health services are in limited supply, so one model of care is to have the first line of defense be twelve sessions with a non-MD therapist, and if that does not yield symptom reduction, then a “higher level of care” is introduced, and this often means medication. The issue of whether to start medication immediately or to wait to see if psychotherapy can help is a highly debated topic, with no clear answers. Thanks.

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