Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Psychiatry in Transition’ Category

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 »

Psychiatry as a “Lifestyle Specialty”

Posted by Dr. Vollmer on November 23, 2016

With Thanksgiving approaching, I want to publicly thank my patients for giving me the privilege of entering their interior, knowing the courage and strength it takes to expose one’s deepest thoughts and feelings, both conscious and unconscious. My inner world is deeper and richer as a result of my work, and for that, I am eternally grateful. Having said that, I now return to my rant about the changing nature of my profession. Psychiatry is becoming a more popular specialty choice for medical students. The word on the street is that these students classify career choices based on how lucrative they are, and/or how “sensible” they are, meaning that certain specialties, are what they call “lifestyle specialties” in that the profession offers the opportunity to spend time doing other things, which usually means spending time with family. These “lifestyle specialties” contrast with surgical specialties, or life and death professions, like cardiology, where the commitment to one’s career has to trump other activities. Psychiatry, as a “lifestyle specialty” sends me flying with outrage and confusion. How does listening to physical and sexual abuse, deeply traumatic losses, and terribly self-destructive thoughts, create a “good lifestyle”? The emotional toll of getting down deep with patients is significant, thereby decreasing the bandwidth for listening to other important people in your life. This is a major occupational hazard, and as such, the “lifestyle” is compromised. When I challenge medical students with this notion, the feedback is the following: “I plan on just doing medications, so it won’t be so bad.” Oh my, I say to myself. How do I respond to that? First, I want to say that I do not understand what “just doing medication” means. I understand that they think they will be doing 15 minute visits in which they will be tweaking medications, for the most part. So, they are creating a superficial interaction, on purpose? They are signing up for boredom, in exchange for leaving the office by 6 pm? I am horrified. They, these students who claim that psychiatry is a “lifestyle specialty” are embracing the dullness of the work, when, in fact, by my way of thinking, psychiatry is the most stimulating field, in that one has no algorithms. The psychiatrist, at least in my day, must constantly be thinking on his feet. These “med checks” involve little thought, in that the medication is either increased, decreased, or stays the same, and in so doing, no deep conversation is had or sought after. And this is OK because the hours are good? I continue to be beside myself with a deep sense of grief, that the profession I entered is not the profession that exists today.  I know that with technology, with global trade and with clean energy, many professions of yesterday are gone forever. I am slowly accepting that mine is too.

Posted in Psychiatry in Transition | 4 Comments »

Psychiatric Identity: What Does It Mean To Be A Psychiatrist?

Posted by Dr. Vollmer on October 13, 2016

What does it mean to be a psychiatrist in 2016? As I teach many UCLA Psychiatry Residents, this question comes up on a weekly basis. My identity, feeling not much older, but in fact being twenty years older, is vastly different from their budding professionalism. I see myself as someone who listens, someone who privileges past experience as causing current symptoms, as someone who deeply feels that developing in-depth narratives is a healing process. I see myself as someone who has a toolbox which includes medication, but I do not privilege that over my other tools. They see themselves as someone skilled at “psychopharmacology,” a word I have come to despise, as that word has justified the development of pill-mills, doctors who have an assembly-line of patients, lined up to get a prescription, as if it is some sort of food line. I see myself as developing long-term relationships with patients, not that patients will see me for their whole lives, but rather patients will see me as a resource for their whole lives. They see themselves as not knowing their patients, not recognizing them on the street, or knowing their major milestones. Their identity makes me wonder two things. First, how do they not burn out? If they don’t develop relationships with their patients, how do they get up every morning and do their job? Where is the passion, the life-force, which makes them feel fulfilled? “It is not enough to help someone,” I say, “but it is important, for your own satisfaction, to know who you helped.” Second, and similar to my first question, how do they feel stimulation? Our medications have stagnated since the 90s. Our new treatments are expensive, and not necessarily robust. Understanding and listening is a stimulating and constantly changing experience. There is novelty on an hourly basis, and yet, prescribing medication can become painfully routine.

One resident, quoting another resident, said that they did not want to learn psychotherapy because it is “boring”. I was quite shocked by the comment, but my response was “of course it is boring, if you don’t have the skills to know how to listen, then it is boring.” Mastery is very important to self-esteem. Learning a new skill is both humiliating and time-consuming. “Psychopharmacology” is a relatively quick learning-curve, leading to a short-time to mastery, which I understand is seductive. Yet, what about the long haul? How do these residents do in twenty, thirty years? My hunch is that their passion goes elsewhere. They develop intense hobbies, and have intense relationships outside of work, while being a psychiatrist is their “day job”. I can see how this gives them a nice life, a comfortable salary, and time to themselves and to their families. At the same time, I am overwhelmed with sadness that the passion in psychiatry seems to be dying. Whereas when I trained, my colleagues and I spent countless hours trying to understand a patient’s dynamics, while we were doing patient care,  the younger residents, by and large, are more eager to “get out of the hospital” so that they can have “a life”. For us, our profession, caring for patients, was our “life”. It is not that we did not have other relationships, but it was that the priorities were closely aligned, meaning that professional and personal work mattered, if not equally, close to equally. One could argue the value of that lifestyle, but from my point of view, my generation, and those that came before me, were blessed with the privilege of work that felt passionate. My students, although, for the most part,  are not interested in that “passion,” they remain curious, as those who are curious about history, as to how I think, and at least in that way, I still have a place in their education.

Posted in Psychiatry in Transition | 2 Comments »

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 | 5 Comments »

Psychiatry In Transition

Posted by Dr. Vollmer on September 1, 2016

 

 

 

 

http://blogs.scientificamerican.com/mind-guest-blog/can-psychiatry-turn-itself-around/

 

Many people ask me whether I exaggerate the issues in my profession, so I am always glad to read works from psychiatrists who have similar concerns. In this article, Nathaniel Morris MD, a psychiatry resident at Stanford outlines similar concerns of how we sabotaged ourselves by getting greedy with regards to “medication management” and in so doing we have lost the trust of our patients. Can we turn ourselves around, he ponders. I hope so, because if we don’t we will get folded into Neurology, and the curiosity about the unconscious might get lost in the profession.

Posted in Psychiatry in Transition | 2 Comments »

 
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