Pull

As a child growing up in a middle-class suburb of a sleepy maritime town in Eastern Canada, I often had to check under my bed for an intruder. In the ten minutes I had spent in the bathroom preparing for bed, had a murderer furtively walked up our well-light driveway, squeezed through the open window into my first story bedroom, and crawled into the eight inch recess under my twin bed? The prospect of me actually finding a bloodthirsty, ravenous predator awkwardly jammed next to my tennis shoes between my box-spring and u-click hardwood flooring was infinitesimal. The violent crime rate in my community was significantly below Canada's already low national average and, despite this, the nightly-checked deadbolts on all three outer doors and the industrial grade siren installed on the roof of our garage demonstrated that security was not taken lightly by my parents. Despite these reassurances and the observation that nothing else in my room was out of the ordinary, each night before falling asleep I had a feeling in the pit of my stomach that could only be calmed by a quick peek below. This is one example of what I call pull.

I continued these nightly checks until I was at least fifteen. I am not surprised or embarrassed that I was checking under my bed until that age; I am curious about why I stopped. Did the impulse or fear that informed those nightly checks disappear? Not likely. Rather, I remember developing a stronger internal resistance to doing them. I told myself that it was childish to succumb to them. I reminded myself of the logicalities described above. The weight was just as heavy, but I cut the rope that exerted pull.

We are taught to ignore pull. Why wouldn't we? It is the desire for the 3rd piece of cake even though we are trying to lose weight. It is the need to get the last word during a fight with your spouse. It is the thing keeping you from finishing your paper or mowing the lawn or taking the car for an oil change. Pull also may contribute to mental illness. It can run out of control when you can only focus on how shitty you feel or how much everyone hates you or how you'll never be able to overcome your diagnosis. But this is just one side of pull. Pull is there when you feel a deep-seated love after connecting with a close friend. Pull is also present when you walk past a long-haired, scruffy youth who is street side in the pouring rain with a downward gaze and sign that reads "Left home. Broke. Need money for food and shelter." When we hold back an "I love you" to a friend because we are worried about how they'll take it or we brush off a 16 year old who left an abusive home, we miss the benefits of pull. 

When I interview patients, I get to experiment with pull. When a patient shares that their relationship with their partner is falling apart toward the end of the interview, my cognition might be screaming "hurry up! there is only 8 minutes left and you still have to rule out a diagnosis of OCD and ask them about their family history  of mental illness". But I may also have a feeling of pull, something that is responding to the halt in the patient's breath, the widening of their eyes and the subtle downward twitch in the corner of their lips as they deliver such a statement. Pull may be saying to me "Whoa. This is really important to them. Let's fill in the details later and just explore their experience in their marriage". As I experiment with listening for and following pull in my interviews, I find the depth of my relationship with patients is growing.

I am not suggesting that we blindly follow the weight of pull off of blind cliffs or to the bottom of the ocean. Nor do I want to check under my bed each night for an intruder. But I have found tremendous experiences in following pull. Be mindful of it. Play with it. As you begin to observe the voices of both pull and reason you can use your fully developed adult brain to choose pull. Get on the swings in your neighborhood park. Ride your bike to work. Connect with a friend. And when your adult brain yells out for you keep your pants clean or pass up your buddy's offer for beers, side-step it and follow your pull. 

Choice is a funny thing. On one hand, it is something I work towards. I want to be unique. I wear my hair differently than Jim. I buy different shoes than Topher. I have a different job than Krista. And so on.

This desire for self-expression is felt by many of us, and it leads to a society that places a high value on free will and liberty, or, in other words, choice. This choice is all around us. A simple trip for food creates multiple decision points and each decision point requires choosing between many different options. Assuming dress, time of day, and mode of transport are already in place, one must decide whether or not to visit the grocery store or a restaurant. The grocery store decided, there are then countless other decision points through which one must past, consciously or unconsciously, in order to leave the store with even the smallest basket of essential items.

If hundreds of choices have to be made before I can leave the grocery store with a carton of milk, then I must have to consider thousands or tens of thousands of choices before I decide to end my marriage or before society endorses a particular system of government. But this is not the case. Ironically, when it comes to answering some of the most complex and important decisions in our lives, we are often blind to choice and we feel that we must make one of only a few options. A husband considers whether or not he will leave his wife after finding her in bed with someone else, so too the average parishioner decides between belief in God or atheism and the average voter selects the Democratic or Republican candidate. Non-binary perspectives such as moving to an open relationship, an evolving belief in God, and starting or supporting a group that promotes an alternative system of government are often not considered.

As a resident in psychiatry, I am having to process painful, complex, and intense experiences on a regular basis. I make decisions that profoundly impact the lives of others. Each time a patient cries in front of me as I break the news about involuntary admission I continue to learn the consequences of my decisions. As I make these choices I feel next to helpless; I can feel myself frantically searching for dry ground.  The sky is dark and the sea is rough. The salt burns my eyes. I see a couple small spots of land, but I can't make out anything else. I'll go for that one;  if I can't control the storm, then at least I can choose from which piece of earth I will weather it.

Psychiatrists often do everything they can to make it to a spot of dry ground in this torrent sea of complexity and emotional pain. We cling to it. Only after many waves continue to beat down do we realize that our unfortunate spot of land is made of sand; it is wasting away with each movement of the sea. Then it disappears; we are left to be tossed blindly to our next temporary refuge.

We, as humans, are incredibly uncomfortable with uncertainty. There are distortions, half-truths, shortcuts and frank lies all around us that society seeks in order to balm the wound of chaos. Tweezers and toothpaste are confiscated from weary travelers while the same jets are carrying around pallets full of airmail that is loaded on unchecked. One, three, five, seven, and fourteen day weather forecasts are broadcast every half-hour over the radio. Predicting the economy, something of our own creation, is done by armies of bright minds; you be the first to invest your life's savings in the next surefire investment.

Psychiatry is the art of turning chaos into certainty. Were you raped in your early 20s and now, ten years later, you're having intrusive thoughts about it? Are you so afraid of navigating large groups of people that you haven't left your apartment in 2 months? Is the death of your child three years ago still causing you to have a low mood? If so, Psychiatry has the answer for you. Well actually, it has three. They are...are you ready?..post traumatic stress disorder, agoraphobia, and major depressive disorder. Not only can Psychiatry capture these incredibly complex life experiences in four, one, and three words respectively, but it can recommend a treatment too! Fluoxetine! Yes, that's right, it doesn't matter whether you were raped, have dehabilitating anxiety, or overwhelming grief, it is one class of drug for all of you. And there is no need to deal with any of that annoying psychotherapy either. Boring! Oh sure, you might benefit from something like CBT or DBT or EFT, but I focus on scientific things like diagnosis and medication. You should talk to someone else like a counselor about that. 

That is the state of Psychiatry today. If you are like me, then you feel frustration, fear, and injustice. This bothers you on a deeper level than spurious claims about the economy or rain on what was supposed to be a sunny weekend. This is because we are simplifying and pathologizing the human experience. A weather forecast is created based on a small chunk of information: what we have discovered and can measure. This information is used to generate predictions about a system about which we only understand a small fraction. We are doing this to the human experience. Just as a tornado can't appreciate why it's a tornado, as humans we are not meant to be able to understand our entire existence. And just as a tornado simultaneously demonstrates incredible beauty and ravenous destruction, we are not meant to blot out the bits of the picture we don't like. This is the paradox of uncertainty; acceptance of it is the way to a greater truth. Sometimes this involves experiencing tremendously intense emotions. That is part of the human experience. But the role of Psychiatry is not to accept and experience the pain of the unknown, but to define a clear enemy and destroy it.