Arjune Rama, MD

BOOK REVIEW
Here We Are Now: The Lasting Impact of Kurt Cobain
by Charles R. Cross; New York: Harper Collins, 2014
192 pages • $22.99 (hardcover)

Twenty years ago, Kurt Cobain, lead singer of Nirvana, committed suicide. I was only 12 years old when he died. I had just come home from school and was watching MTV when white printed words crawled along the bottom of my screen announcing that “Kurt Cobain was found dead of an apparently self-inflicted shotgun blast to the head.” Over the next few hours, MTV News anchor Kurt Loder introduced me to words such as “heroin,” “addiction,” and “depression” many years before I would explore them in psychiatry residency.

Since his passing in 1994, countless pseudo-intellectual “think pieces” have been published on his short life and abrupt death. Having read many of these speculative and frequently unsubstantiated write-ups, it was with a skeptical eye that I reviewed Charles R. Cross’s 

Here We Are Now: The Lasting Impact of Kurt Cobain

. He earned my trust after his thoroughly researched Cobain biography.1 While the biography is an excellent read, it is by no means a necessary primer for 

At fewer than 200 pages, Here We Are Now is a quick read divided into 6 chapters describing the late musician’s lasting influence on popular music; impact on fashion; a discussion of the meaning of Grunge; his effect on Seattle and his hometown of Aberdeen, Washington; his addiction and eventual suicide; and a commentary on his legacy.

Cross triumphs by revealing Cobain’s struggle in a way that will be compelling to both clinicians and non-clinicians alike. However, 

 is worth the read for clinicians, particularly the sections chronicling Cobain’s heroin addiction, his foray into substance abuse treatment, and the public health impact of his death. He deftly pulls in statistics and expert interviews that suggest Cobain’s end fit neatly into the suicidal paradigm we see in the clinic every day. Cross delves deeply into his subject’s family history, previous suicide attempts, and substance abuse history. Although this is a book about an extraordinary artist, in these sections I felt like I was reading about any young adult on my patient roster at risk for 

Some of Cobain’s addiction and substance abuse history has been explored in other books. Still, I found the public health information particularly fascinating. I was surprised to learn that there was genuine concern that Cobain’s suicide might have a ripple effect among young adults worldwide. To discuss these concerns, Cross draws from interviews with a past president of the 

 as well as the Chief Medical Examiner at the scene. Through the eyes of a suicidologist, we see that the number of suicides actually fell in the wake of Cobain’s death as a function of a well-coordinated public health outreach effort.

In addition to being a well-researched piece on a modern tragedy from a mental health perspective, I think clinicians of every stripe will be drawn in by Cross’s personal experience documenting Cobain’s rise and fall. Cross was editor in chief at the influential Seattle music newspaper, 

, before and after the alternative rock explosion of the early 1990s. He describes the sad and strange experience of being the first person to feature Nirvana in print as well as being among the first to confirm Cobain’s death. Cross’s personal heartache and professional obligation become intertwined in a way that I think will be familiar to clinicians.

This article was originally posted online on 4/15/2014 and has since been updated.

Dr Rama is a psychiatry resident at Yale University School of Medicine in New Haven, Connecticut. Follow him on Twitter: 

Heavier Than Heaven: A Biography of Kurt Cobain

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Clinicians will be drawn in by author Charles R. Cross's personal experience documenting, Here We Are Now: The Lasting Impact of Kurt Cobain. Cobain, lead singer of Nirvana, committed suicide 20 years ago this month.

Kurt Cobain: A Modern Tragedy From a Mental Health Perspective

podcast in my office as I checked my clinic schedule for the day, I couldn’t help but smile when he announced that August 9th marked his 14th anniversary of being clean from alcohol and cocaine. However, I found myself completely distracted from my work when he reenacted an internal dialogue from his addicted past-two Mark Marons struggling to accept each other-a splitting of self that I am sure many of my alcohol-dependent patients have also experienced:

F--- that! I’m going to f---in’ drink to that.

Hell yeah! Now I can accept me because now I’m cool, I’m loose. 

Look at me making people cry and hurting myself!

As a psychiatry resident physician, I treat addiction almost daily. However, my understanding of dependence will always be limited by the fact that I haven’t suffered from addiction first-hand. So I thought, “Who better to help me understand recovery than the brutally honest, 14-years-sober Marc Maron?” While talking to him for an hour from my office in New Haven, Connecticut, I felt like I was on a 

 The intro to one of your recent podcasts got me thinking that you could help me get a better understanding about alcoholism. What was involved in your recovery? Meds? Therapy?

 Let’s see . . . I was once diagnosed as dysthymic. I’ve been in and out of therapy at different points in my life. I went to rehab once when I was younger. Also, I was on Prozac briefly and then I was on Wellbutrin for a while. I could probably still use an anti-anxiety drug (laughs). Like I said on the show, I’ve also been in Alcoholics Anonymous.

 How did AA figure into you getting sober?

 For practical tools to deal with the addicted brain, the stuff I learned in Alcoholics Anonymous and the community of AA just totally worked for me. If you would have told me back then that I wouldn’t desire a drink or that I wouldn’t desire to do drugs at some point in my life, I don’t think I would have believed you. I still have my vices-I drink a lot of coffee and I’m hopelessly addicted to nicotine in the form of lozenges but those aren’t destroying my life or my health like other things would have.

 Yeah it’s not like you’re going to wrap your car around a tree because of some lozenges.

 I think a big problem for psychiatrists when it comes to understanding addiction is that many of us have no experience with it on a personal level. So there’s a built-in disconnect between the treater and the patient.

 Well, yeah, because you guys are just taught to medicate and suggest things. (Pauses) Have you even read The Big Book

 I know, I should . . . I treat people who swear by it and I haven’t even looked at it.

 Yeah see that’s the thing with all you guys. Most therapists have never read that f---ing book. But you send people to AA meetings, don’t you?

 But you have no understanding of what the program is! I can’t understand why its not assigned to you guys.

 That’s a really good point. Looking at my shelf right now I see 

The Neuroscientific Basis and Practical Applications of Psychopharmacology,

 but when it comes to books that become part of what people in recovery use, I don’t have to read them. I could read them on my own, but they’re not part of the curriculum.

 I think a lot of you guys see it as some sort of goofy spiritual system. But there’s a certain brilliance to it. The program uses very simple language so it works for people who are geniuses or for people who are morons. And it works everywhere -there are programs going on in rooms all over the world and the feeling in all of them is the same. The emotional hunger, the need, the selfishness-its all the f---ing same! Everybody in those rooms has been to hell and back twice. They’ve f---ed up so much that now they’re these demons in exile.

 It sounds like you haven’t really found a lot of value in the conventional mental health care system. How would you describe your relationship with it?

 Oh not entirely . . . I’m in therapy now and it’s helping a lot. Even with therapy and AA, it took me 26 years to get 14 years in a row sober. I was in and out, in and out.

You’ve said that there’s something therapeutic for you about simply doing your podcast. Why do you think that is?

I’m just trying to connect with someone for an hour. People used to do that. It’s about community and interaction and helping people. People are designed to help other people. But we live in a culture where people are consumed by their own bulls--t and they don’t think they have time to help other people.

A lot of people have said your podcast has helped them out-alcoholics included. What do you think about that?

Yeah, you know, alcoholics-sorry, I’m getting choked up now-don’t know how to ask for help. They’re stubborn and rebellious so it takes a lot for them to ask for help. I can’t tell you how many times I’ve been in an AA meeting and I’ve been moved to tears just hearing stories where they ask for help.

What was it like getting sober? What has it been like staying sober?

You know, life is life. And life certainly doesn’t get any easier when you get sober. Look, alcoholics are hypersensitive, selfish people who are prone to self-pity and resentment, so very minor things can send them spiraling into chaotic anger and despair. For a year I went to meetings 2 or 3 times a day . . . which I could do because I’m a comic so I had a lot of free time. I can’t tell you how many times in my first year of sobriety that I’d talk in the meeting and say, “This is f---ed, I f---ing hate this, I’m out of my mind, you guys are idiots, this whole f---ing thing is stupid.” And after the meeting someone would come up to me and say, “You sound great!” (laughs). Because that’s what they were doing when they started.

As far as staying sober, I don’t drink or do coke, but I’ve still got problems. I have f---ing horrendous anger problems, issues with panic, and I am filled with dread a lot of the time.

 Working in a university setting, I’ve heard literary scholars say things like, “It was the opening of his mind via substances that helped him make his best work.” What do you think about that perspective when it comes to artists who are substance-dependent?

What people forget, English professors included, is that those artists were probably geniuses-so to give that much credence to a substance is romanticizing and unfair. Would we not have that art if it wasn’t for drugs? I don’t know. But I guarantee you that at that moment in time, most of them weren’t thinking that way. They weren’t thinking, “I’m a genius. If I take this medicine or if I get strung out on this s-t, that’s when I’m doing to do my best work.” These were people who were sick and they couldn’t help themselves. Whatever the relationship was between their mental health and their addiction, you can speculate all you want, but it’s not a system built to generate brilliant things.

If you could talk to a clinician-in-training about how they can better help people suffering from addiction, what would you say?

[long pause] I would tell them to think about addiction the same way I tell alcoholics: “You’re going to die from this. Nobody survives this. One way or the other, it’s going to kill you. It may take a while, or it may happen in one night for a million different reasons-a bad mix of drugs, drunk driving, catching a bullet because you’re scoring drugs in a s---ty place, whatever. There’s a million ways its can kill you-but it will kill you. Even if you’re 65-sure, you’ve made it that far, but then your liver goes bad. I know guys who haven’t shot dope in 20 years but now they’ve got Hep C. You’re dealing with a chronic condition. And it’s going to kill you.” That’s what I would tell them.

Editor’s Note: This piece originally appeared in the Slate Culture Blog, "Browbeat," on September 2nd, 2013 (reposted with permission).


http://www.slate.com/blogs/browbeat/2013/09/02/marc_maron_alcoholism_and_drug_addiction_an_interview.html

Dr Rama is a psychiatry resident at Yale University School of Medicine. He lives in New Haven, Connecticut, with his wife and daughter. Follow him on Twitter: 

Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholism.

 New York: Alcoholics Anonymous World Services; 1955.

If you could talk to a clinician-in-training about how they can better help people suffering from addiction, what would you say? A Q&A between Arjune Rama, MD, and comic Marc Maron.

Life as a Demon in Exile: What Marc Maron Taught Me About Addiction

Falling Into the Fire: A Psychiatrist’s Encounters With the Mind in Crisis

In my first year of psychiatry residency, I felt overwhelmed by frequently heartbreaking, sometimes hilarious, and often outright bizarre situations on the inpatient wards. In addition to reeling from the volume of cases, I was struck by the staggering ambiguity of treatment decision making; often no one therapy or combination of therapies seemed to be the clearly correct choice. To help boost my clinical confidence, I looked for books by psychiatrist-writers to see how they managed the uncertainty inherent to our field. Although I found a few entertaining novels and insightful essays, even the best of the lot felt dated or failed to depict realistically a clinician’s decision making process on today’s inpatient psychiatric services.

I am pleased to say that Dr Christine Montross’s latest book, 

, succeeds in filling this void. Dr Montross takes her readers through a series of 7 clinical vignettes experienced during her psychiatry residency and in her early practice as an attending psychiatrist. The cases include a woman who presents to the emergency department innumerable times after swallowing objects like barbeque skewers and 6-inch knives; a young man whose spiritual fervor may be heralding a psychotic disorder; and-perhaps most compelling-a woman whose intrusive ego-dystonic fantasies of murdering her newborn son present a gripping diagnostic and management dilemma.

However, Montross’s work is more than simply a collection of interesting vignettes. Frequently she pushes her reader to confront ingrained biases toward some of our most challenging patients. For example, in unabashed detail she describes her thought process while she managed a seizing psychiatric patient (Phyllis) with a history of non-epileptic psychogenic seizures:

While Phyllis’s body continued to shake, beating against the floor, I felt the full force of uncertainty as to whether her seizures were neurological or psychological in origin. I was flooded with a range of feelings, all of them uncomfortable . . . When I first got to Phyllis, my mind began charting its way through seizure protocol, but a history of pseudoseizures complicated the picture and immediately shifted the course of action from clear to murky.

When it is clear that this spell was indeed non-epileptic, she relates the frustration that such clinical scenarios evoke: “I was surprised to feel mostly overcome by anger. I felt as though this woman had 

 Montross takes this conundrum a step further by discussing it with renowned neuropsychiatrist W. Curt LaFrance, Jr. He reminds us that Phyllis is truly suffering; there is nothing 

 about her disease. Furthermore her condition is treatable if we are willing to bring our most empathic selves to bear.

While Montross’s gift for storytelling and provocative questions provides a lively read, what makes this text unique is the personal but eminently relatable material interwoven with the cases. Somewhat suddenly, not unlike in real life, a chapter will take the reader out of the hospital entirely and place him or her into Montross’s shoes as she walks through her front door, unclips her beeper, and takes on her role as a mother and partner. Her sharp transitions simulate how our clinical and home lives, for better or for worse, frequently bleed into each other. With great humility Montross writes about the poignant reality checks she receives from her non-physician partner as she puzzles over cases. During these personal passages I felt I was reading not just about the practice of psychiatry, but rather the practice of being a psychiatrist.

More than simply a collection of interesting vignettes, the author of this book frequently pushes readers to confront ingrained biases toward some of our most challenging patients. 

Note: The patient below has been completely de-identified in order to protect his/her health information.

“You don’t have any idea what you’re dealing with, do you?” asked Mr Johnson a mere 2 minutes into my interview. The scene is the Crisis Intervention Unit. The time is 3 AM. I have a feeling my breath is terrible. The hospital pizza I engulfed earlier in the evening has decided to stage a churning acidic protest in my guts. However, far worse than my half-closed eyes, my halitosis or my gastrointestinal distress is the fact that he’s absolutely right. Mr Johnson is here because he has come to the realization that living sober is about as awful as living as an alcoholic. As a result, he has decided life is simply not worth living.

As a practitioner, I have found that patients caught in this double-bind are among the most frustrating to treat. They are living proof that substance dependence treatment can be quite shortsighted. The logic is charmingly simple and irritatingly simplistic: if you’re drinking too much, then you should probably stop. Once you stop, all will be better.

To properly understand the failure of this logic, we need to distinguish the brain from the mind. Although our medications and therapies are effective in removing alcohol from the brain, we are less successful filling the empty space left in the mind. Mr Johnson’s alcohol use started as a coping strategy and slowly evolved into a way of navigating the world: a drink to take the edge off at a dinner party; a libation or five to take the edge off of a bad day at the office; a quick stop at the corner bar after work to steel himself against a troubled marriage and a wayward teen. Alcohol played prominently in the way his mind functioned for years.

After “treatment,” suddenly there was no sedative to bring out the best “Mr Johnson” when he attended a dinner party. Frustration from days at the office lingered long into the evening. Problems at home, at one time nicely obscured by liquor, were now seen in sharp relief.

When Mr Johnson accurately noted that I couldn’t appreciate his situation, I was reminded of my personal development thus far. Like most physicians, I am a person suited to delayed gratification, long-term goal-setting, and possessed of a persistence to achieve these goals. This isn’t to say that I’m superior to him. Rather, for reasons as arbitrary as genetics and birthright, the decision centers of my brain do not have to compete with the influence of a substance such that my mind can look at the ups and downs of life with balance. As a result, I have little to no tangible life experience with which to help his mind function without the aid of a substance.

So after staring blankly for a few seconds (which seemed like minutes) at Mr Johnson, I dispensed momentarily with my medical training regarding suicide risk assessment or attempting to present treatment options to achieve sobriety. Instead, I sat on the edge of his bed and said, “You’re right. I don’t know what I’m dealing with. This sounds absolutely awful, though . . . tell me what it’s like.” Given the constrictions of a busy crisis unit, I still had to complete my evaluation, disposition decision, and documentation within an hour. Eventually he was voluntarily admitted to the hospital out of concern for serious potential harm to self.

I have no delusions that my brief talk filled the void in his mind left by the removal of alcohol. However, during our discussion it occurred to me that patients like Mr Johnson are constantly marginalized in the hospital setting. Throughout medical school and into residency I have heard the phrase, “He’s just going to go out and drink after discharge anyway . . .” more times than I can count in reference to the disposition of patients like Mr Johnson. It’s true, the relapse rate for patients who are newly sober is staggeringly high. So what are we as practitioners to do?

We need to listen. And I mean, really listen. We need to be taught by our substance-dependent patients because, more than likely, we have zero background with which to help them. Listening in this way may be very uncomfortable, as it requires us to step away from the familiar books and diagrams that put us in the revered position of “Doctor” and step toward the unfamiliar thought processes of those who have put their lives in our hands. We cannot hear our patients if we try to remain on this imaginary pedestal: our ears are simply too far away to catch anything helpful.

As a result, I strongly encourage my medical students to read actual descriptions of real patients’ experiences with addiction and better yet, listen to one or more of their patients who is willing to describe their personal addiction stories. I believe that the more and varied stories we read and hear, the better equipped we are to understand the cold vacuum left behind when alcohol is removed from the equation. As we accumulate a greater war chest of patient experiences, we can better apply our skills as physicians to fill a space once occupied with alcohol-lubricated decision-making with smooth yet sober coping strategies. In this way, we can help change their minds.

which has granted permission to post this article, published on their website at 

Arjune Rama, MD
Resident Physician, PGY-2
Yale University School of Medicine
Department of Psychiatry

As we accumulate a greater war chest of patient experiences, we can better apply our skills as physicians to fill a space once occupied with alcohol-lubricated decision-making with smooth yet sober coping strategies. 

Author | Arjune Rama, MD

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