Shirah Vollmer MD

The Musings of Dr. Vollmer

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These are my main blog entries.

Critical Thinking: A Therapeutic Goal

Posted by Dr. Vollmer on February 26, 2018

 

 

 

Critical thinking — what the philosopher John Dewey called the ability “to maintain the state of doubt and to carry on systematic and protracted inquiry,” is the goal of reflection. To modify Dr. Dewey’s quote, psychotherapy/psychoanalysis aims to help the patient develop critical thinking about one’s own mind and about the minds of those that influenced them. “I am not interested in symptoms” I say, in a provocative manner, to my class, knowing that saying that contradicts all of their previous education in psychotherapy. “I am also not interested in symptom-relief,” I say, taking it one step further. “What I am interested in,” I say, “is how the patient is thinking about his life and why those symptoms are manifesting at the particular time, and in the particular way, in which they do. ”

Karen, sixty-two, comes to mind. She has what could be called Generalized Anxiety Disorder, and I prescribe her medication, so in that sense, I am interested in symptom-relief, but mostly I am curious why she has to worry. I am helping her be curious as to why her mind is preoccupied with worry. The key words are “has to”. As I understand anxiety, it is often a symptom of a deeper issue of insecurity and loneliness  and I would like to explore that with her. I want to explore that with her in a way that makes her curious about it in a way which generates a  “systematic and protracted inquiry” and which carries on both inside and outside my office. This is what I do, and this is what I teach. Sure, I tell patients with anxiety to try yoga, meditation, and dietary interventions, but that is merely the beginning, because as time progresses, the issue becomes, “so what is really go on here?” To that question, there are endless answers, requiring a “systematic and protracted inquiry.” Dr. Dewey, may he rest in peace, is my hero.

Posted in Anxiety Disorders, Teaching, Teaching Psychoanalysis, Unconscious Living, understanding | 4 Comments »

Gender Health?

Posted by Dr. Vollmer on January 11, 2018

https://www.uclahealth.org/med-peds-care/gender-health-program

 

Image result for ucla gender health program

 

With deep respect for UCLA as an institution, and with deep respect for my training which has entirely occurred at UCLA, and with deep respect for the many departments within UCLA that I have been affiliated, I am quite curious and, dare I say, skeptical, about a “gender health program”. Reflecting back on my training in the 1980s (yea, I am getting old, I know), UCLA was doing transgender surgery, mostly in the department of urology. Mostly they were turning male genitalia into female genitalia. Other tertiary care medical centers were doing this too, and so this was a “standard of care” a phrase which has now been replaced by “evidenced-based medicine”. In the early 90s they stopped doing this surgery and so patients seeking a change in genitalia sought private practice doctors, both here in LA and around the world. Medical tourism was a popular notion among male-female transgender folks as they could pay out of pocket a fraction of the cost in another country, and that would include their airfare, a fancy hotel, and an American trained physician working in another country (usually their birth country). Somewhere around 2010, the “medicalization” of transgender patients took off, with the example being in LA, that children’s hospital started a clinic…

http://www.chla.org/the-center-transyouth-health-and-development and then pediatricians throughout LA, when faced with a patient who expressed discomfort with their gender, would be sent to Children’s Hospital. The assumption is that CHLA is a good hospital and so, therefore, they must appropriately deal with transgender issues, since most pediatricians have no training in this area. Somehow, UCLA seems to want to join the party, and so the Gender Health Program is born. I say this, with the complete disclosure that I am not aware of the politics, or the motivation behind opening this clinic, but I do enjoy speculating publicly (to my 50 or so readers), as to how transgender issues seem to come and go within the medical profession. Having Gender Dysphoria..as opposed to Gender Identity Disorder (GID)..see below

 

GID was reclassified to gender dysphoria by the DSM5. … The American Psychiatric Association, publisher of the DSM5, states that “gender nonconformity is not in itself a mental disorder. The critical element ofgender dysphoria is the presence of clinically significant distress associated with the condition.

 

…is a mental disorder. I am not sure that I agree that those who have distress over their gender are mentally ill. Sure, they need a prescription for hormones, and possibly surgery, to change their gender, so they do need medical care, but whether they need mental health care has more to do with individual preference. A patient, for example, might have extreme distress over the size of their nose, but they don’t need to see a psychiatrist if they opt for rhinoplasty to attempt to minimize their distress. I know this statement is very controversial when it comes to gender, but I think this argument is worth consideration. If the patient is curious as to why their nose distresses them so much, then mental health intervention makes sense, but if there is no curiosity, then mental health care is harder to execute. In the 70s being gay meant you had a mental illness. That quickly got fixed when psychiatrists realized the absurdity of that notion. Being bisexual, or uncertain of your sexuality, is also not a mental illness. So, I would say that being uncertain about your gender is not a diagnosis, but only a nodal point, which suggests thinking about how to proceed. As with all big decisions, we, as psychiatrists, can help people through them, but it is also true that people make big decisions without our help and do just fine.

Returning to the Gender Health Program, I can see the advantage of pooling patient populations in order to develop an expertise. I can also see the marketing advantage that the program makes people feel like they will have a place of understanding. My issue is that Gender Health is a made-up term. I wish they would call it a Gender Program. I am not sure what Health has to do with it, as the patient may not be sick to begin with.

 

 

Posted in Gender | 2 Comments »

Patient Sculpting

Posted by Dr. Vollmer on December 19, 2017

Image result for patient sculpting psychological

 

Hans Loewald  discusses the idea of patient sculpting, meaning that the therapist imagines the patient without his neurosis, and in so doing, imagines the patient having a more fulfilling life. What would the patient be like if he did not live out the guilt of his parents, for example. Lewis, sixty-six comes to mind. He is the son of holocaust survivors. Parents who instilled in him a sense that the world is a frightening place and he must be suspicious at all times. Lewis has embraced this philosophy unwittingly, living his life in constant fear, but not exactly understanding what he is afraid of. Imagining Lewis without anxiety is what some theoreticians call an “analytic stance”. If Lewis could come to understand that he “inherited” this fear from the trauma his parents experienced, then he could begin to separate out his reality from theirs. In so doing, Lewis could come to experience life in a more relaxed and engaging manner. Moreover, his physical symptoms of irritable bowel and intermittent headaches might improve substantially. A patient without anxiety uncovers the goodness of his soul, as anxiety can obscure that. Keeping the vision provides hope for patients. All of this is not spoken, and yet, magically transmitted between therapist and patient. How to teach these concepts is challenging and yet also very fulfilling. As with sculpture, each student has to find his method. The art of psychotherapy lies in its creativity and in its uniqueness with each therapist/patient dyad. There, I have said it again.

 

https://en.wikipedia.org/wiki/Hans_Loewald

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 4 Comments »

Is Psychiatry As Bad Off As I Say It Is?

Posted by Dr. Vollmer on March 6, 2017

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Check out Kelly Brogan MD…http://kellybroganmd.com/, a psychiatrist, similar to my thinking, advocates for mental health without medication. Now, I do not completely agree that medications are hurting patients, although sometimes that is true, but I do agree that we as psychiatrists have gotten trigger happy, which means we are too eager to prescribe, and too reluctant to listen and put symptoms in context. I have recently taught second-year psychiatry residents (UCLA-15 total), psychodynamic psychotherapy students (New Center for Psychoanalysis-9 total) and I am about to teach primary care doctors .https://www.cme.ucla.edu/courses/event-description?registration_id=146702 about the diagnosis and treatment of anxiety disorders.  In each of these very different audiences I lament the loss of history taking in psychiatry, associated with the rush to prescribe and the consequences being unrealistic expectations and poor understanding of one’s personal dynamics. Associated with this are tremendous health care disparities in psychiatry where those without means are given care which is significantly lower quality than care given to those with discretionary income. Further associated with this are training programs where students learn to read checklists as opposed to asking and listening to open-ended questions. The patient’s narrative is lost and with that comes the loss of the excitement and joy of self-discovery; this loss being for both patient and provider. Burn-out seems like an inevitable consequence of our new model of care, but it will take many years to document this and so we must wait for evidence to validate our suspicions. Meanwhile patient care is suffering, and those with means can seek out care that makes sense, while those dependent on public funds are left to focus on symptom relief and not bigger picture understanding of what is killing their vitality. “I make students depressed” I say frequently, always to laughter, which goes with the grain of truth this gloomy picture represents. Exposing the problem remains the first step. Hence, I will repeat myself until this broken system starts to mend.

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

Did I Mention I Was Teaching Transference Tonight?

Posted by Dr. Vollmer on February 22, 2017

Image result for transference

Freud initially thought that transference was an impediment to treatment, but as the years went by, he began to “discover” that understanding transference was the holy grail of treatment, meaning it is the part of psychotherapy which creates personality change. In other words, how we feel about ourselves, based on early relationships is often recreated in our meaningful relationships and if we form relationships which are harmful to our self-esteem, then we need to reformulate our opinion of ourselves, based on a new relationship. This new relationship, in the form of psychotherapy, allows the patient to examine how he projects on to others ideas from his past, and in so doing re-affirms his previous notion that the world is mean/cruel/withholding towards him. If the patient can see his own projections then he can open himself to new possibilities which includes relationships in which he feels valued/loved/cherished. This is a simple notion, which in practice, requires many hours, in fact, at times, many years of treatment to see how deeply held beliefs can be faulty and damaging.

Joe, thirty-two comes to mind. “I am going to disappoint you,” he tells me with great certainty. “Why do you say that?” I ask, thinking about his declaration. “I disappoint everyone in my life. I just do.” He says with little elaboration. “You mean you disappointed your mom,” I say, thinking that he is referring back to his earliest relationship in which he felt terrible sorrow for not making his mother happy, and in fact, disappointing her by not becoming a doctor or lawyer. “It must be terrible to feel that you disappoint people,” I say, thinking about what it is like to think that you will cause a significant other deep pain. Joe starts to cry. His tears speak volumes to his sense of inevitability that he disappoints; that is just what he does. “Maybe you disappointed your mom, but that does not mean you disappoint everyone,” I say, stating the obvious, but also knowing that it needs to be stated. “The issue is that you feel like a disappointment, and that is a terrible burden to bear,” I say, trying to help Joe understand that he carries around this painful feeling that he cannot shed, since he is so attached and identified with his mother. “I wasn’t abused,” Joe says protecting his mother. “Not in the traditional sense, “I say, “but you weren’t cherished for who you are, and that is a different kind of trauma,” I say, trying to help him understand the childhood feelings he carries forward into adulthood. “I don’t get it,” he responds impatiently. “Yes, we have more work to do,” I say, knowing that this is a painstaking process.

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

Teaching Transference

Posted by Dr. Vollmer on February 16, 2017

Trans·fer·ence
transˈfərəns,ˈtransfərəns/
noun
  1. the action of transferring something or the process of being transferred.
    “education involves the transference of knowledge”
    • PSYCHOANALYSIS
      the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis ).

    How do you teach this concept? I wonder. We repeat behaviors from the past and impose them in the present, and in so doing, our behavior is out of proportion to the present situation but our behavior makes sense in a historical context. In other words, all actions are reactions to past experiences as well as reactions to current experiences. So, if Barb feels that I am being mean to her in session, I may in fact be mean to her, and/or she may get triggered by something I said which reminds her when her mom was mean to her, and in that situation, I am the trigger, but she does not see that immediately, so she feels very hurt and disappointed by me. With time in psychotherapy, Barb and I can come to see how she felt my behavior was “mean” and she can also talk about how it reminded her of how her mother treated her when she had a boyfriend that her mom did not find suitable for her. As we unpack her feelings of hurt and disappointment, Barb comes to see how in other parts of her life, particularly in her close relationships, she often feels hurt and disappointed, and this may, in fact, be her carrying forward painful experiences she had with her mother. “Maybe I am too hard on my boyfriend,” Barb says with the suggestion that her insight into her behavior is slowly expanding. Helping Barb understand how she feels that everyone will treat her as her mom did, opens her eyes to the understanding that maybe she carries with her painful assumptions, which, when tested out, turn out not to be true, but without opening her mind to the fact that she is making assumptions, she then constantly feels hurt and disappointed. Through talking about the transference, Barb has the opportunity to grow emotionally, such that she can begin to understand how she can take a benign comment, such as “I wonder what you find attractive about your boyfriend,” and given her history with her mother, she hears “what on earth could you like about that man?” In her mind, she is prepared for a judgmental, critical attitude towards her boyfriend, such that she cannot entertain the possibility that my question is one of curiosity and not criticism. Clearly, tone is critical in this discussion, but even with a neutral tone, there is the sense that Barb is so convinced that the discussion is going to be antagonistic, and as such she must go on the defensive when talking about her boyfriend. This is a simple notion of transference, but one which I hope will illustrate the point. The point being that by reacting to our past and not our present, we, who have been hurt in childhood,  continue to feel the pain and we do not open ourselves to feelings of acceptance and love. In essence, understanding transference can  be transforming, creating a life-changing  and maybe even a life-saving experience.

     

See also…https://shirahvollmermd.wordpress.com/2014/02/03/teaching-transference-2/

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

Psychic Retreats

Posted by Dr. Vollmer on February 14, 2017

Tomorrow, in my Psychoanalytic Technique class, the topic is silence, and what to do about it. The meaning of silence, the challenge of silence, and the patience with silence will all be ripe for discussion. We will springboard from John Steiner’s work about psychic retreat, where he teaches us that patients often withdraw into silence as that is a safe space; safe from anxious and depressive feelings. More to the point, many people, particularly males, who withdraw in social circumstances, due to fear of having feelings, are often labeled as “on the spectrum” when in fact, they are using a defensive psychological organization to cope with psychic trauma. The misunderstanding between trauma symptoms and “spectrum” symptoms is particularly upsetting to me, because it is one thing to understand a patient as trying to cope via withdrawal as opposed to understanding a patient as incapable of nuanced feelings and social skills. This distinction is critical and it takes time with patients to really understand this difference. A severely traumatized individual will have no friends because he/she is frightened of the feelings generated by friendship, and this can seem identical to the “spectrum” individual who has no friends because he/she is not able to have the reciprocity required in relationships. Two fictional examples come to mind. One, a young male, isolated, lonely, and despairing, has never had friends because he is antagonistic and arrogant, by his report. In the intensive treatment he is often silent, requiring what I have called “hide and seek” such that he hides and I need to seek out his psychological state of being. Without my seeking, he remains hidden. The meaning of my seeking is that it serves to reassure him that I am indeed interested in his mental state. The issue of how long to remain silent as opposed to “seeking” him is the art of my work. The second fictional example is a fifty year old woman who often says, ten minutes into the session “that’s it. I have nothing more to say.” This seemingly abrupt ending to her thought process has puzzled me for many years. It is clearly defensive in that she protect herself from deeper intimacy with me, but at the same time, she is frustrated by her inability to deepen her treatment. Her psychic retreat would not be confused with “spectrum” issues and yet, she isolates herself in our sessions such that there is no reciprocity. She does not play “hide and seek” since she simply hides from me, in that “she is done”. She does not leave however, as she waits, perhaps with unconscious hope, that there is more to be said. Our work is focused on understanding these retreats and how historically speaking, these withdrawals saved her from feeling unloved in her family. Both these fictional examples illustrate how silence is as important as verbal output, as they both convey how the patient organizes his mental interior and as a result how the patient can share, or not share, those very private experiences. John Steiner has helped us a great deal with talking about the quiet, the dark space, if you will, within the psycho-therapeutic hour.

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

The Analytic Surface

Posted by Dr. Vollmer on February 9, 2017

Still thinking about the analytic surface…just sayin’

Shirah Vollmer MD

“Tell me your story,” I like to say, which leads to a confused look. “The whole story?” A 20-year-old patient named Libby responds. I think 20 years is not that much, but to her, she thinks the summary of her life is an impossible task. The open-ended question is designed to see where the patient will begin. Will she tell me where she was born, whether her parents stayed married, or will she focus on her friends or her academic life. As she constructs a narrative, it is my job to formulate hypotheses about why she is in my office. Of course there is the stated reason she came, but there are many unstated, and unknown reasons she is there as well. I am looking for, what some authors would term, “the analytic surface,” which means where to take her narrative and go deeper. Libby spent a great deal of…

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Should Psychoanalytic Teachers Get Paid?

Posted by Dr. Vollmer on February 8, 2017

Tonight I begin my new class in the psychoanalytic psychotherapy program at the New Center for Psychoanalysis. My class is on clinical technique, about what do you actually say when you are in the room with someone, if you are attempting unconscious exploration. In the past, this has been a stimulating class to teach with bright and interesting students and I have always felt that I got back more than I gave forward, and yet, many people have asked me why I don’t get paid for this activity. Tradition is the short answer. Those who taught me, whom I am eternally grateful to, were not paid, so I tell those interested that I am paying it forward. Upon further reflection, though, I wonder if the quality of teaching would improve if there was a stipend associated with the activity. Would market forces create a healthy competition where only the best teachers were asked back, and in turn, the teachers would have incentive to be on the top of their game? In the psychoanalytic community, this discussion is taboo. Like so many traditions, the “young” people are not supposed to question older, more established practices. Like the movie “Moneyball,” the senior members are quite certain they are making the best decisions, even though big data showed that, in fact, their “traditions” failed them. As a medical student, doing rotations in different clinical settings, I learned quickly that the practice of medicine was highly dependent on the reimbursement system, where, in the days before productivity measurements,  doctors who were salaried tended to work less than doctors who were fee for service. This seems obvious in that if someone is paid the same whether they see ten patients or twenty patients, then they are going to argue to see ten patients, and vice versa. Reimbursement systems, like all behavioral systems, impact behavior, and physician behavior is included in this paradigm, of course. So, am I saying that I would be a better teacher if there was a salary associated with it? I think so, but I am not sure. It is an interesting question.

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

Meaning Making: Class in Review

Posted by Dr. Vollmer on February 6, 2017

30 students, different backgrounds, all engaged in a lively discussion of what it means to have meaning, and how patient’s come to us (clinicians) in search of meaning because either they have lost meaning or they never felt they had any. The discussion was broken up into to parts. Part one involved the fictional tale of a middle-aged woman who could not find any inner peace. Externally her life seemed enviable, but internally she never felt any traction. To say that she is depressed misses the point, we discussed, as her disposition was cheery, and her self-care was excellent. Yet, she never felt that what she did really mattered, either to herself or to others. In this fictional case, we explored her childhood roots, her exposure to her parents and our presumption about their internal world. We talked about what it meant to her parents that she was born, and how downstream that caused her to feel unimportant and lost. The students asked lively questions about how to help someone have meaning, when no obvious intervention seems to take hold. The obstacles to having meaning were discussed, as in this tale, the obstacles had to do with her internal alliances to her family in which if she did not mirror the meaning her parents put on the world, then she felt a huge sense of unconscious betrayal and so she could not latch on to new passions. The second part of the morning involved another fictional case, this time of a young adult who was trying to find his way in the world and the obstacles he felt in doing so. Issues of gender, sexuality, professional identity were all mentioned, again in the context of trying to make his parents proud of him, while at the same time developing his own sense of meaning. The relationship between meaning and attachments were discussed in length, as most meaning is made through both conscious and unconscious attachments in that passion is derived from feeling like one key person in your life is going to be very proud of you and in that mental image, enthusiasm is born. The underpinnings of happiness were discussed in a positive psychology model as contrasted with the persistent focus on the underpinnings of distress. Meaning is made if the person can have his life make sense to him. That is, often, but not always, a tall order. And so, my next class is on my mind. How about Healthy Happiness? It is a thought.

MEANING MAKING: HOW TO HAVE A THERAPEUTIC CONVERSATION  |  View Full Calendar

Presented by Shirah Vollmer, M.D.

2/4/2017

General Admission: $55.00

Student Rate: $30.00

How patients integrate events into their lives on a deep psychological level is
fascinating and psychoanalytically rich. One person’s motor vehicle accident is a
small matter, whereas the same intensity motor vehicle accident to another
person is a major catastrophe. Understanding the differences in how people
interpret their worlds is the fascinating work of using psychoanalytic thinking in a
therapeutic setting. This class examines how people have both conscious and
unconscious meaning associated with their lives and as such, they react in ways which both make sense to them and, at the same time, confuses them. As
these layers of meaning are uncovered, a therapeutic conversation ensues
which enriches the patient’s understanding of himself, and thereby creates a
calmness which allows them to get in touch with creative juices and along with
that, a deeper sense of vitality. They experience psychological freedom which is
liberating in ways they could not have imagined before they entered deep or
intensive psychotherapy.
 
Learning Objectives
As a result of attending this course, participants should be able to
• Learn how to probe for conscious and unconscious meaning in a patient’s
presenting complaint
• Recognize how psychoanalytic understanding can aid symptom relief
• Identify how stimulating thought in the patient and helping the patient to be
curious about themselves, produces therapeutic gain
Shirah Vollmer, M.D., is a member of New Center for Psychoanalysis, teaches
in the Training and Psychoanalytic Psychotherapy Programs, and maintains a
private practice in West Los Angeles.

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

 
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