Meds vs. “The Talking Cure”

Not that it’s a simple opposition.  Most good practitioners today believe that meds have an important supportive role to play in enabling people to make use of psychoanalysis (PSYA)/psychotherapy (PSYT).   But do check this out:

http://nsnbc.me/2015/06/19/shocking-report-from-medical-insiders/

It’s always good to remember that while the sciences have excellent protocols for generating, handling and interpreting evidence, they have no more purchase on absolute truth than any of our other ways of making knowledge.  This point does not undercut the value of science.  It simply posits the truths science creates not as revelations but as crafted knowledge, the results of many experiments, hard thought, argument, discussion, testing, logic, intuition, quantification, qualification–and its effectiveness can be seen all around us.  To say it is fallible is simply to make a practical point that every scientist worth his or her salt ought to agree with.  Exception should perhaps be made for he physical “laws” of the universe; “irreversibility,” for example, appears to be non-negotiable.  But I think it is still fair to recognize the creaturely factors in how we study and interpret those laws.   This is not a post-structuralist attack on science.  Instead, it honors our amazing achievements in the treatment of mental/physical health.

But I am not a big fan of the notion that the sciences have a special “epistemological privilege” over all other ways of understanding phenomena.  They have particular excellent ways of approaching knowledge, not particularly excellent ways.  The more we learn about the brain, the more stunning its conscious and unconscious capacities for the generation and interpretation of meaning, improvisation, real-time responsiveness to environmental factors, pattern-creation and adaptation, and intersubjective learning appear to be,  These are capacities that benefit enormously from training and experience, and as I have argued elsewhere, they are capacities brilliantly aided by training in the arts and humanities, and they are also capacities brilliantly aided by PSYA/PSYT.  Meds affect brain chemistry in potentially helpful ways, but (so far as I know) there is little evidence that they remake the neuronal networks of associations among memories (episodic and procedural), sense-perceptions, and abstract symbolic activities that make us who we are.  These “associational pathways” are in fact the result of lifelong (and beyond) co-creative interactions between our psycho-bio-social beginnings and the environments and histories that have been in constant interaction with them.  We are glorious complexities, and should use medication only when there is little chance we can grow well without their (temporary) assistance.  They are never, for the reasons just cited, substitutes for the work and play of (inter)subjective development, nor have they been created by infallible minds and procedures.  Inform yourself about any psychotropic medications you take, but take this process seriously; consult with your psychiatrist, read studies published by the most stringent and prestigious journals, find out who funded the research in question.  Don’t fly off the handle because “the latest study” says this or that is okay or not okay. This takes work, but please; what’s more important than your (extended) mind/body, not just for you, but for the well-being of all?

Bad Feelings

I haven’t read this book yet–http://www.huffingtonpost.com/2014/11/11/why-negative-emotions-good_n_6107708.html?cps=gravity–but it makes a point that’s fundamental to psychoanalytic process:  the capacity to tolerate bad feelings is lifesaving and even vivifying.  Knowing that feelings are signals and therefore highly mediated responses to reality (inner and outer) helps us keep perspective on them while we are feeling them.  That means that we are thinking while feeling, and thus enabling connections to be made between those brain functions that create our awareness of time and help us make decisions and those much older ones that produce affects and emotions.  I strongly disagree with efforts to avoid or discourage discussion of a patient’s traumatic experience because (in this superficial way of thinking) the patient might be “re-traumatized.”  What is true is that no therapist should push a potentially sensitive topic on any patient.  The point of psychoanalysis is to enable patients to take the time they need to broach such topics themselves.  Readying patients for intense emotional experiences, not forcing them, is the nature of our work.  (In this respect, not a classical Kleinian!)  In this, psychoanalysis certainly finds itself at odds with both the cultivation of melancholy and the (particularly Californian) command that we be happy.  Neither contributes to the brain/mind’s strength, courage, or curiosity.  Neither helps us discriminate between old bad feelings that have been triggered by current events, on the one hand, and emotional guidance about our current situation on the other.  In the former case, there’s good reason to pay attention to the links between past and present–that much tells us something, for sure–but not necessarily good reason to let those feelings overwhelm you or “become” your experience.  In the latter case, paying attention to, which means letting yourself feel, bad feelings might be the only thing that can really help you make a change you need to make.  Nor can we feel what others feel, as Shakespeare would put it, if we can’t feel our own feelings.  Emptiness is not an improvement over rage or crushing disappointment, even though, when we are helpless infants, it can sometimes be our only way of defending against madness.  Point being that once our brains have done some growing up, we are much less helpless than we were as babies, so we can think, and act, anticipate and repair, reach out or stay home.  Unless, of course, we are still ruled by fear of our own feelings.

Unlearning

I recently gave a talk at a wonderful conference on “Pedagogies of Unlearning” (see link) and was impressed once again by the similarities between educational and psychoanalytic theory. Unlearning, for those unfamiliar with the term, has a few different meanings, but in a nutshell, it means we have to change our minds, unlearn old things, resist feeling that we’ve already learned what we need to learn; and if we are teachers, we need to figure out how to unsettle or even eschew “explanation.”  The convergence was modeled by, among others, Deborah Britzman’s talk on writer’s block (see link), which raised the question of the temporality of the assignment (whether one given to ourselves or by others), and why we so readily feel that we don’t have enough time to write (well)–for that matter, why we ensure we don’t have enough time, by procrastinating, which is part of the writing process for so many of us, not necessarily simply an obstacle to it.  Britzman’s talk set me to thinking about insurance companies’ insistence on treatment plans and short-term or once-a-month psychotherapy, which is perhaps analogous to the so-called “student success” movement’s emphasis on “progress to the degree,” i.e. getting rid of students who want or need to take their time, and getting rid of programs that don’t contribute in any obvious way to zeroing in on the degree per se.  The student success movement, in essence, opposes what is known as “enrichment” as a needed component of education, e.g. courses in English for new immigrants, painting classes for the elderly, art and music appreciation classes, and much much more.  (I discuss this in “Duologue” in connection with recent efforts to take accreditation away from the City College of San Francisco.)  I believe one of the most important arguments for psychoanalysis as a technique is precisely that it gives the patient time.  This is partly because time is precisely what trauma sufferers didn’t get; by definition, trauma means that you haven’t had time to prepare, so you’re overwhelmed.  To not be hurried along is vital to un/learning, because we get attached to ideas, which makes them hard to give up; mourning takes time.  So does working through other kinds of attachments (to old expectations about relationships, for example).  Relentless speed-up, of course, makes this difficult, and I think it’s responsible for a lot of the psychological malaise in and around us; we’re rarely allowed to “stay” anywhere for awhile to explore where we are, so trauma is always in the air, or just around the corner.  So, in contrast to conventional wisdom, I want to say to my students as well as to my patients:  take your time.  Take your time.  Take your time.

For Us All: A Love Letter to Our Students On the Occasion of the Isla Vista Shootings, May 2014

UCSB is a research university. That means faculty are engaged in scholarly and scientific pursuits they feel passionately about, whether they are contributing to research on aging, or trying to understand why the arts have been so valuable to our species as to have been, forever, our companions. These preoccupations often seem to take priority over teaching and getting to know our students. We teach a lot of large lecture classes. We dream about sabbaticals. But UCSB promotes undergraduate research as a way of involving undergraduates directly in that part of our mission, and we also teach (and wish we could teach more) small seminars, and we work with our undergraduates in labs, through internships or research assistanceships, on senior theses, in campus activism, on committees. We don’t always know our students’ names, but even if we don’t, we know our students’ faces. You keep us thinking about what matters, about what we need to learn, and what kind of knowledge we need to make, for the future. You keep us young. We hope we give you things too—a feeling for what a body of knowledge is, and can do; ways of thinking, making and doing that change your brains and minds forever, so that all we’ve learned in the past can be part of what you will take into the future we won’t otherwise be able to share with you. Our minds and our hearts are so much more entwined than we realize.

What the faculty have learned in the aftermath of the Isla Vista shootings is how much we love our students. Perhaps love isn’t the right word for the bonds that link people who think, learn, and work together, who share interests, even fascinations. We need a richer lexicon to describe these relationships. But we will use the word because it expresses something of the intensity of our concern, regard and gratitude for you.

We love you. You are part of us, and we are part of you. We know learning is difficult and that you manage a lot of boredom and anxiety every day. We know we don’t always connect well with you, as people or as experts in our fields. But when news of the shootings spread, we were desperate to know whether or not you were okay. We emailed you, telephoned you, scanned news sources, hoping you would not be among the dead and injured, feeling dreadful because we knew somebody had to be among the dead and injured, someone who was smart and hopeful, someone who was important. We’ve been so relieved to hear from you, so worried when we haven’t. I didn’t hear back from Chris Martinez, a student in my Honors Seminar, because he was killed by Elliot Rodger.  I’m heartbroken.  We’ve all been overtaken by our feelings. But we are glad to know, and want both the living and the dead to know, how much you mean to us.

Research on social connectivity is growing more brilliant every day. There is still much we don’t know about how feelings and ideas become, or always already are, communal phenomena. But we know that feelings and ideas are transpersonal. And so we know, partly because we are part of a knowledge-making community, how really true it is that we are all affected by the shootings, how much we have reached out to each other, and how long it will be before we can enjoy again the shockingly good fortune of being alive. We are just so terribly sorry for those who had to leave us before they were ready.  Chris, we don’t want to say goodbye to such a brilliant and kind young man.  I can’t, yet.

Please be well. If we can help, tell us, and we will tell you. If you need peace and quiet, we will be respectful. If you want to cry, we will cry with you. We will protest the unfairness of life right alongside of you. Please be well. Remember that we love you.

For My Students

The title of my last blog post horrifies me today, as I contemplate the shootings and injuries of so many UC Santa Barbara students last night in Isla Vista, CA.  Still I ask my students and my university to face this nightmare rather than soften or obscure it.  Isla Vista needs our attention.  It has been preyed upon by slumlords for decades, and now has one of the highest population concentrations in the world.  That population consists largely of exploited, neglected students abandoned to the tender mercies of “market forces,” and even more exploited and neglected Mexican-American families, many of them recent immigrants, all “living” anywhere from 3-5+ people to a single bedroom.  For that matter, it’s not hard to find 4 or more people renting one leaky garage, or people living in closets and paying hundreds of dollars a month for the privilege.  The violence of the recent police response to the vast party known as Deltopia suggests that the situation in IV has been misdiagnosed, and for a long time.  Our students need to feel that the larger community cares about their welfare.  They have been stranded in Santa Barbara’s out-of-control housing market, with very few beds available in UCSB dormitories, at the mercy of vendors selling the worst possible crazy-making food, with more liquor stores than salad bars. It is, in short, a ghetto.  And people nobody cares about tend not to care about other people.  The older families living in IV are beleaguered by and suffer from open conflict with the party houses that are taking over.  No one is helping them either.  I hope the community will treat IV not as an unruly world in need of crackdown but as an unruly world in need of the kind of attention that encourages a return of respect and concern.  Sheriff Bill Brown has made clear to the press that he regards this (so far) as the work of a “madman,” and he is right in a way.  But Elliot Rodgers, who appears to have been the murderer, was a young man in very deep trouble.  Probably nothing and no one could have stopped this violent acting-out against women–Rodgers posted a video on YouTube (now removed) that excoriated women, especially sorority girls, for refusing his sexual advances, and vowed to avenge himself, and then killed six people (we don’t yet know how many were women) and critically injured seven more.  But how different is he from the frat boys who put date-rape drugs in women’s drinks and then violate them sexually?  Not as much as said frat boys and their parents and the society that nearly always lets them off the hook would like to think.  But everytime a symptom “breaks out” in Isla Vista, there are flurries and posturings, and then once again nothing is done to address the context that imperils the lives of young women, and sometimes young men, thus perpetuating the cycle of carelessness and dehumanization.  What Isla Vista needs is serious rent control, housing codes, and enforcement thereof.  It needs medical and mental health clinics. It needs a town government.  It needs a little care.  

Triggers

http://www.nytimes.com/2014/05/18/us/warning-the-literary-canon-could-make-students-squirm.html?emc=eta1

As concerned as I am for student mental health, I have to part company with those who are asking for warnings on syllabi and the like about potentially triggering classroom material. My chief objection to this kind of labeling is as follows: we don’t do justice to the phenomena of suicide, depression, war, trauma, by referring to them as “course material.” They are everywhere. They are the tragedy of our time and of all times. They are happening to you and to me and those we love and those we don’t know but still care about. They affect and shape all of our ways of producing knowledge, not just literary or film studies, but history (whose stories get told, and by whom?), economics (are we driven by rational interests or passion?), statistics (counting the dead in World War I), chemistry (Big Pharm), psychology (the American Psychology Association’s refusal to condemn torture), physics (the Bomb). Some disciplines are good at generating the appearance of neutrality and dispassion; others are more candid. But, as Michel de Certeau put it, each knowledge discipline is subject both to the “law of the science” and to the “law of the group.” Even this distinction is too clear-cut, since scientific practice is itself heavily determined by the law of the group; scientists used to resist multiculturalism, fearing it was an attack on “universals”; now comparative research helps us make many more fine, and important, distinctions (cultural differences in how caregivers address infants, for example) than we once could. In my understanding of psychoanalysis, we need, above all, to be aware of our “badness” so that we can learn to bear the almost-inevitable concomitant of unbearably bad feelings, so we can free ourselves as much as possible from Blake’s “mind-forged manacles.” We do not have a problem with course material. We–I–have a problem with a world that turns a blind eye to cruelty.

The War Against Veterans

http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=113&session=2&vote=00046

The above link indicates that in a recent vote, U.S. Republican Senators voted overwhelmingly against improving health benefits for veterans, and U.S. Democratic Senators overwhelmingly in favor. I wish this made me feel better about the Democratic Party’s commitment to the people’s health, mental and otherwise. But it certainly makes me feel even less hopeful about the Republican Party’s approach to healthcare. It is stunning, is it not?, how many southern and western states benefit financially from hosting large U.S. military installations, but don’t think they should invest in the well-being of the soldiers who live and work there

The message sent by such political gestures is a shaming one: if you can’t afford the (preposterously expensive) private medical care available in the U.S., then you deserve neither health nor life. In other words, the decisions this country makes about healthcare don’t simply neglect or aggravate our difficulties, they compound them psychologically.

As an educator, I try to communicate to my students that their minds matter. In a different way, I try to communicate the same feeling to the people who see me for psychotherapy/psychoanalysis. Since minds are embodied–the feedback loops between minds and bodies are innumerable, complexly organized and highly active–our bodies matter too. But the forces deciding our healthcare, while masquerading as considerations of scientific and statistical fact against speculation and sentimentality, have no regard whatsoever for the knowledge being produced today about the nervous system and its many needs for things that (according to the Gradgrinds of today) are neither “necessary” nor even obviously “useful.” (See my book STAYING ALIVE, which argues for the interdependence of thriving and surviving). After complexity theory, there is no such thing as a drop in the bucket, because there are no more buckets; we can never know what kinds of effects our actions will have–all we know is that they are likely to have multiple unforeseen reverberating effects throughout many different networks of force, power, and desire. So, despite the hopelessly naive (from a political standpoint) nature of the following suggestion, I suggest it nonetheless: we all have to do everything we can to believe in the importance of every creature’s life, because our assumptions about what does and does not affect us have been put all in doubt. Hierarchies of value are no longer supportable in the era of causal parity and strange attraction from a distance. That is to say: love where you can love, and where you can’t love, respect.

Urgent Urgent

Not long ago I attended a talk given by a local mental health information group on how to identify the onset of mental illness in transitional age youth. The talk was interesting, but I was a bit upset by the speaker’s statement that because, statistically, girls and young women talk more about wanting to kill themselves than do boys, one needn’t be too concerned about their statements–suicide is probably not imminent. But if you have a boy, and they have a suicide plan, you should take that very very seriously, and act immediately.

Every time this observation was reiterated I reacted almost physically. I think this is the difficulty with quantitative assessments. Why would we want to gamble with respect to the life of a young woman? Cost-efficiency? Suppose the young woman in question happens to be the statistical anomaly? Those of us trained in psychoanalysis, I think, are more likely to focus on the individual–not without reference to cultural, social, environmental factors, but with reference to how those factors converge idiosyncratically in the life of a particular human being, and with the ethical understanding that all life is precious.

I’m wondering how people who are both psychoanalysts and psychiatrists would respond to this issue.