Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Teaching’ Category

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 »

Free Association: Making Meaning Unconsciously

Posted by Dr. Vollmer on January 30, 2017

Image result for free association psychology definition

What has meaning in our lives? Why do we make the decisions we do? How do we choose our friends, our lovers, our jobs? When we lie to ourselves, how do we get at our authentic “truth”? The answer, according to psychoanalysts, is straight-forward: Free Associate! This means exercising the mind in an unrestrained way to determine what pops in and out at any given moment. For example, sitting in traffic, it is curious what thoughts arise to consciousness? Frustration, anger, acceptance, or imaginative thinking? Thinking about thinking takes time, and effort, and in the presence of a therapist, can present issues of shame and guilt. Sexual thoughts, greedy thoughts, competitive thoughts, can all bring a sense of unworthiness to the relationship, and as such, those thoughts can be suppressed leading to feelings of conscious anxiety without known antecedents. The hallmark of psychoanalytic work is allowing time, and openness to see what the patient brings to the relationship, which is in stark contrast to the “T” therapies (such as CBT, DBT, IPT) in which the therapist has an agenda. The lack of an agenda is KEY to understanding the meaning that patients’ assign to the experiences in their lives. The other KEY is time and patience. For patients to free associate, they must  speak without fear of judgment, and this can only happen in the context of a trusting and reliable relationship. This “frame” as you will, provides an opportunity for patients to feel safe to “free associate” since free associating is a scary activity. Being afraid of one’s own brain is the hallmark of anxiety disorders, and as such, to make friends with one’s thoughts is a journey of self-discovery and self-acceptance. The length of this journey is not knowable from the outset, and hence restrictions on the number of psychotherapy visits is simply absurd. Thought suppression, the hallmark of Cognitive Behavioral Therapy (CBT) is antithetical to thought acceptance in that thought suppression might provide temporary relief, in the longer term, buried thoughts resurface in ways that can be more disturbing and more unpredictable, whereas free association offers the promise of a more sustaining treatment in that the technique helps the  patient cope with whatever uncomfortable thoughts come to mind. The point here is not to say that CBT is bad for everyone but rather to say that it is not good for everyone, and should not be a one size fits all approach to anxiety disorders and/or depression. Psychopharmacology is another intervention for anxiety/depression, and as such, medication can facilitate free association in that the patient may feel more relaxed in order to allow his brain to connect seemingly unrelated ideas. Hence medication can be a tool which eases the psychotherapeutic process, a benefit of medication which is usually not touted. In summary, it is the loss of free association in psychotherapy which saddens me. The restriction of thought takes away both a deeper relief in patients and a deeper sense of work satisfaction in the provider. Superficial treatments bring superficial results and thereby superficial feelings of job satisfaction. Deeper treatments bring the opposite. We have deeper treatments to offer patients, but as I have said many times, as a field, we have lost our way and forgotten about that.

See also..https://shirahvollmermd.wordpress.com/2012/10/03/free-association-not-so-free/

Posted in Free Association, Psychoanalysis, Teaching, Teaching Psychoanalysis | 6 Comments »

Meaning Making: Shameless Advertising

Posted by Dr. Vollmer on January 25, 2017

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.
 
Saturday, February 4, 2017, 9:30 AM – 12:30 PM • 3 CE/CME credits
$55 Pre-registration, $30 Student Rate, $65 at the door
At..
2014 Sawtelle Ave.
LA, Calif. 90025
In preparation for my upcoming class I am reading Victor Frankl’s book, Man’s Search for Meaning. as well as learning about cognitive semiotics. Semiotics is the study of meaning-making, the study of sign processes and meaningful communication. Plus, I am learning about Ikigai, the Japanese concept meaning “a reason for being”, which is similar to the French phrase Raison d’etre. The word ikigai is used to indicate the source of value in one’s life or the things that make one’s life worthwhile. These concepts arise in the consultation room where patients search to articulate distress. How does one talk about not having meaning in their lives? One common pathway is through psychosomatic illness. The patient feels convinced that there is something terribly wrong with them, but the doctors have not discovered it yet. Indeed, sometimes that is true, but it can also be true that the patient feels psychologically empty, and through a belief system that their body has betrayed them, they can focus their psychological distress on the search for a diagnosis. Psychopharmacology springs to mind, as many patients believe that antidepressants will give their life meaning, and indeed, this belief system, along with a relationship with the prescribing physician, can jump-start the patient to re-engage with life in new and exciting ways. Is this the placebo effect? Indeed, placebos give patients a sense of a before and after experience. “Now that I am taking this drug, now that I am doing this diet, now that I am meditating,” fill in the blank, patients have an opportunity to feel a new beginning, which sometimes gives the patient permission to feel excited and renewed. In other words, the patient imbues meaning into the new activity which gives them a sense of excitement and vitality. Meaning often comes from relationships, new or old, in which the patient seeks to feel a closeness and in so doing pursues activities that he/she feels the other person would also find meaningful. Patients, for example, suddenly feel they are going to change careers and become psychotherapists. In part, this may be a good career choice, but at the same time, it may be a way for the patient to feel closer to his therapist. These partly conscious, partly unconscious decisions are derived from a search for value and depth which goes beyond Freud’s dictum that what man seeks most is pleasure. So, you wanna take my class? I would love to have you.

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

Can A Patient Have A Bad Attitude?

Posted by Dr. Vollmer on December 14, 2016

Image result for bad attitude

A bad attitude can be a symptom of depression. Depression is a mood state we psychiatrists treat. So, is it possible that a psychiatrist says to a patient “the reason you are not getting better is that you have a bad attitude,”? As the story relates to me, I have no way of knowing the validity of that tale, but I want to take a moment to consider the notion of a psychiatric patient with a “bad attitude”. The idea feels so shaming and so blaming to me, I can hardly believe a psychiatrist could express this notion, and yet, at the same time, as more psychiatrists are “pill-mills” and as we know that our pills have limited efficacy, the frustration from the psychiatrist could translate to blaming the patient. Maybe we do not understand our tools, or for that matter, the human mind, enough to understand why people either get better or do not get better. Can we accept that amount of humility in our profession, or do we need to assume that a poor outcome has to do with the patient? The absurdity makes me laugh. If the patient had a “good attitude” what is he doing in our office? We treat “bad attitudes,” not by being accusatory, but by trying to understand the underpinnings of this “attitude,” or to put it another way, we try to understand it in historical context. Of course, historical context takes time and energy, along with carefully honed listening skills, a set of strengths that are no longer taught in Psychiatry Residencies, leading, to what I see, as professional suicide for all of us. The hard truth is that when our pills fail, which they often do, we must be able to use listening skills to help patients sort out their mental suffering so that they can have a narrative which helps them navigate their life, both past and present. If we lose these skills, the job satisfaction will be poor, and patient satisfaction will also be poor. The result, as I see it, will be a complete disillusionment with the field. There, I have ranted again. I just cannot say this too many times or too many ways. The state of my profession is dire, and we need to have an open discussion before we die completely. That is my hope, that these posts will stimulate a forum to push back and encourage psychiatrists to listen deeply, to learn how to listen in a therapeutic manner. The “good ol days” were indeed better than our present. I maintain that point of view and I am open to talking about that further. The gauntlet has been laid. I wait.

 

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

Affective Intensity

Posted by Dr. Vollmer on November 29, 2016

Image result for affective

 

And so begins again my class entitled “Building A Psychoanalytic Practice”. Some might call this a marketing class, in that the class is designed to help students deepen their work by transitioning some of their patients from once a week to multiple times a week. In so doing, an analysis, or deep psychological work, can occur. The focus of the class is to help students see the barriers, both conscious and unconscious, to working analytically, on both sides of the proverbial couch. One of these barriers is that more frequent visits invite an affective intensity which can be frightening to both the patient and the therapist.  Feeling shame or guilt, for example, can be deeply painful and de-stabilizing, and so there is often a strong desire to paper over these feelings with directives, platitudes and a lot of time between sessions. Increasing frequency makes the sessions less of a “dear diary” and more about “what is really going on here?” Looking down into the bowels of the mind, ultimately results in a more mature view of the world, but in the short-term increases anxiety and causes psychological discomfort. Dealing with difficult feelings, even if it is for the greater good, is the challenge of analytic work. Hence, as I said in my last post, this work is not a “lifestyle specialty,” but rather it demands the capacity to handle so many different types of feelings, the ability to listen and feel, in a way which is both empathic and thought-provoking. The therapist, the psychoanalyst, must facilitate the exploration, the archaeological dig, as Freud called it, in a way which titrates the associated feelings such that the patient is  stimulated to reflect on himself, but not overwhelmed and paralyzed by the experience. At the same time, the analyst needs to use his intuition to comment on how seemingly unrelated events, may, in fact, be related on a psychological level. It is this weaving of the affective domain with the cognitive domain which makes the work of the psychoanalyst challenging on many levels. Like starting chemotherapy, both the patient and the physician might be frightened about what untoward effects might happen, and yet, there are few other choices, for some, if they want to rid themselves of their poor judgment and self-sabotaging behaviors.

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

What Does It Mean To Be Spiritual?

Posted by Dr. Vollmer on September 29, 2016

Image result for spiritual

 

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.

Posted in Psychoanalysis, Psychotherapy, Teaching, Teaching Psychoanalysis | 2 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.

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

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’.

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

The Open Narrative

Posted by Dr. Vollmer on April 3, 2016

 

The open narrative, free association, is a window into the psychological functioning of the patient. This is one of the basic tenets of deep psychotherapy, or psychoanalytic work. By observing the order, the style, and the content of the narrative, the listener can begin to develop hypotheses which lead to the guiding principles of the patient’s internal world. Frank, fifty-one, is a good example. Upon the first meeting he quickly tells me that his brother, when Frank was four, and his brother was six, passed away from congenital heart disease. Right away I am clued into this tragic death of his brother as an organizing principle in Frank’s life. Despite the fact that I later learn that Frank has been divorced twice and has three children, his primary attachment appears to be the psychological loss of his parents after his brother died. “They were never the same,” Frank tells me, despite the fact that I did not ask about them. Frank returns to the story of his brother on multiple occasions. He attributes this loss to his chronic anxiety and poor work performance. He says he could never feel confident because he could never make his parents forget about his brother. He reports that he tried to make his parents happy but he always felt that he could not. Life had dealt his family such a horrible blow, he would tell me, that the dark cloud could never recede. If I structured my interview, I would never know the centrality of this experience for Frank. The loss of his brother would be a check mark on a set of routine questions. It is only by allowing him the space to make his narrative do I learn how he has constructed his interior life. Listening to narratives is a difficult skill; one that requires intense attention and thought. It is my fear that this skill will die in my field,  as newly trained psychiatrists do not have the time with patients to hone this skill. As I continue to write this blog, this is less of a fear and more of a harsh reality. The deep listeners of the future, with few exceptions, will not be psychiatrists. The tides have changed.

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

 
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