Projections, page 14
Changing of value on any timescale—fast with an instantaneous new insight, slower with growth and maturity, slower still even over millennia as the world and species evolve together—allows adaptation to shifting conditions by tuning inner exchange rates for the competing currencies of suffering and reward. The experiences of borderline patients, and insights from modern neuroscience, together show that valence—the sign of negative or positive experience, aversive or appetitive, bad or good—is designed to be changed, and readily.
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Neuroscientists can now set these exchange rates, adjusting with precision how likely an animal is to do almost anything, with optogenetic targeting of specific cells and connections across the brain. For example, depending on the specific circuits targeted, we can cause animals to become more or less aggressive, defensive, social, sexual, hungry, thirsty, sleepy, or energetic—by writing in neural activity with optogenetics (in other words, dictating that just a few spikes of activity occur in a handful of defined cells or connections).
As the subject’s behavior changes instantaneously, shifting to the favor of one pursuit over another, and thus seemingly switching from one system of values to another, sometimes a psychiatrist cannot help but think of borderline patients. These individuals can be swift to react strongly with value assignments or changes—for example, treating a new acquaintance or a new psychiatrist as an archetype of the category: the deepest friend, the best doctor. And this positive categorization so powerfully expressed can be erased or reversed in an instant—transitioning (after a caregiver’s perceived misstep, or after attention from a partner is perceived as inadequate) from best to worst, all the way to catastrophically negative.
This binary switching in people is sometimes attributed to skilled acting and manipulative intent—but my perspective (shared by many) is that these labile states are truly felt, overwhelmingly so. Extreme reactions reflect all-or-nothing feelings, subjective states adapted to uncertain life experience. The survival skills of a traumatized child—though this does not describe all patients with borderline—become the distortions of a suffering adult human being, living life in chronic negativity, with everything framed in terms of what might be strong or pure enough to distract from unrelenting sirens of psychic pain broadcast throughout the patient’s inner world.
There are deep and powerful brain structures through which these effects can be borne out. Some of these circuits and cells (like the dopamine cells near the brainstem) broadcast their influence far and wide, sending connections nearly everywhere in the brain—including to the recently evolved frontal regions where our most integrative decision-making and complex cognitions occur, as well as to older regions that manifest survival drives in their most basic forms. Positive or negative value can be easily attached by these dopamine cells to even neutral items like an unremarkable room. With optogenetics, turning down the electrical activity of dopamine neurons in the midbrain, by providing a flash of light every time a mouse enters a neutral room, causes the animal to begin to avoid the harmless room, as if it were a source of intense suffering.
This experiment may be accessing a natural process, since a different but interconnected deep brain structure, the habenula, (a structure—so ancient it is shared with fish—that fires away during hopeless, uncontrollably negative, and disappointing situations), acts through turning down the dopamine neurons in the midbrain naturally, just as optogenetics does experimentally. This circuitry can thus impose sign, or valence, where none was present before.
It has been discovered that early-life stress and helplessness can increase habenula activity, and borderline patients may be locked in constant uncontrolled negativity from their habenula-to-dopamine neuronal connection—or other related circuitry. Fixed to a baseline of pain, they may live out a hard-learned lesson about the way the world is that could have only been internalized by the young.
Cutting may reveal such a negativity of the borderline patient’s inner state. This behavior might recalibrate that negativity, introducing a new, sharp, and fresh pain that is controlled and understood, rather than the uncontrolled (and inexplicable) feeling from childhood. So lifelong suffering, at least for a moment, is renormalized into almost nothing by comparison with the new self-generated sensation. Intense negativity—as long as it comes with agency, with control, with a reason—can be desperately sought.
Modern neuroscience may thus begin to reveal how Henry, and those like him, could come to dwell in such a state, with early-life trauma seeding negative-valence predisposition into the arable field of the young and vulnerable mind, and sowing deep instability in the valuation of human connection. Studying fish and mice, our cousins with whom we share key ancestors, shows how powerfully and instantaneously the value of absolutes can be accessed and changed by activity in a few specific cells and circuits in the vertebrate brain—and thus very likely in our brains.
We each have a narrative in our minds, an in-progress drawing easeled up and ready to go to explain ourselves and others, to justify our sense of self and our relationship to the moment. We carry that depiction around with us, and we also carry those of our friends and family and others who are important to us, as images which we consult from time to time. It has been hard for those who most love and cherish the borderline patient to build such an image—to really create and hold an internal model mirroring their loved one’s narrative and suffering. But with a little help from modern neuroscience, these friends and family and caregivers and others can now begin to imagine, and perhaps nearly understand, living life this way.
Early-life trauma can happen to any animal, but our young may be most vulnerable because they have the most to internalize. Our evolutionary (and cultural) strategy for learning has been to lengthen childhood, and so as a side effect, extend risk. Other animals might for other reasons come to live in negativity as well, without a means or reason for signaling this inner state to the outside world, but borderline-like symptoms may most readily reveal themselves in the context of the complex social networks of human life—and when our unique planning and toolmaking allow for discovery of behaviors like cutting. Even Henry, as I found out later, did not stumble across that particular innovation on his own.
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Henry had many superficial cuts on his arms that were rapidly healing and uncomplicated. As borderlines go, he was still mild, still just figuring it out. Even his known childhood trauma was not so bad, at least as known to me, at least by comparison with what I had seen in others—a difficult divorce for sure, but far worse can happen.
And yet Henry’s suffering was real. His family was broken, and every experience that he shared was warped in some way by this fundamental loss, which was a burden squirreled away whole, unmeted, bending his inner form, creating counter-confusions of positive and negative, black and white, reality and imagination, until the only dialectic that mattered was the one at the heart of everything for him: connection and abandonment, water and oil, unblendable.
For the first three days of our hold, a measured process of ministration was set in motion—of set rhythm and duration as with any 5150. The one held, the newcomer, is made warm and then made available, like a new lion cub introduced to the pride; the patient is first given a bed, and then in firm and steady ritual is visited by members of the caregiving team. Several days follow of this gentle and insistent attention—from nursing assistant, nurse, medical student, resident, physical and occupational therapists, clinical psychologist, medical consult team, social worker, attending physician—alongside the other patients, all strangers held together and each with a different reason for landing there. It is altogether a more complex and challenging brood than could be prepared for by instinct or intuition.
The time spent by any one patient on a locked ward is typically just a few days, which seems not enough time for cells or circuits to change fundamentally, nor for significant therapy-driven behavioral modifications. Yet each morning, a life-or-death judgment must be made by the clinical team on the locked ward. As we evaluate patients subject to the 5150, those truly recovering and those simply recanting cannot be easily distinguished. All we have to make these judgments are human interactions and words, alongside published statistics and accumulated individual clinical experience. This is not enough; still, deep in danger we estimate the risk, because there is nothing else to do and there is nobody who knows more. Each day we must decide to continue, or release, our hold.
Even more unsettling, a deadline bears down. By morning of the third day, the hold expires and the patient is automatically released into the world even if danger continues—unless additional steps are taken. Numerology seems the only relevant consideration in setting the term of this three-day limit, since the duration maps onto no specific medical or psychiatric process. Three days, compelling and biblical, Old Testament or New: three days and nights in the belly of the beast, three days and nights in the heart of the earth.
If acute suicidality continues, two more weeks of care can be sought in a different kind of hold called a 5250 in the California code. But then judgment truly comes calling, in the form of a nonmedical outsider with right of passage into the psychiatrist’s territory. This is the hearing officer, a judge arriving on the unit—trailed by another visitor, the “patient advocate,” who is to play the role of pushing for release. The doctor (if still feeling that release may be unsafe) can make a plaintive case to continue care, to keep the hold—only now, this happens against opposition. This is an uncomfortable charade, a doctor arguing against someone named the patient advocate—while the doctor’s whole calling and sense of self is built around helping patients heal in safety. Yet doctor and patient advocate must rise in battle, civil and gracious yet with secret ruffs half-risen, necks itching.
When animals within a species come into conflict, natural mechanisms from ancient circuitry can act to minimize damage. Rituals signaling size (as with measuring wide-gaped mouths against each other, in hippos and lizards) often allow the smaller rival to escape safely, and both to conserve energy. This conflict avoidance works when the stakes are not life or death, as in many mating conflicts where other such chances are present or may come later; but if opportunities are sparse, de-escalation of the conflict is harder. In the hearing on a locked unit, in these rituals, no de-escalation is possible, and the stakes are existential—truly life or death, but not for the combatants. The one with life interest in the outcome, the patient, waits in another room, with no presence or voice.
I had won almost every hearing before this one, and expected the same with Henry. But after only a few minutes, the ruling from the hearing officer, coming with godlike finality, was that I had lost. The edict for Henry was discharge: freedom and danger.
With no personal stake in the decision, I should have found letting go to be easy; but the outcome of this one was hard for me, and I found myself running through the case and the hearing in my mind again and again. Objectively I could understand the hearing officer’s decision. Though I was concerned that Henry had not contracted for safety—he refused to make a promise to not seek suicide—his self-harm so far had been undeniably nonlethal. That fact was enough for the hearing officer, and perhaps it should have been enough for me.
I also should have been pleased that such a high value had been placed on personal autonomy by this decision, since I valued freedom too. I understood—all sides understood—that if a secret suicide were planned, it could now proceed, but in this case personal freedom had been deemed of greater significance than that small risk, upon the balancing of two categorically different fundamental values. This subtext is the core conflict of every such hearing—patient freedom versus patient safety—and thus both sides are the patient advocates in a real sense. Advocates for autonomy or for security: there is no older or deeper conflict, and none closer to the beating heart of borderline.
I struggled with this verdict, but I understood a source of my internal conflict; I was not blind to the transference. The parallel with my own life was not subtle—at least in one aspect, the early-life collapse of the home—and I could not help but wonder about my own son, only five years old at the time I treated Henry. While no hint of his affliction ever showed in my son, I did not have that perspective on the day of the hearing—and Henry developed his symptoms late. It was not until after his summer breakup, nineteen and with the sun still cold on his skin, that he had watched a movie on his laptop showing explicit cutting in a girl of thirteen—and the concept had clicked, hard, for him. He tried it right away, copycutting with crude tools and coarse strokes behind the community college gym, and then went straight to show his father.
Why did he go first to his father, to reveal his wounds? Perhaps it was simply to make the hurt known, to connect by shock and blood. But why not begin with his mother instead? She was the one he had seemed to fault at first: he had pointed to her as the one who had left the family, the one who had abandoned the nest. Henry’s chief complaint—“My father said, ‘If you kill yourself, don’t do it here at home. Your mother would blame me’ ”—was this the key clue, a meaningful signature of pathology in his father instead, in ways that we did not yet understand?
These are the mysteries that a few days cannot uncover; obscured still, Henry’s story had not been truly told. There was no time for deep connection. Henry had somehow revealed little of importance, that we could grasp anyway, in his two and a half days on the unit. He did exhibit a superficial form of progress, a decrescendo of sorts—gradually toning down his violent language, the descriptions of his desire to die, to drown in blood. But I knew how readily he could present different stories at different times, depending on what was needed, and I was not reassured. I wanted the time to help him.
If I had played the hearing differently, I might have found some way. Holds in California can be placed or extended, not just for suicidality, but also for danger to others, and for grave disability. But despite Henry’s rage he was not violent, and never had been, to others; his bloody visions were just that: a churning of violent imagery not coupled to the power stroke of action. This left only the route of finding evidence for grave disability; perhaps a plausible argument could be imagined from his nakedness on the bus, a case to be made for his inability to provide for at least one of the basic-needs triad: food, clothing, and shelter. But Henry undeniably had, and knew how to access, resources addressing all his needs. The bus incident, like his cutting, was serious but not lethal, and so Henry stepped out of the unit on a foggy Sunday morning.
I watched him walk down the hall toward the escalator and the main hospital exit, canvas bag over his shoulder. He was uncured, untreated even, but I told myself there was little more that could have been done. His was a disorder untouchable by medication, he had wanted to leave soon after admission, and upon discharge he had refused even my outpatient referral for a specialized group behavioral therapy. The clinical literature predicted Henry’s future would include more of these parasuicidal actions like cutting, that were revenging and rewarding in ways I would never fully understand. His wounds would heal and then reappear, as relief continued to come from the act for him—a desired injury, a counterstrike against internal suffering beyond my imagination. Henry had no choice; for a time he would have to continue to seek these stigmata, and to seek others—not skin to skin, but self to self, coercing human warmth across space and time.
His destiny in the long run could be the mellowing of borderline symptoms that usually comes with age—but time could instead bring suicide, the ending of the self, at a rate of 15 percent: the highest incidence for any disease, any burden of humanity. One hope was that those who cared for him could learn to use the state he was able to evoke in them, projecting that ancient feeling of the invaded self, magnified a hundredfold, back onto their own internal representations of Henry. Powerful empathy can be stoked from sparks of anger.
My own flare of rage had long since died away, though I knew I was still vulnerable to him, and would always be. Henry projected into me, and was close to me, as the written word is close to paper. But I felt that I had exhibited to him only a pleasing dupability, in my earnestness to reduce his pain. And for a time I couldn’t see my son without thinking of Henry. He had written his story atop my own, like a medieval monk inscribing new text upon a scraped and reused parchment, carving symbols of judgment and revelation onto animal skin stretched thin.
CHAPTER 5
THE FARADAY CAGE
Hegel made famous his aphorism that all the rational is real and all the real rational; but there are many of us who, unconvinced by Hegel, continue to believe that the real, the really real, is irrational, that reason builds upon irrationalities. Hegel, a great framer of definitions, attempted with definitions to reconstruct the universe, like that artillery sergeant who said that cannon were made by taking a hole and enclosing it with steel.
—Miguel de Unamuno, Del sentimiento trágico de la vida, translated by J. E. Crawford Flitch
The new thoughts came with all the surety of a change in season, in a gathering together of signs. Like the air of early fall, the first few weeks seemed to bring a shift in pressure in her mind, with a hint of wind revealing itself—a shimmering of her highest leaves, a rustling in the neural canopy.
She could feel the change in her skin as well, a subtle tingle, a chill of early fall. The sensation stirred a memory from a dozen years ago: Wisconsin in September, with her brothers AJ and Nelson, chasing Canada geese along the lakeside. Winnie had been seventeen after that summer of lymphoma chemo. Nothing had ever felt so charged as her return to the outdoors that fall after methotrexate—all around her and within her, even to her lungs, and to her brain, a mist of the season had seemed infused, clear and crystalline. In remission they had said, a likely cure, and they were right.
