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In Search of the WHY

On Monday, you guys made some extremely thoughtful comments in response to my post about cyclothymia, and specifically, about whether a person's disclosure of a mental illness affected how you thought about the person's behavior.

Also on Monday, Julie Musil guest-posted on unlikeable characters over at Lisa Gail Green's blog . She gave a thoroughly excellent analysis about how to help readers sympathize with a character who on the surface appears entirely unsympathetic, and her primary suggestion was to help the readers understand WHY the character had become the way he/she was. If you haven't read this post, you should!

Now, I deal in the business of understanding why. Pondering the why is what keeps helping professionals from something called client-blaming. Client blaming ... is sucky. However, it happens with stunning frequency. A client engages in the exact behavior he/she sought help for, and we're like, "ARGH. Why doesn't he just [insert whatever you've told him/her to do here]?!?" And then we get mad. We get frustrated. We want to give up.

When I get a whiff of this kind of sentiment, either from my supervisees or inside my own head, I know it's time to get back to the drawing board. And I know exactly what I need to do: I need to dig a little deeper and get to the WHY. It's the only way I'll be helpful, the only way I'll be able to provide the kind of help my client deserves.

Amazingly, also on Monday, I READ A BOOK THAT CAPTURES THIS PERFECTLY. And by "this", I mean the why of it. It's Julie Musil's post come to life. For anyone trying to write a potentially unsympathetic, seriously flawed, at-risk-for-being-unlikeable character, this book is a must read. Oh, and for the rest of you, too. It's so very good.

Something Like Hope, by Shawn Goodman (who happens to be a school psychologist), is about seventeen-year-old Shavonne, who resides in a juvenile detention center and is at high risk for not having much of a future. This lean little book is about how she decides how she's going to live.

The book begins with Shavonne in an isolation room after she's busted the face of one of the guards--one who's stuck by Shavonne and clearly cared about her. Maybe I should mention that Shavonne does this after stealing the lady's sandwich and lying about it. Shavonne then tells her new, kind, and well-meaning therapist to eff-off and screams her way out of the therapy session.

Yeah, she does.

Shawn Goodman manages a very difficult task here. Despite Shavonne's hostile behavior, it's not difficult at all to care about her, like her, worry for her, or emotionally invest in her.

Because this book is relentlessly focused on the why.

Many of the characters in Something Like Hope are kids NO ONE likes (and who most people fear). These kids do bad things. These are kids no one wants to "excuse." They've hurt people, and stolen things, and broken things, and messed stuff up. And frankly, they're likely to do it again if pushed the wrong way. Or maybe, even if they're not.

And yet, in simple, clean prose, Mr. Goodman gets inside Shavonne's head, shows us what she's been through, what ALL the girls in that place have been through, what they're dealing with now, why it's so hard to hold it together. Without wiping away the things they've done or glossing over their jagged edges, he shows us the why. He shows us where they came from, what was taken from them ... and what was never given to them in the first place.

I read this book in one afternoon and was grateful to have a box of tissues nearby. It made my heart hurt, but it also made me so happy. Shavonne's story is beautiful in a terrifyingly fragile way. I've known kids like this in real life, and I know that if I really understood the why, it would read like Something Like Hope.

Have you read this book? Can you recommend others that focus on the WHY? Do you ponder the why of characters' behaviors in the books you read (or write)? How about in real life?

For the Sisterhood of the Traveling blog this month, Lydia asked: “What formal writing experience do you have? (classes, degrees, major/minors). Did it shape your writing?Have you ever considered getting an MFA?” She answers it today on her blog. Laura gave her answer last week, and I'll give mine next week!

Medical Racism in America a Giant Mind Boggling Game Without End

An explosive book that came out last year, Black and Blue:  the Origins and Consequences of Medical Racism, should have reverberated throughout the medical community and caused we physicians to closely examine our own prejudices and how they have affected the behavior of, and our relationships with, our black patients. 

So of course there has hardly been a whimper in the medical community. I did see a rather bland, "balanced" (almost namby-pamby) review by two African-American psychiatrists in the American Journal of Psychiatry, the official journal of the American Psychiatric Association. I don’t think much will come of it.

The author of the book, University of Texas professor John Hoberman, explains many of the reasons why the medical profession does not look at itself much in this regard, most of which I will not discuss in detail here. One of the biggest reasons can be summed up in one phrase: the mutual estrangement of puzzled Whites and resentful Blacks.

John Hoberman

Just to be extremely clear, there is no doubt that the problem of racist beliefs in medicine started with white racists and not their black victims. Many of the ideas about physical and mental differences between Blacks and Whites came from the colonialist opinions of Europians that Africans were more primitive than white people – less further along than Whites on the evolutionarily scale and therefore sub-human. Thus, their bodies and minds were supposedly simpler and therefore less or more prone to certain diseases. 

As seen originally by colonialists,  the black body, being more simple, was hardier than the white one. Black skin, for example, was thought to be tougher. This conveniently provided slaveholders a justification for working their slaves in the cotton fields for long hours in the hot sun. At the same time, being supposedly simpler mentally, slaves could be thought of as less likely to get depressed, so the myth was born of the happy black slave, grinning from ear to ear with his strong white teeth while eating watermelon, content being taken care of by his benign white masters.

While physicians in general no longer express these ideas, derivatives of them became part of medical folklore and were passed down as an oral tradition from medical student to medical student. For example, observations by white doctors of what a non-naïve individual would see as the understandable reluctance of Blacks to be put under anesthesia (and therefore under the complete control of a potentially racist doctor), was instead put together with the notion of black hardiness, and voila!  Black patients are far less likely even today of being given adequate anesthesia during surgery.

Hoberman describes in detail how racist ideas from the past have morphed into medical folklore about Blacks concerning the treatment of diseases of nearly every organ system.

Disparities in the health care of white and black patients such as the one just mentioned have been endlessly documented, so their existence should not be in the least controversial. White doctors unfamiliar with the racist history of American medicine, however, are likely to misinterpret the mistrust of their black patients as an innate tendency to be non compliant - or just plain lazy - which in turn makes the white doctor reluctant to put a whole lot of energy into convincing black patients to follow their advice.

Black patients have good reasons for their mistrust of the medical profession, including of psychiatrists.  White physicians tend to think that 1962 was a long time ago.  That was the year the American Medical Association stopped deferring to Southern state medical associations (doctors have to join the state and national associations at the same time), and allowed all African American physicians to become members.

Then again, I guess 1972, while more recent, seems like the distant past to such physicians.  That was when the Tuskeegee Syphilis Experiment came to public light -  a clinical study conducted between 1932 and 1972 by the U.S. Public Health Service to study the natural progression of the untreated disease in rural African American men who thought they were receiving free health care from the U.S. government. The men were never told they had syphilis, nor were they ever treated for it.

When I moved to Memphis, I was impressed that seemingly every African American I spoke with was aware of this history – even those who were not particularly educated.  For white doctors, not so much. Unfortunately, human beings have very long memories. The Serbs and Albanians, for example, still have strong feelings about a battle that was fought in the year 1389! 

It doesn’t help when white doctors like conservative commentator Sally Satel blame treatment disparities entirely on the resistant attitudes of black people without any reference to this history.  She also writes that racial profiling is important in medicine and justifies this idea (http://www.nytimes.com/2002/05/05/magazine/i-am-a-racially-profiling-doctor.html?pagewanted=all&src=pm) with the example of the implications for choosing medications based on the real difference in the racial distribution of different versions of enzymes that metabolize certain drugs (different alleles on the genes responsible for producing the metabolizing enzymes). 

In picking on one of the extremely few areas where there actually are racial differences, she ignores the far greater quantity of ideas within medical folklore purporting differences that do not in fact exist.  Like the supposed proneness of the black brain to produce hallucinations in psychiatric disorders, for example (originally attributed by doctors to its “primitive” state).

The mistrust of racism in medicine has unfortunately led a significant proportion of Blacks to believe in some seemingly far-fetched conspiracy theories. Many Blacks believe HIV and birth control programs were invented and designed by the white establishment in order to commit genocide against minority groups. 

These conspiracy theories even reached all the way to Africa, leading to the disasterous AIDS policies of South African president Thabo Mbeki. To most Whites, these theories sound completely irrational and paranoid. Of course, historically, Planned Parenthood was indeed founded by an Anglo-American eugenicist, one of whose goals was to limit the number of children of east European immigrants to the United States, whom she considered genetically inferior beings.

There is also a rather crazymaking problem for Whites who attempt to take an interest in the whole problem of the consequences of racism on black folks. This problem was exemplified by the vicious attacks on Senator Patrick Moynihan for his 1965 report, “The Negro Family: The Case for National Action.” The report discussed the “pathology” that racism had created for many Blacks and their families.

According to the Hoberman’s book, the black intelligentsia protested the report with sentiments something akin to, “How dare some white social scientists tell black people who and what they are?”  They thought that the report pathologized and stigmatized black urban culture, and that it seemed to be an oblique endorsement of old racist biology that regarded black people as inherently diseased and beyond salvation.

This has led to a situation where even today it is considered a breach of academic etiquette for any white social scientist to theorize about Black culture. I personally was crazy enough to do some of that in my first book, since a problem seen frequently in the Black urban poor community provided the clearest example of a point about the development of family system dynamics I was trying to make. Fortunately - I guess - that section of my book was completely ignored by reviewers. Whew!

So one of the reasons that white doctors are reluctant to look at their own attitudes and the history and consequences of medical racism is a fear of open discussions about that very subject. They do not want to be considered racists. So what are they supposed to say?  That racism did not create a host of problems for African Americans, so they do not seem to pathologize them and over-generalize about them? If it did not, then what is the big deal? If they ignore the problems, they could then be accused of covertly wanting racist practices to continue. Damned if you do, damned if you don’t.

Maybe if we just do not bring up the subject, no one will notice. Except maybe for that troublemaker Hoberman.

So here we have the explanation  for the “mutual estrangement of puzzled Whites and resentful Blacks” phenomenon. To oversimplify a bit, Blacks will not tell doctors that they are mistrustful of white doctors (and of Black doctors as well, for reasons discussed in the Hoberman’s book) for fear of being labeled as paranoid, and white doctors are afraid of getting labeled as racist no matter how they discuss the problem!

This is a perfect example of the family system game without end on a larger, societal scale, which makes solving this problem so devilishly difficult. No one trusts anyone else who claims they want things to be different, so anything anyone does or says can be - and invariably is - reframed as just the same old thing – just another manifestation of the Black belief in the incorrigible racism of all Whites, or of the White belief in the presence of innate Black pathology and inferiority. No wonder we get stuck!

This game without end can lead to paradoxical and at times bizarre situations. Hoberman bemoans the fact that black kids are much less likely to get stimulants for “ADHD” than white kids, which he attributes partially to white doctors’ subconscious belief in the stereotype of the “happy Negro” described above. Black mothers, on the other hand, do not want their kids to take these drugs because they believe that the drugs would be used to pacify young black males and rob them of their spontaneity, thereby making social control of Black people easier.

I doubt that the motives of most White doctors are that pernicious, but the mothers are actually right about the effects of the drugs. In this case, the idea that stimulants are being used to control behavior is correct, and the black kids are better off not getting the drugs. The problem is not, as Hoberman implies, that black children are not getting a needed medication, but that too many white kids are getting medication they do not need instead of getting family therapy! Of course, black families are not getting as much of that as white families either.

The author’s solution to the problem of medical racism, although he probably does not know about the concept of the game without end nor necessarily totally appreciate the intricacies of interpersonal miscommunication, is for medical schools to teach the history of medical racism and about the presence of incorrect folkloric beliefs that many physicians still hold. This way, the doctors would hopefully not misinterpret the lack of cooperation they receive from their black patients, and take time to explain more about what they are recommending, and reassure the patients that they understand any reluctance the patient may have to follow their doctorly advice. 

Hoberman admits, however, that there are not very many people available who are qualified to even begin to teach such a course.

As to his book itself, it is sometimes annoyingly repetitive, and at time a little confusing. When he discusses discrepancies in the care of black and white patients, it is sometimes unclear if his examples are due in his opinion to medical mythology, a misunderstanding of actual differences, black mistrust of white doctors, or all of the above. Nonetheless, since there aren’t many books that take this whole subject on, I recommend it.

BIPOLAR DISORDER IN OUR WORLD TODAY

So what really is Bipolar Disorder?

Bipolar Disorder,  also known by its older name "manic depression," is a mental disorder that is characterized by serious mood swings. A person with bipolar disorder experiences alternating “highs” (what clinicians call “mania“) and “lows” (also known as depression). 

Causes of Bipolar Disorder

Some of the known causes of Bipolar disorder include:

Genetics

Bipolar disorder tends to run in families. People with certain genes are more likely to develop bipolar disorder than others. Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, not all children with a family history of bipolar disorder develop the illness.

Genes however, are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder, despite the fact that identical twins share all of the same genes. Research suggests that factors besides genes are also at work. It is likely that many different genes and environmental factors are involved.

Brain structure and functioning

Studies on the brains have shown that prefrontal cortex in adults with bipolar disorder tends to be smaller and function less well compared to adults who don't have bipolar disorder. The prefrontal cortex is a brain structure involved in "executive" functions such as solving problems and making decisions. This structure and its connections to other parts of the brain mature during adolescence, suggesting that abnormal development of this brain circuit may account for why the disorder tends to emerge during a person's teen years. Pinpointing brain changes in youth may help us detect illness early or offer targets for early intervention.

Some individuals also develop Bipolar disorder as a result of injury to the brain especially those parts of the brain that are responsible for our moods.

Symptoms of Bipolar Disorder

In everyday life, people have a variety of moods and feelings. These feelings include frustration, joy and anger. Usually these moods last one day rather than several days. For people with bipolar disorder, however, moods usually swing from weeks of feeling overly “high” and irritable to weeks of feeling sad and hopeless with normal periods in between.

An important distinction between bipolar disorder and the normal emotions of life is that bipolar disorder results in an inability to handle daily activities. The person cannot work or communicate effectively and may have a distorted sense of reality (for example, unrealistically high or low opinion of one’s skills).

Bipolar disorder often is not recognized by the patient, relatives, friends or even physicians. However, recognizing the mood states that occur is essential. Treatment can help a person with bipolar disorder avoid harmful consequences such as destruction of personal relationships, job loss and suicide.

During a manic phase, symptoms include:

• heightened sense of self-importance
• exaggerated positive outlook
• significantly decreased need for sleep
• poor appetite and weight loss
• racing speech, flight of ideas, impulsiveness
• ideas that move quickly from one subject to the next
• poor concentration, easy distractibility
• increased activity level
• excessive involvement in pleasurable activities
• poor financial choices, rash spending sprees
• excessive irritability, aggressive behavior

During a depressed phase, symptoms include:

• feelings of sadness or hopelessness
• loss of interest in pleasurable or usual activities
• difficulty sleeping; early-morning awakening
• loss of energy and constant lethargy
• sense of guilt or low self-esteem
• difficulty concentrating
• negative thoughts about the future
• weight gain or weight loss
• talk of suicide or death

Bipolar disorder may also be present in a mixed state, in which one might experience both mania and depression at the same time. During a mixed state, one might feel very agitated, have trouble sleeping, experience major changes in appetite, and have suicidal thoughts. People in a mixed state may feel very sad or hopeless while at the same time feel extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, if you are having psychotic symptoms during a manic episode, you may believe you are a famous person, have a lot of money, or have special powers. If you are having psychotic symptoms during a depressive episode, you may believe you are ruined and penniless, or you have committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes misdiagnosed with schizophrenia.

People with bipolar disorder may also abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. It may be difficult to recognize these problems as signs of a major mental illness.

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Diagnosis

Doctors diagnose bipolar disorder using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM). To be diagnosed with bipolar disorder, the symptoms must be a major change from your normal mood or behavior. There are four basic types of bipolar disorder:

1. Bipolar I Disorder: This defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks.
2. Bipolar II Disorder: This is defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.
3. Bipolar Disorder Not Otherwise Specified (BP-NOS): This is diagnosed when symptoms of the illness exist but do not meet diagnostic criteria for either bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
4. Cyclothymic Disorder, or Cyclothymia: This is a mild form of bipolar disorder. People with cyclothymia have episodes of hypomania as well as mild depression for at least 2 years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder. 

A severe form of the disorder is called Rapid-cycling Bipolar Disorder. Rapid cycling occurs when a person has four or more episodes of major depression, mania, hypomania, or mixed states, all within a year. Rapid cycling seems to be more common in people who have their first bipolar episode at a younger age. One study found that people with rapid cycling had their first episode about 4 years earlier—during the mid to late teen years—than people without rapid cycling bipolar disorder. Rapid cycling affects more women than men. Rapid cycling can come and go.

When getting a diagnosis, a doctor or health care provider should conduct a physical examination, an interview, and lab tests. Currently, bipolar disorder cannot be identified through a blood test or a brain scan, but these tests can help rule out other factors that may contribute to mood problems, such as a stroke, brain tumor, or thyroid condition. If the problems are not caused by other illnesses, your health care provider may conduct a mental health evaluation or provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should discuss with you any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professional should also talk to your close relatives or spouse about your symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania. Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depression. Unlike people with bipolar disorder, people who have depression only (also called unipolar depression) do not experience mania.

Bipolar disorder can worsen if left undiagnosed and untreated. Episodes may become more frequent or more severe over time without treatment. Also, delays in getting the correct diagnosis and treatment can contribute to personal, social, and work-related problems. Proper diagnosis and treatment help people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear. Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs (self- medication). However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder. Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses. These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Treatment

Bipolar disorder cannot be cured, but it can be treated effectively over the long-term. Proper treatment helps many people with bipolar disorder—even those with the most severe forms of the illness—gain better control of their mood swings and related symptoms. But because it is a lifelong illness, long-term, continuous treatment is needed to control symptoms. Treatment is more effective if you work closely with a doctor and talk openly about your concerns and choices. An effective maintenance treatment plan usually includes a combination of medication and psychotherapy.

Medication

Different types of medications can help control symptoms of bipolar disorder. Not everyone responds to medications in the same way. You may need to try several different medications before finding ones that work best for you.

Keeping a daily life chart that makes note of your daily mood symptoms, treatments, sleep patterns, and life events can help you and your doctor track and treat your illness most effectively. If your symptoms change or if side effects become intolerable, your doctor may switch or add medications.

The types of medications generally used to treat bipolar disorder include:

• mood stabilizers
• atypical antipsychotics
• antidepressants.

Psychotherapy

When done in combination with medication, psychotherapy can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

• Cognitive behavioral therapy (CBT), which helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
• Family-focused therapy, which involves family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication among family members, as well as problem-solving.
• Interpersonal and social rhythm therapy, which helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
• Psychoeducation, which teaches people with bipolar disorder about the illness and its treatment. Psychoeducation can help you recognize signs of an impending mood swing so you can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

Other Treatments

1. Electroconvulsive Therapy (ECT)—For cases in which medication and psychotherapy do not work, electroconvulsive therapy (ECT) may be useful. Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.
2. Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, your doctor may suggest a change in medications. If the problems still continue, your doctor may prescribe sedatives or other sleep medications.

Helping People with Bipolar Disorder

If you have a friend or relative suffering from Bipolar Disorder, you can:

• Offer emotional support, understanding, patience, and encouragement
• Learn about bipolar disorder so you can understand what your friend or relative is experiencing
• Talk to your friend or relative and listen carefully
• Listen to feelings your friend or relative expresses and be understanding about situations that may trigger bipolar symptoms
• Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
• Remind your friend or relative that, with time and treatment, he or she can get better.

Never ignore comments from your friend or relative about harming himself or herself. Always report such comments to his or her therapist or doctor.

Common Misconceptions about Bipolar Disorder

The prevailing myths about Bipolar Disorder include:

Myth: Individuals cause their disorder.

Fact: Bipolar disorder is caused by a complex interplay of genetic, biological and environmental factors.

Myth: You can will yourself out of mood swings.

Fact: Left untreated, bipolar disorder can wreak havoc on a person’s life. It requires both medical treatment and psychotherapy.

Myth: You’ll never be normal.

Fact: Many patients in the beginning feel like they won’t be able to accomplish their goals, that bipolar will prevent them from getting married or getting the job of their dreams. Though patients’ lives might require certain changes, they can pursue their dreams. For instance, student patients might take fewer classes every semester and take longer to graduate, but they still achieve a college degree.

Bipolar is easy to diagnose.

Fact: According to Elizabeth Brondolo, Ph.D, a clinical psychologist specializing in bipolar disorder and professor at St. John’s University in New York, it’s often very difficult to diagnose bipolar disorder based on an initial visit, even a prolonged one. This typically occurs because our self-awareness changes with mood.

It can be hard to translate the experiences and moods one has into the symptoms for Bipolar Disorder. For instance, what might appear to one as confidence and clever ideas for a new business venture might be a pattern of grandiose thinking and manic behavior.

Medical treatment is worse than the disorder.

Fact: Many people perceive medication as worse than the illness. Although some people can experience a bad reaction to certain medication, you don’t get hooked on medication like you would a street drug, said Monica Ramirez Basco, Ph.D, clinical psychologist at the University of Texas at Arlington and author of The Bipolar Workbook: Tools for Controlling Your Mood Swings.

References

http://psychcentral.com/lib/living-with-bipolar-disorder

http://psychcentral.com/lib/symptoms-of-bipolar-disorder-manic-depression/000911

Mental illness in art

The British Journal of Psychiatry has a collection of pages of art from the Royal College of Psychiatry's ">"Psychiatry in Pictures" project, which is just what it sounds like, art about mental illness. Following are some of the pieces included in the project that in one way or another illuminate, depict, or comment upon panic and anxiety.


This one is by a Sri Lankan artist named Sujith Rathnayake, who produced a bunch of art along these lines when he entered a psychiatric hospital after the terrible tsunami at the end of 2004. I categorically do not want to co-opt someone else's tragedy for my own purposes, but I don't have a problem saying that this piece's evocation of the sense of being overcome by forces you can't outrun really resonates with me. More.


This one's by an artist named Ian Palmer. Again with the "trapped" theme. Hello, agoraphobia! More.


This is "The Sleep of Reason Produces Monsters," by Francisco de Goya. The more we learn about the brain processes involved in panic and anxiety, the more it appears that a version of this -- the "sleep" of reason, or the inability of the "executive function" areas of the brain to calm the brain's more primitive fear centers (see the bottom of this post for a more detailed look at this) -- is central to anxiety and panic. More.


This one's by a then-11-year-old ADHD patient named Darcy Easton. "The Scream" is pretty much the Mona Lisa of anxiety-related art, and it's interesting to note how many plays on that famous painting there are floating around. More.


"Number 15 Digital Cry" is by Steve Blundell, and depicts his experience of depression. See what I mean about "The Scream"? More.


"The Maze" is by William Kurelek. In the author's words:

The subject, seen as a whole, is of a man (representing me) lying on a barren plain before a wheatfield, with his head split open. The point of view is from the top of his head. The subject is then roughly divided into the left hand side of the picture, with the thoughts made in his head represented as a maze; and the right hand side, the view of the rest of his body. The hands and feet are seen through the eyes, nose and mouth, tapering off into the distance and the outside world. The Maze. An exitless one, it occupies and divides the inside of the cranium into groups of thoughts, the passageways being calculated to do the grouping. The white rat curled up in the central cavity represents my Spirit (I suppose). He is curled up with frustration from having run the passages so long without hope of escaping out of this maze of unhappy thoughts. Outside World. Grasshoppers and drought (sun before the clouds) represent the mercilessness of Nature, which bankrupted my father, a farmer, and brought out of him the cornered beast. The thorny, stony ground is a kind of T.S. Eliot Wasteland — spiritual and cultural barrenness: the pile of excrement with flies on it represents my view of the world and the people that live on it. The loosened red ribbon bound together the head of a T.S. Eliot Hollow Man, and was united by psychotherapy (Dr Cormier), but since the outside world is still unappealing, the rat remains inert. Before the head was opened, burrs (bitter experiences) choked the throat and pricked the sensitive underside of the tongue, and when it was opened the sawdust and shavings (tasteless education) spilled out from on top the tongue: mixed with the sawdust are symbols of (to me) equally tasteless Art, painting, literature and music. The burrs also represent, in the eye socket, the successive evaluations of my character by any friend during the process of acquaintance, all repellant but hopeful till the last, when the heart is discovered to be a grub. On the tongue and in the throat, the Kurelek family (big burrs produce little burrs), representing my father as the hard domineering blue burr opening up the mushy yellow burr, my mother, to release a common lot of burrs, my brothers and sisters, and one unique orange one — myself. The last burr, spearing culture, is I at the university. The inverted one is I as a child, trapped painfully between two aspects of my father, the one I hated and the one I worshipped.

If this post is up your alley, check out the series of PANIC! posts called "What fear looks like":
Part 1.
Part 2.
Part 3.

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Scarecrows The Only Way to Inspire Jealousy and Rank Fear in Ones Neighbors

Above: An extremely menacing and possibly predatory scarecrow terrorizes a neighborhood. It is joined by evil brethren from the local garden center.

I would like to tell you the secret for making your home shine like a diamond in a sea of mediocrity. And that secret is this: Scarecrows. The more scarecrows a property has, the more it will breed stirrings of fitful and vengeful jealousy in the neighbors; pride of ownership in you, the owner; and rank fear in the local squirrel, neighbor, and bird populations.

I have only three scarecrows, as I have recently learned the secret over the past weekend, and have been unable to get to the supermarket to buy scarecrow-making equipment due to the heavy snows. My scarecrows are named after familiar friends and companions of mine, so they are called Johnny-Laid-a-Turd, Repticilus Vaginicus, and She Who Chews Soup. I have placed them in menacing attitudes in various spots about my property.

As soon as I placed my first scarecrow I sighted my neighbor peering out of her upstairs window through her binoculars. I could tell right away by her shocked expression that the scarecrow had terrified her greatly—and her greatest terror lay in the fact that she, poor wretched thing, had not a single scarecrow gracing her property. My first scarecrow was wearing very little at all but a loincloth I had fashioned out of a bathtowel, and I had nailed him on a cross-like structure near the foot of the driveway. Soon after, my neighbor went out in her car, casting me dark looks of aspersion. I believe she went to the local Shop-Rite to purchase some stuffing and scarecrow-pelt material, and perhaps she was caught in the ensuing blizzard? Serves her right, the plagiarizing poseur that she is!

While she was out, I took the opportunity to set up my second scarecrow on the roof overlooking the driveway. Despite the cold weather (Christmas was rapidly approaching), I dressed this scarecrow in a cast-off Lilly Pulitzer dress that no longer fits me due to ingestion of strudel.

It is very important to dress one’s scarecrows appropriately. Outdated costumes that make your scarecrows look like “hayseeds” or “rubes” will only cause your neighbors to laugh at you, not foam at the mouth with jealously. It is difficult to get your scarecrows to look properly menacing while wearing cocktail attire, but it can be done. I suggest buying a pen of the Sharpie brand and drawing very dark eyebrows with a vigorous, up-and-down squiggling motion that makes the scarecrow look like it’s saying “Grr! Grrr!” This has always made my scarecrows look angry and fit to kill, even while holding pink paisley handbags.

I know I have only three scarecrows but I intend to get more very soon.

It is important that your scarecrows are homemade. Storebought scarecrows are often cheap and shoddily made, and their faces melt off in the first heavy rain. Plus, their costumes are not name brand, and that is a dreadful embarrassment. There is nothing more humiliating than seeing a squirrel fearlessly nibbling at the privates of your scarecrow—knowing the damned thing was false by the cut of its collar or the crease in its pant legs—while you are eagerly waiting for that same scarecrow to menace the underthings off your hoity-toity neighbor across the street.

A scarecrow that is not properly menacing should be eliminated from your property, before you become a laughingstock. I always choose compostable materials when constructing a scarecrow, so that I can toss my scarecrow in the compost heap without fear of damaging our Mother Earth. This is why my most recent scarecrow is made entirely out of congealed soup.

No one else on my block has a scarecrow. It is quite pitiable. Not only will their vegetables be snacked upon by all manner of avian pest, but they have to live with the fact that I have beat them to it as a trend-setter. If they were to all invest in scarecrows now, they would most certainly appear to be copying me. It is too late for them. They are doomed to sink in a sea of mediocrity. My neighbor is probably furiously stitching away at her new scarecrow, glaring at me through the window as she does so, but I shall still boldly stride through her property, snacking her vegetables as much as I like. It shall not deter me, although she is using Very Menacing rosemary spriggets for its eyebrows. Rosemary that she could have used in a stew but chose to employ against me, her sweet neighbor. Such is the nature of jealousy, my friends.

You who do not live on my block, however, can still adopt this trend and look smart and chic! I will not begrudge you, especially if you live far across the country where you and your derivative brethren will not bother me. This is why I am sharing the secret of making your property the Very Best It Can Be. With scarecrows!

Here are the best ten tips for building your scarecrows with the proper menace, and with nature-friendly and affordable materials:

1. Encourage your children, if you have any, to participate in the construction of the scarecrow. A child’s poor artistry and inability to construct arms of equal lengths will give your scarecrow a horrible, deformed quality that would never be achieved in those factory-made knockoffs. If you do not possess children of your own, you may borrow one of mine. They have unmedicated spatial inconsistencies that will give your scarecrows that je ne sais quoi.

2. It is best to patent your scarecrow with the U.S. patent office, especially if you have found a way to make him sentient and/or capable of perpetual motion without fresh ingestions of petrol.

3. When arranging your scarecrow in the most menacing attitude on your property, it is often advisable to rest its hands gently upon its privates. This will cause neighbors to wonder if it has molestation on the brain. Were it to become sentient, this would be unpleasant. This will cause them to lie awake at night thinking agitated thoughts, and limit their abilities to do better than you in any way.

4. Straw, chaff, wheat, spelt, and so on are poor choices for scarecrow stuffing. I prefer Gluten-free ingredients that are not liable to be pecked by wild turkeys and doves, causing my scarecrow to look decrepit and decayed. Gluten-free pasta, crackers, and breads are readily available at most health food stores, including Mrs. Greens and Whole Foods.

5. Try to make your scarecrows diverse, reflecting the breadth of our colorful, human tapestry. A sea of white scarecrows dangling from wooden staves and crosses will just make your home look like a rarified country club. This is not what We want to achieve.

6. A scarecrow’s handbag should always be of an appropriate seasonal hue. If a scarecrow is wearing a light, white summer frock, do not choose a heavy black handbag, for example. This sort of thing will result in rude talk amongst the very neighbors one is trying to menace.

7. Scarecrows can be made much more menacing by the application of odors, such as Go Away Evil ™, or by installing soundtracks that play artists such as Peter Cetera. A scarecrow that appears to be singing “I am a man who will fight for your honor” will disturb and agitate many passersby.

8. Accessorize, accessorize, accessorize! I mentioned handbags earlier. The handbags are much more menacing if they are filled with real grenades, loose bullets, or the carcasses of the scared-stiff animals that you have managed to trap by freezing them in the aural glare of a Peter Cetera marathon. Scarecrows also look nice with necklaces made of human teeth.

9. Remember that the goal is to keep people off your property and cause them to tremble in fear whenever your name is mentioned. Then, and only then, will perfect domination be achieved! If any scarecrow fails to fulfill this purpose, it should be terminated without remorse. It is best to terminate during a neighborhood Block Party, at the exact moment that the ice cream truck arrives. In winter, substitute with the arrival of the local Caroling group.


10. Local teens tend to think that scarecrows are a subject for hilarity, not mind-numbing terror. Teach them a lesson by air-dropping a batch of homemade beauties atop their homes during “Movie Night” or a sleepover. Make certain the scarecrows you choose to drop are the ones most likely to become sentient at the most surprising moments, or else the hollow thumping may simply remind the callow teens of turds striking the roof.
  
It is best not to overdo the scarecrows. I know that I earlier recommended “the more scarecrows the better,” but I have recently revised my view due to an article I read in The New York Times. I am a little bit scared now, as the one I made out of soup has dissolved into my yard in the heavy snows and, therefore, into our water table.  

I would rather not share the entirety of the article's content here, due to copyright restrictions, but suffice it to say that my prescient warnings about sentient scarecrows came true for one poor homeowner in Marietta, Georgia, who had covered every square foot of her property with a matching scarecrow in a gingham outfit with black button eyes (Pfah! Hardly menacing!), in an effort to control the local goose population. Not only were Ms. Scribb's geese not deterred, but her scarecrows turned on her in a gruesome bloodbath that is soon to be made into a motion picture. Let this be a lesson to you! Keep your scarecrows to a minimum. I suggest 15 at most. Good luck to you.

The Manny Diaries Chapter 13 I Found My Smile in Two Gallons of Mezcal

"Miss Jennifer! Miss Jennifer! I'm going to buy ten chickens tomorrow!"

Such were some of the first words that Manny spoke when he finally reached me by phone from his new home in Oaxaca, Mexico. And boy, did he ever sound drunk. Happy drunk, mind you. Ebullient drunk. Almost giddy with drink.

"Ten chickens! Like, 20 cents a piece. Hey! Do you know you can get two GALLONS of Mezcal here for only $16. Two gallons! Not that I'm drinking anything because, man, I'm about a mile high up in mountains and it's beautiful and I don't need to drink or do anything bad at all. Nyet! Nyet!"

Will he name one of his new chickens "Bun-Bun"?

Was that Russian he was speaking? Yes, he revealed to me that he can speak about 10 different languages fluently. Never once while he was staying with us had I heard him speak one word that wasn't English or mangled English.

"Any Eastern European language there is, I can speak it. I don't like to tell people because they will get an impression of me," he said. "Like a wrong impression or a weird impression, you know?"

It seemed odd that a man who forgot how to pronounce words like "guacamole" and called a "beet" a "parsnip" and a pork loin "that other meat--the meat, you know the one, that's not chicken and not beef, dammit, what's that called?" would have such a facility with languages. But I didn't argue.

"Nyet!" he said again, and then: "Dammit! There I go again. It's so confusing, all these languages going around in my brain."

"How about Spanish? You learning Spanish?"

"Yeah yeah! Uno, dos, tres, nachos!" I laughed. "What, what?" he said.

Mexico was treating him rather well. He loved it there, after only two or three days. He could see the President of Mexico's house from where he stood! The food was fresh and good and unbelievably cheap. He repeatedly remarked on the cheap price of the Mezcal and then quickly added "not that I'm drinking it" after every reference. He mused about the two gallons of Mezcal that were about to be delivered to his casa, and sniggered gleefully over the cheap price. "For cooking. And maybe a sip with lunch. Just a splash," he coughed.

He insisted that we all come down for a visit and live like kings. Heck, we should all just move down there permanently, because it was heaven on Earth. "Those boys can run wild in the agave fields!" he said. "It's the safest thing! A mile of space! They would be perfectly safe to just run wild. Except there are these burros...these really big burros. What are they called? Burritos...OXEN. I mean, bulls! You don't pet those guys. They could gore you."

That is one big Burrito!

The trip down had gone perfectly. His large bag weighed two pounds over the weight limit, but the woman in the baggage area had winked and waved him onward. The Federales treated him kindly and laughed at his jokes, despite the fact that he'd been gurgling free double Absoluts on the plane (apparently Aeromexico hands these out for free, plus hot breakfast. What an airline!) "I would not be escaping from anything, of course. Who the hell wants to escape TO Mexico?" the Manny snorted at customs, as they all laughed and waved him through.

His new landlords met him at the airport and took him out for dinner: A huge meal with tequila shots that amounted to about 8 dollars total for three people. After this he became really chatty and mentioned that in Vietnam, he had killed 163 people. Apparently, they keep a tally. It's considered a sort of honor, a point of pride. I think it has haunted Manny his entire life.

"That's a lot of dead people," he said, almost soberly. His landlady had hushed him and said, "Let's not talk about that, okay? Not out in public and not to other people, at least?"

"I almost screwed my pooch there, Miss Jennifer!" he said. "163 people. That's a lot." There was a long moment of silence and then he was off and running again:

"Do you know how salty the salt is here? And how sugary the sugar? I took a big lick of a salt pile and it was so salty I almost threw up. They have mountains of salt! Your dad, I mean your husband, would hate all that salt. The sugar is just so sugary. And the sun? I'm brown like a beautiful Mexican girl! I've found my smile. I have finally found my smile. There is nothing better than this. Do you know how much free booze there is, Miss Jennifer? I mean, I'm so happy, I'm not needing to drink at all. Just a little with breakfast, lunch, and dinner, you know?"

From left to right: Breakfast, Lunch, Dinner.

He called back about 10 times in the next two days. He sounded a little lonelier; he asked to speak with the boys and they all shouted things like "We miss you!" as we poked them and pointed at the phone. He'd received his chickens and was prepping to name them. They each produced about one egg per day. He thought he might name three of them after the "little guy, the middle one, and the big one," our sons.

"You really ought to come down here. I'll pay for your trip! I'm working on a new business plan. Pretty soon I'll be making 10K a month. Hey, did you know that you can get a meal down here with eggs, beans, chorizo—all you can eat—plus three shots of Mezcal, all for three bucks?"

The last time he called was June 21. I recall that when he had been gone a few days we took note of a strange sort of melancholy, almost as if we had been at a funeral. "I feel as if someone has died," I said, in the parking lot of Trader Joe's. And then there was the thought: He has gone there to die. We will never see him again.

We will never see him again.

Never again will I be worried that, upon stepping out of the shower robed and towel-turbaned, that Manny will sight me and recoil and stammer his way into a doorframe. Never again will I see the plate of fresh-cut fruit that he has laid out for the boys at 6 am, making sure there is an ample supply of red apples (the only ones youngest son likes!) in proportion to green apples, along with cuts of watermelon and pineapple. Never will I see the chaotic mess he has made of the kitchen after a stir-fry extravanganza, with drippings down the edge of the stove. We won't hear him moan and cry out: "The pain! The pain!" as he plods up the attic stairs to his dark aerie.

I hast barfed profuse filthy dishware whilst I wast cooking.

Here is what I wonder on this rainy, desolate, wind-cooled night: As he steps out beyond his meager possessions (wok, pot, coffee carafe, lemon squeezer, spoon) and looks past the casa to see the burros plodding along, carrying firewood against the sunset, is he perhaps, strangely, the happiest of beings? Does he know even one sure thing that we do not, if even for the briefest of moments? He has claimed his smile. He knows better, perhaps, than to expect its certainty each dawn.

We dream a fiction. We can never really know the truths that fools and madmen hold in their dark, stung, longing hearts.