by Robert Coles
The most moving, to me, happened in the waiting room during John’s surgery. From time to time a nurse from the operating room would come in to tell Carol what was happening. Carol, from politeness or bravery or both, always stood to receive the news, which always left us somewhat encouraged and somewhat doubtful. Carol’s difficulty was that she had to suffer the ordeal not only as a wife but as one who had been a trained nurse. She knew, from her own education and experience, in how limited a sense open-heart surgery could be said to be normal or routine.
Finally, toward the end of our wait, two nurses came in. The operation, they said, had been a success. They explained again what had been done. And then they said that after the completion of the bypasses, the surgeon had found it necessary to insert a “balloon pump” into the aorta to assist the heart. This possibility had never been mentioned, nobody was prepared for it, and Carol was sorely disappointed and upset. The two young women attempted to reassure her, mainly by repeating things they had already said. And then there was a long moment when they just looked at her. It was such a look as parents sometimes give to a sick or suffering child, when they themselves have begun to need the comfort they are trying to give.
And then one of the nurses said, “Do you need a hug?”
“Yes,” Carol said.
And the nurse gave her a hug.
Which brings us to a starting place.
Kay Redfield Jamison
from AN UNQUIET MIND
Psychiatrist Kay Jamison bravely writes of her own manic depression in a book that has been called “one of the best scientific autobiographies ever written.” In this excerpt, Jamison, listens as a speaker at a medical conference blandly offers an update on “structural brain abnormalities in bipolar illness.” The speaker also shows slides of the brain taken with the newest technologies. Jamison contemplates “the personal side of having manic-depressive illness” and “the professional role of studying and treating it.”
KAY REDFIELD JAMISON is the founder of UCLA’s Affective Disorder Clinic. She is the author of Night Fall Fast: Understanding Suicide and Touched with Fire: Manic Depressive Illness and the Artistic Temperament.
Sitting on one of the hard, uncomfortable chairs that are so characteristic of medical conferences, I was semi-oblivious to the world. My mind was on hold after having been lulled into a mild hypnotic state by the click, click, click of the changing of slides in a carousel. My eyes were open, but my brain was swaying gently in its hammock, tucked away in the far back reaches of my skull. It was dark and stuffy in the room, but beautiful and snowing outside. A group of my colleagues and I were in the Colorado Rockies, and anyone with any sense at all was skiing; yet there were more than a hundred doctors in the room, and the slides were going click, click, click. I caught myself thinking, for the hundredth time, that being crazy doesn’t necessarily mean being stupid, and what on earth was I doing indoors instead of being out on the slopes? Suddenly, my ears perked up. A flat, numbingly objective voice was mumbling something about giving an “update on structural brain abnormalities in bipolar illness.” My structurally abnormal brain came to attention, and a chill shot down my spine. The mumbling continued: “In the bipolar patients we have studied, there is a significantly increased number of small areas of focal signal hyperintensities [areas of increased water concentration] suggestive of abnormal tissue. These are what neurologists sometimes refer to as ‘unidentified bright objects,’ or UBOs.” The audience laughed appreciatively.
I, who could ill afford any more loss of brain tissue—God knows what little chunks of gray matter had crossed the River Styx after my nearly lethal lithium overdose—laughed with somewhat less than total enthusiasm. The speaker went on, “The medical significance of these UBOs is unclear, but we know that they are associated with other conditions, such as Alzheimer’s, multiple sclerosis, and multi-infarct dementias.” I was right; I should have gone skiing. Against my better judgment, I pointed my head in the direction of the screen. The slides were riveting, and, as always, I was captivated by the unbelievable detail of the structure of the brain that was revealed by the newest versions of MRI techniques. There is a beauty and an intuitive appeal to the brain-scanning methods, especially the high-resolution MRI pictures and the gorgeous multicolored scans from the PET studies. With PET, for example, a depressed brain will show up in cold, brain-inactive deep blues, dark purples, and hunter greens; the same brain when hypomanic, however, is lit up like a Christmas tree, with vivid patches of bright reds and yellows and oranges. Never has the color and structure of science so completely captured the cold inward deadness of depression or the vibrant, active engagement of mania.
There is a wonderful kind of excitement in modern neuroscience, a romantic, moon-walk sense of exploring and setting out for new frontiers. The science is elegant, the scientists dismayingly young, and the pace of discovery absolutely staggering. Like the molecular biologists, the brain-scanners are generally well aware of the extraordinary frontiers they are crossing, and it would take a mind that is on empty, or a heart made of stone, to be unmoved by their collective ventures and enthusiasms.
I was, in spite of myself, caught up by the science, wondering whether these hyperintensities were the cause or the effect of illness, whether they became more pronounced over time, where in the brain they localized, whether they were related to the problems in spatial orientation and facial recognition that I and many other manic-depressives experience, and whether children who were at risk for manic-depressive illness, because one or both of their parents had the disease, would show these brain abnormalities even before they became ill. The clinical side of my mind began to mull about the visual advantages of these and other imaging findings in convincing some of my more literary and skeptical patients that (a) there is a brain, (b) their moods are related to their brains, and (c) there may be specific brain-damaging effects of going off their medications. These speculations kept me distracted for a while, as changing gears from the personal side of having manic-depressive illness to the professional role of studying and treating it often does. But, invariably, the personal interest and concerns returned.
When I got back to Johns Hopkins, where I was now teaching, I buttonholed neurology colleagues and grilled my associates who were doing the MRI studies. I scurried off to the library to read up on what was known; it is, after all, one thing to believe intellectually that this disease is in your brain; it is quite another thing to actually see it. Even the titles of some of the articles were a bit ungluing: “Basal Ganglia Volumes and White Matter Hyperintensities in Patients with Bipolar Disorder,” “Structural Brain Abnormalities in Bipolar Affective Disorder: Ventricular Enlargement and Focal Signal Hyperintensities,” “Subcortical Abnormalities Detected in Bipolar Affective Disorders, Using Magnetic Resonance Imaging”; on and on they went. I sat down to read. One study found that “Of the 32 scans of the patients with bipolar disorder, 11 (34.4%) showed hyperintensities, while only one scan (3.2%) from the normal comparison group contained such abnormalities.”
After an inward snort about “normal comparison group,” I read on and found that, as usual in new fields of clinical medicine, there were far more questions than answers, and it was unclear what any of these findings really meant: they could be due to problems in measurement, they could be explained by dietary or treatment history, they could be due to something totally unrelated to manic-depressive illness; there could be any number of other explanations. The odds were very strong, however, that the UBOs meant something. In a strange way, though, after reading through a long series of studies, I ended up more reassured and less frightened. The very fact that the science was moving so quickly had a way of generating hope, and, if the changes in the brain structure did turn out to be meaningful, I was glad that first-class researchers were studying them. Without science, there would be no such hope. No hope at all.
And, whatever else, it certainly gave new meaning to the concept of losing one’s mind.
Robert
Coles
A YOUNG PSYCHIATRIST LOOKS AT HIS PROFESSION from The Mind’s Fate
In this essay, a young doctor in psychiatric and psychoanalytic training is looking at the profession he has just entered. First published in the Atlantic Monthly in 1961 when he was just beginning his psychiatry practice, Robert Coles wrote that those involved in psychiatry must strive to avoid “a death of the heart,” to avoid becoming numbed by the work they do; instead, they must keep their hearts alive, vitally engaged with and by those they treat.
ROBERT COLES’S most recent works include a literary anthology titled Growing Up Poor and Lives of Moral Leadership. This essay is taken from a collection of Coles’s essays titled The Mind’s Fate.
Recently, in the emergency ward of the Children’s Hospital in Boston, an eight-year-old girl walked in and asked to talk to a psychiatrist about her “worries.” I was called to the ward, and when we ended our conversation I was awake with sorrow and hope for this young girl, but also astonished at her coming. As a child psychiatrist, I was certainly accustomed to the troubled mother who brings her child to a hospital for any one of a wide variety of emotional problems. It was the child’s initiative in coming which surprised me. I recalled a story my wife had told me. She was teaching a ninth-grade English class, and they were starting to read the Sophoclean tragedy of Oedipus. A worldly thirteen-year-old asked the first question: “What is an Oedipus complex?” Somehow, in our time, psychiatrists have become the heirs of those who hear the worried and see the curious. I wondered, then, what other children in other times did with their troubles and how they talked of the Greeks. I wondered, too, about my own profession, its position and its problems, and about the answers we might have for ourselves as psychiatrists.
We appear in cartoons, on television serials, and in the movies. We are “applied” by Madison Avenue, and we “influence” writers. Acting techniques, even schools of painting are supposed to be derived from our insights, and Freud has become what Auden calls “a whole climate of opinion.” Since children respond so fully to what is most at hand in the adult world, there should have been no reason for my surprise in that emergency ward. But this quick acceptance of us by children and adults alike is ironic, tells us something about this world, and is dangerous.
The irony is that we no longer resemble the small band of outcasts upon whom epithets were hurled for years. One forgets today just how rebellious Freud and his contemporaries were. They studied archaelogy and mythology, were versed in the ancient languages, wrote well, and were a bit fiery, a bit eccentric, a bit troublesome, even for one another. Opinionated, determined, oblivious of easy welcome, they were fighters for their beliefs, and their ideas fought much of what the world then thought.
This is a different world. People today are frightened by the memory of concentration camps, by the possibility of atomic war, by the breakdown of old empires and old ways of living and believing. Each person shares the hopes and terrors peculiar to this age, not an age of reason or of enlightenment, but an age of fear and trembling. Every year brings problems undreamed of only a decade ago in New York or Vienna. Cultures change radically, values are different, even diseases change. For instance, cases of hysteria, so beautifully described by Freud, are rarely found today. A kind of innocence is lost; people now are less suggestible, less naive, more devious. They look for help from many sources, and chief among them, psychiatrists. Erich Fromm, in honor of Paul Tillich’s seventy-fifth birthday, remarked: “Modern man is lonely, frightened, and hardly capable of love. He wants to be close to his neighbor, and yet he is too unrelated and distant to be able to be close.... In search for closeness he craves knowledge; and in search for knowledge he finds psychology. Psychology becomes a substitute for love, for intimacy. . . .”
Now Freud and his knights are dead. Their long fight has won acclaim and increasing protection from a once reluctant society, and perhaps we should expect this ebb tide. Our very acclaim makes us more rigid and querulous. We are rent by rivalries, and early angers or stubborn idiosyncrasies have hardened into a variety of schools with conflicting ideas. We use proper names of early psychiatrists—Jung, Rank, Horney—to describe the slightest differences of emphasis or theory. The public is interested, but understandably confused. If it is any comfort to the public, so are psychiatrists, at times. Most of us can recall our moments of arrogance, only thinly disguised by words which daily become more like shibboleths, sound hollow, and are almost cant.
Ideas need the backing of institutions and firm social approval if they are to result in practical application. Yet I see pharisaic temples being built everywhere in psychiatry; pick up our journals and you will see meetings listed almost every week of the year and pages filled with the abstracts of papers presented at them. These demand precious time in attendance and reading, and such time is squandered all too readily these days. Who of us, even scanting sleep, can keep up with this monthly tidal wave of minute or repetitive studies? And who among us doesn’t smile or shrug, as he skims the pages, and suddenly leap with hunger at the lonely monograph that really says something? As psychiatrists we need to be in touch not only with our patients but with the entire range of human activity. We need time to see a play or read a poem, yet daily we sit tied to our chairs, listening and talking for hours on end. While this is surely a problem for all professions, it is particularly deadening for one which deals so intimately with people and which requires that its members themselves be alive and alert.
It seems to me that psychiatric institutions and societies too soon become bureaucracies, emphasizing form, detail and compliance. They also breed the idea that legislation or grants of money for expansion of laboratories and buildings will provide answers where true knowledge is lacking. Whereas we desperately need more money for facilities and training for treatment programs, there can be a vicious circle of more dollars for more specialized projects producing more articles about less and less, and it may be that some projects are contrived to attract money and expand institutions rather than to form any spontaneous intellectual drive. We argue longer and harder about incidentals, such as whether our patients should sit up or lie down; whether we should accept or reject their gifts or answer their letters; how our offices should be decorated; or how we should talk to patients when they arrive or leave. We debate for hours about the difference between psychoanalysis and psychotherapy ; about the advantages of seeing a person twice a week or three times a week; about whether we should give medications to people, and if so, in what way. For the plain fact is that, as we draw near the bureaucratic and the institutionalized, we draw near quibbling. Maybe it is too late, and much of this cannot be stopped. But it may be pleasantly nostalgic, if not instructive, to recall Darwin sailing on the Beagle, or Freud writing spirited letters of discovery to a close friend, or Sir Alexander Fleming stumbling upon a model of penicillin in his laboratory—all in so simple and creative a fashion, and all with so little red tape and money.
If some of psychiatry’s problems come from its position in the kind of society we have, other troubles are rooted in the very nature of our job. We labor with people who have troubled thoughts and feelings, who go awry in bed or in the office or with friends. Though we talk a great deal about our scientific interests, man’s thoughts and feelings cannot be as easily understood or manipulated as atoms. The brain is where we think and receive impressions of the world, and it is in some ultimate sense an aggregate of atoms and molecules. In time we will know more about how to control and transform all cellular life, and at some point the cells of the brain will be known in all their intricate functions. What we now call “ego” or “unconscious” will be understood in terms of cellular action or biochemical and biophysical activity. The logic of the nature of all matter predicts that someday we will be able to arrange and rearrange ideas and feelings. Among the greatest mysteries before us are the unmarked pathways running from the peripheral nervous system to the thinking areas in the brain. The future is even now heralded by machin
es which think and by drugs which stimulate emotional states or affect specific moods, like depressions. Until these roads are thoroughly surveyed and the brain is completely understood, psychiatry will be as pragmatic or empirical as medicine.
Social scientists have taught us a great deal about how men think and how they get along with one another and develop from infancy to full age. We have learned ways of reaching people with certain problems and can offer much help to some of them. Often we can understand illnesses that we cannot so readily treat. With medicines, we can soften the lacerations of nervousness and fear, producing no solutions, but affording some peace and allowing the mind to seek further aid. Some hospitals now offer carefully planned communities where new friendships can arise, refuges where the unhappy receive individual medical and psychiatric attention. Clinics, though harried by small staffs and increasing requests, offer daily help for a variety of mental illnesses. Children come to centers devoted to the study and treatment of early emotional difficulties. If the etiologies are still elusive, the results of treatment are often considerable. Failures are glaring, but the thousands of desperate people who are helped are sometimes overlooked because of their very recovery. Indeed, it is possible that our present problems may give way to worse ones as we get to know more. The enormous difficulties of finding out about the neurophysiology of emotional life may ultimately yield to the Orwellian dilemma of a society in which physicists of the mind can change thoughts and control feelings at their will.