Tag Archives: Inner world

Avant Garde Psychiatry

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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.

The fanciful alternative

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“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.

 

 

 

 

 

 

 

 

 

 

 

 

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

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“…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.”