Note from Eshrink’s Editor: My father had a reunion with his classmates who graduated from the Ohio State University Medical School back in the 50s (1956 I think). Last month, one of the few classmates left in his class sent him and article from the Wall Street Journal. Here is the link to the article https://www.wsj.com/articles/its-time-to-bring-back-the-asylum-ec01fb2?reflink=desktopwebshare_permalink. I’ve included a PDF version at the end of this blog post.
This letter is my dad’s response.
July 31, 2023
Dear Jim,
Thanks for the WSJ article regarding asylums. It resurrected memories of an incident which I wrote about previously (Passing the Torch) when during my residency my attending physician for whom I had a great deal of respect, invited me to share a cup of coffee with him. This was a bit unusual, and my first thought was to wonder what I had screwed up. Imagine my surprise when he announced that he would be retiring at the end of my rotation on his service and wanted me to be the first to know. The casual observer would likely have seen Dr. Ristine as a tough old bird rather than as warm and fuzzy, yet patients warmed to him instantly. He arrived daily at the hospital wearing a beret and driving a battered topless corvette which had lost the battle when he used it to pull out a stump on his farm.
Prior to his stint in academia, he had been assistant director of the department of mental health. His face was flush with anger as he described his frustrations in that job. He reported that he made occasional visits to the various state hospitals where he would often sit and cry as he witnessed what he saw in the “backwards.” His efforts to secure more funding for their treatment went unheeded by the legislature, for as he said, “Severely mentally ill folks don’t vote,” and therein lies the problem. It has oft been said that “you get what you pay for” and we pay very little considering the magnitude of the problem. The National Institute of Mental Health reports 5.5% of Americans suffer from a serious mental illness. Dr. Ristine seemed to be saying that it was now my turn to attempt to fix the problem, which was obviously way above my pay grade. Nevertheless, I was touched by his openness and still fondly recall that coffee break.
Surprise, surprise, more than a half century later, I must confess that I have also failed at fixing the problem, but Dr. Ristine had found the solution as had many more who had gone before. As with most contemporary problems the solutions can be found by following the money or in this case the lack of it. After the French Revolution Pinel unchained his patients, moved them out of the dungeons, and allowed them to exercise outside. Unfortunately, such ideas which came to be called the Moral Treatment of Insanity, were rare, and it is estimated that more than 1,000 psychotic folks were burned at the stake.
The heroine of the movement was Dorothea Dix who became a tireless advocate for the mentally ill in the mid nineteenth century. She addressed political bodies throughout the country and even convinced the Pope to launch an inquiry into hospital treatments of the mentally ill. She was very successful and largely through her efforts a system of asylums was built. These asylums were usually large attractive buildings with assurances that they would offer the latest in modern treatments. Unfortunately, there was a lack of effective treatments for the more serious cases and most, if not all, became permanent residents. It is difficult for us to imagine what it must have been like to deal with large groups of people so paranoid that they lived constantly in terror, and whose suspiciousness made it impossible for them to accept help. Little wonder that caregivers were driven to try unproven and sometimes garish treatments out of desperation, and that the introduction of Thorazine was greeted with enthusiasm. Within a year over 70% of psychiatric beds were emptied. Finally, there was a medication with proven ability to affect delusions and hallucinations, and it was widely hailed as a possible cure for schizophrenia.
Mr. Oshinsky begins his piece with a series of instances of murders at the hands of mentally ill persons. Such stories are real attention getters, especially the gorier ones, and will certainly get more press than articles about drunk drivers who kill. They will also provide more grist for the NRA crowd’s message that it is the mentally ill not guns that are the problem and reminds us to be careful around those with psychiatric problems as you never know which one is a homicidal maniac. In reality such assaults are rare and mentally ill folks are more likely to be victims rather than perpetrators of homicides. Such attitudes do little to eliminate the biases suffered by the mentally ill.
The author’s statement that our Mental Health system is a “mess” is accurate in my opinion, and it lacks provision for long term care, but the system has suffered mostly due to inadequate funding. As his last official bill signing prior to his assassination in 1963, President Kennedy signed a bill authorizing the establishment of Comprehensive Mental Health Centers throughout the country. The idea was to provide care in patients’ home communities. Eligibility for funding required the provision of 5 essential services including: inpatient, outpatient, social services, medication management, and emergency services. My hometown was the second in the nation to receive such a grant, and a decade later I was recruited to become its director. I was exhilarated by a staff who were dedicated to the welfare of our patients, and frustrated by local politics, the difficulty of recruiting psychiatrists to a rural area, but most of all by the limitations of our budget.
Kennedy’s bill was designed to provide operating expenses for a limited period of time, less than half the proposed facilities were ever built, Reagan eliminated the program as part of his budget squeeze, and now managed care pays for little more than crisis intervention with hospital stays averaging less than 2 days. I agree that our laws regarding involuntary commitment need to be revised. After all it is not unusual for such correcting laws to swing too far afield, and indeed in their zeal to “deinstitutionalize,” they failed to recognize there are still patients who require custodial care in spite of our best efforts. It is also true that without corrective action abusers will find their way into the system and Nurse Ratchets, though rare, do exist, and a community-based system is likely to shed more light. Which poses the question, without “One Flew Over the Cuckoo’s Nest” would we even be having this conversation.
The idea of asylums as he described them is attractive except for the fact that we already did that with poor results, and some would say to repeatedly do the same thing expecting a different result is the definition of insanity. Many have also posited that the location of asylums for the insane have always been located in out of the way places with the idea that out of sight is out of mind while congratulating ourselves that they are not chained in a dungeon…but thousands are in jail. Though we no longer burn witches at the stake, the stigma of mental illness is alive and well. I abhor the term behavioral health to describe mental illness which infers that behavior, not illness, is the problem. Unfortunately, it is aberrant behavior which usually gets the public’s attention rather than its cause. The term is widely used even by professionals including the mental health center where I last worked. My efforts to convince the staff that although efforts to convince a psychotic person that a fireplug was not a urinal were laudable, it was unlikely to get to the root of the problem. Medical insurance still offers minimal coverage for mental health problems. Employers widely discriminate. In many ways mental health problems are treated differently. If mental illness is illness, why not treat it as we do other chronic diseases? The answer of course remains the same as it was in Dr. Ristine’s day: it is too expensive.
The accomplishments of reformers back to the Middle Ages have always been short-lived by lack of adequate funding. Bedlam, one of the earliest hospitals from the Middle Ages was designed by a famous French architect. It was said to be a marvelous structure but eventually deteriorated due to lack of funds. Understaffed and underfunded, their financial problems were solved by the sale of tickets to the townspeople to come watch the lunatics, and bedlam was added to our vocabulary as a word signifying chaos.
Sorry about boring you with all that stuff, but sometimes when I get started it is hard to stop, and this diatribe will likely end up as a blog. It was great to hear from you and reassuring that someone is beating the grim reaper. I have no doubt that you will be around for another reunion. Do you have any idea how many of us are still alive? It seems to me that almost all of the guys I really knew are gone.
We just returned from our family vacation at North Carolina Beach. I think it might have been our 25th but the string was interrupted by the covid thing. All the kids, grandkids and their significant others were there, and the trip was a gift to Barb and I from the kids in honor of our 70th anniversary. We had a great time and I feel incredibly fortunate to have such a great bunch of people who actually care for a gimpy old fart.
I agree that the world is a mess right now and I have grave concerns that our progeny may not experience many of the blessings we have enjoyed, but spending time with these kids gave me hope for I think they are smarter than we were and more capable of cleaning up the mess than were we. Meanwhile, I see the buckeyes are rated #3. I think it’s time for a national championship.
A few days ago I received my copy of the PSYCHIATRIC NEWS wherein there was an article by Dr. Jon Grant, professor of Psychiatry at the University of Chicago entitled: Gambling Disorder Not Uncommon but often Goes Undiagnosed. A couple of days later the following slick little brochure from the Ohio Lottery Commission showed up in my mail:
Play the Games and win the CASH that IS going to let you live like a KING
It even came with a coupon which could be worth $500 when turned in along with your latest “scratch off” ticket purchase. With the aid of a magnifying glass, I was able to read the fine print at the bottom of the brochure and noted that 1 million such brochures were printed. I believe it is reasonable to assume that there would be one out of that 1 million who would get the 500 bucks if in the unlikely event all the coupons were actually turned in.
There was also inscribed in that fine print the Lottery commission’s oft repeated oxymoron to “play responsibly.” That phrase, which also accompanies their ads on TV, always takes my blood near the boiling point because I don’t believe my government should be in the business of promoting addictions. I also believe that any behavior with the potential to do harm and even destroy lives should not be encouraged. Gambling is by its very nature irresponsible.
Afterall, we don’t instruct people to take heroin responsibly.
Yet even Dr. Grant who is editor in chief of THE JOURNAL OF GAMBLING STUDIES , says: “When done responsibly gambling can be fun, thrilling, and potentially rewarding, yet hiding in plain sight are millions of people struggling with gambling disorder.” However, Dr. Grant does not share with us how we can be certain that we are immune from developing gambling disorder. I doubt there are many gambling addicted people who begin gambling with the intention to gamble irresponsibly, or who start gambling with the intention to become addicted.
During my career I saw many patients who admitted to having gambling problems, and probably many others whom I did not diagnose for those afflicted frequently focus on unrelated symptoms, embarrassed to admit to a gambling problem. Others may admit to gambling, but deny it is a problem. Related financial problems are written off as a string of bad luck and denial is expressed by the typical addict’s mantra of “I can quit any time”. They may see their only problem as simply a string of bad luck which can only be overcome by continuing to gamble in order to recoup their losses.
One patient who comes to mind was a very pleasant 40ish single mother whom we shall call Alice. I had been treating her for depression for several months with little success. She had gone through a nasty divorce from an abusive husband which had taken a toll on her self-esteem. Alice had married young, had few skills, took a low wage job, and managed to barely survive financially with minimal and erratic child support from her ex-husband. As is often the case with those of poor self-image she became involved with another poor choice long enough for him to introduce her to the joys of gambling by taking her to a casino where she became enamored with the slot machines. Following the breakup of that relationship, she discovered the bingo games at her church and would often do 4 or 5 cards simultaneously. Scratch off cards and lottery tickets consumed every dollar she could find. There had never been any mention any of gambling until she arrived for a session one day, tearful and overwhelmed with guilt.
She confessed that she had stolen money to gamble from her teenage son. Her intent of course was to put it back when she won, behavior all too common with those who are addicted. Alice was referred to Gamblers Anonymous, and continued in treatment for her depression until shortly before my retirement. When last seen she was doing well, however relapses are common. Alice was typical of those with a significant gambling problem in that she also had another psychiatric diagnosis which leaves one with the traditional chicken-egg controversy – did gambling cause the depression or was the depression the result of the gambling problem.
It has been estimated that 1% of the population is suffering from gambling disorder as it is described in the American Psychiatric Diagnostic and Statistical Manual of Mental Illness (DSM), although accurate statistics are difficult since many cases go undiagnosed, and are often not discovered until a family crisis uncovers the problem as had occurred with my patient. In addition to family disruptions, bankruptcies, and homelessness, addiction to gambling also carries with it a significant mortality rate. Rates of gambling related suicide attempts have been rated as between 12% and 30%. Such a variation suggests we don’t know the real number, and indeed we know suicide rates are underreported due to kind hearted physicians who wish to spare families embarrassment due to the social stigmata attached to the act and to ensure that life insurance policies will be honored.
The gambling capital of the U.S. is also according to Michelle Trudeau of National Public Radio the suicide capital of the country averaging one daily. She reported on a Harvard study in which residents of Las Vegas had a 50% higher risk of suicide than the rest of the country and that visitors to the city were twice as likely to kill themselves. The coroner of Las Vegas ascribes this to the fast pace of life in a boom town and downplays the effects of gambling – surprise, surprise.
According to our Attorney General we have four different commissions that regulate gambling in my state (Ohio). When I was a kid, gambling was illegal with the exception of horse racing which could only be wagered at the track. In 1973, the Ohio constitution was amended to allow a state lottery. It was passed with a great deal of ballyhoo that the profits would be used to fund schools, and who could be against such a worthy cause? However, 50 years of the lottery does not seem to have done much to change financing of education. At least I didn’t notice any decrease in my property taxes.
10 years ago, our first casino opened. The rational given for legalizing such facilities was that our neighboring state, Indiana, was attracting gamblers from Ohio consequently; would we not rather have them spend their money in Ohio? Recently, our Governor signed a bill allowing betting on sports with no rationale I could find other than they are already doing it, so why not let the government in on the action?
It seems that gambling of some sort has always been with us, and that fleeting euphoria which overtakes us when we beat the odds seems to be hard wired. It may be simply another example of the “pleasure principle” which Freud talked about or perhaps a feeling of superiority for after all gambling is a kind of competition. However, gambling has a significant advantage over other forms of addiction in hooking us. B.F. Skinner demonstrated conclusively that behavior can be modified more effectively with what he called “intermittent positive reinforcement” which is the essence of all gambling. His experiments with rats are replicated whenever someone plays a slot machine, for as did Skinner’s rats we wait for a reward each time we pull the handle. He demonstrated that his rats were more highly motivated when the rewards were intermittent rather than when predictable, and that such was the case with all creatures tested including humans. He also noted that the behaviors elicited in this manner were very resistant to being extinguished. The same principal applies with gambling which is further amplified by increasing the possible amount of the reward.
Prior to the time when I kicked my addiction to tobacco, I frequently stopped by a neighborhood convenience store to refill my stash of pipe tobacco. On one such occasion, I was preceded into the store by a middle-aged man who appeared to be of modest means. He had arrived in a pickup truck which had seen better days, and the state of his bib overalls showed signs that they had also endured some tough times. His overall appearance and demeanor suggested this guy was a working man with emphasis on the type of work which tests one’s body. It was Friday and I assume it must have been payday, for he grabbed a six pack of Bud light, asked for a pack of Marlboros and a scratch off ticket of some kind. He scratched off the seal, threw the ticket down and asked for another one. Meanwhile the line behind him which included me was stretching so he stepped aside. As I was leaving he reinserted himself in the line and bought another ticket.
That vignette of the sweaty guy in bib overalls throwing away money that was undoubtedly earned the hard way is replayed in my mind whenever I hear that those who gamble should “play responsibly”. During the last few years of my career, I worked in a clinic with patients mostly with very limited incomes usually through no fault of their own. They often shared not only their fears, and troubles, but also their yearnings. Perhaps, the most knowledgeable people about influencing human behavior are those in the advertising industry. They know all about Skinner’s and other experts’ research, and I confess they hit the bulls eye with that cute little pamphlet I mentioned in the beginning of this diatribe, for who living on the bottom rung of the economic ladder wouldn’t like to have the “CASH that is going to let them live like a KING?”
Editor’s Note: One of my favorite shows right now is CBS Sunday Morning with Jane Pauley. They do such a great job at presenting interesting topics in a meaningful way. When I saw the spot about the promising treatments for depression, I thought of dad (eshrink) and knew it would be a great topic for eshrink’s blog. This post is a wealth of information on depression and Eshrink FINALLY weighs in on the TV program that prompted me to have him write it (that’s a little sarcasm that you’ll get when you read his blog) That’s just how we roll 🙂 Here is link to the spot that aired. SAINT: Hope for new treatment of depression – CBS
CHASING DEPRESSION My slave driving editor who sometimes masquerades as a loving daughter has directed me to write a critique of a Jane Pauley TV show that featured information about a newly discovered treatment for depression. Maggie’s interest comes naturally since she had worked in my office as a receptionist when she was in high school, and her interest was undoubtedly enhanced by the presence of depression in our own family. There is no doubt that what we call Clinical Depression is a very common disabling and often fatal disease. Unfortunately, the word depression is also used for less serious mood deviations which often leads to a lot of misunderstanding. It is estimated that over 1 million people worldwide commit suicide each year and no ethnic group or race is immune from its paralyzing grip. Nearly all these victims are suffering from depression.
In 2017 there were 9.6 million people receiving treatment for depression, never mind the millions who were not treated. According to data from the 2017 National Survey on Drug Use and Health, 17.3 million adults in the United States—equaling 7.1% of all adults in the country—had experienced a major depressive episode in the past year.
There is said to be an alarming increase in suicide rates in the United States over the past decade however; such stats must be viewed with caution for in the past, coroners, who in order to spare family members the stigma of mental illness, would often rule suicides as accidental or from natural causes. Unfortunately, the stigma persists although there has been considerable progress towards classifying depression, the major cause of suicide, as a medical illness.
DEPRESSION of the AGES
It seems as if depression has always been endemic in human populations. There are multiple Biblical references offering solace to the despondent, and fables from even older times suggestive of unwarranted sadness. Perhaps the high level of consciousness afforded us by our massively complex brains has in some way contributed to our vulnerability. Throughout history, there have been endless speculation and theories put forth as to the cause of depression including: moral failure, demon possession, witchcraft, sinfulness, masturbation, or sexual deviancy to name a few. Most of these theories blame the victim, which further contributes to the self-loathing that typically accompanies the disease. To this day there are those well-meaning souls who unwittingly aggravate the depression of the one they are trying to help. In my practice, I had some patients with a strong spiritual orientation who become depressed, sought help from their pastor who diagnosed the problem as lack of faith, and suggested they pray harder.
The COMPLEXITY of DEPRESSION
In medicine, as with most things, transparency minimizes speculation. There is little doubt in my mind that an understanding of the causes of mental illnesses would go a long way towards eliminating the stigma associated with psychiatric illnesses. There is also the maxim in medicine that prevention is preferable to treatment of a disease. It is my belief that since it comes in many different shapes and sizes, depression is not a single entity, but more likely a cluster of illnesses producing similar symptoms, much as we see the symptom of fever in many different types of infections. Depression also takes different forms as for example, some patients suffer from severe insomnia while others find escape from the horrible feelings of hopelessness by sleeping for days.
Although depression often occurs spontaneously, it can also be precipitated by extreme stress or loss. For example, grief presents with symptoms indistinguishable from depression. Seasonal affective disorder with its recurrent depressive episodes appears to be related to disturbance of circadian rhythms, and one could make a case for it having resulted from the migration of humans to temperate zones a few hundred thousand years ago. As a matter of fact, depression frequently accompanies a variety of mental health syndromes, not the least of which is bipolar illness in which a manic episode is frequently followed by extreme depression. There is even a separate category of bipolar illness where those afflicted only cycle to depression and don’t experience manic episodes.
A Little Shrink History
It has been my good fortune to have been involved in the shrink business during a time in which there has been more discoveries leading toward an unraveling of the mysteries of the mind than have happened since the beginning of time. For centuries a cure for what was called “the black dog” by the Roman poet Horace and later repeated by Churchill occupied the greatest minds to no avail. Hippocrates was the first to identify the brain as the major control center of the body. The pseudo-science of phrenology became popular in the 19th century, which was the idea that one could diagnose problems, estimate intelligence and diagnose personality types by measuring the size of the bumps on their skull. Although it was soon discredited, its proponent, Franz Gall, is credited for advancing the idea that there is localization of brain function. He identified 27 different areas of the skull which he said controlled different functions.
Franz Gall diagram that identified different areas of the skull that he said controlled different functions.
In the early 1900’s along comes a Viennese neurologist who would influence thinking about the entire field of psychiatry and psychology for a half century. Freud’s focus on sexuality, in a Victorian society in which even uttering the word sex itself was considered in bad taste, gained him much world-wide attention. He developed a form of treatment both lengthy and intensive which he called psychoanalysis. Even now that many of his theories have been discredited, many terms which he introduced have become part of our every-day lexicon.
The Pharma Era
Fast forward a half century and I was in medical school witnessing miraculous advances in medicine almost daily. Following Fleming’s accidental discovery of penicillin there had been a rush to develop antibiotics that might be effective in treating organisms refractory to penicillin. Among those was isoniazid which had proven to be effective in the treatment of tuberculosis. In those days total bed rest was required as essentially the only treatment for TB consequently; patients who were confined to continuously stay in bed for months at a time often became depressed. However, following the use of isoniazid, moods of patients in TB wards often brightened, they became more verbal, less angry, and even happy. This led to investigation of similar compounds and the first group of antidepressant compounds called Monamine oxidase inhibitors (MAOs) were developed. These drugs were effective for some, but not for all patients. They also required great care in their administration as they interacted with many other drugs and there were severe dietary restrictions.
Depression and Pharma
1956 was my junior year in medical school and it was a banner year for the pharmaceutical industry. It marked the development of broad-spectrum antibiotics, i.e., those effective against penicillin resistant organisms. Thorazine, the first drug to ever prove effective in the treatment of schizophrenia was introduced. Within a year more than 70% of patients in psychiatric hospitals in the US were discharged, and there would be no more barbaric lobotomies performed. A group of antidepressants called Tricyclics whose side effects were less onerous than with MAOs came on the market at the same time. The response to these antidepressants, even though understanding of their mode of action was largely theoretical, led to the development of what came to be called the catecholamine hypothesis of depression. It theorized that the symptoms of depression were due to defects in the transmission of chemicals called neurotransmitters which were necessary to transmit electrical impulses between nerve fibers.
No Silver Bullet
Despite all these treatment, relief from depression was still elusive for many patients. Electroencephalography had been around for nearly 20 years, and it had become more sophisticated and especially valuable in the treatment of seizure disorders. Before Freud, there was a guy named Bleuler who wrote a widely quoted book on schizophrenia. As a matter of fact, he is credited with coining the term. He noted that he had never seen schizophrenia and epilepsy coexist therefore concluded that seizures must protect against schizophrenia. With that in mind several people set out to induce seizures as a treatment for schizophrenia by giving drugs known to cause grand mal seizures. The problem was that response to the drugs was unpredictable and the mortality rate was too high even in a non-litigious time. They also noted that although seizures did not have any effect on schizophrenia except for those in a catatonic state, it did seem to be remarkably effective for those who were depressed.
In the 1930s Italians Cerletti and Bini found they could induce seizures by passing an electric current through the brain. This method allowed for better control, and proved to be remarkably effective in cases of severe depression. Electroconvulsive Therapy or ECT as it is called, was widely used throughout the world and I saw firsthand how effective it could be to treating depression that was resistant to drug therapy. It got a bad rap due to the type of complications that could accompany it, such as broken bones, and the movie ONE FLEW OVER THE CUCKOO’S NEST. Additionally, ECT was sometimes used in cases where it was not indicated, yet were we in the shoes of those guys would we not be willing to try it if it were our only tool? Recent developments of anesthetics and muscle relaxants have made it much safer and better tolerated, but it is still mostly reserved for antidepressant resistant cases, yet there are some cases of depression that don’t even respond to ECT, which has been designated the last line of defense.
My Experience with the NEXT SILVER BULLET to TREAT DEPRESSION
After years of research, primarily investigating the neurotransmitters, norepinephrine and dopamine, researchers had become interested in another neurotransmitter, serotonin, which eventually led to the breakthrough development of Prozac in 1987. I vividly recall the first person for whom I prescribed Prozac. He was a very depressed young man in his mid-20s who had been an outstanding athlete and valedictorian of his high school. Unfortunately, he had become severely depressed, and developed a disabling social phobia. He rarely left the home where he lived with his parents, except to keep his appointments, and requested to be allowed to come in via the back door of my office in order to avoid occupants of the waiting room. I had been seeing him for some time, but my efforts were to no avail. On this particular day, a drug rep had left a sample of this new drug called Prozac which had just been approved for general use, and I thought “What the hell, I ‘ll give it a shot!” Two weeks later, David (not his real name) bounced into the waiting room and with a broad smile announced to the receptionist that he had arrived. Indeed, he had. He was proud to inform me that he had just come from a theatre where he had enjoyed the first movie he had seen in several years. My first thought was, “Could I have misdiagnosed this problem, and this guy is actually bipolar?” but he continued to improve and said: “I have finally got my life back”. The last time I saw him he was a sophomore studying engineering at Ohio State University.
Needless to say, David sold me on Prozac. It proved to have a remarkably good side effect profile other than for occasional sexual dysfunction which most people thought was a small price to pay for relief from the horrors of clinical depression. There would follow, as always is the case, a number of other “me too” drugs all of which came under the heading of SSRI’s (selective serotonin reuptake inhibitors), and after prolonged usage would sometimes lose their effectiveness a phenomenon called Prozac poop out, but in my opinion they have remained heads above other treatments. Unfortunately, the SSRIs as with other antidepressants are only effective about 70% of the time, and psychiatrists are often forced to make use of the trial and error method of finding an effective medication.
Seeing is Believing
Other than the unraveling of the human genome, nothing has impressed me more that the development of scans. They always remind me of the STAR TREK physician Bones who could diagnose and simultaneously treat any problem by putting people in his scanner. I am in awe of those engineering types who figure out all this stuff. The Curie’s invention of the x-ray was monumental, but the enhancement of that technology with computers to produce a cross section view was over the top. It was called Computerized Axial Tomography (CAT or CT scan) and provided a much more detailed look at the brain. In addition to hundreds of other medical uses, it was a valuable tool for brain research and a straight forward way to eliminate brain tumors and other brain diseases which often mimic psychiatric syndromes, a problem that had bedeviled psychiatrists forever. It was not long (the late 70s) when along came the PET scan with which one could actually visualize brain function. Even more fascinating and incredulous to me was the MRI which use a powerful magnet to actually turn protons on end to produce an image from the energy given off when they return to their normal position. They produced amazingly detailed pictures especially useful to orthopedists.
MAGNETISM
There has long been interest dating back 200 years or so on the effects of magnetism on the human body. In 1989, after studies suggested that magnetic energy could be effective in the treatment of depression, the FDA approved TMS (trans-magnetic stimulation) as a treatment. It was a very benign procedure that involved placing a 2-pronged electrical coil which produced a weak magnetic field on the patient’s head. The procedure was simple, painless and without side effects, and could easily be performed in a doctor’s office. Analysis of effectiveness of treatments for depression are difficult due to the placebo effect, but double-blind studies (clinical trials in which some administrations are real, others shams, and neither the patient or the physician is aware of which treatment is real) demonstrated effectiveness in some patients, but not all. In general, responses were not seen as very robust, and it was used mostly as an adjunctive therapy along with antidepressants.
This paper is in no way meant to provide comprehensive review of past and presently available treatments of depression, but believe me they are numerous and sometimes bizarre. In the November 13, 2021 issue of PSYCHIATRIC NEWS, Charles Nemeroff MD, PH.D in his review of treatments for depression, notes there are currently 26 medications approved by the FDA for the treatment of depression and another 12 in the pipeline. There is one study published in the May 2020 American Journal of Psychiatry regarding the use of psychedelics like LSD and psilocybin in the treatment of depression. Who’d a thunk it? In addition to the many types of psychotherapy, there also are always a plethora of non-medical procedures touted to be effective. Lest I get carried away and in deference to my editor who is by now tearing out fists full of that beautiful red hair as she screams “When in the hell is he going to talk about the spot on the TV show?” I will proceed to offer my humble thoughts.
SAINT
After watching the Jane Pauley show about the Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT (thank God for acronyms), I found the original publication that described their novel treatment of depression to be in the August 2020 issue of The American Journal of Psychiatry which I had discarded long ago. Since I am a lifetime member of the American Psychiatric association, I continue to be automatically subscribed, but I must confess that since my retirement eight years ago, I tend to scan rather than peruse journals in much detail. Frankly, because the rapid changes in the field with its increasingly complex technologies have left me often wondering what they are talking about. Nevertheless, the Stanford U website reported an astonishing 87% recovery rate in the treatment with this new procedure named SAINT. Even more impressive, was the fact that these patients had all failed on other conventional treatments. Dr. Nemeroff mentioned in his review that the effectiveness of SAINT had recently been confirmed by a double-blind study which lent even more credibility to the reports of its effectiveness.
SAINT: What it is
The procedure involved is a much more complex, powerful and targeted version of the TMS mentioned previously. The researchers (Dr. Cole et al) were able to direct a burst of very powerful magnetic energy to the dorso-lateral prefrontal cortex (you must look that up in an anatomy book if you plan to do this at home) of the brain for 5 minutes per hour for 10 hours daily times 5. They are convinced that their success is dependent on their ability to target that particular area of the brain which has long been suspected of playing a prominent role in mood regulation. The patients and their families who were interviewed on TV were absolutely euphoric in their endorsement of the treatments. They used the phrase “game changer” and one was convinced this procedure would change the world, and I guess it has changed her world. I agree that this treatment holds promise, but think changing the world may be a bit over the top.
CAUTION: With Experience Comes Pragmatic Skepticism
Members of my illustrious family have accused me of being pessimistic by nature, while I insist that I am simply a realist, and much too naïve to be a bona fide pessimist. In spite of this alleged cynicism, Maggie has asked me to share my opinion of this SAINT thing, and I do find it promising however; all those years practicing medicine have taught me that although all people are the same, they are also all different, or as Grandma used to say: “One size doesn’t fit everybody.” Time after time I have found the initial exhilaration associated with ground breaking discoveries in medicine are later tempered by experience. I do feel this may well be a large step towards conquering this dreadful disease.
Nothing that I have written here should be construed to mean that I believe pills or procedures alone are the answer to the problems of mankind. At best I feel that medications or other somatic treatments enhance the therapeutic benefit of human intervention. Pills are important, but so is the hand that dispenses them. I have been heartened by a trend towards more balance in the nature versus nurture debate which has persisted for generations, for in recent years neurochemistry has dominated the psychiatric literature. Those of you who have read some of my other blogs probably know that I have strong feelings about that subject. Again, one size doesn’t fit everybody, but the more tools (based on scientific research) that psychiatrists have to treat the black dog of depression, the better off the world will be. The brain is a wondrously complex organ and the acceleration of knowledge is promising indeed.
Fear is an emotion, without which we could not survive. It alerts us to danger either real or imagined. Sudden exposure to a fearful circumstance triggers the so called “fight or flight” mechanism. Information about a threat to the organism is transmitted to the brain’s amygdala, which instantly sends signals to the hypothalamus. It responds by directing the adrenal glands to secrete more epinephrine (adrenalin) which prepares us to take action against the perceived threat. Our pupils dilate to enhance visual acuity, the heart rate increases to provide more blood to the brain and muscles, breathing quickens and the alveoli of the lungs open wider to absorb more oxygen. Muscles tense and the famous “cold sweat” appears as a preparation to prevent over heating during the anticipated battle or flight. Blood sugar levels increase to provide more energy, and there may be involuntary emptying of bowels and bladder (yes, the term “scared shitless” is for real).
The process is automatic, nearly instantaneous and completed even before a decision can be made as to how to respond to the threat. It can also be activated by fears for others, and most of us have undoubtedly experienced it when we are faced with a child running out in front of a moving automobile, and can even be provoked by imagined threats as in the case of those with phobias. Many seem to be born with a hair trigger for initiating the response and for many it erupts without any stimulus at all, which we call Panic Disorder. It is a common condition, said to account for 12% of Emergency room visits in the U. S.(link to article is here) Panic attacks frequently mimic the chest pain associated with heart attacks. Panic disorder is amenable to treatment and in my experience a detailed explanation of the mechanism involved is helpful, as most are relieved to find they are not suffering from a life-threatening condition.
The Physiological Response to Fear Was Key to Survival
If the threat persists the endocrine system takes over and the amygdala stimulates the pituitary gland to produce adrenocortical hormone (ACTH) which further activates the adrenal glands to produce epinephrine, norepinephrine and cortisol. This mechanism served Joe Caveman well allowing him to either climb a tree or stick a spear into the saber tooth tiger confronting him, but modern-day Joe can neither kill nor run from a boss who he is convinced is determined to destroy him, leaving today’s Joe chronically stressed. Even minor stresses such as being stuck in traffic may lead to fears of missing an important appointment or attendance at his kid’s game. Those hormones so eloquently designed to save the lives of his ancestors were not designed for long term use and their presence at high levels is analogous to keeping an engine revved up for long periods of time while it sits at the curb. This phenomenon is felt to be a major contributor to a variety of medical problems, especially cardiovascular disease.
Existential Fears
Existential fears are not new to our planet. The threat of natural disasters has always been present and persist to this day, but even though we now have a greater understanding of such phenomena, we are still helpless to deal with them in most cases, and find ourselves seeking divine protection from the big ones like earthquakes, floods, tornadoes, hurricanes, volcanoes, asteroids and the like. I have vivid memories of fears of World war II during which invasion of the west coast by Japan was felt to be imminent following the bombing of Pearl Harbor. Even in our small mid-western town there were designated bomb shelters as we were predicted to be next on Hitler’s list for invasion after they conquered England.
I also recall the tears in my Mother’s eyes as we watched my brother board the train headed for training camp only a little over a month after celebrating his 18th birthday. A few weeks later we received a call that he was “shipping out”, but he was not allowed to reveal his destination. Nevertheless, there was some relief since the call came from New Jersey indicating that he was likely headed for the European theater rather than the South Pacific from whence came endless horror stories. In the following months the fear for the family increased as more gold stars appeared in neighborhood windows, and the appearance of a Western Union messenger in the area would fill families with the worst kind of fear i.e. of reading “we regret to inform you…….”.
Since those early days of my life, in addition to a series of senseless wars, a a string of potentially apocalyptic events have occurred with some regularity with only brief periods in which there was nothing to fear on a grand scale. The development of the atom bomb was unique in that for the first time in history it gave the human race the power to destroy all life, and when Russia developed their version, backyard bomb shelters sprung up all over the place. The worst of those fears came close to realization with the Cuban Missile Crisis in 1962. In the 1970s, discovery of depletion of atmospheric ozone also resulted in fear of drastic consequences for mankind. At the same time, there were also warnings about climate change which went unheeded, but now sow fear in many of us for our children, and their children.
Fear & Pandemics
Fear is an unpleasant feeling. It is understandable that we prefer to put it off if the threat is not imminent. Such is the case of the source of our most recent global fear, i.e. the COVID-19 pandemic. Viruses were discovered at the end of the 19th century, and 100 years ago a viral pandemic killed an estimated one third of the world’s population. When I was a kid, polio was endemic, the world recently experienced a frightening Ebola epidemic, and for more than 50 years, scientists had been warning us of another pandemic. In spite of all that experience and warnings we were woefully unprepared for COVID-19. Now, more that 2.2 million people have died from it, and only the pandemic deniers are without fear. As I mentioned in my opening statement, fear is protective, and sadly those who deny put themselves and others at risk.
For many the fear of contracting the corona virus is superseded by more urgent fears such as: job loss, eviction, homelessness, or hunger. There is also the sad fact that a primary concern about closing schools means that without the benefit of school breakfast and lunch programs many kids will go hungry. It is estimated that 13 million kids arrive at school hungry and that 1 in five live with “food insecurity” (I wonder who is in charge of making up these kinds of meaningless terms, but I assume it means they don’t get enough to eat). Yep, here we are, living in the world’s richest country where we pay farmers not to plant crops, but can’t feed our children. Go figure!
The Fear Tactic: A Tried and True Motivator
Throughout the ages, leaders of all stripes have stoked fear in order to provoke the fight response as a motivator to followers not unlike the way our ex (thank God) president cranked up his followers on January 6 to storm the Capitol building. They obeyed their charismatic leader when he told them they must “fight like hell” to save their country [link to video of Trump at Pre-Riot Rally]. During the insurrection they were recorded chanting: “fight for Trump.” The mob was a disparate group. Among the most bizarre were the Q-Anon followers who were there in support of their leader (Trump), who they were convinced was destined to save the world from a secret cabal of Satan worshippers, who among other things, butchered children in order to drink their blood. There were also groups of white supremacists, fascists, and anarchists, along with misguided patriots who had been convinced that the election had been stolen and that our democracy was about to be taken over by socialists. Indeed, in subsequent interviews, some participants were proud of what they had done.
Regardless of motivation, the mob’s behavior confirms the presence of a great deal of anger. It raises the question as to from whence it came. Did it arise from fear? It does appear that they all were motivated by fear of something usually enhanced by misinformation. We still don’t understand much about mob behavior, but I suspect that it must be exhilarating to be able to express suppressed anger when in the midst of like-minded people. Why is it that when angry people congregate, anger tends to escalate, often ends in rage, and draws people into behaviors that they would never consider under ordinary circumstances? Are they drunk with the mob’s power, or is it the need to belong? Does group-think allow them to rationalize their behavior, or is it simply the thrill of acting out? With the crowd shouting “hang Mike Pence’’ and hunting for other members of congress by name, the results of the insurrection could have been disastrous. Unfortunately, the problem has not been resolved as polls indicate there are millions of citizens who still believe the election was fraudulent, the election was stolen, and vast left-wing conspiracies persist.
Fear: The Seed of Hatred
Fear leads to anger, but long-term anger results in hatred, undoubtedly the most destructive force of any society. We now have people in Congress who say they are afraid of suffering physical harm from their colleagues. Some object to the prohibition against carrying a gun during deliberations. They act as if it pains them to conform to the traditional decorum of the institution, and negotiation is a dirty word. We now have large numbers of members of both political parties, each concerned that the other is a threat to our democracy. The Trump followers who invaded the Capitol were determined to destroy democracy in order to save it. They continue to devour misinformation especially the “big lie” that Trump actually won the election.
In my early years I was also witness to other times in which right-wing political groups wrought havoc. In the 1950s, Senator Joe McCarthy managed to instill fear into the citizenry with baseless allegations of communist spies having been recruited into important government and military positions. This was in the early days of TV and his hearings were widely watched. Many careers were destroyed as his House American Activities commission extended their “investigations” to include anyone of note, especially those in the arts since they were known to generally have liberal political views. Later the John Birch society, a political group organized by John Welch, produced all manner of big lies mostly consisting of a grand conspiracy to take over the American government, the most outrageous of which was the accusation that Eisenhower, widely hailed as the one most responsible for winning world war II was actually a communist agent. In both these cases the obvious goal was to create fear, but wiser heads in the Republican party intervened, whereas today’s Republican office holders fear going head-to-head with the exiled king Trump.
Courage: The Antidote to Fear
Courage occurs when values overcome fear. On January 6, 2021 small force of Capital Police courageously faced a mob of thousands in attempting to protect the occupants of the capital building. Two died and multiple others were seriously injured, yet the news of the day was replete with inferences that there may have been some who were complicit in the insurrection. To this day there has been very little mention of the other four souls known to have died that day as a result of anger gone wild. Are they not also victims? And what of those millions of others who have been convinced that the government of which they were once proud is now corrupt, and now fear the consequences?
Active Listening: The Antidote to Divisiveness
The saber-toothed tiger is long gone and we humans have gained dominion over all our enemies except for those darn viruses – things so small we can’t even see them. Now that we have destroyed most other critters, we are so secure in our dominance that we now try to save those who are left, and we find that our only enemies are each other. We talk a great deal about our divisiveness, but do very little to correct it. Back in the days when I was practicing my craft, I saw many couples who were deeply divided. In nearly all those cases it was apparent that they did not listen to each other. Oh yes, they heard each other loud and clear but did not listen. Listening involves more than words. To listen one must be attentive, and hear not only the words but the music i.e. the feelings. To acknowledge those feelings provides validation, a feeling which affirms one’s humanity. For example, to say to a true believer that he/she is crazy for believing the election was stolen is unlikely to be helpful to either party. On the other hand if one responds with something like: “I don’t believe it was rigged, but since you do I can understand that you are pissed off”, you might go on to a meaningful discussion. You might even find that person wanting to know why you were not a believer. God forbid, but you could even end up respecting or even liking each other.*
Since we all have our fears, I can’t finish this thing without once again mentioning my favorite quote on the subject of courage.
TO BE LOVED DEEPLY GIVES US STRENGTH, TO LOVE DEEPLY GIVES US COURAGE
P.S. This was a difficult paper to write because I continue to ignore the advice of my high school English teacher Miss Higgins who said that most authors select topics that are too broad in scope, and consequently do not do justice to their topic. Some of us are just slow learners
*Editor’s Note: I recall an interview with former FBI Director James Comey after the election and prior to the holidays. When asked for any advice regarding the holidays and interactions with those who were upset about the election results or even believed the false accusations that the election was rigged. I thought Comey’s statement was interesting and relevant to eshrink’s blog subject this week. Comey talked about people’s fear of being wrong…their fear of being duped. He talked about the countless cases he had seen where people had been defrauded of their life savings and/or their retirement by unscrupulous “investors” who promised their money was safe. To his shock, many of these victims would not only refuse to testify against the accused shyster, they sometimes would testify on the shyster’s behalf. Oftentimes, the fear of being wrong or the fear of being “taken” trumps everything else. Victims of these crimes had a belief that they could “see through” a fraudster and they had a deep seated belief that the shyster was a good business person. His advice was to understand the person’s thinking from the lens of fear.
Life can be defined as a finite period of time characterized by continual change. Consequently, since nothing is permanent, we all experience losses. Some are trivial, others are devastating. We are now living in a time of great turmoil with millions of people subject to losses beyond their control. Thousands of homes and businesses have been destroyed by the effects of climate change with fires, floods and storms throughout the world. Many more have been displaced by wars and political upheavals with thousands having lost their homes, possessions and way of life, but the most immediate and tangible threats are due to the COVID-19 pandemic where in addition to the loss of over a quarter million lives, several million remain unemployed, and self-imposed isolation has taken a toll on mental health.
According to the CDC, 8 out of 10 deaths from the virus have been in those over age 65, but they noted even those in their 40s and 50s are at higher risk than younger folks. Many studies have documented that widowhood carries with it a mortality rate of well over 30% during the 1st 90 days of bereavement and 15% thereafter, powerful evidence that loss of loved ones has serious consequences for survivors. The pandemic has limited traditional mechanisms of dealing with grief since last goodbyes are often denied due to isolation policies, and funerals, wakes, and life celebrations are limited. Time will tell if their lack will result in an increased prevalence of unresolved grief.
Grief | Loss due to death vs Loss due to breakup
Meanwhile, we are still subjected to the ordinary losses associated with the process of living. Much of my time as a psychiatrist was devoted to helping those afflicted with the pain of losses, as I am sure is true for most clergy, counselors, social workers, psychologists and bartenders, etc., but it is only recently that the Board of directors of the American Psychiatric Association has recommended that unresolved grief be considered a diagnostic category. Although death of a loved one may seem the ultimate loss, in some ways it is easier get over than the termination of a relationship via other means, such as divorce or breakup of an important personal relationship. The finality of death encourages one to move on, but when the object of one’s affections is alive a relationship real or imagined will persist. Thus, Don Jackson, a renowned family therapist said there is no such thing as divorce. Or as I have often said: divorce is like a death in the family, but you can’t bury the corpse.
Our nature requires relationships. Relationships help to define our identity, i.e., who and what we are. For example, I am often introduced as Barb’s husband which provides considerable information about me. Our identities are also shaped by those with whom we associate even the organizations to which we belong or those we choose to lead us. Long term relationships invade one’s personal space to the extent that we often absorb some of the involved person’s personal characteristics to the extent that they become part of who and what we are. Consequently, their loss may result in what I call a psychological amputation. Thus, in the face of such losses, one is left with the feeling that a part of one’s self has been taken away.
As with the loss of a physical body part, a psychological amputation can result in myriad feelings and reactions in addition to sadness. There may be anger, at times even rage, directed to whomever one blames even him/herself. Instances in which rejected suitors have stalked, assaulted, or even murdered, are unfortunately not rare, which naturally leads one to question the nature of such alleged love. There may be feelings of betrayal at the deceased for being abandoned or for behaviors thought to have hastened his/her death. God is often a target for anger, especially in deaths, and in such instances the Biblical quote: “the Lord giveth and the Lord taketh away” rarely provides solace. Although I have found that referral to the patient’s pastor or Rabbi is frequently helpful.
GUILT
Anger may also be self-directed resulting in guilt. In such cases, the patient may spend endless hours ruminating over what he might have done to prevent the loss or even worse how he could have caused it. A close friend of mine, who shall remain nameless, continues to have pangs of guilt over her Grandmother’s death nearly 80 years ago because as a child she had “sassed Grandma” shortly before her sudden death.
There are instances in which survivors may feel guilty for not grieving enough. One case from many years ago, which has stayed in my mind, involved an elderly lady who was referred to me by her family doctor with the complaint that she had lost the strength in her right leg. An extensive workup had not yielded a diagnosis and the referral appeared to be a hail Mary. She walked into the office unassisted. Although using a cane, she appeared to walk quite well. Her story was that her husband of many years had recently died following years of a debilitating illness for which she had been his primary caregiver. She reported that she rarely left the house during all that time, having obviously taken seriously the vow about “in sickness and in health.” Shortly after her husband’s death, she was excited to visit a friend in a neighboring village whom she hadn’t seen since her husband became ill. After starting her car, she was unable to move her leg to the accelerator in order to drive away -a classic case of conversion reaction, resulting from the guilt she felt over enjoying her new found freedom.
The Affect of Death on Children’s Developmentand Attachment Theory
It has long been noted that children who become orphaned are at risk for significant relationship or mental health problems later in life. (This is a relevant post from Psychology Today). Konrad Lorenz’s studies of imprinting demonstrated the importance of relationships in young animals, and Bowlby, with his Attachment Theory, came to similar conclusions regarding humans. When the process of attachment is interrupted prematurely it may leave the child lacking in skills necessary to develop healthy relationships, and leave them impaired for life.
Much has been written about the stages of grief. However, I have not found that concept particularly helpful, for in my experience people do not always follow a particular pattern of behavior when they have lost something or someone, though I have found that denial is frequently present especially when the loss involves another human life. Although at a conscious level there is realization that a person is gone, a survivor may behave as if expecting them to return. In such cases there are frequent slips in which the deceased person will be described in the present rather than the past tense. There is resistance to disposing of clothing and other personal effects, or to removing the voicemail greeting from the family phone. Frequent trips to the cemetery are common and may involve imaginary conversations with the deceased. The survivor may be said to have “held up” surprisingly well during the burial proceedings.
Perhaps, the most painful loss of all is the death of a child, and in my experience the most likely to result in denial. Although at a conscious level the parent knows their child is dead, they may continue to insist that their room will remain untouched as if they are waiting for him/her to return. Deaths by suicide usually introduce a series of unanswered questions which further complicate the healing process, often leaving survivors blaming themselves.
It goes without saying that it is very difficult to resolve a problem without acknowledgement that it exists, and in my experience, denial following the death of a loved one is quite common. It is usually the first hurdle that must be overcome in order to find resolution of grief. There are numerous exercises which may be ordered to help one achieve acceptance. My favorite is to arrange a visit to the graveyard with a close friend or pastor, simply say goodbye, and have a good cry. For those in denial, there is usually a great deal of resistance to using that word, and the mere suggestion to carry out those instructions is often met with tears.
Loss of Relationship by means other than death can be even more complicated.
The break-up of young lovers, especially first loves, is complicated not only by the level of passion involved, but their lack of experience in dealing with loss. They should be taken seriously as such losses can result in serious suicided attempts especially in teenagers. But for anyone the loss of a love object can be devastating for with it go dreams of an idyllic life with the hope of loving and being loved. It may result in sadness, depression, anger, or even violence.
How to Survive Loss
Hope is invaluable with the loss of things which are replaceable for it inspires one to action. The streets of our big cities are littered with homeless people most of whom have lost hope, while those who have lost their homes in fires or other calamities, although saddened and depressed by the loss of all their possessions, need hope if they are to replace that which has been lost. However, with abandonment by a loved one hope can hinder resolution. It goes without saying that one cannot live in the moment if they are stuck in the past, which happens when we continue to dwell on recovering something which is beyond reach.
Recovery from loss is simple but not easy.
We must “let go” if we are to “move on.”
We let go by grieving. Grieving is the process by which we allow ourselves to grapple with and purge intense disabling emotions following a loss. Grief can be initiated by the loss of anyone or anything to which a person has a personal attachment.
Cultures have developed various traditions which seem designed to promote resolution of grief following deaths. In a previous blog I have written about those I experienced in a rural midwestern village 75 or 80 years ago, but my favorite funeral celebration is the traditional New Orleans jazz funerals in which the funeral procession is led by a brass band to the graveyard while playing a funeral dirge, then following interment the band marches back toward the decedent’s home playing a lively Dixieland tune. The message could not be more evident. There is acknowledgement of the sadness of death followed by the celebration of life, a perfect example of letting go and moving on.
Other Types of Loss
In addition to the loss of loved ones, since the word pandemic entered our lexicon, we have been subjected to losses of some of our most precious possessions. It has been said that you don’t fully appreciate the importance of something until it is gone. Granted, it has been catastrophic for those who have lost jobs, housing, or businesses, but the isolation and cumulative effect of the loss of activities which we previously would have considered mundane have also taken a toll.
On a positive note, if there is one, perhaps we have learned to know the value of some of those things we previously took for granted. There is also hope that constriction of our social activities may result in more family cohesion. Who knows? Maybe kids and parents will even start talking to each other. Losses of all kinds are bound to get our attention, and there is often a lot we can learn from them, especially those we create by our own mistakes for failure is the great educator.
CATHARSIS
Although in rare instances, loss may result in a sense of relief, in nearly all cases, there will be strong feelings elicited as previously mentioned. Such emotions are disabling and must find expression, a process which we call catharsis. It is not a good time to do the strong silent thing when consumed by grief.
As I have mentioned many times, we are herd creatures, which is hardly a new concept having been the subject of John Donne’s poem, “NO MAN IS AN ISLAND” written in 1624. As such, we are dependent upon others whether we like it or not. In the face of intense emotions we can become overwhelmed and confused. In such times more than ever, we need validation, i.e., someone who we trust to listen, be supportive, and reassure us that our feelings are rational. Indeed, the process of attempting to communicate those feelings verbally helps to organize one’s thoughts, and a recent study in the American Journal of Psychiatry, has confirmed what we already knew, which is that confiding in others helps prevent depression. After all, that is how I made a living.
Surviving Loss is a PROCESS
Usually catharsis is not a one-time thing and there will be triggers that will resurrect some of those feelings in milder form from time to time, but most will learn to let go of past traumas by focusing on the road ahead. Hopefully, they will come to understand that to look back over their shoulder will likely cause a stumble, and that they must let go of the past in order to move ahead.
With millions all over the world facing serious losses, we are not only “all in this together,” but we are also very much in need of each other and there has never been a better time for us to be our “brother’s keeper.”
It appears that Marijuana use has now become a socially acceptable practice. Not only are states falling in line to legalize recreational use (I don’t like that term for it seems to equate smoking weed to working out at the gym), but I was surprised the other day when I happened on to an interview with Liz Post who is the great granddaughter-in-law of Emily Post, the etiquette guru. Liz has taken up the etiquette banner and continued as director of Emily’s foundation for the last 30 years. She has written her own books of etiquette, this latest of which caught my attention. It is titled Higher Etiquette, and is all about proper behavior in marijuana involved social situations.
A few days later, I was confronted with a full front-page spread in our local newspaper about our county’s latest industry, a facility for growing marijuana on a large scale. It was hailed as a major success for the area and projected that it would eventually employ more that 100 people.
The story featured a half-page picture of the interior of a huge greenhouse inhabited by large plants. Apparently, since the owners realized potheads would see the photo as their idea of heaven on earth, they assured us that the facility would be heavily guarded. Medical marijuana (whatever that is) was legalized in our state in September 2016.
The new law only authorizes the use of cannabis orally or topically in the form of pills, elixers, tinctures, and lotions etc. Dispensaries were licensed by the state and product can be obtained with a note from a licensed physician confirming that the person is suffering from one of a list of 21 maladies; although the state medical board is authorized to add diagnoses to the list as they see fit. The law prohibits home growing of weed and smoking it, but allows inhalation through a vaporizer. (I would anticipate there will soon be a brisk business in vaporizers). Not only does this and similar laws across the country violate federal law governing the use of marijuana, it appears to me to bypass Federal Drug Administration procedures which require extensive testing for both efficacy and safety before any drug can go on the market.
Efficacy of Cannaboids
There is a great deal of anecdotal information concerning the efficacy of cannabinoids for a variety of medical problems. In the early 1800s an Irish physician found cannabis extracts helpful in relieving stomach pain and nausea in people suffering from cholera, and recently the FDA approved 2 drugs containing THC, Marinol and Syndros, for treatment of nausea and anorexia in patients undergoing chemotherapy for cancer. It is also said to be useful in the treatment of refractory epilepsy, chronic pain problems, glaucoma, and various neuromuscular diseases such as multiple sclerosis to name a few. Prior to the dawn of modern pharmaceuticals, cannabis extracts were widely sold as a treatment for stomach ailments. Now, nearly 200 years later we don’t know much more about them than we did then.
Other Naturally Occurring Plants in Medicine
This is not the first time that a naturally occurring plant would be found to be useful in treating medical conditions. For example, back in the dark ages when I was a general practitioner, digitalis, which was extracted from the foxglove plant was the treatment of choice for a variety of cardiac problems. More recently, taxol, a substance extracted from the bark of the Pacific Yew tree has proven effective in the treatment of ovarian cancer.
The Problem with Pot
The fact that THC is a mood-altering drug complicates the issue of doing the proper research to discern its effectiveness, side effects, and dangers both in the short term and with prolonged use.
There is also the possibility of an enhanced placebo effect. Does drug-induced euphoria tend to mask symptoms, and if so is that bad thing?
The more significant reason for the lack of knowledge as to the effects of marijuania on the human body is due to Federal Drug Administration’s reluctance to allow scientists to possess it in order to evaluate it properly.
In 1970 Nixon signed into law The Controlled Substances Act which listed marijuana as a Schedule 1 drug along with heroin, LSD, and other dangerous and /or highly addictive drugs. This was during the time of the War on Drugs, and the FDA was so uptight that they refused to allow possession of any of these drugs for research purposes. Of course, as usual they zigged when they should have zagged for this was a time when new tools were becoming available to researchers with which to evaluate the effect of drugs on the brain, and an opportunity to learn more about the drug was lost. With such information, they could have been in a position to inform us as to the possible consequences of their use, and perhaps more specifically define how or where they might be useful or harmful.
Follow the Money
With one foot firmly planted in the door with the medical thing it is not surprising that the Marijuana Rights and Regulations Amendment will be on this fall’s ballot. It would legalize the use, possession, and sale of marijuana for persons over the age of 21, and would allow the Ohio General Assembly to enact a tax on its retail sales. As nearly as I could tell there are no proposed restrictions and if passed, potheads can rejoice at their new found freedom. Likewise, entrepreneurs would like to see some of that drug cartel money stay right here in the US of A, and why shouldn’t stoners throw a few bucks into state coffers for the privilege of getting high? Those who grow their own (in limited amount) will pay $50 for a license which is not a bad deal when one considers a cigarette smoker pays $1.97 in taxes for a pack of carcinogens.
If one follows the money, it would seem that the proposed bill would pass, and become law. According to one PR organization (ABCD Inc.) the potential profits are nothing to sneeze at. In their 2018 Cannabis Price Index, they project that in New York city alone 77.44 metric tons of pot was consumed in 2018 with a revenue of well over $8oo million, and if taxed at the same revenue as cigarettes $354 million for the city. I have no idea how they came up with those figures, but if true it is little wonder there appears to be an active campaign espousing the virtues of cannabis involving not only established stoners, but big business and politicians as well.
History of Pot
According to the DEA Museum, the oldest known written record on cannabis use is from the Chinese Emperor Shen Nung in 2727 B.C. There is some evidence that its psychoactive qualities were known then. However, the plant was used primarily for its fibers, which were used to make rope, cloth, and a variety of other products, and is thought to have been low in the concentration of psychoactive chemicals. Although hemp and marijuana are of the same species, i.e. cannabis, it is thought that one variety was developed over time with the goal of increasing the levels of tetrahydrocannabinol (THC), the chemical responsible for its mind-altering effects.
A Higher High
The process of increasing the potency of weed has continued and has accelerated during the last 20 years – not surprising since users are always looking for the “good stuff.” One study found the average potency in Europe and the U.S. to have nearly doubled between 2008 to 2017. The THC levels had gone from 8.9% to 17.1% with one variety reaching 67%.
This same study compared rates of psychosis between areas with different levels of cannabis potency and found that indeed those cities with the more potent stuff reported more psychotic episodes. As a matter of fact, those who had used higher potency stuff were twice as likely to eventually have a psychotic episode compared to those who had never used. Even more worrisome was the stat that daily users of high potency weed were four times more likely to experience psychosis. This raises the question as to whether THC may have long term side effects. This is not at all surprising; after all THC has long been categorized as an hallucinogen even though until now a weak one.
Pot and the Teen Brain
With the frightening (to some of us), statistics as to the prevalence of pot smoking among adolescent and even younger children has come realistic concerns as to the effect of pot smoking on their brains. This has become increasingly worrisome with recent discoveries of the so-called “plasticity” of the developing brain i.e. the effect that various stimuli may have on its structure and function. Such changes may not become readily apparent until years later and to that end the National Institute of Health has instituted The Adolescent Brain Cognitive Development Study that will follow 10,000 children through adolescence hoping to find what sort of factors, including drugs, affect their brains. Unfortunately, it will take many years for the study to be completed.
Not So Fast…
Although such information is incomplete, I feel it is premature to judge cannabis to be an innocuous substance, as many would have us believe. I recall similar reassurances regarding cigarettes, e.g., that they were not addictive, harmless, and simply a relaxation aid. It was true those people on billboards, in the magazine ads, and the movies looked really cool with one between their fingers. I was one of those gullible slobs who tried looking cool for 50 years, and was rewarded with a couple of cancers. I was also left wondering how much damage I had done with all that second hand smoke. Of course, I knew that I was not addicted for I could quit anytime I wanted, it was just that I didn’t want to (the same words I have frequently heard from my pot smoking patients).
We’ve Been Down This Road Before
At the beginning of the 20th century, cocaine was toted as a wonder drug with the potential to cure a potpourri of illnesses including drug addiction. Its health benefits were even extoled by adding small amounts to a soft drink which in honor of the presence of cocaine was named Coca Cola. Two of the best-known pioneers in their respective fields of medicine became addicted as a result of their experiments with the drugs. William Halsted who is credited with devising many of the surgical techniques still in use today became incapable of functioning due to his addiction as did Sigmund Freud who likewise became addicted by testing the use of cocaine for psychiatric illnesses. In the 1960s along comes Timothy Leary a Harvard psychologist who promoted more potent hallucinogens as treatment for depression, to increase awareness of otherwise untapped spiritual states of being and other kooky stuff. He was eventuallyHe was eventually disgraced when he was found to be using prisoners as subjects for his experiments.
Why?
Whenever there are discussions with anti-dopers about mood altering drugs, the question frequently arises as to “why they do it.” Freud attempted to answer that question with his “pleasure principle” theory, an idea which was a couple of thousand years old having previously been described by the Greek philosopher Epicurus. This was the idea that the pursuit of pleasure and avoidance of pain are the essence of life, and therefore all behaviors can be explained by this instinct, furthermore conforming to societal norms is simply to delay gratification of those instincts.
Addiction
The term addiction is not easily defined as it seems to be used in different contexts, but it is clear that the more pleasant the effects of a substance, the more likely it is that one moves on to an insatiable craving. With prolonged use physiologic changes occur as our body adjusts to the presence of the new substance and bad things happen when it is suddenly withdrawn. The extent of its effect on our body/brain is called its potency. A 2- pack-a-day cigarette smoker is apt to have some headaches and grumpy days for a week or so, but a very heavy use of alcohol over a long period of time can result in delirium tremors, a condition which carries a significant mortality rate when untreated. It appears that in some heroin users, the passage from craving to addiction is almost instantaneous.
Of course, the foregoing description of addiction is woefully simplistic for it is a very complex subject with much disagreement among the experts. My point is that without some regulation governing potency of cannabis we may be in for some unpleasant surprises. Having over the course of my career seen large numbers of marijuana smokers, I am convinced that it is by no means innocuous. I also question the conclusion of pot supporters that it is in no way addictive. I believe that it is especially dangerous in children and that many who are exposed at a young age may be permanently damaged.
So, What’s the Answer
Many of you may be thinking: “OK smarty pants, if it is such a big problem, what can be done about it?” The answer is not much. It is clear that the current situation has not worked except to provide opportunities for criminals to make a buck and for addicts to sell in order to finance their habits. Apparently, we did not learn our lessons from the results of prohibition. As with alcohol, cannabis is easy to produce in most any climate and even more difficult to control than opiates, which must be imported. There are some steps I think would be helpful in minimizing the problem:
For the states to continue to have their own laws about pot causes confusion. The federal government should legalize the stuff.
The FDA should set standards and monitor compliance.
It took 100 years for the realization that tobacco companies were spiking cigs with extra nicotine, we should test cannabis for potency.
Anyone who gives or sells the stuff to kids should spend significant time in the slammer (I have seen instances where pot smoking is a family affair).
Many organizations saved lives with an all-out effort to make smoking uncool, let’s give marijuana the same treatment.
With legalization will come more use, encourage NIMH to make research into the drug a priority
Please, please, no advertising. Think it couldn’t happen? That’s what the temperance union thought following the repeal of prohibition.
After pushing pills and other remedies for well over a half century I have concluded that there is usually a downside to whatever chemicals we put in our bodies regardless of their positive benefit. In spite of rigorous evaluations, clinical trials and such we often see unexpected side effects…sometimes years later. The current practice of prescribing cannabis based on anecdotal information without benefit of rigorous clinical testing is in my opinion irresponsible. Nevertheless there is little doubt we have a serious drug problem, and the consensus is that cannabis is safer than most other street drugs. Prohibition offered further proof that “the pleasure principle” thing would not be denied no matter the consequences. Legalizing alcohol did not solve the problem, but it was not as bad as the alternative, and following that model seems to me to be the more sensible approach in dealing with cannabis.
The other night while dining with friends, I was asked for my professional opinion as to the mental health of our President. My response was not very professional as I responded “I think he is nuts!” There is a caveat, especially important in our business, that one must carefully consider any pre-determined bias before rendering a diagnosis, and my response suggests that I had violated that rule.
In retrospect, I realize that my friend was asking for a less flippant answer to his question. Anyone who owns a TV (or uses Twitter) would probably agree that Mr. Trump’s behavior is different from what we are accustomed to seeing in our politicians. His detractors suggest this is evidence of significant mental disorder while his supporters applaud him for being earthy and “unconventional.”
I have previously written (click this link to read that post from 2016) about Mr. Trump in not very flattering terms concerning his mental status, and the non-position taken by the American Psychiatric Association of which I am a lifetime member. Those mental health professionals who insist that Trump is mentally impaired and therefore unfit to hold office in most cases make a case for the diagnosis of Narcissistic Personality Disorder. After the conversation with my friend, it occurred to me that most people might be unfamiliar with what signs and symptoms might lead to such an impression
In the first place, it may be helpful to explain what we in the shrink business mean by the term personality disorder as people sometimes overuse a term and its true meaning from a psychiatric standpoint gets watered down (for example: a person who might say upon having a bad day or disappointing day, “I’m so depressed” when in reality they aren’t clinically depressed, just a little down).
Personality Disorders | Definition by Psychiatrists
The general criteria listed in the American Psychiatric Association’s Diagnostic and statistical Manual of Mental Disorders or DSM which is now in its fifth edition. The definition of personality disorder as summarized in DSM IV is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” (not caused by such things as drug abuse, or other medical problems). Unfortunately, for me the criteria as listed in DSM V are more complex, and since I am a simple-minded person I will stick with DSM IV in my discussion (but perhaps more to the point I am reluctant to invest a hundred bucks in another 900 page dust collector for my bookshelf). In either case, it is clear that those who suffer from a personality disorder are very different.
Signs & Symptoms of Personality Disorders
Signs of personality disorders characteristically have been present for long periods usually from childhood. These patients are difficult to treat. Although some psychotropic medications may be helpful, the gold standard remains long-term intensive psychotherapy, a commodity which is in short supply these days. The symptoms usually serve a protective function. Consequently, patients in treatment have difficulty giving them up. An even bigger problem is that in many cases people who need treatment most are those lacking in insight. Consequently, they are convinced there is nothing wrong with them. This is especially true in cases of narcissistic and sociopathic personality disorders. They believe they are perfect in every way so why in the world would they need a psychiatrist?
Narcissism | Signs | Symptoms | Cause
The term narcissism is from the Greek myth about Narcissus who fell in love with his image while gazing into a pool of water. This did not work out too well for him for he eventually committed suicide when he realized his true love was himself. A bit of narcissism is not a bad thing…as a matter of fact most therapists would probably report that low self-esteem is one of the most common problems they see and that they spend a great deal effort trying to help their patients learn to like themselves. But as with most things in life, it is the extremes which cause us problems. We all know people who are arrogant and self-centered, but those with a narcissistic personality disorder take that to the level where their self-image is so far removed from reality that it approaches the delusional.
He/she of the narcissistic personality disorder is the master of the superlative. He is never simply good at something, he is the best. Others are not bad, they are the worst. Everything in life is measured against the perfection that only he possesses. The need to maintain this distorted image of himself dominates his life and leaves no time to consider the needs of others. He is convinced he is special, and deserves special treatment. He courts admiration or subservience in relationships, and is pathologically intolerant of criticism. This preoccupation with self, frequently distorts perceptions and may affect judgement.
As with many mental health problems, the causation is up for grabs. There may be some abnormality of brain function, environmental factors, or both. Some postulate that excessive adoration by parents is the cause, while others feel the opposite, namely that excessive criticism is the culprit. Whatever the cause, most agree that such extremes of narcissism serve the purpose of protecting a very fragile ego. His need for attention is never satisfied. Indeed, the tenacity with which the narcissist holds onto and nurtures these false opinions of himself leads one to suspect an underlying desperation at the core of his being. The most readable synopsis of narcissistic personality symptoms I have found lie in a pamphlet distributed by the Mayo Clinic as follows:
They have a sense of entitlement and require constant excessive admiration
Have an exaggerated sense of self importance
Expect to be recognized as superior even without achievements that warrant it
Exaggerate achievements and talents
Preoccupied with fantasies of success, power, brilliance, beauty or the perfect mate
Believe they are superior and can only associate with equally special people
Monopolize conversations and belittle or look down on people they perceive as inferior
Expect special favors and unquestioning compliance with their expectations
Take advantage of others to get what they want
Have an inability or unwillingness to recognize the needs and feelings of others
Be envious of others and believe others envy them
Behave in an arrogant or haughty manner, coming across as conceited, boastful and pretentious
Insist on having the best of everything (for instance the best building, golf course, yacht, wife, etc.–the examples are my words NOT Mayo Clinic’s example–they used car and office)
Narcissism & Trump
So, there you have it – all you need to make a diagnosis. You Trump watchers have certainly observed enough behaviors to decide if the shoe fits. If you conclude that the diagnosis of Personality Disorder fits, you should be concerned as to the fitness of POTUS to handle the job. Those so diagnosed are prone to react in irrational ways when their distorted view of themselves is threatened and consequently are very sensitive to any kind of criticism, often reacting with over-the-top rages. Mistakes are never acknowledged for to do so would shatter the myth of their perfection. They react poorly to stress and to change, and there is no doubt that POTUS must be under mountains of stress considering all the investigations currently underway with many of his former supporters on their way to jail.
While in the midst of writing this, I was directed by one of the friends I mentioned in my opening statement to a YouTube presentation by John Gartner, a Ph.D. psychologist at Johns Hopkins. Dr. Gartner is convinced that Trump is demented. Gartner is adamant in his diagnosis and convinced that he should be removed from office. In spite of Gartner’s intensely verbalized political views, he does make a good case for an Alzheimer’s type dementia. However, I believe the evidence he presents is not unusual for one afflicted with a narcissistic personality disorder who is under threat of losing that shield, which protects him from facing the reality of his deficiencies.
Narcissism Exposed (“s#@t hits the fan” time)
As I have mentioned in previous blogs, my major concern is that the current investigations will turn up things which he will not be able to deflect with his usual strategies of denounce, deflect, or deny. Recently, he has seemed less rational with a 2- hour long rant at the Conservative Political Action Conference, and the strange attempts to demonize John McCain months after his death. In the so-called Twitter storm from last week, he seems enraged at everyone within range. It appears that his only respite is the campaign rallies at which he is able to bask in the attention accorded him, confirming to him that he really is “The Greatest.”
Some say our President is “crazy like a fox”. It is true that he has turned self-promotion into a very successful career, even becoming the world’s most powerful man. Those same talents have served the additional function of satisfying insatiable ego needs. I believe that Trump’s narcissism governs every aspect of his life, and explains the “crazy” things he does and says. I believe that he is psychologically vulnerable and likely to demonstrate irrational and impulsive behaviors if his defenses are destroyed. With that in mind, I hope all these investigations do not burst the President’s fragile ego for that could be disastrous.
Editor’s Note: I was slow on the editing of Eshrink’s post and so much has happened since he originally wrote this article. The Attorney General released a 4-page summary of the Mueller Report on a Sunday while many of us were watching our brackets bust during the NCAA basketball tournament. I kept asking why the full report wasn’t being released to the public (the taxpayers paid for it, as POTUS continues to remind us in the context of money wasted) or at least released to Congress (it seems Nancy Pelosi wonders that, too.) However, Eshrink’s post about Narcissistic Personality made me think maybe the inner circle knows more than we think about the stability of POTUS and his psychological vulnerability that could lead to an even worse outcome. History will tell the tale… I’m sure those working inside the Oval Office will have plenty of great material for books once this crazy time in our republic’s history is behind us–if the Republic survives that is. God Bless America. We need all the help we can get!
SEXUALLY ABUSED KIDS
Last week I published a tongue-in-cheek response to an op-ed I had read in the editorial page of our local newspaper. The admonishment of the writer of the op ed that we should limit our talk about childhood sexual abuse stirred up some painful memories for me of patients who were attempting to overcome the effects of childhood sexual abuse.
A True Story
One case in particular comes to mind. This patient was an attractive young woman who came to see me with vague complaints and reported she had come because: “I just want something for my nerves.” After initial hesitation, she was able to give a more detailed history. Her general presentation confirmed my initial impression that she was suffering from clinical depression. She seemed shy and avoided eye contact until I asked if she worked, at which time she looked directly at me as if to assess my response as she hesitantly told me she worked as an “exotic dancer.” Apparently, I passed the test, for at that point, she unloaded in great detail how she had chosen such a career, and how she hated it.
She grew up in a blue collar family. Her father was a factory worker who forbade his wife from working. Her dad was a periodic, episodic alcoholic, and when drunk, was violent and abusive. When sober he was easily provoked. Mother was cowed, totally submissive, and seemingly helpless to protect her children from her husband’s rages. My patient (we shall call her Mary) along with her two older brothers developed strategies to avoid Dad when he was expected to come home drunk. As Mary grew into adolescence, her father began to take notice of her, and finally on the return from one of his nightly drunken forays came into her room and raped her.
But this was not the end of the abuse for the old man had the temerity to excuse his behavior by telling Mary that it was only because he loved her that he was sexually attracted to her. She accepted his advances as she was terrified at the thought of his beating her as he periodically did her mother.
Think it couldn’t get any worse?
Think it could’t get worse than this? Wrong. Soon her brothers emulated their father and to make matters even more unbearable bragged about having sex with her to their friends at school. As you might expect, this led to pursuit by many of the boys at school who were convinced that she was an “easy lay.” And where was Mary’s mother while this was going on? Mary was convinced she was aware, and attempted to convince herself that mother was so beaten down as to be rendered helpless, but she was also horrified to think that her own mother might have offered Mary up to her father in order that she would not be a target of his rages. Emotional Extortion
Mary’s father had promised all kinds of dire consequences if Mary should ever breathe a word to any one about his behaviors. She knew that she would get no support from her mother were she to seek outside help. By now, even Mary’s teachers were convinced that she had become a problem as they heard that she was promiscuous. There was a reluctance to tell anyone due to the intense feelings of shame she felt about the incestuous relationships. There was also that long held custom of blaming the female in such situations, of which Mary undoubtedly was well aware.
The Spiral
The effect of all these prohibitions was made evident as she several times during the session asked for reassurance of confidentiality. In such a situation, the only sensible thing for her to do was run away, which is what she did. From then until the time of our session, her chronology was a bit hazy. I suspect that some pimp thought he had struck it rich when he discovered this beautiful little runaway. Although she did not admit to such, it seems likely she did engage in prostitution. In any event, at this point I felt it not necessary to probe deeper into her past for I had already seen enough pain to last for the rest of the day. It is enough to say that somewhere along the line she did find a way to use the only tool available for her to make a living in a semi-legitimate manner by swinging around a pole naked. Unfortunately, I never saw her again but noted the “men’s club” where she had been working was closed down by the sheriff. Her name was not listed among those who were arrested.
Sex abuse survivors suffer long after the abuse ends
You may be thinking stories of this kind unusual, but they are not rare. It has been several years since that day I saw Mary, but I still think of her occasionally and wonder what her life is like now. I hope she found a good guy to marry has a couple of kids and is living happily ever after. But in my heart of hearts I know that is very unlikely. Those who have suffered such abuse usually have serious trust issues which interfere with the formation of meaningful relationships. Even though they know on a rational level that the abuse they suffered was not their fault, they often blame themselves by questioning whether the assault was brought on by their seductiveness, which is reinforced by the oft heard “she must have done something to bring this on.” They lack self-esteem, devalue themselves, and feel unworthy. When shown attention, they may be suspicious and distance themselves while others may become promiscuous, feeling they have nothing to offer other than sex. In their search for love, they find themselves in a series of abusive relationships a la the repetition compulsion which Freud so eloquently described.
Meanwhile, I continue to fuss over the op ed that I sarcastically commented on in my most recent blog. I was curious when I first saw the title of Ms. Flowers piece, but as I read on I became so angry that I could have had a Lindsey Graham type temper tantrum on the spot. I immediately wrote a rebuttal in my passive aggressive style, which Maggie thought was worthy of publication however; I feel the subject of child abuse deserves something more than a few smart-ass comments. I felt that Mary’s story speaks eloquently as to the effects of childhood sexual abuse. Fortunately, most cases are not so horrifying as hers, yet even less aggressive acts can have long lasting effects.
More light required Yes, I was angry with the writer for her blame the victim tactic, and her concern about Kavanaugh’s “pain” but not one kind word about Dr. Ford. But the clincher for me was closing statement in Ms. Flower’s op ed in which she writes: “That we have now reached the point that assaulted children are considered appropriate conversational tender sterilizes the soul and induces a nausea that can’t be eliminated…”I submit that such an attitude is a major contributor to child abuse. For too many years as with Mary, most such vile acts which have robbed many children of their innocence often leaving them significantly impaired with a lifetime of suffering have been carried out in secret.
There has been some progress in shining the light on the problem e.g. there are now mandatory reporting laws in most states which require physicians, nurses, social workers, emergency rooms, psychologists, etc., to report their suspicions that a child is being abused, and yes that includes the sexual abuse which Ms. Flowers insists should not be a subject of “civil discourse.” It is also encouraging that many charged with caring and working with kids are being prosecuted, and that the veil of secrecy that has surrounded the violation of children by priests is being lifted. However, the National Center for Victims of Crime reports some very disturbing statistics which confirm sexual abuse of children remains a serious problem:
1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse;
Self-report studies show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident;
During a one-year period in the U.S., 16% of youth ages 14 to 17 had been sexually victimized;
Over the course of their lifetime, 28% of U.S. youth ages 14 to 17 had been sexually victimized;
Children are most vulnerable between the ages of 7 and 13.
75% are abused by people they know and often those whom they trust
23% of reported cases are perpetrated by kids under the age of 18
40 to 80% of such juvenile offenders have themselves been victims
As we have witnessed in that infamous recent Supreme Court hearing, many of the old habits which allowed such awful acts to be inflicted on our children are still in place. The issue must not be swept under the rug as Ms. Flowers suggests but should be considered “civil discourse” of the highest order. Pedophiles do not feature a sign on their foreheads announcing their sexual proclivities therefore; those to whom we entrust our children deserve careful scrutiny. My own experience in that regard accentuates that truth.
Wolf in Sheep’s Clothing
He was a person for whom I had a great deal of respect. We first met when I was a psychiatry resident, and I was impressed with his knowledge and competence as a board-certified child psychiatrist with many years of experience in institutional practice with a University affiliation.
Upon completion of my residency, he invited me and a couple of other recent graduates to join him and form a group practice. Fortunately for me, I received another offer for later I was shocked to find he was sentenced to a lengthy prison term for child sexual abuse. He had apparently managed to abuse children, in most cases, who were residing in institutions, where complaints would likely be ignored. Of course, no one knows how many lives he may have ruined. In retrospect I realized I had missed all the warning signs.
Yes, it is my most ardent belief that the problem of childhood sexual abuse deserves serious attention and more “civil discourse” not less of it.
This title was chosen by my son for reasons which will soon be obvious. His youngest has just left home, this time for good, and he and Sue are now presiding over the proverbial empty nest. It is a frequently quoted truism that if you truly love someone you will let them go when it is in their best interest to leave. I was reminded of this last night as I watched Casablanca…one of my favorite movies in which that theme was paramount. Though it is a noble act to let go of those you love, separation is painful, and usually results in significant changes in our lives.
We experience multiple types of transitions during our lifetimes, but since we are at heart social beings, or to put it more crudely, tribal in nature, changes in our relationships are apt to generate the most intense feelings. It is something of a paradox that as the world gets smaller, we find so many people of whom we care to be geographically farther away. Yes, indeed we are able to communicate with ease yet Facebook is a rather poor substitute for a next-door neighbor, or a relative living in the neighborhood. Prior to the industrial revolution, one’s cadre of friends and relatives was unlikely to change very much, and most people were born and died in the same place, often even in the same house. Now neighborhoods are in a constant state of flux, and there is a lower expectation of lifelong relationships.
STUCK WITH THEM
No wonder our children are among the very most important people of our lives. Since humans require nearly 2 decades to reach maturity and carry our DNA, we tend to form very strong bonds. We are often identified as “Johnny’s” father or mother. We live vicariously through them and share their triumphs, failures, joys, and sorrows. In many ways they are our second chance at life as we attempt to steer them away from repeating our mistakes. As the years go by our intimate involvement in their lives blurs with our own–they become part of us and in doing so shape our identity, i.e. who we are. GRIEF WITHOUT A CORPSE
With all that in mind, it is not surprising that separation anxiety is a common affliction. When the kids grow up and leave, something more than their presence is missing. It is as if a part of ourselves is gone. Not only is the nest empty, but we feel an emptiness within ourselves, a kind of psychological amputation. In my experience, this emptiness is most profound when the youngest one leaves for with it comes the realization that nothing will ever be the same. This time they are leaving to build their own nest. THE FUN TIMES
Life is an ever-changing process. We begin as totally helpless and dependent creatures and experience a myriad of transitions during our lifetime all designed to produce an individual capable of building and presiding over that nest. Some of those changes are more dramatic than others. There are the first steps, the first words, the first solo bicycle ride, the first day of school, the first sleep over and a few thousand other adventures all with a goal of achieving sufficient independence to allow them to face the world on their own. WHY DID I GET INTO THIS?
But it is not all sweetness and light. There is the messiness, the lack of discipline, the terrible twos, the out of bounds phase, the adolescent rebellion, the sleepless nights, and the continued testing of limits to name a few of the frustrations inherent in the child-rearing business. Those little buggers are also expensive. According to the USDA the average cost of rearing a child in 2016 was over $245,000 which does not include costs for higher education (but for the kids, I could have been a millionaire). Considering all the chaos they generate it is little wonder that we don’t occasionally wish them to be grown up however; one should keep in mind the maxim to “be careful what you wish for.” BEGINNING AND END
According to the Bureau of Labor Statistics 67.3 % of high school graduates enrolled in college last year (2017). It seems safe to assume that most of these kids would leave home while in school, but retain a close connection to their old familiar environs. In many cases the college transition is a prelude and training for that final fly away. The days when we dumped kids and their gear off to a strange new environment were certainly memorable to Barb and me.
Our first experience with the off to college scenario was painful for all involved. Molly, our firstborn (now deceased), who suffered from serious medical and emotional problems was unable to complete that transition. Next in the line of succession was Peter, who was much too macho to display his feelings, but I was already missing him by the time we pulled away from his dorm. After a four-year hiatus, it was Trudy’s turn. Trudy, the adventurous one, was on the phone almost immediately, tearful and very upset to find beer being consumed at the sorority rush parties that she attended. We had no idea where this came from for temperance had never been emphasized at home. As you probably already suspect. her distress was short lived and as was her habit she soon became involved in everything. THE LAST ONE STANDING
Of course, those separations were painful, but none so telling as Maggie’s departure for we were now returning to a house inhabited only by Barb, myself and Grover the dog. Maggie was one who had insisted on an out of state school, for she was eager to assert her independent status. She wanted distance from childhood connections. Her reaction to the college transition was a convincing testimonial for that “be careful what you wish for” thing. Permanently engraved in my memory is the sight of that sobbing, skinny little red-haired girl who stood there all alone in that huge empty parking lot making feeble attempts to wave goodbye as we pulled away. Barb wanted to go for one last hug, but I insisted she had already had several last hugs. We were later told that she cried for the next month and lost 20 pounds. [See an earlier blog post about Separation Anxiety + Mental Health} NOT ALL SWEETNESS AND LIGHT
In case you are thinking this gang of mine is the Partridge family incarnate, think again. It is true that to date we have come through our transitions relatively unscathed, but not without trials and tribulations. In spite of their best efforts some families are overwhelmed by circumstances beyond their control. Barb and I are indeed fortunate that in spite of our screw-ups we have ended up with 2 generations of exceptional people, and the beat goes on. STILL AT IT
It so happens that this month marks the beginning of significant transitions for every one of my Grandchildren which of course they will undoubtedly handle better than do their parents (or Grandparents for that matter). My three oldest grandchildren are already emancipated and starting new and more challenging jobs. Another is off to her first year in college, and our youngest is entering high school. As mentioned in my opening statement, Carter’s room is empty, and home is now in another city far away. Trudy’s is the only nest still occupied. LIFE GOES ON
Whatever distress the kids may feel from leaving those years of memories behind is apt to be short lived compared to that of their parents. There is hope for Mom and Dad however. In return for enduring the vicissitudes of child rearing God has rewarded us with grandchildren. Thus, we have an opportunity to get all the goodies and none of the crappy stuff ,which leaves me wondering what it would be like to be a great grandparent. Stay tuned for the answer!
Last night I happened upon a documentary about death on PBS. It included an introductory presentation by a woman who reports that she had found resolution to her fear of death by directly confronting it. She had made a point of viewing dead bodies at every opportunity and had even taken a job at a crematorium, which seemed like overkill to me. To complete her story, a vignette of that entire process was shown. I did not find watching the incineration of bodies as particularly entertaining, and Barb left the room saying she was repulsed. In spite of my interest, (I had always wondered how this procedure was done), I shared Barb’s feelings perhaps even more intensely for this is the method I had chosen for my disposal.
THE BIG QUESTION
Many years ago, I think it was the late 60s, Peggy Lee recorded a song titled: IS THAT ALL THERE IS? which has haunted me all these years for it expresses to me the most fundamental existential questions. What is life, where did it come from, why are we here, how did it happen, who or what caused it? When the answers to these questions seem almost within our reach, new questions arise and we end up confounded all over again. We humans are undoubtedly unique in our ability to even ponder such questions. As a matter of fact, we have no clear idea what life is let alone what it is all about. Our definitions of life are simplistic and do little to help us understand what it is. For example, for some time there have been efforts underway to actually synthesize a living cell, but those involved in such efforts cannot agree on the criteria for determining when something is alive.
WHAT IS DEATH?
Death on the other hand is defined as the absence of life, but is it? At this time of the year, one third of the world’s population is celebrating their belief that life is eternal. Muslims likewise hold strong beliefs in an afterlife as do many other religions. Freud described religion as a symptom of neurosis or in some cases psychosis. Karl Marx famously insisted that religion was the opiate of the masses. Both saw religious dogma as a defense against the vicissitudes of life: for Freud, defense from anxiety, and for Marx defense from the pain of domination. In spite of his atheistic beliefs Freud was reported to have said during a prolonged, and painful terminal illness that he envied those who had strong religious beliefs.
As our brains evolved to become huge cauliflower like globs of neurons, we developed the ability to not only perceive reality but to predict future events. This ability has served us well, but there is a down side in that we became aware of our mortality. Floyd, my dog who sleeps at my feet as I write this, is able to predict certain outcomes. For example, he has learned some of the routines of the house and knows when I put on a coat that he might be able to bum a ride. He will undoubtedly see dead animals during his lifetime, may even experience grief, but I feel fairly certain that he does not realize that in a few short years he will die.
RELIGION AND THE DEATH PROBLEM
Back in my younger days when as an academic I knew almost everything about everything, I found that death was one of those things even I did not understand. I was especially interested in how our awareness of mortality affected our thinking, values, behaviors, personality development, and even our mental health. My research on the subject of attitudes toward death indicated that certain diagnostic categories of psychiatric patients had attitudes significantly different from the norm. All very interesting, but I was left with the classic chicken egg dilemma, did their illness cause their unique attitudes or did those attitudes contribute to the illness? But that’s how it is with any scientific endeavor, to answer one question will only lead to more questions.
The study did tend to confirm what everyone already knew in that some people look forward to death while others fear it. In the former category is the late Billy Graham who on multiple occasions insisted that he was looking forward to his earthly death, and the beginning of a new (much better) life. Muslims are so convinced of an afterlife in paradise that they are willing to martyr themselves to ensure their admission. As a matter of fact, all religions seem to have in common the pursuit of a solution to the death problem. Those of strong faith have been shown to have less fear of dying, but in one study those adherents uncertain of an after-life were even more fearful than atheists who were convinced that there was nothing after death.
DEATH OR RELIEF?
Death may also be attractive to those suffering from extreme pain either physical or mental. Patients whom I have known to have suffered both serious physical and emotional distress at various times in their lives invariably report the emotional pain to be more difficult to endure. When combined with feeling there is no hope, for such people suicide may seem their only option.
On one occasion in the days before Google, I was approached by a patient asking what would be the lethal dose of phenobarbital. He reported that his mother had been ill for several years with several surgeries leaving her without ability to speak, a horribly disfigured face, and severe pain. She was on large doses of pain medications, and her illness was terminal. She had told her family that after careful consideration she had decided she wished to die sooner rather than later and wanted her family to be with her as she died. Had she been a family pet her assisted suicide would have been declared merciful, but in her case it was criminal. Go figure. On the other hand many agree that to countenance euthanasia is to start down a slippery slope.
CLINGING TO LIFE. FIGHTING DEATH.
There are others for whom life is so precious, or is it that death is so threatening, that they cling to life in spite of enormous pain or disability. Such was the case with my daughter who shortly before her death said: “I don’t want to die Daddy.” Was she afraid? I will never know for my response was to reassure her she was not dying rather than to address her feelings about the death she knew was imminent. Thus, her cry for support was brushed off and she was left to deal with the most difficult time of her life alone. I should have known better. Sometimes it is difficult to practice what you preach.
A recent example of one who chose to follow Dylan Thomas’s advice to “Rage, rage the dying of the light…….” Is exemplified by the late Stephen Hawking, who was diagnosed with Amyotrophic lateral sclerosis as a graduate student and told he could not be expected to live more than two years. In spite of total paralysis and the loss of his ability to speak, he went on to become a major contributor to the science of cosmology and was described by some as a modern day Isaac Newton. He was a prolific writer in both the scientific and lay literature in spite of limited ability to communicate. In his later years, he gave lectures all over the world with the use of a voice synthesizer operated by his only remaining functioning muscle group which was in his cheek.
LETTING GO
Sometimes death can be viewed as an opportunity to be reunited with a loved one. One very personal example of this was with the death of my Mother. My Father had been dead for a couple of years and Mother was staying with us. Her only known medical problem was a few episodes of cardiac arrhythmia one of which had resulted in hospitalization and successful treatment. I suspected she would be discharged the following day and stopped in to see her as I made morning rounds. I was surprised at her response when I asked her how she was feeling when she said: “I am feeling just fine, but I have been thinking a lot lately and have decided it is about time for me to be out there (the cemetery) beside your Father.” I thought little of her comment and went on to my office. A short time later I received a call from her nurse telling me she had died. We should all be so lucky as to go that way, in charge and at peace. This and similar stories have led me to believe that we have more control over our demise than is apparent.
SEX AND DEATH?
Perhaps the weirdest thanatophilic attitude toward death is in its libidinization which was not only observed in my research but in Greek mythology. In the story of “The Rape of Persephone,” Pluto, guardian of the underworld ascended from Hades to seduce the maiden Persephone. Throughout history this theme has been repeated many times in different iterations. You may be thinking: how can there be anything sexy about death? I told you it was weird. This brings me back to the young lady who was interviewed extensively on the PBS special. She not only presented her story of how she overcame her fear of death, but was filmed giving a lecture to a group of alleged thanatophobes. It occurred to me that she possibly could have gone overboard as she talked of the joys of death in a husky voice accompanied by a sexy smile. But in case you want to learn about even weirder stuff you might want to check on the necrophiles who enjoy sex with corpses. There is also John Wayne Gacy who admitted to having orgasms as he watched his victims die.
NEAR DEATH EXPERIENCES
None of those interviewed in the PBS documentary seemed more certain of life after death than those with histories of near death experiences. Their stories were consistent and the interviewees were very credible. Many others speak of witnessing from above the attempts made to resuscitate them, and report seeing a tunnel with a bright light in the distance. There have also been some who have reported very unpleasant experiences, and following their recoveries vowed to change their ways. There is one neurologist who suggested these experiences were simply the result of cerebral ischemia (diminished blood supply to the brain), but there is little doubt in the minds of these survivors that their experiences were real. One such survivor suffering from a terminal cancer reported she was looking forward to her death and we were told she died two months following the filming of the program. The others all said their lives had been changed since the experience, and that they had developed a kind of serenity they had never known previously. Although not mentioned in the broadcast, I am also aware of at least two books written about going to heaven and one describing a 20 minute visit to Hell, accounts which I found less credible.
CREATING YOUR OWN AFTERLIFE
Spookiest of all in my opinion was an in depth look at the so-called cryogenic procedure in which bodies are frozen in liquid nitrogen with the hope that in future years technology will allow their illnesses to be cured, and they will be able to do a secular version of the Lazarus trick. Cellular biologists believe it is impossible to do even a very quick freeze without doing permanent damage to the body’s cells. Nevertheless, there are people who are willing to pony up large sums of money to have their bodies frozen and stored in hopes of being brought back to life. One website reports they have over 100 such bodies stored in huge tanks of liquid nitrogen. As for me, I think I would prefer to take a shot at heading down that tunnel toward the bright light.
DEALING WITH OUR MORTALITY
There are many behaviors unique to humans for which one could make a good case to result from awareness of our mortality and even the concept of death. Denial is the most powerful tool that can be used to decrease anxiety, and typically the way most of us deal with the reality of death. Those things we don’t understand are the ones we find most frightening. Freud for all his foibles had much to say about death, although discounting religion, he presented some interesting comments about our denial. One which rang true to me was his statement: “It is indeed impossible to imagine our own death, because whenever we attempt to do so we can perceive that we are in fact still present as spectators.” I can’t help but wonder if he got this idea from Mark Twain’s story about Tom and Huck attending their own funeral. Nevertheless, he does make a point. We like to give instructions as to how our funeral or lack of should be conducted sometimes with great detail, and without consideration for the idea that such services should be for the benefit of those who grieve. Do we really believe we will be able to hear what hymns are played?
In spite of our knowledge of the inevitability of death we continue to seek token immortality. We select monuments, have portraits made, buy life insurance, establish charitable trusts, write wills, work hard in order to be able to leave something behind, and even write blogs in hopes we will be remembered; and continue to live in the minds of others. Not surprisingly there are often attempts to retain control after death. I recall one example of a friend who was noted to be an in control kind of guy who liked to keep his wife under his thumb. He wrote a will in which he specified that her inheritance would go to charity in the event she should remarry after his death. There are so many other questions which have gone unanswered. For example, to name a few: why do some enjoy the thrill of risking their life, why do some like to frighten others with the threat of death, why do some appear to actually enjoy killing. We seem to be unique among the animal kingdom in those behaviors.
ARE THERE ADVANTAGES TO THE REALIZATION OF OUR OWN MORTALITY?
Lest you think I am totally morbid in these thoughts, I should admit there are some obviously useful things surrounding this mortality thing. We tend in many ways to view death as punishment. We use terms like “he deserved to die,” and “the wages of sin are death.” Throughout history, assassinations have been carried out to punish those accused of misdeeds, and the most serious crimes are still punished by death. If we were convinced we would live forever, would we behave instinctively without regard to consequences, in other words would we have developed a super-ego? In like fashion what about creativity and the urge to complete projects if time were not limited? There would be no need for monuments or for offspring to mourn. Would we feel the need to band together with others? It sounds to me as if life would be boring.
MY STRATEGY
Well, enough of this death stuff. I hope the next PBS program will be about life. Meanwhile, I plan to adopt the “eat drink and be merry” strategy. Barb recently told me she had decided to concentrate on living each day to the fullest as long as she could. I suppose this would not leave much time for worrying about such mundane issues as dying. Maybe she will be willing to give me some lessons.
Addendum by retired eshrink editor:
My dad and I discussed the topic of this blog before he wrote it. I told him of a pivotal moment during college when a marketing professor posed the question, “What if this is all there is? Despite what you’ve been taught in church or by your parents, what if this life is all you get?”
It was if a light bulb went off! Religion uses “heaven” and “hell” (the “afterlife” in general) to relieve us of the anxiety of our own mortality and in some instances, to control us. You want to get to heaven. You don’t want to go to hell. Here’s what you need to do. As if, all chaos would ensue if we thought this was the one life we get to have.
Indeed, that was the point I got from this professor. The realization that this life is the one that is real and I better be a full participant because it’s the only one I know I have. Don’t use an “afterlife” idea to put off living this life fully. Don’t get me wrong, I hope there’s something really good after this life. My version of “heaven” is being able to use the heaven TV network to check in on all my people to see what’s going on because I don’t want to miss anything! Also, I would like to create my own weather, get to choose my own “age” during my time in heaven, visit with everyone else who is dead, and most of all, get all of those big questions answered. I freely admit that I’m afraid to die because I’m afraid of the unknown…I’m with Freud, I’m envious of those people who have no doubt in religion’s teaching of an afterlife. However, I must admit I have never understood why highly religious people who think their dead family member has gone home to Jesus to the next life, cry so much at the funeral. If you truly believe that without a doubt, wouldn’t you be happy for them?
However, I do believe there is something more and hope there is something more, but no proof to date.
So, I try to use mortality to make sure I live well in this moment that I have been so fortunate to be given and even more, to put life’s perceived “stresses” in perspective. “It’s not life and death” I’ll tell myself.
Since my husband died suddenly at a fairly young age , I also use “death” as a way to live my life double for those who don’t get to be here. I try very hard not to take one minute for granted. Life’s short. It’s not a dress rehearsal. Treasure the gift. Be present. Make every minute count.
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