House Call

A primary interest of my work is, “getting to the bottom of it.” What underlies the way we experience and behave in the world. What is the nature of the foundation upon which our house is built. As a way of describing this process of exploration, I begin this blog with a look at the underpinnings and foundation of my perspective. In other words, I wish to give you some idea of, “where I am coming from.”

I am a physician and accustomed to people coming to me for something having to do with feeling and/or functioning better. Through the therapeutic process, some have greatly benefited. So perhaps, I can offer something of value to you, who by virtue of choosing this site are likely looking for the type of help some doctors provide.

My medical knowledge is built on providing help for only two problems; dis-ease/dis-comfort, e.g. pain and/or dis-function. That’s it. Please remove the pain and/or restore function. Doctors diagnose and treat disease. During the course of my career, the medical profession was moved from within and without to consideration of prevention of pain and dis-function. Much to be said for the shift. Is health the absence of dis-ease? Were doctors shifting to health stewards? Possibly, though the prevention suggests doctor as security guard.. A football strategy is called the, “prevent defense.” The sole goal is to not lose in the last minutes of a game. The strategy is well accepted. In most other athletic contexts, when teams or individuals employ the strategy knowingly or unknowingly when in the lead, this defensive posture often results in loss of the lead. Do we want to spend energies worrying about getting sick or losing in all its many forms?

Of course, other motivations may exist for this move toward prevention. Now, we don’t have to be sick to seek medical care. The tent is enlarged and before long we have a medical-industrial complex. Perhaps you would like me to pull back? Isn’t this about helping people feel better? What’s with the editorializing? Seeing how this first blog is something of a mission statement, in keeping with my swerve into business, an “organizational” value. Everything is connected and so grist for my mill and hopefully as we go along, your mill as well. Another value: phenomena of interest in this world is multi-dimensional, layered, sometimes paradoxical or returning to the medical world, with the unintended consequences, e.g., side-effects. Or, there is, “More than meets the eye.”

In addition to diagnosis, treatment and prevention of dis-ease is societal interest in health and by extension, high-level functioning and the general term, well-being. This aspirational interest and the related activities go unnoticed in medical education and conventional medical practice. The life coach, fitness-personal trainer, nutritionist, self-help author and spiritual teacher have filled that space. Also included in that group and fitting for the contemporary world are the technologists who talk of “hacking” our physiology or brain. If technology can increase so many efficiencies in the external world, why not shift that attention and know-how to the internal world.

While addressing the common infirmities, also called disorders and conditions, as well as the trend towards prevention, my practice is strongly directed to this third, seemingly non-medical area of great interest to many. In so doing, among the other implications of this way of seeing the world, you will likely notice my approach towards the dis-ease model will take on a non-medical cast. As an immediate example, the use of a simple hyphen in a word allows new meaning to emerge. This expansion of interest will be apparent in this blog. You might even wonder at times if the writer is a physician. In the work I do with attention on the whole of human experience, aspects other than a conventional medical perspective play a major role in my thinking and practice. For now, best to start at the beginning of my development as a physician.

Looking back to my early days of medical training, the word conscripted comes to mind. Although I chose to become a physician, as part of entering the, “service,” I naturally had to invade and see the blood. I was nervous as a student on call when first being asked to start an IV on a patient. One thing leads to the next, and before long a new sense of self emerges; something ennobling or, “heady” about it all. I can and will be there to do what is needed to help. I seek and even welcome the responsibility, the Hippocratic Oath further infusing me with awareness of sacred privilege.

All true, yet as will always be the case, more to the story. Physicians are trained to diagnose and treat dis-ease. Where is the person in this definition? And where was the person when studying the myriad manifestations of dis-ease? As a medical student on surgery rotation doing rounds with a group of eight or so, the Chief Resident excitingly leading the charge said, “Let’s go see the gall bladder on the sixth floor.” The study of the various systems; gastro-intestinal, circulatory, endocrine,,,,,,,also took on a mechanical quality, as if we were looking at inanimate objects.

The beginning of clinical rotations offered some hope of finding both the patient’s and my humanity through the act of physical diagnosis. We learned to listen to the patient’s story of symptoms, after which we performed the physical exam – touching, listening, seeing and at times, smelling for clues. By looking into the eyes with a certain lens, we could see evidence of hypertension or diabetes. With a reflex hammer, tuning fork, pin and cotton ball, we could surmise the site of the injury to the nervous system. Through the stethoscope was heard the tell tale heart murmur. The diagnostic process was an intellectual and sensory challenge, and particularly to my liking, an art. And then came the treatment side. Once the diagnosis was made, the senior medical students and interns would pull out a pocket sized drug manual informing them of the medication and dosage for all the major illnesses. Now watch for side-effects, change the dosage, the medication or add a medication. This part of doctoring asks and engages very little of me, and as it turns out, very little of the dis-eased. Passive, impersonal and “algorithmic” as some psychiatric residents I have taught say when describing why they chose psychiatry rather than other medical specialities. They look to psychiatry as a branch of medicine where formula, or as it were and is, the formulary is less applicable.

With psychiatry, now at last a person exists. Also, the problem involves everything about us – our thoughts, feelings and behaviors. Or, how we experience and function in our life. What more is there? Here is what’s more. On my first day of the psychiatric rotation, we do rounds with the department chair. Of the ten or so people we saw who were suffering from depression, his treatment decision for most was ECT – electro-convulsive therapy, AKA, shock therapy. Under anesthesia, the person receives electrical current to the brain evoking a controlled convulsion/seizure. As primitive as it sounds and is, the treatment is very effective for some depressive conditions. But this is my introduction to the practice of psychiatry. What happened to talking with patients?

Some “conditions,” and now I’m going to interrupt this telecast…………Time for foundational ideas, or in keeping with the spirit of a mission statement, my values. Words are important. After all, until I begin using other mediums, words are all I have in this forum. I call into question terms like mental – disorder – illness – condition -abnormality. Although this rewording will initially sound unwieldy and contrived, I prefer mindbody rather than mental or physical. More than prefer, using this language helps move us in the overall and much valued direction of connection, and specifically the important relationship mindbody. Maintaining the separation of mind from body is detrimental to addressing the myriad faces of, conditions-disorders….Rather than conditions…. how about the infinite manifestations of mindbody experience, some of which are seriously impairing and/or painful. In these dramatic human experiences, the ability to talk is significantly limited. For these sufferers, therapeutic measures other than or in addition to talking seem to be necessary.

When beginning this blog post, I had some intention to write in an orderly and economic fashion, to in effect, “stay on course,” or, “get in, get out.” I have to abandon this ambition and aesthetic value in favor of a more strongly held and contrasting value. I’ll use the comparison of tourist and traveller. I can ride the tour bus and adhere to a tight schedule spelled out in the itinerary set in advance. Or, with a more general sense of plan, I can wander the side streets, go off road, have an unexpected conversation with a local or follow the scent. The traveller finds his way, the tourist’s way has already been found.

At times you might wonder, “What’s his point,” or, “Where is he going?” The wonder could even turn to irritation, “Get to the point!” To which I would answer, “Looking around as a way of discovering the point is the point.” Writing is a process of discovery, or at least this writing. And by the way, are you in a hurry to get somewhere? Where are you going? Is there something more pressing than how you are going about living in this world. Hopefully, you will find this blog useful, or more importantly, meaningful, in your efforts to craft your life. Or, maybe not. These clothes may be ill fitting, the food too salty or the story hard to follow.

Back on the highway. So, if the sufferer can’t talk, then what. Chlorpromazine, trade name Thorazine came on the market in 1952 and was seen as a dramatic advance in the treatment of the so-called psychotic disorder called, Schizophrenia. The medication markedly reduced the symptoms. Cut to 2021 and medication for the treatment of “mental disorders” is the majority of modern day psychiatrists’ primary, if not sole, therapeutic agent. And this approach is used for people who are fully capable of talking. Psychiatrists are now being trained to practice like the Internal Medicine, now called Primary Doctor physician. Diagnosis – Treatment, primarily through medication, thirty patients a day, in mostly fifteen minute slots.

I became a physician to be a psychoanalyst so that I could help people via the, “Talking Cure,” Psychoanalysis as in Freud, the couch, say what comes to your mind, and analyst to analysand in response to a question, “what are your thoughts?” Much has been and could be said, satirized and argued about Freudian thought, the impact on our culture and the value of the treatment. For now, something less controversial yet germane to the self-admitted, “freely floating” topic. His theory of development brings us smack dab into mindbody. He directs us to our hard-wired animal self, through focus on the undeniable drives to eat, eliminate and procreate. About as basic and foundational as we can get. In his view, suffering stems from the obstacles in us interring with satisfying these biological necessities. Makes sense. Trouble if needs can’t be met. Is this a mind problem or a body problem? For now just consider how these essential, very “bodily” pushes get entangled with our feelings, thoughts and behaviors. How many of us have “issues” around food, digestion and sex. As long as we’re talking foundation, how about adding sleep and energy? And, what kind of life does one have when eating, eliminating and sex are experienced with both sensual pleasure and also as effectively done-satisfied? Although surely more is to life, this degree of mastery and regulation is quite a strong foundation and springboard for living.

A second important Freudian concept is The Unconscious. Seeing as how this aspect of ourselves is hidden, defining it or, “getting at it” will be hinted at rather than, “pinned down.” We may believe, “There is a will, there’s a way.” Can we will ourselves to “just relax” when very anxious? Can willpower keep us on a desired way of eating? Might there be something stronger in us overriding our will?

Why is the athlete who “can’t miss” in a game described as, “unconscious” or playing, “out of her mind?” Why does a great poker player or salesman rely on “tells” in doing their work? And what is a “tell?” A tell is behavior occurring outside of a person’s awareness, yet revealing something significant about the person. Here is my favorite Freud quote: “He who has eyes to see and ears to hear may convince himself no mortal can keep a secret. If his lips are silent, he chatters with his fingertips. Betrayal oozes out of him at every pore.

Imagine understanding a poem only concretely or limiting your description of a movie to the plot, actor names and length. No underlying meaning, no symbolism, no different level of understanding. Is Bob Dylan’s, “Like a Rolling Stone” simply about a stone that rolls? Might there be more meaning to the stone, to the song? Can two or even more levels of reality exist in us? Do we say what we mean? Are we always straight talkers? Consider we conceal without always knowing what we are concealing. We don’t know because whatever “it” is exists outside our conscious awareness, outside our figurative reach.

Speaking of reach, we have voluntary muscles and involuntary muscles. We can consciously choose to reach for anything with our arms and hands. Those muscles are under our control. We have muscles in our intestines and blood vessels outside of conscious reach. Our heart muscles contract whether we like it or not. These involuntary muscles get their walking papers from a system working autonomously. This system truly runs the show and all on its’ own without our input.

This system is formally called the Autonomic Nervous System and further divided into the parasympathetic and sympathetic nervous systems. The parasympathetic system is for resting-digesting and feeding-breeding. The sympathetic system is more activating and involved in the “fight or flight” response. You can see both systems are crucial for keeping us safe, at ease, and functional in the ways we need to be. Disruptions in the ANS account for most of our dis-eases, dis-comforts and dis-functions. Consider The Unconscious as the ANS – out of conscious reach yet of disproportionally greater impact than that which is conscious and within our reach. “Getting with” our ANS-Unconscious – connected and in synch – is central to living well. In other words, good things will come from connecting to that which is outside of our control. Now that idea could easily sound non-sensical. How can we have a relationship with something outside of our reach. When we are considering The Unconscious, rational explanation has its’ limits. Or, The Unconscious follows different rules, has a logic of its’ own. We have to get at it through means different from what we are accustomed.

Speaking of different rules, we highly value certain people who can go where we can’t. We might say they are better able to access that which is hidden or out of reach for most. They are in contact and connection with that which is unknowable in the usual sense of the word and/or obscured due to internal and/or societal prohibition. Howard Stern makes $100,000,000/year. We value him because he can ask any celebrity if they like anal in the same inviting, curious, friendly and matter of fact manner when asking if they like taking walks. “No monitor” is how we describe, and often pejoratively, those people who create discomfort for us by virtue of a vigilance we must maintain in their presence lest they say…….

And what about Robin Williams? From where did his material come and so quickly in the moment? A common description of such an individual is, “Force of Nature.” The Force of Nature is The Unconscious – powerful, dynamic and irrepressible. He could tap into it. Doing so allowed him to make connections we can’t make through, by comparison, plodding rationality and logic. What manifests are novel juxtapositions striking us as hilarious. Let’s add other crowd pleasers who seem possessed of something, “unworldly.” The athlete who is, “really feeling it today,” the baseball batter, “really seeing the ball” or the golfer with great “touch” around the green. The much admired athleticism is from the ability to tap into yet another aspect of our animal selves – the senses. So primordial, so necessary for survival, so innately pleasurable and yet for some reason, what I call deep sense-uality is unavailable for many.

To bring this description to a close while providing a link to the third important Freudian concept, a word on Oprah Winfrey. I believe her unparalleled popularity and financial success was largely due to her accessibility to others which in turn was due to making herself accessible to herself. She revealed herself directly, giving voice to her most personal experiences. She said what many can’t say due to embarrassment or shame or due to somehow blocking the truth of their experience. In other words, relegating thoughts, feelings and memories to a darkened chamber – unidentifiable, effectively unknowable from our conscious awareness. Her disclosures helped us to acknowledge to ourselves and even express the previously hidden.

Through personal revelation, she brought to light the long-term effects of painful, e.g., traumatic experiences of everyday life. Freud believed the nature of early life experience greatly impacted childhood development and by extension, our adult life. So, from adapting to the circumstance of childhood, we develop a characteristic way of thinking, feeling and behaving. We think-believe the world is rejecting, affirming, punitive, promising, deceptive…….We tend to feel anxious, hesitant, optimistic, calm, angry, detached…We tend to be-(have) passive, take charge, procrastinating, withdrawing, forward, argumentative, compliant………..And, these “ways of being” develop without conscious plan, as an almost instinctual response to the experience of our first relationships.

How we experience and behave in the world is predictable. The past predicts the future because we are consistent. In the employment interview, get the prospect to talk about their experience with previous managers, or as the case may be, managees. We predict behavior based on past behavior. The college recruiter or drafting professional team talks to past coaches to determine if the player is coachable. If you get good at it, and we are all hard-wired to to do it, many questions would be unnecessary. Simply observe and reflect on your experience of the person. They are demonstrating live and in color how they are in relationships, in how they relate to you and to themselves. This readily available knowledge is explainable in Freud’s quote and also in the well accepted idiom, “Actions speak louder than words.”

Freud identified this consistency in the term, transference. We transfer our experience wherever we go. In particular, how we experience and act in relationships. We may think we are starting anew. Soon enough comes the same old, same old. Or, try as we might, we continue to get in the same abusive or volatile or distant or,,,,relationship with a nasty or hotheaded or distant or undependable or rejecting…… person. The same story is told. This scenario is true for everyone. Even in the best relationships, everyone has their “stuff,” more commonly called, baggage reflected in recurrent reactions and behaviors leading to spats, blow-outs, silent treatments and “you’re the problem not me” standoffs …….. I am sure you know someone who always provides the latest installment of their grievance with the world, e.g., people. The story, the script, the song, the software is running without our full knowledge – automatic – unconscious.

The practice of psychoanalytic therapy follows from the key ideas I described. At some moment a symptom(s) will emerge – anxiety, headache, fatigue, anger, digestive problems……… The symptom is part of the story. Like a rolling stone, a prominent and difficult to deny element in the song. Options: Try to deny and ignore. When that fails, redouble usual ways of managing – throw self into work, swim more laps, drink, eat…..Those methods fail and sometimes create additional problems – Work now dissatisfying, shoulder strain from swimming, DUI, indigestion….Seek professional help. Natural response is to want to get rid of the symptom. Could be incessant and urgent plea to the doctor. If doctor and pleader on same wavelength – medication to attempt to remove symptom. Perhaps some degree of success. Come back in six weeks with clues to your story now eliminated and therefore nothing to discuss or analyze. You have largely returned to baseline.

Back to trauma. Consider we all have suffered some form of trauma-injury. At the time of injury – fractured foot – we cast it ourselves based on available inner resources. Imperfect fixing of the fracture. Can manage to make of go of life and sometimes surprisingly well. Yet, the foot forever remains vulnerable to Stress. Now we’re talking degrees of shaky foundation. Under the “weight” of stress – the expectable challenges of life – re-injury and now Symptom(s).

Or, we can begin interpreting the song and its’ central symbol – the rolling stone. We can see the symptom-symbol as valued information awaiting connection to all that we are. And being symptomatic provides opportunity because the re-broken foot cries out in pain as it long ago did. Fortunate for us, fixable in a new and better way. After all, we were just children back then with limited resources doing the best we could under the circumstances. So, do you want to look and explore who you are, where you have been, where you want to go……..?

Back again to trauma – a particularly impacting form as in the most noted in our culture – sexual abuse. The actual experience may have been, “forgotten,” residing in our unconscious. Or, the trauma is remembered and the basic facts can even be spoken about. What are “forgotten” are the feelings, the thoughts and behavioral response, as if nothing happened. Again, relegated to the unconscious. So in order to restructure, re-adapt, we have to get access to the unconscious – to give life to what has been instinctively deprived of air, paradoxically, in the attempt to survive.

The symptom is a message from the unconscious. The bodymind experience has broken through to conscious awareness. The rolling stone is the first thing popping into Dylan’s consciousness. He works it, starts writing, explores – new symbols emerge – connections are made to something bigger – much bigger than a rolling stone. He has a new song – a new story. He is more alive. We are more alive because of him and all the other artists who can access our deepest parts. We can do this for ourselves – create something new in the discovering, or is it re-discovey of our, at one time by necessity, shut off and down personal and shared humanity. And lest you think the symptom has been left festering, this therapy typically alleviates the presenting symptom quickly without even directly focusing on it.

So now my work involves guiding the exploration of you; anything and everything, towards the goal of greater freedom, effectiveness and well-being. Or, helping you to get unstuck so as to grow and evolve; expanding your repertoire – tools for navigating the endless challenges of living. Like a marketer, sounds good – promising, heading for blue skies……Here’s a big catch: The process takes place in the context of a relationship. How we experience and behave in relationships is ultimately where the action is in terms of our experience in life and how we act in our life. And our relationship with ourself, others and the world at large is for many of us, at some level, fraught. Working with or managing a person in the business world, coaching an athlete, raising a child, being raised as a child or treating a sufferer means encountering the dynamics, rarely uncomplicated dynamics of relationships. The four year-old makes one of the possible hitches perfectly clear to the parent in this oft-heard challenge – assertion -disputation, and truth be told, insight, “You’re not the boss of me.”

Many schools of psychotherapy exist. Many professionals do psychotherapy. Many also will contrast their approach from anything having to do with the Freudian perspective. The creation or discovery of psychoanalysis was the formal beginning of modern day psychotherapy. Most all subsequent forms retain aspects of what Freud created, including more modern psychoanalytic thinking. At least one important distinction exists. Psychoanalysis, unlike the preponderance of existing psychotherapies views the relationship between therapist-analyst and analysand as a central focus of attention in the process. Enough for now about the theory and practice of psychoanalysis. Suffice it to say, just as medical training and psychiatric training equipped me in specific, overlapping and different ways to help me help others in the face of wide ranging, often intense human experience, psychoanalytic training has done so as well.

And now the limitations. Psychoanalytic therapy is lengthy, time consuming and expensive. We live in a different world from which it originated and was accepted. Some updating is necessary to better fit the times. The talk of making connections and understanding oneself is often very satisfying and energizing, though not necessarily leading to behavioral shifts. For me, the process, given Freud’s emphasis on our biological selves can ironically have a mind without body quality. The instinctual is insufficiently engaged. To make a musical analogy, emphasis can too easily be on the lyrics rather than music, the latter containing the raw emotion, and taking liberty with language, the viscerality.

In the years since psychoanalytic training, I have discovered other therapies, experiences and techniques which work faster, penetrate to the deepest parts of ourselves, disrupt behavioral patterns, create new pathways in the brain, e.g. mindbody and are of the times. Rather than a psychoanalyst, a different label for now would be eclectic physician-psychotherapist. In the next blog I will describe other experiences that have contributed to my perspective and practice.