Fear of Feeling Graduation Address etsu department of Psychiatry June 25, 2006

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Fear of Feeling

Graduation Address

ETSU Department of Psychiatry

June 25, 2006


Allen R. Dyer, M.D., Ph.D.

I am pleased to be with you on this occasion and honored to make some remarks. I would like to add my welcome to the new residents and express my congratulations to the graduates. I take great pride in watching your development and the competence and confidence you have attained over the past several years. You now have the credentials to match, which enable you to get a REAL JOB, but more importantly you have the education that will enable to you be professional leaders -- not just tradesmen.

I have chosen as the theme for my remarks, “Fear of Feeling”. In a very real sense, it would be nice if we could just medicate away symptoms and not have to deal with complex emotions and messy feelings. But it is also important to understand feelings, demonstrate to our patients that their feelings can be bourn, they we can tolerate their feelings, and they can learn to dear with them. It is said that Eskimos have 14 words for snow. The English language barely has that many words to convey the rich variety of emotional life. Indians have 22 words for love. We might pay attention to that. In an ideal world, children would learn the names of feelings when they learn the names of colors. They might start with a basic box of eight. If they’re boys, that might be as far as they get.

Our focus on symptoms over feelings reminds me of the caution President Eisenhower offered about the military-industrial complex. We have developed a co-dependency with the drug industry, which might well be called a medical-industrial complex.

The close relationship of physician and pharmaceutical is of course not a new situation. Chaucer commented on it in his Canterbury Tales, written way back in the 1300’s. The pilgrims traveling to Canterbury told stories to pass the time. Among them was a Doctor of Medicine:

“In all this world there was no one like him,

to speak of medicine and surgery;

He knew the cause of every malady.

And all the apothecaries in a tribe

gathered to make the remedies he prescribed.

They had known each other for a goodly while

and each profited from the other’s guile.”

We marvel that Chaucer noticed these things so long ago. What is generally not known is that there were a number of psychiatry professors among Chaucer’s pilgrims. First there was a Franklin.

“His beard was white as a daisy.

And he well loved a bit of bread

dipped in wine in the morning.”

Though our dean no longer has his white beard, we know that he maintains his sanguine disposition and his pleasure in epicurean delights.

Next there was a miller.

“The Miller was a stout fellow of 16 stone.

He was strong of muscle and big of bone.”

“A Haberdasher, a Dyer, a Carpenter, and a Weaver

were all there in the livery of one impressive guild-fraternity.

Each was wise and would have justified a plan

to make each of them an older man.”

(Thus it says in the original or something like that.)

Chaucer’s tale did not include a Cancellaro, but mine does. I know you have been spending many months with Dr. C. learning neuroanatomy, and there is a question I would like to pose. Is it really necessary for the modern psychiatrist to know all those structures and pathways, OR is it sufficient to have forgotten them?

One part of the brain that is almost forgotten in modern psychiatry is the cerebral cortex, that part of the brain that deals with thinking, memory and association as opposed to the lower brain, especially the amygdala, the seat of the emotions. It is important that they be connected, and in many instances it is our job to make sure the connections are made.

A distinction from the old days of psychiatry that remains important is a distinction of cognitive styles, obsessive on the one hand and what we used to call “hysterical” on the other. Obsessiveness has become a disorder, and hysteria—such an unflattering term—is all but forgotten. But both are important defenses, defenses against feelings that might seem too uncomfortable to bear. The obsessive personality is a heady, cerebral, individual, given to thought, and distanced from feeling. The hysteric is just the opposite, prone to emotional volatility, overreaction, perhaps hurt feelings, and impulsive actions. In the old days, many situation comedies and much psychotherapy focused on this tension. The obsessive was attracted to the colorful passions of the hysteric, who in turn admired the logical order and stability of the obsessive. They drove each other mad. We might say they personify the tension between the cerebrum and the amygdala;

Of course we hear these themes in our offices, in the stories that are told to us, but also they have been captured in the great stories of literature. One of the advantages of being married to an English professor is that these great characters come into our lives and become part of our conversations. On New Year’s Day in Bangalore, Sue announced that her resolution for the New Year was to re-read Shakespeare, all thirty-eight plays. And of course I get to share in this theatrical feast, a bit of which I am going to share here this evening, a couple of scenes from Shakespeare, and a Shakespearian scene from real psychiatry.

Hamlet, for example, is an obsessional character, who cannot steal himself to the deeds he must do, namely avenge his father’s murder. He is caught in a vicious Oedipal complex between his mother and and his father, then step-father, and his adolescent love for Ophelia, whose father Polonius has told her to reject Hamlet. Sir Laurence Olivier interprets Hamlet so intelligently, cerebrally; Kenneth Branaugh, so passionately, overwrought, hysterical. A very interesting and quite good production by Zepherelli, who also did an outstanding movie of Romero and Juliet, cast Mel Gibson as Hamlet, inspired by his role in Lethal Weapon, a crazy guy with little regard for his own fate.

I invite you to imagine how as a psychiatrist you would respond to Hamlet if he came into your office and presented his famous suicide soliloquy.

To be, or not to be: that is the question:

Whether 'tis nobler in the mind to suffer

The slings and arrows of outrageous fortune,

Or to take arms against a sea of troubles,

And by opposing end them?

To die: to sleep;

No more; and by a sleep to say we end


The heart-ache and the thousand natural shocks


That flesh is heir to, 'tis a consummation

Devoutly to be wish'd.


To die, to sleep;

To sleep: perchance to dream: ay, there's the rub;

For in that sleep of death what dreams may come

When we have shuffled off this mortal coil,

Must give us pause: there's the respect

That makes calamity of so long life;


For who would bear the whips and scorns of time,

The oppressor's wrong, the proud man's insult,

The pangs of despised love, the law's delay,

The insolence of office and the spurns

That patient merit of the unworthy takes,
Who would burdens bear,

To grunt and sweat under a weary life,

But that the dread of something after death,

The undiscover'd country from whose boune

No traveller returns, puzzles the will

And makes us rather bear those ills we have

Than fly to others that we know not of?
Thus conscience does make cowards of us all;

And thus the native hue of resolution

Is sicklied o'er with the pale cast of thought,

And enterprises of great pith and moment

With this regard their currents turn awry,

And lose the name of action.

How would you deal with such a patient? How many times have you heard someone say they would kill themselves except that “the Almighty had set his cannon against self-slaughter”? Would you ask him if he could contract for safety? Place him on one to one with Rosencratz and Guildenstern? “Madness in great ones cannot unwatched go.”

Would you place him on an SSRI? What would you make of his story of hearing his dead father speak to him from the ramparts? Auditory and visual hallucinations? Perhaps indication for an atypical anti-psychotic? Or do you accredit the supernatural? Would you want to make these visions go away or try to understand their meaning? Would you approach this problem from above, at the level of the cortex, or below at the level of the amygdala?

Shakespeare, I think, is doing exactly what Freud taught us that we must do, keep in consciousness those things we would rather forget. He keeps alive those complex feelings and motives that compel us. He shows us that we have options and helps us imagine the consequences of our actions. He teaches us ethics by forcing us to look at ourselves. He, like Freud, teaches us how to look at ourselves.

Shakespeare, like Freud, understood that histories are developmental histories. He gives us evidence that we should always look for in understanding how our characters got to be the way they are.

Freud himself was interested in Shakespeare and most especially in the character of Richard III, the evil monarch who gave us such memorable lines as

“Off with his head”

or when his cruelty fails to achieve his aims,

“A horse, a horse, my kingdom for a horse.”

Freud felt that Richard III’s evil stemmed from a narcissistic injury, his deformities, hunched back and withered arm. Richard felt that he was cheated by fate and hence entitled to subject others to pain.

One of his most fascinating historical characters is Henry V. Where Hamlet hesitates, Henry is decisive.

We meet Henry as young Prince Hal. As a young man Harry spends too much time in taverns, drinking and otherwise misbehaving, sometimes afoul of the law. His father understandably worries what will become of him.

At last his father dies; he grabs the crown and gets his own play. Henry V is in many ways a tale about growing up. Harry puts aside his old ways and his old friends and sets himself—rather ruthlessly-- on the task of administration. Henry V is often seen as a play about leadership. I think it is that and more. It is also a play about the politics of expediency.

Harry needs to establish himself and chooses the devise that is so often used to transition boys to men, a war. The play opens with his bishops reviewing some ancient claims against the French for lands he would like to control. The warrants for the claims don’t really matter; he has already decided that he wants a war.

The French ambassador arrives with a diplomatic solution and a gift, tennis balls. Harry understands the insult to his manhood. He lacks balls. At first he is enraged, amydaloid. At first he has trouble finding his voice, not knowing what to say, but at last he threatens, “We will smash these balls across the courts of France.”

The key scenes in the play center around the battle of Agincourt, which ultimately the English win, even though they are seriously outnumbered. One day in a hundred year war. Olivier made a movie of this play near the end of World War II, which served as patriotic inspiration for the British. Kenneth Branaugh -- an Ulterman like Dr. Moore -- who has witnessed decades of insurgency in Northern Ireland, produced a spectacular movie version, which dwells more on the horrors of war.

Sue and I saw Brannaugh and Emma Thompson on the Royal Shakespeare stage in Stratford-on-Avon in 1984. The scene that most impressed us theatrically was the scene that occurs the night before the battle when Harry--disguised so his men won’t recognize him--wanders through the camp taking the measure of his men. “A little bit of Harry in the night.”

The Stratford production we saw employed spigots of real water, hundreds of gallons pouring down on the stage. It was very convincing and apparently historically accurate. The battlefield in 1415 was a muddy bog, favoring the English: when many of the French nobles in their heavy armor were knocked from their horses, they actually downed in the mud.

Morning dawns, Harry dresses for battle; he has the pulse of his men; he knows their anxieties and their concerns. He climbs up on a wagon and delivers his famous inspirational speech:

This day is called the feast of Crispian:

He that outlives this day, and comes safe home,
Will stand a tip-toe when this day is named,
And rouse him at the name of Crispian.
 
He that shall see this day and live old age,
Will yearly on the vigil feast his neighbours,
And say 'To-morrow is Saint Crispin's:'
Then will he strip his sleeve and show his scars.
And say 'These wounds I had on Crispin's day.'
 
Old men forget: yet all shall be forgot,
But he'll remember with advantages
What feats he did that day.
Then shall our names,
Familiar in their mouths as household words,
Harry the king,
Bedford and Exeter, Hamid and Goswami

Warwick and Talbot, Simpson and Shah and Rosas

Salisbury and Gloucester

Be in their flowing cups freshly remember'd.


 
This story shall the good man teach his son;
And Crispin Crispian shall ne'er go by,
From this day to the ending of the world,
But we in it shall be remember'd;
 
We few, we happy few, we band of brothers;
For he to-day that sheds his blood with me
Shall be my brother; be he ne'er so vile,
This day shall gentle his condition:

And gentlemen in England now a-bed


Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin's day.
There is a scholarly paper called “Ducks, Rabbits, and Henry V”. It uses the famous figure-ground images of gestalt psychology, viewed one way it is a duck, the other a rabbit.

Henry V can be seen as a duck-rabbit depending on your perspective, pro-war, anti-war, Olivier interpretation, Brannaugh interpretation, or psychiatric interpretation. Does Henry undergo an amazing transformation when he achieves manhood or is he still the charming rogue, now using power to serve his own purposes?

Shakespeare gives us a lot to consider. When Harry is wandering through the camp disguised, he encounters dissent, his own men questioning the justice of the war.


KING HENRY V (in disguise)
Methinks I could not die any where so

contented as in the king's company; his cause being

just and his quarrel honourable.
WILLIAMS
That's more than we know.
BATES
Ay, or more than we should seek after; for we know

enough, if we know we are the kings subjects: if

his cause be wrong, our obedience to the king wipes

the crime of it out of us.


WILLIAMS
But if the cause be not good,

the king himself hath a heavy reckoning to make,

when all those legs and arms and heads,

chopped off in battle,

shall join together at the latter day

and cry all 'We died at such a place;


some swearing, some crying for a surgeon,

some upon their wives left poor behind them,

some upon the debts they owe,

some upon their children rawly left.


I am afeard there are few die well that die in a battle;

for how can they charitably dispose of any thing,

when blood is their argument?
Now, if these men do not die well,

It will be a black matter for the king that led them to it.

Duck? Rabbit?

Obsessive? Hysterical?

Cortex? Amygdala?

Conscious? Unconscious?

Remembered? Forgotten? Or repressed?
Those of us that are privileged to hear people’s stories, their confessions as it were, and their worries, have responsibilities to help them understand their experience. We must demonstrate to them that we are not afraid of feelings and can witness their suffering. It is not enough just to medicate their symptoms.
I would like to bring this home by sharing one more scene, this from a recent student oral exam. It is not unlike the stories we hear every day. I think it is worthy of a Shakespearian source.

Patient: I got hurt a couple of times in explosions.

Once I hit my head on the front of the Hummer and blacked out. Another time there was an explosion on the left.

I was knocked to the right and the gunner fell on me.

I broke a couple of discs. They say I’ll have to have surgery.

They give you some Valium and Percocet and send you out again. It was a good time, eating Valium and shooting the hoods off cars. Then I get crippling headaches.

I can’t go out and throw a ball with my sons.


Then I got a negative drug screen. I don’t know how it happened. You get 900 “Ataboys”, and one “Oh Oh” and you’re screwed.

I considered killing myself with my 9mm, but that’s no good.

I’ve got my boys to think about.
The smell of burning flesh stays in my mind. I saw an 11 y o girl with her back blown off. Her eyes and mouth were open, like “What happened?” There’s no way to describe the feeling.
MEDICAL STUDENT (noticing tearing): Can you say what you’re feeling?
PATIENT: I don’t like to talk about it.
MEDICAL STUDENT: (Pause) Can you say why it’s hard to talk about it?
PATIENT: I feel mad and sad at the same time.

I seen three of my buddies blown to hell. (Excuse my language.) They scrape up the body parts and hand them to you in a plastic bag. What are you supposed to do with that?


I blame the commanding officers. They think they know everything, and they don’t listen. We should have never been out there doing missions without radio contact.
I start crying and don’t know why. I feel sorry for the kids.

You kick in the doors, and they’re terrified. You have to do it. You never know who’s going to pop at you next.

They look at us like we’re the most evil things on earth.

I credit the medical student with having the patience to listen to this story. It is human nature to disattend from intense feelings and keep such experiences at a distance. This is actually a hopeful story. An intelligent patient, who is aware of his feelings and able to articulate them. All the drugs he was given didn’t dull his empathy. He cared about the children.


Story telling is an art, but equally important is story-listening. It is the art that we cultivate every day. It is the art that gives our patients the courage to feel-- and the courage to be.







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