Projections, page 6
When we can, we often steal the time to do this in psychiatry, almost instinctively, even during the besieged rush of an on-call shift, even in cramped and awkward confines like Room Eight that night. It can be hard to hold us back, as hard as it is to hold back surgeons from cutting to heal; we all live, and move, in the crafts we have built for ourselves.
Without the right foundation, nothing works in psychiatry. Without structural threads to weave upon, there is no new pattern that can be created. As psychiatrists, our first instinct is to start to link together what recovery will mean for that person—the intertwined threads of the biological, the social, and the psychological—not in a rush, but in awareness of the time that will be needed to construct something strong and stable. We do this even if we may never see the patient again, as I suspected that night; I was discharging Mateo to the care of his family, and to outpatient treatment. I would continue rotating on through the hospital, in my own ecliptic path, while Mateo would follow his arc in the universe; in all likelihood our paths would never intersect again.
But the amount of time I was taking was extreme, I realized after nearly an hour had elapsed. It was not until the call shift ended, and I was driving home with tears leaking from my eyes, diffracting the traffic lights, that I saw a larger picture—and saw that it was also about another human being, another patient.
I took so long with Mateo that night because I had been unready for him, for that particular hell, as I had been only once before—and so the therapy was for myself as well, for my own tears that were coming. A connection across time had been formed in my mind. It was only with those tears that I saw the link with Andi, who had brought me to the same place and for whom I had been just as unready. Andi, the little girl from years ago with the brainstem finding—long gone, on a journey none could share.
This time, I had thought I could do something—not much, but something. And that matters—realizing at a place and moment you have been called to be whatever it is that humanity can be for a person. That is not nothing.
* * *
•
Years later, following our optogenetics and BNST anxiety work, an even deeper connection between Andi and Mateo revealed itself. There was a curious commonality to these patients, who represented the two lowest moments that medicine had brought me to, from which I had to work hardest to emerge. What had actually brought each of them to the hospital the night I was on service had been fibers failing in virtually the same deep spot of the nervous system. This spot was the base and bedrock of the brain, in the pons, where eye movements and tears and breathing are controlled, and where next-door neighbors in my patients were disrupted—the fine chords, the sixth and seventh, of lost harmony.
But the significance of this, if any, I cannot define. I know only that the site is deep, and old.
The naturalist Loren Eiseley wrote that a symbol “once defined, ceases to satisfy the human need for symbols.” Eiseley collected observations from the natural world and recorded the ideas stirred in him by these images as symbols—like a spider out of season, surviving in the dead of winter, having built a web by an artificial source of heat, the globe of an outside lamp. He was moved by this image, despite his near certainty that “her adventure against the great blind forces of winter, her seizure of this warming globe of light, would come to nothing and was hopeless….Here was something that ought to be passed on to those who will fight our final freezing battle with the void…in the days of the frost seek a minor sun.” Hope, represented by complex life fighting on in the face of inescapable cold, moved Eiseley, and moves scientists and artists similarly. It is close to the heart of what moves us to tears.
For Mateo, there was no hope left to cry for, now that his wife and baby were gone. His lack of tears was also his blindness of the future. But, in some form, I knew, or thought I knew, that he could love again, in time. Hope was not dead, though he could not see this, and so the tears came for me, and not Mateo.
The true end of hope shows up only as extinction, when the last member of a sentient species eases to the mud alone. In the history of our lineage, this finality would have become real many times over, in the fine lost branches of our greater family tree. The Neanderthals and others, in the last traces of their last days, lived out that tragedy for which all else is metaphor.
Extinction is normal. Each mammalian species, on average, gets a run of about a million years, it seems—with a few close calls thrown in the mix until it finally happens. So far, modern humans have lasted only about one-fifth of this interval—but already we have survived some mysterious crises that can be inferred from human genomes, when effective breeding population sizes around the world may have plummeted to a few thousand individuals.
Such demographic events alone could help explain the prevalence of odd traits with little obvious value—behaviors somewhat unrefined, having found (like crying) incomplete purchase in the population due to only a mild benefit. When a species goes through a population-size bottleneck—where only a small fraction survives or migrates—whatever traits were present in the chance survivors (or migrants) then for some time enjoy outsize prevalence, whether or not the traits were unusually important to survival. This could be the case for crying emotional tears—and help explain the seeming uniqueness of such a trait, among animals.
On the other hand, perhaps we needed this truth channel more than other related species—in building ever larger and more complex social structures over time. Crying could have come along as first just a misrouted brainstem projection, but the responsible genetic variant might have found purchase in the mingling populations of East Africa as our modern lineage arose, when we used our fingers and brains to build one another houses, constructing durable communities at great cost. Perhaps tears were needed after we had grown too good at the last forgery, at gaming the last signal of grimacing or keening. Builders need solid ground; social builders need ground truth.
The last Neanderthal—a big-brained, bruising, nearly modern human, the last member of a branch of our family tree that buried the lost with ritual and care—died just an eyeblink ago, clinging until the end in caves near what would become the Gibraltar seashore, in final retreats hidden from, as Eiseley said, “the first bowmen, the great artists, the terrible creatures of his blood who were never still.” They may have cried at weddings, at births—but when the last starving Neanderthal watched the last baby trying desperately to nurse, skin on skin but fluid failing in the ducts…there was no hope left for doubt, there was no future left to question, or to fear. There were no tears then, under the moon without answers—just a dry streambed, set back from a salt sea.
CHAPTER 2
FIRST BREAK
Horns of the long-lived stag began to sprout,
The neck stretched out, the ears were long and pointed,
The arms were legs, the hands were feet, the skin
A dappled hide, and the hunter’s heart was fearful.
Away in flight he goes, and, going, marvels
At his own speed, and finally sees, reflected,
His features in a quiet pool. “Alas!”
He tries to say, but has no words. He groans,
The only speech he has, and the tears run down
Cheeks that are not his own. There is one thing only
Left him, his former mind. What should he do?
Where should he go—back to the royal palace
Or find some place of refuge in the forest?
Fear argues against one, and shame the other.
And while he hesitates; he sees his hounds,
Blackfoot, Trailchaser, Hungry, Hurricane,
Gazelle and Mountain-Ranger, Spot and Sylvan,
Swift Wingfoot, Glen, wolf-sired, and the bitch Harpy
With her two pups, half-grown, ranging beside her,
Tigress, another bitch, Hunter, and Lanky,
Chop-jaws, and Soot, and Wolf, with the white marking
On his black muzzle, Mountaineer, and Power,
The Killer, Whirlwind, Whitey, Blackskin, Grabber,
And others it would take too long to mention,
Arcadian hounds, and Cretan-bred, and Spartan.
The whole pack, with the lust of blood upon them,
Come baying over cliffs and crags and ledges
Where no trail runs: Actaeon, once pursuer
Over this very ground, is now pursued,
Fleeing his old companions. He would cry
“I am Actaeon: recognize your master!”
But the words fail, and nobody could hear him.
—From Ovid, “The Story of Actaeon,” Metamorphoses, Book III
An image can take root and grow. Here, it is of a young father with his two-year-old daughter in the 767, slowly banking harborward, nearing the burning steel tower—it’s a frame of the moment when he at last knows the impossible truth, his pulse thudding thickly but she’s calm amid the chaos, because Daddy said there were no monsters. He’s turned his daughter’s head firmly toward his own—she’s a frail warm spot glowing within an infinitude of cold—for a moment of silent communion before their sublimation.
A little girl and her father, searching each other for grace as the plane roars into the second tower—this wordless image became physical, sown across the world into the arable mind of a man named Alexander, as he sailed through the Cyclades. Quickened, germinating, the imagined scene gathered form—investing all the soil of his thoughts, insatiably drawing to itself all the fluid of his soul.
* * *
•
The fundamental rules of Alexander’s life had already been rewritten just before September came, and so it may be that his brain—fallow for decades—was ready when the outside world was transformed as well. In 2001, as the shortening days of late summer brought chilly afternoons and crimson leaves to the San Francisco peninsula, Alexander stepped down at sixty-seven from the insurance company where he had labored for decades—as a fairly effective underchief, but where he was no longer nimble enough for the shifting strata of Silicon Valley. His domain would now be at home only, among the coastal redwoods of Pacifica, in the high-raftered house he and his wife had built in a foggy ravine twenty years earlier—big enough for their three sons and perhaps some grandchildren. He was a stately man, slightly bent, in the growing calm.
No warning notes had sounded in his life, no explanatory story was found that his family could share, by the time I met them in the emergency room six weeks after September 11. By then, his whole world had been blasted apart—not by exploding jet fuel, but by ferocious, exuberant, unstoppable mania, bearing no resemblance to anything that had come before in their lives. It was first break—that moment when links to reality snap in response to a windstorm of stress, or to the scythe of trauma, or to other triggers unknown—and the human being first comes untethered. First break, when those with mania or schizophrenia are cut loose—at great peril—and sent aloft by their disease.
In September, when the storm tide began to rise, Alexander had been only marking retirement—sailing the Aegean with his wife, traveling in antiquity. Now less than two months later, back home, he was transformed, brought to my emergency room by police and family. What had been swept along by the hospital process and settled, what I saw first, had no visible flaw. Not knowing him, I saw only a crisply alert man scanning the newspaper with intensity, fiercely cross-legged next to his gurney.
The elusive, protean mystery of psychiatry came next—discovering what it was that had changed for this person, and why. No brain scans exist to guide diagnosis. We can use rating scales to quantify symptoms, but even those numbers are just words transformed. So we assemble words; this is what we have. Phrases are pulled together, and molded into a narrative.
The people involved talked, all of us—in different combinations: the patient, the police in the hall, the family in the waiting room—all searching for the right frame. For someone with no mania in his past or family: why him, why now? He had experienced the day itself, the strike to the heart of his country, no more intensely than any other person.
Even the pain he had felt, in empathy for the lost, by itself did not merit this extraordinary consequence. Death comes badly for conscious beings and always has. The unthinkable is universal, but mania is not common. Nevertheless it came for Alexander—after a delay.
For a week after September 11, Alexander was just a bit on the stoic side, only revoicing the common thoughts of shock and pain around him. He read stories of the victims, but then began to focus on two of them, a father and a daughter, a pairing he had not lived personally. A scene emerged and grew more detailed, and he spoke to his family of imagining their final moments—while inside his brain, a secret remapping had begun. In ways still mysterious, new synapses were formed, and older connections were pruned away. Electrical patterns shifted, as scripts were overwritten. For a week his biology silently learned its new tongue, and then it reached out, expressive at last.
The first manifestations were physical. He nearly stopped sleeping, becoming fully alert and charged with life for twenty-two hours a day. Never the chattiest before, Alexander now could not hold back a vast volume of words that came out in a pressured torrent—turbulent and interjaculating—yet still coherent, at first. The content of his speech changed too—he was saltier, charismatic, uplifting, and illuminating. Beyond language, his whole body was affected; now ablaze in new youth, he was suddenly voracious and hypersexual. No old bull out to pasture, he was an organic being newly ready to react, to interface—his skin surfaces were functionalized and available. Life was lacier, compelling, alluring.
Projects and goals came next. They were valorous and numerous, with a tinge of excitement, a subthrill of risk. He bought a new Dodge Ram pickup, with a heavy-duty trailer hitch and extended cab. He ran all night, read books all day, and studied theory of war, writing pages on the movements of forces and reserves. A theme of self-sacrifice appeared and grew stronger; he wrote letters volunteering to join the navy, and was found one evening rappelling down a redwood trunk in the fog, training for war. He was breaking from his lifelong chrysalis, transforming into a newly emerged monarch.
There had been a certain charm to the transition, up to a point, but then he veered into thoughts of good, evil, death, and redemption. He had dwelt until this event in a sort of unperforated Lutheranism, stormless and modestly nourishing—with minimal connectivity to any other part of this life. Now he began to speak with God—first calmly, then frantically, then in a scream. Between these prayers there were sermons for others, in which he became irritable—swinging between euphoria and crying.
Nearing midnight before admission, he ran from the house with his quail gun, throwing branches and bark at his sons as they tried to stop him in the yard. Police found him two hours later, at bay in a thicket near a dry streambed, ready to strafe the stinkweed. They took him and subdued him with the mundanities of medical-legal incantations, all the energy still brimming up behind his eyes like tears.
The fury had dimmed externally over the next several hours in the hospital. By the time I spoke with him, he had only a rhythmic motor pattern, like a caged pacing lion, except it was a vocalization, a refrain again and again: I just don’t understand. With clarity, with surety in his own form and role, he could not understand his family’s reaction—why his every action did not seem perfectly logical to them, an example which all should follow.
The fixity was striking, and pure. Alexander’s first break had been a clean separation, without the messy compound breaks of psychosis or drugs. He was dislocated. Unchurched.
What next for the new warrior—dopamine-receptor antagonists perhaps? He did not want help, saw no need for our process, and refused treatment. In the closed system of his pressured logic, there was pure clarity, and explosive danger. An irresolute messenger, I wavered before him as he described the image that had grown in his mind, of the girl on the plane, with the father holding her head gently and firmly, locking eyes so she could see only him until the end.
Pictures came to me, intense associations. The unique abstraction of psychiatry—science with language, medicine with text, upon which the most effective care is built—allowed me to spend each day immersed in words and images, moving beyond story to allegory, even if doing so was futile—in dialogue with history, with neuroscience, with art, and with my own experience. Here the first story that came to me, provoked by his transformation, perhaps prompted by the image of Alexander sailing among the Greek isles, was Ovid’s hunter Actaeon—son of a herdsman—who was turned into a stag as a punishment from the angry goddess Artemis, after he was caught spying upon her bathing in a stream. He had new strength, new speed, a new form—he was given strong horns and fleet hooves—but the timing was off, the context was all wrong. He had become a prey animal in the midst of his own hounds—Blackfoot, Trailchaser, Hungry, Hurricane—who tore him to pieces. Perhaps it was an Actaeon I saw before me, transformed by the moon goddess, with the police and me as Arcadian hounds, and Cretan-bred, and Spartan—the whole pack, with the lust of blood upon us, baying over cliffs and crags and ledges where no trail runs.
But then…unlike the case with Actaeon, whose new form of a stag had no value, for Alexander there was a use, grim and suitable, for the new form he had been given. In this sacrifice, he was perhaps more of a Joan of Arc—like Alexander, born far from military life. In her case it was on a small farm in Lorraine where the mystery began to speak to her. Without trying to diagnose a historical figure—always tempting but usually unwise for psychiatrists—I could not help but imagine how her alteration happened to briefly work well for her. When she was only seventeen, as France began to fall before English armies, she emerged into a new way of being—not disorganized as in schizophrenia, but goal-directed, focused on continental politics and military strategy. She talked herself to the side of the Dauphin with a firm conviction that she was essential, and with a powerful religiosity that allowed her to infuse the fight with a spirit seen as divine—bearing banners not swords, living through maelstroms of crossbow bolts, advancing through her own blood to the coronation.
