Archive for March 15, 2013

Rescuing Freud and Redefining Insight

Eric Kandel has done what Sigmund Freud could only hope to do.  Over a century after Freud abandoned his attempt to develop a biological theory of the mind, Kandel has achieved the long sought for synthesis that links behavior, mind, and brain in a coherent model.  This achievement comes to us now through the persuasive voice of this Nobel winning psychiatrist and neuroscientist’s latest book, The Age of Insight: The Quest to Understand the Unconscious in Art, Mind, and Brain (Random House 2012).

“Insight” has always struck me as a sloppy and troublesome word in the shoptalk of psychotherapists, so the title of the book did not immediately win me.  At the Massachusetts Mental Health Center where Kandel trained in the early 1950’s and I trained in the early 1980’s, “insight” signalled a territory occupied by  psychodynamically-oriented psychotherapy and psychoanalysis, a smugly superior sort of understanding than anything that could be achieved by cognitive psychology, behaviorism, or biological psychiatry.  Until this latest book by Kandel, it has never been clear to me how deep such hallowed insight went.

I first heard Kandel speak in the early 1980’s when he returned to Mass Mental to tell us about his bench research on the aplysia snail neurons as a step toward working out how brains learn—snail brains and human brains.  We psychiatry residents were stunned by the audacity of one of our own graduates to ditch humans for snails as a route to understanding the molecular basis for learning, memory, and the unconscious mind (see Kandel’s In Search of Memory, 2006).  At the time it was not clear to anyone whether Kandel had found the royal road or a dead end, but he was a captivating speaker willing to take risks with his career.

Kandel reminds us in The Age of Insight that as recently as the mid-1800’s it was considered radically insightful when Rokitansky, the dean of the Vienna School of Medicine, insisted on physical exams and autopsies for the diagnosis of disease.  Probing the live and dead body was literally digging deep beneath the surface appearance of illness for the causes of disease.  Fifty years later it was equally radical for Freud to assert that the unconscious mind runs the show—another insistent step toward digging beneath the surface.

For all the impact of Freud’s “discovery,” the unconscious mind as a concept eluded precise definition, anatomical location, and quantitative measurement for most of the twentieth century.  While the rest of western culture found the unconscious mind mysterious, fascinating, and transformative, science could ignore it because it could not be measured.

Now Kandel and a growing band of neuroscientists have described the next radical step inward: the neural basis for both the conscious and unconscious processes of emotion, learning, memory, visual perception, and face recognition.  It is now possible to locate in time (by EEG) and space (by fMRI) the traditional “Aha!” moment so iconically associated with insight-oriented therapy.

Kandel effectively shows us at many points throughout this 600-page book how Freud has proved helpful to neuroscience (see the figures on p 376 showing how Freud’s tripartite model maps onto brain neuroanatomy).  While acknowledging Freud’s substantial limitations, Kandel bridges the gap between psychoanalytic theory and modern neuroscience, persuasively rescuing his forefather from drifting into apparent irrelevance.

Kandel shows us that we clinicians now have a new level of insight to strive for, one that penetrates deeper than the tenets of any single brand of psychotherapy, one that blends the language of brain chemistry and neural circuits with the languages of psychodynamics, cognition, and behavior—in this book, the expressive behaviors of three Viennese painters from Freud’s day.

That Kandel can frame this landmark synthesis in a dual homage to three artists and one great essayist from his hometown underscores Kandel’s own literary agility.   In this rare instance, the scientific pioneer is also the gifted messenger.

Psychiatrist’s Guide to Double Tractor Flats, Christmas Eve


You may wonder why a psychiatrist would bush hog on Christmas Eve in southwest Ohio and how he might feel about ending up with not one but two flat tires—on the day before Christmas, when most people are thinking about other things. It’s not as easy as you might think to flatten a tire on a tractor big enough to haul a bush hog. I’ve been driving this Ford 2000 five-gear tractor up and down our hill for 26 years, thrashing through plenty of nasty stuff and never had a flat.  Never thought it was possible to get a flat.

The truth is the morning of Christmas Eve I was cheating to beat the rain, which came with a promise of possibly turning to snow on Christmas—cheating on taking care of my family and their presents in the proper spirit of the season. The day before I’d already bush hogged half the hill, which holds the neighborhood glory of being the best sledding hill around, good enough to draw strangers who can’t bear to drive by without trying it out. Our house was now full of in-laws, some of whom had heard about this place but were seeing it for the first time, came all the way from Albany to join us.  If I could just finish the other half, we’d be ready for the big glide.  Every year it’s a race to groom the hill before the first snow.

The other truth is I love grooming this hill, all five acres of it.  In the thickest season it can take me four or five hours, but I get to know every gopher hole, how the springs are running, how thick the brambles around the angel tree have grown, how wet the bottom land is below the springs.  I always find the mint patch with my nose before I see it.  In the heat of the summer the swallows chase me, diving for the frantic bug life fleeing my blades.  I’ve chewed on some of my most painful problems out there.  The rhythms of the loops up and down the curves of that hill make it a place where you can’t do much else but watch your track and think about things.

If you don’t watch your track this hill and this machine will beat you many ways, reminding you you’re just a shrink pretending to be a farmer.  The combination of running springs and gopher holes in one gully where the grade steepens means that the big tires will spin, lose their grip–then you have to raise the bush hog, then reverse downhill enough to back out of the slippery area, then head up at a softer angle. When the grass is chest high, you can’t see where it’s wet until you spin out.  There are some parts where you can’t see the bottom from the top and the grade steepens enough that you can only mow downhill and then at a certain speed the clutch slips out of gear, sending you into a free fall coast until you hit the flat and the clutch kicks back in.  Generally, it’s safest to mow up and down the fall line.  Angling across the fall line runs the risk of rolling the tractor.  I’ve never rolled it, but I’ve played out in my mind many times exactly how I would jump from a rolling tractor.

The other truth is this will be our last Christmas at this house before a move into town later this winter.  This will surely be my last bush hogging of the hill.  Better finish it right.

But on my second loop a light rain started and by the fourth the grass had taken on enough water to make yesterday’s easy climbs now not so easy.  Twice I spun out in that gully and had to take that softer angle up.  The third spin out came as the rain picked up and I had to turn in for the day, which might have led to more thoughtfulness towards our house guests.

But later that morning Frank, my brother-in-law, pulled in from Indianapolis and announced that our tractor had a flat.  I’d parked it in front of the house in the grass near our cars, where the tractor could contribute to the general conversation.  So of course Frank couldn’t miss catching the flat.  Frank’s a gearhead and doesn’t miss anything to do with our cars or bikes.

At first I didn’t believe him.  Those tires take any beating, never go down. But the left rear big tire was so flat the rim could cut the tread if it weren’t on rain-softened ground.  The wheel itself is four feet in diameter, about a foot wide, and the tread depth at least an inch.  The flatness of that tire told of the impressive weight of the tractor frame.

Over lunch we chewed on the problem.  How do you fix a flat this big?  Or do you just buy a whole new tire?  Where?  How much? Thousands of dollars?  What’s this tire made of?  How do you jack up a tractor?  Frank didn’t have the answers.  He’d never messed with this dimension of the automotive world before and didn’t seem eager to start now.

I tried ignoring the problem, putting it off in the name of Christmas.  Tried wrapping a few presents, writing some cards.  But deflation is an intolerable state of mind.  By four o’clock Frank and I were back out there, him with his cigar and me with a jack I pulled out of our Toyota. Over lunch when I had suggested we try this jack, my daughter-in-law observed that this sounded possibly dangerous, and she asked what weight the jack was built to take and what the weight of the tractor was.  Neither number was familiar to me, nor was that line of thinking.  I could have looked up those numbers, but I tend to approach problems the other way.

By the time Frank came out for his cigar, my daughter-in-law was deep into a nap and I had the Toyota jack wedged between the left axle arm and a couple of 18 inch 4 x 4 blocks, stacked on their sides on the ground, blocks from some old book shelves stored in the garage for over ten years, just for this day.  I cranked the jack up with the flimsy handle and raised the wheel high enough to take the weight off the tread and expand the tire. Then I hooked up an automated pump from the lighter socket of the Toyota to the nozzle of the big tire—a pump Frank had given me some Christmases ago—and amazingly we heard a slight hissing in the top of the tire which, with the help of some water, we traced to a pinhole that spewed a beautiful line of tiny bubbles into the water pooled in the tread.  Then, when we boasted of our find to my son, Reed, he listened closer and found a second pinhole eight inches away.  That’s what sons are best at, one upping dads.

These two irresistible pinholes, origins still unknown, led us to hustle to Pep Boys and come home with a Tire Plug Kit, which after much boring and reaming and grunting allowed us to plug both holes.  After re-inflating the tire, not a bubble oozed from either plug site. I felt pretty damn cool about it, ready to go wrap a few more presents, until I reached down to remove the pump from the nozzle and heard the familiar hiss, now coming from the nozzle site.  And now the other wheel, the right rear tire, also looked softer, seemed to have widened at the base—not flat, but not full either.  Two flats?  Suddenly I felt again like a shrink pretending to be a farmer.

Christmas served as a dutiful distraction.  The snow came the day after.  The sledding on one half of the hill was sticky but good enough.  No one complained about the unmowed half of the hill, but in my mind deflation still ruled.  Now the problem was how to take a hundred pound wheel in for repair?  And who repairs such tires?  None of the tractor supply stores deals in tire repair, they told me, but a sassy receptionist at the third tractor supply store told me about Walt Luti Tire in Lebanon, 20 minutes north of us. They would fix it for $38 if I could get it there.

Most psychiatrists don’t know that a rusted one inch lug nut is too big for a one inch socket.  I measured the lug nut, borrowed a socket set with two one inch sockets from my buddy Steve Sprovach, along with his Super Penetrant Liquid Wrench dissolving solution and a ratchet handle about a foot long. When his sockets were too small, that set me back a couple of days and took another whack at my self-esteem. This tractor is not mine.  I’ve borrowed it every year and the least I can do is return it in decent shape.  My reputation was on the line.

My brother steered me to Blue Ash Tool and Rental, where I took my chances on a 1 and 1/16 inch socket, instead of a 1 and 1/8.  The guy in the overalls who watched me take my chances on this choice also mentioned that removing rusted bolts might require a pipe extender on the ratchet handle to get the leverage you need, but that leverage could also achieve enough pressure to crack the socket.  I took that message as some combination of helpful advice and fair warning.  The socket rental was only $3.50 a day.

You can imagine my satisfaction when the rented socket slipped on like a crown onto a tooth. Snug fit. Then I slipped Steve’s ratchet handle on and promptly got it jammed against the rim as I tried to turn it.  Most psychiatrists wouldn’t anticipate that a ratchet handle could get jammed against a tire rim, but in my defense, I did manage to reverse the ratchet switch with a pair of pliers, remove the ratchet handle and then, in a stroke of packrat genius, found an eighteen inch pipe in the garage which slid over the handle.

The sound of a rusted one inch lug nut popping free under the torque of this socket setup was like the first snap when a large tree falls to the axe.  The power of the ages is released.  Man over machine, finally.  All eight lug nuts yielded, eventually. I rolled the tire into the back of a borrowed van and hauled it up to Walt Luti–an easy fix for them.  The hissing around the nozzle, Luti explained to me, was the air leaking out after we had plugged the tread holes. He explained to me I had an inner tube the way I sometimes explain to my patients they have an amgydala in their brain. Plugging a tread when you have an inner tube is a silly thing to do.  If he was amused, he didn’t rub it in.

By the time I got the first tire back Monday evening, the second was half flat. Still no clue about why.  Same drill again with the jack, socket, and Liquid Wrench. It was dark last Tuesday night when I finally got the second fully inflated tire back on and all eight lug nuts tight—13 days since the first flat. It was dark, but not too dark to try it out.

You can imagine what a feeling it is to comb that hill in the dark, feeling your way up and down the thicker grass, feeling the grip of full tires even in the soft turf. You can imagine how it is to kiss that hill and that bush hog good bye, running those loops as much by memory as by sight. Full inflation is a wonderful state of mind.