Wednesday, November 18, 2015


"Paranoia strikes deep.
into your life it will creep..."
~ Stephen Stills

Of all we could say about paranoia, one thing is pretty clear: it's a symptom of something gone wrong. When we're coping well with life, we aren't generally suspicious or mistrusting without reasonable cause. Even under stress, when we are compensating, as we say in "shrink lingo," we're able to distinguish between real and imagined threats. True, we may not be able to cover every single solitary possibility imaginable -- no one's perfect -- but we do our best. And most days, in most situations, that's good enough.

In extraordinary situations, however, things can change rapidly. With good coping skills and a healthy ego, we're okay, maybe even better than okay. With poor skills or a weak ego, it's not so good. It may even get scary once in a while. Especially to those of us who are on the outside looking in. 

I'm referring specifically to the rash of paranoid ideations that have found their way into video and print in response to the terrorist attack in Paris. Don't let those Syrian refugees into America, they say, you can't tell the good guys from the bad guys. Well, maybe not, but haven't bad guys been able to enter the United States for a long time? What self-respecting, evil, scheming bad guy is so stupid that he'd masquerade as a refugee and expose himself to serious scrutiny, when he could simply walk through customs with a legal passport on any other day?

That's the problem with paranoia, especially the socially-acceptable kind. It checks its brains at the door and starts shouting about the sky falling when the issue is actually much closer to the ground. It becomes irrational even when couching its rhetoric in rational terms. It is true, America has endured terrorist attack before and it only makes sense to be prepared. Once burned, twice cautious. To become obsessed with the possibility to the point we abandon our leadership role on the world stage isn't caution. It's more like crazy.

These are times for brave, sensible people. People like the Parisian father who explained to his young son that memorial flowers and candles were there to protect them from bad people with guns. He's too young to grasp the concept that flowers and candles represent the collective will of good, solid, brave people who refuse to give in to terror. Someday he will, though. When he does I hope he also understands that paranoia is a warning, not a watchman to be heeded.

Creative Commons image by Katlew via

Sunday, August 24, 2014

The White Coat Brigade

Although I wasn't running late, it still felt that way. It was my second day of residency and a meeting with the psychiatry training director had me intent on arriving early. At my hospital, residents have access to a parking garage, unlike lowly medical students. Having been one of them for so long, the garage looks to me like the Taj Mahal. Anyway, after driving round a couple of minutes and coming up empty-handed, I spied an empty space marked, "Physician Parking Only." Wouldn't you know it? I thought, may as well have Dirty Harry guarding it. I started to drive past when the lights came on. 

"Wait a minute, that means me."

If there was a single thing typifying the impact of residency thus far, this incident depicts it. Over and over something happens -- entering the resident's lounge for the first time, hearing my name called with the title "doctor" appended to it, having other residents smile in greeting -- something happens to remind me I'm not in Kansas anymore. Medical school really is finished, I really did graduate, and I really am here, at long last.

It's kind of funny, when you think of it, the way reality creeps up and sinks in. I don't know if it affects other people like this, but I can't help thinking about how everything feels. Maybe that's why I'm in psychiatry: just being here isn't enough; I have to take it in and digest it. And unlike some third year rotations I was glad to bid farewell to, I want these first six months of inpatient psychiatry to poke along at pace that would make a snail impatient.

It's weird, though.  I feel like a buck private who's been given a battlefield commission. Only a few years ago I was an enlisted man, now I'm at the opposite end of the food chain -- or chain of command, as the case may be. Sort of. As a first year resident, I'm little more than a medical student with a title. But the people I work with didn't know me back then or in my life before that, on the front lines of mental health care. They only know me as I am now, a member of the White Coat Brigade. It's up to me to let my behavior spell out what I learned while serving on their side of the coin. 

Nothing is automatic, but it's all as pleasurable as it is satisfying. Especially sitting down with patients for therapy knowing it's partly what I'm getting paid for. I'm here to learn everything I can, but I'm also here to work and at this point, psychotherapy is something I can do quite legitimately. It's one of the tools I've had rattling around in my backpack the past few years, waiting for its time to come.

(Creative Commons image by Kids_Safari2 via Flickr)

Thursday, June 5, 2014

His Final Breath

The invitation was a Father's Day special that read, "What did your father teach you or how did he inspire you with regard to medicine?"

It would have been much easier had it been, "What did the Old Man have to say about the Big Slab (biker slang for the interstate)?" Then I could respond, in my best gravely ZZ Top growl, "He had me on a Hogg before I could walk. Why, he and mom almost named me 'Harley,' you know, as in Don Henry's song, Harley?"

There was a motorcycle mama and her man
With a wind-burnt tan and a Harley
Roarin' through Bakersfield when her water broke
They pulled into a hospital and for a little joke

They named him Harley
They bought a sidecar
And a small bandanna band
And they loved their Harley

Leaning closer and jutting out my long ZZ Top beard, I'd look at you over the tops of my Ray-Ban sunglasses and whisper with mock menace, "You do know Don Henry --  don'tcha?" 

But, that wasn't the question and my father never owned a Hogg or any other kind of motorcycle, much to my distress as an adventure-seeking teenager. Much to his relief, I might add.

Nope, my father didn't teach me a thing about motorcycles except I could get killed riding one. I came close one Fourth of July weekend, racing my uncle's beat-up Vespa scooter round his property as fast as first gear would take me. A patch of soft soil brought an end to my dirt bike career. They say speed kills, but in my case, it just knocked me out. No, I wasn't wearing a helmet -- in those days we didn't worry about head injuries quite so much and besides, my uncle didn't have one, anyway.

Dad did teach me a great deal about horses, though, mostly how to love them like your best friends. For a tough guy -- not a gruff guy -- he had a soft spot for horses. I remember the night he woke me up and led my mother and I out to the barn where we watched a baby colt being born. It was my first "childbirth." There was poetry in his relationship with horses and he taught me how to write my own over the years.  

He also taught me a lot about hard work, accepting responsibility, taking risks, and following your heart, all of which he exemplified regularly. It's been sad that he didn't live to see me through medical school. I would have dearly loved to share the folly and fun of my daily efforts to become a physician with him. Some of the situations I managed to get myself into would have had him laughing until he cried. Others wishing he could board a plane, despite his illness, to stand alongside his son when he experienced hard times.

If my father taught me anything about medicine, apart from how to "doctor" horse injuries. it was that I never knew as much as I thought I did. People will surprise you. His own life-long struggle with chronic pain resulting from a back injury at age 19, made him a model of endurance that earned the admiration of his physician. He worked through pain that would have laid me out and did it every day. His determination to wave off the beating wings of the death angel until his final heartbeat was a testimony to his disbelief in the word, "quit." 

So, what did he teach me? Where do I start? He taught me everything worth knowing and then some. He taught me about his fallibility, his fears, and to accept and overcome my own. He taught me to tolerate what I couldn't change and change whatever I could. He taught me how to face the worst life has to offer by going through it with me until I was ready to go through it alone. 

And that's when he took his final breath.

Happy Father's Day. 

(Creative Commons image of Billy Gibbons of ZZ Top by Filipe Neves via Flickr; "Harley" words and music by Don Henry who owns the copyright)

Sunday, June 1, 2014

Warm Days and Woodchucks

I hate moving. I used to think I was good at goodbyes, but you want to know the truth? I
suck at it. It doesn't matter whether there's a really good reason for riding into the sunset, I still find reasons for wanting to stick around long past closing time. Days I couldn't wait to resign my job in Colorado turned into days I loved it, even though I was leaving for medical school at last.

It's the same way now, even though I'm leaving to begin residency, also at long last. Only this time, I don't have to look for reasons, they're all around me. For instance, about ten minutes ago, the dogs and I were making our afternoon rounds along the edge of the hayfield when my big dog pulled up suddenly. I looked down and he was nose to nose with either a big woodchuck or an equally large beaver. They resemble one another and despite my friendly greeting, he didn't seem inclined to introduce himself, so we hurried on.

But things like that make it hard to move.  Cool, quiet, starlit nights, immune to the sounds of the city. and breezes off the freshly mowed hay, later in June, are things I'll miss. Yes, I'll get to see the Detroit Zoo and perhaps hear the Detroit Symphony, but my roots are in the country and I'd gladly trade the zoo for the porcupine that lives under the barn or the woodchuck in the hayfield.

I know this is my "big chance," as they say in show business, and I'll be glad to settle in and get to work. Time passes quickly, I learned in medical school. Residency will, too, and sooner than I imagine, I'll be packing again, to come home. In the meantime, though, warm days and woodchucks make me appreciate the life I've had, here on the farm, that much more.  

(Photo copyright 2014 by the author)

Thursday, May 22, 2014

The Secret Life of Walter Mitty

Beauty doesn't ask for attention. ~ Sean O'Connell

My friend and co-author, Dr. Lynn Smith and I used to talk at length about what we called the "Walter Mitty personality type." Risk-aversive, detail-oriented, traditional (though not necessarily conservative), and inclined to play by the rules. Good, solid people like Bilbo Baggins, who aren't likely to rush out their front door in pursuit of adventure. Their secret is, they'd like to. They dream about it, but they can't let go. Until they have to.

This is the story line for the marvelous film, The Secret Life of Walter Mitty (2014), starring Ben Stiller. By day, Mitty is a quiet, unobtrusive supervisor in the photographic negative department of Life magazine. At any other time, his imagination may have him miraculously rescuing damsels in distress or besting arrogant, narcissistic asses like the one in charge of transitioning Life from a print to online format. In daydreams, he's everything he's not from 9 to 5: creative, brave, articulate, and appealing. In life, he can't even bring himself to speak to the woman who's stolen his heart.

Whatever author James Thurber originally intended, this particular film version depicts a journey of the soul. Mitty is an ordinary guy who's become a worker bee. He contributes, he's efficient, he does his job very well. His life has purpose but no passion. He'd like it to and his daydreams are filled with it, but he's ambivalent. Even his e-Harmony profile is incomplete. He's at a crossroads and needs a guide, a mentor, someone who can show him how to make his own choices and live his own life.

Enter Sean O'Connell, played by Sean Penn. O'Connell is a photographer of the old school. He still uses film and submits his photos for publication by snail mail. He doesn't own a cell phone and would probably misplace it if he did. He's unpredictable and follows his own rules. As it happens, he sends Mitty a roll of film with instructions indicating the last negative on the roll is his preferred photo for the final cover of Life

The problem is, Mitty can't find it. It wasn't enclosed in the packet containing the rest of the negatives. Nearly at wit's end, he notices a photograph of O'Connell and imagines him beckoning for him to follow. Without warning, Mitty dashes out the building and boards a plane for Greenland, O'Connell's last known location. No baggage except a briefcase, no clothes except for what he's wearing on his back. 

Unable to hook up in Greenland, he follows O'Connell to Iceland, and on to ungoverned Afghanistan in the high Himalayas, where he stumbles upon him, photographing the elusive snow leopard. O'Connell explains the negative was in a wallet he sent Mitty as a gift. Ironically, the negative was in Mitty's possession all the time, but he was so focused on where it ought to be he couldn't consider where it might be.

O'Connell thought he was being "playful," assuming his partner would get the joke. Mitty saw it differently. Sixteen years and millions of negatives made him good at his job but lousy at spontaneity. In the course of things, he'd forgotten how to play. He's not alone; a lot of us are like that. The pressures of life and work build until we take everything so seriously. We turn to alcohol or drugs to unwind, but they don't help, not really. They disinhibit, that's all. Play is something more basic, more in touch with what makes life worth living.

Observing O'Connell refuse to take a shot of a snow leopard because the moment itself is too precious, Mitty realizes some things are too special to be captured. They can only be experienced. Moments later, playing soccer with a group of young Sherpas, he learns that play and transcendence are linked, and both can find expression in the work we do. Mitty knew all about work. What he needed to learn was how to play once again.

On returning to New York, Mitty confronts the arrogant narcissist in a way that, unlike his earlier fantasies, doesn't involve physical violence. Having rediscovered himself in O'Connell's company, he is able to speak as a mature man with a secure and certain center, to a spoiled and self-centered child. No longer fearful and timid, being with the archetypal "wild man" has changed him. He commands respect and his words carry weight. 

Does Mitty ever get the girl? You have to see the film to find out. Sorry, I'm only willing to leak so much. Besides, you do want to see why that bloody negative was so important, right? Most of all, The Secret Life of Walter Mitty is worth seeing for a contemporary glimpse at the ultimately spiritual journey to earn and achieve maturity, to become confident, to feel truly capable as a human being. It's a study in contrasts, too, between Mitty, who is willing to undertake the journey, and an arrogant narcissist who for all his posturing, has not and probably never will. 

(Creative Commons image by Sheng Wang via Flickr)

Sunday, May 18, 2014

Narcissist or Antisocial?

Following-up on my last post, "Mirror, Mirror," a reader wrote and asked if I might address Antisocial Personality Disorder in contrast to pathological narcissism. There was a time when I thought doing so was pretty straightforward since antisocial personality disorder was usually associated with a criminal history. I've since realized that's too simple because narcissists who become violent can end up with criminal records and antisocial types can be attractive and charismatic in the same way we usually think of narcissists. 

The picture becomes even more complicated when you think about other features they may have in common. For instance, both are well-known for being manipulative, self-centered, and resistant to feelings of guilt and remorse or responsibility for the damage they cause. "Lack of empathy" is how we describe this professionally, but in simpler terms, it means they can't imagine how it feels to be on the receiving end of their behavior. If a person's ability to empathize is impaired, they tend to act without considering the impact of their actions on others. The way this is expressed gives us an idea about how the narcissist and antisocial type differ.

Despite their belief that they are independent and need no one, narcissists really are very dependent upon others. The arrogant type needs admirers and the covert type, someone to use as a resource for self-esteem. As a consequence, in the initial stages of forming relationships, these individuals are seductive, conveying the image of the perfect friend,  colleague, or significant other. What they want is something else. Like the vampire's victim who willingly exposes her neck again and again, they want your trust, availability, and eager compliance. Only when you've been finally worn out, do they toss you aside like a wrinkled, faded newspaper.

Antisocial types can be seductive, too, but their goal is to obtain something specific and move on. Once they have it -- your money, property, virginity -- the relationship is over. You could say the narcissist invests for the long-term and the antisocial for short-term, immediate gains. A classic example is the retirement scheme that drains seniors of their financial resources, operated by the "pleasant young man who was so eager to help" and has skipped town with the money. Antisocial types consider people too much trouble to spend a great deal of time on them -- it's what you have that they find interesting. Narcissists want you and that's why they are so appealing.

Notice how both types can use people freely without the inconvenient interference of Freud's Super-Ego or conscience. Covert narcissists may be vaguely aware that others consider their behavior wrong or hurtful, but ultimately, how others feel doesn't matter to them. Arrogant narcissists and antisocial types simply don't take morality or conscience into account; they are ruled by pure self-interest. 

All three types are inclined to excuse their behavior on various grounds and criticize their victims for any negative consequences. Instead of internalizing blame and feeling guilty or ashamed, like most of us, they externalize these feelings and try to make it sound as though you're the one with the problem.  Techniques like "gaslighting," making up information in order to prompt a victim to doubt their perceptions or sanity, are commonly used to cover their true intentions. The antisocial type doesn't care whether their behavior violates the law; the idea may even be exciting to them. Arrogant narcissists can't imagine being held responsible for their actions since their natural superiority places them above culpability. Covert narcissists are convinced no one would even consider thinking of them as blameworthy in the first place. 

The reason covert narcissists feel immune to blame is due to their adeptness at creating a facade of innocence and using it to conceal their ulterior motives. Many find it hard to believe such a sweet, caring and ethical person could be deliberately deceptive. And, of course, this is precisely what the covert type is counting on. Their carefully-crafted, false persona enables them to operate surreptitiously, sometimes going undetected for years. Publicly, they don't wish to appear bothersome; privately, they are extremely high maintenance, intentionally draining others of their energy and well-being. 

In a sense, antisocial and narcissist exist on a continuum with the antisocial type lying more towards the asocial extreme and arrogant narcissists on the extroverted, social end. More introverted, yet also socially-oriented, the covert narcissist lies somewhere toward the middle. All of them exhibit an absence of regard for the thoughts, feelings, and values of others. All of them find it easy to lie and all of them are predatory to some degree. 

Predatory is a strong word but it gets to the heart of the matter. The individuals we've been describing are serial users. Whether they appear innocently grandiose or intentionally deceptive, they view others as resources, as means to an end. Adulation is just as important to an arrogant narcissist as ill-gotten gain to a criminal antisocial type. A covert narcissist plans his emotional ambush as carefully as a master thief. To them, the rest of us are sheep waiting to be sheared or resources waiting to be tapped. That we might be anything else never crosses their minds.   

(Creative Commons Image of Narcissus by Tiago Costa Nepomuceno via Flickr)

Enhanced by Zemanta

Thursday, May 15, 2014

Mirror, Mirror, On the Wall

Bond:  "You're cleverer than you look."
Q:  "Mm, still, better than looking cleverer than you are." ~ Die Another Day (2002)

As most readers already know, I'm a fan of 007. For several years, Timothy Dalton was my favorite -- he possessed a certain darkness that rendered the "killer" aspect of Bond's character believable. Well, move over, Timothy, Daniel Craig does it even better and with a conscience thrown in for good measure (Skyfall, 2013). I like that best of all: Bond is capable of empathy, he is not a narcissist.

He is brutally honest; he's willing to do pretty much whatever he has to in order to get the job done, but looking clever means nothing to him if it's not real. Were he a narcissist, on the other hand, looking clever would be everything. Furthermore, he would think himself exceedingly clever, even though he was not. It's difficult for me to imagine Bond gazing dreamily at himself in a mirror and saying, "Mirror, mirror, on the wall, who's the cleverest of them all?" He hasn't got time for such nonsense; a narcissist has nothing but time for it.

That's one of the many problems with narcissists: they believe their own press. They think they're far more intelligent than the rest of us, true or not. They're wise, we're foolish, they're cosmopolitan or sophisticated, we're naive or impressionable. If a narcissist appears to admire someone, it's because they covet what the other possesses. Admiration is a cover for competition and narcissists are poor losers. 

Ironically, the narcissist's intelligence tends to be less lofty than they'd have us believe. Engage them in a discussion and you'll discover their knowledge base frequently represents a collection of disconnected assumptions and quotes selected from sources they consider influential. Original thinking is not their strong suit. They're like Mockingbirds, whose song is a chaotic repetition of all the other birds in the sky. What matters is not what they think but how impressive they sound, citing statistics and references, and leaving you breathless in their presence. At least this is the case for the arrogant-type narcissist.

Covert narcissists are less willing to risk their fragile self-esteem by trying to impress you with how much they know. Instead, they prefer to listen, treating you like an amazing conversationalist who has them hanging on every word. In the process of winning your trust, they're actually searching for those points at which you are most vulnerable. The time will come when they'll use those points to your detriment, revealing themselves to have been a cunning adversary clad in the guise of a friend. 

It probably sounds terribly unfair, if not unkind, to draw attention to the predatorial aspect of pathological narcissism, but it's necessary in the same way we have to recognize the killer aspect of the James Bond character. The difference lies in the fact that Bond doesn't kill indiscriminately. He's not a cold-blooded murderer despite the numerous notches he might carve into the handle of his Walther PPK. He only shoots (or stabs or drowns or blows up) those who have it coming. There's either justice or necessity in his sights.

Narcissists are rather indiscriminate. Anyone is a good enough target if they're vulnerable and nearly all of us are, to some extent or another. Narcissists wish to demonstrate their self-assumed superiority and doing so is their ultimate value. We are either their privileged audience or an unwitting resource for supporting their self-esteem. We are never individuals worthy of respect and dignity. We are things and for a narcissist, one thing is as good as another, as long as our life blood lasts and we don't realize what's happening to us.

Prevention is the best defense and discovery our key strategy. Learning to recognize the wolf in sheep's clothing is hardly a waste of time. You can't avoid a predator if you don't know what one looks like or how s/he behaves. My four-footed neighbor, Freddy the Porcupine, has only one natural enemy, but you can be certain he knows who that is and how to steer clear of his habitats. In the same way, learning how to identify pathological narcissism and its practitioners is the way we sidestep being reduced to the level of "things" and retain our humanity. Trust me, this is definitely worth the effort.     

(Creative Commons image of Bond and Q by Andrew Becraft via Flickr)
Related Posts Plugin for WordPress, Blogger...