Navel-gazing from dissertation

This is my second doctoral dissertation. When I was writing the first, my brother died of leukemia. He died of pneumonia following a complication of his bone marrow transplant, and I sat by his side as he panicked, distressed and unable to breathe. I had no idea what I was supposed to be doing. Eventually we said a brief goodbye and he was intubated. I sat by his side, holding his hand and not knowing what to do, while the ventilator pumped air into his lungs until his heart stopped beating.

In the early stages of working toward my second doctorate, I had a chance to remediate that experience by being at my grandmother’s deathbed. She was always a difficult woman, but she had lost the ability to speak, and in many ways this made things easier for her caregivers. We knew it was serious and came when we heard she had punched the orderly in the face who was trying to feed her. I took turns with my mother, sitting by her bedside, as my grandmother, like my brother, was dying of pneumonia. This time, thankfully, there was no talk of adding a ventilator or heroic measures to keep her alive. After two weeks, it was a Sunday when she was evidently about to pass away. The nurse had ordered morphine, but in the UK a doctor had to be called from another hospital to sign for it (see http://painpersonalitypsychotherapy.blogspot.com/2009/03/worst-of-evils.html for a discussion of the power of doctors over the dispensation of opiates). My grandmother was evidently in a lot of pain, although she was unable to use her voice to communicate it, doubly silenced if Scarry is right about the difficulty of putting pain into language (http://painpersonalitypsychotherapy.blogspot.com/2009/03/body-in-pain.html). Finally, the doctor arrived, and I went to her, holding her hand and making eye-contact to comfort her, and said, “The doctor is here, he can give you something to help with the pain.” I tucked her blanket and went to close the door, so she would not overhear the doctor and my mother talking in the corridor outside. By the time I got back to the bed, my grandmother had lost consciousness and never regained it. The doctor examined her and the morphine was added to her drip while my mother and I continued to sit with her, prayer book ready. But it was the gentleness of that last caring communication with my grandmother which I felt transcended my ordinary experiences, in a way that informs my work with patients in pain.

Knee, Happy New Year

This is my knee, before the surgery I had yesterday. The picture was taken at the ski resort, you will have to imagine the snow. The bones are fine, but I tore my ACL ligament. Now I have a new one threaded inside there, taken from a cadaver and sterilized with gamma radiation. There are 6 holes in the skin. I will spare you the technicolor pictures of the inside of my knee. I am supposed to be able to walk on it with a brace, but it hurts. Maybe tomorrow! Meanwhile, I am icing it using a special machine and writing the alphabet with my toes every hour so my muscles don't waste away.

I am not sure if I should drink champagne tonight on top of the pain meds.

Anyway, I liked this version of Auld Lang Syne (links to Scotland TV):

Should auld acquaintance be forgot,
And never brought to mind?
Should auld acquaintance be forgot,
And days o' lang syne ?

CHORUS:
For auld lang syne, my jo,
For auld lang syne,
We’ll tak a cup o’ kindness yet,
For auld lang syne.
And surely ye’ll be your pint-stowp!
And surely I’ll be mine!
And we’ll tak a cup o’ kindness yet,
For auld lang syne.

CHORUS

We twa hae run about the braes,
And pu’d the gowans fine;
But we’ve wander’d mony a weary foot,
Sin auld lang syne.

CHORUS

We twa hae paidl’d i' the burn,
Frae morning sun till dine;
But seas between us braid hae roar’d
Sin auld lang syne.

CHORUS

And there’s a hand, my trusty fiere!
And gie's a hand o’ thine!
And we’ll tak a right gude-willy waught,
For auld lang syne.

CHORUS

(According to Wikipedia, these are Robert Burns' original 1788 lyrics)

Writing Difficulties

Writing is hard. This morning, I talked on the phone with my aunt in Israel, who is a very good chronicler of family histories. She asked how I was getting along, and I told her that I had finished reading, but I was still writing my dissertation. I said it was really hard. She reflected that up until now, everything has been easy for me. I finished my undergrad studies, my first doctorate, without every experiencing any difficulty, and now I was finding something that was difficult, that had already taken a long time and was going to take even more time.

I'm not sure why this is. Maybe I've bitten off more than I can chew, the topic keeps expanding. I prune stuff and then it expands again. My first dissertation was about visual perception and eye-movements. I just clapped together the two papers I had already written (one in press, the other already published) and a talk I had given at a conference. The hardest part was making the changes requested by the external examiner. Now I think that would be easy, I have certainly learned in the intervening ten years to be less defensive. But the writing itself is hard.

Here I am, sitting in a cafe, writing this instead of continuing with the 20-odd pages I have down. Perhaps it is hard because last time all I had to do was describe the mechanics of things, and now the problem I am facing is more complex and my own view on it shaped by the integration of many different perspectives. It would take a book to write down exactly what I think about pain and how it can be treated. But I have a clear action plan, just to summarize the 9-10 books that have shaped my opinions, and worry about integrating them later.

A friend and fellow-student from the days of my previous degree just sent me a draft of her first novel. When we were both studying science, we each said we would write a novel by the time we were 30. Well, that deadline has been and gone, but if she can finish a book then so can I.

Facing the Catastrophe

I finished reading Jon Kabat-Zinn's book on stress reduction. Now I have to face the catastrophe of actually writing my dissertation, since I'm done with my self-selected reading list. I wonder whether to go about this by returning to the beginning and summarizing the first book I read, The Worst of Evils (a history of pain relief) or start by summarizing the treatment (Kabat-Zinn's book). It's a lot less scary writing here than opening up a Word document, so I'll start, in the spirit of things, with where I am now.

Kabat-Zinn outlines in his book an 8-week stress reduction class that he taught at Massachusets General Hospital over a period of many years. The first two weeks are devoted to a meditation he developed, called the 'body scan', during which patients notice and feel the sensations in all the parts of their bodies, literally from toe to head, while lying supine on a mat. In the next two weeks, they learn to breathe while doing yoga stretches. The next weeks include sitting meditation, sometimes with a focus on an image of a mountain, or on lovingkindness, or simply breathing. He included guidelines for walking meditation. During the final two weeks of the course, patients practice on their own, first without and then with Kabat-Zinn's meditation tapes. The book is studded with vignettes of patients' miraculous recoveries from pain, or at least regaining control over their lives or learning a new sense of dignity in the face of adversity. Following the chapters describing the different techniques are Kabat-Zinn's views on stress, meditation, mindfulness - all presented in a straightforward manner easily used with a general audience. What impressed me the most was the high rate of continuation with the practice, about 90% of people who attended the course were still practicing 6 months later, 42% 3 years later and 30% 4 years later. I heard from a professional who attended the course that Kabat-Zinn has a profoundly empathic style and a talent for relating personally to each of the students in the class. He must also be very charismatic, to have achieved such a high practice rate at followup, since meditation is hard to practice regularly on one's own. Reading the book makes me want to start a class like that, I think my patients would have a lot to learn from it.

On a more philosophical note, I am not sure about some of Kabat-Zinn's views. He says that we are not our pain, we are not our thoughts - but if so what are we? A disembodied intention, a stream of awareness, a renegade shard of some greater unity? My own view is that I am part of a larger tapestry, but at the same time 'I' am a discrete part of it with ends (birth and death) bound to my body by the reality of my pain, filled with thoughts and feelings that as much as they are shared with others within the cultural milieu are also a defining part of who I am. This doesn't matter so much except that instructions such as 'being in the pain' have to be explained a lot more clearly to someone who believes that there is somewhere else to go.

So this afternoon, instead of facing the catastrophe and beginning to write, instead of resting my knee so that it will heal faster, I went on a lovely leisurely stroll with my friend, up on the Berkeley Fire Trail. This trail was described by Dorothy Wall in her book, Encounters with the Invisible, about her struggle with Chronic Fatigue Syndrome. In fact, it was where she first met her husband, before the disease overcame her and when she was still able to jog. I felt sad that I couldn't run on the trail, where I have ran many times before. On the other hand, I enjoyed walking hand in hand with my friend, whereas when we run he always runs ahead.

Intersecting circles

At the end of her book, Encounters with the Invisible, Dorothy Wall writes about planning a trip to the mountains, the first in ten years after she collapsed with Chronic Fatigue Syndrome. She and her husband spread maps of the Sierras on the bed, planning their route. I finish reading this book after returning from my trip to the mountains, and think about illness as an internal journey, one that is unplanned and unmapped, into uncharted territory, without even giving one's consent to go along for the ride.

Just last night, I was saying to my friend how healing it was to go out to the mountains, healing for the spirit to experience all the varied scenery, the change in air, and the sense of aloneness while at the same time being in the company of others. As we were walking, I thought about the people who had laid the trail, carving stairs in the rock, the people who must come out every spring to mark the trail with rows or piles of rocks on the white granite shelf, and all the footprints from this summer's hikers that must wash away if not with the first rain and snow then with the meltwater. My friend said that in the past, before cars, most people never traveled more than 30 miles from their birthplace. I don't know if that was ever true. But I do think that places used to be more varied than they are now. Even in my own childhood, in the 70's and 80's in Britain and Israel, I remember each town having a different local character whereas now they are populated by the same chain stores, the same shopping malls and people. The villages in the mountains here in California retain their own character, for better or worse. We were lucky to find someone awake at midnight to give us a room to stay!

When I got back to the office today, somebody asked if I had makeup on, she thought I looked nice. I explained it was just being outdoors all weekend that put some color in my cheeks.

Dorothy Wall talks about a picture taken before her illness that she used to look to for reassurance of who she was. Then, in a later chapter, she realizes how one can never return. I think this is best captured in TS Eliot's Four Quartets: "Fare forward travellers! Not escaping from the past/Into different lives, or into any future;/You are not the same people who left the station..." We assume a continuity of self which is shattered by an illness that flies in the face of our ordinary can do mentality. Wall remembers her grandmother and her father reading to her from The Little Engine that Could the lines "I think I can, I think I can... I thought I could, I thought I could." Interestingly, the author of the eponymous engine was a house pseudonym of the publishing company, and the story one that had been retold many times. My grandmother used to read me that story, as I was reminded when I heard my mother reading it to my children. I believe that in life we are to some degree following tracks, but our engines are generally facing backwards and we spend most of our lives running away, even if we think we have eyes in the backs of our heads to see the next mountain and chug up it. My mother used to believe in geographical solutions to her problems, generally problems of the body that she attributed to the physical environment, both internal and external. She never realized that they were her fellow travelers and simply changed.

We generally choose the path of our physical bodies through space, and this helps us feel alive, like the Little Engine. We can spread out maps and navigate through the world. The effects this will have on our inner experience are less predictable. I think of all the times I might have bumped into Dorothy Wall in the streets of Berkeley, like leaves floating on a stream bumping into each other, maybe never to meet again, maybe to cross further downstream.

I think of my relationship with my friend, who thinks too much. Now he's got me thinking as well! As we walked through the burnt forest at the end of our hike, I was thinking for some reason that I would give him a facing edition of Dante's Divine Comedy for his next birthday, when he turns 35. Apparently, that was Dante's age when he wrote that or started writing it, contrary to the common myth that people in those days only lived to 30. "Nel mezzo del camin di nostra vita..." I wonder if there is a particular circle of hell for overthinking, where all the Little Engines that Could chug up and down a mountain, never realizing that they are traveling backwards and going round and round in circles, never noticing that it's always the same mountain, and that they are not all alone in the woods.

Identity and Pain

I presented my idea that pain is essential to identity in my philosophy group, during a discussion on identity and the internet, and it led to some stimulating conversation which I will attempt to recapture here. To put my argument in a nutshell, when I'm dreaming (or online, in some assumed identity) I can't pinch myself to sense if I'm real. Some people objected to the distinction between what is real and what is not. Others argued that identity is a social construct determined by our interactions with others. One person said that emotional pain is equivalent (or identical, in the mathematical sense) to physical pain, and somebody else took that further to argue that emotional pain experienced in online relationships can have the same function of binding one to one's identity as physical pain has in real life. These arguments helped me crystallize my idea as follows:

The term identity has many meanings. One of them is how I see myself. Another is how I present myself to others, which may take the form of several different identities or fictions. Yet another is how others see me - although I can assume different identities, I can't entirely control how others see me. How I see myself is then influenced by how others see me. It's as though I look in a mirror and make myself up a certain way, then I go out in the world and copies of me are created in other people's minds, none of which are exactly the way that I wanted them to be, and then I see myself as I am reflected in their minds have to go through the whole process again. The internet, chat and e-mail communications with people have been for me a very distorting mirror in which to see myself, and I hypothesize that is because it's much easier to lie online so people are used to others wearing masks and project a lot more of their own interpretations about what might be hidden behind the mask. So I end up being reflected in all these people's distortions, and having to endlessly recreate myself. Some people suggested that this is a bandwidth problem, that text communication online lacks the richness of interpersonal, non-verbal communication. I agree that is part of the problem, and it sets the ground for the bigger problem of the possibility of lying (false identity) and consequent distrust or suspiciousness. Anyway, this realm of identity seems to be all mirrors and smokescreens.

Another realm of identity is an attempt to answer the questions, who am I and how do I know? This is where pain comes in. Pain is different from the other senses because my pain is in some way unique to me. We can all see the same table, touch it, taste the same ice-cream - albeit our experience might differ somewhat. But only I feel the pain in my body, and you feel the pain in your body. I can feel your pain, but this is qualitatively different from feeling my own pain. Emotions, like the other senses, tend to have objects - and can therefore be stimulated by objects of the imagination. I can imagine or recollect or meet online something terrifying, and feel fear in my body, feel my heart beating, my palms sweating, etc. Equally I can imagine something that makes me cry or laugh, or feel sexually aroused. But I can't imagine something physically hurting me and feel the pain in the same way. I can't even 'remember' the sensation of having an attack of gallstones a few months ago and the pain in my abdomen, because I can't imagine the object associated with that. Unconsciously, I think there is a way we can experience pain (or its absence) by hypnotic suggestion, but not by conjuring up an object of the imagination like with the other senses and with feelings. This unquestionable experience of pain, together with its inevitably aversive nature - I can't feel pain and not want it to stop - prevents me from getting lost in the hall of mirrors described by the other realm of identity. It also impacts my choices regarding inflicting pain on other sentient beings, whereas while I'm stuck in the hall of mirrors of the internet I have little or no compunction to act morally in the sense that my transgressions will not result in somebody getting beaten up or bleeding to death. If they exist, they will simply come back in another form.

I wonder if emotional pain, and the feeling of another's pain, bear the same relationship to the experience of pain as does memory of one's own pain? Going back to the idea of a community of pain, and how when I was in pain different people looked at me and communicated with me non-verbally, I am reminded that the sharp, shooting pain of gallstones brought to mind the searing abdominal pain of puerperal fever, when I felt as though I was going to die.

There is an inherent contradiction in the questions who am I, and how do I know? Because at some level I invent who I am and then I know it's a fiction. How do I know pertains to the I that came before the invention and that is the I that is raw intention, and the I that comes after the fictions, the bodily sensations that I do not invent or wish into existence.

When I started talking about this idea with my children, somebody (it may have been me) brought up the serenity prayer: God grant me the serenity to accept the things I cannot change,
the courage to change the things I can, and the wisdom to know the difference.

Meanings of Identity

I was thinking that identity is related to pain, in the sense that when I hurt I know that I'm real, and that I'm really me. Now, reading Dorothy Wall's book Encounters with the Invisible, on her experience of Chronic Fatigue Syndrome, I think of a different meaning of identity. She writes about 'passing' for a healthy person, when really she is ill - both in her own mind, for many years, and then when her body denied her that pretense at least during those times when she went out into the world. Experiencing her pain internally, she refused to identify externally with an image of pain and illness. Her picture on the dust jacket, taken perhaps during this illness, shows a friendly, lively woman smiling engagingly at the camera from behind her large glasses. Yet she was exhausted, in pain, and had to rest for weeks after a walk in the park or a visit to the acupuncturist. This brings to mind at least two meanings of identity, how I see myself, and how I present myself to others. Then also, is it how I see myself (implying a mirror or a camera, a disembodied eye) or how I feel myself to be from the inside?

My experience is that there is a secret community of those in pain. When I twisted my knee dancing and then took a bus along Mission Street, a black homeless woman saw me standing and offered me her seat as she was getting off at the next stop. I don't know how she knew I was in pain because my sprain bandage was hidden under my pants and I was trying to look and feel normal. Another time, I was suffering from the pain of gallstones while shopping at the Farmers' Market, and the vendors at the fish stall looked right through me as though I wasn't there, moving on to the next person in the line. When there was nobody else waiting, I finally caught their attention, and they sold me a piece of fish without ever making eye-contact. On the other hand, the man in a wheelchair looked up at me and smiled, and the saxophone player playing blues on his saxophone held my gaze for a moment and nodded. I felt like one of the dead, in the story Where the Dead Live by Will Self. In this story, the author suddenly notices that his mother who has been dead for many years is actually still walking the streets and she tells him that when you die you simply go to live in another part of London. But maybe I'm not as good at hiding my pain as those who experience this more of the time.

So identity is how I present myself to the world, how I see myself, and how I feel on the inside. In math, identity means more than just equality. It is symbolized by equal with an extra, third parallel line, and signifies two quantities which are always equal, not just arbitrarily so in the present context. There are many circumstances in which how I see myself is not identical to how I present myself to the world, and then there is also how the world sees me, that can cause a re-interpretation of me to myself. I am thinking of my friend who had a Lithium atom tattooed on his wrist, expressing his identity as a nuclear physicist, only to discover it contains a star of David which has a whole different set of meanings, and is used as a symbol of identity by people with bipolar disorder because Lithium is often used as a medication in that condition. I might have my identity indelibly carved on my body, only to find out that other people see it differently from my intention. Bodily sensations such as pain, even the sensation of having a tattoo or piercing, are unquestionable, unlike all these images and how they are seen. Maybe I mean something deeper than identity is bound up with pain, a felt sense of who I really am.

Why is it so easy to spend 40 minutes fussing around on facebook as I just did, before I started writing this? Probably because of the limitless play around identity and its representation or misrepresentation. I listed myself as no longer single and a couple of friends sent me their cheery regards. When really I am still single, just no longer listed as such, taking a break from dating. And for some reason, I felt a need to take the trouble to correct them... Plus I invited my friend to play chess. Maybe he will ignore my request, that would probably be best for both of us.

Bodies are interesting

When I was in my 20's I co-taught an undergrad anthropology class on 'The Body and the Senses.' At the time, I saw my role as teaching the anthropology students about sensory neurophysiology and brain anatomy. They didn't like me very much! Today I realized for the first time that bodies are actually pretty interesting.

I finally finished reading Elaine Scarry's book, The Body in Pain. She links pain and creativity or imagination, albeit rather tenuously, by defining 3 kinds of objects that she names a 'weapon', a 'tool' and an 'artifact'. A weapon has two ends, with power on one end and sentience (pain) on the other end. A tool is similar to a weapon, except that it has power and sentience both on the same end, acting on an inanimate surface. An artifact is a lever or arc that has no obvious ends and is a projection of the body onto an object which is then interjected by other bodies. Examples of artifacts are clothes, languages, and God. Riding on the bus this evening I noticed that we surround ourselves with artifacts, the crust of the earth is cluttered with them. I think we are as much made by them as making them. For instance, Scarry talks a lot about the chair as an artifact, and imagines Adam making the first chair for Eve to ease the pain of her body standing on her feet all day. But Western man (and woman) is shaped by the chair, chairs make our bodies lose the ability to bend in the middle and sit on the ground. The internet makes us lose our memory. We are made out of this stuff as much as we are made out of our genes and the food we eat.

One of the things that interests me, which Scarry barely mentions, is that this stuff we are all made of is co-created. Unlike Adam making the first chair for Eve, our chairs carry within them a whole history of chair design. When I was 6 years old, I used to wonder if my life had really happened, or if it was just a dream that I had dreamt and I was still really only 3. At that age I had to learn a new language because we moved to a different country, and I realized that I couldn't have invented a whole new language myself so therefore at least some part of my life was real. Artifacts can go beyond the creative capacity of a single individual, even a single generation of people that happen to be living on the earth at the same time.

We imbue objects and artifacts with sentient qualities, and can get quite upset with them at times. In some ways, I think this is a good thing. For example, my son was once upset that his surfboard had hit him on the head, so he spent a good few minutes cursing and being angry at the ocean. God can safely be blamed for most mishaps. Without God, we have only ourselves or other people to blame and that can be problematic. A student in my yoga class seemed tired, and I asked her after the class how she was feeling. She seemed a little embarrassed by the question, and said she wasn't doing too well today because she had skipped her cardio workout. I felt so sad for her, feeling that she had to do so much and that I was asking for more. Later I complimented her on listening to her body.

Going back to the theme of yoga as a religion, I realized the other day that when I took my yoga mat to the park I was noticing all the other people carrying yoga mats. I notice them all the time now. The mat is evidently the artifact of the new religion, since yoga can be practiced perfectly well without it. Most reminiscent of a Muslim prayer rug. The mat serves to protect our skin and hands from the surface of the world. I will [unconsciously] enact death by lying on it, but not get too close to the dirt?

Over the years, I came to my yoga teachers for advice on what to do for different aches and pains - asthma, blocked sinuses, backache, pain in the knees and neck. Not only for myself, but also for my ex. I trusted them more than my doctor, whom I thought to be in the pay of drug companies, and I found them more helpful than a massage therapist, because they told me what I could do for myself rather than doing it for me. I never thought about this up until now, perhaps I just regarded them as experts on the body, but I came to them as one would to a priestess or a shaman.

Summary of philosophical conclusions so far:
- Pain reminds me that I'm me, in my body, which is in the world and not in my imagination.
- Yoga has the elements of a religion. It has no god, but it incorporates ritual enactments of death. The central artifact of modern Western yoga is the mat.
- The power of yoga to heal pain may be based as much on faith as exercise.

Also thinking about eating disorders, and the problem of trying to attract clients to a group. If I have an eating disorder, then I am at war with my body. The therapist has to align with me and not with my body, so saying things like 'accept your body' and 'be diet free' would be counterproductive. If I have a pain disorder, then my body is at war with me. The therapist has to align with the part that experiences the pain, because that part feels like the real me.

Sleepless in Berkeley II

Another sleepless night in Berkeley - maybe it's something in the air, the full moon - who knows? At least this time I rode my bike through without having to stop for the busy traffic, and the pedestrians I encountered were on the whole friendly, saying hello as they stuffed guitars and other instruments into their truck. Some were yelling, but only at each other not at me.

Reading about identity and the internet for the next philosophy group brought to mind my readings on pain, and a conversation I had earlier in the day while hiking down from Las Trampas. Pain is what brings us back to the self, establishing the reality of both self and world as in pinching yourself to make sure you're not dreaming. Pain means that the world is real and not all in my imagination, and also that I am really me, in my body, which is in the world. The boundary of the body, the skin, is what binds me to the world. In the world of words, on the internet, there is no real me. I was reading the history of Multi User Dungeons (MUDs) and I looked at some of their websites. Perhaps they need to specify whether killing other characters is allowed, because there is no possibility of causing bodily pain only social pain. I would be curious if players ever experienced bodily pain as a result of their characters' adventures online. I imagine that other sensations such as sexual ones are possible, even likely, but I wonder about pain. Perhaps the imperative 'do not kill' comes from the possibility of inflicting pain on a fellow sentient being, and when we know others are not sentient we just don't care in the same way. I am the intentional, willing I that can create my own identity in a world of words and also the sentient I that experiences unwilled pain.