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.

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...