Shirah Vollmer MD

The Musings of Dr. Vollmer

Treating Confusion

Posted by Dr. Vollmer on February 19, 2015


Struggling to define what I do, to describe who I treat, and whether I see my patients as mentally ill, I have come to see that mostly, by no means everyone, I work with confusion and psychic pain. Do I think that everyone with psychic pain is mentally ill? No. Do I think that confusion can be measured, such that Big Data can monitor my “progress”? Of course not. Do I think that confusion is deeply personal and layered deeply with both conscious and unconscious layers? Of course, I do. Does medication help with psychic pain? Yep. Does putting someone one medication mean they are mentally ill? Of course not. Being psychically bruised is not the same as mental illness. Taking medication for a bruise makes sense. Labeling someone as mentally ill does not.

On another level, my field is also confused, just like my patients. We cannot define our terms, and we cannot establish indications for treatment, or modalities of treatment which create lasting change. We are desperate to measure something, even if what we measure has no inherent value. We hold hope for neuroimaging studies and pharmacogenomics to give us more objective evidence of what we are treating, and we seemed shame to say that we are as confused as our patients.

I advocate for embracing our confusion as a way of coping through life’s challenges. Confusion, although psychically painful, also leads to exploration and discovery, as Freud taught us years ago. He described understanding the mental apparatus like an archeological dig. We do not know what we will find, but the fun is in the adventure of not knowing, and being open to seeing things. Yes, inquiry into the workings of the mind is fun, while at the same time, it is layered with challenging feelings of guilt and shame.

Finding a path in life which feels fulfilling, connected and warm is a never-ending challenge, as one cycles through the stages of development, both one’s own development and those they love. The dynamics of aging, combined with the dynamics of mental processes create a constantly changing landscape in which to make meaning and happiness. Like all other endeavors, there are times when one’s personal navigation tools fail, and so this presents  an opportunity for new tools and new ways of understanding the world.  I help with that. That is what I do.


4 Responses to “Treating Confusion”

  1. Shelly said

    I like that. However I’m wondering how you would deal with patients at the beginning of their mental decline, such as those suffering from Alzheimer’s, Huntington’s Disease, Lowe Body Dementia, etc…? I suspect that the patients with real functional cognitive disorders are a lot less fun to work with, their changing landscape is different, their dynamics of aging is skewed, and their ability to accept personal navigation tools is extremely limited. We quantify their decline differently as inhibitions and shame slants and quality of life becomes a whole separate ballgame. Just wondering….

    • Yes, neurodegenerative diseases are another issue. I would not call these mental illness, but rather I would stick with the descriptive term of neurodegenerative disease, or brain rot, which I sometimes say. Yes, this is a deterioration of brain functioning which limits the patient’s ability to take a birds eye view of their situation, and hence they are typically not able to engage in thoughtful discussions about their confusion. Consequently, working with these patients, often means helping their loved ones cope with their changing landscape. That is where the “fun” is. Thanks.

  2. Eleanor said

    I have always had a major distaste for the term “mentally ill” when used in non specific global terms. Treating psychic pain and confusion as mentioned does NOT mean one is mentally ill. It has been my understanding (and please correct me if I’m wrong on this) that psychoanalysis in itself as a treatment modality takes a certain amount of ego strength to begin with, to be able to tolerate the treatment itself. I would be interested to hear what you think Shirah regarding the continuum between psychic pain/confusion and being “mentally ill”. Where is the diving line and what determines that? Thanks.

    • Thank you Eleanor for bringing out this line in the sand issue, of when does psychic pain bleed over into mental illness. In extreme, it is easy to say, because patients who are delusional and hallucinating, with an obvious deteriroration of functioning, fall into the chronic mental illness category. This is about 1% of the population. So, the majority of people, by my way of thinking, are not mentally ill, but do have psychic pain, and as such, they can benefit from psychotherapy, psychopharmacology and behavioral interventions. You are right that a certain amount of ego strength is necessary for deep psychotherapeutic work, and so it is often a sign of mental health that one can endure deep exploration. Yet, the issue is that clinicians are forced to make a diagnosis to prescribe medication, and hence the medicalization of psychic pain, leading to terrible confusion both among providers and lay people. Thanks again.

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