Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Psychiatry in Transition’ Category

Neural Networks

Posted by Dr. Vollmer on November 15, 2017

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The chemical imbalance theory is out. Neural networks are in. That is what I learned yesterday. With the introduction of Transcranial Magnetic Stimulation (TMS), a neuromodulation therapy for major depression and post-traumatic stress disorder, there is now the theory that mood disorders, and anxiety disorders are a result of a neural network failure and as such, therapies which jolt neural networks help patients feel better. Further, by examining EEGs and looking at brain electrical activity, clinicians might be able to predict who can benefit from TMS therapy. As I understand from Noah Phillips MD, a professor at the VA affiliated with Brown University, we, as psychiatrists, are exploring the notion that patients get better by changing the electrical activity in the brain, a re-boot, so to speak. At the same time, TMS, although FDA approved (it should be now called Food, Drug, and Device Administration), TMS is costly, time-consuming and not paid for by insurance. It is done at tertiary medical centers and in private practice. As with the use of psychopharmacology,  I am of two-minds about this technology. On the one hand I am excited about the new way we understand mood and anxiety, and the expansion beyond neuro-chemicals into neural networks makes a lot of sense to me. The brain is a complicated machine, and like a machine, things can go wrong, and re-setting it is very exciting. On the other hand, this technology supports the loss of a narrative. Patient is sick. Patient gets fixed. Next Patient. The medical model of human suffering dominates the clinical picture, and the individuality of the patient is lost to the physician, leaving the narrative to “lower-level” professionals. Clearly both can operate in harmony. Doctors could administer TMS and do psychotherapy, except that the model of care does not support combining these modalities using the physician as the deep listener. I am grateful to be so close to UCLA so that I can be exposed to the latest and greatest in psychiatric health-care. At the same time, I will always have a sadness when I go to lectures, that there is such little interest in the human component of mental health care. To put it another way, as psychiatry focuses on the brain, it has lost its mind.

 

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

Posted in neuromodulation, Psychiatry in Transition | 4 Comments »

Teaching, Teaching and More Teaching

Posted by Dr. Vollmer on August 23, 2017

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So, where, whom and why do I teach? The where is easy: UCLA, New Center for Psychoanalysis and LMU (sometimes). The whom, is also easy. I teach psychiatry residents, child psychiatry fellows and psychotherapists. The why is the challenging question. It keeps me stimulated mentally and it keeps me feeling young and in touch with the next generation. That is the short answer. The longer answer is more complicated. Do I like the admiration that sometimes results from a teacher/student relationship? Yes, and no, is my answer. Yes, it sometimes feels good, but no, with that admiration comes the flip side of “falling down” at times, as the student matures professionally. The teacher/student relationship, like the parent/child relationship is fraught with both idealization and devaluation. Like raising a child, in the beginning, there is a feeling of deep love, on both sides, but as the relationship develops over time, the dynamics get more nuanced, more layered with good and bad feelings. To teach is to grow, I would like to say, and I believe that to be true. Yet, with all growth, comes pain, and struggle, and so the challenges are large. I see myself as a life-long student, and as such, I have signed up for the life-long struggle of learning, growing, and expanding, which can feel exciting, but it can also feel  remarkably humbling. No one said growing is easy, and so it is not.

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

TalkSpace

Posted by Dr. Vollmer on July 19, 2017

Meaningful therapy from every device

It can be difficult to wait days or weeks until your next appointment. With Talkspace, you can send your therapist a message whenever you’re near a laptop, tablet, or smartphone. Your conversation carries over seamlessly across devices and uses banking-grade encryption to keep it safe and confidential.

How Therapy Works on Talkspace

Getting Started

During Therapy

Your Own Therapist

Once you’re matched, you’ll be working with the same licensed therapist every time.

Write When You Want

You can set aside some time every day, or write when the mood strikes you. Your room is always open.

Regular Responses

Therapists respond 1-2 times per day. If you need more, simply schedule a video chat.

Customer Support

Customer Support is available to help answer non-clinical questions about how Talkspace works.

https://www.talkspace.com/

 

 

Oh my, the world changed again, and I just woke up to text therapy. Talkspace is a company that offers packages for texting therapy. Do I text my patients, you wonder? Absolutely. I have embraced the technology early on, as I find texting a great way to communicate and keep in touch. Having said that, what do I think of therapy that is only done by texting. I am simply outraged. Free association is the mainstay of psychodynamic psychotherapy, and so the critical feature is to allow the patient an open space to understand how their mind works by listening to how they put ideas together. Texting, like tweeting, limits the amount of verbal output and as such, limits the depth of the experience. Plus, writing and speaking are two very different forms of communication, and there is something very valuable to a verbal exchange which happens like ping-pong, where ideas feed each other. This is the basis for the “good fit” in psychotherapy where the patient’s mind and the therapist’s mind need to be able to feed one another for the therapeutic process to get started. To only have text as a therapeutic tool is to me, yet another way, in which mental health is being diluted from a high quality profession, to one that can be done “easily” with a smart phone. The complexity of psychotherapy needs to be embraced and not denied. This Talkspace company, although perhaps profitable, strikes me as a very poor substitute for good treatment. Once again, the question arises about whether I am resisting new technology or whether new forms of treatment are not necessarily better forms of treatment. Both, of course, could be true. In this case, the latter seems clear to me. New is not better, it is just new.

Posted in Psychiatry in Transition | 7 Comments »

New Job: Editor of PCFA Newsletter!

Posted by Dr. Vollmer on April 6, 2017

PCFA Newsletter header

 

 

 

 

https://www.semel.ucla.edu/pcfa

 

In the continuing plea for a psychiatry of days gone by, I have accepted the job as Editor of the above Newsletter. I have been a member of the board of this organization since 1995 serving in various capacities including child psychiatry liaison, member of the retreat committee, member of the diversity committee, secretary and now Editor of this newsletter. This organization is a support to the psychiatry trainees in UCLA affiliated programs including the San Fernando Valley Program and the UCLA-Harbor program. We provide low-cost psychotherapy to trainees, along with supervision of trainees.  In addition we   provide many didactics. For example, in addition to my work on the board of the PCFA, I do individual supervision to four adult psychiatry residents, a shift for me, as I used to provide supervision for child psychiatry fellows.  In addition, I give the adult psychiatry residents lectures on childhood assessment, and in the past, I gave the child psychiatry fellows a class on child psychotherapy. Now, I am adding on by helping this newsletter publicize our work, as I feel the strong pull to remind psychiatrists, at all levels in their careers, that listening is an important art, which could sadly be lost, if we are focused on fifteen or thirty minute appointments, with infrequent follow-up. It is my hope that by carrying the torch of listening, both by teaching this art and by doing this art with trainees, then psychiatry will maintain one of its major therapeutic tools, that is, the talking cure.

Posted in About Me, Psychiatry in Transition | 2 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 »

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 »

The Politics of Psychotherapy

Posted by Dr. Vollmer on February 2, 2017

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How do you teach psychotherapy? What does it mean to supervise? Who should teach psychotherapy? I am involved with this question at both psychoanalytic institutes where psychoanalysis is taught and in psychiatric residencies where psychiatrists are taught. In both institutions, the teaching is done by those willing to teach, and not necessarily by the best teachers. Further, as with all work environments, friends are tapped first, again based on personal relationships and not necessarily based on what is best for students. And despite my continued plea for humility in this field, the sad truth is that we don’t know how to teach it, and student satisfaction is no proof of good teaching. Like psychotherapy itself, we have no clear guidelines about what to do and we have no clear guidelines about how to measure our effectiveness. My answer, not surprising to my readers, is to accept that psychotherapy is an art, and as such, those who choose to enhance themselves our signing up for art school, learning ideas and concepts, but no firm path to doing the work. Further, I value my credentials and I think those are important, and as such, those who teach, in my opinion, should have completed training programs which are recognized by the field, such that dynamic psychotherapy should be taught by graduates of psychoanalytic institutes since they have spent hours reading and discussing psychoanalytic concepts, and without this rigor, the depth of discussion is limited. Yet, since teaching is mostly a volunteer activity, few leaders want to impose restrictions, and so quality control is often sorely lacking. Politics is everywhere. Friends take care of their friends, and so opportunities are shared, sometimes to the detriment of students. Navigating around these waters is the art of life. Recognizing that merit based promotion is often rivaled by cronyism. We help our patients wrestle with these ideas, and so as therapists, we should understand it. I think we do, but it is still a challenge.

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

Why I Blog? The List

Posted by Dr. Vollmer on January 16, 2017

Image result for blog1. I am overwhelmingly sad by what I see as the death of my profession, and the transformation of psychiatry into a specialty that has more similarities to Neurology than it does to Psychology.

2. As a result of number 1, I see patient care being compromised significantly, and as such, many vulnerable people are being mis-labeled and “educated” to see themselves as ill, as opposed to experiencing human suffering.

3. Also as a result of number 1, those attracted to the field of psychiatry are not necessarily interested in the human mind and the various nuances and uncertainties which flow from this immensely fascinating organ.

4. Although I have a passion for psychoanalysis, I am also concerned that psychoanalysts are trying to “justify” their position by developing outcome measures, when in fact, human beings, at least in terms of their mental state, are not measurable. I think we have to come to accept that if insurance companies what outcome measures for our work, then we cannot accept insurance.

5. Further from number 1 are patient expectations that human suffering can be significantly alleviated with a medication, which although sometimes that is true, for the vast majority of people, it is not true.

6. Psychiatrists, by my way of thinking, jumped on the ship of “medication management” and in so doing, committed professional suicide for all of us. The result is less job satisfaction, less patient satisfaction, and poor patient care.

7. The “is bad care better than no care question” plagues all of health care, and in particular mental health care. I blog to struggle with those issues.

8. I blog to focus my teaching, to learn to make my points concisely and directly.

9. I blog to think clearly about hypothetical, or fictionalized patient scenarios. It is a “consultation,” if you will.

10. I blog to describe the thoughtfulness that goes into listening; to review the lost art.

 

Posted in Musings, Psychiatry in Transition | 6 Comments »

The Shame of Ambivalence

Posted by Dr. Vollmer on December 6, 2016

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The grey areas of life tend to be the most anxiety provoking. The desire for a black and white world is universal, and this desire increases under stress. Tolerating mixed feelings, as a parent, as a spouse, as a professional, is the challenge of deepening one’s psychic existence. Tomorrow, as we explore the prospect of building a psychoanalytic practice with new students in the profession, we will discuss how, just like with our patients, the biggest obstacle may not be the fees requested from patients, the time required from the patient, but rather self-sabotage, the reluctance in these students to push forward with their stated goal for career development. Clearly, the patient has fears about deepening psychic work in that the digging up of past experiences can be fraught with pain and anxiety, but perhaps less well known, is the fear in the analyst which makes the psychoanalyst half-halfheartedly promote intense psychological discoveries. According to Roy Schafer, becoming an analyst entails an unending effort that includes tolerating confusing uncertainties about our understanding of our patients and our role in effecting therapeutic change. In other words, the psychoanalyst, but first accept a lack of understanding of his patient, and second accept that if he does understand his patient, he may not be able to bring about symptom relief, or psychic growth. According to RS Wille, the analyst must trust in the relationship between patient and analyst and in the analytic setting as sources of meaning. He suggests that in varying degrees, all analysts struggle to maintain their analytic identity. Lena Ehrlich says we, as psychoanalysts have a reluctance “to recognize the limitations of our influence and how, despite our best efforts, our patients are ultimately responsible for how they lead their lives.” This is challenging work because the psychic arena, the material in the office, as described by Parsons is make up of “symbolism, fantasy, transference and unconscious meaning.” As such, psychic reality becomes the domain, a reality that cannot be proven by fact, but rather can feel right, or resonate with the patient. It is this search for resonance which guides the work, but this search comes with great humility, that resonance may or may not reflect deep meaning. In essence, working as a psychoanalyst stems from a conviction, not a science, not a religion, but a conviction, that engaging with people in a deep way, keeping the patient’s interest in the foreground, allows for psychic growth. This conviction is shake-able, and so we, as psychoanalysts, must allow ourselves to question and consider alternatives, while at the same time, remind ourselves that all intense relationships are ambivalent, even therapeutic ones.

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

 
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