Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for March 29th, 2016

Intensifying Treatment: Who Decides?

Posted by Dr. Vollmer on March 29, 2016

Springtime is time to teach, for me. Tomorrow starts my class entitled “Building A Psychoanalytic Practice”. Our first reading, by Stephen Bernstein MD, discusses the process in which patients begin coming once a week, and for some, there is a transition to more intensive work, meaning twice, three, four or five times a week. To people unfamiliar with psychoanalysis, this might seem to be an absurd amount of psychotherapy. Yet, for those in psychotherapy who feel a sudden or gradual  sense of being understood, of being heard, of feeling significantly less anxious, intensifying treatment makes a lot of sense. Yes, yes, there is significant time and money involved in such a commitment, but let’s put that aside for the moment. The relationship, as Bion famously said, provides a containment,  meaning a psychological enclosure in which difficult and painful feelings can be processed. Outside of psychotherapy those feelings can lead to panic attacks and generalized anxiety, but in the context of a therapeutic relationship, the opportunity to process those feelings often leads to diminishing anxiety, and hence the person feels contained. The inability to contain a patient is seen as a therapeutic challenge, and not necessarily a reason to refer for anti-anxiety medications. The referral, Bion might say, sometimes implies that the patient’s anxiety has overwhelmed the therapist, leading to greater hopelessness in the patient. The struggle to contain the anxiety is the work of the therapy, and sometimes that work requires greater muscle power which can only be achieved by adding more time, which increases the focus on the anxiety, and shortens the intervals between sessions. Like all relationships, the more they are nurtured, the more rewarding they feel, so too, with psychotherapy, that the more the dyad can focus on the issue, struggle with verbal play to understand the psychic pain, the more likely there will be a sense of understanding and psychic relief. The “break it to fix it” model applies here. The patient must experience the pain, intensely, in order to put himself back together in a way which feels both more expansive and more peaceful. Working with patients to increase the frequency of visits, like all aspects of psychoanalysis, is a very delicate process. Some patients may feel that they are “so sick” they need more therapy, whereas others might feel flattered by the desire to spend more time together. Understanding the meaning of proposing a different treatment is the first step towards testing the waters as to whether a deeper relationship makes sense. Therapeutic regression is expected and so both parties are naturally fearful of the outcome. The more time people spend together the more their blemishes are revealed, the more shame both parties can feel, possibly resulting in rage and disappointment, either with themselves or the other. The stew of feelings is expected, but working through them, containing them, examining them, is the work, the art of deep treatment. For some, this will be a life-changing endeavor, again for both parties, but particularly for the patient. For others, the therapeutic regression will cause a stalemate, and there will be a terrible sense of spinning one’s wheels. To enter takes courage. To learn how to enter also takes courage. And so our class will begin.

Posted in Psychoanalysis, Psychotherapy, Teaching Psychoanalysis | 2 Comments »

A Soulmate

Posted by Dr. Vollmer on March 29, 2016



Nortin Hadler, MD, has been doctoring for a long time. He’s old school. Loves a rich doctor-patient relationship, where the whole person – patient – is seen and comprehended.  Treated in full.  But these days, he says, doctors who care are burning out, retiring early, pulling their hair out.  “Today,” he writes, “health is a commodity, disease is a product line and physicians are a sales force in the employ of a predatory enterprise.” Ok! This hour On Point, Dr. Nortin Hadler on how to heal American health care.

— Tom Ashbrook



Posted in Doctor/Patient Relationship | Leave a Comment »

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