Doctor Without Borders: A Bizarre First Brush with Psychiatry

by Matt B. on January 16, 2014

Awaiting my first appointment with a psychiatrist, I look down and notice a brochure. “There is no such thing as mental illness anymore,” it reads. “There are only physical illnesses of the brain.”

Anymore? I wonder. The brochure suggests that mental illnesses were once real, but no longer – now, they’re just illusions. I see the point that the author is trying to make – that we don’t need to mystify mental illness, and that addressing it is simply a matter of biochemistry. But I’m troubled by the metaphysical mistake: if mental illness isn’t real now, then it never was.

The language seems exuberant, huckster-ish. I wonder who might have said such a thing – some large, conservative, professional organization, I hope. Perhaps their marketing people just got carried away.

I look closer. The quote is from the doctor I’m about to see.

* * *

On the wall above his couch hangs a framed poster – a blue silhouette in four poses, beginning in the fetal position and slowly rising to its feet. The picture has a Futurist, Ayn Rand feel – a schematic, angular optimism that I doubt bears much resemblance to real life.

I never end up sitting on the couch. Instead, the doctor indicates a seat next to his desk and prompts me for a history of my symptoms. He wants incredibly granular detail, and as he scratches out notes, I take him in. He is somehow both slight and dumpy, pants hiked up over a cantalouped front-butt. His face is clean-shaven, save for two rebellious copses of long, wiry whiskers. An extremely long fingernail forms the terminus of his left pointer finger.

By this time, I’ve seen enough therapists to know that wisdom doesn’t always come in pretty vessels. But the doctor’s appearance isn’t just unattractive; it smells of ignorance, details overlooked, neglect. The brochure floats back into view.

* * *

By the end of that first session, we were talking drugs. I would begin with 10 milligrams of Celexa, a selective serotonin reuptake inhibitor (SSRI).

The doctor explained that serotonin is a neurotransmitter, and that its release is associated with well-being and happiness. In people with depression, however, synapses in the brain tend to reabsorb serotonin too quickly. As a result, I wasn’t experiencing many good feelings, and when I did, they didn’t last very long. In my depressed mood, I was finding it increasingly difficult to deal with the onslaught of OCD-driven intrusive thoughts.

By using an SSRI, the doctor explained, we would cut off something like the bottom 10% of my emotional range, and I wouldn’t be as likely to fall into such despair. You could think of it like scaffolding, he explained: by providing a supportive platform, the medicine would help create space for me to change my mental habits.

Unfortunately, he added, the medicine would also slice off the top 10% of my feelings – my most joyful and ecstatic moments. I’m sure I asked him why the medicine worked this way, but I’m also sure that I didn’t feel much resistance. I was in far too much pain to worry about a slight reduction in the intensity of good feelings which didn’t appear very often anyway.

My decision to try medicine hadn’t come quickly. In my typical OCD way, I had fretted about it for months: How long had these things been around? Did we really know enough about the long-term effects? What if taking them ended up solving one problem by causing another? What if I gave myself cancer – then how would I feel? Maybe better to just soldier on. As with my decision to see a therapist a year and a half before, though, the daily pain-grind eventually wore down my resistance.

The first time I filled my prescription, I still wasn’t sure I would go ahead. I took the bottles home, placed them on the counter, and stared at them for a moment. And then I realized that I’d already made my decision.

As with anything fearsome, ingesting pills seemed like a big deal until I did it. It was like being afraid of flying and getting on a plane for the first time: fear no longer made any sense. Things were in motion, processes underway.

* * *

People ask if the drugs make a difference, and I don’t know what to tell them. I’ve been taking medicine for a little over 10 years now, and it’s hard to remember what things felt like before.

It was hard to tell even at the outset. As we got going, I would meet with my psychiatrist every month or so. Each time, he would ask a battery of questions about the frequency and intensity of my anxieties.

I found these questions profoundly – even existentially – confusing: How often was ‘sometimes’? What was a ‘moderate’ amount of pain? And what would happen if I provided answers that didn’t track my feelings perfectly? (To provide me some compass points, the doctor would sometimes tell me how I had answered the question at hand on my previous visit. I was grateful, though I wondered whether this was cheating and would skew the results.)

Each of the possible answers correlated with a point value. After we finished the questionnaire, the doctor would add them up and compare the total to my previous visit. Tiny changes meant a lot to him; if I scored a 29 on one visit and a 27 the next, (lower was better) he took that to mean that the medicine was working.

I don’t think he was wrong, exactly; without the numbers, I wouldn’t have been able to tell whether I was making any headway at all. My mind was a tight and constricted place – one panicky, claustrophobic day indistinguishable from the next. Sure, it might not feel much different day to day, but what did I know? I was trying to differentiate between shades of black.

On one level, then, I appreciated having an outside perspective. But I didn’t trust his self-satisfaction, his lack of curiosity. In his mind, OCD was a problem and medicine was a solution – nothing more complicated then measuring and cutting a two-by-four. As he hunched over his pad, diligently recording his notes and charting the coming week’s treatment, there was something of the child about him – the little boy who’d mastered his chemistry set.

* * *

His single-minded faith in the power of antidepressants wasn’t just a professional bias; it was also a personal fetish. At one point, he told me about a fantasy of his. Do you remember Scrooge McDuck’s vault? he asked. The one where he jumps off a diving board and swims in a sea of gold coins? Well, I would like the same thing, only the vault would be full of pills. He leaned back, smiling, fingers tented. I would do the backstroke, he said, circling his arms up and away.

It wasn’t often that he said things like this, but it was more than I might have liked. I began to feel like an addict, indulging my dealer’s stupid stories and annoying eccentricities in order to get my fix. The difference, I suppose, was that I believed in this; I trusted that the medicine was actually useful, even if the man doling it out was a little cracked.

* * *

Despite (or perhaps because of) his enthusiasm for antidepressants, the doctor was decidedly opposed to drugs of any other sort. A few months into our relationship, I called and asked whether it would be safe to smoke pot while on medication. (I had smoked prior to beginning treatment, but I was worried about mixing the two.)

I expected either an outright no or (much less likely) a very qualified yes, so I was shocked when he refused to answer the question entirely. And he didn’t simply refuse; his voice quickly rose, and he threatened to discontinue treatment if I continued with my questions.

I felt sheepish and furious at the same time. No, I didn’t think smoking pot was a fantastic idea, but I did feel entitled to some straight-up answers about its effects from my healthcare provider. “I’m not saying I’m going to do it,” I told him. “But you’re my doctor, and I’m asking you a basic question about how my body works. You’re supposed to answer those questions.”

He cut me off, nearly shouting: “Okay Matt, we’re finished. I won’t be treating you anymore.”

This was worrisome. I felt exhausted just thinking about trying to find a new psychiatrist, much less having to explain my whole story again. I backed down, promising that I wouldn’t smoke and begging him to take me back. He agreed.

I felt shaky, kicked around. How did a man who abused his authority this way even obtain a license? I wondered. And what about all the people in his care who were even less capable of standing up for themselves than I was?

And then it occurred to me: I don’t actually have to listen to this guy. By overusing his professional power so blatantly, he had traded away his emotional influence. This man isn’t particularly wise, I thought. He’s just a supplier, and all I have to do is keep him happy.

I called my psychologist and explained what had happened. He didn’t hide his professional dismay, and he agreed: there was nothing wrong with the questions I was asking. So, I asked, if I smoke pot on medication, am I going to mess up my heart?

“I think if you have a puff, that should be okay.”

“A puff.” How cute. Either this man wasn’t familiar with pot (who uses that word? and who only has one ‘puff’?) or he was trying to maintain a professional stance in the midst of a seamy conversation. I read between the lines: pot was basically fine. But like most healthcare providers, my psychologist was playing it conservative, and he didn’t feel like he could say that out loud.

* * *

For the next several years, I drank and smoked pot regularly. Drinking had its place – it was fun and social and silly – but I loved marijuana. When I was high, my mind slowed down to what felt like exactly the right speed. There weren’t any extra thoughts – there were just the thoughts I was having. And while I still felt things I didn’t like, I didn’t necessarily try to escape. Like everything else, unpleasant emotions felt interesting, deep, and worthy of attention. I was experiencing more true presence than I ever had.

Soon enough, though, OCD infiltrated my smoking sessions as well. I became increasingly focused on achieving a very particular mindstate, so I started monitoring my feelings with counterproductive precision. I didn’t want to smoke too little: what was the point of getting a little buzzed when heavenly feelings and life-changing insights were another bowl away? And I didn’t want to smoke too much, to whoosh right past high and into the dead, stoned space that came afterward; that was just burning neurons for nothing.

Along with my blooming rigidity, I remembered the phone call with my psychiatrist. Despite his outrageous behavior, I began to feel that he had been right. Not on the facts of the matter – we hadn’t even discussed those – but on a moral and emotional level. My OCD was kicking into gear, capitalizing on my tendency to feel guilty about everything and creating one more rule for me to follow. If I wanted to be a good person – if I wanted the right to feel free of guilt – there’d be no smoking allowed.

But that didn’t stop me. Instead, I just went round and round – smoking, maybe even enjoying myself, and then feeling anxious and guilty for days or weeks afterward. I developed increasingly intense obsessions about the costs of smoking: Would I start losing memories? Would I be able to process what I was reading in school as well as I had before? Was I trading away the one thing I had going for me – my intellectual horsepower – in the name of rapidly shortening bursts of escapist fun? I found myself examining my mind’s functioning for signs of decay – every thought contained an extra thought about why I wasn’t thinking as well as I had before. Nights of smoking no longer stood alone; they now came with weeks of stupor and self-recrimination in train.

Then guilt infected the act of smoking itself. Instead of getting high and feeling the moral and emotional hangover afterward, I began to feel regret and fear as I rolled the joint, as I bought an eighth, as I thought about whether to smoke at all.

I could see that something wasn’t working, that smoking no longer provided any distance from the self-cannibalizing tedium of my mind. On the other hand, I felt entitled to at least a little pleasure. Others had their beer, their wine – was this any different? More to the point, weren’t my newfound fears exactly the kinds of things that had driven me to smoke in the first place?

Naturally, I didn’t make any quick and decisive choices about how to handle the situation. Instead, I argued with myself for several more years – back and forth, back and forth, never making any headway or gaining any lasting insight. Until the stalemate broke.

I say “broke” in the passive voice, because I know it wasn’t me doing the breaking. Instead, I simply reached a point where that trade-offs no longer seemed worth it – where depression and self-flagellation had so thoroughly colonized my experience that I didn’t feel much temptation to smoke anymore.

I still vacillated, of course, and if you can use the word ‘relapse’ about smoking marijuana, then I did that too. But eventually, the cycle wore itself out.

* * *

By the time I graduated college, I was up to 30 mg of Lexapro (a newer version of Celexa). This is the “therapeutic dose” for OCD, and it’s where I’ve been ever since.

As I moved around, I found a new psychiatrist, and when he retired, I began getting my prescriptions refilled through my GP. Neither of these latter men cared much for numbers or questionnaires. Instead, they seemed to treat medicine as a natural adjunct to my condition: Oh, you have OCD? Well of course you’ll be taking an SSRI.

I’ve thought about working with these men to experiment with my dosage levels, or perhaps even trying a new medication entirely. But I’ve always held off. For the last five years, I’ve also been undergoing a form of cognitive behavioral therapy known as exposure and response prevention, and I’ve never wanted too many variables in the mix. (If I saw improvement, how would I know what had made the difference?)

More than that, though, the world of medication has always felt deeply murky to me. I’ve asked my doctors questions, of course. (Why this medicine over that one? What are the potential trade-offs?) But even when I ask good conceptual questions, there’s still a communication gap. I don’t know anything about neurochemistry, and I think my doctors feel that they have no choice but to summarize and simplify.

More than that, though, my psychiatrists haven’t always agreed about appropriate dosage levels. I strongly suspect this is because they haven’t all had the same level of specialized training in the treatment of OCD. (As with medicine more generally, psychiatry has its niches, and it isn’t particularly easy to find people well-trained in OCD.)

Of course, nothing is stopping me from diving into the scientific literature myself. But I’ve hesitated to do so – partly because I don’t have the neurochemistry training that would help me interpret it meaningfully, and partly because so much of it is new and inconclusive anyway.

At a more basic level, though, I find something repellent about the idea of second-guessing my psychiatrists. Not because I put them on a pedestal – I don’t – but because the nature of OCD is to second-guess everything (and third-guess, and fourth-guess…). OCD creates an unending trust deficit, and one of the most useful things about treatment is the way it’s helping me relearn to trust. Even if that trust is in some sense misplaced, (perhaps there’s a slightly more effective combination of medicine out there) it still feels valuable to orient myself this way – to place trust in trust itself.

* * *

When I wrote that last paragraph, it felt both true and incomplete. Yes, the aim of OCD treatment is to train in non-reactivity – to not indulge my mind’s compulsive desire to revisit and relitigate everything all the time. In other words, to trust that my life isn’t going to fall apart if I don’t keep myself under 24-hour surveillance.

But that doesn’t mean trusting naïvely, nor does it mean interpreting every one of my questions as compulsive.

And when it comes to my hesitation to learn more about antidepressants, there is something compulsive going on. I’m afraid. It’s an arena in which the stakes feel high, in which I’ll feel pressure to get it right but no confidence in my ability to do so. In other words, a perfectly fertile breeding ground for new obessions and compulsions.

OCD is a clever bastard. It makes me suffer, and then it tells me that there’s no use trying to learn how not to suffer, because doing so will only make me suffer more. In other words, that none of my impulses are trustworthy – that the only thing I can trust is that things will go on like this.

But that is just classic totalitarian bullshit – the regime that tells its citizens that no other reality is possible, and that makes it a crime to think otherwise. In other words, curiosity isn’t always compulsive. The world isn’t already ruined. Things might just be okay.

That might sound like a rather meager cry for freedom, but if you know OCD, you’ll know otherwise.

Time to go to learn about some drugs.

{ 12 comments… read them below or add one }

jesselava January 17, 2014 at 12:07 pm

great piece. the unending mobius strip of doubt is both explained and made vivid in the arc of the piece itself. thanks for helping folks get it.

Vince Carson January 17, 2014 at 10:55 pm

Matt, appreciate you sharing your experience, thoughts on ocd. It takes a lot of courage.

Aryt January 18, 2014 at 1:04 am

What an ordeal!

Here’s an interesting article from the International OCD Foundation:

Josh Weinstein January 18, 2014 at 4:28 am

Wow, love it! Take the power back!

Matt Bieber January 23, 2014 at 12:04 pm

Thanks bud!

Matt Bieber January 23, 2014 at 12:05 pm

This looks super interesting, Aryt. I’ll take a close look – I’m keen to brush up on research’s frontiers.

Matt Bieber January 23, 2014 at 12:05 pm

Thanks, Vince

Matt Bieber January 23, 2014 at 12:06 pm

Ha – hadn’t even necessarily intended that, but of course it would be that way :-)

Murali Rao August 8, 2014 at 9:51 am

‘Mental illnesses are in fact brain diseases’ may be a better statement,
Borrowed from Dr Tom Insel of NIMH

Valar January 28, 2015 at 5:29 am

I read the recent 10th anniversary issue of Scientific American: Mind and I could not believe what I was reading – science fiction becoming science fact. For instance, this technology has gone from non-existent in 2000 to perhaps a few years from clinical use:

I always work on being in the present, but even so, reminding myself of these developments helps my mood. Everything changes, including what we can do about OCD. It just so happens that mental health has presented science with a particularly tough barrier that is finally cracking at the seams.

Sometimes I think we are at the place now in mental health that medicine was in the 1930s, when country doctors generally carried only *three* drugs of proven efficacy around on their house calls (insulin, morphine and digitalis), right before antibiotics changed everything.

Matt Bieber January 29, 2015 at 7:06 pm

Ho. Ly. Shit. Thanks for sending this my way, Valar.

Valar January 29, 2015 at 8:46 pm

I’m glad you read my comment. Similar methodologies that utilize ultrasonic and optical stimulation to rewire brain circuitry are also in the works. Neuromodulation is the fastest-growing area of medicine, and so few people have even heard of it yet! The implications for not just mental health but the entire field of human development, including the contemplative path, are extraordinary.

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