Michael Sperber, MD

Â A great psychiatrist knows the disease, the person with the disease, and the way the two interact. Here are tips, from a clinician who has devoted his career to treating psychiatric disorders.Michael Sperber, MD isÂ a Consulting Psychiatrist, Neuropsychiatry/Behavioral Neurology Service of McLean Hospital in Belmont, Mass.Each "hallmark" is accompanied by a corresponding "related link" to articles of interest to psychiatrists. To view in PDF format, click here.

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A great psychiatrist knows the disease, the person with the disease, and the way the two interact. Here are tips from a clinician who has devoted his career to treating psychiatric disorders.

10 Hallmarks of a Great Psychiatrist

O what a tangled web we weave, when first we practice to deceive.

[[{"type":"media","view_mode":"media_crop","fid":"34351","attributes":{"alt":"Therapeutic Lying","class":"media-image media-image-right","id":"media_crop_2981882476577","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3659","media_crop_rotate":"0","media_crop_scale_h":"79","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"","typeof":"foaf:Image"}}]]Therapeutic lying, a concept that is currently seeping into the medical literature, is defined as the practice of 

 for reasons considered in their best interest.

This essay calls attention to the fact that therapeutic lying is a contradiction in terms-a combination of words whose meanings are in conflict with one another. If “therapeutic” is defined as “having healing or curative powers for the treatment of disease or disability” and “lying” is “making a false statement with the intention to deceive,” lying is not therapeutic and therapy is incompatible with lying. A statement from the Roswell Park Cancer Institute elucidates this:

If there’s one thing sacred in the doctor-patient relationship, it’s trust. Open and honest dialogue on both sides of the exam table is by all accounts critical to effective care. Patients have to be truthful to ensure diagnostic accuracy and an appropriate treatment plan, while doctors need to provide full disclosure about their patient’s health-the good and the bad-to help patients make informed decisions. Indeed, patient autonomy is the cornerstone of modern medicine and 

Therapeutic lying in the context of caring for dementia patients is a complex phenomenon. Its potential value is concisely stated in an article concerned with the subject:

Lies that reduce suffering and stress in patients unable to fully appreciate the cause of distress can be beneficial. Clinicians sanction their use in dementia care and see them as a manifestation of the ethical imperatives of beneficence and 

As an example of therapeutic lying, a caregiver may tell an argumentative patient with Alzheimer disease and hypertension, who is worrying about his wife’s whereabouts, that “she’s gone to the store” rather than telling the patient, “she died 7 years ago.” In this case, the lie is told to avoid a possible conflict that may cause a rise in blood pressure.

Clearly, in a person without dementia, lying may be disastrous. Consider its impact on the moribund protagonist of Tolstoy’s masterful novella, 

What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and that he only need keep quiet and undergo a treatment and then something very good would result . . . this deception tortured him-their not wishing to admit what they all knew what he knew, but wanting to lie to him concerning his terrible condition, and wishing and forcing him to participate in that lie.

Persons with cognitive deficits, it is assumed, will be unaware of such deceptions. This may be a mistaken assumption. The cognitively impaired may intuit being lied to and more aware of deception than one would think. Consider Benjy Compson, the mentally retarded and probably autistic narrator of Faulkner’s 

, who cannot understand such abstract concepts as time, cause and effect, or right and wrong. Despite his cognitive deficits, he is hypersensitive to order and chaos, immediately sensing the presence of anything bad, wrong, or out of place. He senses, for example, his brother Quentin’s suicide, thousands of miles away at Harvard, and his sister Caddy’s promiscuity and loss of virginity.

Instead of lying to a patient with dementia, it may be possible to validate the person’s feelings. For example, the hypertensive patient with Alzheimer disease could be told, “It sounds like you’re thinking about your wife. Would you like to tell me more about her?” As the patient starts reminiscing, he may share his underlying feelings. In this way, one neither agrees nor disagrees with his misperception of the wife’s demise.

In addition to validation, redirection might be helpful. Redirection involves diverting attention to something pleasant. With respect to the Alzheimer patient, one could say, “Where is that photo of you and your wife? Can you help me find it?” This validates that the patient misses his wife and redirects him to a different activity. Neither involves lying.

 Rather than therapeutic lying, it respects the integrity of the person with dementia by having caregivers accept his or her reality in order to better understand what he or she is experiencing. This approach does not negate, belittle, or lie to the patient but requires a high level of clinical skillfulness. In view of the population’s increasing longevity, more effort should be made to teach such skills.

Dickinson’s ophthalmic disorder and telling the truth

Although Emily Dickinson recommended telling all the truth, she was adamant that one present it in an oblique and circuitous fashion:

Tell all the truth but tell it slant-
Success in Circuit lies
Too bright for our infirm Delight
The Truth’s superb surprise
As Lightning to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind8

The reason Dickinson admonished that the truth be presented circuitously may relate to the poem’s last word, “blind.” The lines were written in 1868, 3 years after Emily Dickinson consulted Dr Henry Willard Williams, the premier ophthalmologist at the time, for photosensitivity, eye pain, tearing, and problems with near vision. No records of his diagnostic impressions survive. Iritis, exotropia, and somatopsychic problems are the most frequently conjectured diagnoses.

Their relationship began on April 15, 1862, when the poet responded to Higginson’s lead article, “Letter to a Young Contributor,” in 

 (April 1862), which described his role as its literary editor: “Every editor is always hungering and thirsting after novelties. To take the lead in bringing forward a new genius is a . . . fascinating . . . privilege.”

On April 15, 1862, Dickinson wrote an eager letter: “Are you too deeply occupied to say if my Verse is alive? . . . Should you think it breathed-and had you the leisure to tell me, I should feel quick gratitude.”

 She received a traumatizing response from Mr Higginson. The 31-year-old Dickinson had included 4 remarkable poems (“Safe in Their Alabaster Chambers,” “I’ll Tell You How the Sun Rose,” “We Play at Paste,” and “The Nearest Dream Recedes, Unrealized”). Higginson, who had never before seen such original poetry, was astonished by what he received, and “through an excess of caution and a deficit of imagination,”

 responded that they were “spasmodic,” “uncontrolled,” and advised that she “delay publication.”

The poet, who never recovered from Higginson’s letter, was at first bedridden by what she called “surgery”-it stirred up in her “terror” and associations to death: “Mr Higginson, Your kindness claimed earlier gratitude-But I was ill-and write today, from my pillow. Thank you for the surgery-it was not so painful as I supposed.”

The words “bright,” “dazzle,” and “blind” may be linked to Dickinson’s symptoms. She was a master of using the woe in her life in a constructive fashion. It is possible that Dickinson’s anxieties about her ophthalmic problems inform this poem. She was worried about going blind, and it was imperative that Dr Williams level with her about possibly losing her sight, but essential that he “eased / With explanation kind [her worries since] / The Truth must dazzle gradually / Or every man be blind.”

She had already had a traumatic encounter with Higginson, whose unusually blunt words may have resulted in Dickinson’s ophthalmological problems, which may have been psychogenic. In any case, she never again sought to have her poems published.

Dickinson would have found therapeutic lying insufferable, but based on her own experience, would have admonished that slanting the truth could be far more humane.

In lieu of the euphemisticmisnomer: “Lying”

Medical paternalism appears, at times, unavoidable when caring for patients with dementia, and some clinicians defend telling lies to cognitively impaired patients.

 So-called therapeutic lying, however, is a euphemistic misnomer. It should be eschewed and replaced by the clinical methods of redirection, validation, distraction, and substituted 

 On occasion, lying may be beneficial, but it is never therapeutic.

This article was originally posted on August 11, 2014 and has since been updated.

Dr Sperber is a Consulting Psychiatrist at the Neuropsychiatry/Behavioral Neurology Ser­vice of McLean Hospital in Belmont, Mass; and Supervising Psychiatrist at Thriveworks Boston in Cambridge, Mass.

. Edinburgh: J Ballantyne and Co; 1808. Canto VI, XVII.

 Culley H, Barber R, Hope A, James I. Therapeutic lying in dementia care. 

 Ellison J, Hsu D. A dark side of dementia care. 

http://www.psychiatrictimes.com/dementia/dark-side-dementia-care

 Schwartz SK. Is it ever OK to lie to patients? Roswell Park Cancer Institute. November 2010. 

https://www.roswellpark.org/partners-practice/white-papers/it-ever-ok-lie-patients

. New York: Penguin Red Classic Edition; 2006.

abilitation therapy for Alzheimer’s and dementia care.

http://psychcentral.com/lib/habilitation-therapy-for-alzheimers-and-dementia-care/00012873

 Dickinson E. Tell All the Truth but Tell It Slant

http://www.poetryfoundation.org/poem/247292

 Blanchard DL. Emily Dickinson’s ophthalmic consultation with Henry Willard Williams, MD. 

 Cutcliffe J, Milton J. In defence of telling lies to cognitively impaired elderly patients. 

 Thurman J. Her own society: a new reading of Emily Dickinson. 

 Page JB. Informed consent and substituted judgement. 1999. 

http://forensicpsychiatry.stanford.edu/Files/Consent%20Page.pdf

Articles

Therapeutic lying, a concept that is currently seeping into the medical literature, is the practice of deliberately deceiving patients for reasons considered in their best interest.

Therapeutic Lying: A Contradiction in Terms

“. . . rarer than a great novel-it [Stoner] is a perfect novel, so well told and beautifully written, so deeply moving, that it takes your breath away.”

Survival is the state or fact of continuing to live or exist, typically in spite of an accident, ordeal, or difficult circumstances. Failure to thrive, a term used in medicine to refer to unexplained weight loss, malnutrition, and disability, refers here to the inability to self-actualize, fulfill one’s potentials, and flourish from a psychological perspective.

John Edward Williams (1922 - 1994) was an editor, professor, and author, best known for his novels 

 (which won a US National Book Award) and 

 Its protagonist, William Stoner, is an unusually bright, sensitive, highly endowed human being. He manages to survive a miserable marriage, a painful extramarital affair, the relationship with his alienated daughter, a stalled career in academia, and geographic and emotional separation from his parents, yet he is unable to fulfill his unusual potential. This essay explores the reason-guilt-that Stoner was able to survive but failed to thrive.

A pivotal moment in the protagonist’s life: Shakespeare’s “Sonnet 73”

The pivotal moment in William Stoner’s life occurs during his sophomore year of college when, in a literature survey course, his professor reads Shakespeare’s “Sonnet 73,”

 considered by Shakespeare scholar John Berryman

That time of year thou mayst in ; me behold

When yellow leaves, or none, or ; few, do hang

Upon those boughs which shake ; against the cold,

Bare ruin’d choirs, where late the ; sweet birds sang.

In me thou see’st the twilight of ; such day

Which by and by black night doth ; take away,

Death’s second self, that seals up ; all in rest.

In me thou see’st the glowing of ; such fire,

That on the ashes of his youth ; doth lie,

As the death-bed whereon it must ; expire

Consumed with that which it was ; nourish’d by.

This thou perceivest, which;makes thy love more strong,

To love that well which thou must ; leave ere long.

The professor asks the class what the sonnet means, calling on several students, but gets no answers. Finally, he calls on Stoner. “Mr Shakespeare speaks to you across three hundred years, Mr Stoner. Do you hear him . . . What does he say?” Stoner begins, “It means . . .” but he cannot finish. He tries again and then falls into silence.

That day in Sloan’s classroom is pivotal. As a boy and young man, Stoner had never before considered what something meant, including his own life. He had taken the land, his lessons, his chores, even his life, merely as blunt facts of existence, and stood dumb before them. The bewilderment he feels that day in the classroom leads him to switch his major to English.

Stoner had expected to study agriculture when he entered college but was overwhelmed with the sonnet. Its speaker is an older man, like Stoner’s aging father, who asks a younger man to be aware that his days are coming to an end: “In me thou see’st the glowing of such fire/That on the ashes of his youth doth lie,/As the death-bed whereon it must expire/Consumed with that which it was nourish’d by.”

The closing couplet of the sonnet admonishes that the younger man’s love should grow stronger since the speaker’s time is running out. The sonnet has a powerful esthetic impact on Stoner at the same time that it engenders feelings of guilt in him, and he decides to pursue literature, not agronomy, and teach at the university-not return to his parent’s farm.

“Sonnet 73” contains many of the themes to Shakespeare’s 154 sonnets, including the ravages of time on one’s physical well-being and the mental anguish associated with moving further from youth and closer to death.

The speaker invokes a series of metaphors to characterize the nature of what he perceives is his old age. In the first quatrain, he compares his time of life to the late autumn, when the leaves have almost completely fallen from the trees, the weather has grown cold, and the birds have left their branches.

In the second quatrain, the metaphor shifts to that of twilight, with the remaining light slowly extinguished in the darkness, which the speaker likens to “Death’s second self.”

In the third quatrain, the speaker compares himself to the glowing remnants of a fire that lies “on the ashes of his youth”-that is, on the ashes of the logs that once enabled it to burn-and that will soon be consumed by “that which it was nourish’d by”-that is, it will be extinguished as it sinks into the ashes, which its own burning created. By dropping from a year, to a day, to the brief duration of a fire, Shakespeare shows the increasing momentum of time’s passage as one ages.

In the couplet, the speaker tells his loved one that he must perceive these things and his love must be strengthened by the knowledge that he will soon be parted from the speaker when, like the fire, he is extinguished by time. This sonnet is congruent with the Buddhist concept that the nature of love is confluent with the awareness of life’s impermanence.

It is unclear why the author chose “Stoner” for the name of his protagonist and the title of the book. None of the dictionary’s definitions for “stoner” are particularly relevant to the novel: an attacker who pelts the victim with stones (especially with intent to kill); one who walls with stones; (informal) one who is habitually intoxicated by alcohol or dope; and a person who is a delinquent or a failure. Stoner is not a “pothead”; if he attacks (and it is rare that he does), it is more with the use of passive aggression; although he fails to thrive, he is not a failure; and there is no sense that he walls himself off from others.

[[{"type":"media","view_mode":"media_crop","fid":"25024","attributes":{"alt":"Sisyphus by Titian (1548-1549)","class":"media-image media-image-right","id":"media_crop_4052456763435","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2225","media_crop_rotate":"0","media_crop_scale_h":"265","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Sisyphus by Titian (1548-1549)","typeof":"foaf:Image"}}]]In the context of this novel, the name “Stoner” conjures up the Greek mythological Sisyphus, who was inseparable from his rock. According to the myth, Sisyphus was condemned to roll a rock to the top of a mountain, only to have it roll back down to the bottom every time the summit is reached. The gods, in their wisdom, realized that an eternity of futile labor would be a hellish punishment.

A number of stories explain how Sisyphus came to be punished. One is that he had enchained Death and during that time no human being died. When the gods freed Death, his first victim was Sisyphus.

Even if Stoner’s mythical counterpart is not Sisyphus, he does appear to punish himself. Of what could he feel guilty? He was sent to college with the expectation that he would study agriculture, return, and improve the lot of his subsistence-farmer parents. At graduation, when he informs them he will not be returning to the farm but plans instead to do graduate work in English literature and teach, he looks at his incredulous mother and notes:

. . . her face twisted as if in pain, and her closed fists were pressed against her cheeks. With wonder Stoner realized that she was crying deeply and silently, with the shame and awkwardness of one who seldom weeps. He watched her for a moment more; then he got heavily to his feet and walked out of the parlor. He found his way up the narrow stairs that led to his attic room; for a long time he lay on his bed and stared with open eyes.

It could be said that Stoner punished himself for turning his back on his hardworking parents, going against their wishes by choosing literature over agronomy, and for not returning home to work on the farm and applying what he had learned to improve their lot in life. Stoner’s marital, parental, and vocational disasters could be considered self-punitive attempts to atone for guilt.

Like Sisyphus, who is inseparable from his boulder, Stoner and his name are one.

Whereas Stoner, like Sisyphus, was resilient-managing to shoulder the burden of his life up the steep path he created for himself-and a survivor, his creator, John Williams thrived. Born and raised in northeast Texas, he flunked out of a local junior college after his first year, entered the military, and wrote a draft of his first novel while in the Air Force. After WWII ended, he found a small publisher for the novel and enrolled at the University of Denver, where he earned both a Bachelors and a Masters of Arts. He returned to the University as an instructor in 1954 and taught creative writing.

 sold 2000 copies when it was first published in 1965. It was reprinted by The New York Review of Books in 2007, when it was well-reviewed and became increasingly popular. It is currently a best seller in Europe and Scandinavia. Williams died in 1994 and did not live to see its success.

Thriving has been defined in various ways: to grow vigorous, strong, and healthy, as a successful garden; or to be successful in business or money matters. Public recognition or materiality, however, is irrelevant to thriving. It does not matter if the speaker in “Sonnet 73” was or was not “love[d] more strong.” Shakespeare used the adversity of incipient mortality to create a remarkable poem. Flowering is an inward phenomenon that results when one discovers that “Sweet are the uses of adversity. . . .”

John Williams thrived, although his alter ego, William Stoner, only survived, by turning life’s inevitable “poisons” into medicine. Patricia Reimann described the novel’s subject matter as being the “final things of life. Love, commitment, compassion, work, backbone, truthfulness, death.” (Summarized thus by editor and translator Patricia Reimann of Williams’s German publisher Deutscher Taschenbuch Verlag.)

Dr Sperber is a Psychiatric Consultant to the Neuropsychiatry/Behavioral Neurology Service of McLean Hospital in Belmont, Mass, and a Psychiatrist to Thriveworks in Cambridge, Mass. He reports no conflicts of interest concerning the subject matter of this article.

 Dickstein M. The inner lives of men. Sunday Book Review. 

 June 17, 2007. http://www.nytimes.com/2007/06/17/books/review/Dickstein-t.html?pagewanted=all&_r=0. Accessed October 15, 2013.

. New York: New York Review of Books; 1965.

 Shakespeare Online. Sonnet 73. http://www.shakespeare-online.com/sonnets/73.html. Accessed October 15, 2013.

. New York: Farrar, Straus and Giroux; 1999.

 Livatino M. “Revaluation: A Sadness Unto the Bone: John Williams’s Stoner.” 

. http://shakespeare.mit.edu/asyoulikeit/full.html. Accessed October 21, 2013.

If you haven't read this book that was recently republished by The New York Review of Books, here's why you might want to take a look.

Williams’ Stoner: Guilt, Shakespeare, Sisyphus, and the Non-Thriving Survivor

In the midst of dictating a letter, Sherwood Anderson (1876-1941), then president of the Anderson Manufacturing Company, stopped speaking and began to stare down at his feet. His astonished secretary inquired, “Are you feeling ill?” Anderson continued to look down and spoke cryptically, “My feet are cold, wet, and heavy from long wading in a river. Now I shall go walk on dry land.”

 He is reassuring in a note he wrote to his wife, Cornelia: “There is a bridge over a river with cross ties before it. When I come to that I’ll be alright. I’ll write all day in the sun and the wind will blow through my hair . . .”

That day, November 27, 1912, was pivotal in his life. When he closed the door to his company, he walked for 4 days along the railroad tracks, 30 miles from Elyria to Cleveland, Ohio. He wound up at a pharmacy, disoriented and disheveled, and he was taken to the psychiatric ward of a hospital.

After discharge, Anderson relocated to Chicago where he joined a literary group, sent for his wife and 3 children, divorced her in 1914, immediately married someone else, and began to write 

Winesburg, Ohio: A Group of Tales of Ohio Small-Town Life

 The book, published in 1919, would be proclaimed a masterpiece. The flourishing writer’s group-the Chicago Literary Renaissance-along with Theodore Dreiser, Vachel Lindsay, Edgar Lee Masters, and Carl Sandburg, depicted the contemporary urban environment, decrying the loss of traditional rural values in an increasingly industrialized and materialistic American society. They noted the failure of the romantic promise that hard work would automatically bring material and spiritual rewards.

Anderson later described the events that led to his hospitalization as “escaping from his materialistic existence.” A psychiatrist in the Cleveland hospital where he was a patient might have diagnosed what 

DSM-5 currently terms dissociative amnesia

Dissociative amnesia (DSM-5 300.12) (subtype dissociative fugue) and Journey of the Traumatized Hero


Although it is conjectural for a psychiatrist to make a diagnosis 

 presumably Sherwood Anderson appears to have had a condition DSM-5 terms “dissociative amnesia, subtype dissociative fugue.”

 This condition is characterized by a marked but reversible impairment of recall of important personal information, too extensive to be explained by ordinary forgetfulness.

There is a connection between the events of Anderson’s life and an archetypal human odyssey I coin the “

In this journey, the first step is “trauma,” and PTSD follows, with symptoms of re-experiencing trauma in flashbacks, nightmares, or fearful daydreams; avoidance symptoms (eg, psychic numbing, emotional anesthesia with trouble remembering the precipitating event); and hyperarousal symptoms (eg, being easily startled, feeling tense, jittery, or “on edge”). The journey is an internal-not geographic-process, but physical relocation (as in Anderson's fugue) may occur. If successful, 

, a boon is acquired, and egocentricity ends.

Anderson’s inability to move beyond the abyss led to a psychiatric impasse (

). In Chicago he was able to shift from participant-observer to the role of a 

 and transform the misery of the first 3 decades of his life into literature.


•On December 3, 1926, Agatha Christie, disappeared, only to reappear 11 days later with no memory of the events during that time. On the day of her disappearance, Agatha’s husband, Archie, revealed that he was in love with another woman and wanted a divorce. The couple quarreled, and Archie left their house in Sunningdale, Berkshire, to spend the weekend with his mistress at Godalming, Surrey. Around 9:45 in the evening, without warning, Agatha drove away from the house, having first gone upstairs to kiss her sleeping daughter, Rosalind.

Her abandoned Morris Cowley was later found down a slope at Newlands Corner near Guildford. There was no sign of her, and the only clue was a letter for her secretary saying that she was going to Yorkshire. Her disappearance caused an outcry from the public, many of whom were admirers of Agatha Christie’s novels. Despite a massive manhunt, there were no results at all. Eleven days after her disappearance, Christie was identified as a guest at the Swan Hydropathic Hotel

in Harrogate, where she was registered as “Mrs Teresa Neele” from Cape Town.

Christie gave no explanation for her disappearance. Doctors diagnosed amnesia or a fugue state brought about by depression, exacerbated by her mother’s death earlier that year, and the discovery of her husband’s infidelity. Others speculated Christie was trying to make the police think her husband killed her as revenge for his affair.

, went missing in 1985 and was found 12 years later in Sitka, Alaska, living under the name of “Jane Dee Williams.” While there were some initial suspicions that she had been faking amnesia, some experts have come to believe that she genuinely suffered a protracted fugue state.

•David Fitzpatrick entered a fugue state on December 4, 2005, and he is still working on regaining his entire life’s memories.

•Hannah Upp, a teacher from New York, disappeared missing on August 28, 2008, and was rescued from the New York Harbor

on September 16 with no recollection of the time in between. The episode was diagnosed as dissociative fugue.

•Jeff Ingram appeared in Denver in 2006 with no memory of his name or where he was from. After appearing on national television to appeal for help, his fiancÃ©e Penny called Denver police and identified him. The episode was diagnosed as a dissociative fugue. Jeff has experienced 3 incidents of amnesia: in 1994, 2006, and 2007.


To understand the psychodynamics of the dissociative fugue, one may analyze some of the characters in 

It is a collection of interrelated vignettes set in small town America, loosely connected by the narrator, journalist George Willard, Anderson’s alter ego. It is a remarkable literary venture.

“America should read this book on her knees,” Hart Crane

 wrote. “It constitutes an important chapter in the Bible of her consciousness.” Through George, Anderson gave voice to those who had entrusted him with the story of their lives.

The book begins with an elderly writer who hires a carpenter to rebuild his bed so that it is level with his window and he can see the trees across the way in the morning. After work is completed, the writer lies in the bed and reflects about death. As sleep approaches, in a hypnogogic hallucination, all the people he has ever met pass slowly before his eyes, seen by him as “grotesques”

some amusing, some terribly sad, and some horrifying. Immediately after this experience, he climbs out of bed and writes down everything that he saw in a book, which he calls “The Book of the Grotesque.” The old man conjectures that the world is full of different truths, all of them beautiful, but when a person seizes on and tries to live by one truth alone, that person’s life becomes distorted. He writes obsessively for hundreds and hundreds of pages, but in the end, he never publishes the book.

The “grotesques” live in a mental jail, detached from others, in a town where communication is impossible. They are, however, able to communicate with the perceptive newspaper reporter of the 

, George Willard, to whom they tell their stories, hoping he will find meaning in them and perhaps give expression to it in his writing. Dr Parcival hopes that George Willard “will write the book I may never get written,” and for Enoch Robinson, Willard represents “the youthful sadness, young man’s sadness, the sadness of a growing boy in a village at the year’s end [which may open] the lips of the old man.”

This is problematic for George, who does not know how to interact with or understand them. He is an outsider, and on the continuum between “observer” and “participant,” an observer. As he matures, he becomes more engaged with others in town. Literary critic Irving Howe

 notes that George does not meet the needs of the inhabitants of Winesburg nor they his.

What the grotesques really need is each other, but their estrangement is so extreme they cannot establish direct ties-they can only hope for connection through George Willard. The burden this places on the boy is more than he can bear. He listens to them attentively, he is sympathetic to their complaints, but finally he is too absorbed in his own dreams. The grotesques turn to him because he seems “different”-younger, more open, not yet hardened-but it is precisely this “difference” that keeps him from responding as warmly as they want. It is hardly the boy’s fault; it is simply in the nature of things. For George Willard, the grotesques form a moment in his education; for the grotesques, their encounters with George Willard come to seem like a stamp of hopelessness.

Ultimately, Sherwood Anderson’s dissociative fugue was a gradual shift in psychological stance from observer to participant-observer to

, Anderson became a creative participant, finally giving voice to the grotesques whom the elderly writer describes in the prologue: “Some [who] were amusing, some almost beautiful, and one, a woman all drawn out of shape, hurt the old man by her grotesqueness. When she passed he made a noise like a small dog whimpering . . . All of the men and women the writer had ever known.”


Dissociative amnesia, subtype psychogenic fugue, is characterized by reversible amnesia for personal identity.

 The state is usually short-lived (ranging from hours to days but can last months or longer); usually involves unplanned travel or wandering; and is sometimes accompanied by the establishment of a new identity. Fugues are usually precipitated by a stressful episode. Upon recovery, amnesia of the original stressor may occur (dissociative amnesia

When he had his breakdown, Anderson entered what Campbell

 calls an “abyss”-a psychogenic fugue or other dissociative process that involves the disintegration of the ego and a breakthrough expansion of consciousness. During Anderson’s lifetime, he had 4 wives, 3 children, 2 careers, and 1 masterpiece, 

 In a dissociative fugue Anderson's unconscious mind closed a trap door and he ventured on the journey of the traumatized hero. His words come to mind:

All men lead their lives behind a wall of misunderstanding they have themselves built, and most men die in silence and unnoticed behind the walls. Now and then a man, cut off from his fellows by the peculiarities of his nature, becomes absorbed in doing something that is personal, useful and beautiful. Word of his activities is carried over the walls.

As the dust settles over the literature of past century, Sherwood Anderson, “cut off from his fellows by the peculiarities of his nature”

 (dissociative amnesia), creates a literary masterpiece out of the adversities of his life.

Sherwood Anderson: A Writer in America, Volume 1.

 Madison, Wisc: University of Wisconsin Press; 2006.


. Psych Central. pro.psychcentral.com/2013/dsm-5-changes-dissociative-disorders/004410.html. Accessed June 5, 2013.


Spiegel D, Lewis-FernÃ¡ndez R, Lanius R, et al. Dissociative disorders in DSM-5. 

. New York: William Sloane Associates;1951.


 New York: Princeton University Press, 1949.

To understand the psychodynamics of the dissociative fugue, Dr Michael Sperber analyzes some of the characters in a collection of interrelated vignettes set in small town America. 

Dissociative Amnesia (Psychogenic Fugue) and a Literary Masterpiece

The art of living is the ability to use life’s inevitable traumas in some constructive fashion. This occurs on an odyssey that the resilient take that could be termed “the Journey of the Traumatized Hero.”

This is based on comparative mythologist Joseph Campbell’s Journey of the Hero. In this essay I compare the journeys taken by Jack Kerouac described in 

 to the one of Mohandas K. Gandhi’s, related in 

My Autobiography: The Story of My Experiments with Truth.

 They are vastly different but in one important respect remarkable similar. It marked a turning point in their lives.

[[{"type":"media","view_mode":"media_crop","fid":"13874","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_388148349010","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"631","media_crop_rotate":"0","media_crop_scale_h":"241","media_crop_scale_w":"250","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Following it, Kerouac drank himself to death whereas Gandhi formulated two important concepts by which he lived the rest of his life. The turning point for both occurred at the “Abyss” in a schematic representation of the journey Campbell described. Both died, in a figurative sense. Kerouac, unlike Gandhi, was never reborn. The successful completion of the journey of the traumatized hero requires resilience. Their traumas, resilience and journeys are described in this essay.

Gandhi’s Traumatic Railroad Ride and the Concepts of 


After completing law school in London at the age 23-years, Mohandas K. Gandhi (  ) left India once again to go to South Africa where legal work awaited
him. About a week after arriving, he was asked to travel from Natal to the capital of the Dutch-governed Transvaal province of South Africa for his case.

Gandhi purchased a first-class ticket but was told that he couldn’t sit in the compartment because he was a “coolie” (derogatory term for a non-white person) and would have to sit with third-class passengers. When he refused to move, a policeman threw him and his baggage off the train.

“It was winter,” Gandhi wrote, and “the cold was extremely bitter. My over-coat was in my luggage, but I did not dare to ask for it lest I should be insulted again, so I sat and shivered.” Sitting in the cold of the railroad station after being thrown off the train, Gandhi contemplated whether to return home to India or stay in South Africa and fight racial discrimination.

I was afraid for my very life. I entered the dark waiting-room. There was a white man in the room. I was afraid of him. ‘What was my duty?’ I asked of myself. ‘Should I go back to India or should I go forward, with God as my helper, and whatever was in store for me?’ I decided to stay and suffer. My active non-violence began with that date.

Gandhi’s decision was like that of David deciding to confront Goliath, in this case racial discrimination. It launched his campaign for improved legal status for Indians in South Africa who, at that time, suffered the same discrimination as black people in the United States. He used the trauma of the railroad coach for self-transformation, providing himself with a 

He spent the next twenty years working to improve the rights of Indians in South Africa. The train journey from Durban to Pretoria that he took is the prototypical journey of the traumatized hero.


In the mountains where he was thrown off the train, he decided that he would not express violence of any kind, and the concept of 

“injury”) (Non violence) came to him. It means to maintain not to hurt any sentient being, even minimally, through thought, word or act and is based on the premise that all sentient beings are interconnectedness s and that violence entails karmic consequences.

, “grasp”). This involves refusing to submit to or cooperate with anything perceived as wrong, while adhering to the principle of nonviolence in order to maintain mindful equanimity required for insight and understanding.

I have learned through bitter experience the one supreme lesson: to conserve my anger and as heat conserved is transmitted into energy, even so our anger controlled is transmitted into power.

, a semi-autobiographical novel that Jack Kerouac wrote about its 2 protagonists Salvatore (“Sal”) Paradise (the alter ego of the author) and his friend Dean Moriarty (in real life 

), a free-spirited maverick eager for adventure. Sal much admires Dean’s carefree attitude and sense of adventure and he is initially Sal’s ego ideal as they explore sex, drugs and jazz during the years from 1947 to 1950.

It describes a fierce quest for meaning and belonging, above all for a boon in life. Not content with the uniformity promoted by government and consumer culture, the Beats (Kerouac invented the term which he said stood for “beatific” or blissful, but not “beaten down”) yearned for a deeper, more sensational experience and an answer to the question “how are we to live?”
Kerouac wrote:

Dean and I were embarked on a journey through post-Whitman America to FIND that America and to FIND the inherent goodness in American man. It was really a story about 2 Catholic buddies roaming the country in search of God. And we found him. (Letter to a student, 1961)

It would seem that Sal (Kerouac) was in the midst of an identity crisis:

I woke up as the sun was reddening; and that was the one distinct time in my life, the strangest moment of all, when I didn’t know who I was - I was far away from home, haunted and tired with travel, in a cheap hotel room I’d never seen, hearing the hiss of steam outside, and the creak of the old wood of the hotel, and footsteps upstairs, and all the sad sounds, and I looked at the cracked high ceiling and really didn’t know who I was for about fifteen strange seconds. I wasn’t scared; I was just somebody else, some stranger, and my whole life was a haunted life, the life of a ghost.

Sal (Kerouac) considered that the solution to the identity confusion was found in a person like Dean Moriarty:

the only people for me are the mad ones, the ones who are mad to live, mad to talk, mad to be saved, desirous of everything at the same time, the ones who never yawn or say a commonplace thing, but burn, burn, burn like fabulous yellow roman candles exploding like spiders across the stars.

Sal believed that “The best teacher is experience and not through someone’s distorted point of view.” In the course of experience he discovered his boon, that he was a writer and that the life he had lived with the Dean, the fabulous “Roman Candle,” despite appearances to the contrary, was incompatible with the writer’s life. Finally he became aware that Dean’s selfishness extended even to him as he abandoned Sal, feverish and ill, in Mexico City. This is the moment where their paths diverge and Sal realizes that he has more to live for than just constantly moving, being on the road.

By the end of the book, Sal senses that except for words on a typewritten scroll, his life on the road is gone and his charismatic friend is a charismatic sociopathic car thief- nobody’s friend-is also gone. That is a great boon, because that was friend who had stung him earlier when “suddenly a bug flew into his arm and embedded a stinger in it that made him howl.” (268)

When the sun sinks, Sal sits on the old broken-down river pier watching the long, long skies over New Jersey, and reflects:

just before the coming of complete night that blesses the earth, darkens all the rivers, cups the peaks and folds the final shore in, and nobody, nobody knows what’s going to happen to anybody besides the forlorn rags of growing old, I think of Dean Moriarty, I even think of Old Dean Moriarty the father we never found, I think of Dean Moriarty.

Gandhi, who was being physically intimate with his wife when a servant knocked on the door to tell him that his father was dead, subsequently developed the concept of 

(the term denotes the endeavor to live a moral life to end suffering and reach enlightenment. Practitioners do not kill any living being, do not steal, avoid improper sexual relations, don’t lie, and avoid intoxicants. In this way, he dealt with the guilt surrounding father’s death by transforming it. For Sal, wearing “the forlorn rags of growing old,” only a vacuum existed where the father was once. Perhaps that is because when Kerouac was four, he was profoundly affected by the death of his nine-year-old brother, Grard, from 

. At that time his father wallowed in drinking, gambling and smoking.

Jack Kerouac, who lacked the resilience to bounce back from the adversities of his life, died at the age of 47 from hepatic cirrhosis developed in the course of a lifetime of heavy drinking. The cirrhosis led, in turn, to esophageal varices. When these rupture he hemorrhaged bled to death. 

Following the jazz/blues tradition, Kerouac’s poetry features repetition and overall themes of trouble and the sense of loss in life:


Makes me sick
Inside, outside,
I don’t know why
Something so conditional
And all talk
Should hurt me so.

I am hurt
I am scared
I want to live
I want to die
I don’t know
Where to turn
In the Void
And when
To cut
Out.
[“

Author | Michael Sperber, MD

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