Saturday, November 11, 2006

Reality, Fiction, and Consciousness

Tonight we went to see "Stranger Than Fiction" with Will Ferrell, a decidedly Hollywood movie which is, on the one hand, quite entertaining, and on the other, incredibly thought-provoking. The point of this is not to discuss the plot or premise of the film---something which can be gleaned from most any review or article in the media---but to dig deeper and see that, yes, many layers of reality and unreality can exist simultaneously in this oh-so-literal world. My predilection for things existential certainly fuels such musings, and moments like these---provoked by films, books, plays, or music---only fan my flame. So let's forge ahead, whether it be the frying pan, the fire, or perhaps just the steady gaze of a candle's light.

This film, which riffs on the notions of perception, existential angst, and the relativity of reality, brought especially to mind the recent struggles of a patient. On Hallowe'en night, I wrote of a very unfortunate man who is now debilitated by a miserable constellation of ailments, the most disturbing of all being his sensation that he is fighting with the Devil himself every day, barely resisting mental and psychic torments that eat away at his sanity and diminishing sense of comfort. His pain is palpable, and we feel helpless in the face of such suffering.

Leaving the theatre and talking with Mary, I realized that there are sometimes no rational explanations for conditions or symptoms with which we are faced as providers. There are times when patients present with such intractable psychic suffering that we are helpless in our inability to make any headway in alleviating that most acute distress manifesting before our eyes. How I have watched people cry in fear, tortured by demons I cannot comprehend, only to go home to my cozy house at 5:00 and try to forget what I heard and saw. And sometimes I ask myself, "How can s/he live like that? How can they go on?"

Will Ferrell's character hears a distinctive voice in his head. He entreats his friend---and even strangers---to listen. They cannot perceive the voice that he does. A psychiatrist suggests schizophrenia and medications to alleviate the symptoms. Any moderately well-trained medical professional will, upon hearing a patient speak of internal voices, begin the differential diagnosis by considering a thought disorder or peronality disorder. And why wouldn't they?

But what would a traditional medicine man think? What would an exorcist say? How would a Wicca practitioner approach such symptoms? What, pray tell, would a priest or rabbi surmise? This film made me realize that, of course, there is always a place for antipsychotic medications---which, in fact, our patient is currently taking---but are there not possibly layers of reality and layers of belief that supercede and resist all medicalized and compartmental thinking and treatment? How many of these manifestations simply will not respond when treated within our Westernized box? And, even so, what are we to do in any case?

I recently attended "Psychiatric Grand Rounds" at a local medical center wherein a speaker from the New York City area lectured on the phenomenon of "Ataque de Nervios", a set of symptoms generally manifesting in Latino subjects wherein the patient experiences extreme states of mind---including hallucinations and hearing voices---that does not respond to normal medical/psychiatric treatment. At The Columbia University Medical Center Department of Psychiatry, a specialized bilingual-bicultural staff has created a treatment center in which Latinos are recognized as experiencing psychiatric manifestations which are singularly culturally distinct, necessitating sensitive and non-traditional methods of treatment and diagnosis. Without offering a complete explanation of why Latinos in particular experience such extreme states of mind distinct from what we know as "mental illness", alternative methods of treating such individuals are practiced and fine-tuned through ongoing investigation.

Other organizations ---be they Buddhist, religious, or strictly non-spiritual---offer a variety of patient populations myriad approaches to what some call mental illness or others simply call "extreme states of mind". We must also consider the fact that in cultures like India, those who here in the West would be considered mentally ill are in that culture often revered as sages, individuals particularly "touched" by the Divine. And who are we to say that they are erroneous in their thinking?

Will Ferrell's character presents with a manifestation of symptoms which challenge those around him in their ability to understand and accept his perceptions. Seen as crazy, he is convinced---and perhaps can convince others---that his perceived strangeness is not necessarily what it seems to be. As with my suffering patient, is it not entirely possible that there is something else at play to which we are not attuned, something which only he can sense and experience? The other day, my psychologist colleague and I were discussing this patient's case. She looked at me with perplexity and asked, "So what do you think is going on with this guy?" I responded with a simple question: "Possession?" She looked at me and realized at that moment that perhaps I wasn't kidding. I wasn't. But did I write that in my notes? Take a wild guess.

My point here is this: there is so much we don't know. In fact, I'd wager a bet that there's alot more we don't know than we'll ever know. (Oops, now I'm sounding like Donald Rumsfeld---and that's scary.) We can thump our copy of the DSM-IV, recite from tomes of psychiatry, point to case studies and cohorts, and expound upon our vast realms of knowledge, but in the end, we are not inside our patients' heads, and there are aspects of existential angst that we simply cannot neatly codify. Even so, where do we go from here?

Do I think an antipsychotic may help my patient cope? Yes. Do I feel he might benefit from culturally sensitive psychotherapy? Assuredly. Do I feel that these measures will permanently and irrevocably assuage his suffering? Negative. Are there perhaps aspects of his behavior and psychic distress that we will never understand? Absolutely. Do I wish to see him free of his distress and pain? More than words can say.

We have only scratched the surface of the doors of perception. Consciousness and thought are only primitively understood. The spiritual nature of human beings is even less clearly perceived (and in some quarters baldly mocked and denigrated). I do not understand what is apparently destroying my patient from the inside out and do not pretend to know the answer. We have some tools at our disposal, however insufficient they are, and we can only suggest that treatment which our patient will accept as plausible. But if my patient wants to see a "curandero", or attend a Pentecostal church where he can speak in tongues and be possessed by the Holy Ghost, I will encourage all approaches and their potential for healing. In this world of unknowns and inexplicabilities, the powers of faith and love and compassion can sometimes heal that which is unaffected by science, medicine, and technology. So, is it all stranger than fiction? You bet. And perhaps the only thing we can truly do is let the mystery be and offer what we can. An unsatisfactory answer for the Western mind, but one with which I choose to sit for now, until my own doors of perception open in a as-yet-unforseen way. Until then, reality may continue to simply be stranger than fiction. And maybe that's OK.
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