Shirah Vollmer MD

The Musings of Dr. Vollmer

What Do Psychiatrists Do?

Posted by Dr. Vollmer on September 16, 2015

We diagnose, and yet, our diagnostic system is flawed, and hurtful to some patients and their families. We treat with medication, and mostly that is helpful, but occasionally it is a means to enforce a misdiagnosis and a misunderstanding of the patient’s psyche. We also treat with machines such as ECT and TMS, and that is also mostly helpful, but without a theoretical basis for clinical improvement. I would like to think that what psychiatrists do, what I was trained to do, is listen. Yes, yes, I am on my soap box, talking about the complexity of listening, the use of listening as a healing device, and the respect we show to patients by listening deeply with a thoughtful and theoretical mind which gives us multiple models in which to  listen. How do I market listening? How do I tell the world of drive-by health care that time and patience are the key ingredients to my work. Like cooking a brisket, there is no short-cut. Limiting time kills the value of the product, in that the product is open-ended. Giving the patient “goals” is also antithetical to my model, in that goals imply that the patient comes in knowing what the problem is, instead of my model which says that there is both a stated and unstated, or unconscious, agenda. Marital problems might bring someone to my door, but a hunger for understanding their childhood may keep them coming. If I stated the goal was “marital harmony” then I would miss the opportunity to explore deep-seated feelings which have manifested by displaced anger and aggression. If I shorten my sessions, then I would miss the unpeeling of the onion which only comes after many minutes spent together struggling to understand how the patient suffers. If I speak in terms of “tools” then I miss the point that the patient knows about these tools, but for complicated reasons does not avail himself to them. It is simplistic to expect that short sessions, limited visits and goal setting could overcome lifetime habits of poor decision-making and self-destructive behavior. Why would psychiatrists, those with more training than any other mental health professional, buy into this simplicity? This question represents my struggle. How did we get here? The greed of the 15 minute appointment is one answer, given that it is easy to do the math. Is the answer as simple as that? I think so.

4 Responses to “What Do Psychiatrists Do?”

  1. Eleanor said

    Shirah I normally don’t post anything from your blog on my personal Facebook page but this latest post of yours is so brilliant and so “to the point”, especially in today’s medical climate, I just posted it. Listen, listen, and more (professional, expert, trained and insightful) listening….no time limits, etc etc etc. Enough said. Your post says so much, so well…Many many thanks. 🙂

  2. Shelly said

    Shirah, what do your patients want? Do your patients want to come in and to peel the onion, or do they want to feel better and leave? There comes a point where they have to break free and live adult lives and integrate into society, practicing the skills you have taught them. It is entirely possible that your patients truly enjoy the relationship you’ve built with them and don’t want to “let go” but it can’t go on forever. I agree that the current health system simplifies psychiatric and mental health in the US. On the other hand, years and years of therapy may be on the other end of the spectrum–in some cases, not allowing the patient to grow and live a real life (with all of its challenges).

    • It is interesting, Shelly, in that you envision that patients get “stuck” on the bridge to wellness because it is very painful to leave the relationship that they have built with their therapist, and of course, I think there is a lot of merit to that argument, but in my experience, similar to parenting, there comes a natural time where the patient, like the child, wants to treasure the relationship, but they also want to move on to a more independent existence. In other words, patients use the relationship to heal and then they move on. The duration of this treatment is very individualized, hence my violent raging at limiting the time of treatment. Having said that, the point of this post is to remind people that what we do best is that we listen. We offer few “answers,” but we do offer an opportunity for exploration, for however long that makes sense to therapist and patient. My hope with this post is to change the identity of the psychiatrist from the one “who knows what to prescribe” back to the one who knows “how to think with you.” I want to return to the previous generation when humility was not only embraced, but it was the pillar of our work. Whether the patient comes once or a hundred times, the patient should experience being understood, and not be told what to do. This is my hope. Adding on, I do give patients advice, but this comes after a considerable period of time of trying to understand the issues. More commonly, advice is dispensed without understanding, thereby making a mockery of my field. Thanks, as always, for stimulating this conversation.

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