Sunday, March 24, 2013

The Heart is a Lonely Hunter



Carson McCullers wrote The Heart is a Lonely Hunter when she was 23. It became a literary sensation, though she was already suffering from rheumatic fever and would live most of her remaining life handicapped by a series of strokes. She wrote most often of love, loneliness, and empathy for the human condition.

I haven’t written a philosophical post in a while. Maybe because I’d done enough public searching for meaning in the first years. Maybe because so many read the blog now. And sometimes when I am busy, meaning is lost in the day to day of clinical medicine. In pain, addiction, success, coping, transcendence…but mostly pain, loss, and suffering. That is what people bring to me on a daily basis. And of all my elixirs to offer the most powerful is empathy.

Maybe when people longed for a thing that bad the longing made them trust in anything that might give it to them.
A psychiatrist’s job is a strange one. I sit with people as they cry. I try to sort out the influences of biological and psychologic pathology. I attempt to buttress the strengths and soothe and repair the weaknesses. And I never know what will happen, though I may have seen a similar patient walk through my door a hundred times, say a middle aged man drinking twelve beers a day. One of them gets worse, loses his family, the next one finds his path, quits drinking, and yet another sticks with six beers a day from here on out. Ten thousand variables walk in with every patient and we try to predict the possibilities.

It was funny, too, how lonesome a person could be in a crowded house.
I hate people, sometimes, their selfishness and my own. Our weakness and blindness. The mistakes we make over and over. And I love people, as they push through. It is a great gift that they will share with me all these daily despairs and victories. Sometimes I wish I could be more specific, but another part of my job is the vault of secrets, whether they are fantastic or heart wrenching.

One of the things I struggled with, initially, was a great sense of loneliness. Here I was with so many psychiatrists dismayed by my elixirs and not entirely sure the answer could be found by reading enough Kohut, Winnicot, or Freud. But the blogosphere is plentiful, the world of interested people almost limitless, despite the limitations of the medium and the egos and the foolishness.

I do not have any home. So why should I be homesick?
Our brittle weaknesses almost always come from places of pain. If someone is arrogant, outrageous, narcissistic, or lost, or too easily hurt…at the heart of it is insecurity and the ever-present pain. And where does the wish for finding some truth in the evolutionary medicine come from but dismay and pain? How many people have I seen die from heart disease or complications of diabetes? How many disabled from multiple sclerosis or lupus? And then the daily complaints of fatigue, depression, or constipation. I have few cures and far more questions to ask. 

The modern human race is a dysfunctional, limping family with awesome powers of energy and information. Here on the interweb we strike out and rant and rave and post pictures of our cats.

It was like they waited to tell each other things that had never been told before. What she had to say was terrible and afraid. But what he would tell her was so true that it would make everything all right.

When I sit with people who are dying, they tell me of their families. Their children and lives, and the people they meet on the street, and the color of the air at their favorite summer place. And when I sit with people who are living, they speak of the same, but hardly ever mention the color of the air.

Pain is the currency of my profession. For all doctors, perhaps, and all nurses. The rants, always, the raves, sometimes, and rarely, we hear about the cat pictures, which are, of course, the most important things. When you go out tomorrow try to remember to notice the colors in the sky and the crispness of the wind, because within those small details are serenity. The past is gone, the future is not here. The present is all we will ever hold and experience.

I’m a stranger in a strange land.
I am filled with stories, with sorrows and secrets. Carson McCullers knew these things at 23, and I am much older yet am still figuring them out. When do you call out the brutes, the proud, and the misguided? When do you succor their misery? What is the greater good? Is it silence and a smiling face, or a bitter cut, or perhaps manipulating a character weakness to serve a common end.

Some will benefit from the succor, others the cut. Some won’t learn, ever, and can only serve the good with the benign manipulation. All the terrible and glorious people and their ten thousand variables.

The most fatal thing a man can do is try to stand alone.
It seems like a long time ago that I wrote The Glorious Cause. And I still believe in it, that we have to move forward with open minds, honest skepticism, and a common respect for each other, for science, and for human health. But there are no seekers without flaws, no truths without pain, and no consensus without compromises. The question is are the compromises we make and the new friends we keep worth the cost? Each day those variables change, and the question differs, and the air carries a new scent and a new hue.

We learn so much when we go to those places that cause us pain, yet it sticks to us like glue, and we cannot be free, and we make the same foolish mistakes when we are beset by pain. I hope we can transcend and write and learn and move forward and break through. I hope we can do such a thing together, brute, nerd, narcissist, seeker, mother, warrior, and all the elements of the human family.

Perhaps we cannot get along. Perhaps the compromises we make are not honorable or worthy enough. Perhaps we are too small, too vulnerable, to make it work. That is the human condition, and it is not shameful.
I will not be hurried…kindly allow me to sit in peace a moment.
Every day we are dying. And every moment we live. Every moment there is an opportunity for weakness or triumph or love or serenity. Everything risks pain except perhaps serenity, and that may be why it is the nirvana of choice in lieu of happiness for the wise. The heart is a lonely hunter. We know so little, and expect so much.

23 comments:

  1. There is interminable beauty in the stark truth and gravity of all that you wrote here.

    Thank you.

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  2. We all have a part to play. The question is: will we do it asleep or awake?

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  3. Deep and transcendent. Thx Emily.

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  4. Dear Dr. Deans,
    There doesn't seem to be a good place to put in a plea for a topic you haven't yet covered (I did search diligently), but McCullers' rheumatic ailment - which would be treated sometimes, from what I've read, with prednisone - is perhaps a relevant context.

    Could you please write about the use of prednisone, for the treatment of depression??? My husband and I have been depressed for our entire lives; we come from long lines of depressed people. A few weeks ago, we were worried about the quality of a new batch of prednisone that we were giving our dog (she has IBD)(it turned out that it was just the strong bittering agent in it that was making her treat it differently). So, we each took some, to make sure it was okay.

    Both of us experience total relief from our depression, from two days of dosing (ten and then five milligrams for me; I'm a short female). The relief lasted for about ten days. It was FAR, FAR more effective than any of the many antidepressants we've been put on.

    I found only one clinical trial, done in 2000 (C. Bouwer), trying prednisone on depressed patients. It was a very small trial, but it was very effective.

    I am well aware (due to research on my dog's behalf) of the side effects of prednisone. Of course I'm not seeking medical advice!! However, I wonder, what is the biological basis of this??? We tried it a second time, and it worked, a second time. I have no reason to think that our HMO psychiatrists, whom we see a total of an hour per year each, is likely to be able to tell us WHY this worked.

    In any case, thank you for your blog.

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    1. Prednisone is well known to cause mania (and if you are depressed, lifting you up). It's also an immune suppressant and probably the most powerful anti-inflammatory.

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    2. Thanks for answering. What I find confusing (given that it can cause mania), is that so many people become *depressed* on prednisone, when they take it for e.g. IBD. That seems to be the norm. Why should people who are not-depressed, become depressed when on it, and people who are depressed, get relief? BTW, we weren't manic, and had none of the stereotypical prednisone crabbiness; in fact our *depression* crabbiness wet away.

      I guess that what I wondering is that, if depression is due to inflammation, why shouldn't a powerful anti-inflammatory help (and it seems to)? And why this isn't used, with great care, in some treatment resistant cases. Also, I wonder what one's reaction to it, suggests about other things that might help, and whether a positive reaction might point to underlying hormone problems.

      Where would I go to get answers? Would an endocrinologist have any insights? Or what other sort of specialist? Our HMO is useless for anything but the prescribing of SSRIs, but I could self-pay for consultations. After being depressed for 49 years, and my husband for 53 years, to escape it for ten days was incredible; I have to find out more.

      Thanks again.

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  5. Beautifully written. Sometimes the pain of carrying others' pain (not to discount the irritation of watching their avoidance of connecting with their actual experiences), can way one down on the soul till we become the waves of dysfunction ourselves. Perhaps, in the world which lacks balance, part of it is how much we take on.

    On another tangent, maybe the goal is not to end the suffering. There is so much transformation that happens through the impetus, and also the lens, of suffering, that perhaps the real point is to merely help others access their inner wisdom?

    In any case, you sound sad and tired, in need of a hug from someone.

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    1. I'm tired, and we could almost always use a hug, but everything is okay. Thank you.
      And no, the goal isn't always to end suffering. Sometimes we need to suffer, for example, when we lose someone. The suffering is the cost of the love, of being part of the human community.

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  6. Are you and your loved ones OK?

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    1. We're fine, thank you. I was broadly referencing a community schism.

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  7. Talk about timely.

    Yesterday morning, a good friend of my mother's was found dead after years of battling drug addiction. Recently, she didn't seem to be doing nearly as much "battling" as "riding the wave" following the death of her husband after having lost both of her children earlier.

    Maybe it's just me, but this post was perfectly timed, at least for my life. I'll be sharing this with my mother, who probably needs it far more than I do.

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  8. "The past is gone, the future is not here. The present is all we will ever hold and experience."

    Reminds me of the Jim Morrison poem:

    Now is blessed
    The rest remembered.

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  9. Thanks for this, I couldn't imagine being at the center of this stuff, and yet mostly an observer. The impact of sound brain function isn't small though, I hope you keep your fire for this blog for a long time, it's working for some.

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  10. Very powerful and cathartic to read!

    You took me down that doctor's road I've known so well, but often in the haste and fury of the moment put aside to finish the intense task.

    I began the journey because I felt it was the best contribution one could make. The field has in many ways, lost its way. The unusual individual, finds themselves again.

    Everybody has a hungry heart.

    We are all the better for it.

    www.calorielab.com/news/dr-j

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  11. Thank you for sharing your thoughts, and for feeling "our" pain. Thank you for your keen intellect. Thank you for educating us where no doctor would dare. Thank you!

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  12. Amazing post. Such is life: full of suffering that has been passed on from many generations back and is never completely our fault or completely under our dominion, and then life is also unpredictable in response - something that bewilders and humbles. As you say, this is probably why the wise choose serenity over happiness, that stoic quality of total acceptance and embrace for what is, and letting go of the "what should be" or the "why is it this?", when no definite answer exists in reality for either of them. To let go of the illusion of control, to accept things and people and life for what they are (including ourselves), regardless of whether we can understand them or not, or regardless of whether they can pull themselves together or not. This is love and compassion; this is serenity and peace; this is the true overcoming of fear and pain... And this is also one hell of an arduous path to take for some of us, but it appears we are both seeking it in some way, shape or form. Thank you for the insightful words and for your blog.

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  13. Dear Dr. Deans,

    After five Vipassana courses and seven years of practice, I know that serenity is not merely a stand-in for "true" happiness. Euphoria and bliss are all very well while they last--and experiencing them me might seem like "happiness" for a while--but like any high there's a big price to pay in the form of the inevitable crash. And even if we were to somehow achieve steady-state levels of euphoria, we'd develop a tolerance and thus crave even greater heights of ecstasy in an upward spiral. Perhaps big pharma is working on a compound that will enable us to keep on spiraling upward in a ceaseless state of ecstasy with no crash, but achieving such a goal hardly seems consonant with the paleo principles of evolutionary psychiatry. Serenity is nirvana for humans in their current evolutionary state. Consider yourself chastened.

    Nick

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    1. Chastened? I suppose you are better at serenity than I am.

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    2. You're darned tootin'! I have achieved advanced serenity! I'm the most serene (and humble:)) person around! (OK, back to observing the breath.)

      Thanks for the excellent blog!

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  14. Dear Dr. Deans,

    After five Vipassana courses and seven years of practice, I know that serenity is not merely a stand-in for "true" happiness. Euphoria and bliss are all very well while they last--and experiencing them me might seem like "happiness" for a while--but like any high there's a big price to pay in the form of the inevitable crash. And even if we were to somehow achieve steady-state levels of euphoria, we'd develop a tolerance and thus crave even greater heights of ecstasy in an upward spiral. Perhaps big pharma is working on a compound that will enable us to keep on spiraling upward in a ceaseless state of ecstasy with no crash, but achieving such a goal hardly seems consonant with the paleo principles of evolutionary psychiatry. Serenity is nirvana for humans in their current evolutionary state. Consider yourself chastened.

    Nick

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  15. i feel like the more sensitive and empathetic the individual, the more likely they are to be an effective and compassionate caregiver, but at the same time, they're going to be deeply touched by the work they do, sometimes to the point of emotional exhaustion (and perhaps angst?)... on the one hand it heartens me to read what you wrote, like, here's someone engaged in a deeply human endeavor, with the kind of passion that psychiatry should warrant; on the other hand, i wish there was some way caregivers could be spared the weight of it all. i suppose that knowing you're doing something, instead of standing idly by, brings some peace of mind? my wife has volunteered on the suicide hotlines for ten years now and, best i understand, this is how she doesn't feel devastated by this work (along with it not being her full-time gig, of course). anyhow, i really liked what you wrote. seriously, the first thing i thought was, why aren't all psychs like dr. deans? she seems so amazing! but i bet sometimes it's exceptionally exhausting being what i am calling "amazing", so i had to kind of pause and consider what was happening as i formed that impression. thank you for maintaining such a consistently fantastic and valuable blog. you set a delightfully high bar.

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