EQUANIMITY

(Published in the December 2008 edition of the East Bay Psychiatric Association Newsletter)


I am one of those political junkies who read hundreds of editorials, opinion pieces, and blogs during the presidential campaign this year. Every day I would find points of view from the entire political spectrum expounding on all conceivable perspectives of the campaign and the personalities involved. It didn’t matter what your opinion was about anything—you could find support for it as well as an argument against it every single day.

After all is said and done, however, I have concluded that there was one factor above all others that led to President-elect Obama’s victory. And that factor had nothing to do with his positions on the economy, the war, his running mate’s personality, or what his racial background is. It was Barack Obama’s equanimity—his calmness and emotional cool—that carried the day. Whether during the debates or when his opponents were throwing political attacks or smears at him on the campaign trail, he never exhibited undue anger. He remained calm in every storm, stepping back and discussing what was happening, rather than reacting emotionally.

It is this precise quality of equanimity that we psychiatrists attempt to instill in our patients. We do this in several ways--by modeling such behavior, by helping our patients cognitively reframe their emotional reactions, and through the use of particular medications such as SSRI’s.

In politics, people have to find you likeable in order to vote for you. If a candidate projects irritability, anger, frustration, or annoyance, people will identify with those feelings (projective identification) and begin to feel emotionally uncomfortable themselves. But if a candidate projects equanimity, then the listener feels calmer and more reassured and is more likely to overlook differences in political positions and trust the candidate.

The temperamental quality of equanimity is not only optimal for politicians, but for almost anyone else as well. People with equanimity tolerate disagreement, personal criticism, and conflict without becoming unglued. In Obama’s case, now in this post election period, he even seems comfortable appointing people who were at odds with him during the campaign. He doesn’t appear to hold grudges or be vindictive—he seems to be able to keep his eye on the bigger picture of what he wants to accomplish politically.

If as an employer or manager you want someone to work hard for you and be loyal, then you praise that person when he succeeds, and you moderate and contain your anger toward him when he errs. That is the way to obtain devotion and hard work from your subordinates in any of life’s endeavors.

Developing increased equanimity may be the best investment any of us can make in these difficult economic times. It’s a no risk venture, won’t lose value over time, and will likely pay increased dividends for the rest of one’s life.

MIND FIELDS: Stories From the Other Side of the Couch
(ISBN 978-0-9745540-2-0)

Published by Big Hat Press, Lafayette, California, 2008

(Below is the Forward from the above entitled book of 9 psychiatric short stories):

The short story is a literary genre that has always appealed to me. I suppose this is so because in a single sitting I can complete the reading and feel the satisfaction of coming to the conclusion. I remember as a schoolboy reading O. Henry or Hans Christian Andersen or Grimm’s Fairy Tales and enjoying what I had read because of their brevity and quick resolution. I can remember also the appeal of certain novelists like Thomas Hardy, who held my interest over a longer period of time, and feeling disappointed when my relationship with his characters had ended. But Hardy was the exception for me, and too often I would find myself growing impatient with novelists and their protracted stories, and my interest would wane before I had completed the book.

The short story developed as a distinct literary genre in the 19th century beginning with Edgar Allan Poe. It is defined as a brief fictional narrative, usually between 500 and 10,000 words. For me, a short story connotes something akin to a bedtime story or perhaps a tale or fable briefly related orally from one person to another. The climax lurks right around the corner. There is some suspense, but that suspense is short lived. The conclusion is often ironic, leading to a sense of surprise. Typically, the central character has a problem that must be resolved quickly. A good short story stakes out its territory promptly, peaks the reader’s curiosity and colors in its characters swiftly, and then strikes with the climax, which often catches the reader off guard. Like a good joke, timing is crucial to the success of a short story.

Perhaps the most famous twentieth century short story writer was Nobel Laureate Isaac Bashevis Singer, whose prolific tales are published in collections that take up several volumes. Singer’s works focused primarily on Yiddish themes and were enormously popular. More recent day short story writers have also shown a knack for picking a theme and then developing a number of separate tales connected to that theme. Jhumpa Lahira, in Interpreter of Maladies, writes stories about people of Bengali heritage who have immigrated to the United States. Similarly, Joseph Epstein, in his collection Fabulous Small Jews, writes about conflicts as seen through the eyes of people who have a shared ethnicity. And Thomas McGuane (Gallatin Canyon), Annie Proulx (Close Range), and Thomas Steinbeck (Down to a Soundless Sea) each write their stories centered around a geographic local—Montana/Idaho, Wyoming, and the Big Sur areas respectively. In Steinbeck’s case, the focus that envelops his stories is not just a particular locale, but also a specific time period different from the one in which the author is living. These authors have all mastered the short story genre and were inspirational to me in writing this collection, which is my first book.

The theme that unites the stories in my collection is psychiatry. Most of the characters struggle with psychiatric conditions or defense mechanisms that shape their lives and the story. As a psychiatrist myself with 37 years of experience in the field, I have drawn on a range of specific examples from patients who have confided their struggles in me over the years. However, all of the characters in the book are entirely fictional. They are composites of many different patients’ symptoms or circumstances, as well as figments of my imagination.

While writing these stories, I found that if I allowed my characters to speak for themselves, that they went in directions that I had not anticipated and which at times surprised me. In essence, I found myself experiencing what other writers have reported, that is, I was simply “holding the pen” as the characters lived out their own lives. Nonetheless, the psychiatric problems portrayed in my stories are meant to be realistic, and in that sense I hope that they contain instructive elements as well as provide entertainment. Toward that end, I have provided a study guide in an appendix.


Hugh R. Winig, M.D.
Walnut Creek, California
May 2008

MULTIPLE LIVES

(Published in the October 2008 edition of the East Bay Psychiatric Association Newsletter)


Despite my ongoing classes in Buddhism, I do not buy the idea of “bad karma” coming from bad things one did in a past life, or “good karma” coming from good deeds one performed in a past life. This concept of “past lives” makes no connection to my rational mind and requires too great a leap of faith to appeal to me. But what I do believe is that in the course of one’s natural life span, one does experience multiple lives in the figurative, if not literal, sense.

Twenty-five years from now, assuming you are still alive, your life will be filled with memories of the next 25 years—events that have not yet happened, so you cannot possibly know them. And your current memories of the things that are now fresh in your mind will have faded. One’s psyche will be extremely different 25 years hence from what it is now, and you may discover that your future self will be somewhat unrecognizable to you. Similarly, think back 25 years, or 50 years, and imagine the child you once were, or the developing young adult you may have been. Surely you see yourself today as someone vastly different.

So regardless of any religious bent, it might be fair to say that in the course of a normal lifetime, one experiences multiple lives—not discreet in nature, but vastly different nonetheless. The youngster, the teenager, the young adult, the mid-lifer, the retiree, and the very aged individual may have existed in the same body and have had the same brain, but all of the molecules in that body have turned over and been renewed many times, and the new experiences one has had during a lifetime have changed that person in many ways.

These multiple lives that we experience blend imperceptively into each other and do not occur in quantum leaps. Hormonal and other physiologic factors play a role in the normal aging process. But as psychiatrists, we know also of the psychological impact of traumas and losses on the one hand, or healthy relationships that provide for corrective emotional experiences on the other—it is not just physical change that is part of growing older.

Healthy aging is the subject for another essay, but the reality of change itself, both good and bad, is inevitable, relentless, and universal. We do what we can to transition from stage to stage successfully, but change will occur no matter what. When one looks back on life from the vantage point of 8 or 9 decades, one will view a life cycle that consisted of multiple lives that you may not have been mindful of while living them. It is then that people opine such things as “I should have had more fun,” or “I should have invested differently.”

I have learned through Buddhist meditative techniques to be as mindful as I can be of the moment I am living in and to take advantage of the present to absorb the wonder of simply being alive. While I do not know what my future will bring, I do know that if I live long enough, I will be very different than I am now. The awareness and wonder of that alone is part of the mystery of life that makes us human beings.

POLITICS and RELIGION

(Published in the September 2008 edition of the East Bay Psychiatric Newsletter)

A few years ago I took a class taught by fellow psychiatrist Thomas Lewis entitled “The Neurobiology of Emotions.” It was a fascinating look at how biology regulates our feelings. One of Dr. Lewis’s insights was “it doesn’t do any good to discuss politics because people’s positions are usually hard-wired and not subject to revision. Any such discussion will likely lead nowhere.” This advice is similar to the adage: “Discuss politics and religion, but only with great caution.”

Unfortunately, two of the most critical and important issues for people to talk about are politics and religion. These subjects encompass a mass of theory, thought, and understanding about how societies function. But if one cannot alter one’s notions within these two areas of thought, we are doomed simply to follow our hard-wired beliefs over a cliff, regardless of what new facts may arise. For example, history is replete with examples of those willing to kill themselves and others because of fundamentalist political or religious beliefs. Similarly, despite the enormous volume of modern scientific data explaining the mystery of evolution, the religious belief in creationism persists.

According to Jonathan Haidt, we are not a tabula rasa when we are born. Rather we have a “first draft” of moral intuitions already inborn within our minds. For liberal thinkers this means having moral values that relate more so to concern for doing no harm and for fairness. For conservative political thinkers, this means being biologically predisposed to valuing authority, purity, and group loyalty. Liberals value change and different points of view; conservatives prefer sameness and uniformity of thought within the group. While some cultural learning can modify these inherent moral intuitions, most people’s political and moral beliefs are too hard-wired to be easily influenced by facts that don’t support their preconceived views.

When I was actively practicing forensic psychiatry, I discovered that the outcome of a criminal trial was often determined at the time the jury was selected. The reason for this is that if the legal issues are subsequently argued equally forcefully on both sides, jurors will hear enough of an argument to support their inherent biases and vote for conviction or acquittal based of their preconceptions. Their view of right and wrong is something they carry with them into the jury room before the trial starts.

While it is true that educated people can honestly differ in their subjective assessment of the same facts, there is a limit to subjectivity. The gender of a mouse whose external genitalia are not visible might be ambiguous, but the accurate gender cannot be determined by a simple majority vote of casual observers. A scientific inquiry must be undertaken to determine the facts. Believing is one thing but factual data is quite another or we would simply have the “tyranny of the majority.”

It seems that during this current political campaign that people selectively hear what they want to hear. People believe what they believe based on their genetically determined moral intuitions, regardless of the facts. It is the wise man or woman, indeed, who can step out of his intuitive moral framework and see the other person’s point of view as also valid, but in the meantime it would seem important to “discuss politics and religion, but only with great caution.”

CHAN (ZEN) BUDDHISM and NIRVANA

(Published in the August 2008 edition of the Easy Bay Psychiatric Association Newsletter)


Back in 1970 when I was starting my psychiatric residency, our department chairman, Albert Stunkard, mentioned that he thought that Zen Buddhism was a powerful psychotherapeutic tool. My group of eleven fellow residents looked at each other quizzically and gave the comment little attention. We were far more focused on learning about the established schools of psychotherapy and the basics of psychopharmacology. Why would a psychiatric resident be interested in some Eastern religion? It wasn’t until this year when I began studying Zen that I thought about Dr. Stunkard’s past comment—and now I know what he was talking about.

Chan Buddhism and Zen Buddhism are the same thing—the former is the original Chinese sect, and the latter the word used by the Japanese who studied under the Chinese Chan masters. There is a Chan monastery nearby in Lafayette named Buddha Gate Monastery where I am taking a beginner’s class. This monastery is the only one in the country run exclusively by nuns without the help of monks.

Chan Buddhism’s religious teachings are called Dharmas, which are themselves very meaningful. But more relevant here is that Chan teaches individuals to become enlightened and self aware through meditative techniques that quiet the mind of past, present and future concerns that occupy our thoughts constantly. When our mind is quiet, we become aware of our own intrinsic nature and are more in touch with peaceful thoughts. In neurophysiologic terms, these meditative techniques attempt to quiet the left side of the brain and allow the right brain to dominate one’s perceptions. It is in the right brain where people can experience an epiphany and come to feel at one with the natural world and empathic with other sentient living beings.

Over the years, many people have argued for the legalization of various drugs that enhance these peaceful right-brained perceptions. But the drug culture has led to many casualties--people who have lost their psychological equilibrium. One needs left-brain activity as well to bring balance to our perceptions or we can lose touch with what it means to be human, live in a society, and behave appropriately.

Recently, there was a well-publicized case of a Harvard brain researcher, Jill Bolte Taylor, Ph.D., who suffered a massive left sided stroke in 1996 at age 37. She experienced what she called nirvana (a supremely tranquil state of mind) as she temporarily experienced only right-sided brain activity. She perceived herself as a living membrane filled with fluid that contained molecules and atoms that were connected to all the other molecules and atoms in the universe. She saw herself in the form of a living body that could reach out and affect the world she lived in but only during her temporary state as a human being. She felt entirely at peace, empathic, and euphoric, and could see the meaning of life and her oneness with the universe. As her stroke resolved and her left-brain healed, she returned to a state of psycho-physiological equilibrium that she understood to be her normal self that could function in the real world.

Dr. Taylor now speaks about her experience nationally (see the New York Times article about her entitled “A Superhighway to Bliss,” her You Tube interview on the Oprah show, or her memoir entitled “My Stroke of Insight”). The most fascinating aspect of Dr. Taylor’s experience is that as a result of her stroke, she achieved what the Zen Masters seek to accomplish through decades of meditation practice. They want to hold onto that blissful state of nirvana during which they transcend mundane existence and are unperturbed by anything. This is what Dr. Taylor describes more scientifically as the “deep inner peace circuitry of our right hemisphere.”

Many of the answers to the mysteries and intangible dimensions of the universe —the mystical, spiritual, or cosmic—possibly are already encoded information concealed in parts of our right brain. All religions and philosophies struggle to gain more insight into this seemingly unknowable information. Chan Buddhism appears to have some techniques to give us greater access to this realm. Most people, at a minimum, could benefit from Chan’s ability to enhance equanimity, blissful feelings, insight, and inner directedness.

If I had been more open minded and more aware of Eastern religious traditions as a first year psychiatric resident, it might not have taken me until the near end of my career to appreciate this.

LIVING SMALLER

(Published in the May 2008 East Bay Psychiatric Newsletter)


Have you noticed that the size of people, houses and cars has increased greatly over the past decade or two? My architect son, who thinks in spatial terms, commented that he sees Americans existing on a scale of 1.2:1 relative to Europeans. But now the recent economic downturn in our country has some pundits talking about a 20% chance of a depression, and others predicting the loss of value of the dollar so great that the U.S. economy will eventually resemble an emerging market country. Maybe it’s time we all started living smaller.

This economic downturn, with the certainty of less buying power for most people, got me thinking about the things that are important in life that money can’t buy. Many of my patients who are under emotional stress can benefit from clarification of their values so that they don’t simply expend all their time on the treadmill of earning money and spending money, with no chance to actually find meaning, purpose, and pleasure in their lives.

How one manages money seems to correlate with stress. One patient of mine who was earning $300,000 a year between himself and his wife, complained, “we can’t make ends meet.” I asked him what kind of car he owned, and he answered, “A Lexus SUV.” I then asked him how often he drove his SUV off road, and he answered, “Why would I take it off road?” I proceeded to point out that he had purchased a $45,000 car that was engineered for off road driving, when he could have bought a car for half that amount to accomplish what he wanted from a vehicle. Regardless of how much money you earn, if you spend beyond your means, you can feel poor.

In an attempt at clarity, I have made a partial list of things that I suggest are important toward fulfillment and satisfaction, followed by a list of things not so essential. When measuring the importance of these, it is helpful to distinguish between what would bring you happiness (a long-term emotional state), versus what simply is fun (a short term emotional state). Some are expensive and need to be budgeted for, others are free of cost.

Important:

1) A lot of laughter
2) Freedom
3) A support system of family, colleagues, and friends
4) Accessibility to the natural world for pleasure, exercise, and spiritual awareness
5) Reasonable quality food, clothing, and shelter
6) An intellectual life, including access to good books
7) A cultural life, including access to good music and the arts
8) A recreational life including exercise
9) A spiritual life
10) Adequate leisure time to reflect, read, and relax
11) Some travel and entertainment
12) Meaningful, satisfying work
13) Good health with access to quality medical care
14) A safe, quiet neighborhood to live in
15) Access to information and knowledge

Not so important:

1) A luxury car
2) An elaborate house
3) Fancy furniture
4) Gourmet food and wine
5) Expensive jewelry
6) An expensive wardrobe of brand name clothes
7) Electrical appliances of all sorts
8) Technological gadgetry
9) Recreational vehicles

A financial counselor, when asked by his client whether he could afford to retire yet, said: “It depends on what you want to do when you retire. If you want to play golf every day you will need more money than if you want to play bridge every day.”

It seems important to go through some clarification of values from time to time. Overworked, heavily indebted people encounter more emotional problems, more marital conflict, more problems with their children who may feel neglected, and a greater sense of frustration and dissatisfaction that can lead to problems with physical health.

One definition of being rich is to feel satisfied with what you have. This may be one of the most important keys to happiness. If you have your values clear and your “head straight’ in this regard, you probably have all the money you need, regardless of what happens to the larger economy as the future unfurls.

SCIENCE, FAITH, OR GOOD FORTUNE?

Published in the March 2008 edition of the East Bay Psychiatric Newsletter


I take a bunch of pills every day—ten to be exact. But despite my scientific training and “prove it” attitude when it comes to most things, seven of these ten pills are non-proven, over-the-counter nutritional supplements that I take mostly as a matter of faith. You won’t find me acting this way in other areas of my life, so why do I behave this way is this particular area?

The simple answer is that when it comes to my health, I’ll do just about anything to improve my odds of remaining well and lengthening my life. Scientific evidence seems less important when non-toxic supplements like a high potency multivitamin, glucosamine, folic acid, vitamin C, selenium, omega-3 fatty acids, and vitamin E are concerned. And I haven’t even mentioned the Echinacea tea and other herbal teas I drink routinely to “boost one’s immune system and add anti-oxidants to prevent aging of cells.” I have fallen prey to the poorly documented claims that if I take these remedies I will delay the onset of Alzheimer’s disease, ward off colds, keep my knees and varicose veins from worsening, improve my cardiovascular status, and maybe even live longer.

There is some documentation for these claims from the multi-billion dollar nutritional supplement industry, but for the most part it is anecdotal and has not been subjected to the rigorous double blind studies that I would normally demand. Studies that would definitively demonstrate value or lack thereof for some of these substances could take decades to complete. They may even be too costly or cumbersome to undertake at all. At age 64, I do not have 20 years to learn that it might have been helpful to take some of these supplements for the prior 20 years. By then it will be too late for me, so I have to proceed now on sparse evidence and hope.

I am not looking for the fountain of youth. My hope is an ordinary one--to live to a ripe old age without being afflicted by the physical infirmities or serious decline in cognitive functioning that so many people suffer from in their last years. One of my patients recently told me that her 96-year-old father simply “stopped.” He went to bed one night saying he felt over-tired, woke up the next day not feeling well, held his 94 year old wife’s hand during breakfast, and then died right there sitting at the kitchen table. He had experienced no serious physical decline, no major illness, and no loss of mental acuity. I asked my patient if I could sign up for the same end-of-life contract her father had arranged for himself, and she and I smiled, knowing it doesn’t get any better than that.

To the Editor:

(Published in The New York Times, February 1, 2008)

Re: "The Kennedy Mystique"--op-ed by David Brooks, January 29, 2008

If you were a college student in the early 1960's, as I
was, you know exactly what Mr. Brooks is talking about in
his op-ed regarding the inspirational leadership that Senator
Edward M. Kennedy and so many others have come to recognize
in Barack Obama. I read this essay 3 times before I could read
any other, because it transported me back forty-five years.

It has been that long since I have felt hopeful and energized
about our politicians and about our nation. I hope that
enough people recognize the potential greatness of this
young leader so that he is the one giving the next State of
the Union address.

DIVERSITY

(Published in the East Bay Psychiatric Association Newsletter, February 2008)


When I went to college back in the early 1960’s, my sixteen hundred classmates included only a handful of African-Americans and about the same number of students of Asian ancestry. There was also a sprinkling of foreign students, mostly from prominent, well-to-do families. And, oh yes, there were no women in the class. My college had a sister school which allowed the women to attend the same classes, but the women lived in dormitories at some distance from the men’s living quarters, and they were not allowed to study in our main library or eat in our dining halls.

Almost all of my classmates were white, male, urban, and middle class or above socio-economically. The major points of diversity back then were whether one had gone to public school or to “prep” school, and whether you came from a different part of the country. Beyond that, one didn’t talk much about diversity. In fact, there was some comfort in knowing that most of one’s classmates came from similar backgrounds. Recently, as you will read below, it has become clearer how diversity is advantageous.

Since that era, there has been an enormous amount of effort expended on seeking diversity in universities and in the workplace. Some of this has been driven by the social policy of affirmative action for minorities and disadvantaged populations. Most colleges now also include significant numbers of students from other parts of the globe. And, of course, women not only make up half of the student bodies of what used to be all male colleges, but these gender-equal student bodies now live together and interact in all manners. So much for my college bygone era of homogeneity of the 1960’s!

Now there is new evidence that increasing diversity has been for the good, but for reasons different from what was originally envisioned as simply opening doors for groups previously marginalized. It now appears that there is an inherent advantage that flows from mixing people of different backgrounds when it comes to problem solving.

Professor Scott Page of the University of Michigan has published a book entitled “The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies.” His main finding, using mathematical modeling and case studies, is that “diverse groups of people bring to organizations more and different ways of seeing a problem, and thus faster/better ways of solving it.” Professor Page explains that in today’s world of complex problems, organizations where everyone thinks in the same way lead people to get stuck at the same point. But in diverse groups, people get stuck at different points in a problem, and thus collaboratively arrive at better, faster decisions. In fact, Professor Page found that the most diverse companies are the most innovative. Furthermore, breakthroughs in science increasingly come from teams of bright, diverse people, which is why interdisciplinary work is the biggest trend in scientific work today.

Regardless of one’s political persuasion, socio-economic background, nationality, place of residence, or gender, this new information can help one shape conclusions about social policies as varied as affirmative action, immigration, hiring practices, and college admissions.

No one person can design a rocket ship to get people into outer space, or construct a silicon microchip to run computers. People have to work as teams to accomplish such complex feats, and diversity in groups offers advantages in solving complex problems. It’s a big, interesting, globally diverse world out there, and if our schools, companies, and nation are to continue to be at the forefront of innovation, we had better heed this knowledge while going forward.