La Pluie

"La Pluie" by Vincent Van Gogh, 1889

La Pluie

Even the most sublime canvas
Is but a selective window—
We see what we choose to see,
And the greatest artist
Still filters light and color
Through selective rods and cones.
The rain pours down,
Saturating a freshly plowed field
Bounded by a low wall;
A muddy path traverses the base,
Mountains hover in the distance—
A simple scene captured from
A second-story bedroom view.
What the artist left out,
That which the retina chose to ignore,
Were the wrought iron bars
Embedded in the open window—
No bars embedded in the window of his soul—
At least, he refused to acknowledge them,
Or spared us the pain.

Copyright 2012 © Brian T. Maurer

Talking to a wall

I pad down the back hallway and exit the office through the door marked “Private.”  As I insert my key into the lock to throw the dead bolt, I hear a man speaking in a loud voice.

Not quite twenty yards away, he teeters on the sidewalk in front of the business that abuts our office in this strip mall, head shaven, dressed in a colorful T-shirt, short pants that fall below the knee, white cotton socks and high-top tennis shoes.  Back and forth he ambles, shouting phrases and epithets, gesticulating with his arms as though he were a priest invoking the gods before this makeshift altar of brick and mortar.

The community mental health services agency is housed at the rear of the parking lot.  Many times clients opt for a midday stroll down to the Dunkin’ Donuts for lunch or a coffee.  Mostly they just shuffle by, some seemingly lost in thought; others saunter in pairs or groups of three, quietly murmuring among themselves.  This is the first fellow I’ve seen in a state of heightened agitation.

I step into the parking lot and walk to my car.  He’s still spewing epithets as I fiddle with the key in the lock.  I open the car door and pause momentarily to assure myself that he hasn’t got a gun.

This scenario brings to mind Oliver Sacks’ description of a mentally ill person he encountered one afternoon on the streets of New York.

“My eye was caught by a grey-haired woman in her sixties, who was apparently the centre of a most amazing disturbance, though what was happening, what was so disturbing, was not at first clear to me.  Was she having a fit? . . . [A] slow smile, monstrously accelerated, would become a violent, milliseconds-long grimace; an ample gesture, accelerated, would become a farcical convulsive movement.”  (“The Possessed” in The Man Who Mistook His Wife for a Hat.)

Was this in fact what I was witnessing here in this man acting out before my eyes?

I start the car and drop the power windows.  The man’s shouts become louder, echoing across the expanse of macadam.  Perhaps I should notify someone.  Perhaps I should return to the office and call the police.

As I ponder my civic duty, the man turns and strides up the sidewalk.  Suddenly I see it:  the appendage protruding from his left ear.  He continues to spew venom into the air, but now I know that most likely he’s not mentally ill.

He’s merely carrying on a semi-private conversation through his cell phone with Bluetooth technology.

Addiction: Biochemical bondage or voluntary behavior?

“Addiction is a chronic and relapsing brain disease.”  Few would dispute this statement purported by the National Institute on Drug Addiction (NIDA).  Those of us who work in the disciplines of clinical medicine and research pharmacology have been inculcated with its corollary:  “once an addict, always an addict.”

Such claims conjure up the notion that those addicted to substances remain powerless over their pharmaceutical spells.  Substances like alcohol, nicotine, cocaine, opiates and their derivatives create a physical dependence in those addicted to them.  Denying the body access to such drugs triggers symptoms of physical withdrawal.  Those who succeed in extricating themselves from the regular use of such drugs remain constantly at risk for relapse.  Such facts are borne out by modern research and methods of treatment.

Or are they?

Now comes a work—Addiction: A Disorder of Choice—in which research psychologist Gene Heyman challenges the view that substance abuse is an irresistible act wholly beyond the control of the user.  Although Heyman does not deny that addiction is independent of the brain, he does argue that it is in part voluntary behavior.  He further maintains that “it is not possible to understand addiction without understanding how we make choices.”

Repeated use of drugs ultimately changes brain structure and function by altering biochemical pathways, reinforcing those that mediate the experience and memory of pleasure.  Such neuronal pathways persist, producing cravings even after the addict has stopped using.  If addiction itself is not a brain state, but rather a behavior, the question then arises:  do neurochemical changes in the brain prevent the user from exercising voluntary control over choice and actions?

Heyman argues that “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state.”  He points to a number of studies where, through the judicious use of contingencies, addicts demonstrated the ability to voluntarily change their behavior and stop using.

The more we learn about brain functioning from biochemical research, the more apt we are to regard behavior as something regulated by the action and balance of neurotransmitters in brain.  Ultimately, we might decide that all behavior is involuntary, that each one of us is an automaton, dependent upon the synaptic activity of the moment.  And yet—as any parent knows—behavior can be shaped by meting out consequences and contingencies.  Eventually, children learn to modify their own behavior through voluntary choice.

Heyman extends his argument to include other addictive behaviors such as compulsive gambling, shopping, and sex.  Each involves a craving, an intense impulse and—for Heyman—a voluntary choice.

These arguments bring to mind a passage from John Steinbeck’s epic novel East of Eden, in which he discusses sixteen verses from the book of Genesis about humankind’s ability to wrestle with the temptation of sin.  For Steinbeck, “these sixteen verses are a history of humankind in any age or culture or race.”  The crux of the premise centers around timshel, a Hebrew verb translated as “thou mayest.”

But the Hebrew word, the word timshel—‘Thou mayest’—that gives a choice. It might be the most important word in the world. That says the way is open. That throws it right back on a man. For if ‘Thou mayest’—it is also true that ‘Thou mayest not.’

Steinbeck goes on to develop this idea through character dialogue in the book:

‘Thou mayest’! Why, that makes a man great, that gives him stature with the gods, for in his weakness and his filth and his murder of his brother he has still the great choice. He can choose his course and fight it through and win.

Steinbeck concludes the passage with these words:

I feel that a man is a very important thing—maybe more important than a star. This is not theology. I have no bent toward gods. But I have a new love for that glittering instrument, the human soul. It is a lovely and unique thing in the universe. It is always attacked and never destroyed— because ‘Thou mayest.’

If Steinbeck and Heyman are correct, in the face of seemingly insurmountable odds, struggling addicts might be able to triumph over their addictions by an exercise of the will—one day at a time.

If they are wrong, ultimately we may be forced to confront our own pyschopharmacological demons in the form of serotonin, dopamine, norepinephrine and GABA.

Medicine and Madness

What heals the patient with mental illness: psychotherapy, the doctor-patient relationship, daily exposure to a therapeutic community, or psychotropic medication?

In his book The Soloist, LA Times columnist Steve Lopez explores these options in his efforts to help a homeless black schizophrenic musician, Nathaniel Ayers. Mr. Lopez quotes Dr. Mark Ragins on the treatment of mental illness as outlined in Ragins’ book A Road to Recovery: “Making a diagnosis isn’t as important as making a connection. We’re not even sure what labels like schizophrenia and bipolar disorder mean, nor do we have very strong evidence that medication is the best response.”

According to Dr. Ragins, the history of mental health treatment—diagnosis, prescription—has been a colossal failure. While there is no cure for mental illness, Ragins believes that patients can rebuild their lives in the setting of therapeutic communities—places where they can develop a sense of belonging and learn how to manage their disease.

Ragins’ approach is refuted by a psychiatrist from the Los Angeles County Mental Health Department, who plays down the notion that doctors should focus on patients’ lives rather than just treating their symptoms. “A ‘warm and fuzzy’ embrace won’t get the job done,” she argues. “Chronically mentally ill patients are sick, sometimes dangerously so. They need psychiatric counseling and medication, not sunshine and hugs.”

Traditional allopathic medicine relies on pharmaceuticals to treat illness and disease. The humane medicine movement seeks to create awareness in the power to heal through attentive listening, empathetic understanding and therapeutic touch. Many patients still look to their doctor to prescribe the appropriate drug for their illness. Where do patients place their faith: in the expertise of the physician or in the curative power of the drug?

Many psychiatrists now recognize that patients’ candid discussions of their experiences can help their recoveries. In a recent New York Times article, ‘Mad Pride’ Fights a Stigma, Dr. Robert W. Buchanan, the chief of the Outpatient Research Program at the Maryland Psychiatric Research Center, notes that it’s critical for patients to have open dialogue. “Problems are created when people don’t talk to each other,” he says.

In family-focused therapy, relatives are being enlisted to help manage the patient’s illness. “If you combine medication and family-focused therapy, you get quicker recoveries from episodes and longer intervals of wellness,” said David J. Miklowitz, a professor of psychology and psychiatry at the University of Colorado. “Relapses are less common, and functioning improves, including relationship and family functioning.”

Some people need medication to survive. But no two cases are alike; there is no right and wrong way to treat such patients, no universal therapeutic model.

Mr. Lopez concludes that in the treatment of the mentally ill “there are no magic pills, and thousands have gotten better only to chuck the meds and sink back into the grips of incurable disease.” In the end, Mr. Lopez learns to accept Mr. Ayers as he is, “to expect constant backsliding, to prepare for the possibility that he could be homeless again or worse, and to see hope in small steps.”

And finally, in striving to help another individual, Mr. Lopez learns a valuable lesson himself: “I’ve never had a friend who lives in so spiritual a realm as Mr. Ayers, and I know that through his courage and humility and faith in the power of art—through his very ability to find happiness and purpose—he has awakened something in me.…He has wiped away my professional malaise and shown me the dignity in being loyal to something you believe in, and it’s not a stretch to say that this man I hoped to save has done as much for me as I have for him.”

In the mood

Modern psychopharmacology has provided us a myriad of newer drugs for the treatment of mood disorders. Selective serotonin reuptake inhibitors have largely replaced older tricyclic antidepressants in the treatment of mild to moderate depression. The pharmaceutical industry encourages those on the front lines of primary care medicine to treat patients who meet the criteria for clinical depression for a minimum of four to six months in an effort to prevent relapse of the condition. Yet a fundamental question remains: do we need to prescribe medication routinely for every patient who meets the criteria for a diagnosis of depression?

Dr. Paul Keedwell, a clinician who specializes in mood disorders at the Institute of Psychiatry, King’s College London, suggests that in its milder forms, depression might actually serve to enhance an individual’s well-being. Depression may generate resilience, insight and creativity. Aristotle argued that depression allowed the sufferer to empathize more deeply with others. Henri Nouwen echoed such sentiments in his concept of the wounded healer: that person who, because he has walked a similar road, could more effectively support the sufferer in time of need.

In his essay In Praise of Melancholy, English professor Eric Wilson argues that sometimes feeling bad can do you some good. According to Wilson: “A person can only become a fully formed human being, as opposed to a mere mind, through suffering and sorrow.” Suffering prods us to consider more imaginative and creative ways of dealing with the world.

Many great artists have found inspiration through the depths of despair: witness the works of writers Sylvia Plath, Evelyn Waugh, Ernest Hemingway; artists Paul Gauguin, Vincent Van Gogh, Edgar Degas, Georgia O’Keeffe; musicians Elton John, Joni Mitchell, George Frideric Handel.

Perhaps the poet John Keats said it best when he wrote: “Do you not see how necessary a world of pains and troubles is to school an intelligence and make it a soul?”

Suicides and Shoelaces

Last September at the second annual Cell2Soul conference, Jim Johnson, a retired advertising executive and host of Mason Hill Farm conference center, told me that he reached a point in his life where he resolved to spend the rest of his days helping folks in need. Johnson made this decision after hearing a story about a young man who was poised to jump off a bridge in the Midwest. As he stood by the railing contemplating suicide, a passer-by happened to look down at the young man’s footwear and remark: “Nice boots.” For some reason that small comment was enough to distract the young man from his obsession at that moment, and he never went through with his plan.

“You never know when even the least little acknowledgment might save the life of another human being,” Johnson told me.

According to a recent New York Times article — Midlife Suicide Rises, Puzzling Researchers — the suicide rate among 45-to-54-year-old Americans increased nearly 20 percent from 1999 to 2004. By contrast, the suicide rate for 15-to-19-year-olds increased less than 2 percent during the same period.

Although the reasons for the increase are not clear, the author of the piece offered several speculations. A prime suspect is the skyrocketing use — and abuse — of prescription drugs. Andrew C. Leon, a professor of biostatistics in psychiatry at Cornell, suggested that a drop in the use of hormone replacement therapy in women after 2002, leading to increased rates of post-menopausal depression, might be implicated. Veterans have been identified as another vulnerable group. Myrna M. Weissman, the chief of Clinical-Genetic Epidemiology at New York State Psychiatric Institute, blames frayed social support networks brought about by a hyper-mobile society.

Perhaps more telling were comments from readers, many of which implicated the downturn in the economy, the war in Iraq, the growing societal obsession with youth and physical appearance, the rise of ageism in the workplace, and a nadir of self-belief and optimism between 40 and 50. As a possible antidote, one reader called for a new revolution, where age and wisdom are valued — not discarded, devalued or diminished.

One poignant comment from a would-be suicide caught my eye: “The loss of a loved one is always painful, and questions will remain forever unanswered.” When this particular reader contemplated taking her life, the one thing that stopped her was she didn’t know who would tie her little boy’s shoes after she was gone.

“He couldn’t do it on his own and I hadn’t taught him that skill yet. His huge brown eyes always looked in fascination as I deftly whipped his shoe laces into perfect bows. He smiled and said he would do that someday, too.”

As in Jim Johnson’s story, a seemingly small and insignificant act saved a life and gained a convert.

“Something that minor to me was awe inspiring to a little boy,” this mother wrote. “I now have five grandsons and I tie their shoes, too.”

Prudence and the Pill

In his recent National Post article Robert Fulford opines that Erik Erikson’s psychotheory of human development is now passé.

As a therapist, Erikson was particularly attuned to youth and adolescence. He advocated a psychotherapeutic approach to the adolescent in crisis, where a young person was prompted to examine his situation in light of his social context and family history. Ideally, the therapist would then be able to lead the enlightened adolescent back to health.

This approach is no longer viable. Most third party payers don’t sanction psychotherapy—it’s too long, too expensive. Something else happened as well: the culture of youth changed. Along with the rest of us, Erikson could not conceive of a paradigm shift where adolescence would be transformed by Madison Avenue and changing attitudes toward sex and authority—and by prescription drugs.

In three decades of general pediatric practice, I have witnessed this transformation first hand. With the advent of newer widely-available psychotherapeutic medications, pediatric clinicians are assuming the mantel of child psychiatrists. Citing a study published in the Archives of General Psychiatry, a recent New York Times article documents a 40-fold increase in the number of children and adolescents treated for bipolar disorder from 1994 to 2003. Has the incidence of this disorder truly increased, or are clinicians more aggressively applying this diagnosis to children? If the latter, then what is driving factor?

Because treatment of childhood psychiatric conditions now almost always includes medication, the spread of these diagnoses has become a boon to the pharmaceutical industry. Drug makers and company-sponsored psychiatrists encourage clinicians to consider these disorders with the advent of newer, more expensive drugs. The diagnostic label gives doctors and parents a quick way to manage children’s behavioral outbursts in an era when long-term psychotherapy and inpatient care have become outmoded.

The Times article quotes Dr. John March, chief of child and adolescent psychiatry at Duke University School of Medicine: “From a developmental point of view we simply don’t know how accurately we can diagnose bipolar disorder.…The label may or may not reflect reality.”

Erik Erikson’s concept of treating the adolescent identity crisis is dead. Psychotherapy has been supplanted with the pill. Given that psychiatric drugs have few proven benefits in children as well as potentially serious side effects, which therapeutic approach seems more prudent in today’s brave new world?