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.

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