That way madness lies

To portray something -to make it believable- there has to be at least some understanding by the audience of what is being portrayed. Much in the sense, I suppose, that was suggested in the 1974 paper in The Philosophical Review by the American philosopher Thomas Nagel, asking what it would be like to be a bat. Not so much how it would feel to have the added sense of sonar, or be able to fly in the dark, but more about the consciousness of itself. As Wikipedia explains Nagel’s thinking: ‘an organism has conscious mental states, “if and only if there is something that it is like to be that organism—something it is like for the organism to be itself.”

This is a roundabout way of wondering whether an audience could ever know if an actor is representing something realistically if they cannot imagine what it would be like to be that thing.

Mental illness seems as if it is sufficiently prevalent that most of us would be expected to understand whether or not the author, or the actor, has captured its essence accurately, and yet, for those of us who have not experienced the wide panoply of its manifestations -the majority of us, I suspect- we might be easily mislead. The more gripping or sensational portrayals of illness, might well come to stereotype the lot. To stigmatize the condition.

I was scrolling through the BBC Culture section when I happened upon an article that discusses some of these same issues: http://www.bbc.com/culture/story/20180828-how-cinema-stigmatises-mental-illness

‘… the film industry has generally shown a shaky vision of mental health … It’s not that cinema evades ‘taboo’ themes here; it’s more that it tends to swing wildly from sentimentality to sensationalism.’ To attract an audience -i.e. to make a profit- ‘creative drama is drawn to the complexity and fragility of the mind – but mainstream entertainment still demands a snappy fix. And the definition of ‘insanity’ is inherently problematic.’

I am reminded of the French philosopher Michel Foucault’s book Madness and Civilization -subtitled A History of Insanity in the Age of Reason. He felt that the concept of madness was evolving over time: in the Renaissance, (as a thoughtful summary in Wikipedia puts it) the mad were portrayed in art ‘as possessing a kind of wisdom – a knowledge of the limits of our world – and portrayed in literature as revealing the distinction between what men are and what they pretend to be … but the Renaissance also marked the beginning of an objective description of reason and unreason (as though seen from above) compared with the more intimate medieval descriptions from within society.’

Later, however, ‘in the mid-seventeenth century, the rational response to the mad, who until then had been consigned to society’s margins, was to separate them completely from society by confining them, along with prostitutes, vagrants, blasphemers and the like, in newly created institutions all over Europe.’ (The Great Confinement).

‘For Foucault the modern experience began at the end of the eighteenth century with the creation of places devoted solely to the confinement of the mad under the supervision of medical doctors, and these new institutions were the product of a blending of two motives: the new goal of curing the mad away from their family who could not afford the necessary care at home, and the old purpose of confining undesirables for the protection of society. These distinct purposes were lost sight of, and the institution soon came to be seen as the only place where therapeutic treatment can be administered.’

But, back to the BBC Culture depiction of the role of cinema, ‘our mainstream perceptions of ‘madness’ are still fixated with movie scenes – much more emphatically, in fact, than the novels or memoirs on which they might be based. A classic film like One Flew Over the Cuckoo’s Nest (1975) seals the impression of a soul-destroying psychiatric asylum, where livewire convict RP McMurphy (Jack Nicholson) feigns insanity to escape prison labour – yet is ultimately crushed by the system. The dramatic depiction of patient treatment, particularly its brutal electroconvulsive therapy sequences, had far-reaching impact. In 2011, The Telegraph went so far as to say that the film was responsible for “irreparably tarnishing the image of ECT…’

Unfortunately, unlike many art forms, movies usually require a conclusion, a wrapping up of the story, and a realistic depiction of mental illness may not fit into that convenient format. There may be no black or white: not all characterizations can end either pleasantly or sadly -some are palimpsests, to be sure, but many can reach no definitive conclusions that would satisfy the average moviegoer. Hence the temptation to exaggerate, or at least frighten audiences into an odd manifestation of satisfaction.

The temptation, in other words, to see mental illness as alien, separate -like a creature we could not possibly understand because it is so different. As different, perhaps, as Nagel’s bat. But is it? Or was Foucault really on to something in his analysis of the way ‘madness’ seemed to be viewed in Renaissance literature and art -a view which accepted that at least some of the vagaries, some of the stigmata of mental illness, were merely variations of mental states that any of us could exhibit at times? And indeed, that occasionally intimated unique views on a world from which we might learn some important lessons -a world, though, that we might now discard, or shun as too bizarre. Too frightening. Too… real.

On the other hand, there is a danger of romanticizing the past, of airbrushing its naïveté into soft and reassuring colours; of assuming it was what it was because it had not yet been exposed to the unforgiving exigencies of current knowledge. A time when imagination and reality were sometimes allowed to merge. Encouraged to conflate.

It’s difficult to be certain where present day arts can be placed on this spectrum of understanding mental illness -not the least because it is difficult to know where it should be placed. But, suffice it to say, the more fully the illness is portrayed in all its complexity, the more we might be able to see it as a small, but important part of the tapestry of existence -a fragment of the struggle that marks all our days. And, as for any vicissitude, where there is suffering, we must provide succour and relief, and where there is dissimilarity, offer understanding and acceptance. Tolerance. The soul, says the poet Kahlil Gibran, walks upon all paths. The soul walks not upon a line, neither does it grow like a reed. The soul unfolds itself like a lotus of countless petals.

 

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Give Sorrow Words

It is fairly intuitive to suspect that parental mental health has an effect on both infant and childhood development. Indeed there is a widespread attempt to address the issue with the use of evaluative tests such as the Edinburgh Postnatal Depression Scale to identify or even anticipate and take action to ameliorate the problem.

It was designed, of course, to deal with the disastrous effects a mother’s depression, especially a postpartum one, might have on the health of the newborn -everything from bonding, to breast milk production, to the safety of the baby itself, could be jeopardized with an untreated depression. But, aside from the obvious issues of domestic violence, the father’s mental state is seldom accorded the same vigilance -after all, he is not the one who has undergone profound physiological and hormonal alterations as the pregnancy progresses, he is not the one who has experienced the rigours of delivery, and he is certainly not the one whose hormone levels change so drastically once again in the postpartum period.

And yet, merely to assign the paternal side of the parental equation to a largely supportive role is perhaps to assume there are few mental consequences of the changes that this newly acquired responsibility entails. It is the woman who is under the watchful eye of the accoucheur, and not the partner -even if he attends most of the prenatal visits. And postpartum period is likely even more of a black-hole for partner surveillance.

But the man, too, can undergo psychological changes after the birth, as an article in the Guardian newspaper reports: https://www.theguardian.com/lifeandstyle/2017/nov/13/can-men-get-postnatal-depression

Although not adequately investigated, previous studies suggested that only  between 4-10% of men developed recognizable post-partum depressive-like symptoms, whereas a Swedish study found that ‘28% of men had symptoms that scored above mild levels of depression. Overall, 4% had moderate depression. Fewer than one in five fathers who were depressed sought help, even though a third of those had thought about harming themselves.’ The discrepancy is likely because, unless it is serious, or obvious, the men are less frequently assessed in relation to their spouses pregnancy.

But the answer might not be as easy as asking the father-to-be to fill in the Edinburgh Depression Scale like his partner. ‘The lead author of the Swedish paper, Elisa Psouni, from the department of psychology at Lund University, says the Edinburgh Postnatal Depression Scale (EPDS) used for both women and men is not so accurate in picking up depression in fathers. Her research showed higher levels of depression in dads because it added in a score more reflective of “male” symptoms of depression such as agitation, anger, irritability, working longer hours and drinking too much.

‘Depression in fathers may be rising not just because researchers are looking for it, but because more new dads are struggling. Psouni believes fathers increasingly face the same dilemmas that mothers do – including trying to combine parenthood with working. Fathers who got depressed often had external pressures, such as job issues, and if their partner was depressed, their own risk of depression doubled. Lack of sleep, having twins and conflict in the relationship can all contribute.

‘A depressed dad will play and smile less with his child. Children are deeply affected by paternal postnatal depression with studies showing poorer measures of wellbeing and more behavioural problems at the age of seven.’

I suppose we are all children of our eras, though, aren’t we. We usually see the world through societal eyes. Indeed, I wrote an essay in my weekly series about this back in 2013: https://musingsonwomenshealth.com/2013/08/09/postpartum-depression-just-words/

I was focussed, as were most obstetricians, on the mother of course, but even then I wondered about the effects of pregnancy on the dads.

*

Julie was sitting in the waiting room fussing with her new baby cradled ever so carefully in her arms. I recognized the older woman seated beside her -I’d met her mother several times before the delivery, and as a watchful guardian in the corner during the delivery- but I’d never seen Julie without her husband, Andrew. He’d come to every prenatal visit, and had hovered over her like a tent during her entire labour -at least those times when I was present, anyway.

They were a team, and as inseparable as a shirt from its tie -too inseparable, I sometimes thought. Each decision she had to make throughout the pregnancy -everything from prenatal supplements, types of analgesia in labour, to when to cut the umbilical cord after birth- was made after lengthy consultation between the two of them. She never seemed to be given the option of deciding for herself and yet she seemed to welcome his input. She basked in his concern; she waded in his eyes.

That day, I remember she insisted her mother stay in the waiting room with the baby while she had her routine post-partum check; it seemed a little unusual.

“You’re looking a bit tired, Julie,” I said, when I had finished my post-partum examination.

She nodded pleasantly, but she looked preoccupied. I assumed it was the usual new-mother state, though, and I was happy that her mother had agreed to stay with them for a while.

“Where’s Andrew,” I asked, more to change the subject than out of curiosity.

Her eyes suddenly surfaced from her lap and flew to my face. “Andrew?” she replied, a little too quickly, I thought. “Oh, he’s… at home…”

But there was hesitation in her answer -as if I was being invited to question her some more. “At home…?” I asked, gently. I could see some tears beginning to well up in her eyes. “Is he okay…?”

She sighed and fixed me with a melancholy shrug. “He’s been stressed a lot at work, I guess -he’s taken some time off…”

I leaned forward a bit on my desk to show her I was listening and her face collapsed.

“Soon after we got home with the baby, he began sitting around pretending to read, but he never turned the page. He didn’t want to go for walks with us, and he only played with his food… He started to argue…” She closed her eyes for a moment before resuming. “And even the baby didn’t seem to interest him anymore…” She stared out the window behind my desk, obviously uncertain how to proceed. I offered her some tissue from the box I keep on the desk and she wiped her cheeks. “He said he was afraid of hurting her…” she blurted out, uncoaxed.

Suddenly, she stared at me. “Can you imagine -he was afraid of hurting his own daughter..!”

I must have looked concerned, because she quickly sat back in her chair and almost smiled. “Yes,” she said, as if trying to reassure me. “I realized he was depressed -I’m a nurse, remember- so both of us went to his doctor a week or so ago. He was referred immediately to a specialist who put him on medications as well as enrolled him in some counselling sessions.” Just getting it off her chest seemed therapeutic, and the shadows of a tiny smile began to surface on her lips.

But nonetheless, she looked uncertain, and also perhaps a little bemused. “I didn’t think men could get post-partum depression, doctor.”

I smiled and relaxed in my chair while I riffled through my head for an explanation. “A new baby changes things for both of you, don’t you think? Only, he just doesn’t have the same hormones, Julie…” I added, not certain what more I could say about it.

She actually chuckled at the thought. “Damn! I was hoping you’d tell me he could do some of the nighttime breast feeding…”

 

 

Death, Thou shalt Die

Just when you think that Age has afforded you a full panoply of experience, another one comes along that you are forced to fit into the bookcase. It may be sufficiently unique as to require an entirely new shelf, but more likely, it will be something so obvious that you’re embarrassed you hadn’t thought of it before, and can squeeze it in beside another thing you’ve already read.

The internet does stuff like that -to me anyway. Permutations and combinations of issues I had always believed were immutably fixed in time and space unravel at warp speed making me question the wisdom of any assumptions it was thought safe to trust when I was growing up.

Like Death, for example. It used to be that after someone died, all that remained were memories, and perhaps a few of their possessions. ‘Dead and gone’ was a relatively intuitive reality in those days; ‘Dead and present’ was an oxymoron. Now, most of us have digital feet that continue to walk the screen no matter our corporeal substance. And, apart from the nuisance algorithms that track me from app to app, I had not given those footfalls much thought -until, that is, I came across an article in the Conversation on digital grieving by Jo Bell, Senior Lecturer, Faculty of Health Sciences, University of Hull: https://theconversation.com/how-the-internet-is-changing-the-way-we-grieve-100134

She writes that ‘These days the dead are now forever present online and digital encounters with someone who has passed away are becoming a common experience. […] Each one of us has a digital footprint – the accumulation of our online activity that chronicles a life lived online through blogs, pictures, games, web sites, networks, shared stories and experiences. When a person dies, their “virtual selves” remain out there for people to see and interact with. These virtual selves exist in the same online spaces that many people use every day.’

When I first thought about this -the idea of inadvertently coming across someone, or something from whoever had died- I worried about the effect, and how I would react. But, as the author reports, ‘Yet for some, these spaces have become a valuable tool – especially so for the bereaved. An emerging body of research is now looking at the ways the internet, including social media and memorial websites, are enabling new ways of grieving – that transcend traditional notions of “letting go” and “moving on”.’

I was, of course, aware of the concept and probable value of memorials, but I have to confess that I hadn’t thought of them in terms of lasting online tributes. To be sure, I was weaned in another epoch when, apart from an obituary notice in the local paper, or flowers on a tombstone, there were precious few options to show that you remembered someone. But, of course, people today use the modalities they are used to.

Suicide is a devastating act, not only for the victim, but especially for those who are left behind. It makes sense that the friends would need to process the act as best they could. ‘For many mourners, the most important motivating factor seems to be the need to stay connected to the deceased and to “keep them alive”. And keeping a Facebook page going by actively maintaining the “in life” profile of the deceased, or creating a new “in memorial” profile, allows users to send private or public messages to the deceased and to publicly express their grief. […] The use of social media in this way goes some way towards answering the question of where to put one’s feelings – such as love, grief, guilt – after a death. And many people turn to the same sites to promote awareness raising and fund raising for various charities in memory of their loved ones.’

‘Unlike sentimental objects, social media pages and online spaces allow people to explore grief with others from the comfort of their own home. Talking to people online can also help to free up some of the inhibitions that are otherwise felt when talking about loss – it enables forms of uncensored self-expression that are not comparable with face-to-face conversations.’ Indeed, as they evolve, perhaps ‘online memorial sites and social networking spaces help the bereaved to see how events in the past can continue to have value and meaning in the present and the future.’

I was sitting in a dark corner of my usual Starbucks a few weeks ago thinking more of shadows than of death, when a couple of middle aged women sat down at the next table. Normally, I wouldn’t have paid them much heed, but one of them, a rather buxom lady was wearing a loose white turtle neck sweater that kept snagging one of her hoop earrings. Still waiting for my sausage-and-egg breakfast sandwich to cool, I have to admit I was searching for a divertissement, and her ear seemed as good as any.

‘I visited Krissy again today, Helen,” she said matter-of-factly to her similarly attired and equally Rubenesque friend.

Helen looked up from her still steaming espresso macchiato “That’s nice, dear. Anything new?”

Her friend shrugged and cuddled her cinnamon dolce latte in two serviettes folded to dissipate the heat, I suppose. “Well, a few others must have visited her earlier, because I saw some collars, and a milk bone…”

Helen nodded, but she sat back a little in her chair and left the macchiato to cool in front of her. I could see her staring at her friend, even in the dim light. “Julie, it’s been, what, two months since…”

“Seventy-eight days,” Julie interrupted her with an intensity that made me wonder if her latte had just burned through the napkins.

Helen nodded sympathetically and reached over the table to stroke Julie’s free hand. “I know dear… but…”

“But Krissy loves the attention, don’t you think?” Julie sighed at the thought.

“Loved, Julie. Loved…” Helen corrected her gently, and I could see her begin to stroke her friend’s wrist.

Julie’s face suddenly winced as her earring grappled with her sweater once again.

Helen seemed to think it was more than a simple entanglement. “There comes a time when you have to let her pass, dear,” she said, and squeezed Julie’s hand before letting it go.

“You mean take it down, don’t you…?” There was a look of desperation in Julie’s eyes, although in the shadows it was difficult to be sure. “But people are still leaving bones…” She was almost pleading now.

Helen smiled and reached across the table again, but Julie was already standing up.

“I… I need some air, Helen,” she said stiffly and began to walk away.

Helen shook her head slowly, gulped down her macchiato, and rose to follow her out of the door.

My breakfast sandwich seemed pleasantly warm in the sudden silence, so I took an experimental bite and sat back in my chair to enjoy it. For some things, I realized as I chewed contentedly, memory is enough. I felt no need to Facebook the disappearing sausage and egg…

 

 

 

 

The Mom and Pop Team

From time to time, I think we all need reassurance that we matter. That our seat at the game has not been taken by someone else. Could not be taken… Maybe that’s why we’re given names -so there’s no mistake. And if we’re not there all the time, it’s only because we sometimes have other duties to perform.

In many species, the male role in procreation can seem like that, I suppose: a postal service that’s only charged with delivering letters, not reading them, not dealing with the contents. At least that’s how it looks from across the street. On closer inspection, though, it would seem that the delivered mail is far more complex than it first appeared. It’s almost as if whoever reads the letter not only sees the blueprint, and the construction manual, but much like reading a newspaper, also learns of other important things which, at first glance seemed unrelated, but in the end, profoundly affect the building.

These processes would obviously be difficult to study in humans, so often we have to model them in other species and extrapolate the results to our own kind. Two articles in the Smithsonian magazine outline some of this information.

There are at least two time frames when the male influence on the resulting offspring was unsuspected: before conception -in fact, even before meeting his potential mate- and during growth and development of the fetus, and even its neonatal care. The how is interesting, but equally so is the why, I think.

First, let’s consider the production of sperm in isolation from its immediate need. https://www.smithsonianmag.com/science-nature/dads-pass-more-genetics-their-sperm-180969760

Sperm are produced in the testes, and then travel to a storage area via the epididymis -a long, wriggly 6 meter long tube in the human. It’s in the epididymis that the sperm mature and become motile. ‘As sperm traverse the male reproductive system, they jettison and acquire non-genetic cargo that fundamentally alters sperm before ejaculation. These modifications not only communicate the father’s current state of wellbeing, but can also have drastic consequences on the viability of future offspring.’ Sperm contain genes, of course, but simply having the instructions doesn’t mean they will be carried out. Genes can be turned on, off, or down, by other mechanisms –epigenetics. ‘One of the most powerful members of the epigenetic toolkit is a class of molecules called small RNAs. Small RNAs can conceal genetic information from the cellular machinery that carries out their instructions, effectively ghosting genes out of existence.’ The father’s previous diet, stress levels, and so forth can all have an effect on these small RNAs, and the small RNAs are in turn shed or reacquired as the sperm continue their journeys along the epididymis.

And then, as I mentioned, there is an effect on the developing embryo whether or not the male is actively involved with the female during her gestation or in the subsequent rearing of their offspring. https://www.smithsonianmag.com/science-nature/how-dads-genes-can-prepare-mom-parenthood-180969793  Although the data is from mice, it turns out that ‘The paternal genes a fetus carries can impact the maternal brain during pregnancy, priming her to allocate more or less of her time to tending to her kids.’

‘A child that procures as many nutrients as possible from mom can secure a father’s lineage at no cost to him—but a mother still needs to prioritize her own wellbeing during pregnancy and early childcare.

‘This sexual conflict is well exemplified by a gene called Igf2, which drives the rapid growth of fetal cells. Like most of our genetic material, Igf2 is inherited in pairs—one copy from mom and one copy from dad. But in contrast to other genes, only the version from dad gets put to work. The Igf2 from mom, on the other hand, is stifled through a chemical modification that acts like a muffler on an engine. Mom’s Igf2 DNA undergoes no changes—but the gene’s instructions can no longer be heard over the din of the cellular milieu. […] If an error occurs that also switches on the mother’s copy of Igf2, the baby quickly balloons in size. This could be good news for dad—a big baby is more likely to survive—but mom can get in serious trouble if she has to carry and birth an unmanageably large fetus.

‘To guard against this possibility, females have developed their own failsafe: another gene called Igf2r. The “r” stands for “receptor”: the product of this gene can sop up free-floating IGF-2 proteins before they exert their growth-promoting effects. Unsurprisingly, dad’s copy of Igf2r stays quiet. Such is the phenomenon of genomic imprinting—a form of non-genetic inheritance in which both copies of a gene exist, but only one parent’s version is left intact. Over 150 imprinted genes have been confirmed in mice, about half of which have conserved counterparts in humans.’

Suffice it to say that there are several other paternal genes that code for growth or neonatal behaviours that can affect the mother’s response and subsequent care of her offspring -a kind of effect that evolution has decided would be in the best interests of all concerned.

For example, ‘expression of an imprinted gene called Phlda2 in a fetus hinders the growth of hormone-secreting placental cells. These hormones recruit nutrients to support early development. Unsurprisingly, the offspring’s paternal copy of Phlda2 is kept under wraps. But mothers want their copy to remain switched on. […] Other researchers had noted that these hormones weren’t just working in the placenta, however. Throughout pregnancy, they were actually spreading throughout the mother’s body and accumulating in her brain—leading John [professor of biology at Cardiff University] to suspect that they could also be encouraging a mother to care for her young. […] The team’s work lends credence to the idea that fathers don’t dictate the health of children through genetic inheritance alone. In cases like these, they can even utilize the fetus as a chemical envoy in this battle between male and female, swaying a mother’s priorities towards more attentive childcare.’

During many of the years when I was in active practice of obstetrics, I often felt I needed to be an apologist for the father who did not have to suffer the many exigencies of pregnancy, not to mention the difficulties of labour and delivery. Clearly, after fertilization, his role in the process seemed merely supportive, and often peripheral.

Were I to start my career over again, though, perhaps I could put in a louder word for the importance of our male side -although I’m not at all sure mom would be listening as intently at the end.