Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Psychoanalysis’ Category

Marketing Psychoanalysis

Posted by Dr. Vollmer on December 13, 2016

Marketing psychoanalysis used to be an unspoken taboo, meaning that patients were supposed to come and seek our intensive help, rather than clinicians seeking patients to treat. This worked well when the supply of psychoanalysts outstripped the demand. In the 60’s and 70’s, and even in the 80’s most analytic institutes did not allow non-MDs to enter training, thereby limiting the available psychoanalysts. Further, in the 60’s psychoanalysis was a popular treatment modality, particularly in big cities in which it was fashionable to say, “my analyst says….” There was status to having an analyst and there was a sense that as a result of being in analysis, deeper creativity and deeper meaning in life could be obtained. Further, many insurance companies paid for the treatment, so the cost was not a big issue for some, leaving only the large time commitment the major barrier to care. As time marched on, the 90s brought us SSRIs and with that limited insurance coverage for psychotherapy. In the 80s, non-MDs sued the American Psychoanalytic Association for discrimination, and they won, opening the doors to non-MD therapists to enter in psychoanalytic training. Now, we have many more providers and much less demand, creating a situation in which marketing is essential to prevent professional death. Yet, how do we teach marketing when our senior colleagues find marketing offensive, in that it might diminish the élite aspect to the field? Marketing gives up the notion that we are a sought after commodity. It makes us be more honest with our environment, which of course, is what psychoanalysis claims to do to help patients. This massive shift in supply and demand is the subject of my class entitled “Building A Psychoanalytic Practice.” As I come to the end of my seminar, I hope to convey that our hard-earned psychoanalytic skills cannot be honed unless we have patients, and we can’t have patients unless we announce to the world what we do. Supply and demand has flipped since psychoanalysis came to America. We either adapt or die. It is that simple.

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Analysis as Apprenticeship

Posted by Dr. Vollmer on December 8, 2016

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How do you make a psychoanalyst? No one knows, is the short answer. The tradition has relied on a tripartite model in which the student, a licensed clinician, enters into a personal analysis, attends four years of classes which are four hours a week, associated with one-hundred pages of reading per week, and has three psychoanalytic case control patients, which means three patients come four times a week, and each of those patients is associated with a supervisor who discusses the clinical work. This is a daunting task for most students who have loans to pay and children to raise, and yet, year after year, the five psychoanalytic institutes in town, get students, and every year there are students who graduate, now thinking of themselves as psychoanalysts. To paraphrase Mark Twain, the reports of the death of psychoanalysis are premature. Having said that, there is no agreement about how to develop a psychoanalyst, or how to develop a psychoanalytic practice, and yet, my task is to teach this subject to first-year students. As you could predict, I pull the curtain back and expose the fact that we do not know precise definitions of a psychoanalyst or psychoanalytic treatment, but we accept that we work in a fuzzy field, in which we cannot scientifically prove that we offer help, and yet, we have the conviction that we do. To work with conviction sounds awfully like a religion, and so we discuss that too. In essence, we have, what amounts to apprenticeships, where students find mentors who guide them through their work, and so traditions are passed down, which may or may not be helpful. The student, I emphasize, must find the path that makes sense for them. This provides little comfort, as the mandate is purposefully vague. I have one more class to teach. My students are enthusiastic and confused. I think I did my job.

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Analytic Stance

Posted by Dr. Vollmer on November 30, 2016

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The patient comes in with a stomach-ache, many things could explain it, but the psychoanalyst wonders about the psychology, the historical roots, and the meaning of the  stomach-ache, while the patient wants her stomach to feel better. This cross-purposes describes the “analytic stance” where the therapist is thinking on multiple levels, even if the patient is not. The stomach ache could be present as a way to communicate that she needs nurturing, but rather than asking for nurturing, or saying she needs nurturing, she presents with a stomach-ache because as a child she learned that the only way she could get attention was by being physically sick. So now, as an adult, she experiences psychological distress through her body. In other words, her psychological stress transforms into a bodily complaint, because talking about how her body is betraying her is a comfortable way for her to communicate with a doctor, even if that doctor is a psychiatrist. To say, that she is lonely or scared, or at loose ends, are feelings that she is not at ease to discuss. By contrast, complaining about her stomach is familiar and, in the past, has rewarded her with attention which helps her feel cared for. To understand her stomach ache in context, as code language for asking for emotional support, is the beginning of a psychoanalytic process which might grow into a deep treatment, that is, a deep understanding of her distress. The patient may walk out with the same stomach-ache she walked in with, but at the same time, she is stimulated to consider her distress in different ways, and in so doing, the stomach-ache could gradually recede, and with further work to understand her issues, her stomach-ache may not  come back.  She will discover more direct ways of communicating her feelings and in so doing, her relationships with others, and with herself will feel fulfilling. The psychoanalytic process will pay off, but not in the immediate way of relieving her chief complaint.

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What Does It Mean To Be Spiritual?

Posted by Dr. Vollmer on September 29, 2016

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Spiritual is a word that confuses me. It is not that I do not appreciate the right-brain and all of the fantasies and creative thinking that results, but the word “spiritual” makes me wonder what the patient means when he says it. Do they mean that there is more to life than the mundane aspects of showering, eating and sleeping? Do they mean that the word “religious” troubles them, and so they compromise by using the word “spiritual”? Jay, seventy-one, comes to mind. He was brought up in a devoutly religious home, in which he feels did not “suit him”. He raised his children without any religion, and by his account, he suffers “tremendous regret” about that. In the last decade, he has become “obsessed” with yoga, which he feels to be very “spiritual”. My hunch with Jay is that yoga has allowed him to access the part of his brain which is non-linear, the part which is not focused on competition or comparisons. The “spirituality” of yoga seems to have given Jay the ability to relax, to not worry about his future, to not worry if he will be the next one of his friends to get a cancer diagnosis. It allows him to be “present” as he would say. How do I, as Jay’s psychiatrist, work with his “spirituality”? First, I try to understand the meaning it has for him, and how he integrates this word into his mental space. In other words, I try to understand how he connects this word to other ideas and fantasies in his mind. Second, I try to see how his “spiritual” side might help, and might hinder, his personal growth. This new-found love of yoga might open mental doors for him and allow him to get access to parts of his mind which were previously shut off, but it also might serve as a protective shield, in which he goes to yoga seven times a week as a way of avoiding having relationships with those he cares about. It is our job to explore this together, to try to add historical context to his newly discovered passion. The ambiguity inherent in the word spiritual is our open window into his mind. “Tell me more,” I like to say, truly curious about what it means to him.

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Working With Perception: Learning Counter-Transference

Posted by Dr. Vollmer on September 26, 2016

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What happens when a therapist needs to be liked, needs to feel like they matter, and/or needs to feel like they are nurturing and the patient does not meet the therapist’s need for such gratification? Often, the work grinds to a halt. The patient gets “busy” with other things. The therapist, suddenly, must cancel multiple appointments. These unconscious resistances on both sides of the couch is the meat of psychoanalytic teaching, and yet, the most challenging concept to grasp in psycho therapeutic work. In other words, the beginning therapist must put aside the layman’s notion that “this work is so gratifying” as the need for that gratification can impose a burden on the patient to say they are well, when, in fact, they are still suffering quietly. The therapist’s unconscious need for affirmation can replicate the patient’s role in his/her family to make sure that their parent is happy, at the expense of knowing their own true self. In this scenario, the patient is not only not getting better, but in fact, is being re-traumatized by the alleged therapeutic situation.

Ty, a forty-year old female patient, and Tro, a forty-four year old female beginning therapist start to work together. Ty keeps telling Tro how much she is helping her. Tro reports the gratification is seeing Ty develop and suddenly, after 6 weeks, Ty drops out of therapy, while Tro is aware that Ty remains in a difficult relationship and she has occasional substance abuse issues. Tro is bewildered. On the one hand Ty expressed gratitude at every session, and on the other hand, Ty stopped the work prematurely, according to Tro. “Could it be that Ty unconsciously had to tell you how much you were helping her,  because she sensed your need for affirmation, but that deep down, Ty knew that she was not finding her sense of agency, her sense of her own voice?” I say, to my student, to her amazement and somewhat alarm. “You mean that I am letting my own stuff get in the way?” She asks, astutely. “If by stuff, you mean, your need to feel validated by others, then yes, that could be getting in the way of Ty being more authentic. She may feel she has to care for you and make sure that your ego is intact, as she had to do that with her mom.” I respond, pleased that Tro is quickly grasping the concept of counter-transference. “It is hard to be in a field, where positive reinforcement can be a defense,” I say, trying to make light of this challenging topic. “The holy grail of reward is seeing a patient become less defensive, which does not necessarily translate into holiday cards, or presents. In fact, gifts become a complicated subject, layered with meaning, and sometimes, “you guessed it” I say, a defensive act.

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Borderline Personality Disorder: Bah

Posted by Dr. Vollmer on September 19, 2016

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Primitive mental state-that is what I strongly prefer to say when my students tell me that their patient, or their patient’s mother has “Borderline Personality Disorder.” My reasons are many, which begin with I find this diagnosis misogynistic, given to women who exhibit colorful or spirited emotional responses to stress, thereby imposing a judgment in which emotional reactions are somehow pathological. I accept that women and men, as a general rule, express themselves differently, but to say that a woman who describes dark moments in her feelings a “borderline” is to inhibit the facilitation of emotional expression. Second, I find this diagnosis a way of saying that the doctor does not like the patient, and finds the patient’s emotional experience objectionable. It is as if the doctor perceives the patient in a compassionate way, then the doctor diagnoses Major Depression, but if the doctor starts to feel uncomfortable with a patient, then he/she is more likely to throw the personality disorder label on the patient. Third, the terminology “Borderline Personality Disorder” does not convey the process in which the personality needs help. I prefer the developmental model of personality in which some of us fail to develop, or we develop and then we regress to more primitive expressions of our feelings which often involve rage and bodily and/or property destruction. If we were to use the term “primitive mental state” then we convey a certain hopefulness, that with all states of mind, they are fluid and subject to maturity and emotional growth, whereas “Borderline Personality Disorder” implies a life-long struggle which borders, pun intended, on hopelessness.

My students, taught this diagnostic system, are almost always taken aback by my objection to our language, which shapes our thinking, and hence our interventions. The advantage of a big institution, like UCLA, for example, is that students are exposed to multiple ways of approaching this complicated organ, we refer to as the brain. This seems to give little comfort, when I encourage them to challenge their rock stars. Students, like patients, have a transference to their teachers, and so learning new information, in such an intimate setting, is not an emotionally neutral experience, but rather it is an experience filled with identifications and defensiveness. Therein lies my challenge. I need to work with both the conscious and unconscious aspects of my student’s brain, while at the same time, not go too deeply into their own personal dynamics. Like psychotherapy, this is a delicate dance, which most of the time goes well, but occasionally I need to be mindful, not only the layers in treatment, but the layers in teaching as well.

Posted in Borderline Personality Disorder, Psychiatry in Transition, Psychoanalysis, Psychotherapy, Teaching Psychoanalysis | 7 Comments »

The Internal Analytic Frame

Posted by Dr. Vollmer on April 13, 2016

Parsons (2007) suggest that “the analytic setting exists internally as a structure in the mind of the analyst”; it is “a psychic arena in which reality is defined by such concepts as symbolism, fantasy, transference and unconscious meaning”. Whereas the external frame is focused on time and money, the internal frame is defined by privileging the notion that so much of human motivation is beyond awareness and as such, our behaviors confuse us, depress us, and sabotage us leading to uncomfortable feeling states. The combined effort of patient and therapist to understand motivation, often based on repressed past experiences, leads to an opening up of mental doors and a release of compulsive behaviors. In so doing, the patient not only gets symptom relief, but also a way of being in the world which feels expansive and exciting as opposed to constricted and limiting. As with Lacey from my previous post, the notion of limited time and money is often a metaphor for the limitations of one’s mental existence. It was only when she hurt her knee that she could see the parallel between physical limping and mental limping. Complicated knee injuries often require intensive work with a physical therapist, and so complicated mental suffering requires intensive work with a psychotherapist. The meaning of the symptoms is the holy grail, not the resolution of them. As such, diagnostic classification is far less important than a case by case approach to mental suffering. Geneticists like to say that depression is a “heterogeneous disorder”; a phrase I find amusing given that a “heterogeneous disorder” means that each case stands alone and to date, no one can identify a common thread. Psychoanalysts, on the other hand, search for the underlying meaning and importance of this psychic suffering.   Haley, sixty-one, comes to mind. She lost her husband twenty years ago, and by her report “she misses him every day and she is sad all the time.” “Why do you think you need to keep him top of mind?” I ask, wondering what her husband meant to her. Would she feel she betrayed him if she were to feel happy again? I wonder silently. Her sadness persists for a reason; a reason she is yet to understand. The conviction that together, Haley and I can come up with some ideas about why she remains psychically glued to her late husband, is the internal analytic frame. I do not mean to say that Haley could not benefit from medication, but that does not change the notion that deeper understanding of her symptoms will free her up to have multiple feelings and  in so doing she will be less stuck in her sadness. This invisible conviction, this internal analytic frame,  is the backbone of deep psychoanalytic work, regardless of the frequency of visits.

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The Analytic Frame

Posted by Dr. Vollmer on April 12, 2016

The “analytic frame” is a way of describing the notion that patient and therapist engage in a verbal contract in which the job of the patient is to show up and pay the bill, while the job of the therapist is to help guide an understanding of the inner workings of both the mind of the patient, and where relevant, the mind of the therapist as well. Breaking or expanding the frame is not taboo, but something which should be carefully considered. The invisible frame is a strong reminder that the therapist is there as a facilitator and as such, should not bring his/her needs into the therapy room. Of course, the therapist has unconscious needs from the patient, such as a need for appreciation, but these unconscious needs should be fodder for discussion, if the patient feels those needs are interfering with his/her treatment. The frame, like any boundary, allows for freedom within the limits, as a playground is fenced, but there is freedom within it. Respecting the frame, the boundaries of treatment, allows for the safety of the experience, the safety of knowing there is privacy and there are limits to how much the therapist will share his/her issues. Maintaining the analytic frame is the work of the therapist, and so in my class tomorrow, we will talk about how unconscious reluctance to maintaining that frame may cause the therapist to discourage patients from entering deeper treatment by colluding with the obvious issues of time and money. Lacey, fifty-four, comes to mind. With three little children, a full-time job and an underemployed husband, she is “certain” she cannot come more than once a week for treatment. The therapist agrees with her, as the therapist is also a mother of young children, and so imagines her time limitations. As time goes on, Lacey has a ski accident and hurts her knee. Suddenly, she is going to physical therapy three times a week and paying for it out-of-pocket. “I am glad you are going to physical therapy and taking care of your knee, but I am also aware that when it comes to your body, you find the time and the money, but when it comes to your mind, you are convinced that you have significant limitations.” Suddenly, Lacey is taken aback and agrees that she knows physical therapy will help her knee, but she is far less certain if increasing her psychotherapy will help her life. The therapist, upon hearing this, begins to reflect that her collusion with the lack of time and money was simply a projection, and that Lacey’s reluctance for deeper psychotherapy, was not about her limited time, but rather her hopelessness about the process. The therapist did not encourage creating an analytic frame for Lacey to feel a sense of hopefulness about this. It is possible that the therapist, thinking how busy she is in her own life, did not want to increase her time commitment and so conveniently fell into “there is no time and there is no money” way of thinking. The two-way street issue presents again and again. And so our class will delve into the challenge of creating this ‘analytic frame’.

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Therapeutic Ambition

Posted by Dr. Vollmer on April 6, 2016

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In today’s class we discussed how the goals of the patient are not necessarily the same goals of the therapist. Typically, the patient wants symptom relief, whereas the dynamic psychotherapist wants an understanding of the symptoms in order to achieve a deeper sense of well-being. The patient thinks short-term, while the therapist thinks long-term. This, as Howard Levine MD describes is “therapeutic ambition”. As a parent tries to help a child have a bright future, so a therapist helps the patient, not just in the here and now, but in their future as well. “I just want to stop binging,” Kelly, age fifty, tells me. “I want to understand what binging means to you,” I reply. Through understanding the behavior can lose the power, the compulsive action, as Kelly may no longer feel the need to abuse her body in that way. As I have gotten to know Kelly, we have come to understand that for her, binging was a sign of rebellion, against her rigid and judgmental mom. In an indirect way she was punishing her mom by binging such that as she understood this, she no longer felt the need to eat in this out of control fashion. The therapeutic ambition manifested as a desire for Kelly to understand herself better, in contrast to Kelly’s goal of eating normally. Although Kelly reached her goal, the method had to do with uncovering unconscious motivations and desires, rather than focusing on her diet and exercise routine. Holding to bigger picture is what deep therapeutic work is about. Moving away from symptoms towards unconscious mental processes is the basis for the work. Easy to say and hard to do. that is how the class ended.

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Mental Representation

Posted by Dr. Vollmer on April 5, 2016

The psychotherapists’ technique of waiting and responding is contrasted with waiting and meeting. Can the patient trust what comes to his mind, that spontaneity of thought? This requires the capacity to tolerate uncomfortable thoughts and feelings. On the other side of the room, the practitioner of psychoanalytic therapy must have both patience in listening as well as clinical intuition to say what comes to mind. In saying what comes to mind, either as the therapist or the patient, one must risk an uncertain outcome as to how it will be received. This courage. as I often talk about in these posts, comes from a mental representation that negative feedback, either one’s own, or from the listener, can be tolerated and digested. In other words, the ego is not shattered, merely bruised. This work is based on the basic tenet that so much of what we do and what we say has layers of meaning, only a fraction of which, we are aware of. Being able to listen to ourselves is the first step towards listening to others. Defenses rise up as we are scared to get in touch with our own minds, causing painful anxiety and self-sabotaging behaviors which are designed to numb ourselves from ourselves. Josie, fifty-one, comes to mind. She is a woman who has a very rigid life. She is trapped in her routines in a way which makes her feel confined and bored. When I ask her to tell me more about her feelings, she says “I have said it all. There is nothing left to say,” further enforcing her notion that she is boring and confined. “Your mind is confined, as well as your behaviors,” I say, hoping to help her see how she imposes barrier to her thinking which leads her to see herself as shallow. “You say that a lot,” she tells me, with the tone that she needs to hear this  repeatedly, with the hope that one day she will understand better as to why she is so blocked. Josie is engaged in the treatment. She wants to have a fuller  life, while at the same time, her fear of change, and all of what that means to her, is inhibiting her mental exploration. Articulating this internal struggle is our work. One day, I believe, Josie will know herself significantly better.

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

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