Shirah Vollmer MD

The Musings of Dr. Vollmer

Psychic Retreats

Posted by Dr. Vollmer on February 14, 2017

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

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

The Analytic Surface

Posted by Dr. Vollmer on February 9, 2017

Still thinking about the analytic surface…just sayin’

Shirah Vollmer MD

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

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Should Psychoanalytic Teachers Get Paid?

Posted by Dr. Vollmer on February 8, 2017

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

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

Meaning Making: Class in Review

Posted by Dr. Vollmer on February 6, 2017

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

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

Presented by Shirah Vollmer, M.D.

2/4/2017

General Admission: $55.00

Student Rate: $30.00

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

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

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 Dynamic Psychotherapy Is Important…

Posted by Dr. Vollmer on February 1, 2017

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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 »

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 »

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 | 3 Comments »

 
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