Psychiatry – Page 155 – Art Smukler, MD

There was a very interesting article in the August issue of Psychiatric Times, “Compartment Syndrome in Psychiatry”, by James Knoll IV, MD.

I have spent a lot of time with a psychologist (in prison), which I had never done before in my life, in order to try to figure out how I could have done it… There are these mafia people who can kill people all day long, do terrible things, and then go home to their families… But the thing is that you can compartmentalize things in your life. Bernard Madoff

Bernard Madoff has apparently been examining his behavior with the help of a psychologist. His observation that one can compartmentalize, not only applies to him, but to many of us. I see it often in the office, and we all see it in the world around us:

In psychiatry, an individual can separate off certain thoughts and feelings, so that those thoughts do not encroach or disturb. This may either be a conscious or unconscious process (Freud). The process may be likened to invoking a mild state of dissociation in an attempt to confine and reduce anxiety (Gabbard).

Today, I saw a couple who sought advice on how to deal with their thirty-year-old son. He would curse at both his parents when he disagreed with them, storm out of restaurants after screaming that his mother was stupid, and then refuse to discuss anything. He has a history of alcoholism and numerous bar fights when he’s drunk. He denies that he has any alcohol problems and won’t seek help. At the same time, he writes long, loving letters to both his mother and father, telling them how wonderful they are and how he’s so lucky to have such giving, caring parents. He is a college graduate, has a good job, and supports himself.

Unlike the normal ambivalence that many feel towards their parents, this man has compartmentalized these feelings of love and hate. If he can keep his hateful feelings out of his conscious mind, he doesn’t have to feel guilty. If he can deny and compartmentalize his drinking, he doesn’t have to stop.

In some people, the compartment divider is like a hermetically sealed, case-hardened ship door. Sometimes the divider is flimsy and both sides of a person’s personality can shift back and forth. In therapy, it’s much better to have a patient with a flimsy door. The aberrant behavior is more accessible to examination and possible change. Unfortunately, patients who compartmentalize can be very difficult to treat. It may take a long time to forge a therapeutic relationship and chip away at the need to drink, have sex, overspend, or steal millions and millions from unsuspecting investors. Anything that feels good is hard to change…

Bernard Madoff did what he did because he could. His psychological compartment was so hermetically sealed that he could look friends right in the eye and get them to invest more money, up until the day he was caught. He seems like a man with only the vestige of a conscience (a sociopath). Most of us, even though we might like money and power, would feel too guilty. Unlike Abe Lincoln, we might not walk five miles to return a nickel, but we wouldn’t come close to being Bernard Madoff.

Thanks!

Hi, I’m Art Smukler MD, a psychiatrist in private practice and on the teaching faculty at UCLA. For many years I have treated adults and adolescents with depression, anxiety, schizophrenia, bipolar disorders, obsessive compulsive disorders, addictions, attention deficit disorders and many others. I love what I do, because helping people understand the mystery of what is happening to them both fascinates and enriches me. Unlike other areas of medicine, where doctors use their intellect and medical instruments (stethoscopes, x-rays, MRI’s etc.) to make a diagnosis, a psychiatrist uses his intellect and a part of his own being. Theodor Reik, a Freudian-era psychoanalyst, called it listening with the third ear. It means actually listening to someone and feeling what they feel, or more commonly what they don’t feel. You have a sixth sense, so to speak, the ability to feel what’s in their heart which may contradict what they are saying.

I feel differently than many currently practicing psychiatrists who only use the computerized part of their brain. Sadness plus lack of energy plus early morning awakening plus lack of interest in life equals DEPRESSION. The common treatment is take a Prozac and see the doctor in three weeks. What happened to the human being trapped inside all those symptoms, who still has no clue as to what’s happening except that now he has a diagnosis and a pill? The drug companies, insurance companies, and doctors think it’s all fine. Even the patient feels better — for a while. Then what? Then the same sequence of events that triggered the initial problem can set it all up again…

The logic of the unconscious, the part of us that is not available to conscious thought, has different rules than the logic of everyday life. My professional life has been spent trying to understand those rules. I want to share my experiences and what it’s like to do what I do. I want to do my best to let you inside my mind… Show you what and how the third ear works and to de-mystify the incredible process of psychotherapy.

Sometimes listening with the third ear falls on deaf ears, and medication is not only helpful, but essential. Sometimes psychotherapy is a combination of encouragement, education and caring, and other times it is a deep uncovering process that exposes years of repressed feelings and memories. Sometimes, but not often, a patient may even need ECT (electroconvulsive therapy).

Psychiatry is the study and understanding of the mind-body connection. It combines science, intuition, experience and caring. It is a unique, wonderful field and it will be exciting to share it with you.