Harlan laughed. Joseph dismissed me with both hands. He was a small man, no more than five three. Small and unathletic, yet the old man’s clothes he wore as a boy were long gone. He dressed in Armani suits for evening wear, Banana Republic clothes for casual wear, and jogging suits for a night like the one we had just spent. He was in a red and white one now, on his feet, twirling away from me in disgust. “That’s bullshit.” He turned to face me. “That’s beneath you, Rafe. I’m sorry to hear you resort to that bullshit.”
“I’m sorry, too. I don’t want to resort to bullshit. What’s wrong with my point?”
Joseph stared, as if searching for signs of sarcasm. He couldn’t find any, since there were none. He sighed. “Artificial insemination proves that a sperm and an egg make a baby, not love.”
Silence greeted this remark. Not a respectful silence, recognizing logic triumphant. I think we felt dismay at what this implied for humanity’s future.
“So your point,” I said, after the room’s gloom persisted long enough for Joseph to check each of our expressions, settle back in his chair, pick up his espresso cup, note that it was empty and replace it on the coffee table. “So your point is that since Prozac can relieve depression’s symptoms—”
“Not its symptoms!” Joseph’s tone was so sharp that Harlan jerked his head away and pretended to clean out his ear. Diane smiled at him. Joseph ignored his pantomime. “Don’t diminish it by saying symptoms. What is depression if not a collection of symptoms?”
“Exactly,” I said. “What is depression? That’s the question you haven’t answered, any more than artificial insemination answers the question of what is life. A patient goes to a doctor and complains that he can’t sleep, he has no appetite, he has trouble concentrating, he feels his life is joyless, and that there’s no hope for any of these things to change. The doctor says he’s suffering from depression. He prescribes your drug and some of those things are changed. He eats more, sleeps more. His doctor praises him, his family praises him—”
“That’s not all—”
“Let me finish. The patient goes off the drug. And he can’t sleep again, he can’t eat, he has trouble concentrating—”
“So?” Joseph appealed to Diane. Evidently he had given up on me. “You put him back on the drug. How is that different from a recurrence of any illness? A person is infected, you give him an antibiotic. That doesn’t mean he can’t infect again.”
Diane looked to me, mouth set, arms crossed, like a professor waiting for an answer. I could understand why she might, sensitive to my friendship with Joseph, refrain from answering him herself, but why look at me so crossly? I hoped the annoyance was meant for Joseph. Harlan also looked at me expectantly. They appeared to be demanding that I refute my friend. I wasn’t sure that I wanted to refute him: I wanted to know if he was right or wrong and I doubted debate offered certainty.
My tone was an appeal, not argument: “Tell me, Joseph, how is it different from the person who feels awkward at a party, getting drunk every time he goes to one? Or a ghetto kid—who is right to feel his life has few prospects—buying crack to feel a surge of bliss? Have you cured depression, Joseph, or simply created socially acceptable addicts? Maybe you’ve helped the depression. Or maybe you’ve invented your own illness, and used that to overwhelm depression.”
“Oh, come on,” Joseph said. “Are you telling me antidepressants are completely useless in your work? That you would rather have people sink lower and lower—”
“I see you still haven’t read my book, Joseph.” He didn’t respond. Harlan smiled to himself. Getting no admission or denial, I continued, “Yes. At best drugs are useless. At worst they add a new problem. I never use them.”
“Because you’re biased,” Joseph said conclusively, as if making a private judgment, not scolding me.
“Because they’re dangerous.” I insisted. “Are you denying that tricyclics are addictive? Are you denying that neuroleptics cause tardive dyskinesia?”
“In some patients!” Joseph complained. “That’s why I didn’t finish reading your book. You throw out everything because some of the drugs aren’t perfect. Is the couch perfect?”
“No. In fact the couch is slow and hard work. Hard for the doctor, hard for the patient, hard for their families, hard for everyone. Not drugs. They’re easy. Drugs make patients easy to deal with. Easier for doctors and hospitals and their families. But what they don’t do is cure depression or schizophrenia. And what’s more, Joseph, and you know this is true, long term those drugs diminish personality—”
Joseph was on his feet. “I knew it. You haven’t read the research on Prozac.” He finally married his actions to his clothes and went jogging, out of the living room and down the hall to his study.
Harlan leaned forward, shook the espresso pot, and asked Diane if she wanted more.
“Not if you have to make it,” she said.
“I don’t mind,” Harlan said. “I’m depressed. I got nothing better to do.” He stood up, carrying the empty pot. “I like the idea of Joey inventing his own disease.”
Joseph appeared with reading material for me. One was a dissertation in manuscript. There were two issues of the New England Journal of Medicine, and finally a popular paperback by a psychopharmacologist. “She’s a dope,” Joseph said as he handed over this book, “but read her case histories in the last chapter for the descriptive data on Prozac’s effects. You haven’t read it, right?”
“Right,” I said. “Remember, Joseph, I would never use drugs on children—”
“I know, I know,” he handed me the rest of the pile. “These reports indicate that Prozac is different from any other antidepressant. It’s only been in use a year—”
“I know that, Joseph.”
“—and I want you to look at the rat studies on kindling.”
“Kindling?”
“You don’t know about kindling?”
“No,” I admitted.
“That’s irresponsible,” Joseph squeaked.
Harlan groaned.
Joseph’s voice stayed high. “I’m sorry. But it is. I know you don’t believe in psychopharmacology,” he appealed to me, “but that doesn’t mean you should ignore neurobiology. Freud wouldn’t.” Diane mumbled something. I couldn’t hear what because Joseph continued, “The kindling research has a bearing on your abused kids. They prove that emotional trauma can change brain chemistry.”
“They prove it?” I asked.
“In my opinion that’s the only reasonable conclusion you can draw from the kindling studies. Stress and trauma start a vicious cycle in the brain. And I believe the inescapable conclusion is that it means it can only be healed with drugs.”
“Give me a break,” Diane said. Joseph ignored her.
I glanced at the New England Journal of Medicine article. “Prozac and the New Self,” it was called. I said, “Point taken. I haven’t done enough reading to debate it with you.” I looked at my old friend and let him win. “Okay, Joseph, I’ll do my homework.”
CHAPTER SEVEN
A Crisis of Faith
I SHOULDN‘T BELABOR THE OBVIOUS TO PROFESSIONALS. WITHIN A FEW years, Joseph’s claims for Prozac were widely hailed in the media. Nowadays, it is an almost accepted fact that Prozac produces profound character changes in many patients, particularly mild depressives, people with low self-esteem, or emotional sensitivity, namely the sort of neurotic who had been considered psychoanalysis’s exclusive province. Namely patients like Gene Kenny. Prozac’s supporters claim that their patients aren’t merely relieved of the immediate physical effects of emotional pain; their experience of everyday rejection, loss, conflict, guilt and so on is altered, both in how they feel and react.
So why not prescribe Prozac for Gene? Readers of my book The Soft-Headed Animal know there is no proof, as Joseph Stein himself admits, that any psychological condition, ranging from schizophrenia to mild mood disorders, is organic. Shocking though it may seem to a lay audience inundated by half
-truths and wild claims from psychobiologists, geneticists, and drug companies, there is no scientific proof that what we call mental illness exists. When autopsied, the brains of suicides, schizophrenics, manic-depressives, indeed the whole range of psychiatric disorders, show no measurable difference from the brains of people we label as mentally well. Only if (and this if is crucial) the “mentally ill” were subject to shock therapy, neuroleptics or sedatives do their brains show damage. Few things in psychiatry are as clear as this evidence: mental illness—insofar as one can consider it organic—doesn’t exist and the fashionable physical and chemical treatments, if used for long, may cause brain damage, irreversible damage that truly is a mental illness.
This confusion between the fact that drugs can change how people act and feel, and whether this constitutes a cure of their psychological crises, runs through every level of our society. Prozac, as an example, is supposed to “treat” depression by raising the amount of serotonin in the brain. And yet no scientist can show that depressed patients have lower levels of serotonin than people who are considered normal. (Some psy-chobiologists, to make their flawed logic consistent, respond to this fact by suggesting the entire population take Prozac.) When Prozac artificially raises serotonin, a minority of patients report they have more energy and accept defeat and frustration with less sadness. What its advocates leave out is that snorting cocaine can be shown to have the same effect, just as smoking cigarettes can be shown to improve concentration, and that alcohol can relieve anxiety. The difference—and it has a profound effect on the results of clinical trials of psychiatric drugs—is that when people medicate themselves with illegal narcotics, cigarettes, or alcohol, they don’t have a psychiatrist telling them they are ill when sober and cured when drugged. None of the material Joseph gave me clarified the murky logic of psychopharmacology. Insight alone doesn’t always cure. Drugs don’t cure. Not if the goal is an independent being, a person who is free from both a therapist and a pill. We like to call our profession a science, our patients sick, and our treatments medicine, but the psychiatrist, whether armed with a drug or a couch, is treating a perception of illness with only the prejudiced testimonies of its victim and an intolerant society to confirm his success. In that context, broad claims of success must always be regarded skeptically. Then and today, I could find no proof that medicating Gene Kenny would have been anything more than surrender to the modern culture of instant gratification.
Nevertheless, our New York coffee table scientific argument had several important consequences for me. What I did not, and could not have realized at the time, was the consequence it would have for Gene Kenny. That night his case seemed to be the least likely to be affected by the question Joseph and I debated. What was significant appeared to be entirely personal. Diane maintained an angry silence during the cab ride to her apartment. I had Joseph’s recommended reading in my lap. I tried to begin a few conversations. She answered in monosyllables, including when I apologized on Joseph’s behalf for treating her as if she weren’t a psychiatrist. “I’m just a stupid cunt to him,” she insisted. When we arrived at her door, she said, “Maybe you should go to your place tonight.”
“Okay,” I said, fighting the shrink’s impulse to talk this out immediately. She believed in that principle as fervently as I and must have had a good reason to delay.
Her tension at rejecting me relaxed. She kissed me affectionately and whispered, “I’m sorry. I’m just very tired.”
Not much of an excuse for a trained analyst. I played along. “Sure. Call you tomorrow.”
I wanted to study the articles anyway. I had an intuitive feeling that there was something valuable in Joseph’s dogma. And there was. I stayed up late reading, especially fascinated by the kindling studies on rats that suggest stress and rejection create biochemical changes which may then go on to have a life of their own. Of course they don’t really answer the age-old cause-and-effect argument, but they do call into question whether talking therapies alone can succeed in undoing the damage. They also, by the way, imply that early treatment is vital, very encouraging for someone who, like me, treats abused children and sometimes despairs of preventing long-term difficulties. I had lured “Timmy” out of his multiple personality defense against his abusers, but how could I feel secure that he wouldn’t suffer again later, in much the same way that Gene had reappeared with his old problems in a new guise?
By morning, I knew I had to investigate the kindling research. I called Joseph at eight o’clock. He promised to send unpublished material on a variety of neurological studies. Joseph was gracious and not smug about my apparent surrender to his point of view. (I didn’t tell him that I was unimpressed by the Prozac data.) Diane phoned soon after I hung up.
“I’m sorry,” she said in a sleepy voice. Her register is naturally low and husky. The morning gave her an even lower octave. It was sexy.
“Nothing to be sorry for,” I said.
“Did you sleep well?” she asked.
I told her, probably with a little manic excitement, that I had been up most of the night reading and I felt exhilarated.
“You don’t mean you agree with him?” she asked.
I tried to explain that I didn’t think agreement or disagreement with Joseph was the point. I know I concluded with pomposity. “What’s important is the truth,” I said.
Diane grunted. “Well, I certainly wouldn’t want to stand in the way of the truth.”
I was irritated. Diane is an excellent practical therapist: no one could be more dedicated and few of greater help to their patients than she. On the theoretical level, however, she lacks curiosity or broad-mindedness. Her bias is for what has evolved out of Freudian-based talking therapy, what I practiced in my first go-round with Gene, namely the therapist replacing bad parenting with good parenting, providing some insight and a lot of warmth and encouragement. In graduate school, once Diane had her “faith”—as is all too often the case with psychologists—she read opposing philosophies or techniques only to refute them.
“Somewhere out there is an answer, you know,” I said grumpily. “And if it can be found a lot of people’s lives will be better.”
She didn’t reply at first. I heard her bed sheets rustle. I could imagine her shifting to sit up, raising her navy blue blanket to cover her breasts. “She’s lovely,” Aunt Sadie commented to me after I introduced Diane. “She looks like your grandmother when she was young.” Sadie meant my mother’s mother. I was amused—and sufficiently appalled—to check an old black and white photo of Nana to reassure myself that the similarities were superficial. That Diane was a product of a long line of strong Jewish women was undeniable, however, and in that sense my feelings for her were incestuous. “I love that you’re tall,” she whispered one morning, legs drawn up, curled into a ball, cuddling against me as I stretched out to the limits of her bed. Had my mother once said the same words to Francisco? I pictured Diane: warm and trusting in my arms. Be careful, I thought, you don’t want to become a stranger to her intimacies. She sighed. “Look, Rafe, who are you kidding? You’ll be the last shrink on earth to say to your patients, ‘Take two Prozac and call me in the morning.’”
“Of course.”
There was another silence. She sipped something, probably coffee from the big white cup she had bought in Paris on our trip, to remind her of our room service breakfasts, especially their delicious, strong coffee.
“Can I say something?” she asked.
“Sure.”
“Your friend Joseph is jealous of you.”
I laughed—couldn’t stop myself in time.
“I’m serious,” she complained. “He’s not only jealous of you. He’s in love with you.”
I glanced at the clock. Although it was Saturday, we had a series of sessions scheduled, beginning in an hour and a half, with three children housed in temporary shelters. The family and juvenile courts had appointed us to evaluate them. The weekend, unfortunately, was the only time Diane and I could fit them
in. One was severely battered by a stepfather; another, a seven-year-old girl who had been raped and sodomized by her thirteen-year-old uncle; and the last was the abusive adolescent uncle, Albert, himself a victim in early childhood of his mother’s sadistic and incestuous behavior. (She would force Albert to perform cunnilingus and, after orgasm, burn him with cigarettes or whip him with an electric cord. Being subjected as a child to a combination of sex and violence, by the way, seems to be the background profile of serial killers. With Albert, especially, the implications of the kindling studies might be particularly meaningful.) Surely Diane understood that too much was at stake for me to care if Joseph’s motives were impure. Albert, the nascent serial killer, had been put on Ritalin for attention deficit disorder by the state hospital. The psychiatrist who ordered the medication had decided that a thirteen-year-old African-American, living in the South Bronx, who had never known a father, whose mother was a crack addict, who, from the age of five, had been used for sex and physically tortured by his mother, was suffering from a chemical imbalance rather than from his life. Ritalin is a much less specific drug than Prozac or other drugs Joseph was then developing. He had conceded publicly (as have most scientists) that, whatever Ritalin’s benefits to caretakers as a sedative for disruptive children, it is dangerous, both addictive and likely to cause brain damage if prescribed for long. Sure, it quiets upset children—it would quiet any child. Ritalin’s widespread use for the so-called illness of attention deficit disorder, or the even more specious “illness,” learning disorder, was my main concern in writing The Soft-Headed Animal, the book Joseph had never finished. My duty with this thirteen-year-old rapist—besides the legal question of his state of mind when he sodomized his niece—was to evaluate his care. Joseph’s arguments were not academic—to us or to our patients. He conceded that Ritalin was a poor choice; his point was that the severe trauma experienced by children altered their brain chemistry irrevocably and, no matter how skeptical I was, I couldn’t prove him wrong simply because no drug exists that truly helps.
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