Remember, Remember the 5th of September

2008
you and I walking down Lambdon Quay on a cool, clear night
to Frank Kitts Park to watch the fireworks
Obama newly elected, Spoltopia newly born and delicate
so much Hope

2009
Heading to the Munger Trail for your first century
A Curious George jersey.
Looking back, this still feels like the Best Year.

2010
You were back from Alaska
still wounded
has it ever healed?

2011
My feet a little numb from the cold Gisborne sands
Back in Aotearoa, and warm in a way
no words can describe

2012
Legs still a little tired from Mt. Matthews
Watching the fireworks again,
But now from home, Te Kainga
our bedroom window.
Your old wound open, a secret . . .

2013
Apart
Spoltopia dying, the one thing I would die for
Wondering
Does she have fighting instinct to save this, our child?

Summer

25 July 2013

This needs to ripen, but no too much.

The thought is well enough formed now to describe, if not yet to name. To be sure, this is living inside my own head again. Only this time not the dark internal cacophany that grew hidden and briefly overtook the last decade. Time, and the decisions made have well and truly made me. Whether on the marae, upon the streets of Unreal Cities or in this now-familiar corner  . . . discovery is replaced by scope, the vision of middle age.

Is all growing growing apart? The black and white and red threads hold tightly together as they pass through the eye of the needle, so that they may pass at all. But once past, what remains is letting go. The experience of her sitting beside me, regressed enough by the drink to let me know that she could not really see me, and that any self-making I had undertaken was what I would take away from the relationship, not bring to it. Welcome back, indeed.

And today, in of all places, a kitchen remodeling discussion. I felt the familiar pang of the value proposition dying, as I have seen it countless times in medicine. I suspect if I proceed I will be getting Abilify countertops and Pristiq appliances, when a MAOI would have done better. I suppose beginning that conversation with a vision and no great concern about cost is like coming into the ED with anxiety, fully insured when there’s an open bed. In other words, my own fault. A better student of one’s illness would not be carried forward by the perverse incentives in the system.

Then, after a convivial evening, to watch the cross-purposes unfold in real time. I mean, really, who goes to a cocktail party, dinner and downs half a dozen drinks before mentioning at 2130 that “we” have homework due tomorrow. If you are lucky enough not to be in the “we’, the only real move is to step aside. Wierdly, Kristen took sides, and even odder, the side of cross-purposes.

26 August 2013

Therapy is exposure in quiet chambers, a cut that does not kill and so a gift, if we can but experience it this way. It is not easy, and it is not a zazen. Simulacra such as catharsis, confession or endless thought experiments are easier, but of little value. For some, even the dim lights are too hot.

Process: change you will notice

To think, speak and act more adaptively in a world that is oftentimes, but not always, sane. (Game theory?)

what shall I think? “whatever you are thinking” is the easy answer. Free association is easy once learned, and deceptively difficult to cultivate. Mindfulness is a good place to start. Unlike CBT or DBT, however, it is important not to consciously do anything with the observations for some time, such as look for upstream “triggers” or downstream behaviours. Notice also that I do not say “feel”, as we need to reserve this term and keep it as close to a meaning of “body sensations” to work analytically. The assumptions going in are (1) bodily drives are limited aggression and libido (full stop)  and so (2) the primary suite of feelings are very limited--pleasure, anger, disgust, fear--depending on how these urges match with subconscious calculation of their achievability. Finally,  because drives and primary emotions are fundamentally pre-linguistic, we damage them (but also provide “grist for the mill”) when we dress them up intellectually as ambivalence, jealousy, dissonance or guilt. In practice, this requires a discipline (learned or enforced) of expressing thoughts declaratively through a “scene”, vignette or sequence that should be described as narratively (show, don’t tell) as possible:

For example,

“That morning at the office, when I saw Tina enter and I noticed myself focusing on her breasts. This was followed by a fleeting vision of myself sucking on them, like a child, but at the same time very sexual. I felt very warm at first, but then more of a prickly-heat or flushing sensation, very embarrassed.”

“Think a moment and try and say more about what you mean when you say embarrassed.”

“Let’s see. I suppose ashamed that I was thinking such a thing.”

“But you said embarrassed, and that word tends to be used for situations where one is caught by an observer. Was someone else around, or did she seem to react as though she were aware of your thoughts?’

“No, I was alone, and she was rummaging through her purse and couldn’t see me through the glass, anyway.”

“okay”[silence]

Note the therapist does not make an interpretation. Some might be tempted to see the “offer” of shame as an invitation to expose a superego-id conflict and to go fishing for similar experiences (“can you tell me a time when you have felt this before?”). However, such a response invites association that is not free, or the patient’s, for that matter. This therapist keeps the follow up as literal as possible, asking for clarification then retreating back into silence, thus allowing the patient’s association to continue, which it does:

“You know, now that I think of it, the afternoon before I overheard one of the secretaries telling another that Tina was still breast feeding her 4 year old. I chuckled to myself at the time; I guess at the disapproving and gossipy tone of it. But I also remember being very distracted and irritable on the ride home. I masturbated as soon as I go home, which is unusual for me as it makes me quite sleepy after. But you know what, I felt much better [laughs]

what shall I say?

Effective free-association usually results in less talking, rather than more. A comfort with silence, a willingness to let thoughts pass or  to tolerate a bit of anxiety while seeing how they play out internally.

what shall I do?

30 August 2013

The last payment . . .

I think you understood better than I did during our divorce proceedings that monthly payments were not a “punishment”, but quite literally a form of accountability. Over time I came to see this, and it served as a reminder that I must own my actions, my words and my choices. Sometimes the money was difficult to come up with, other times I hardly noticed. But each and every month for a time equal to our marriage I was confronted with the fact that not acknowledging my shortcomings had carried a price, and that I could either change or pay forever.

The misery that is divorce is only compounded if afterwards one chooses to heap blame on “the ex.” Moreover, it is a perverse kind of refusal to let go, and an unflattering exercise in vanity. The fact is, one can only ever know and change what he got wrong, and there was plenty in my case. From the very beginning of our relationship, I behaved as if love somehow excused my words or actions. I was thoughtless, narcissistic and glib. Worse still, I hurt you. Not once, but time and time again. I know it wasn’t all awfulness, and I have many fond memories of our time together, but I was a failure at our marriage and that has humbled me.

I do not owe you any more money, Sandy, but feel that the “payment” would be somehow incomplete without a genuine apology and an acknowledgement of the positive feelings that have survived all these years. And so . . . I am truly sorry for the pain I caused you. I love you, and will always.

3 September 2013

3AM. Reflections upon doubt. It seems to me that there are two categories of self-doubt: doubt in one’s character (“Am I a good person?”) and doubt in one’s ability (“Am I able to do this?”).  The two intersect in the question, “Am I strong enough?”, which is a question of  will, but also of faith in one’s “better” self.

The meds and the alcohol were a shield of sorts, but from what? Perhaps nothing more than the daily grind of low-grade conflict, negativity and frustration that we all must find some way through. In this case, they served an adaptive purpose . . . until they didn’t anymore.

I can see how both confidence and practical self-regulating skills can atrophy after a period of reliance on meds and alcohol, but of course they do not disappear altogether. In the end, perhaps it’s a “locus of control” exercise: learning how to reach inward to self-contained regulatory mechanisms, then reaching out to others (matee, sponsor, friends) before reaching for the Rx or bottle. A good cry, a good chat and fight the good fight. Repeat.

One thing you need never doubt is my love for you.

Remembering Tua Hekenui

For Tua Hekenui, who lived his tikanga, challenged ignorance with laughter and has passed on

Wharenui

A look inside the wharenui, always from the outside

As a pakeha practicing psychiatry in a kaupapa Maori setting, I do not posses the mana tupuna for this whaikorero. My mahi, however skilled or virtuous, bears the scars of colonialism. The concepts of mental illness and wellness, ingrained in me through my American culture and subsequent medical training, bear laughably little resemblance to the increasingly lost ways of the tohunga. In Aotearoa, those who care to look around--instead of only ahead-- cannot help but notice the fragmentation of the things that connect people to the the language, the land and one another. I am not Maori, but I can see when something is sick. Still, I am perfectly at home at Te Whare Marie, where the meeting house and clinical offices sit side by side, where we begin the day with mihi, karakia, waiata . . . and checking the fax machine. And so it is that this Frankenstein's monster of a mental health service picks up the pieces, mending nga tangata with whatever is at hand: a prayer, a comforting word, a safe place to sit, a meal as often as a medicine.
In our practice at Te Whare Marie, I am guided by the example of Dr Allister Brown and Wiremu, who through years of work together no longer struggle to reconcile the different processes by which they "heal," to the very great benefit of their tangata whaiora. There is still a part of me that cannot help but interrogate the space between them, in the spirit (I tell myself) of anthropological investigation, but in the end no more than a puriri moth stuck and dying on a collector's pin. Against this habit of treating things not fully understood as specimens, I have asked kaumatua Hemi Pou to extend his korowai so that I may move briefly under its shadow as I pass through the marae-- for its protection, and mine.
There are now many didactic resources available to define Maori words and concepts. This is not one of them. Rather, it is an attempt to create a sense of the experience of working, training and seeking care in one small corner of Te Ao Marama.