Academics, chief residents, inpatient docs, scoff all you want. I defy anyone with a serious public outpatient practice to tell me you do not have at least one, usually several, patients like this. They are one of psychiatry's ill-kept secrets, and I recall discovering them among my attendings' clientele when I was an on-call resident years ago. Luckily, my attendings were of a philosophical generation. Their explanations went straight to the big picture and skipped any attempt to make pharmacological sense or to apologize. These are broken people, they told me. Their lives are unbearable if experienced with any clarity. We help them to stay numb as an alternative to having them, or someone else nearby, get physically hurt or die. And then, over the years, we find something in them to appreciate or to make contact with, some little bit of life left within them. Such appreciation, such contact, must be seen as having value in itself and not as a means to an end.
While dampening the idealism of the clinicians, I have myself practiced a sort of psychopharmacologic idealism. Every single psychotropic on the previous list has been tested with a taper since I inherited this patient several years ago. I have had small victories: buspirone(Drug information on buspirone) is gone, oxcarbazepine(Drug information on oxcarbazepine) has replaced carbamazepine(Drug information on carbamazepine). But any attempt at the big ones--fluoxetine, valproate, clonazepam(Drug information on clonazepam), the antipsychotics--inevitably results in emergency department visits, phone calls from a frightened wife, broken windows, punctured walls.
At first I thought we were having a symbolic dialogue about dependency and autonomy through his drastic reactions to any change I would make. I spent lots of phone time reassuring him and getting him to try and hang on, to wait some medically respectable interval before reinstating his former dosage. But after I stopped questioning his regime, there were no further problems until the latest therapist rocked the boat. The patient has taught me, and now he trusts me completely. Our contract is that I will keep him numb. He watches the sports channel and dozes periodically; sports is our topic today. His face is flat, his speech a bit slurred; his half-smiles, though, are still worth the wait.
On my desk beyond him is the latest issue of Neuropsychiatry Reviews in which Elio Frattaroli, M.D., speaks from his new book Healing the Soul in the Age of the Brain (Viking, 2001). His words are an eloquent compensation for today's symptom-driven, mindless psychiatry. He speaks of unconscious conflicts and symptoms as an opportunity for spontaneous growth. True believer in psychotherapy that I am, I still find myself playing with ironic titles of my own. Numbing the Brain While Losing the Soul? Or maybe å While Grieving the Soul? å While Glimpsing the Soul?
No, there is nothing mysterious here, no hidden conflict to reflect upon in the situation of my pedophile patient. The horror is mostly above board, and if we go looking for more, he lands in the hospital.
Reflection, growth, awareness: such noble statements of value are necessarily one-sided; they always leave something important out. I still hide the newspaper's morning headlines from my 9-year-old, the suicide bombings, child abductions and rapes. From my 17-year-old, I do not. I suppose the difference is that I expect him by now to have developed his capacity for numbness. I must have been teaching him right all along.
Perhaps the Enron and WorldCom executives learned that lesson too well, oblivious to the future pain of the people from whom they stole even as these same people typed their memos and brought them their coffee. But clearly, we all learn adaptive numbness. It is a universal and essential complement to awareness. They must exist in some shifting equilibrium for us to survive in this sometimes hostile and overwhelming, sometimes hospitable and nurturing world.
The "psychic numbing" (DSM-IV language) we are considering here parallels physical processes like hibernation and dormancy. Each seems to allow the organism to await better conditions (why else would my patient brighten while discussing sports scores?); each may end either in death or in a reawakening. I do not delude myself that even with all the time in the world I could "facilitate the maturational process" (Frattaroli, paraphrasing Winnicott) in some idealized psychotherapy with my patient. If his soul is healed, it will be by a Power greater than myself--by a change in the conditions within which he lies dormant. Both forms of psychiatry, biological and psychodynamic, may function as vast defense mechanisms against the recognition of just how bad life can be, and how helpless we are before that fact.