Monday, November 23, 2009
Are you anti-psychiatry? I have been asked that many times since publishing The Lily Pond. The answer is a clear No. I don't think I would be standing here, and possibly not standing anywhere, if not for the excellent psychiatric care I have received for the past five years. The third section of The Lily Pond gives a view of that care, which includes managing a crisis as well as embarking on the writing of this book.
Lest this be mistaken for a ringing endorsement of the mental health system, let me add that those five years are the only time–in a psychiatric career stretching back more than thirty-five years–that I have felt myself to be in good hands. My previous shrinks ranged from passable (possibly) to lacklustre to frighteningly bad. To put good health care into perspective, I’d like to read a portrait of the kind of care I’d come to settle for. If you find it funny, be sure to listen for the punchline at the end, which comes at my expense.
Heather and I called my Toronto shrink The Idiot. I had been seeing him once a month for several years, whenever I needed my prescription refilled. He wouldn't phone it in to the pharmacy or write for more than one month: he wanted to bill for the office visit. The appointment lasted for half an hour. He spent at least half of that time, every time, finding my file folder, fixing his coffee and stirring it by the machine. Sometimes more time was wasted because he couldn’t remember my name. He would come back with a file for Barrens, or Burnez, or Marks, or Michaels. He never did learn my name in the several years I saw him, and he mispronounced it each time I told it to him again. When I showed up for one appointment and the nurses said, with nasty looks, that he had moved–only one had any idea where his new office might be–I guessed that his privileges at that hospital had been suspended. He worked now in a little brick building over a pharmacy; he seemed to have cut a deal with the pharmacist, since he urged me to fill my prescriptions downstairs and sulked and made difficulties if I wanted to go elsewhere. He had the insufferable bombast of the dullard still vested with authority. After the 9/11 attacks, he treated me to a thirty minute harangue on Egyptian politics; that was the price of pills that day. He raised the dosage as I requested–as I increasingly needed–but asserted his authority by lecturing me on my condition, making inane speculations, sometimes rationalizing his own laxness by flattering himself for having the sagacity to know when a patient was capable of self-monitoring. But eventually, if you have been seeing for years a doctor you call The Idiot, you have to ask yourself: Who is? Seeing a doctor you find contemptible is a position of the utmost precariousness. He broke most of the ethical rules of psychiatry, but that wasn’t what scared me most about him. What frightened me was that I could wind up in hospital under his care, and then he would have the power to do as he saw fit with me. I knew more than a little about what that could mean.
Yes, that’s how bad it can get. But the joke is really on me. I am the other fool and incompetent in the passage, someone whose sense of self-worth and personal horizons had shrunk to the dangerous point where he would accept that level of care and not look, not feel he could or should or must, look for better.
I think that good psychotherapy is necessary for every person suffering from mental illness. People tell me that resources are strained and this is not possible. Really? It might save on excuses if we agreed on this premise at the outset: There is enough money to do whatever we decide is worth doing. And its corollary: if we’re not doing something, it’s because we haven’t felt collectively that it’s worth doing.
Even the most effective drug treatment–and I know people whose lives have been literally saved by mood stabilizers and antidepressants, to name just two classes of drugs–still leaves unaddressed many issues of self-understanding, self-acceptance, self-forgiving that cannot be left out of mental health. In addition to being enormously helpful, psychotherapy is extremely interesting, mysterious and unpredictable. When it is fruitful, it is not only challenging but also suprising and even exciting.
Go to a physiotherapy clinic, a gym, a chiropractor’s office, a massage therapist, a medical supply store, a mattress shop or a furniture store, and you’ll meet people–all of us, sooner or later–willing to invest time and energy and dollars on ways to help weak and ailing body parts. Is the psyche worth caring for even half as well as we care for our ankles, knees, necks, and backs?
Tuesday, November 17, 2009
Along with the personal Do’s I’ve discovered, there are also lots of Don’t’s. Here are a few.
Don’t panic...try not to. There is a degree of amnesia to my condition, so that every time I lurch upward into mania or downward into depression, it feels like the first time, and I lose all memory that I have been here before and gotten through it. Retaining a thin thread of memory, enough that I can say, “I know this place; I was here before, and I left again,” is one of most important results of my recent years of therapy. It’s a lifeline to cling to, a thread to guide me out of the labyrinth.
Don’t forget the past. And its flipside: Don’t enshrine the past as law.
Don’t overgeneralize, i.e. don’t throw the baby out with the bathwater. I meet patients who are virulently anti-psychiatry, and I meet others who are passively acquiescent in their treatment. I have been both and I know both to be self-destructive. I feel sympathy with the anger, fear, sadness and distrust of people who have had bad experiences, but recovery means not ruling out any possible resource, while judging each one’s benefits and costs rigorously. Ruling out a whole class of experiences on the basis of a few adverse encounters could cost you valuable allies. It cost me dearly, and I regard the fifteen years when I shunned the mental health system, drifting through a series of rented rooms, short-term jobs and very bad times, as some of the worst and most pointless years of my life...years when I despaired of finding any external help whatsoever and had to be pushed back into it.
People have wondered how I can talk about electroshock in the same breath as drinking too much in rented rooms. But noting certain similarities between experiences is not the same as equating them. Jolt and juice are both ways of battering the brain, though the juice usually happens in slower motion. And when staring at a ceiling lowered to about two inches above your face, it’s never a bad idea to ask what role you might have played in disappearing the horizon.
Don’t forget what they did to you.
Don’t forget what you did to yourself.
Sunday, November 15, 2009
The phase after the aftermath is usually called recovery. It’s a word you hear a lot these days, often in connection with a specific trauma: in recovery from addiction, from abuse, from mental illness. But I think recovery, properly understood, is universal–something each person is, or should be, engaged in. If you think of recovery as learning how to make your wounds and losses part of your life–fully acknowledging them without allowing them to overwhelm or completely determine you–then I would ask: Who is not in recovery? Who has not suffered wounds and losses? Who is not trying to live with them? Who is not facing serious challenges in the present? Who is not trying to build, out of a heap of cracked and broken, along with beautifully solid, pieces, a whole life?
Clearly, recovery understood in these terms can never refer to a final or finished state. It can can only gesture toward a process, a continual set of reorientations that come from the willingness to tinker, like an amazed and persevering chemist, with the basic elements of your experience.
This means that every recovery is personal. Individual and changing, an ongoing negotiation. What works? It is intensely, even ruthlessly, practical: the person who wants to actively recover has to be as wily as a fox in sniffing out potential help, discarding harm, and bold enough to experiment to discover which is which. This is the search for what Pat Deegan calls “personal medicine”: the procedures and prescriptions that work for you.
My own personal medicine cabinet is stuffed, by now. Here are a few items from it, to give some idea of the range of idiosyncratic possibilities.
Diet. I'll spare you the details, but I eat a lot better now than I did in my twenties, and overall, I’m a little less crazy. I know there’s a connection.
Sleep. This remains one of my biggest problems. Especially since I know that accumulated insomnia is one of the surest triggers for my worst episodes. I’ve tried most of the mood stabilizers, but they’ve had side effects I couldn’t tolerate. I take clonazepam and lorazepam which help with sleep. I take another over-the-counter relaxant: alcohol. Naturally I worry about addiction, especially as I see my dosage climb with the years. But I’ve also wondered which would harm my liver faster: too much alcohol, or long stretches of 1-3 hours of sleep a night, which I suffer frequently. This isn’t an excuse or an apologia for booze. It’s a weighing. A balancing.
Light therapy during the winter, since there is still a seasonal component to my swings.
My biggest discovery of the last few years has been the benefit of large (very large) doses of the omega-3’s, along with other vitamins. I began this regimen four years ago and have no doubt that it’s given me more stability.
Hydrotherapy. The eternal solace of water. I seek it out wherever I can. Bathtubs. Showers. The overcrowded YMCA pool. Puddles, streams, rivers. Lake Ontario. I crave the ocean, but I am a two-day drive from the nearest one.
Longo’s supermarket. It almost never fails to pick me up. I like the bright lights, I like the vivid colours, I like the silver-haired produce manager who dispenses helpful advice (often with me lurking nearby to listen) on when a mango is ripe or why the asparagus lasted longer this year. No matter how dismal my day has been, I leave Longo’s with bagfuls of that most useful thing: food. In a hungry world this is no small achievement.
What I call the small-circle cure, which I take in small doses regularly, but in large doses a couple of times each year. This means reducing activity and stimulation to a bare minimum. Dimming the lights, unplugging the phone, cancelling social engagements. And, as I feel my ability to think in sequence ebbing away, scaling my reading down from the love life of Anna Karenina to the love life of Britney Spears...and then further, to just flipping through books of pictures or watching reruns of The Sopranos. To return to the idea of functioning: Someone seeing me lying on my side beside a single lamp, flipping pages of Rolling Stone or People, might see a low order of functioning...and it is, in a way...but it is a much higher order of functioning than I showed in the years when I tried to keep reading and writing through these spells, which can last six weeks or more, and added terrible frustration to depression when I could understand nothing, produce nothing. Self-acceptance, I’m coming to see, involves a better understanding of one of the simplest words: and. I am a person who reads, and writes, challenging texts...and I am a person who, at times, cannot read or write the simplest sentence. The two facts are not mutually exclusive; they mustn’t be, since I’m living both of them.
Understanding and. If I’ve learned anything, it’s that the effort to include, and re-include, is central to both the word and the process of recovery.
Friday, November 13, 2009
Before Came After was the title a poet I once knew gave to her first, self-published collection. It stayed with me as a truth about (at least) the psychic order of things: you have to be on the far side of something to catch more than a glimmer of its approach. Saying that, though, casts doubt on all the conventions of sequence and finality embedded in our language. The far side? The far side? Or just...another side? They are conventions we need, of course. The narrative of beginning-middle-end is one of the most profoundly practical of human inventions: the equivalent of fire or the wheel, in terms of helping us shape and use experience. Saying A led to B led to C–though we know better; know, as the best stories always imply, it could not be quite so simple–allows us to mingle timeless truths with the timed necessities of tigers and ticket-takers. But it never hurts, as a refinement of that fire-wheel, to remind ourselves of the inescapable circularity of all processes. Before comes after. After comes before. There is no such thing as a conclusion, but if there were, it would double as the ideal introduction.
I want to pick up my story on the other side of crisis, that first episode as it’s sometimes called, which in my case was very protracted. Whatever treatment is used, even if it’s old-fashioned time, the easing of crisis is not a return to health, but only the first step in such a return. It is that dazed mixture of relief, exhaustion and bewilderment commonly called the aftermath–a fragile condition, a thin soil in which hope may try to put down roots. A passage in the second section of The Lily Pond describes this state of aftermath. I’m not alone in the passage, appropriately, since the emotions of aftermath, like the emotions of crisis, ripple out to affect everyone close to the patient, especially family and friends. A feature of aftermath that I don’t think is talked about often enough is the intellectual challenge it poses. Most people can imagine the emotional blow that trauma inflicts, and that is what most accounts focus on. But what has also been damaged, perhaps even shattered, is the personal narrative of self and life we are all telling ourselves, which must now resume with drastically altered prospects and circumstances. Simply put, serious mental illness poses a constant question that is very hard to answer, but which must be answered in some fashion: Who am I now in the light of that? What can I now expect? What can I do?
In May of 1979, the water level of French River reached its highest point in living memory. ...I came north with my parents to open the cottage; I remember loading the boat as it floated beside the gas pumps at the marina, three or more feet above the usual docks even at high water. I remember little else about that springtime trip; probably there was little of me left to remember with. I had only recently been discharged from a psychiatric ward after a year-and-a-half siege. It was really a siege of seven years, beginning with my first serious depression and psychiatric treatment at age seventeen, which cut short my last year of high school and inaugurated a long, chaotic slide away from active and communal life, culminating in the self-mutilation that earned me a diagnosis of schizophrenia and embarked me on the hospitalized ordeal of neuroleptic drugs, electroshock treatments and hydra-headed symptoms that came close to killing me, and, in the sense of obliterating all vestiges of my former life, in a way did kill me. My amnesia of that springtime trip north with my parents seems fitting; I could not have accompanied them except as a dazed and depleted survivor, a convalescent with tremors and scars and a battered brain, a broken and wide-eyed child though nominally a man of twenty-four, gaping at the debris left by the flood.
Floodscapes present ambiguous vistas–at least to those Noahs lucky enough to survive them.
There is destruction, obviously.
But, also, new shorelines.
Deep (fertile?) mud.
Tuesday, November 10, 2009
In Praise of Puzzlement
It’s time to sing of puzzlement as a desired, and desirable, state of mind. It’s time to paint in lush, layered grays. Living grays.
A friend wrote me the other day of G.E. Moore saying, of the young Wittgenstein, “I have a very good opinion of him. He is the only student who looks puzzled in my lectures.”
In brutish schools of thought (often among the most powerful and influential schools of thought), puzzlement is typically derided as a sign of the infirm or timid mind. It can be. Just as it can be sign of the strongest and bravest. Do you have what it takes to live with–live in–“maybe...maybe not”?
I see you’re critical of the mental health system. Yes...to a point.
You think you know a better way. Yes...to a point.
I don’t have a one-treatment-fits-all program to suggest. I’m left with–left in–puzzlement, but out of puzzlement I do have a couple of questions to pose.
1) Why has one of the oldest and most low-tech approaches to mental illness fallen so out of favour? I’m talking here of the “rest cure” as it used to be called, making use of the healing power of time and quiet as the wounded psyche sorts itself out. I think of this sometimes as I walk around the now-disused grounds of the old Ontario Hospital, a place I was almost sent to for the long-term care that we patients called “bagging.” I find those lawns and chestnut trees restful and restorative now...I suspect I would find them even more so in a time of acute illness. Not, certainly, as a “bagged” person, a warehoused shell of myself–but as a broken soul in need of sanctuary, of asylum, in need of the long, slow time necessary to reknit brokenness. No matter how successfully it is managed, trauma takes time. Time to occur (since it occurs in waves, even if one event precipitates it)...and a long time to come back from.
2) Now, I know that part of the answer to my first question is that we have other treatments now. More focused ones, usually pharmacological but also psychotherapeutic. The “rest cure” was partly because the ones prescribing it had nothing else to prescribe. But that’s only part of the answer. Another part has to do with our haste these days to restore a patient to functioning. “Time heals,” we say, but do we act as if we believe it? It takes courage to trust time–the courage to wait and see. And I have absolutely nothing against functioning. At my best, I juggle a full-time job with serious reading and writing, seeing family and friends, other hobbies and interests–I like being active and productive, as only someone who has spent months and even years out of commission, can. But I think we all fall into the trap of defining functioning too narrowly. And of making it a kind of idol. Functioning can’t really be understood in abstract or absolute or general terms, but only in individual terms, as part of a larger concept of overall mental health. It’s likely that, after the onset of illness, a person’s means of functioning will change, temporarily or permanently; it may also fluctuate, which is certainly true for me. I’ve had to develop–and this is something I’m still doing–a new model of functioning...one that fits the person I am now.
Can there be any person for whom this is not true? That is, anyone who, to answer the question What can I do today? must not first ask the question Who am I today?
“Who decides what functioning is?” I asked Dr. George in one of our first sessions.
She looked puzzled. At last! I’d seen psychiatrists furrow their brows in anger, in disbelief, in impatience...in any one of the rainbow hues of pique. When had I last seen a brow furrowed in honest perplexity?
“You do,” she said. “Who else?”
Sunday, November 8, 2009
Recently I came across a quotation that I’ve been turning over in my mind. It’s by the philosopher Ludwig Wittgenstein, who said: “You must always be puzzled by mental illness.” What did he mean? I wondered. I decided it was not a statement for confusion or against certainty, but rather for curiosity and respect for the mystery of others, and against a too-easy certainty. And I would broaden it; I would say: You must always be puzzled by other people. Not because puzzlement is a good in itself, but because if you aren’t puzzled, you aren’t paying attention, and if you aren’t paying attention...what can you discover that you don’t already know?
Every psychiatric history, no matter how long (and mine is over 35 years long now), begins with something very simple: an encounter. Typically, this encounter occurs between a doctor and a patient, maybe late at night, maybe in an emergency room. In one sense this is a unique situation, but it shares features with any other encounter between strangers: curiosity, fluctuating levels of trust and suspicion, needs (on both sides), hope...and fear, assumptions, and expectations. What it always contains is a large portion of the unknown. Whatever knowledge and experience both persons bring to the encounter–whatever inner stars they have learned to steer by–these can’t change the fundamental fact that the person facing you is unique, unlike anyone you have met before.
A passage early on in The Lily Pond describes such an encounter:
The emergency staff of North York General Hospital could not have had much more than questions on the morning of November 11, 1977, when a twenty-two-year-old white male, agreeably calm and strangely articulate, presented with a deep transverse incision in his belly and shorter slashes across his abdomen and above his left knee. The main wound was of the size and in the place that a later examiner would ask about the patient’s appendectomy, and the patient himself spoke wryly of his “self-Caesarean,” adding that he guessed it was “in the wrong direction.” He also produced a thick hardbound book with a pebbly red cover, which contained some two hundred pages of close-packed writing alternating with drawings and collages, the artwork garishly colored and badly smeared in places from the artist’s taste for thickly applied oil pastels. An interviewer, glancing from time to time up at the patient, riffled through the massed output, too quickly to take in more than an impression of frantic copiousness; the crucially telling point that the book had been new and empty a week before probably did not emerge. I sometimes wonder about those first examiners, whose faces I cannot remember. Where are they now? What are they doing? If still alive, the oldest would be long retired, in advanced old age; the very youngest, residents then, would be in the latter third of a career in medicine. It was twenty-eight years ago, longer than the life of Keats. But whoever they were, and whatever little they had to go on, one thing was certain: they had to do something. The stitching up must have been in some sense soothing to both patient and practitioner: here, at least, was an unquestioned good. An obvious need fitly addressed. Now what?
“Now what?” sets the stage for a new encounter.
Saturday, November 7, 2009
One of the most rewarding aspects of publishing a memoir on mental illness has been the opportunity to speak to different groups of people about the many matters that fall under the umbrella term “mental health.” Doing this–in venues that have included a hospital (the one where I once spent a year and a half), a bookstore, an art gallery, a church, and various meeting centres and community halls–I’ve been struck by the sheer need of so many people to talk about these issues. A need, it’s very clear, that is mostly unmet. At times, the urge of unburdening that fills the room has felt almost overwhelming.
The talks have been an evolving process. Each time I’ve written something new for the occasion, while incorporating pieces of previous talks. So each talk represents a further stage in climbing a rock face–or descending into a rock pit, since the same muscles and equipment are needed to explore upward as downward–...reaching out from a line of pitons already secured, in order to hammer in one or two more.
Three of these talks–one audio-visual, one audio-only, and one text–are posted in their entirety online, and are accessible from the links on the upper righthand side of this blog.
Some listeners have asked me, however, for printouts of particular points made in the talks. To supply these, and to review the points myself, I will be entering portions here over the next few weeks. Where necessary, I will make slight adjustments so the passage stands better alone. I hope, too, that in the process new thoughts will occur to me, which I can include as additional entries.
Whenever, over the years, I heard the question: “Do you talk the talk, or walk the walk?”–I always had an unsatisfied sense of only two doors? I get to talk, or walk...that’s it? I would rather talk the walk and walk the talk...if I can.
Talking the Walk, Walking the Talk.
Or, since people tell me that in these Twitter Times no title should exceed three words: Talking the Walk.