Sprituality.....

I was born and raised a Methodist.  My father was a Catholic and had some problem with that church despite the fact that many of his siblings were devout.  To this day, I have a vague notion of what being a Methodist means.  I remember going to a church that looked like a large house from the outside.   It was a very modest building.  There were a hundred or so people on the inside.  They became familiar faces over time.  I was always interested in what the clergy had to say and the message varied considerably.  I did not know it at the time, but being a protestant clergy is a very political position.  People have to like you or they start to talk and that talk can eventually undermine your ministry.  Even as a kid I thought I could figure out how serious the minister was by what he said.  Was it a rote presentation or did he brings things alive.  I don't mean in the entertaining sense.  Could he (we only had male ministers in those days) get a serious lesson across in an inspirational way?  I was always impressed with how little commentary there was about this central feature of the church service.  It seemed routine to go there, listen to the sermon, sing a few songs and leave.  No enduring message or feeling.

It wasn't until I was a teenager that I saw the inside of a Catholic church.  I was there for my father's funeral.  Several of his devout siblings arranged for the funeral service to occur in the Catholic church despite the fact that (to my knowledge) in my 15 years on earth at that time - he never set foot in church.  In assessing what the church looked like, I recall thinking that "this is the big time."  The structure was huge compared to the Methodist church and the architecture was inspiring.  No wood framing.  There were concrete arches, stained glass, symbols, and actual sculptures of Christ on the cross everywhere.  In a Methodist church there is usually one large plain wooden cross.  The stained glass is always basic with the words: "Faith, Hope, Charity".  The acoustics were definitely different.  Words spoken in a Methodist church tend to project out about 15 rows and rapidly drop off in volume.  In the Catholic church the sound carried and echoed all the way back to the last row.  That last row was at least 4 times the distance of the last row in the Methodist church.  Since then I have been in many churches Catholic and Protestant - typically for weddings and funerals.  Even though the church architecture can be an impressive instrument for the speaker - it all really comes down to the clergy.  Are they doing more than dialing it in?  Are they inspirational?  Is there intellect behind the spoken words?  Can they convey the idea that there is something much larger than our individual conscious states out there?  Those were my first lessons in spirituality.

When I was in the Peace Corps in the 1970s, a fellow volunteer introduced me to a book called Zen and the Art of Motorcycle Maintenance by Robert Pirsig.  On the surface, it was a book about a cross country motorcycle trip by the author and his son.  Below the surface there were lessons about philosophical approaches to life - both eastern and western philosophies.  There was also a flashback to a crisis in the author's life when he was in graduate school and developed a psychotic depression while in the midst of an academic interpersonal conflict with one of his professors.  The lessons for me from Pirsig's book was that spirituality is really independent of other contexts.  He summarizes it in this statement:

“The Buddha, the Godhead, resides quite as comfortably in the circuits of a digital computer or the gears of a cycle transmission as he does at the top of the mountain, or in the petals of a flower. To think otherwise is to demean the Buddha - which is to demean oneself.” ― Robert M. Pirsig, Zen and the Art of Motorcycle Maintenance: An Inquiry Into Values.

After reading Pirsig's book five times, I concluded that he had an unprecedented intellectual look at what he described overall as values.  He also had a look at spirituality in a very unique way and could see it it places where it is not commonly seen - like welding or motorcycle mechanics.  Moreover, it was also a view that made immediate sense to me.  I had been doing the same thing for years.

That brings me up to my work as a psychiatrist.  In that work, spirituality ranges all of the way from religious delusions to the higher power concept in Alcoholics Anonymous and all points in between.  I don't know how many people I have talked with who believed they were God or Jesus or Satan or The Antichrist - but I have had hundreds of conversations about those topics.  On the quieter end of the spectrum, I have had even more conversations with people who were anhedonic, hopeless, spiritually bereft and who felt abandoned by God.  Many of these folks felt as though any spirituality they had was gone.  They lost interest in it like everything else and they had doubts about whether they wanted to get it back.  Did it really mean anything when they had it?  Getting it back turned out to be a critical part of their recovery.  I try to figure out a way to describe it in my clinical assessments and it is difficult.  Some have suggested using the term to capture the Gestalt of the person, but I think it is more complex than that.  In many ways it is like describing people who are charismatic and trying to use the appropriate descriptors.

There is an experiential aspect to spirituality that requires concrete examples rather than me just writing about it.  For that I will turn to a couple of examples from the best interview program anywhere - MPR's Fresh Air with Terry Gross.  I consider it a laboratory for the spectrum of human consciousness and it contains a lot about spirituality.  The first example comes from a story about Iris Dement.  She is a folk singer who began singing in the Pentecostal Church.  Until you hear an explanation of someone who is in that church or experience what they are doing - it is very unlikely that you know what is happening.  After carefully developing the context during the interview she summarizes it at this intellectual level (1) :

   "I saw my parents use music to survive.  They had to have that music.  My mom had to sing and my dad had to go to church and he had to hear that music washing over him and through him.  It wasn't a, "Oh, this is nice"; it was a, "I'm not going to make it if I don't have that."  So I've felt that that's my job.  That's how I think of what I do.  I have to give people that lifeline, you know, that I saw my parents reach out for, and that I was taught to reach out for, and so that's what I aim to do.  And I guess I don't feel like I can do that without that connection to the spirit."

When I listened to that interview and heard that quote, I realized that had just experienced one of the best examples of spirituality.  I encourage anyone with an interest to listen to the audio and have that same experience.  I think that you have to look past your taste in music to what motivates this artist.  Too many people get stopped in their tracks by thinking: "I don't like folk music" or "I don't like country music" or some appalling lack of knowledge of the Pentecostal faith.  Listen to the audio from the perspective of what motivates Iris Dement and keeps her going.

The second MPR experience on spirituality just occurred and it was the final push for this post.  I heard Terry Gross interviewing the Iranian born photographer Abbas on his series of photographs about what people do in the name of God.  The process of the interview is again very important.  Gross sees a spiritual element in one of the photographs but Abbas does not.  He comments that his relationship with God is purely professional - he has no stake in religion.  At the same time he describes some experiences that were moving while he was engaged in photography(2) :  

"Of course.  You know, I mean, you can't touch such a subject without being touched and moved.  I remember very vividly, for instance, a mass in France among the Benedictines, you know, it's monks. They're different from priests, you know, monks - very moved by a mass.  Normally when there's a mass, I don't listen, I just take photographs because it's always the same.  But this time, you know, the father who was saying mass was very spiritual.  He was talking about Jesus, not as a distant prophet, but as a personal friend.  So suddenly I start listening, and I became very moved.  In most religions, at least one event made me - well, I wouldn't say a believer but a participant....."

Like the Iris Dement story, I encourage listening to the actual audio and Abbas description of his technique before and after this excerpt.

What is spirituality?  It is not the same thing as religion, but for some people it is very close.  I also think that it is not easily acquired.  I don't think it is as easy as declaring a higher power.  Spirituality might be haunting rather than reassuring - it may not be a good feeling but it probably leads to a sense of calm.  I like Abbas's idea that it can make you a participant.  I can see it as an unconscious emotional force that probably has some obvious and many not so obvious origins that leads to consistency and may be noticeable by observers.  Some very spiritual people are described as serene and others as inscrutable.  It is not listed in the DSM-5 and that is a good thing.  It is another aspect of conscious experience that psychiatry neglects for the most part.   As far as I can tell, it is like an experiment in consciousness.  Like the examples I gave - you know it when you experience it.


George Dawson, MD, DFAPA


References:

1.  Terry Gross.  Fresh Air on National Public Radio.   For Iris DeMent, Music Is The Calling That Forces Her Into The Spotlight.  October 21, 2015.

2.  Terry Gross.  Fresh Air on National Public Radio.  Photographer Abbas Chronicles 'What People Do In The Name Of God'.  November 19, 2015.

3.  Melissa Block.  All Things Considered on National Public Radio.  A Nephew's Quest: Who Was Brother Claude Ely?  July 14, 2011.

Story of the importance of Pentecostals in rock and roll, especially Brother Claude Ely - with parallel comments about the spirituality involved in that music.  If you doubt it - read the last two paragraphs of the written story first.

Subtext of "The Autism Spectrum"

I was free associating to public radio a while ago as I listened to Terry Gross interviewing actor Timothy Spall on playing J.M.W. Turner (1775-1851).  Turner was an English artist in the 1800s, renowned for his use of color and light.  His painting above from 1839 was voted Britain's favorite painting in a 2005 BBC Radio poll.  I placed it here to illustrate these techniques that are visible looking toward the sun as it illuminates the cloud cover and some outlines at the horizon as it sets.  Some of the technical aspects of his painting that distinguish him from his contemporaries include the use of a white primer, limited use of underdrawing (sketching before the paint is applied), painting fast with a hard brush and palette knife, and parsimonious use of pigments (see reference 1 for details).  Spall studied art for two years in preparation for this role and was eventually able to recreate a Turner painter.  He describes Turner as possibly one of the greatest landscape painters of all time.  He also teaches how words change in meaning over time when describing how the sublime art movement grew out of the romantic and had as its goal "to capture the beauty of nature, as well as its terror and its horror."

The actual film Mr. Turner as described in the Fresh Air episode seemed somewhat different than the one described.  It did cover the last two decades of Turner's life.  In it we meet Turner, his ex-wife and two adult daughters, his housekeeper, several of his colleagues, and a woman who he meets when she is married and marries when her husband dies.  We see enough of these relationships to develop an impression of what may be going on.  The relationships are set against a visually stunning backdrop of the cinematographer shooting Turner as he travels to sketch seascapes and eventually convert them to paintings.  In many cases, such as the painting at the top of the post we see the scene blend into the painting.  The cinematography of these scenes is some of the best that I have seen anywhere.

I think the key about whether you might enjoy the film or not depends a lot on whether you can appreciate Turner's eccentricities and the attempt at portraying the depth of his character.  He certainly does things that many would find repugnant.  The impression that I had about his relationship to his family was that he had abandoned them.  His ex-wife was somewhat intrusive in attempting to get him to show some interest.  She did not seem to impress him in the least and he would typically walk away.  He did not attend the funeral of his daughter and when asked told people that he had no children, while his father had a facial expression of disapproval in the background. On the other hand he did marry a widow and stayed with her until his death.  Along the way he had a sexual relationship with his housekeeper.  There was one scene of perfunctory sexual intercourse between Turner and his housekeeper.  No words were spoken between them during that scene or at any point to suggest that they had any emotional intimacy but the actress in this case projects a strong sense of caring for him and eventually travels to see him when he is dying in his new home.  She appears saddened when learning he has a new wife and walks away without seeing him.

Throughout the film Turner communicates at times with a series of grunts, even though he has communication skills as good as anyone else in the film.  He has a characteristically gruff and unkempt appearance and only seems to smile when he is in the midst of a deathbed delirium.  I think that presentation is what led Terry Gross to ask the question about whether he might be on the autism spectrum and Spall's excellent response on subtext.  Spall speaks to the fact that he portrayed Turner's inner anguish after hearing that one of his children had died despite his overtly dismissive relationship with them.  He expands on the relationship with his housekeeper and what that means.  He describes his intellect as implosive as a reason for the communication in grunts at times, even though he could be quite articulate at others.

That response was a great one in so many ways.  It explodes the idea that observable behaviors mean much of anything out of context.  If I am gruff appearing or eccentric does that mean much of anything by itself?  Probably not.  Being gruff or eccentric appearing is not really a risk factor for seeing a psychiatrist and it is unlikely that those features mean much of anything.  And what about the communication style and the frequent grunting?  The first time I heard it I had the impression that it was the equivalent of the modern day English expression "oi"  or the American expression "hey".    I did not see it as the typical communication problems in autism.  It also speaks to the larger headlines of famous people who either think they are "on the spectrum" or somebody else thinks there are.  That comes from a number of sources - not the least of which is the popular notion that reading the DSM without being trained in psychopathology means much of anything.  Should a person get evaluated for congestive heart failure by a doctor who has just pulled up an internet site that lists the diagnostic criteria for congestive heart failure or is it better to see a doctor who has made the diagnosis many times, and by learning those patters of illness can successfully parse cases that are in the grey zone (eg. is this congestive heart failure or asthma?).

That is the ultimate value of Spall's comment on subtext.  There is not a lot that is explicitly known about this character in the film.  Certainly nowhere near as much explicit content as Spall discusses in his interview.  And yet he is pointing out that there is something implicitly there to suggest that Turner is not autistic (whatever that might be).  One of the many misconceptions about psychiatrists is that we want to diagnose everyone with some kind of disorder.  A substantial number of the people I have seen over the years want to know that they don't have a problem.  They either ask me up front or at the end:  "So do you think I have (bipolar disorder, Alzheimer's Disease, alcoholism, OCD, borderline personality disorder, etc.)?"  They are relieved that I know the subtext and can say no.  Some people will just ask the generic question: "Do you think I am crazy?" and I explain why that is not a relevant question.  In many cases I just have to tell people:  "I know that you are being treated for this disorder (usually bipolar disorder or ADHD), but there is no real evidence that you have it.  I have treated hundreds of people with this problem and there are a number of reasons why you don't have it.  And by the way, if you don't have the disorder - I would not recommend that you take medications for the disorder."  In rare cases I will see a person who asks a very specific question: "I have been in psychotherapy for 5 years now.  That is a long time.  Do I need to keep going?" and I am obliged to give them my opinion.

Often the observations have to do with non-verbal behavior like Sprall's comment on Turner.  What does silence mean from one meeting to the next?  In one meeting it means tacit unanimous agreement.  In the other it means just the opposite.  What happens if I see a young man thrashing about on the floor and the people around him are panicked and implore me to "Do something doctor?"  Instead of calling a code I reach out and pull him up off the floor and he stands there looking mildly anxious.  And what about that anxious patient who has a piece of pipe in his hands and says: "Do you want a piece of this?"  Instead of confronting him and telling him what to do, I explain what is really happening here - he is scaring the hell out of people (including me) and it is unlikely that an old man with glasses is going to fight him or anybody else.  He apologizes and drops the pipe.  I can recall walking into a gas station in Northern Wisconsin on brisk winter morning at about 7 AM.  A large man crashed into me and my wife right in the front doorway.  I grabbed him by the jacket, he went limp and I lowered him to the ground.  "What are you doing?  What's wrong with him?" my wife asked excitedly.  He was drunk at 7AM and in a stupor on the ground.  In all of these situations things are not what they seem to be.  We all act quickly based on limited information and the chances for error are great.

One of the more critical subtexts is what happens when a person you know very well appears to be different in some subtle way but there is no clear way to describe it.  The standard mental status exam including their cognitive screening turns out to be a very blunt instrument in this situation.  I have talked with people and done complete cognitive screening and when I see them again, they have no recollection of ever seeing me again despite a perfect score on the cognitive exam.  The only differentiating points were the smell of whiskey in the air and a coarsening of affect.  In other cases, a person may deny all problems including the ones that are the focus of treatment and exhibit a slight clouding of consciousness as a prelude to serotonin syndrome or neuroleptic malignant syndrome.

All of that commentary, representing a significant part of psychiatric practice has to do with subtext and not reading a diagnostic manual.  I thank Timothy Spall for his response on the issue of the Autism Spectrum, because it is really about a lot more than that.  I have always been impressed with the observations of artists and my English professors in looking at theories of human behavior and the applied metaphors.  It is also an indication of how difficult it is to be an actor.



George Dawson, MD, DFAPA                



References:

1:  Antonino Cosentino.  Cultural Heritage Science Open Source.  J. M. W. Turner (1775–1851).  Technical Art Examination.  March 24, 2014.

2:  Terry Gross.  Fresh Air.  Timothy Spall Takes On Painter J.M.W. Turner A "Master of the Sublime."  December 14, 2014.  Be sure to listen to the audio to appreciate Spall's voice and accent in this role.




Supplementary 1:

The painting here is: "The Fighting Temeraire tugged to her last berth to be broken up" by J.M.W. Turner.  It was downloaded from the WikiArt web site that advises that the copyright expired because the painter died more than 70 years ago.

Supplementary 2:

Don't try any of the interventions described in this post at home.  They are likely to backfire.

Supplementary 3:

Definition of Subtext from Theatrecrafts.com:

"Subtext or undertone is content of a book, play, musical work, film, video game, or television series which is not announced explicitly by the characters (or author) but is implicit or becomes something understood by the observer of the work as the production unfolds.  Subtext can also refer to the thoughts and motives of the characters which are only covered in an aside. ...."

Schizoaffective Disorder and Surfing Music

I will disclose my biases on schizoaffective disorder from the outset.  My decades of acute care experience suggests that it is a lot less common than suggested by medical records.  Reflecting on the unique experience of seeing people hospitalized many times over the course of 20 years, the most frequent pattern I observed was clear cut bipolar disorder turning into a diagnosis of schizoaffective disorder or in some cases "bipolar disorder and schizophrenia".  Since I worked at this hospital long enough and had the memories of my enthusiastic young psychiatrist self and my compulsive documentation to count on, I can say that the most frequent pattern was patients presenting with manic episodes turning to the less specific diagnosis.  Most of these people were in their 20s or 30s when they experienced a clear cut manic episode.  There was no doubt about it because of the rapid onset and mood congruent psychotic symptoms.  They responded well to treatment and I discharged them from the hospital.  They would be rehospitalized from time to time, either on my inpatient service or another.  I would eventually see them in more detail after another 5 - 20 hospitalizations, look at the chart and notice that for some time, the diagnosis had become schizoaffective disorder.  Some would ask me about the diagnosis and some recalled the original diagnosis.  If they asked my opinion, I would always tell them what I considered to be the best answer: "As far as I am concerned, your diagnosis is still bipolar disorder.  I am basing that answer on your first hospitalization and your response to treatment.  You don't have any residual symptoms.  Having episodes of bipolar disorder for various reasons does not change the diagnosis."

One of the biases that exists about this diagnosis is that it tends to be more chronic and difficult to treat than bipolar disorder.  The reality is that bipolar disorder can be associated with a significant number of losses in terms of social network, net worth, and in some cases functional capacity.   There are frequently problems with alcohol and use of other intoxicants. Primary psychiatric disorders are always made more complicated by addictions. Like schizophrenia and depression, psychiatric research has not done a good job of defining the cognitive problems associated with bipolar disorder or coming up with successful treatment approaches. Although some rehabilitative approaches are in place for people in Assertive Community Treatment (ACT) programs, successful treatment is usually based on getting the mood symptoms in remission and the prevention of rehospitalization and suicide.  I have treated people on an outpatient basis with chronic mood disturbance and a diagnosis of schizoaffective disorder - bipolar type who work and function at an excellent level.  If they ask me what the diagnosis is - I tell them that it is probably bipolar disorder, even if they have episodic hallucinations.  I tell them "probably" because I know how the diagnosis of schizoaffective disorder is made.  And also because they are functioning well and I don't think that there is a lot of good information on the prognosis of that disorder.  At some level I am also probably biased by the idea that bipolar disorder has a better diagnosis.

My experience with the schizoaffective disorder diagnosis is a necessary backdrop for the following comments from the screenwriter Oren Moverman on whether composer Brian Wilson has a mental disorder:  "Yes, and it's public knowledge. It's called schizoaffective disorder, and it's really a combination of some schizophrenia symptoms, like hallucinations, and mood disorder, such as depression." (see transcript for reference 1).  Moverman is the screenwriter for the Brian Wilson biopic Love and Mercy.  For younger people reading this, Brian Wilson is the founder and composer for the rock and roll group The Beach Boys.  When I was in middle school in the 1960s, people of my generation started dancing to this group.  Their early genre was known as surfing music, based on that culture in southern California.  In these interviews Wilson talks about how he got started writing surfing music.   During the broadcast one of the early songs was Catch a Wave and that immediately brought me back to this time:





The Beach Boys were very successful in that type of music and made a significant comeback in the 1970s and 1980s with different types of music.  Behind all of that was Brian Wilson, a widely acknowledged musical genius who also performed live with the group in its early days.  Wilson is also known for his mental illness and substance use problems as well as his involvement with a highly controversial therapist.  The therapy methods included exerting total control over Wilson, by living with him 24/7 and having him under constant supervision by several case managers.  Wikipedia states that the cost of these services was about $20,000/month.  There was an initial 14 month episode of involvement followed by dismissal due to a dispute over fees and then another episode of involvement prior to permanent dismissal and placement of a restraining order.  Although that therapist seems to be credited in many ways with saving Wilson's life and getting him back to composing music, he was also reported to his California psychology licensing board for violations of professional conduct and according to Wikipedia resulted in a loss of license.  That same source points out that Wilson developed tardive dyskinesia and impaired functional capacity from prescriptions from this therapist's "staff".  I did not see any reference to prescribing psychiatrists or physicians.

This brings me to the inspiration for this post.  Once again it is Fresh Air's longtime interviewer for this program - Terry Gross.  In this series of interviews, Gross starts out with a story about the release of a new film about the life of Brian Wilson titled Love and Mercy.  She has two interviews that she conducted with Wilson from the past and a current interview with the screenwriter of the current film. One of the full length interviews is available on the Fresh Air web site from 2002, but I could not find the one from the 1990s.  There are also excerpts of earlier interviews played in the current interview.  The author starts out describing the focus on three discrete periods in Wilson's life and how that proved to be too much and how the focus had to be narrowed to two periods in the 1960s and 1980s.  Because of those time frames, Wilson is played by two different actors Paul Dano in the 1960s and John Cusack in the 1980s.  Moverman comments on the technical aspects of the film, like the reason for focusing on the musicians.  He also comments on the therapy controversy and states that Wilson was misdiagnosed and overmedicated.  At that point Terry Gross comments that the California Board of Medical Quality Assurance was investigating the therapist because medications were being prescribed and he was not licensed to prescribe them.

One of the most interesting aspects of Gross's work is the historical context.  She has commentary from Brian Wilson in an earlier interview commenting on the therapist controversy:

WILSON: "He's been performing a health operation on my head. He's done something that's impossible that nobody could do."

GROSS: "What do you think he's done that's really worked for you?"

WILSON: "Well, what he's done that worked for me was he's taken my body and transformed not only my physical shape, but he's transformed the chemistry within my blood, you know, from dirty to clean. And when you go through those transformation periods, you go through a little hell, you know what I mean? It's a little bit of hell to have to come through all that, all right?......."

Moverman thought that Wilson was referring to getting him off of intoxicants when he refers to blood chemistry.  Listen or read the complete transcript but in this section Wilson emphasizes the need for moving ahead rather than focusing on revenge for something that happened in the past.  I encourage anyone interested in this particular story or recovery from mental illness to listen to Brian Wilson's spoken words in these interviews with Terry Gross. 

Any acute care psychiatrist will probably be interested in this story.  For me it highlighted a number of issues.  Whenever I see a story like this, the usual way it is handled in the media is to get an expert and try to make diagnosis.  This is exactly the wrong thing to do at many levels.  One of the main concerns is the interplay between substance use and psychosis and mood symptoms.  In my experience, 95% of people seen in acute care and addiction settings are misdiagnosed with bipolar disorder, schizophrenia, depression, and even attention deficit hyperactivity disorder when they have a clear substance use problem that is responsible for those symptoms.  That does not mean that medical treatment is not necessary, but it probably means that it will be temporary.  I am not prepared to say that was an issue in this case, only that when you have seen that problem as often as I have that is one way to approach the issue.  The other dimension here is how difficult it is to effect changes and help people get back on path when they are clearly engaged in high risk and what is described in these transcripts as destructive behavior.  There are really very few options left for people with problems as severe as the ones that Brian Wilson was going through.  In most cases, it is a number of emergency department visits and brief admissions to psychiatric units.  I can say without a doubt that problems this severe are not reversible by those interventions or outpatient visits for twenty minutes to see a psychiatrist every one to three months or seeing a therapist every week for an hour.  Most people stop seeing the therapist after a visit or two.  They may have the thought that they are seeing the therapist because it is somebody else's idea.  

I certainly do not condone the therapy methods used Wilson's case, but fully acknowledge that our current systems of care are not likely to produce a positive result for persons with severe disabilities.  Above everything else this is a story of recovery.  Brian Wilson endured acute symptoms and significant disability and came out the other side.  He continues to write and produce music and that music inspires millions of people.  


George Dawson, MD, DFAPA


References:

1:  Fresh Air with Terry Gross.  'Love & Mercy' Brings The Life Of Brian Wilson To The Big Screen'.  June 18, 2015.

2:  Fresh Air with Terry Gross.  Producer And Arranger Brian Wilson, A Genius Of Rock.  August 27, 2002.

Supplementary:

I have not seen Love and Mercy yet but will probably add a few comments here when I have.

Attribution:

By Brocken Inaglory (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

The Mind and the Power of the Spoken Word

My usual drive home from work last night.  It was a late night and on these nights I get to listen to Terry Gross interviews on Fresh Air.  In two interviews, I heard two excerpts of speech that for both the content and the way they were delivered were just compelling.  Gross typically replays interviews of famous people that she has interviewed right after their deaths.  Her interviews are generally so comprehensive and have offered insights into the person that they serve as great memorials to that person and their work.  The first in an excerpt from an interview with Christopher Lee, the actor.  I have seen him in many roles, but remember him best for his work in Star Wars and Lord of the Rings.  He died last Sunday at the age of 93.  In these sentences, Gross asks him how he decided to play Dracula.  Only the words are listed below.   The interview occurred 25 years ago and he would have been 68.  Listen to the audio to capture how these sentences were delivered spontaneously:

LEE: "I never thought of him as - I never thought of him as a vampire, ever.  I mean, the blood is the life.  That's one thing you have to bear in mind.  And it is for all of us, isn't it?  Here's a man who is immortal.  Here is a man who, through being immortal, is a lost soul.  Here is a man who experiences the loneliness of evil, something he can't control, who wants to die but there is a force in him, a malefic force, which drives him to do these terrible things.  I said earlier the character is heroic, based on the real man - a war leader and a national hero, I may say, in Romania to this day - Vlad the Impaler....."

The second interview was with several people to commemorate the life of jazz great Ornette Colman who died this week at the age of 83.  He discusses how he innovated a type of jazz that was so controversial that it polarized people to the point that they would show up in clubs where he was playing and fights would break out over the music.  People would swear at him and try to strike him.  One of the musicians interviewed said that he witnessed Coleman being punched in the face over his music.  Here he tells Gross about his instructions to his fellow musicians about how to play his innovative style of music:

ORNETTE COLEMAN: "I had - originally, I had told them, I said, you know, the bass - the basics of music is first learning how to play music on the instrument that you choose to play.  Secondly, to eliminate the problems of having a style that get in the way that you think or feel.  And third is to not get so hung up in the technique of your instrument that you cannot play music anymore.  So - and I demonstrated those kind of things to them.  And since I first started, I was using just the trumpet, the bass and the drums, which was not lots of musicians at that time, so it was very simple for me to give them the information that I had figured out."

Equally interesting are the musicians interviewed and their descriptions of Coleman, his music, and the times.  They are Don Cherry, Denardo Coleman, and Charlie Haden who were all members of Ornette Coleman's quartet.  It seemed evident to me, that their performances were ground breaking.  They are all dedicated musicians at the top of their game, but more than that - they know how to work together.  At one point Gross asks Ornette Coleman a question about about working with his son Denardo.  He comments on the nature of the question and basically concludes that he likes to work with someone who knows what he is trying to achieve.  I strongly encourage listening to the recording of these men and their descriptions.

These interviews are very interesting to me from a number of perspectives.  The first is the experience of having your fantasies exploded.  If you watch a lot of films, there may be a time when you say: "I can do that." or "He/she acts the same way in every film".  That certainly might be true, but it also might be true that you are seeing a small fraction of the person in that particular role and it is difficult to have an appreciation for everything that went into it.  I have seen Robert DeNiro movies since his first critically acclaimed role in Bang the Drum Slowly.  I saw that in a dilapidated theatre in northern Wisconsin and it was apparent he brought a lot to the role.  But it wasn't until I saw him interviewed by James Lifton about 40 years later that I had an appreciation of the level of art he was exposed to in his childhood or how early he had started in acting.  

It is easier to appreciate the genius of musicians.  The only thing that is needed is an instrument and your own feeble attempts at trying to create music.  Even the most basic rock and roll requires more than casual effort.  I was trained to play cello and clarinet in grade school and high school and like most people let it slide after that.  Science and athletics seemed more important.  With the rudimentary training, I think that I can safely conclude that jazz, especially creating an entirely new and controversial style of jazz is a sign of real genius.  This excerpt from an interview with Charlie Haden, jazz musician and bass player for Coleman.     

CHARLIE HADEN:  "I was 19 years old, and we played all day long. And he had a room full of music strewn all over the floor, the walls, the ceiling; he was constantly writing music.  And he told me before we started to play, he said, Charlie, I've written these pieces now and here's the chord changes.  Now, these are the chord changes that I heard inside myself when I was writing the melody, but these are just a guide for you.  I want you to be inspired from them and create your own chord structure from the inspiration or from the feeling of what I've written.  And that way, constantly a new chord structure will be evolving and we will be constantly modulating, and we'll be listening to each other, and we will make some exciting music.  And that's exactly what happened."

I heard this and thought about the true genius of Coleman as a manager.  Imagine if you worked for a guy like Ornette Coleman doing any less complicated work.  A person who told you, well here is the basic structure of your job, but I really hope that you can innovate within these constraints and create new ways to do it.  It is difficult to find areas in life where somebody had that kind of vision in terms of people working together to create something but Ornette Coleman clearly did.

I talk to people for a living and have for 30 years - typically 60 to 90 minute initial interviews.  I don't like to impose too much structure, but I do have to cover at least 200-240 information points in varying degrees of detail.  Many of the people I talk with are like the above excerpt from Christopher Lee.  They are brilliant and have a command of the language.  Their vocabulary is excellent.  I gauge it by how many low frequency words they tend to use.  The words can't be jargon.  They have to be the same words that we all have access to in a dictionary.  I was taught at one point that there is a rough correlation between compound sentences and intelligence.  I usually comment on both the vocabulary and sentence structure in my dictations that record the results of the interview.  In some cases I comment on the emotional impact of a more objective observer - how someone standing in the room might be affected.  Psychiatrists are limited in the range of descriptors that they can use, largely because the field has limited itself to significant psychopathology.  That is fine for clear situations when those descriptors occur, but what about the majority of situations where they do not?  I like to push the envelope and explore those situations.  What if I am talking to a person who most people would see as being charismatic and that is the overwhelming aspect of the interview?  What if the person talks as if they are reading their answers out of a book containing compound sentences and low frequency words?  What if they are surprisingly different than what it says on the consult request?  Can I make those determinations?  I routinely do.

Another interesting aspect of these interviews is the time dimension.  In the course of clinical practice it is common to hear clinicians compare notes on how they conduct their clinical practice.  There are various external and internal rules applied to come up with the duration of interviews.  The entire duration of the interviews with Lee and Coleman were 15 minutes or less, but they were excerpted from longer interviews.  In psychiatry at some point, a decision by the psychiatrist is made about how much (if any) non-clinical discussion can occur.  The clinical discussion is driven by the billing and documentation guidelines determined by governments and insurance companies.  I have found that rarely accounts for all of the relevant treatment factors.  At the minimum, there is some source of stress at home or at work.  Some additional issue or question that requires a more detailed discussion.

In other interviews, I hear amazing stories like Charlies Haden's description of meeting Ornette Coleman.  One of a kind experiences from the full range of absolutely inspiring to absolutely traumatic - communicated to me with a full range of positive to negative emotions.  Not everyone is a genius, but everyone has a story to tell or history to give.  I have spent all of my life spinning that information down to see if there are any syndromes in that hinterland that is two standard deviations out past most human behavior.  I don't really know when it happened but at some point, I realized the importance was in all of the information.  I realized that when somebody says: "How much time do we have doc?" or "Do you want the short version or the long version?" that the correct answers are "All the time you need." and "The long version."  If the long version gives enough detail about the person's life, it allows me to say: "There is absolutely no way that you have that diagnosis from the history you just gave me."  It gives me more than enough to answer the more common question: "So doc - am I crazy?"

You never really know the whole story without all of that information communicated directly to you by the person who lived it.

George Dawson, MD, DFAPA

References:

Listen Back To A 1990 Interview With Actor Christopher Lee - June 12, 2015  Interview and Transcript.  NPR Fresh Air with Terry Gross.

Fresh Air Remembers Jazz Innovator Ornette Coleman - June 12, 2015  Interview and Transcript.  NPR Fresh Air with Terry Gross.


Attribution:

The photo of Ornette Coleman:  By Nomo michael hoefner http://www.zwo5.de (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Hyperbole and a Half blogger on NPR

It's Tuesday night and I just finished a lecture at about 7:40 and headed home.  That involves about a 45 minute drive down Minnesota Highway 8.  The last two days in Minnesota have been bitterly cold.  That first bitter cold that feels like it is 35 below, but it is really only there to steel you against 35 below.  It was actually 19 above.  The only consolation to driving down one of the most dangerous roads in Minnesota in the dark and bitter cold is that I get to listen to Terry Gross on NPR.  To make things even more interesting she was interviewing a depressed blogger with huge appeal on the internet.  She writes the popular blog Hyperbole and A Half.  

Terry Gross started out with a lot of questions about the quirky cartoon character that blogger Allie Brosh uses to represent herself on the blog.  The interview proceeds through some introductory excerpts but comes to the author's depression at about the 13:38 mark and goes for about 20 minutes.  As I am listening to her talk about depression, I am thinking of the hundreds of people I have talked with about their depressions.  I am always trying to find out if I missed anything or if there is a different way to view all of these unique presentations of depression.

Ms. Brosh's description of depression and its personal and interpersonal toll is unique among descriptions of depression I have seen in the media.  She talks about the transition from an emotional depression with excessive emotion and self loathing to a state that is totally devoid of emotion.  The "emotional deadening" in some ways is a relief and she later says that it has lead to reduced anxiety.   She has thought of herself as too emotional and thought it was interesting that she no longer had that weakness.  She blogs about it as Adventures in Depression and Depression Part Two and we have already learned that these were very popular posts on her blog.

In one example, she describes an interaction with a friend telling her that her cat has died and she states she is not able to generate enough "organic emotion" that she needs to be concerned about showing an appropriate facial expression to her friend.  Her concern is that she is doomed to live an emotionless state and that rapidly equates to meaninglessness and eventual suicidal thinking.  She talks about needing to manage this information to protect people and also protect herself from their emotional reaction.  She is eventually able to tell her husband and mother, but even during this interview she discloses that her husband may have heard details of her plan that he had never heard before.  This disclosure is clearly painful and she pauses - overcome with emotion.

The emotion in the interview is familiar to me.  It is how people really describe severe depressions.  They don't recite symptoms in a diagnostic manual, they talk about what the depression means to them and how it affects them and their relationships.  They talk about how it affects their inner life.  They talk about what seems to help and what strategies are useful and not useful.  In the moment, it can be painful to be around a person with depression.  Any empathic person resonates with the emotion in this interview.  At one point Terry Gross apologizes for putting her through it.  Things are tense.

Ms. Brosh talks about the type of interpersonal interaction that was most useful.  She cautions against advice giving like "try yoga" or be thankful for everything that you have and you will come out of your depression.  What was helpful was somebody taking her seriously and listening to her experience especially her thoughts about suicide.  As you listen to the interview she is clearly changed by the depression and has adapted to it.  Her main deterrent to suicide was the impact it would have on the people she loved, but we also hear how tenuous that connection can be during severe depression.  We learn that one of the thoughts that would keep her going if she got depressed again would be the idea that she knows she will come out the other side.  Terry Gross asks her about treatment and whether "any kind of therapy or medication that alleviates some of it?"  She clarifies that she is about 60% recovered.  Despite some initial concerns about medication she found that it (bupropion) was "very helpful".

I found this to be a powerful piece  about depression.  It describes the feeling and thinking state of the depressed person and the associated problems with relatedness.  At one point Terry Gross comments on the artistic aspects of creativity that flows from the depression and Ms. Brosh appreciates than comment.  With all of the abstract discussion of depression in the popular press and the assembly line treatment approach in health care systems, this interview is a more genuine discussion and rich source of information about what it is really like for the person and the struggle to recover.  I highly recommend listening to the audio file and reading the blog.

George Dawson, MD, DFAPA