I did not intend for my next blog to start with a poem. I had a plan of sorts-- a general direction of where to head next—and then I heard this poem and that shifted. Kind of how life tends to work, isn’t it? When plans change we get to choose whether we move with the flow or get stuck in the ruts and ditches of a forced agenda and failed expectations.

                        MAGDALENE–THE SEVEN DEVILS by Marie Howe

“Mary, called Magdalene, from whom seven devils had been cast out” —Luke 8:2.

The first was that I was very busy.
The second — I was different from you: whatever happened to you could not happen to me, not like that.

The third — I worried.
The fourth – envy, disguised as compassion.
The fifth was that I refused to consider the quality of life of the aphid,
The aphid disgusted me. But I couldn’t stop thinking about it.
The mosquito too – its face. And the ant – its bifurcated body.

Ok the first was that I was so busy.
The second that I might make the wrong choice,
because I had decided to take that plane that day,
that flight, before noon, so as to arrive early
and, I shouldn’t have wanted that.
The third was that if I walked past the certain place on the street
the house would blow up.
The fourth was that I was made of guts and blood with a thin layer of skin
lightly thrown over the whole thing.

The fifth was that the dead seemed more alive to me than the living

The sixth — if I touched my right arm I had to touch my left arm, and if I touched the left arm a little harder than I’d first touched the right then I had to retouch the left and then touch the right again so it would be even.

The seventh — I knew I was breathing the expelled breath of everything that was alive and I couldn’t stand it,

I wanted a sieve, a mask, a, I hate this word – cheesecloth –
to breath through that would trap it — whatever was inside everyone else that
entered me when I breathed in

No. That was the first one.

The second was that I was so busy. I had no time. How had this happened? How had our lives gotten like this?

The third was that I couldn’t eat food if I really saw it – distinct, separate from me in a bowl or on a plate.

Ok. The first was that I could never get to the end of the list.

The second was that the laundry was never finally done.

The third was that no one knew me, although they thought they did.
And that if people thought of me as little as I thought of them then what was
love?

Someone using you as a co-ordinate to situate himself on earth.

The fourth was I didn’t belong to anyone. I wouldn’t allow myself to belong
to anyone.

Historians would assume my sin was sexual.

The fifth was that I knew none of us could ever know what we didn’t know.

The sixth was that I projected onto others what I myself was feeling.

The seventh was the way my mother looked when she was dying.
The sound she made — the gurgling sound — so loud we had to speak louder to hear each other over it.

And that I couldn’t stop hearing it–years later –
grocery shopping, crossing the street –

No, not the sound – it was her body’s hunger
finally evident.–what our mother had hidden all her life.

For months I dreamt of knucklebones and roots,
the slabs of sidewalk pushed up like crooked teeth by what grew underneath.

The underneath —that was the first devil. It was always with me.
And that I didn’t think you— if I told you – would understand any of this -

* Published in the July/August 2011 issue of the American Poetry Review (Vol. 40 Issue 4, p48)


So I was walking and listening to Marie Howe read this poem during her interview with Krista Tippett on the podcast On Being  (to fully appreciate it really must hear her read it in her voice!). I wept. I passed neighbors and still I wept. I wept for this woman hiding the “underneath” so others could not see. There was no word or phrase in particular that held me. It was the experience of the poem. My brain heard the words but my body felt them. It was like awakening from a dream-- already having forgotten the plot and details, yet the experience lingers, and with it the faint awareness of an important remnant distantly remembered.

It occurred to me that poetry is a form of mindfulness, a meditation that causes us to pause and notice and remember what we have forgotten in the busyness of day to day life. This is not a new thought, just one I’d forgotten!

Then I started thinking. I thought about this woman in the poem, who would, in my profession, be simply labeled Obsessive Compulsive and started on an antidepressant, or, perhaps, also labeled with attention deficit disorder and started on a stimulant, so she could focus better and make it through her list more efficiently – her insight, creativity and idiosyncrasies lost.

I thought about what these symptoms of OCD or ADHD, or any other label, mean-- really. What I believe it means is that she—like us-- is all too human. That she copes with her emotions and her fear of the “underneath” by trying to control simple mundane things. That her busy worried brain goes back and back over her lists, and each time gets lost in her own stories of the pains and losses in her life, and the more often she does this the more deeply that pattern becomes ingrained in her brain, like the rut in an old record player.  It is these pains and losses and her stories that connect her to me – to all of us. Yes, that is the beauty of a magnificent poet and poem, but it is also the gift of emotions and even suffering. They allow us to connect. They allow us to look at another and see ourselves--if we allow ourselves that vulnerability.

We lose this connection when instead of sharing emotions as a ubiquitous human bond, we pathologize emotions. Now I become different from you. I feel abnormal because I do not know that you share the same pain and so I keep mine buried inside so you cannot know:

                               “ — I was different from you: whatever happened to you
                                              could not happen to me, not like that.”

These labels serve to separate us, to cast others apart as broken and unfixable -- not wanting to see that we too share fragments of these broken pieces. With suffering we have a choice –we can open our hearts or build concrete bunkers. I know I have done both, and I would imagine, if you are honest, you have too. Building these walls and numbing our emotions, whether it is with food, alcohol, sex, drugs, relationships, work, medications, or whatever we prefer—these lessen the possibility of healing and transformation.

Emotions are not like a cut that can be covered with a band-aid until healed. They must be aired and acknowledged. The work, ultimately, is not to build higher walls or find larger band-aids, but to slowly, carefully, gently break down the walls and unpeel the band aid, with the support of others who have been down the same path. In the poem, Mary did this by expressing her most feared thoughts to others despite her reluctance to do so. She spoke her truth and exposed her vulnerabilities. Warning: This path requires courage and persistence, but it leads to true healing.

So how do we do this? There are many ways, but all begin with the intention to do so. One place I like to start is with mindfulness of the breath and the body. It is a powerful, well researched tool with no known side effects, but the repeatedly demonstrated ability to rewire the brain and create healthier, more functional grooves in the vinyl synapses there.

I like to use Dr. Daniel Siegel’s hand model of the brain to explain how mindfulness can change the structure and function of the brain, rewiring the deep grooves that no longer serve us. If you fold your four fingers over your thumb you will have created a simplistic model of the brain. Imagine the forearm as the spinal cord coming up to meet the base of the hand at the wrist. This is the primitive, reptilian part of the brain—the brainstem. It is the regulator. It maintains the heart rate and respiration. It also is responsible for mobilizing a response to threats.

The thumb in the middle of the hand is the limbic system where our emotions and memory are centered. This system acts as a security guard, constantly scanning the environment looking for anything that could possibly go wrong based on sensory data from past experiences. Anything that is perceived as a threat leads to a “Code Red” alerting the brainstem and body of danger.  Cortisol and thousands of other neurochemicals are released through the body warning each and every part of a possible threat.

This is a very useful system evolutionarily. If we found ourselves face to face with a tiger we would quickly respond by running like hell, fighting or freezing and hoping we might yet go unnoticed. But in the modern world this poor guy is way overworked and stressed out. He has to filter non-stop data from our phones, TV, computers and environment, on top of the data spewing in from our body, emotions, thoughts and behaviors at any given moment. He does the best he can, but without some awareness and mindfulness, this system becomes overloaded and hypervigilant under the best of circumstances, and if you have a history of trauma, this system is even more hyperalert and hyperactive.

When this part of the brain is under Red Alert, the pre-frontal lobe in the cortex,  the top part of the hand folding over the thumb, essentially gets turned off. When there is a threat it is not the time to start analyzing the situation – oh, my gosh a bus is heading right at me…what should I do? freeze? move backwards? forwards? moving forward makes sense but what if the driver speeds up? …I might not have enough time to get across… so maybe if I moved back.. but then I could hit by the car behind it?...maybe I should just stand still and hope it goes around me…

While you are busy deliberating, as the pre-frontal lobe loves to do, you are  likely to be smashed by the bus. To avoid this the  “evolved” cortex takes a back seat to the security guard, which is great if we actually are in the path of oncoming bus, but not so great if we are merely obsessing over a text from a friend about whether the emoticon was meant to be taken seriously or sarcastically, and suddenly wondering if she is mad at you and what you might have done wrong and if maybe she misread your text from yesterday and so on and so on and so on over what turns out to be absolutely nothing.

When we get caught in catastrophizing thoughts like these our body responds as if there is a threat even if it is only in our heads. If you are unaware of how often your brain loops through negative thoughts about all the things that might happen but likely never will, or things that already happened, that you wished you’d done differently, take a few minutes to try and be quiet and just breathe and see how often you get interrupted. Notice what the thoughts are that are doing the interrupting. There is a good chance that most of thoughts are not great insights of profound value but repetitive loops – much like Mary’s in the poem, although almost certainly less “poetic”!  

If we do not learn techniques to rewire and balance this ancient protective system we are at its mercy. Fortunately, mindfulness can help us do this – whether it is the form of reflective yoga, qi qong, tai chi, seated meditation, standing meditation, or even mindfully writing a poem. The techniques serve as tools to literally rewire and balance the brain so it is less rigid and reactive and more flexible and reflective. Ideally these tools are not just practiced for a set period of time during the day or week, but incorporated into everyday life – washing the dishes, driving in traffic, waiting in line and the countless other moments we often spend just trying to get something done as quickly as possible so we can move on to something else.

There is a wealth of fascinating research for another blog, but studies have shown that meditating thirty minutes a day for eight weeks causes the brain to rewire significantly enough that the changes can be seen on a MRI scan. The security guard part of the brain becomes less active, and there is greater balance between the limbic system and the frontal lobe. We retain the ability to react to urgent threats, but are able to return to equilibrium once it has passed. We develop an increased capacity to recognize the daily threats that only exist in our minds-- and shift our focus back to the present.  It allows us to reassert some control over our lives and our emotions, so we do not get stuck in the ditch when life does not move according to plan or get trapped by our fears and expectations.

When we are less reactive and less at the whim of our security system then we can feel safe enough to stop building such thick high walls around ourselves and others. It allows us to connect rather than disconnect. It allows us to be present rather than numb. It allows us to actually notice our lives as we are living them with greater equanimity. It allows us to be less fearful of acknowledging our “underneath” for fear of not being understood:

                              “The underneath —that was the first devil. It was always with me.
                               And that I didn’t think you— if I told you – would understand any of this –“

I hope you understand.

 

 

  Sources:

Psychiatry Research: Neuroimaging Volume 191, Issue 1, Pages 36–43, January 30, 2011  “Mindfulness practice leads to increases in regional brain gray matter density"

http://www.psyn-journal.com/article/S0925-4927%2810%2900288-X/abstract

Marie Howe reads Magdelene and the Seven Devils on podcast, On Being:

http://www.onbeing.org/program/feature/magdelene-the-seven-devils-by-marie-howe/5336

 

“And what do you do? “

It is such a simple question but a difficult one to answer. The simple answer, “I am a psychiatrist,” leaves me feeling defensive and, unfortunately, ashamed. I am used to the awkward laugh. Pause. And then some version of, “Gosh, I should come see you,” or even more often, “My wife (or some other significant other –fill in the blank) should make an appointment.” Wink. Wink. Ha. Ha. (Note: this is rarely stated if the Other is standing right there, but if She is, the laughter is louder to make it clear it is a joke—REALLY, I swear!)

That is not the problem – for me anyways. My defensiveness and shame arise because I feel the need to make clear that I am not one of THOSE psychiatrists-- the ones who meet with you for 15 to 30 minutes, label you with one of the ever expanding list of pathologies defined by checklists in the psychiatric “bible”, the DSM-V, then simply hand over a prescription, sometimes two, as casually as handing over a Pez candy out of a Mickey Mouse dispenser. In fact, a growing body of research contends that giving you a Pez, with the assurance that this will work for you, is likely to work just as well as the actual antidepressant you will be given, minus the potential short and long term side effects of a “real” pill.

Few psychiatrists have read these articles, even though they have been published in top journals like the New England Journal of Medicine. They are not to blame, as I assure you, these articles are not exactly part of required reading in psychiatry residencies—at least not in mine! Psychiatrists are, after all, no different than anyone we may treat, in that we are apt to avoid the unfamiliar and those things that do not fit into our already established dogma of beliefs. Although we may be quick to spot this tendency in others, we may be less likely to see it in ourselves!

Many of the “dysfunctions” you may be diagnosed with used to be considered “normal”, like, say, grieving for the loss of a spouse or a child for more than a couple weeks; or feeling anxious when trying to meet too many needs at work and at home with no time to oneself; or being diagnosed with cancer and feeling overwhelmed; or being angry and not able to focus on your work at school when your dad has been deployed to some war torn country; or just a whole host of other normal responses to life’s losses and challenges.

The psychiatric community and their friends, the pharmaceutical industry, have conveniently determined, however, that we humans should not have to suffer with emotions like grief or anxiety, and that despite living in a world constantly vying for our attention 24 hours a day with cable TV updates on every bad thing happening everywhere in the world, and Facebook and Twitter feeds on everything happening to everyone you know, that somehow we should be able to focus and concentrate at all times or take a pill so that we can do so more easily.

(In fact, your psychiatrist may be prescribed a pill if you had a difficult time focusing on that last very long sentence!)

So with your newly acquired diagnosis, you will be sent on your way with your script and a plan to follow up in a month to see if that pill has “solved” the presenting problem.  At the next visit you will be evaluated for how you are doing. If you are “better” it will be assumed it was because of the medication, or medications, bestowed upon you with great authority. If you happen to be worse it will be assumed it is because you need a higher dose or an additional medication-- often to contend with the side effects of the first-- or perhaps you didn’t take it correctly or “compliantly” enough, and sometimes because, well, why not? Two Pez of different flavors must be better than one, right?

Actually, not. Despite all the talk about evidence based medicine, research has consistently found that two antidepressants do not confer benefits over one, but do significantly increase the risk of side effects. Yet most psychiatrists continue to hand out multiple medications because with only 15 minutes to assess you there’s not much time to explore WHY you might be having these symptoms. It is easier to write if off to a “chemical imbalance.” Seeking the CAUSE for the imbalance and exploring what in this person’s life may need balancing requires more time and attention.

Although there is ample evidence of frequent side effects from medications, it is rarely assumed that someone might be doing worse BECAUSE of the medication. A recent study revealed that over 900,000 emergency department visits a year are secondary to receiving a psychiatric or sleep medication. The conclusion to this study was that this is a small number of people given the 28.5 million people on psychiatric medications, although there was an acknowledgment that this is a gross underestimation as most people suffering from side effects never visit the emergency department.

In fact it is those people who do not visit the emergency department that often appear in my office because they have heard I am a “holistic psychiatrist.”  “A what?” you may ask with a puzzled look. It is that response that causes me to pause before using that phrase to answer the question of what I do for a living. This answer usually requires a longer explanation.

I explain that I most often use my prescriptive powers to help people get off their medications. People seek me out because they either don’t want to be started on medications, and intuitively realize there might be other healthier solutions to their depression and/ or anxiety besides taking a pill; or they were recently started on medications and whenever they attempt to explain to their physician that the medications are making them feel worse, they simply get written off as being anxious and started on a medication for their anxiety; or they have been on medications for decades and nothing has ever worked and they have given up hope in finding a cure in a pill.

Regardless of which particular reason they arrive, my approach is pretty much the same. I am not particularly interested in which diagnostic code I can check off and match with a medication. I am interested in their life, their story, the whole person sitting in front of me --with no computer between us. Of course, I want to know about their  symptoms and their particular flavor and experience of depression or anxiety or psychosis or mania with which they present, but more importantly I want to know about what was going on in their life when the symptoms began, what effect those symptoms had on their life then and since; what fears they now carry about any of those symptoms reappearing; what they believe about their “illness” and what is says about them; what their family believes about the illness and what it says about them. I want to know what they find meaningful in their lives, what they believe in spiritually, what sort of balance they have in their life between work and play. I want to know what they do to relax.  I want to know about their relationships and the support they receive or don’t receive. I want to know what they eat, what they do for exercise, what they do for play, what brings them joy. I want to know about their emotional life – what they are allowed and willing to express and how they do that, and what emotions are kept silent and buried, stewing beneath the surface.

These aren’t unique questions. They are the questions psychiatrists always used to ask before their jobs got reduced to 15 minute medication checks. In fact, these are questions I was trained to ask as a resident, but then was not given enough time to ask when I became an attending at the same hospital system. As an employee getting enough RVUs -- which means seeing more people for less amounts of time so the hospital can make more money-- was and is considered more important than taking time to listen and be present with patients in order to facilitate healing. Time, listening and presence are at the core of all healing modalities, but they don’t earn revenue.

So after gathering this information, I attempt to weave the narrative of their lives together with the latest research on the amazing neuroplasticity of the brain, and how we all have the capacity to rewire our brains to better focus and concentrate and manage stress and emotions using tools like meditation, breathing, biofeedback, guided imagery, hypnotherapy and others. Mind you, these are not tools I learned in medical school or residency, which is a shame given the vast amount of research accrued demonstrating their efficacy. There are, unfortunately, no attractive former cheerleaders turned pharmaceutical reps visiting weekly with a free lunch and shiny expensive brochures of smiley, happy people advocating for these free (no patents and padded pocket books available!) but empowering and effective techniques.

 I educate my patients about emotions and their intrinsic value in guiding us forward on our life paths and the dangers of blocking or numbing our emotions whether it’s with drugs, food, alcohol, work, distraction, or prescribed medications, like antidepressants and anxiolytics. I attempt to plant a seed to reframe their moods and emotions as normal messengers alerting us when life is out of balance, rather than pathologizing them as a threat to be feared and avoided. For those on antidepressants or considering them, I discuss the research showing the long term psychological consequences of their use including feeling emotionally numb, caring less for other people and feeling fewer positive feelings, as well as repeated studies demonstrating that in cases of mild and moderate depression antidepressants are no more effective than a placebo.

For those interested I debunk the mythology of neurochemical imbalances and educate them about a growing body of research, still largely ignored by the psychiatric community,  that suggests that depression, along with 80-90% of chronic disease, is more likely a result of inflammation, which is primarily caused by stress. If stress is a primary cause of what we call mental (and physical) illness, wouldn’t it make more sense and be far more empowering to learn how to manage stress ourselves rather than cover up its emotional effects with a medication?

Learning self care skills empowers someone for life rather than making one dependent upon a doctor and his or her prescription pad for ones well being.  It shifts us out of a mindset that we have been dealt a bad genetic card into the recognition that most mental and physical illness is more a matter of epigenetics—the interplay of our genes with the environment, which includes our beliefs, thoughts, emotions, behaviors, diets, and lifestyle—in other words CHANGEABLE factors.  If this is true, as an ever growing body of research indicates, then we are not passive players doomed to a lifetime of pills but active participants in our own healing (or wounding). By collaborating in our healing process, are we not removing the sense of powerlessness and helplessness which fuels anxiety and depression, replacing it with a greater sense of control and self-efficacy, which research clearly demonstrates reduces the risk of mental illness?

So I have started this blog to break my self-imposed silence about my views on the state of psychiatry (and medicine in general). For years I have been listening to colleagues discuss patients and their medications. “I have tried Zoloft, Effexor, Cymbalta, Abilify, Risperdal, Ativan and Depakote and nothing has worked. Can you think of any other medications I might try?”  I listened and suggested that, perhaps, medication is not the answer, as the person walked away with a puzzled, even hurt look. (I wish I were making up that conversation, but I am not.)  Please don’t get me wrong. These are good people (most, anyways) with good intentions, who are practicing medicine the way we were trained to practice medicine in medical school and residency and within the confines of a medical and insurance system that only pays for shorter and shorter visits.

What I have learned since med school and residency, however, is that there are other safer, equally effective and more empowering ways to manage depression and anxiety and often even what we call bipolar and schizophrenia. I have come to these conclusions based not only on my own experiences as a doctor –and patient—but also based on massive amounts of research, that sometimes manages to get published in the big medical journals funded by glossy pharmaceutical ads, but still gets overlooked, because it does not conform with the dogmas of the profession that create blinders difficult to see past.

Also, please understand that I am not saying medication should never be used. There are times and places for medications, but they should be used judiciously and wisely and not handed out like candy for every problem and every “negative” emotion, but reserved for use only after other safer and more self empowering options have already been tried.

Fortunately a growing number of physicians—and patients-- are speaking up and out about their dissatisfaction with psychiatric (and medical) care.  I feel compelled to add my own voice to these comrades. I used to think I had nothing to add to this discussion. It has already been said. But clearly it has not been heard, and it is not fair to sit back and cowardly leave the work to others. I realize that if medicine is to change, and really it must, then I –and others--must speak up in hopes of reaching a tipping point, when the old, paternalistic, reductionistic medicine, that looks for a quick fix in the form of a pill to solve every problem, makes way for a more self-empowering, holistic approach to medicine that recognizes the connections between mind, body, spirit and environment. A system that empowers patients with practical efficacious tools of self care and reimburses physicians to utilize the most powerful tools of their trade – time, listening, presence, compassion and hope in the context of a collaborative healing relationship.

Until that happens I will no longer remain a silent observer, but intend to keep writing and speaking up and I hope others will join the discussion.

Resources:

New England Journal of Medicine, Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy, January 17, 2008 http://www.nejm.org/doi/full/10.1056/NEJMsa065779#t=articleTop

JAMA, Emergency Department Visits by Adults for Psychiatric Medication Adverse Events, July 9, 2014

http://archpsyc.jamanetwork.com/article.aspx?articleid=1885708&utm_source=silverchair%20information%20systems&utm_medium=email&utm_campaign=jamapsychiatry%3aonlinefirst07%2f09%2f2014

Huffington Post, New Research: Antidepressants Can Cause Long-Term Depression, November 16, 2011

http://www.huffingtonpost.com/dr-peter-breggin/antidepressants-long-term-depression_b_1077185.html

Psychological Side Effects of antidepressants worse than thought, University of Liverpool, February 25, 2014

http://www.psychcongress.com/article/psychological-side-effects-antidepressants-%E2%80%98alarmingly-common%E2%80%99-16173

http://www.eurekalert.org/pub_releases/2014-02/uol-pso022514.php