Sleep Apnea - The Reluctant Psychoanalyst Gets Treatment (Cont.)

I posted some time ago about having been tentatively diagnosed with sleep apnea.  Since then I have: been to a dentist specializing in sleep appliances; seen a sleep physician; had a “sleep study” where I spent the night at a clinic with electrodes attached to my head; met with the sleep physician again; had another sleep study while using a CPAP machine; returned to the sleep dentist and had an appliance made; and dealt with the insurance industry.  What a nightmare!  Not so much the individual components (though the nights spent in the sleep clinic were among the worse night’s sleep I have ever had), but the amount of time that it has taken to have a treatment, the frustration of continuing to sleep poorly while knowing that a solution might be achievable, the out-of-pocket costs, and, ironically, the lack of dreams have all been part of the nightmare.

When I last posted, the diagnosis was still a hypothesis.  I was referred to the dental sleep specialist.  He evaluated me, had me fill out a brief self-report form and took X-Rays of my neck.  He explained that my symptoms were consistent with sleep apnea.  He further explained that the difficulty that leads to apnea is part of the paradoxical nature of sleep.  We need to relax our muscles in order to be able to sleep.  The danger, of course, is that if some muscles relax, our throats collapse and we can’t breathe.  This occurs with greater frequency as we gain weight and as we age – also something about my being tall contributes to the difficulty in maintaining the opening.  When the opening collapses, we panic, awaken in a fright with our adrenaline charging, and aren’t able to quickly get back to sleep.

Despite a presumptive diagnosis, the Dentist ordered a sleep study in order to definitively establish the diagnosis.  This required waiting for an intake meeting with the sleep physician, who explained what the sleep study would entail, then waiting for an opening at the sleep lab.  (Two months into the process, my secretary was concerned about her sleep, made a same day appointment to be evaluated at a different center and was in the sleep center for a study within two days, and then had the subsequent sleep study with the CPAP a week later – apparently different places work at different paces!) 

The folks at the sleep lab were very pleasant.  They applied electrodes to my scalp and to my legs, a band to measure respiration, and then had me sleep under video surveillance in a hotel bed.  A week or two later, the results showed that I had awakened from apnea events 15 times in the night, which suggested that I had a mild sleep apnea.  Consistent with my experience, I awoke from the last event about 4 am and did not return to sleep until it was time to wake at 6.  When I met with the physician again, he explained that this meant that I was not getting into the deep sleep that included REM and dreams and therefore was not dreaming at the usual rate.  By this time, school had been up and running again, I was anxious again, and I was not dreaming again – and his machines were supporting what I knew. 

The sleep doc recommended that I be fitted for a CPAP machine in addition to or perhaps in place of the dental appliance, so I scheduled for another sleep study, this time with the CPAP machine on.   When I went back for this, I was less than pleased.  The CPAP keeps the airways open by forcing air in through the mouth and nose.  Because I breathe through my mouth as well as my nose, I was fitted with a mask that covered most of my lower face – I looked like a WWII fighter pilot except that the mask was plastic instead of leather.  Sleeping with the machine on was like sleeping with your head sticking out the window of a car going down the road at about 60 miles an hour.  This was not a pleasant experience for me.  The sleep doc said that I would get used to it over time and claimed a higher success rate than for dental appliances.  The dentist stated that many could not tolerate the CPAP.  Ultimately, it took so long for the insurance to OK the CPAP that the dental appliance had already been made, and I decided to try that out before taking on the CPAP, paying for it, and wondering whether I would be able to tolerate it.

The dental appliance works by forcing the lower jaw forward in sleep and, in the process, moving the tongue forward.  This creates a larger breathing space at the back of the mouth – dramatically so.  In fact, when the appliance was put in place, I could feel how much easier it was to breathe while I was awake, something that seemed surprising to me.  The reluctant wife noticed immediately that I was not snoring and she has been able to dispose of the earplugs she has been using to protect her own sleep.  And especially immediately after starting to use the device, I was bombarded with dreams.  Likely this is related to something called REM rebound.  When we deprive laboratory animals of REM sleep for a night or two (Rats relax when they go into REM sleep so we can prevent REM by having them sleep on a very small island in water.  When they fall asleep, they roll off the island, get wet and wake up).  After having been deprived of REM, animals spend much more time in REM on subsequent nights, seemingly making up for lost time. 

My sleep pattern, in the weeks since getting the appliance, has changed dramatically.  I am dreaming again!  This means that I am waking up from those dreams – so there are unresolved issues that I can’t quite paper over in my sleep – but I am, by and large, able to get back to sleep after awakening – I think about the dream, perhaps analyze it, perhaps I pick up the thread of it and fall back asleep in it.  This doesn’t always work.  A couple of nights I have awakened and not been able to get back to sleep for a couple of hours, but this generally happens earlier in the night – at 1 or 2 – not at 4.  And the dream that awakened me has generally been disturbing – lately I’ve been dreaming, in whatever coded or not so coded fashion, about the state of my career and how dreary it is.  And this, combined with a laundry list of things that I must remember to do, can keep me up for some time.

I don’t know yet know over the long haul, how this will work out, but it seems to be a good start.  My jaw is a bit sore after having been forced into a new position and it has been very expensive.  I think more expensive than it needs to have been.  My regular dentist was appalled at what I was charged for the sleep device.  I think I will shop around next time (I saw one advertised on TV that was probably a glorified mouth guard for  $9.50), but this was also a lesson in what desperation will do to our willingness to pay for treatment.  The longer the treatment dragged out, the more I seemed willing to pay as I became more and more frustrated by not being able to do something basic to a psychoanalyst’s functioning – to sleep – and even more centrally - to dream.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

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I.H. Paul's Letters to Simon - The Reluctant Psychoanalyst Reads a Professional Classic

Recently there was a meeting at my institute between various faculty members and a group of young, enthusiastic psychiatric residents and psychology graduate students.  The topic was: How should the students learn about psychoanalytic approaches to treating clients/patients?  We thought about various things that had worked in the past: analysts presenting their cases or teaching classes about basic psychoanalytic concepts, but when someone suggested a book club, the energy in the room picked up.  And then, as we discussed various books that we could read, it was clear that there was a special place in the hearts of the analysts for a book by I.H. Paul (1973): Letters to Simon.

Letters to Simon is modeled after C.S. Lewis’ Screwtape Letters.  Lewis was writing to Christians – warning them as it were – by presenting a series of letters from a wise and avuncular devil to a neophyte who was just learning the craft of temptation (I have posted about an imaginary meeting between Lewis and Freud here).  Paul writes to his – presumably imaginary - nephew, Simon, a neophyte therapist just learning the craft.  In Paul’s book we do not read the correspondence of the student – we know about it only from the references to it in the master's letters. 

We were all excited to recommend Letters to Simon, it held an important position in each of our development and, as the leader of the resident group characterized it, we seemed so attached that she did not recommend asking to borrow our texts – we valued them that highly.  That was true, but we also were somewhat concerned about how well the book had held up.  It was written at a different moment in the development of psychoanalytic theory.  It was a time when psychoanalysis was in vogue – and a time that predated some important developments in both psychoanalytic theory and technique.  So when we agreed to read the book together, it was with some trepidation and some anticipation that I picked it up.

Simon’s letters were still warm and clearly written.  They do, indeed, have a time bound perspective – but from that perspective they clearly articulate good psychoanalytic technique and provide an articulate rationale for that technique.  Simon’s perspective is that the intent of Psychotherapy (he referred to his particular perspective by this handle, though I think it describes the dominant, middle of the road psychoanalytic thought at the time he was writing) is to increase the autonomy of the client/patient.  To this end, the job of the therapist is to be as unintrusive as possible – to assiduously avoid suggestion – and, instead, to offer interpretive help when that is available, and silence when it isn’t.  This creates a picture of the analyst that is still dominant in New Yorker cartoons – a silent, all knowing, but somewhat stilted, formal and unavailable therapist isolated behind a couch offering pronouncements.

The book is longer and denser than I remembered it.  Despite its informal tone and format, there is quite a bit of challenging material between its covers.  It also failed the primary test that I have for technique-based texts: it did not evoke any current patients that I am treating.  So it was with some trepidation that I approached the book club.  I spent time, somewhat defensively, preparing to help them understand why this book was so important to the development of the analysts in the group, to explain how we have developed since then, and to promise to look for books that were more current and likely to be more relevant to their experience.

So, imagine my surprise when the group – a small group, it met during the holidays, maybe that has something to do with it – was very excited about the text.  They found it to be a reassuring, avuncular voice just as we had a generation earlier.  They were taken by the model and appreciative of it.  As neophyte therapists, they found it very useful to have a clearly articulated model – a handbook, as it were, of what it is that they are to do in the therapy session.

I now realized why the book had failed my test of a good technique article - the focus is not on clients/patients and their experience, but on the experience of the analyst/therapist.   While I found that distracting, these novice therapists found it helpful to have a clearly articulated set of rules, just as the analysts with whom we had met earlier had found it orienting.  But, these rules were not the current rules of engagement.  They work best with a very narrow range of clients – really the most healthy ones – and they lead to certain limits in treatment outcome – clients/therapists become more comfortable with their inner worlds, but they can also become too autonomous – taken with themselves, they have trouble relating well to others.

So, now concerned about the opposite end of the spectrum, I took the position that, while the students clearly were finding the book helpful, its position was not the only one – and was not a particularly current one, and I maintained that they ought to think about what this technique, as articulated would promote – autonomy (as advertised) – but what might be lost in pursuing this – a sense of the relationship between the therapist and client and the ways in which articulating that relationship – being more real and present with the client/therapist – could lead to therapeutic outcomes that would influence more than just the capacity of the client/patient to be comfortable with their own thoughts, but also to move towards being more comfortable being in relationship with others while also being connected with their own thoughts.

The students, for their part, ended up comparing two of their teachers and the conflicting approaches that these teachers offered – one represented, more or less, by the book, and the other represented, more or less by my corrective.  This led to a conversation about the tension between the two positions, the virtues of both, but also the limits and concerns associated with each.  Hopefully I was able to inhabit an avuncular space that helped these novice therapists continue the process of developing the skills that are part of this complex but also very human art.  And next month we will read something much more contemporary – Wearing my Tutu to Analysis and other stories...

To access a narrative description of other posts on this site, link here.
   For a subject based index, link here.

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Henrietta Lacks, HeLa Cells and Experimentation - The Reluctant Psychoanalyst Reads Nonfiction

Henrietta Lacks was an African American woman born in 1920 in Maryland.  She died in 1951 and likely would not be someone about whom we would ever know anything except that the cervical cancer cells that would eventually kill her were taken from her when she was a patient at Johns Hopkins University Medical Center.  They were cultured and they not only lived outside her body, but they multiplied rapidly, proving hugely useful to the study of cells and pathology all over the world.  Rebecca Skloot recreated Henrietta’s life in her recent book The Immortal Life of Henrietta Lacks.

The book is the result of a collaborative relationship with Researchers, but mostly it is the result of a collaborative relationship with Henrietta’s four surviving children, her husband, and other members of her family.  In significant part, it is the story of the relationship Rebecca Skloot developed with Deborah Lacks, and, perhaps more impressively, with Deborah’s brother Zakariyya in order to tell this story.  Deborah and Zakariyya are children of a woman who died very early in their life.  They were raised in part by their father, who was very poor, but also by, in Zakariyya’s case, a wicked aunt who locked him in the basement when he was “bad” and beat him with an electrical cord.  Neither of them is well educated, and both are very angry that their mother was taken from them – at times they believe that Hopkins killed their mother - and both harbor beliefs that Skloot is working for Johns Hopkins and is trying to exploit them further – a belief that is supported by the actions of the staff at Hopkins who have, for instance, taken blood from the family in order to study their genes without explaining that this is what they are doing. 

Skloot begins the book by stating in the preface that she wants to keep the language usage of the family – and others in the book – when they are speaking.  This helps her descriptions come to life, but so does the patience that she shows in getting to know the family, working with them to help them understand what her mother’s cells are from a scientific perspective, and in terms of what they have done for science, and to understand what the now adult children’s perspective on their mother’s cells are and how they believe them to be imbued with characteristics that are related to the person that their mother was.  This allows for what feels to me like a very sensitive articulation of the people that Deborah and Zakariyya are, bearing in mind the limits that a white person, no matter how compassionate, will run into in exploring the mind of an African American in the South (see my blog on The Help) – with the further complication of being a representative of the dominant culture that has medically exploited the family. 

Despite – or maybe because of Skloot’s sensitive portrayal, I found myself thankful that Deborah died before the publication of the book.  She would have been, from the description in the book, a person that would be very hard to feel compassion for.  In my mind’s eye, Deborah appears on a talk show or in a news clip.  She is hard, angry, and speaking with very poor grammar.  Even having read the book, I have a hard time embracing her – accepting her – doing much of anything but cringing as she talks.  Who she presents on the outside prevents me from appreciating who she is and, I think, feeling that she deserves, for instance, any compensation for what was taken from her mother. 

Knowing someone from the inside out – and being able to describe them from that perspective – while also knowing them as they come across and being able to appreciate that and the power that their presentation has – is a very psychoanalytic means of engagement.  Which raises the question, who is this for?  In this family, whose mother’s cells were taken without her permission, cells that started a whole industry that has earned many people very good lives and brought considerable wealth to some; this family who has endured interviews and articles that have portrayed them in a variety of ways; this family who is now being interviewed by a journalist who, it turns out, will profit from a very successful book and support the publishing industry, what is the proper and just compensation they should receive?

The answers of the family members themselves vary.  Deborah wants recognition for her mother.  She wants the scientific community to know the person who produced these famous and useful cells.  I think the book accomplishes this.  All of the family members are aware of the irony that the cells have made tremendous health interventions possible – from polio vaccines to treatments for cancer – treatments that they cannot afford.  The book does not change this situation.  Zakariyya, and many of the men in the family, want money.  But Zakariyya is visibly softened, and clearly and very movingly appreciates, the pictures of his mother’s cells that a scientist gives to the family.  Seeing the cells through a microscope and learning about them are, at least through Skloot’s and our eyes, moments of epiphany for Deborah and Zakariyya.  Skloot, herself, sets up a scholarship fund for the children in the family from part of the royalties from the book.  This is money, but with strings attached.

What compensation should our patients receive for the treatment that we provide?  This may sound like a funny way of putting it, but we are “practicing”.  We are learning from our patients as they are learning from themselves and from us.  We are looking into their psyches just as other scientists look into the cells of the patients that they treat.  We, like those scientists, and like the author, need to be compensated to be able to provide the service that we do.  The service that we provide is to help articulate the narrative that has brought the people that each of us serve to the point where they are when we engage with them.  The position of the courts has been that what we take from that and apply to our next patient or, in the case of the book, how we use what we have come to learn about the family and the experiences that they have had, are ours to use as we will to forward the good of human beings and to profit from.  Our patients take, when the treatment is successful, greater insight, a more cogent narrative, and skills to navigate life’s insults a little more gracefully.  They may also be relieved of some measure of pain and inner turmoil.  But, they are not free of the events that led them to seek treatment.  They do not get the concrete compensation that something like money would represent.

Dr. Karl Menninger used to ask whether it was ethical to charge for empathy.  Some have responded that empathy is not paid for, our time is.  Skloot, I think, deserves compensation for her time and expertise.  But that comes from the perspective of a fellow professional.  Our system of compensation has always placed minimal value on the raw materials of wealth and poorly compensated those who unearth or concretely produce them.  Instead, we have placed value on those who organize, understand, and develop the raw materials.  I have certainly pursued the ability to do that, not as a means towards wealth, but I am certainly glad that our system of rewards fits with my predilection towards production.  I am also thankful that I have had the means to achieve the opportunity to make those kinds of productions.  Skloot offers the family support in making the transition to becoming that kind of member of society.  I will be curious to see what comes of that.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

For other posts looking at Race in America see: James Cone's The Cross and the Lynching Tree, and applied to a Rock Musical, Dorothy Holmes presents to the 2016 Psychoanalytic Convention, 2017 Convention Aktar, Powell and Trump, hearing Ta-Nehisi Coates talk, Black Lives Matter,  John Lewis' March, Get Out, Green Book and Blackkklansman, Americanah, The Help, Selma, August Wilson's Fences, Hamilton! on screen, Da 5 Bloods, The Black Panther, and Ta-Nehisi Coates' Between the World and Me.

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The Wired Hermit - The Reluctant Psychoanalyst entertains an Old Friend

Development is central to analytic theory and technique.  Development is also one of those words that I just didn’t understand in graduate school, and I don’t think it was one that I was exposed to much before then.  I remember teaching Introductory Psychology and explaining that kids thought differently than adults did, but I didn’t really believe it – or, I guess I believed it, but I didn’t get it.  Through my own eyes, I had always been myself.  Or maybe, I had always been myself, damn it.  I remembered what I had seen and heard and the perspective that I had and I still had that perspective and I wasn’t going to be convinced otherwise.  Ironically, of course, this perspective has changed as I’ve aged.  I now remember fondly the intensity of youth, but am no longer driven by the destabilizing energy that used to push me from pillar to post.  I have also lost some of the certainty that I once had.  Of course, I have traded it in on wisdom and a broader world view… OK, some things never change, or do they?

 My first personal experiment in development across the life span occurred when, in my mid thirties, I decided to travel back to Florida, a state that I left when I was twelve and my family moved north to Ohio.  I left behind my best friend Jimmy, whom I had only known for three years, but who was someone I felt deeply connected to.  He and I had been in a gifted child program together and we had bonded by competing over just about anything.   We played one-on-one tackle football – he was faster and could outrun me but I could outmuscle him and run over him, we played chess – and derived strategies and gambits that I use to this day, we spent sixth grade being excused from both math and English class because we tested out at the beginning of the year, so we sat outside together and, instead of reading the A encyclopedia entry for Algebra as we were supposed to do, we played a game called dots where we connected those dots to create boxes.  We were mean and vicious competitors, but we were also careful and considerate friends.

I sensed that Jimmy was different from my other friends.  His parents were very protective and – though I didn’t have the word for it then – conservative.  In fact, as I was preparing to look him up again, I reasoned that they must have been Baptist, something that I don’t think I knew or cared about in sixth grade, but something that was, indeed, a very important part of Jimmy’s family’s and of his own identity.  So when the other kids started teasing Jimmy because he didn’t know about the birds and the bees and were threatening to tell him, I thought it best to protect him from them and, in my twelve year old moral system, to let his parents tell him about this sacred secret when the time was ripe based on their perspective (Sex education in Florida in the late sixties simply did not happen in the schools).

So, when I looked up Jimmy, I knew where to look.  He would be working in his father’s furniture store, living in the town we had lived in, and following in his father’s footsteps.  And I was right.  I called the furniture store and explained my wish to the person who answered the phone.  They said, let me transfer you to corporate headquarters, and there was Jimmy.  We renewed our friendship and, though he was older and more mature – he now not only knew about the birds and the bees, he had two children and three stepchildren – but he was still very much himself.  He was conservative, true, somewhat naïve about the world, but very involved in his community and with his family.  It was now apparent to us, in ways that it had not been when we were children, how different from each other we were, but because of the childhood bond, we renewed our friendship and have maintained and enjoyed it since.

The second experiment was much more recent and one that was not as intentional.  Last summer, when we travelled to California, I looked up my friend John whom I had known when we were both psychology postdoctoral trainees together in Topeka Kansas.  John was then and is now a Monk.  When we were in training together, he lived, on the weekends, at his home monastery in Atchison Kansas and stayed, during the week, at a parish house in Topeka.  He has since joined a hermitage in Big Sur, California and that is where we visited him this summer.  My children were not excited about going to visit Brother John.  It was going to be a long drive in the car, which they hate.  And my stepdaughters, who are Jewish, were concerned that a religious person would try to convert them.  I, frankly, wasn’t certain what to expect.  I had kept up with John, on a somewhat sporadic basis, after our training, but he had become much more monastic – indeed hermit-like - and no longer went on trips that allowed him to drop in on me.  Indeed, we had also fallen out of email and snail mail contact. 

The girls, and my boy, became quite smitten with John.  He immediately took their side in arguments over things like the amount of sugar they should eat, and brought them a big bag of chocolate to munch on in the cell we stayed in.  And the cell was nice.  John also gave us a lovely tour of the hermitage and was present and forthcoming about what he did, while simultaneously being very interested in all that we were doing.  Previously I had known him primarily as a psychologist and, though I visited him at the Monastery and spent considerable time with him both professionally and more personally, I had thought of his ability to listen empathically, to think about situations and dilemmas critically, and to be avuncular – in the ways that he was with the children – as attributes of his psychological identity.  But this time it was not so clear.  And this had to do with more than the setting.

Last weekend he returned the favor of the visit.  He came with his iPhone, his iPad, and his Mac Book.  He was wired – or more precisely wireless.  We spent considerable time with him at a very busy time in the semester.  While I was looking forward to seeing him, I was concerned about how we would manage large swaths of time that we would have together.   In retrospect, I shouldn’t have been.  He has lived in community for the better part of his adult life.  He knows how to be with others and to create space both for himself and for them.  But he also knows how to be present when he is present.  And this has a different quality than it did twenty years ago.  No longer an actively practicing psychologist, John talked about the joys and also the difficulties of living in community.  He also listened – in particular to a dilemma that I was having about a very difficult matter at work.  And he was able to helpfully articulate my experience.  He was curious about my spiritual development and that of the Reluctant Wife, but he neither pried nor proselytized.  In fact, he was respectful of our positions and of our experience more generally.  There had been a very subtle but also a very profound shift in him.  No longer was he as quick to point out the proper action, but he was, in a very compelling way, more certain of himself.  He was more comfortable in his own skin, and this allowed me to be more comfortable in mine.  Mind you, I enjoyed being with him before.  And our current relationship was continuous, especially in terms of the content of our conversations with our previous one, but it was also new, and based, I think on a more profound sense of love that John feels for himself and for the broader community of humanity in all its guises.  He had become, in the last twenty years, a monk.

Now John was always a believer.  He talked, twenty years ago, about his own psychoanalysis and about how people had said that the analysis would analyze his faith right out of him, and he responded that, if his faith was truly part of him, the analysis would enhance it.  And, while I am sure that the analysis did enhance his faith, something has developed in the time since then, something deeper, harder to articulate, but something that is truly wonderful, and comforting to behold.

Interestingly, in the fifteen years that I have now re-known Jimmy, he, too, has developed.  In part as a result of seeing me having realized one of our shared (though never spoken to each other) dreams of being a University professor, he brought his work with his father to a close, went to graduate school, and has become a professor himself.  He has just earned tenure but also courageously searched out a new job that will allow him to do the work – studying and helping family businesses succeed – that turns out to be his true calling.  He has also become a Presbyterian!

Traditional psychoanalytic developmental theory focuses on the earliest parts of life.  Some analytic thinkers have even considered character to be set in place at a relatively early age.  Others, Erik Erikson was one of the first, are champions of lifelong development.  I have witnessed the growth and development of my child.  I have come to rethink my own early development.  And I have witnessed across a span of years, the constancy but also the profound development of my adult friends.  Across time each has become more like himself.  This is certainly not the only developmental arc, but it is one that turns out to be neither stultifying – quite the opposite, I find it fascinating – nor erratic.  Instead there is a quality of achieving a goal – of moving towards something that is both defined and ineffable.

To access a narrative description of other posts on this site, link here.   For a subject based index, link here.

To subscribe to posts (which occur 2-3 times per month), if you are on a computer, hit the X button on the upper right of this screen and, on the subsequent screen, hover your cursor over the black line in the upper right area and choose the pop out box that says subscribe and then enter the information.  I'm sorry but I don't currently know how you can subscribe from a mobile device - hopefully you have a computer as well...

One Flew Over the Cuckoo's Nest - The Reluctant Psychoanalyst watches a classic

           One Flew Over the Cuckoo’s Nest, both in the form of Ken Kesey’s novel and Milos Formans’ film starring Jack Nicholson and featuring Danny DeVito and Christopher Lloyd in early roles, and Louise Fletcher in her Academy Award winning performance as Nurse Ratched, were powerful influences on me as an adolescent.  R.P. McMurphy, Ken Kesey’s alter ego, based in part on Kesey's experience as a psychiatric orderly, is a petty criminal who chooses an insanity defense in order to get what he believes will be lighter treatment at a psychiatric hospital than he would get in jail.  Instead, he runs into Nurse Ratched, authority figure extraordinaire, in her starched uniform and her rules upon rules intended, in her mind, to help the patients improve, but, as is apparent to the most casual observer, serving to protect her world view and to keep the patients repressed.  Meanwhile McMurphy’s self-sacrificing rowdy mischievousness leads to actual therapeutic change as the patients unite against “The (Wo)Man” and become cured of their stutters, their self doubts, and, in the final glorious scene, their physical and spiritual imprisonment.

            When I first read the book, I was also enthralled by The Electric Kool-Aid Acid Test, Tom Wolfe’s journalistic account of Ken Kesey’s band of Merry Pranksters who roamed the United States in a school bus named Further.  I was an adolescent, and found the collective call to set aside attachment to what is reassuring and instead to forge ahead into a brave new world of living in NOW a powerful siren pulling me towards a destiny that was somehow different, grander and more substantial than what I had previously been led to believe could be in the cards for me by what I now suddenly realized were inhibited, uptight, establishment individuals who just were not “on the bus”. 

 How surprising, then, to reread the book in my early thirties, while working as a psychologist in a mental hospital, to find myself empathizing with: Nurse Ratched.  She seemed, instead of evil, to be essentially scared.  Sitting on top of a ward full of what seemed unpredictable people, she created a cool, crisp exterior to mask the anxiety that she felt being in charge and charged with caring for 18 men, including the inhibited son of her best friend, but also men with a wide range of moderate to severe disturbances.

            In contrast, in both the book and the movie, R.P. McMurphy is carefree and has nothing to preserve or to protect.  Much like my 16 year old self and Kesey’s Band of Merry Pranksters, he could react against the strictures of Nurse Ratched and have great fun stealing a boat to go deep sea fishing because he was a ward in a loony bin and the worst consequence he would receive is being sent back there. 

            As I saw the movie again the other night on Family movie night, I was curious to see whether the Nurse Ratched character was as sympathetic as she felt on the page.  I suspected that she was not, and, indeed, that turned out to be the case.  The film heightened the tension between the two main characters and hardened the conflict into one that pitted good versus evil instead of two three dimensional characters together hating but respecting each other.  In the penultimate scene in the movie, McMurphy clearly observes Ratched in all of her glorious evilness – he watches it build and we feel his moral superiority, and we revel – even my sweet 12 year-old stepdaughter reveled – in his evening the score.

            The movie version, though, turns the drama into something bigger, and therefore less human, than the struggle between two flawed people.  Especially because it loses track of the idea that, in addition to being mirrors of each other, the protagonists are necessary to each other.  McMurphy can no more live freely without a society, necessarily including the nurse Ratcheds in that society, than she can live without a group of patients who depend on her.  The balance between them is better maintained in the book because they are both aspects of the author – as Dostoyevsky remembers Dickens telling him in this morning’s New York Times Book Review, “that all the good, simple people in his novels… are what he wanted to have been, and his villains were what he was (or rather, what he found in himself), his cruelty, his attacks of causeless enmity towards those who were helpless and looked to him for comfort, his shrinking from those whom he ought to love.” *
           In the movie, we no longer see that Nurse Ratched is also Kesey's alter ego - the scared orderly trying to maintain order with his own internal chaos - instead, we can imagine that Ratched is outside ourselves – an evil to be vanquished or one to be escaped from – rather than an inevitable partner, someone we carry within ourselves who is trying to protect us from ourselves and is also capable of doing terrible violence to ourselves (and those under her care) if we let her.  On the other hand, Kesey’s Merry Pranksters, without someone to limit and contain them, terrorized towns when they showed up with their unbridled aggressive acts (I think there is an odd and eery parallel in the events of 9/11).  The Merry Pranksters were sustained by money from Kesey’s books, money that required all kinds of Ratcheds working in publishing and then actually printing and selling those books, not to mention wannabe Keseys like me who bought the books to catch a glimpse of the world that I would love to inhabit but didn’t quite dare - in part because I had to show up for my part time job to afford the books I loved.  

Further, when the Ratcheds are not there, when the institutions like the one depicted in the film are not there to contain, support and, occasionally to treat individuals like the ones depicted in the film, and adequate alternatives are not established in the community, we discover that the mentally ill are living among us – homeless and sometimes desperate, until they engage in criminal activity, if they are lucky, so that they can come to the attention of mental health treatment in the penal system (because the institutions like the one depicted in the film - as problematic as they were - no longer exist.  We phased them out in favor of "community psychiatry", but have never funded that to the point that the mentally ill are adequately cared for).  Of course I am condensing a lot in this paragraph, but I think that mirrors the danger of the collapsing of good and evil into two separate entities the way that the movie does.  When we try to make the world simpler, we come up with simple solutions, but this can, unfortunately, distort the world and lead us to fail to anticipate consequences that are, in retrospect, easy to see when realize that the simple solution has been applied to complex problems deserving nuanced solutions.


* (NOTE: Though this quote later turned out to be a hoax, I have left it in this post because it so accurately describes Kesey's writing as I perceive it - even if Dickens never said it, it captures what I am imagining occurs within all of us when we write and when we read.  I think that it spread so quickly across the internet because so many people resonated with the sentiment that the underlying logic of these two men meeting, much less communicating wasn't questioned - plus, it was the New York Times that published it.  Since this time, I have heard many authors supporting this sentiment - Eric Cornwall who wrote under the pen name John Le Carre, endorsed this on a broadcast with Terry Gross on Fresh Air.  In that interview, he talked about writing about characters allowing him to more authentically inhabit himself by expressing the contradictory aspects of his nature - aspects that were more tightly bound in his functioning, for instance, as a spy, but also as the child of a con man, in real life.)

Postscript 5 years later (2018): I was thinking about this post this morning and realized that I only briefly mentioned in an oblique manner the hero of the book - and the person through whose eyes it is told: Chief Broom.  This massive man, whose elective mutism allows him to listen in on all the staff machinations as he apparently mindlessly sweeps his broom from room to room in the hospital is the moral center of the film.  A psychotic inpatient, he is also a Native American from Washington State, Kesey's home before he moved to San Francisco and became a psychiatric hospital orderly.  To get inside the mind of his narrator, Kesey wrote in the first person about Broom's psychotic episodes while taking LSD.  Most of the writings were discarded because they were drivel, but Kesey hung onto and edited in a sober state enough of them to give the best account of what it is like to be psychotic that he could muster.  The underlying message of the Native American, whose close proximity to nature was disrupted by the intrusion of the Europeans, reclaiming his soul as a result of interacting with the most destructive European of all - the psychopath with a heart of gold McMurphy - may account for the lasting value of this book and film.  Despite my dismissal above of McMurphy and Kesey as role models - their questioning of the inherited values of dominating nature rather than appreciating it - of control versus wonderment - they continue to have tremendous resonance with me and, I believe, many viewers who are concerned about the dangers of dictating to nature rather than learning from her.  A post on the Overstory, a Pullitzer Prize Winning novel about a current iteration of the man vs. nature dilemma may be of interest.

Postscript 7 years later (2020).  I am struck that the film and a campy series about Nurse Ratched have both been released on Netflix as the re-election of Trump (or the election of Biden - it is the day after the election and it is unclear how this will turn out) has loomed.  The wonderful thing about the film is, I think, because there is so clearly a good guy and a bad guy - and the good guy is the outsider - it may appeal to the Trump inside us - my 16 year old self was as enamored of Ayn Rand as of Ken Kesey.  While I hope that in my next postscript we will have passed beyond the phase of having a psychopath with a (presumed by some) heart of gold as President, but I think we should have learned that this narrative is very close to our hearts as a nation.  We identify with Kesey and the gender split in the vote may help us realize just how threatening the maternal figure that Ratched represents is to us and the lengths we will go to in order to avoid empowering her (imagined - and depicted in the movie) type to care for/dominate us. 

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Emma Donoghue's Room - The Reluctant Psychoanalyst Re-experiences Closeness and Loneliness

Room, the 2010 novel by Emma Donoghue is the story of a mother confined in a 12X12 shed for seven years. She creates a world of wonder for her now five-year-old son Jack out of the meager resources available to her.  This is a story in the tradition of the 1997 Italian film Life is Beautiful and Cormac McCarthy’s 2006 novel The Road.  All three of them are about a parent navigating a threatening and horrific world with his or her son – Life is Beautiful is set in the holocaust, The Road in a post- apocalyptic landscape and now Room, in the narrow confines of a shed, pits a mother against a jailer upon whom she is totally dependant.  Each narrative describes a grim and beautiful task, that of protecting a child against the obvious threats of an evil world.  In so doing, each of the parents preserves the human nature, the joie de vivre, and the integrity of their child from a soul-killing world.  I can’t help but wonder about this theme resurfacing in these three popular works in part because each of them also resonates with the everyday and very complicated task of raising a child in our current environment, one that appears benign (especially in comparison to these three universes), but one that actually contains insidious threats posed by everything from fast food, internet porn, and school bullying to our own distraction from the task of parenting by all the demands in our adult worlds. 

Room does, indeed, create a universe similar to the other works; however, it struck a very different set of emotional notes for me.   In this book, instead of primarily identifying with the parent, I found myself immersed in the world of the child.  This is partly because the other two works are about a father and son – and it is easier for me to identify with a father than a mother – but mostly it is because this story is told from the point of view of the five year old.   

I think the story worked for me because of my reaction to it.  It evoked in me longings – longings for closeness with my mother.  The mother in this story is never named – she is just Ma.  When Jack learns that she has another name, he rejects it as foreign and never includes it in the narrative.  Jack’s Ma is not just his Ma, but mine.  The closeness that he shares with her is the kind of closeness that I once had with my Ma and that we necessarily, and not without a great deal of pain and angst on both our parts, had to give up. 

Not surprisingly, then, it was in the giving up of the closeness that takes place in the book that I found myself wrestling with the author.  As she introduced plot elements that led the mother and son to move away from each other – more specifically as the mother moved away from Jack, I found myself wanting to argue with her.  I wanted to say to her, “Look, this wouldn’t really happen this way.  This woman has dedicated herself, despite considerable difficulty, to this child.  And she will continue to do that indefinitely.  Just because the situation has changed does not mean that she will be any less unwavering in her devotion.”

This criticism comes not from a theoretical or intellectual psychoanalytic perspective (though I kept trying to figure out a way to cloak it that way), but from my own five-year-old self’s wish to not lose his mother and his sense of closeness to her, or more precisely, her devotion to him.  When they are in Room together, Ma spends all of her time with Jack.  The other creatures in his world are Bed, and Wardrobe (where he sleeps), the characters in the stories he reads and Dora and other characters from TV (itself another presence in the room), and the jailer whom he never sees, Old Nick.  Though I had a brother and a sister, and my father was a presence in my home, in some ways they paled - they became as shadowy and partially alive as Bed and Wardrobe – in comparison to my Ma.  The intensity of the connection with my mother is like no other I have felt in my life, until I had a son of my own. 

In my life, the separation from my mother came from both sides.  She moved away at various points in my development for various reasons of her own, but I also moved away from her – especially during adolescence and later in my development.  Part of the violence of my movement away was the wish to get some distance from a relationship that felt so intense that at times it felt like it threatened to engulf me.  And, from the perspective of myself as a mature, more or less well-organized adult, the wish to create distance that I direct feels under my control; when my mother wants to be closer it is her wish to be closer that is uncomfortable, not the distance between us.  And it is from this perspective that the book, though certainly flawed in a variety of ways, worked for me because it un-worked me.  I felt betrayed by Jack’s mother as she moved away from seeing the world through her son’s eyes and instead articulated her own wishes and needs.  As she moved more and more into her own skin, I became more and more upset with her.

The most painful part then, for me, of this coming of age tale – and it is a coming of age tale for both the mother and Jack, as weird as it is for a five year old to be coming of age – is the separation – the pulling away – of the mother from Jack.  And this, in turn, is because it causes a type of regression in me.  I am no longer the relatively mature adult, but instead my five-year-old self emerges, a self that longs for his mother’s closeness, or, more accurately, from Jack’s perspective, simply expects it to be there.  When she pulls away from me, I feel helpless, scared, and concerned about myself – in the form of Jack.  When Ma creates a plan that requires Jack to act, I am certain that he is not up to the task.  And when he demonstrates competence, I feel like the plot is strained.

My regression is induced by the book’s narrative.  Psychoanalysis is intended to induce a similar regression; one that is intended to help us remember what our earlier life was like.  Of course, it can never be as it once was.  I can read from Jack’s description what his mother is thinking and feeling even though he doesn’t have access to that – he really is five, while I am just remembering what it was like to be five.  But remembering what it was like creates an opportunity for me and for analytic patients.  We have the emotional immediacy of something occurring now – not in the distant past – and we know now, and feel now, the other side of the coin – that we not only want to distance ourselves from closeness (in this case) but we also desperately desire it and are puzzled by the autonomous strivings of those on whom we depend.  Like my patients, when these competing and complementary desires become alive to me, I can work on reconciling them in whatever way I will.  But this reconciliation will not involve simply denying one half of it – my desire for closeness – but will involve integrating that desire with my own desires for autonomy, desires that mirror the desires of Ma.

Ultimately, Ma's movement away, which leads to my movements away, can lead to a position where I am more comfortably autonomous, but also more comfortable expressing my needs for closeness and connection.  Especially when the kind of firm base that Ma’s attention has provided to Jack and to me is exposed by her absence, but also her reasonable, if intermittent availability, we can learn to grieve the loss of the closeness, and also to embrace the freedoms the autonomy affords.

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Lawrence Durrell's Justine - The Reluctant Psychoanalyst Reads a Classic

     Justine is the first of four novels that make up the Alexandria quartet.  I must confess that I have not read the other three and don’t know when or if I will.  Justine stands on its own as an intensely disturbing meditation on love.  Told in a free form style where events are related in the first person based on “the order in which they first became significant for me” rather than in linear fashion, it has a very dream like quality – it is hard to keep track of characters and events but, just as in a good dream, this doesn’t seem to matter. 
     The title character is the object of intense desire – the narrator calls it love – of many people.  Centrally she is loved by her second husband, Nessim.  Her first husband’s novel about his love for her is quoted extensively throughout, and it is used to articulate the love of the narrator, who has an extensive affair with her and who is now also writing a novel about her, while maintaining powerfully attached relationships with his lover, Melissa, and with Nessim.  Indeed, Justine and the narrator himself maintain that Justine’s affair with him is a way of more fully expressing her love for Nessim.   Nessim, in turn, ultimately has an affair with Melissa and the love quadrangle thus becomes complete around the edges.
     Perhaps because of the intensity of the relationships between the four central characters, auxiliary characters abound.  The sharpness of the depiction of them stands in contrast to the amorphous, elusive, shifting quality of the four central characters and particularly of Justine.  It is as if the more you know and love someone the more ephemeral, translucent and unpredictable they become.
     Justine is, in many ways, the perfect object of desire.  Complexly, powerfully and intimately available, present to her lover physically, emotionally and historically, she is also elusive.  The author ties this to a childhood molestation and to Justine’s lingering feelings for the perpetrator.  These feelings are complex, poorly articulated, and we are left to conclude that they include multiple desires - even murderous ones.  I believe we are left to conclude this, rather than the narrator articulating them directly, because Justine does not, herself, know them and she can not articulate them, except, perhaps, through action.
     One of the problems with thinking about a book like this from a psychoanalytic perspective is that it is written under the influence of Freud.  The two epigraphs quote the Marquis de Sade (who also wrote a book titled Justine) and Freud.  Reviewers have stated that Durrell was intending to portray a quantum reality – a post Einsteinian and Freudian view of personality as malleable and essentially unknowable.  The question then becomes whether the analyst is seeing in the mirror simply a reflection of the ideas that come from his discipline to begin with.
     Books like Justine – in so far as they reflect aspects of the real world – are a big part of why I am a reluctant psychoanalyst.  I was raised in a world that promised a very different vision of love than the one presented here.  In the world I was led to believe existed, and the one I came to long for, people who were simple and true could find each other, know each other deeply and well, and live happily ever after.  This worldview, though, is dependent on a static view of human character.  Indeed, part of what made a personal analysis attractive to me was a comment someone once offered, “The well analyzed person never unintentionally insults someone.”  When one of my analytic teachers offered the opinion that the goal of analysis is to teach self-analysis, I vehemently objected.  My wish was to attain a post analytic state where my unconscious would be known and continued analysis would be unnecessary.  Freud’s dictum – where there was id, ego shall be – seemed to promise this was possible.  I wanted a refund!
     Justine, when she is rediscovered after having resolved her central dilemma, is dull.  Her hair is cut; she is living in a kibbutz, farming, and is no longer desirable.  Once her dilemma is resolved, Justine is flat, and no longer worthy of being an object of desire.  I am reminded of the vague dissatisfaction that I feel at the end of a romantic comedy when the boy finally does get the girl (or the other way around).  It is the chase, it is the hunt, it is the drama of the unknown and, at least from the perspective of this novel, the unknowable, that keeps our interest alive.

It is also the case that we prefer that the drama have a conclusion; that the conclusion should come in two to four hundred pages or, in a movie, play or opera, within 2-4 hours.  We can immerse ourselves in the chaos of the unknown for only so long.  Reading the other three books of the Alexandria quartet can wait.  I’m not sure that I want to re-immerse myself in this unsettling world from a different perspective.
     Psychoanalysis can provide some closure as well.  While it does not, in my experience, lead to the post-analytic state that I longed for; it does improve the dialogue between the conscious and unconscious states.  And while this does not eliminate conflict (nor does it, in my case, prevent unintentionally offending others), it does lead to having a stronger base from which to venture into the unknown and tools to better appreciate more and more of the terra incognita that lies both within myself and between myself and others.  It provides a narrative structure to the chaotic elements of my experience.  Strangely, then, and perhaps perversely, Justine (and the rest of the, as yet, unread Alexandria quartet), reassures me that, reluctant though I may be, I am on the right track.  There is always more to be known about the complexities of the human soul.  This, though, is a double-edged sword.  There are many times that I wish that I could turn off the analytic process and stand somewhere, anywhere, on a nice bit of solid ground, secure in the knowledge of something not contingent, not relative, but absolute, certain – like the speed of light.

Postscript:  I have just finished a post on The English Patient.  In it, there is a similarly enigmatic love object, though the focus of the book and movie is on the lover rather than the beloved.  I think - now years later - that the true focus of Justine may actually have been the author and that she is the object not of his love so much as his fear of love.  That actual contact - the somewhat naive kind of love contact that I refer to in the post above (and reference in terms of a reunion in the post on the English Patient) is an anathema to the more Gothic romantic view - a view of loving someone who must, necessarily, be unknown - because it would be terrifying to actually know her - and to be know by her.  I am reminded of Freud's callous disregard for Dora's inner life - including that she might want to actually be loved by Herr K. - not fondled by him - something that Freud was blind to in his work to get a handle on her and the complications of being present to someone else.  I suppose I am also a reluctant psychoanalyst because it turns out that actually making contact with someone else - being present to them and while being present to ourselves is much more difficult than we imagine it.  And it may be that sexually abused women - especially women who have been abused by people whom they trusted to love them - can sniff this out in us - can expose in us just how complex our best intentions are - including their base components.  This leads them to mistrust us - and we to mistrust them, but also ourselves in their presence.  This gives them a certain allure - a dangerous allure - as they, and we, try to discover something noble in a sea of desires, each of which seems to have a base component.

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