Avant Garde Psychiatry

I see my early life as divided into distinct stages: the first decade was a time of innocence and wonderment, the second decade a grand rehearsal for adulthood. Young adulthood had not begun until I turned 20. That order of my early life seems quaint today. In our 21st century Western society, we have a “cultural growth spurt”: innocence gives way at 6, adulthood rehearsal occurs in preteens, which turns into “adulthood” in middle and late teenage years. Consequently, many arrive at their actual young adulthood jaded, wizened and bored.

While young people experience maturity at an accelerated pace, our instincts cannot be pushed to match the rapid social and cultural changes. Thus, the juxtaposition of contemporary experience and ancient instincts is more a collision course than a harmonious shared journey.

This interplay between nature and nurture is made even more discordant by the breakneck, exponential progress of modern technology. This is a very recent phenomenon. In the past 10,000 years, from early agricultural society until 300 years ago, every member of a generation could expect to live life analogous to the previous generation or the future one. Every generation was identical in all aspects of daily life: The velocity of travel, life expectancy, the total dependency on the elements; all have barely progressed throughout the millennia. Humans lived in moving frames of a “perceptual here and now”, invariably bound by the limits of their senses. The elders were seen as a possessing trove of information by experience, something that the “Google generation” finds useless and quaint.

In recent time, and especially over the last 50 years, we have advanced so far, that other than the laws of physics nothing seems to limit our senses, and our perceptual experience, from endlessly expanding. The artificial expansion of our senses, the ability to hear and see far distances and into the past, the velocity of travel, the boundless communication, the immediacy of information all give us powers unimagined a hundred years ago.  But what about our instincts? They have had no chance to correspond in similar expansion. They take a very long time to change: in fact, only a thin veneer of culture separates us instinctually from other mammals. Our emotional life, while sophisticated compared to other primates, had not been challenged by rapidly added abilities until the industrial revolution. The discrepancy that exists between our everyday life and our inner world is growing: we are emotionally akin to a toddler operating a space shuttle. The automatic pilot is on and as long as nothing unusual happens, and the toddler does not touch anything detrimental we have the illusion of adequacy.  But it seems to me that handling adversity has become increasingly inefficient. Further, there are numerous new challenges, some developed as recently as 10 years ago. The contemporary psychiatrist cannot take comfort from the permanence of human nature. In a way, human nature is struggling under the increasing assault on what used to be our boundaries. I made up the notion of “Avant-garde psychiatry” in order to examine this unprecedented friction between nature and nurture – between our mammal core and technological abilities.

Instant messaging gets a prominent place in “Avant-garde Psychiatry”. Anyone who ever waited for an important letter to arrive would have had a particular wait time in mind – several days – and particular time frame – once a day for mail delivery.  The agonizing anticipation got resolved once a day – the letter has either arrived or not. If not, the anticipatory clock would stop until the next mail delivery.  Now, an unanswered text (and to an extend an email) starts annoying within minutes of sending yours and continues unabated until you get an answer.  Anything other than an immediate response starts a little nucleus of discomfort in the back of your mind.  This discomfort is often minimal and replaced eventually with similar, newly unanswered discomforts. Of course, text messages differ in importance: An unanswered text to a potential lover becomes exponentially intolerable and often paralyzing. Some develop a psychiatric problem living in constant fear of “the silent treatment” and often experience lack of an answer as one.  The immediacy of communication, especially of the aptly named instant messaging, confuses the senses into believing the texters are having an actual dialogue. In any type of conversation getting no acknowledgment and response, is stressful and often rage provoking. The drift from written communications like letters and faxes to written conversation has not created a similar change in how we perceive it. We use instant messaging – a type of written communication – with the inner rules of conversations: our feelings and perceptions are mismatched. Many develop “instant messaging tension” which a similar, phone conversation would never provoke.

Another consequence of texting is “anxious re-reading” and “over sharing”. We do not have to struggle to remember what was said since our text “conversations” are available for rereading. Those who suffer at baseline from anxious ruminations tend to develop anxious rereading which is equally painful. Worse, we often combine anxious re-reading with oversharing; another digital phenomenon. In oversharing, many who would have never dreamt to secretly record and share phone conversations, see no issue with sharing their text conversations with others. Interestingly, the more personal the exchange the more likely it is to be shared with others. The anxious re-reader overshares the intimate conversation attempting to gain insight for hidden meaning. The question “what did he/she mean by that?” can occupy 3 girlfriends for an entire evening even if there is nothing unusual about the text, and nothing unusual was meant. While in itself not a psychiatric problem, text re-reading and oversharing offers a totally new way for distraction.  We get distracted by texts when we sleep, we get distracted while we drive, work, eat, watch television, and are often “engaged” in and endless group “chat”.  Most texts provide unimportant information, and many can wait.  But the immediacy and accessibility of texts, anytime and anywhere, is astonishing. Only fifteen years have passed from never having texted in history to the development of a compulsion to read a new text, respond immediately and wait for an answer in ever multiplying loops.  I cannot think of anything similar that went from nothing to permeating any personal space or time, in merely 10 years.  What does it do to our psyche?

Psychiatrists have always relied on Human nature as a basic point of reference.  It is therefore quite unsettling to observe human nature rapidly mutating in front of our eyes.    Many inventions deemed essential for the moment, have dwindled in popularity and all but disappeared.  But the new format of communication is not going away.  Because it addresses an essential, unmet need of humanity: It enhances our conscious, word -based communication, at the expense of nonverbal and subconscious transmission of information. This triumph of word based communication is apparently so satisfying that we are willing to give up all vestiges of freed attention that could have been dedicated to merely sitting and thinking.

The brain performs most of its activities close to the speed of light as it transmits and receives information without our conscious awareness.   Conscious thinking is not fast enough to decide instantly what should be screened out and what should be focused on. Hence our attention span shifts slower to enable us to decide what information is worthy of attending to. Communicating via text is akin to being surrounded by many people all talk to us at the same time about different issues, while being unaware of the others.  The unfettered immediacy of text communication interferes with our ability to triage information and decide what is important and what is not.  Several aspects of communication have to be sacrificed for that immediacy: the most important being the absence of emotional modulation.  Our communication evolved from the dense, multi sensorial expression we shared with our primate cousins. The development of verbal language offered accurate communication in large groups, without losing the nonverbal nuances. Texting as conversation is dry and cryptic, word-based communication. This self-imposed simplicity and emotional poverty over our communications leads to the ever-increasing banality of contemporary discourse.  But the really interesting question is how does it affect the way we interact with our own self.  Would you adhere to the nonverbal abstract and emotionally nuanced way you communicate with yourself?  Or would the new, increasingly concrete communication modality, take over your inner world?

Contemporary psychiatry has to be Avant-garde.  Literally ahead of the times as new inventions challenge our instincts and senses at a breakneck pace.  The voyeurism of Instagram, the urgency of dating apps, the giddiness of snapchat and the bonhomie of Facebook – all those have existed in more crude forms. They are all built around our ancient instincts:  curiosity, community, and desire to mate.  But the mind has never had something like texting (or other instant messaging modes).  Blogs and tweets and talkbacks, have democratized the public space, and created new venue for people to broadcast their opinions and thoughts.  But texting has never been here before.  We never had this ability to communicate with anyone in the world, whenever and wherever they are, predicated on brief, word based transmissions, where “emoticons” serve as the affecting melody.   The rate and universal enthusiasm by which we made texting into an ever-present, essential and addictive aspect of our lives indicates some primal power at play, catapulting us to unchartered terrain.  The promise of “wearables” – the applewatch3 can fully replace the mobile phone – portends further diminution of self-reflection.  We are going to wear our communication device 24/7 offering uninterrupted entry to our attention.  And to think that mobile telephone in its current permutation is less than 15 years old. Exposed to this constant external attention grabber, what attention would be left for communication with our own self? How can our internal needs (already mostly ignored, suppressed and denied), compete with the avalanche of bite size information? Avant-garde psychiatry is like the sierra club. Fighting to preserve what is becoming extinct by raising awareness to the consequences of those extinctions

As is aptly demonstrated by the current American regime, a brave new world in which communication devolves to the “nuance” equivalent of grunts, but the technology is nuclear, is not that safe for the future.

Hunger, Diet and Lies – the problem with losing weight in societies of plenty

Some years ago, a colleague told me that he is embarking on a new weight loss program.  It was purportedly based on cutting edge metabolic concepts, thus, producing a high rate of success without really eating less. It is about “boosting the metabolism”: It was easy, it made you thin a long while – for life!

My colleague was very excited. The following week I saw him and asked how it was going.  He was crushed: “it’s a diet!…” he exclaimed with profound disappointment. He stopped dieting a few days later.

Therein lies a major problem for those who struggle for years with the desire for weight loss. We hope that we could lose weight without feeling hungry. We find the feeling of hunger intolerable – we must vanquish it before it even starts!  Our relationship with hunger has changed in modern times. What those of us in the society of plenty call hunger is very different from what people who don’t have enough food experience. In fact, our instinctive reliance on the assured availability of food – something that billions in the world cannot even fathom – has caused us to lose our tolerance for being hungry.

On the other hand, being overweight – a desirable trait once strictly the domain of the wealthy and powerful – became associated with possessing lower economic status, and being unhealthy and physically and aesthetically undesirable. Many overweight people are discriminated against, maligned by health professional and ridiculed and bullied as kids. The hip culture’s control over advertising, visual image, fashion, and social media vehemently denounces fat unless concentrated in the “right places” decided by “fat setters”. Whether for health reasons, social success, or self-image, the pressure to lose weight (or its more ruinous cousin – be skinny) is enormous.

The dilemma for those who want to lose weight is quiet clear – you cannot lose weight without being hungry – literally. Hunger, like thirst, is how your body notifies you it is getting too little nutrition to continue without using the reserves, which is exactly what we want when dieting. But our threshold for hunger is very low and our tolerance to it is even lower.

In fact, an entire diet industry is out there to convince you that there is a way around the feeling of hunger. Their promise: You can use your nutritional reserves (i.e., lose fat) without your body realizing it. “Unaware” of the caloric deprivation, your body would not sound the intolerable warning – hunger.

The failure to lose weight involves two types of lies. First, are the lies you tell yourself either by minimizing what you actually consume, or by repeatedly making yourself promises that you are unlikely to fulfill (“tomorrow I will really start dieting!”). Second, are the lies you tell your body hoping it would not notice the actual number of calories you consume (“I eat only healthy calories”, “everyone else had two deserts”, “I only ate half a doughnut”, etc. ). This particular “bargaining dialogue” with your body is unlikely to be successful as you and your body are at cross purposes: you want your body not to notice certain calories (“this is Carob not chocolate”). Your body, on the other hand, has evolved over millions of years where calories were scarce, hard to get and uncertain. It has the opposite mechanism you hope for: It knows how to use every calorie you consume, and those you don’t immediately need get stored in case the next meal would not be available for a while.

An attempt to convince your body that calories from Carob somehow don’t count, or that certain foods have different caloric meaning according to say, your blood type (!) and even weirder, anti-physiological “strategies”, is doomed to fail. The vast majority of overweight people who have normal caloric absorption in their intestines – are typically struggling for most of their lives with the pesky 15 to 30 pounds of unwanted weight. People who suffer from certain chronic medical conditions or from obesity are dealing with other physiological dimensions and require a different look into their weight gain or loss. But for the average overweight adult the following tenets should suffice to lose the weight they want to lose and even better, keep it off.

Effectively there are three types of diet:

  1. Diet for weight gain
  2. Diet for weight maintenance
  3. Diet for weight loss

Accordingly, there are three clear rules:

If you want to gain weight eat more calories than what your body needs.

If you want to maintain your current weight eat more or less what your body needs.

If you want to lose weight eat less than what your body needs.

That’s it.

What your body needs should be determined individually but essentially, in order to lose a pound a week you need to eat 500 calories less than the number you need to maintain your weight. Remember: your body needs daily the same number of calories; if you eat less than it needs it would not “suffice” with what you give it – it would use the caloric reserves to reach the same number, i.e., it would start to consume your fat deposits.

Please consider that diet number 3 – for weight loss – entails dealing with the great intolerable – hunger.  You cannot give your body less than what it needs without feeling hungry.  We have different thresholds for feeling hungry, some get used to it and some cannot tolerate even the thought of it.  But a diet without the feeling of hunger is not going to succeed.

The good news is that in order to lose 10 pounds you need to diet for 10 weeks. That is 2 and a half months.  Some lose weight more slowly than others, and they may need more than 10 weeks to lose 10 pounds but the idea is that diet for weight loss is NOT a way of life.

I know that many diet consultants would have you believe that in order to lose weight you should adopt a new life style of eating a certain way and exercising. That is true but for weight maintenance and not for weight loss. The difficult psychological toll of a diet is the inner struggle against self-deprivation. Think about it:  you want to eat now, your body wants you to eat now, and yet you consciously deprive yourself of those immediate wishes for the sake of a non–immediate outcome. This is a very hard struggle; it is the major hurdle to maintaining and completing a weight loss diet. But the emphasis is on complete : a weight loss diet should have a finish line since you cannot afford to lose weight indefinitely!  A weight loss diet is not a life style – it is a temporary, unpleasant deprivation for a very clear goal.  Weight maintenance is a life style choice.  Staying around the amount of calories your body needs per day and restricting fluctuations to about 3 pounds up and down would make sure to maintain the weight at which you wish to remain. And an added bonus is that you would have a better quality of life, sleep better, have or develop less aches and pains and be more energetic. A weight loss diet is unpleasant but limited in time ( I remind you that we refer to the ubiquitous 15 pounds of weight many wish to lose and not to those who experience obesity.)  Weight maintenance means you eat what you need, and some days what you want, while being aware of your caloric intake and weight and in control of both.  This is a good, doable life choice that can eliminate the cycles of weight yo-yo with its great disruption of metabolic stability and health. Being in control of your intake and weight can halt once and for all the waves of guilt, self-recrimination and loathing and the sense of always being a bit out of control due to the unsuccessful struggle with your weight. What you need is a brief period of weight loss diet replaced by a long-term life choice to pursue a weight maintenance diet and avoid eating for weight gain. This is all you need to be rid of your S&M relationship with food.

I can imagine that at this point you are disappointed: where is the trick? Where is the secret to make weight loss diet pleasant, nonintrusive and lasting?  Perhaps some food combinations? Or foods that should not be mixed? Or hypoglycemic sugars? Or metabolic boosters? Something, anything that will promise us that diet is going to be painless, by tricking our body to use the fat reserves while inducing no hunger bells, i.e., still eating as much or more than we need – like stealing something without triggering the alarm.

The secret is that there is no trick.  The only way to trick your body is by interfering with the hunger and satiety mechanisms.  As we increase our understanding about leptin and ghrelin – the “appetite hormones” – we may soon able to tweak them. Within the next decade, some manipulations of the brain’s “appetite centers” may abolish the feeling of hunger even if we eat for weight loss.

But is it going to be the end of fear of dieting? Of course not. Most people (and other animals) in areas and periods of plenty, eat more than they need to function. Indeed, the brain rewards eating by releasing pleasure inducing substances. The ever presence of plentiful food, especially one deemed tasty, causes craving and addiction not unlike other pleasure principle substances or activities. We do not eat because we are hungry – hence controlling hunger would result only in partial reduction in failure (failure to lose weight, to maintain the new weight or failure in both).

In truth diet for weight loss stinks!

What about exercise and physical activity?

The vital importance and benefits of being physically active are beyond question. I suspect that many non-athletes are committing to exercise with the goal of losing weight. The logic goes as follows: “I burn calories when I am physically active: I cancel out my caloric intake by ‘burning calories’ through exercise – If I exercise vigorously enough, I would be able to lose weight without eating less.”

In reality, the connection between what we eat and how we burn it is for the most part out of our hands. Our metabolism is fortunately not under our conscious control much like our breathing isn’t, and for a good reason: Had our physiological activities (of which millions occur every second) been under our conscious control we would have died before completing our first breath! Sure, we have some latitude: we are in charge of the fuel and liquid intake, the environment where we choose to put ourselves into, the amount of physical activity we perform, how much we sleep, whether we consume substances that are deleterious to our health, in short most of the interactions between our body and its environment. The rest, whatever happens inside the body, our cells, their relationship to each other and the minute by minute homeostasis and balance, is left to the “automatic” control of the body. Our body and all of its functions are a “driverless” car, best left to its own.

But what about what we call our metabolism? Most of us are confused about what metabolism actually means. The simplest definition I could google is: “Metabolism is the chemical processes that occur within a living organism in order to maintain life.” This succinct statement encompasses virtually millions of complex activities that occur in the body at all times. The energy for the physiological activities is measured in calories. The body needs a certain supply of calories to maintain all life functions inside it. This happens whether we lie in bed or run 10 miles. Which is a good place to point out an evolutionary mechanism: We evolved to be active especially as it pertains to finding food, escaping predators and interacting with our environment.  What we now call exercise was once considered simply daily activities. Since it took such effort to find food, it made sense that the act of finding food would not cost a lot of energy – otherwise it defies the purpose. Therefore, physical activity, even strenuous exercise, does not cost a great deal of energy.  The body goes through the daily energetic requirements that are essential and mostly unchanged day to day. In other words, exercise burns a very small number of calories compared with the basic metabolic needs of the body.

The physical activity industry is extolling the virtues of exercise for weight loss by “burning calories”.  While these notions of “burning” and “calories” are nebulous and at best inaccurate, the problem is not merely semantic. Many people turn to exercise with the hope of losing weight. As it does not happen (certainly without a diet for weight loss) many become disappointed and drop out of physical activity. Some essential physical activities that are touted for weight loss – especially walking –are often neglected. Consequently, the majority of people who are not athletically inclined have an ebb and flow relationship with physical activity. Resolutions, new exercise fads, clothes that don’t fit, a special occasion, a medical scare, all ignite briefly an acute determination to exercise for weight loss, only to become disappointed by lack of change on the scale and of waist size. Discouraged, many descend back into the sedentary life so typical of  the American life style.

To reiterate, physical activity of any sort is essential to our health and wellbeing.  But it is not essential to weight loss, and certainly cannot make the body lose weight without dieting for weight loss – meaning consuming less calories than the basal physiological needs require.  Then and only then, would the body be forced to use its energy storage – our fat deposits.

As I mentioned above, dieting for weight loss sucks! Dieting for weight loss entails deprivation, feelings of hunger, and a great deal of discipline and self-control. The idea that diet can somehow be fun, care free activity, is an illusion promulgated by those who spare the overweight public the burden of an inconvenient truth. While many are set for failure due to misinformation and unrealistic expectations, the politics and financial interests behind the “eat more” society are making sure we eat more then we need and spend more time sedentarily absorbed in screens and hope for the best. (For a great discussion about the politics behind weight gain I highly recommend the book  “Why Calories Count – From Science to Politics” By Marion Nestle and Malden Nesheim – both professors of nutritional science. The authors discuss the politics and finance behind our “eat more” society and how it promotes the obesity problem that interferes with millions of lives in terms of quality, longevity and physical and emotional well being.)

I personally believe that since a successful diet, any kind of diet, is a function of adherence, and adherence is a function of personal choice it is important to state the basic tenets clearly and simply. If stated unadorned and practical, using the truth – even the inconvenient one – the potential dieter would be informed enough to make his or her own choices, understand the obstacles and embark on an open-eyed strategy.  Only when the expectations and the course of action are clear and a reasonable time limit is set, can a diet for weight loss succeed. The more rules, regulations, changes, steps, food combinations etc., the less successful the dieter would be. Also, the more complicated the diet, the greater is the chance that it hides beneath its ostensible “scientific” glint some inconvenient facts about weight loss and hunger and unsuccessful lies.

Here are my 10 tenets of weight loss:

  1. You cannot “trick” your body. It would use the fat reserves only when not getting enough calories from your nutrition.
  2. Everything digestible you eat, breaks down to the tiniest elements and gets absorbed into the body.
  3. Metabolism is a process that happens in every cell of the body. You do not control your metabolism nor are you able to “manipulate” it
  4. Most of the calories we consume go into routine life processes. Physical activity consumes less than 10 percent of the calories we eat. Unless you are an athlete, exercise does not contribute significantly to weight loss.
  5. Most overweight people do not have hormonal reasons for becoming and staying overweight.
  6. Successful weight loss diet is a daily commitment for a limited time. It is not a “life style” change.
  7. Any time you eat more calories than what your body needs – you are eating for weight gain.
  8. It is helpful to use an app for calories journaling provided you do not cheat and/or deduct calories “burned” by exercise.
  9. It is helpful to weigh yourself frequently to make lying to yourself harder to do.
  10. Every person can lose weight. In times of starvation there are no overweight people.

In short, the inescapable simple strategy for successfully losing weight is consuming less calories than one needs.

Diet is a difficult and unpleasant commitment. It is an act of continuous self-deprivation, it can put you in a bad mood, and cannot be sustained over long periods of time.  However, it is safe to say that no one can diet on your behalf. It is a decision that you need to make, a commitment that you need to keep, temptations that you need to resist, and deprivation you must impose on yourself.  Most overweight people would have preferred to lose some weight and had it been easy many would have succeeded. With the realities of our life, with plenty of calories to consume, many are unsuccessful.v

Science continues to break new frontiers and perhaps someday humans would lose weight without skimping on calories or food. Perhaps it would happen in your lifetime and you prefer to wait for that amazing breakthrough. It is of course up to you. Both weight loss and weight gain can be viewed as opposite ends of the same spectrum. With the years, we tend to gravitate closer to the weight gain side. It is no wonder: our body wants us to eat and rest. It evolved when hunger and strenuous physical activity were daily realities. We had to eat little and work hard and had very little leisure and very short life. So eating more and moving less is actually natural and aligned with our body and we get rewarded for that by our brain.  So it makes sense that most of us prefer to rest and eat more. In order to lose weight, you need to struggle with your body’s natural tendencies, hence give up certain pleasures and be miserable for a while. But this is also what makes losing weight so rewarding: not only are you going to feel lighter and better. You would enjoy the sense of satisfaction of having made a positive decision for your life and having accomplished it.  This is one of those wonderful accomplishments that you can claim all the credit for. And it is up to you.



Closure and other unhelpful memes

Definition of Meme: an idea, behavior, style, or usage that spreads from person to person within a culture.

Memes (discrete units of knowledge, gossip, jokes and so on) are to culture what genes are to life. Just as biological evolution is driven by the survival of the fittest genes in the gene pool, cultural evolution may be driven by the most successful memes. — Richard Dawkins

In my time as unit chief at Mount Sinai Medical Center in New York, I sat in many team meetings. Those were comprised of different disciplines typically present on a psychiatric in-patient unit. One day in discussing a certain patient on the team I asked a colleague how she intended to go about treating him. Her answer, given with firm certitude, was: “We have to strengthen his ego”.  I looked around me, earnest intelligent faces of dedicated professionals, all beamed with a certain satisfaction: We have a strategy for this patient! I could not help myself: “and how do you suggest we go about strengthening his ego? I asked half facetiously. I am still waiting for the answer.

I view the use of memes as an expression of mental laziness akin to driving the 4 blocks to the dry cleaners. We slip each other words that describe whole concepts, unexamined and painfully inaccurate. “Strengthening the Ego” “Love”,” hate”, “happiness”, “overreaction”, “too much”,  “not enough” and so many others – some hip, some lame but all products of the “thinking in a nutshell” mentality.  We package dried essence of complex notions into convenient and easy to swallow capsules.  We say words to describe particular emotions without context (Next time you are angry, stop and think at what or with whom before you say it.  You’d be surprised how discovering a context – however superficial –  can help in dealing with your unpleasant feelings.)

Granted, in everyday parlance we are not concerned that our conversant might miss the depth and breadth of our connotations. Listening to random conversations, or watching TV makes it easy to assume that most people simply don’t care what weight their words carry, have nothing special to say, or both:  so the vagueness of their statements is not an obstacle to most discussions.  In fact, those who labor to make themselves clear and precise are often seen as pretentious or tiresome bores.

An area where the lazy use of vague memes is unacceptable is in the medical and psychiatric dialogue. Therapeutic conversation cannot be based on vagueness. The internist would ask you where does it hurt, and the psychiatrist would ask you what do you mean by the expression/word you just used. Whereas most people can pinpoint a pain to a certain area, one discovers that in psychiatry the situation is completely different. Even when pressed, most people identify the “good” reason rather than the “real” reason for their emotional pain. I do not suggest that people are intentionally obfuscating how they truly feel, or why, from their psychiatrists. We have emulated memes to such an extent, that we use them even in our private of privates, even in our inner world. You may be tormented for a long time by a certain meme of a concept that can be proven false and needlessly injurious, and be freed from it in one or two sessions.

The word “closure” is one of my pet peeves. Its basic definition is: “an often comforting or satisfying sense of finality.”  The meme’s connotation, especially in romantic disappointment, goes something like this: understanding the relationship, why and what went wrong, and what happened around the breakup (before during and after).  However, the meme does not say who gives the sense of closure.  And many feel they need to “get closure” from the ex-romantic partner.  That of course is a catch 22 since as long as you feel you need closure from someone, especially from an ex romantic partner, you cannot really “get closure”.  Instead of cutting this painful branch of your life, you continue to need the person who hurt you, if only for “a closure”.   When you actually stop and think about what is a closure, why do you need it and who should grant it, the burden of “waiting for a closure” becomes vastly more manageable.

To paraphrase Socrates “The unexamined meme is not worth keeping”.  We so often find ourselves ensnared by murky nebulous concepts.  Take happiness:  Most people, certainly the younger, aspire to be happy.  Yet it is very difficult to be (or feel) happy and very easy to become sad or unhappy. Further, it is difficult to overcome unhappiness and very easy to lose happiness.  We are clearly not “wired for happiness”.  And yet happiness is always on top of our wishes and aspirations.   We have chosen the most elusive and unreliable sentiments as our most urgently desirable ambition.  What a terrible mistake.  How many people have spent years of their life, feeling robbed of something that was never theirs (or any other person’s) to have.  Progressively bitter, disappointed and farther away from the beguiling shores of unattainable illusion.

Another unhelpful meme is unconditional love. The term love, once a mythical meme, is surprisingly insipid in its contemporary everyday use: “I love Iced coffee”, “I love my yoga teacher” etc.  It now mostly means “I feel good about it” – when “it” is something that you like and wish to continue to associate with. But what about someone you believe you are supposed to love in a stronger more consistent way, for example your romantic partner?  Often, we feel that our love needs to be unconditional, through thick and thin. Simply put, unconditional love means that there are few conditions that can compromise your love for a certain person. This of course is not possible: our love waxes and wanes as life supplies an endless stream of conditions that interfere with our love to someone or something.  We can love someone and then feel resentment, and annoyance, and fondness, and tenderness and rage all in the span of a few hours and often intermingled into a jumble of feelings.  In fact, the closer the person the more complex the feeling and the less chance for having any sort of “unconditional” emotions.  And yet many people spend periods of terror realizing they resent their spouse or failing to feel “steady love”.  Feeling resentment toward a person you are supposed to love is scary: “Is the relationship deteriorating? “.  Perhaps, but not for having unsteady, “conditional” love.  In fact, love for another person should be conditional.  If it isn’t conditional, you are in trouble for allowing your feelings for another person become independent from who they are and what they do. The more your feelings reflect the reality of your relationship, the better chance they have to grow and prosper.

Which bring me to another unhelpful meme – ruinous in fact-  the notion of “being in love”. In my line of work, I often attend hearings in family court.  Many people who are getting divorced and feel mostly resentment and acrimony towards their spouse, tell me the reason they got married was “falling in love” with each other. While my impressions are limited by scope and geography, I think it is safe to assume that most unarranged marriages were fueled by being in love with the future spouse. Now bitter and mistaken they wonder what were they thinking to marry that person. When pressed, most answer that “he” or “she” was different at the beginning. So they fell in love with someone who was different and indeed people change over the years. But is it possible that you were in love with someone who mutated into a totally different person? Is it possible that the person you initially thought was worthy of choosing as a life partner morphed into someone you now despise and cannot wait to break away from? Perhaps. But it is also possible that it was you who changed.  You fell in love with someone which means your emotional “high” stood in the way of your rational appraisal – you were as fit to make a decision as someone who is drunk or high on cocaine.

When the grounds for marriage is “being in love” you risk marrying someone different from the flesh and blood person. How different depends on how skilled you are in lying to yourself.  Those who are masterful in it often end up having bad life. They married someone who is not who they fantasied, and use self lies to convince themselves to do nothing about it.  If you are lucky, that momentary lapse of reason would turn out a winning gamble. Of course, much is dependent on ongoing mutual growth as a couple. But it is still a gamble, an impulse buy that turns out to be disastrous for many stuck in living together. Once so much in love with each other, they relate to each other as two disdainful inmates stuck together in one prison cell.

Spend some time amidst toddlers. They are full of wonderment, original and quirky thinking and idiosyncratic use of language. But they cannot collaborate beyond parallel play, without a standard use of language. Verbal communication transformed us, weak primates, into effective coherent groups, capable at first of hunting down huge prey and eventually of taking over the world. No wonder we believe there is power in numbers, hence submit ourselves to linguistic common denominator: we make use of convenient memes to communicate efficiently even if what we say is sloppy, inaccurate approximation of what we could have said. If you pondered at 10 what is the meaning of the word love and how it is related to how you feel, you realize that pondering the subtle hues of a concept works for you only if it is new. Sooner than later every new concept no matter how exciting falls into the homogenizing machine and becomes a nebulous meme. But what about your conversations with yourself?  Why communicate with yourself according to the lowest common verbal denominator?  After all you have a denominator of one with yourself. There is no reason for mediocracy in your own inner dialogue while you are the only one who can truly understand you without words. In a way, the use of preverbal communication, the one you had before you learned language, is actually preferable. The words, and especially the unexamined concepts are often the source of unnecessary pain. You pace relentlessly in your mind’s inner prison, unwittingly manufacturing causes for disappointments, feeling robbed of what has never been yours, and growing increasingly bitter at the unfairness of your life. That unhelpful way of living is actually a choice:  much like choosing active life style over sedentary ones, learning something new over passively absorbing the bombardment of inane drivel we get from media sources, you can choose to define your own concepts to yourself, in any way you want to. If you choose to continue to use unexamined memes in your own inner world don’t be surprised to find out that you are not “happy”, that being “in love” was a mistaken premise for tying the knot, that you cannot “get closure” from others, that you can achieve no “success” and so on.  Common denominator works for physical things: most people would agree about what makes something first class and why it is better than second class. Most people react with wonderment to a beautiful sunset, or colorful butterflies, or the scent of flowering jasmine. Colorful is better for us than gray, cool breeze better than hot humidity: there are so many concepts we can agree about without having to explain.  But there is no universal love, or happiness, or success, or resolution, etc.  those are truly in the eyes of the beholder.  You are the beholder of your life: you are in charge of chronicling and giving meaning to your feelings, your beliefs and your thoughts.

Consider: you rarely meet a “soulmate”, someone who knows how you feel, what you believe and what you are thinking. This is not a common experience. Rather, we mostly suffice with approximation, recognizing that we cannot be fully understood by the others, no matter how much we want them to. We want so much to be understood that we barter the infant preverbal subtlety for a tired, conceptual uniformity.

Is it a problem?  Not really. As species, we committed to our type of language, one that is meant to convey complex concepts in a terse direct way. Saying “The space shuttle exploded two minutes after take-off” brings the listeners up to speed about a special situation, without lingering on the numerous issues revolving this event. Most feel very uncomfortable with saying nothing. People who follow a vow of silence are seen with curious awe as if they were extraterrestrial. We want to know what is going on, we want to tell what is going on, we are constantly talking to each other. For myself, I prefer to ponder relevant concepts in the privacy of my inner world. I don’t need language, words for my inner dialogue. I can understand myself without words: much like my dreams do not obey any known physical laws, my inner dialogue does not follow any linguistic structure. Why should I adopt unexamined concepts to animate the way I think about my own life?

Practicing medicine and especially psychiatry, has taught me not to assume on behalf of my patients. I also do not suggest to anyone what to think or what to feel. But I can suggest how to think about certain concepts. I suggest how to think about something the way a yoga teacher suggest how to hold a posture in a more efficient way. Next time that you feel bitter or disappointed at the way your life has become, promise yourself to spend some time thinking about the terms you are using to evaluate your successes and failures, your relationship with others, and most of all your relationship with yourself.  Remind yourself every day: 1. that this is your only life, 2. that you are destined to live it as yourself, 3. that you bear the outcome of your decisions and 4. that you are free to define yourself to yourself in any way you want provided you do not expect the others to agree with you.

Forgetting those four simple principles may result in you pretending that this is not your only life, that you can live them as someone else, that your decisions and choices have little bearing on you, and the most self-crushing: defining yourself by the opinions of others. Sadly, many people abandon the reality of their life for some beguiling but unreal alternatives. Those who live fake life becomes increasingly bitter: “this is not the life I was supposed to have”. Well of course it isn’t! you chose to live a life different from the one you were supposed to have. It is never too late to live your life as you and nobody else.  You will be amazed at how natural it would feel to be you.

” You have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist”.  Friedrich Nietzsche


Planning for your Past

It’s springtime, and as nature flares with abundance in my garden, the squirrels are roaming happily, anticipating the prosperity of the coming months. But every fall, as they become busy collecting acorns from the old oak tree and stashing them in their winter pantry, I wonder if they are saying to themselves: “very soon the air will freeze, there will be no food available and the ground would be covered with snow – better collect acorns now and prepare for the winter.” Who knows? But for us, humans, planning ahead is constantly on our mind. We fantasize the future ahead of us: we prepare clothes for tomorrow, we plan our vacation, and we even brush our teeth so they would not decay years from now. The past seems to us, well, in the past… The past is over, immutable, forever frozen in our personal and communal history. But is it really gone?

As you move along with the passage of time your tomorrows become your yesterdays.  That is the only certain part about your future. It constantly becomes your past until there are no more tomorrows left.

The growing number of yesterdays in your life, relentlessly pile on top of each other in the memory banks of your brain. Your experiences are etched in your memory whether you want to remember them or wish you could have forgotten them. An investment in the past is a secure deposit: no one can take it away from you. Conversely, an investment in the future is invariably a gamble. You reap the benefits if your life proceeds according to “your plan”. You lose if something untoward happens to throw you off course.

But how can you plan for the past? Can you change it? You certainly can, and in more ways than one. Here is how:

The simplest way to affect the past is by considering that today is tomorrow’s past. Today is your last chance to shape what would be forever locked up in your memory.  It is a simple notion but if you teach yourself to act accordingly, your present would invariably become richer and much more powerful. You will learn to pay attention to your life as it is happening, to see your experiences as layers of memory ever expanding and reshaping. Perhaps a better metaphor is to view your life as a tree growing inch by inch ever strengthening and intensifying.  No matter what happens to you, you have the solid roots and the sturdy frame as your foundation. Learning to appreciate and enjoy what you already have instead of what you have not achieved yet is a basic tenet of contentment. In that context, planning for your past may not sound so strange.  You invest today not only for tomorrow but also for yesterday. Your life is not only your wishes but also your experience and memories.  Today is not too late, but rather the exact time to make a positive impact on what you will remember tomorrow. Some of my patients find this notion scary:” does it not make you too self-conscious about what you are doing?” But this is exactly the point: You must be self-conscious to live your life right. Being oblivious to what you are doing, and more importantly, to the impact that it would have on your memories is not going to make your life easier. And while it might be easy to be oblivious to your present experience, it is in fact very difficult to forget it once it is etched in your brain. Being conscious of your choices make the memory of them more palpable than their consequence; you would not have to kick yourself “what was I thinking” style, since you would remember what you were thinking by paying attention to your decisions. In other words: Plan for the past by taking care of the present.

But what if you, like many, have lived your life as if your past is unimportant? You have a problem. Eventually you are forced to look back and realize that you wasted so many wonderful moments of the present by focusing on the future.

Remember, your present is the only tangible part of your life. Do not allow anyone to infuse it with negative energy or waste your time. Social by nature, we are conditioned to favor our surrounding over our inner world. We spend time (voluntarily!!), in situations and with people that are negative for us. Indeed, we often use those around us to distract ourselves from ourselves. With time, people and circumstances come and go, but our inner world, the slowly growing sediments of memories, is always there with us.  When faced with the option, no one wants to part from her/his own memories – think of the horror of Alzheimer’s disease.  We know that our memories shape who we are, what we become, and how we review our life.  In middle age, when the past gets longer than the future, the growing majority of your life is your memories of them.

It makes sense to invest more in what inexorably becomes a growing part of your life, then in something that may never happen to you no matter how much you plan for it.  Obviously, investing in your past is also an investment in your future – whereas planning solely for the future risks infusing your past with an endless stream of disappointments.

You might be a risk-taker and more prone to gamble. Or perhaps you are buoyed by your imagination and fantasy. Conversely, you might be paralyzed with worry.  But the past stays with you, immutable unalterable, whether you view your future as an endless source of possibilities or anticipate some impending doom. If you use the minute you are currently inhabiting to ponder your life’s timeline, it is easy to see that the minute that just passed is more stable and certain than the one which would come next.

In his “In Search for lost time” Marcel Proust likens memory to an edifice comprised of memories stacked on each other, the oldest ones at the bottom and the newest being added continuously on top.   Our memory of a minute ago is freshest and sharpest:  the passage of time pushes the older memories under the newer ones and makes them more blurry and harder to retrieve.  At times, a scent or a flavor remind us that nothing is gone or lost.  Everything that ever happened to you is etched in the recesses of your memory.

There are so many memories that you would rather forget, some contain scars of recent and distant traumas; Good, desirable memories are usually hazy – while taunting, cringe-worthy ones suddenly appear uninvited. Much like food and water for your body, you need to add constant supply of good memories to your personal edifice: Planning for the past entails a conscious construction of positive experiences for retention in your memory.

Consider: assuming you can choose between positive and negative experiences, how many negative ones would you choose? Indeed, even the most mundane day, offers the choice between pleasant experiences and  aggravating ones.  Whenever you linger on the bad, or forgo of the good, you create an eternal bad memory; Today’s good experience is tomorrow’s good memory.

Invest in your past.  Orchestrate pleasant moments; a good cup of coffee on a break, nice music for the commute: little tiny pleasures.  Their memory will populate your inner world with points of warmth and light.  You will like yourself better as you are consistently and deliberately good to yourself. By being engaged and fascinated with your life, your days cease to pass unnoticed, hurried, but rather be savored for their complexity and simplicity alike.

The fanciful alternative

“When a dream comes true, you lose a dream”  Dr. K.


The future provides an endless parade of fanciful alternatives. “Wouldn’t it be nice if…” – you say to yourself and suddenly that thought becomes, well, a possibility. We are immersed in figments of our imagination that add false trajectories, existences, and memories. Some imaginings like nostalgia and daydreaming sweeten the memories, and upgrade the present. Other, painful imaginings e.g. anticipatory anxiety, pessimism, bitterness, and vengeance mar our happiness.

Enduring fantasies can feel very real. So real, in fact, that we often experience them as an alternative to our actual life. That alternate “reality” is a cause of many bad decisions and wrong turns into second-rate life trajectories. We can assume therefore that decisions based on reality vs. fantasy are bound to produce choices more beneficial to your life.

Unfortunately, you are by definition totally subjective and biased about your own life. Moreover, the fantasy bias increases with the importance of the choice. In other words, the higher the stakes the more your imagination hinders your ability to be accurate. And so, ironically, the more trivial situations engender more accurate decisions. We make numerous small decisions every day and very few are truly regrettable. So choosing for example a blue shirt over a green one, even if it is the wrong choice, has negligible effect; hence the potential for serious error is minimal

Conversely fateful decisions made at major crossroads in your life, invoke various worries and doubts. Tying the knot on the route to irreversibility, be it professional, personal, or material, carries the possibility of a big mistake. Some just dive in and try to make the most of it. Others are paralyzed by the odds and drown in hesitation. Your imagination is rapidly fluctuating between the blissful and the catastrophic. This quickly devolves to a battle between hope and pessimism – a battle between rivaling imaginings. Indeed, the richer your imagination the greater your indecision would be. Your dreams so elusive, your fears so preposterous all suddenly become credible. Agonizing and ambivalent, we become susceptible to anything that would point at the right direction. Pessimism paralyzes, optimism liberates; so many crucial decisions are predisposed towards the fanciful, the fantastic, away from the real. The misguided person is left to a lifetime of growing awareness, the sinking feeling that it had all been a mistake. The decision was made based on a fanciful alternative, that misplaced beacon luring you to the barren rocky shores.

We are often encouraged to follow our dreams. We are encouraged to work hard, to sacrifice, to deny ourselves many pleasurable experiences. We are told it is the honorable way: hold tight and persevere, and what seemed a fantasy would become true. It is up to you. It is your choice, just follow your dreams!

But why should you?

Well, it really depends on the dream. The more modest the dream the more feasible. The greater the dream, the wider the gap from reality, the less control you exert over your life’s outcome. Similarly, fanciful goals that require great dependency on the others are tremendously risky.

But how would you know it? How can you determine or calculate the distance between your dream and the reality? Key future trajectories are formed at an early age, usually in early adulthood. The mind still smolders from the fires of adolescence; you are still discovering your newly formed sense of restraint. You are not a good judge of future realities. How can you make a wise decision?

I suggest you start from the reality. It makes sense: Being already present and measurable, it is a good frame of reference. Planning your life based on your dreams is a risky business. If you are wrong, and miscalculate the distance between the reality and your dream your leap of faith can potentially send you tumbling into the void, comprised by poorly fitting, misadjusted, and increasingly difficult life.

So you follow your dream at your personal risk.

I made up an example to illuminate this point: Say that you have always been fascinated by the charmed, nomadic life of a traveling circus. Here today, gone tomorrow, endlessly parading down main streets and touring far-off, wondrous countries. One day, the famous Mederano circus set its tent in your hometown. Holding our mother’s hand in the gathering crowd you were fascinated by the circus’ legendary “little people” show. In a flash everything made sense to you: I will be a little person at a circus. That is your dream, that is your future.

One day the moment had arrived: a small advert in the newspaper called for applications to the little people show. You applied, got the job and promptly appeared for your first rehearsal. The act itself was quite easy: all you had to do is roll round, feign fear of the monkeys etc. The problem lays elsewhere; you are over 5 feet tall whereas the other little people were less than 4’. You were simply way too tall for the job. In order to play a little person you had to spend hours contorting yourself, tying your legs with straps, walking on your knees. After each performance you had to spend agonizing hours, stretching your aching legs and getting the circulation working. Conversely, your short statured colleagues easily hopped into the role, performed with ease and subsequently transformed into their non-stage persona in a matter of minutes. You have achieved your dream, but you were a misfit in your chosen career: gone were the sweet reveries, your fervent young heart was dealt a painful blow; forever doomed to futile mediocrity. You surrendered the reality to your dream and hence, despite your honest efforts and your daily sacrifice, you condemned yourself to a second rate life.

I am not one to criticize. Since the age of five, I wanted to be a physician. That was my dream, my ambition, and my sole future plan. Fortunately, it worked out very well – many years after graduating, I love my profession with a passion that never subsided: I am lucky this way. But I am fully aware that I took a wild gamble, following the dream of the 5 year old me. I do not know what sparked that trajectory. Perhaps it was my amazing pediatrician Dr. Chlenov: I still can see her listening to my chest; a Lucky Strike cigarette (no filter!) dangling from her lips. My mother would fuss before the doctor’s arrival, changing my PJ’s combing my hair and giving me last instruction not to speak unless spoken to etc. Finally the doctor arrives, thin and Spartan, her salt and pepper hair closely cropped, her eyes deep and sad sparkling kindly above her reading glasses. My mother would rush to bring the doctor tea and cake with deep respect and gratitude for all the times the doctor came to our house.   And she was there in rainy cold December nights or the intolerable afternoons of august, looking after my sister who suffered from asthma. Nothing seemed more exciting than being a physician, and it still does not fail to fascinate and delight me.

But most people spend inordinate amounts of time questioning themselves and their choices. Instead of exploring all possible choices and try to fit yourself into one of them, a preferable strategy would be to invest your time familiarizing yourself with yourself. Every revelation, every authentic piece of character is a solid investment in a life of thoughtful decisions, and flexible attitude towards the reality, and acceptance of the passage of time and how you spend it. But that requires discerning between a false beacon and a safe heaven. Following a far-fetched option -no matter how alluring – will almost always lead to a bad outcome. We are constantly offered accounts of those who dreamt big and made it against all odds. We find it inspirational, perhaps even a road map for turning an otherwise regular life into their fanciful possibilities. But another’s dream could be your nightmare. It so depends on your life, your luck, your personality, the people you choose to associate with, your abilities and inabilities: in short, it depends on the unique building blocks that make you an individual. Dreaming another’s dream is merely a competition with someone who has already won – and it makes the same amount of sense. Safer dreams, those based on your reality are not as exciting as the Fanciful alternatives: but they are yours.













The Hunting Ground

Last week I watched the documentary “ The Hunting Ground”. Ostensibly it deals with rape on American college campuses, but the real accusatory focus is on the shameful behavior of the Universities’ government. Briefly, the documentary claims that when a female student chooses to complain – all too many do not – there is a bias against siding with her.

In one segment, an interviewed male student felt the furor is exaggerated: “so there was a sexual act, he said, and she said no. Does that constitute a rape?” One wants to shout at the screen: Yes!! This is exactly what rape is: a sexual act imposed on an unwilling person.

Hopefully, the interviewed student, so flippant about rape, would come to reevaluate his position when he himself has a daughter.

But perhaps in that inane statement he betrayed the mindset leading to the discrimination against students who are sexually attacked.

While college administrations are ordinarily swift to address other forms of bad behavior such as cheating, the student who complains of sexual assault is often stonewalled. Even when a rape kit identified the accused, an argument on his part that the act was consensual, is often grounds for acquittal.

Once thrown into the realm of “he said, she said” the victim has to argue the veracity of her unwillingness to engage in sex. In order to understand the victims we need to reevaluate our concepts about gender behavior. Few aspects of human conduct are as dissimilar as the sexual behavior of men and women. Perhaps the most distinctive one is the fact that women are not as constantly available to sexual encounter as men are. Of course this is a generalized statement and does not apply to all. But I wager that if two adults engage in sexual activity the person who is more likely to say no is the female. Men are often quite opportunistic in their sexual behavior while a woman tends to be more cognizant of the way she relates to a prospective sexual partner.

I am sure that some would argue that this is merely a “nurture” phenomenon; that women have a different sexual conduct than men since they have been conditioned to be this way. Some may even argue that the entire premise is wrong and that women are as predatory and opportunistic in their sexual engagement as men. As a long time investigator of human nature, I tend to disagree. Had this been the case, more women would have raped many more men. Statistics tell us that the number of men raped by women is insignificant, indeed infinitesimal (by rape I mean the same definition I used before – the male partner is forced to have sexual relationship against his will and despite his protestations).

Why is it important at all?

I think that the relative sexual freedom, the engagement in casual, non-committal sex, has tragically biased our culture to apply a different threshold to the definition of rape. In all the rape instances in the documentary, the male and female were students of roughly the same age, and most (but not all) knew each other. Those images conflict with the mental image of a rapist; anonymous maniac springing from behind the bushes, brandishing some sort of weapon and violently overpowering the victim. Accused college students get acquitted, or receive very mild censure, since their claim for consensual sex is often accepted. In fact many of the young women who dare to complain are questioned suspiciously about their motives(!!) for coming forward. While the males walk around proud, the women are shamed, often publicly, and some have been driven away from the school by public scorn for being a “liar” a “slut” etc. This level of injustice, mind boggling when you watch the documentary, can only exist if despite the “no means no” campaigns, the power of the woman’s “no” is feeble, suspect and relative. In other words, in many of those cases, deans, female and male professors, closed ranks around the institution “image” and preferred to believe that the accuser’s “no” actually meant “yes”.

At the root of the problem is our misconception about gender differences in sexual conduct. This willing blindness, inadvertently leads to minimizing the victims’ authentic feelings before during and after the sexual assault.   In campuses where every perceived adversity is showered with counseling, sensitivity training etc., a young woman is left isolated and unsupported in her quest to overcome her trauma. It is heartbreaking to watch the suffering of the victims. In my practice I am often a front line witness to the emotional wreckage and lasting scars that a rapist leaves in his wake.

Understanding the nuances of female sexual behavior, its difference from that of male’s, and the awful and lasting effects of forced sex – the humiliation, the violation, the loss of trust, depression, suicidal ideation, shame, self loathing and doubts – calls for an urgent discussion about the definition and threshold of what constitutes a college rape.

The statistics are on the side of the victims. According to the CDC, the chances of a woman getting raped in college are 1 in 5. The vast majority of complaints are found to be true. Worse, most female victims never come forward. Yet I found the documentary very surprising. Not about the prevailing rapes. I was aware of the statistics for a long time. The shocking part was the callus manner by which the featured colleges handled the victims’ complaints.

In fact, a rape incident in college often follows the exact script described above by the student – who was “ using it” to defend his accused male peers: There was a sexual act and she said no.

Consider how powerful this NO is: if someone attempts to touch you against your will and does so disregarding your protestation you would feel violated. In fact you would BE violated. In social situations we have been able to consider unwanted physical closeness as a cause for censure and reprimand. Why do we not accord that to victim of forced physical intimacy in colleges?

Many young women arrive at college with certain trepidation: How can she escape being labeled a slut or a prude? Where is the silver lining between those extreme? How can a young college student exercise her sexual freedom and needs, without being stereotyped one way or the other? This is a heady task for a young woman fresh out of high school and barely out of adolescence. In high school, the rules of behavior are tightly scripted. In college she is thrown into uncharted territories without any road map

The “responsible adults” at the college are expected to support a young woman’s right to be the sole master of her body. She can make her own decisions about how to “use” it, she can change her mind: how she feels in a particular moment should dictate the boundaries of engagement.

How is it that in American campuses, the bastions of progressive thinking, a most vile form of regressive, primitive male behavior is allowed to go unpunished? The documentary offers three theories: 1. It causes embarrassment and bad public relations to the colleges. 2. Since rape often happens in fraternities, colleges are loathe to upset fraternity alumni who are major donors and 3. When the rapist is an athlete, especially a star athlete, the financial loss from his expulsion outweighs the ethical behavior. I do not know if that is the prevailing reason in most cases although at least in one case it is very compelling (watch the documentary!!)

But I think the colleges should not get away with such a cynical view. Somehow we expect institutions to behave badly when it concerns their bottom line. But the statistics show that in cases that do not involve human rights violation, or misconduct, the financial considerations carry a lower weight. The cynical explanation is not necessarily the entire story; even the shockingly small number of violators how are found guilty of sexual assault – cases where the victim has been found truthful –  often recieve a ridiculous punishment (a “weekend suspension” is a particularly contemptuous example). Some of the most egregious cases that resulted in expulsion were reversed to full restitution the following year. Watching the documentary, I had to conclude that college administrators do not think that a “sexual act when she said no” is a serious enough violation deserving real consequences for the perpetrator. There is simply no other possible explanation. Despite the statistics supporting the veracity of vast majority of complaints (more than 90 percent!) most colleges featured expelled or suspended less than 5 percent of those found guilty of sexual assault.

This is a very important documentary. At least it was very important to me. As a father about to send his daughter to college, I was hopeful that our colleges would be keen to defend the rights of every student from oppression and assault. Indeed it is the case in many instances except for when a student is raped. Apparently, when it comes to female sexual rights, at least in the featured colleges, her saying “no” means “yes”.






Your personal life – the virtue of self-centeredness

Recent terrorist attacks in Europe highlighted the distinction between personal life and life in general. Those closest to the horror: the wounded, the family members, friends, coworkers, experienced a personal sense of loss. The rest have been touched by degrees of distance.

In millennia of human life a small, very present circle was all a person knew. Hunters/gatherers roamed in groups of 100 people. Most have not ventured more than 30 miles radius from the place they were born. The low density of human population made it unlikely for one group to meet another. It seems safe to conclude that early humans knew everyone in their life and that each individual, especially an adult, was quite important.

In our modern world, despite a huge growth in population, social media, swift transportation etc. we seem unable to broaden our circle beyond a relatively handful of people. Research shows that today the average person is personally familiar with 500 people at the most. Which brings me to the point I made at the start: the number of people whose absence would tangibly and permanently impact your life – your personal world – is not much larger than that of your prehistoric ancestors..

What does it mean to you?

Self-interest is an essential part of emotional health: you focus on taking care of yourself. It may seem paradoxical but think about it: focusing on yourself and taking care of yourself, prevents you from being selfish and emotionally exploitative – i.e., expecting the others to center on you. After all, someone needs to attend to your needs if you do not.

Clearly a difference exists between your perception of the world at large and your own personal world. Your territory might be vast, your social network incredibly large and yet the number of meaningful people and places whose absence would be painful for you and linger in your thoughts is quite small and not much different from that of your prehistoric ancestors.

Your personal world is held together only due to your existence. Its complex inter-connections have little meaning to anyone but you. You are the center of your inner and your personal worlds.

While your inner world is you – and would cease to exist when you do, your personal world, the chain of people and places connected by your own perception, obviously does not depend on you to exist. However, with you gone, your world would lose the meaning that your presence created.

And yet despite the obviousness of the above comments, we often behave as if all realms of our existence are interchangeable: worse, we tend to view life as a collective experience, which is governed by Platonian notions of absolute ideals. We try to adjust our personal life to their ideal, universal manifestation rather than make our personal life the anchor point for everything we do.

Consequently we travel the time allotted to us with a host of misleading notions that invariably impede our satisfaction from our life. For instance, we share a belief of the supremacy of the “love ideal”, even though it is a constantly vacillating and unreliable emotion. We aspire to happiness despite it being so hard to achieve and even harder to keep. Similarly we view self -interest, an essential part of survival, as an act of selfishness.

Sadly, we waste countless hours agonizing over notions that are patently unrelated and untrue for our personal life- struggling with irrelevant notions over what we actually experience. We see conflicts where there are none, alternatives that don’t exist, and deny ourselves complex feelings such as the possibility of loving and hating someone or something at the same time. No wonder that the highly idealized notion of selflessness is so appealing to us despite it being counter-intuitive and biologically subversive.

Go ahead, put yourself first. It is your duty to yourself. Do not saddle the rest with taking care of you. It may seem strange to ponder at first, but selflessness, not focusing on one’s self, is actually a very selfish position. As a little baby you were justified in being selfish –you were so helpless that you could not take care of yourself. No one expected you to wash yourself, exercise, keep a sensible productive agenda; you could not even turn without help. As soon as you could, you started wanting to do things on your own. But in our rushed, over protective society your caregivers made every attempt to limit your autonomy. You did not gather your food, you did not dress yourself, and you did very little on your own. You were discouraged from taking care of yourself except when it comes to bodily functions: toilet training, brushing your teeth, feeding yourself etc. And so we grow thinking that our main duty to ourselves is that of hygiene. While important, other aspects of self care (such as creating your life around your own thoughts, feelings and talents –making your life as little stressful as possible) are sacrificed for tenuous altruism, and a set of universal notions irrespective of their relevance to your personal life. The notion of emotional self-preservation is shockingly absent from the everyday experience and discourse. We throw ourselves into situations that we already know would cause us stress and discomfort, we overburden ourselves with tasks; we flood our brains with meaningless trivia and entertainment. In a word, we are often horrible to ourselves. At the end of the day, beaten and exhausted by the life we created for ourselves, we look for diversion in spurious romantic relationship, inauthentic friendships, drugs and alcohol consumption and desperate attempts at self-deceit.

Go ahead, put yourself first. You are the most important person in your life. There is nothing wrong with it. It is the simple truth. Taking good care of yourself would empower you to pay noble and sustained attention to the others, to good causes, to charitable acts; all that is beautiful and rewarding in being useful to the others. Your altruistic efforts are sustainable over time only while you simultaneously and consistently focus on yourself. Think about the fact that while the world is wide and the number of people is staggering, you actually spend your emotional time with the same 500 hundred people and the same few places and scenario. So those need to be the best they can be. Don’t accept into your life what is bad for you. You simply don’t have enough space or time to be that careless about it.

Remembrance of Times Past – Personal vs. collective memories and the ownership of your life

“…when you dared not go to sleep for fear of your dreams.” Terry Prachett

Once, many years ago I was rowing in a small French lake with a young Swiss woman I had met on the bus going there. I was twenty, in medical school, and used the summer break to backpack across Western Europe. The day was spectacular, the young woman was lovely, and I was very happy. It struck me however, that this is it. Even if we returned here tomorrow, it would not be the same: I will never be 20 again, on this lake in this boat with this young woman whose name I still remember. Faintly, a poem formed in my mind: A simple, inelegant lament for time lost. The following day, or was it several days later, on the train to Amsterdam, I wrote it down.   I still have it somewhere, a page, torn hastily from a copybook, with pale blue ruled lines.

My young self, a sentimental rover, spent many lovely days with amiable, ever shifting cast of backpackers: earnest morning conversations in an Amsterdam café; predawn on a ferry deck watching the starry night my sleeping bag touching another’s. Who were they, what was I? Too late; time erased all memories like waves lapping letters in the sand. My life, once languid and clear, has quickened its pace and now the years are wheezing by me, my days a fuzzy blur.

Marcel Proust, the genius of capturing time lost, wrote: “For although we know that the years pass, that youth gives way to old age, that fortunes and thrones crumble (even the most solid among them) and that fame is transitory, the manner in which—by means of a sort of snapshot—we take cognizance of this moving universe whirled along by Time, has the contrary effect of immobilizing it.”

Conjuring up snap shots of the inner world – fading scenes faintly etched in the memory – is Proust’s prescription to immobilizing time. But we want to immobilize the good times – the ones worthy of the effort. Yet only few fortunate ones can remember extended periods of unbroken joy. For most of us sadness is a frequent companion, lingering stubbornly however much we try to cheer. Conversely, happiness is sporadic and frail, collapsing at the first sign of adversity.

We seem to be wired for sadness. We are unable to delete bad memories, and spend sleepless nights in lonely struggle with uninvited thoughts. Adulthood, with its daily burdens, turns our memory into a foe, an albatross weighing down our life. Tethered to each other by a sameness girdle, we amble through life, dreading being alone, in the authentic solitude of the real self.

It wasn’t always this way. As a child, the world surrounding you was scary and unfamiliar whereas your inner world, your imagination, offered you the best refuge. There, you could daydream for hours, making up little stories, enjoying your self, literally. Your childhood experiences, lacking in substantive history, were mostly fantasies and blissful ignorance.

Come puberty, and whatever equilibrium you discovered between you and the world surrounding you, is irrevocably upset by adolescence’s push for conformity. Being compelled to try and be like everyone else, you grow ashamed of your originality, you consider your private fantasies weird. This reversal of perspective – growing more comfortable among the others, while becoming scared of the inner you – is viewed by most of us as the right of passage into adulthood.

No wonder we feel conflicted by originality, idiosyncrasy, and otherness. The child in you, the natural inhabitant of your private world, is fascinated by the different, the mysterious, the unknown. However, that fearless explorer, your innocent self, is mostly barred from experiencing the different. At the exit from childhood, you are banished forever from the Garden of Eden; you tasted the fruit of knowledge, your awareness efficiently draining the bliss out of your ignorance.

Adult life is often marred by uninvited memories of time lost, humiliating defeats, inglorious moments, feeling rejected and abandoned by those we once loved. We anxiously scan our memory: might we unearth some exuberance at last?

Reliable pleasant memories are necessary to immobilize time: Immobilized time is essential for observing your authentic personal experiences. Your personal experiences, those shared by no one else but you, sustain your ownership over your life. Our memories cannot be separated into neatly packaged capsules of “good” or “bad”. Even a blissful recollection crossing into your consciousness can drag with it a bad one. You might wish for a dream and end up with a nightmare. Your inner world, neglected by your frantic flight from sadness, can often appear unfamiliar to you.

So how can you connect with your individuality? How do you unveil your inner world to yourself? Creativity is a great facilitator. It works to externalize your inner self, and introduces your self to you. Now, you may argue that there is no need for introductions. You have been with yourself since birth. True, but who is the self you know? Most of us live with our manufactured self. The self we create to introduce ourselves to the others.

As toddlers we were very authentic – that sweet affecting innocence of children, is in fact an expression of authenticity. Not having learned yet the social games, little children are brutally honest and bad liars. But we learn to be inauthentic as a condition for social acceptance into adulthood. We try to impress, to distract, to lie, to exaggerate; we shed crocodile tears, fake our emotions and display phony sympathies. We say we expect the best of each other, but in truth we settle for the lies. (Just try to express for one day all that you really think and you will discover the social price of authenticity.) This deception, even if socially beneficial, hurts your relationship with yourself, and becomes a constant source for self-loathing.

Remember how you used to perform as a little child to your parents? You were assured adoration no matter how silly or untalented your little performance was. Buoyed by the glimmer in your parent’s eyes, you twirled faster and faster until dizzy and giddy you fell on the floor and pretended to sleep. You were a significant person in your parents’ life, why can you not be in yours?

Be creative! Do something that only you can do. It does not matter how silly or untalented, so long as you do it yourself. Make something out of nothing with your imagination. It is for you; you are the loving audience and the adoring fan. And it would be totally and truly yours, the only thing in your life that is exclusively yours. To quote Marcel Proust again: “What we have not had to decipher, to elucidate by our own efforts, what was clear before we looked at it, is not ours. From ourselves comes only that which we drag forth from the obscurity which lies within us, that which to others is unknown.”



Usefulness – Surfing the River of Time

I prefer the present to the future: the current moment offers a possibility for course correction, just before it slips back into the immutable past. Surfing on the river of time, requires an appreciation of immediacy; a perpetual closeness to your own self. Conversely, distant aims provide no quarter – your life – inexorably drifting off course.

Inattention to the present robs you of the only slice of time where you truly exist.

Focusing on the past or the future gets you to bypass your actual life, miss instant opportunities, and slowly relegate your life into forgettable smokescreens.

It is very hard to focus on the train of todays, made blurry by the rush of all tomorrows into the waiting yesterday. An eye blink, yet another present is forever lost in the black hole of yore.

Start by paying attention to what is happening now, together with you. I like to think about it as collecting sunsets (which I do) – sunset, spring, a good cup of coffee, all volunteer their beauty slowly and presently.   You and the sunset are here and now: The sun sets leisurely into your past and you continue forward as the last drops of light give way to the evening. Picture yourself sitting by the river of your life, fascinated by the minute representations of your now.

Imagination allows our attention to constantly dart between the past, the present and the future. It instigates us to perceive ourselves as moving back and forth along a static time. We zigzag above our time like a bee’s dance over a flowering bush.   This innate inattention to the present is complicated by the numbing sensory onslaught of the 21st century. Our swelling virtual world competes with what we actually experience. Drowned by the digital deluge, our introspective antenna fails to register our humble, unadorned present.

TV, social media, YouTube, video games, you pause for nothing short of sensory explosions. The fabricated reality, glimpsed through various media portals, has long taken over your true self. You happily entrust your ideas to information illusionists. You care about the ones you will never meet, and covet places you would never be invited to. Life by the shock value is a choice like any other; you need no one’s permission. However, the virtual playground comes at a price. Your real life, cast like hollowed husks, get only cursory attention. Your delight is vicarious; you no longer own your pleasures.   Your fantasies are generated elsewhere, rammed into a craving brain. The trivial sirens allure you to the external, to the irrelevant, to a life not lived by you.

I often exhort my patients to live their own life. This simple advice – get rid of the redundant emotional stuff and just be yourself – is absolutely the most difficult one to observe. And it should have been so easy: after all you are yourself!   Why do we struggle so hard to become what we already are?

In a badly lived life you have an amorphous sense of self. Ambivalent, indecisive, you alternate between competing “selves”, swept passively in your lifetime, a billiard ball knocked into this and that tributary. Undoubtedly the randomness guiding your trajectory has little in common with you.

Staying connected to the time of true existence, your now, is the only way to live your own life. Whether you recognize it or not, in reality you only live at this moment. The rest, the entire perceived arc of your life is in your imagination. So paying attention to where you are now guarantees that you are mostly alive. The more minutes you experience in your real life the longer and richer your life would become. Emotional substance is not an external nutrient. Emotional substance gets generated from the inside, from your own experiences from your memories and your feeling and the entire edifice of the years having passed since your birth. Emotional substance is not a shared experience; it hails from the most private, intimate recesses of your inner world. It is here, inside you, waiting patiently to be noticed. Come back, don’t linger outside of your life, in strange fields of other people’s realities. Don’t let them distract you from your own humble quiet, translucent one.

Hesitant, somewhat reluctant you dislodge yourself from external seduction and start noticing your own reality. It may not be as wonderful as the fantasy, nothing is, but it is real. And it is yours. And you can do something about it now.

Obviously, having spent all this time away from your self, becoming introspective would take some time and practice. Like a novice acrobat, you need to be tethered at first. This is where usefulness comes in handy. Being useful anchors you to the recipient of your kindness. Objects can be passively useful but humans have to do something both active and present. Strive to be useful to someone or something that is here with you. You cannot be useful in retrospect. And since the future happens only in your mind, prospective usefulness – doing something for the future benefit – amounts to no more than a fantasy.. It is the tangible effect of usefulness, the active conscious engagement with the present that can stimulate the “muscle memory” so to speak, necessary develop a usefulness reflex.

Try to be useful to someone or something everyday. It can be anyone including yourself. It can be an animal, a plant, or even an inanimate object. So long as you do something useful that is happening now it satisfies the practice criteria. When you get to know the pleasure of being grounded through usefulness, it will become a reflex, an automatic daily event, much like putting first your feet on the floor when getting out of bed. What is considered useful? It is for you to decide. Pay attention to the possibility of contentment and well being that follows being useful. It is there, waiting for you to discover. You will feel anchored to yourself, to your life and to your own presence here and now. No more passive stumble down the river of your life. You can stand tall, taking in where you are, when you are, able to maneuver, to dodge obstacles, to be in charge of the only thing that you truly have, yourself and your life.

Success and the taunting choir of the soul

Being disposed to the others’ perceptions of oneself is natural for social beings. When people speak to me about peace of mind they usually mean freedom from imaginary onlookers – the taunting choir of the soul. Never is this torment as difficult as during adolescence. Teenage years, when all aspects of life are experienced under the magnifying glass of one’s peers, leave us exhausted and determined to stop caring about what the others are thinking. Luckily, except in some specific conditions, we are mostly able to ignore this internal reproach. However, the natural yearning for others’ perceived approval continues to flicker inside. Living with mock tribunal is a price we pay for our consciousness. But life is strewn with insecurity landmines. Trigger one, and you are instantly mired with teenage- like angst, all over again. The demons are not gone, just dormant.

“Success” is an explosive trigger, which instantly awakens the subterranean insecurities. The thought about “success” – or lack thereof- is irresistibly attractive to ones secret tormentors. And it is obvious why: We cannot nail success down. Like beauty and power success is a slippery, unreliable concept. It is not absolute but relative to our expectations and fantasies regarding our life. But even worse, it is also relative in our mind to the success of the others. Being naturally competitive, we learn at the outset of our life that if everyone succeeds, no one truly does. If everyone flew first class and drove an expensive sports car and have a wonderful position and great life it would not have been as enjoyable as being the one who has it when the others don’t. We cannot help but measure success comparatively to the others’.

Consequently when we think of our success we instinctively present it to the inner tribunal’s approval. Approval brings a sense of excited gratification. But should thinking of success morph into thoughts of failure and lowliness, a sneering cacophony drowns any attempt at dispute. We feel publicly shamed, even though it is only a thought, our most private possession. Ridiculed by our imaginary tormentors our inner world becomes very dark, and sad. Much like happiness, power, and other elusive objects of human desire, holding to success is a slippery business.

What interferes with our ownership over our success?

People asked to describe their private concept of success invariably deviate to the public notions. Sophisticated people, non-traditional cynics, those who abhor customs and communal norms are trapped in the most mundane interpretation of success. If you are a 2 star general, you are more successful than a one star general and less than a three stars one. We secretly envy those who choose not to join the race, who seem happy to assume an unassuming role, who are satisfied leading perks-free life. Many fables, folklore and inspirational teaching extoll the virtue of simplicity, of being satisfied with less. And yet we do not have a good sense of how those idealized imaginary people live their inner life. Are they really content? Is absence of competitive impulse a pre- condition for inner peace? It probably is.

But realizing the virtues of modesty does not really help us. Competitiveness, wanting to have something at the expense of the other, the wish to be at the top of the heap, is part of human nature. It shows itself in so many permutations, it thwarts social philosophical and political attempts at equality, even when those are universally accepted as a good thing. Be it a country, a society, a segment of the population or an individual we all want more than the others. And since we do not know all of the others, whatever we have kindles a wish for more. Out and about, we can convince ourselves we have enough. But pondering success at night, alone in our thoughts, results in covetous desires rather than noble meditations

Once you accept this innate yearning, it becomes obvious that you should better develop your own notions of success. The communal, general concepts would never allow you to feel a sense of satisfaction. After all you usually navigate with an idea of a destination. Fame! Love! Fortune! Power! Those nebulous, universal destinations promise to steer you into the most congested roads. Competing neck to neck with the misguided others, you find yourself in a crawling traffic jam at each twist of your life plot. Every summit once surmounted, presents a new one, and then other peaks surround you, tauntingly unreachable. What is love? What is fame? What is fortune? What is power? You must have a clear destination to know whether you have arrived

Suddenly you are unsure: what is the next station? Are you at all on the right track?

But of course! You always are on the right track; in fact you have only one track, your lifespan. The problem is that some of the turns ahead are mysterious and scary. And the destination is unannounced. In fact we mostly stumble blindly through our life, frequently improvising, clutching a delusional sense of control for comfort. You have no idea whether your life is predestined or a train of random twists. But one thing is certain: you do not posses the script. In other words, planning for the future is a gamble fueled by wishful thoughts.

Can such predicament be translated into sweet, and predictably satisfying life?

It can for sure! But first you need to refocus your outlook and bring it closer to you. You deserve to be closer to yourself. You deserve to see life through your own eyes: Do not be an extra in another person’s life.

The closer the focus the more you will notice the countless joyful opportunities strewn on your way. Instead many of us fly over our own life like shooting stars – rushing blindly through the sky.

Nothing can guarantee bitter disappointments, as the following common mistakes:

  1. Defining your success in generalized and vague terms,
  2. Establishing your success on a rigid script, and
  3. Subjugating your struggles to a distant, lofty destination.


The misapplication of your desires, constrains your ability to recognize and enjoy your genuine, unscripted successes. Feeling unfulfilled, you increasingly idealize and envy the others, and may feel you are a relative “failure”.

The remedy to the above is to use a microscope rather than a telescope. Don’t pursue an enormous and distant picture; better train a microscope on the details of your life. Suddenly, many hitherto unnoticed accomplishments, come into sharp focus. Your little victories, the sensation of your skin after a luxurious steam shower, the taste of a good meal. Every attainable innocent pleasure can easily trigger contentment. Under the microscope, your lifespan is full of countless opportunities to make it as pleasant as possible.

Decisions guided by impersonal goals, should better be left unpursued (except when altruism or sacrifice are eliciting your sense of satisfaction.) That is a simple principle: Your life should flow from you, and be designed to accommodate you. If you subjugate your needs to another person, or a situation, or a group – resentment, bitterness, and self-pity will inexorably mar your life.

Don’t aim for a successful life!

Aim for successful minutes!

Aim for successful minutes to outnumber unsuccessful ones.

Attach your success to what makes sense to your world, best suited to your abilities, most likely to fulfill your needs.

Adjust your notion of success; let it yield to the changing circumstances of your life.

Claim and own your life and your goals and your notions. They are yours after all.

Don’t invite or accept unnecessary hardship into your life.

Do not submit your life to your success. Submit your success to your life.

Use every opportunity to congratulate yourself for something well done.

A continuous string of daily mini -successes is independent of the “Big one”. The Big Success may cost you too much and deliver too little and too late, if at all.

Your little personal successes are consonant with a big universal one. Just remember not to sacrifice the former for the latter.

Pay close attention. Collect moments of pleasure. Give your self a chance to enjoy your own life. Pay close attention.