Nostalgia

Nostalgia is an interesting word.  It comes from the Greek roots, nostos meaning a return home, and algos meaning pain, suffering.  Originally, it was used to describe severe homesickness.  Over time, it has evolved to mean a bittersweet yearning, usually associated with fond and idealized memories of the past.

It’s almost June, almost the beginning of summer vacation.  It’s a time when I recall memories of summers past, years spent at summer camp, and I am filled with nostalgia. From age thirteen through age twenty-three, my summers were spent at the J Bar CC Ranch Camp, just outside of Elbert, Colorado.  I began as a camper.  My final year was as the camp’s assistant director.  In between are most of my memories of adolescence.

Ironically, the first week of my first year at camp I suffered from nostalgia, in the original sense of the word.  At night, I buried my head under my pillow homesick, ashamed and afraid of being teased.  That phase of nostalgia quickly passed.  For most of the nine years that followed, I looked forward to being at camp from the beginning of June through the end of August. It was a safe place to be and to grow.  Now, my nostalgia is that bittersweet yearning, the lovely memories of a time long past, the experiences that were my transition from child to young adult.

I think of camp and I am flooded by a collage of words and phrases, words triggering my memories and emotions, each calling to mind a story. Horseback riding, swimming, archery. Hikes up Pike's Peak. Camp outs. Campfires, music sung, guitars played.  Star-filled skies. My first ‘girlfriend’. My first dance.  The mess hall, the rec hall, the corral. Capture-the-Flag.  Hailstorms, often followed by rainbows.  Meadows filled with wildflowers.  The sound of pine trees in the wind.  The smell of pine trees in the rain.  The final campfire of summer. Old friends.

Not loving my first year of medical school, I did my second year of medical school over two years, while working half-time as assistant director of the camp.  I was trying to decide whether-or-not to continue my medical training or to make camping my career.  As assistant director, I became involved with boards and budgets, hirings and firings.  Camp was no longer camp.  It was a job.  I returned unambivalently and fulltime to medical school, never regretting my choice. No doubt, though, my years of camp counseling influenced my eventual decision to become a child psychiatrist.

I have a strong yearning to return to camp, just once more, to walk the land that I remember so well.  To this day I can clearly visualize the terrain, every hill and every valley.  Once, many years ago, I visited camp with my wife.  Prior to that visit, I told her what a beautiful place it was.  My wife saw it and was not nearly as impressed.  Yet, she found my comment reassuring.  I told her, “That which is beautiful is not necessarily loved, but that which is loved is necessarily beautiful.”

The Name of the Rose

“Perhaps the mission of those who love mankind is to make people laugh at the truth, to make truth laugh, because the only truth lies in learning to free ourselves from insane passion for the truth.”  So says the protagonist Brother William to his young pupil Adso as they survey the monastery and its great library burned and in ruins.

I recently reread The Name of the Rose by Umberto Eco.  Published in 1980 this historical novel and murder mystery is a difficult read, but worth the effort.  The story takes place in the early 14^th century within the walls of an Italian Benedictine monastery.  It was a turbulent time in the history of Christianity.  There was contested leadership within the church and a direct challenge to established church authority with the rise of monastic orders.

The protagonist, Brother William, is a Franciscan monk called upon to investigate a series of murders that occur within the walls of the monastery.  William, once an inquisitor, no longer relies upon the inquisition’s harsh methods. Instead, his tools of investigation are logic and philosophic inquiry.  William is mentor to a young Benedictine novice, Adso, in whose voice the story is narrated.

Woven into the story's multiple mysterious murders are a series of theological debates, told as they would have taken place in the 14^th century.  Religious ‘truths’ were passionately argued. One man’s truth was another’s heresy.  To be on the wrong side of an issue could mean death.  To be on the right side, especially if martyred, could mean sainthood.

One debated ‘truth’ concerned monastic vows of poverty.  For those taking such a vow, this was their measure of faith and piety.  Not so according to established church leadership, believing that ascetic vows posed a threat to church wealth, power and authority.

Within the monastery was a great library.  There was debate about the purpose and usefulness of the library. Some saw the library as a great repository of knowledge.  Others argued that God’s words, as revealed in the Bible, stood alone.  Books were extraneous, the product of man’s arrogance, man’s sinful pride in cleverness and knowledge.

Laughter itself was cause for dispute, one side seeing laughter as a joyous acknowledgement of God’s goodness, the other side arguing that laughter was derisive and frivolous, making light of man’s sinful state, working in service of the devil.

In the novel, religious ‘truths’ were argued with fatal results  The murders and motives solved, William warns his young pupil, “Fear prophets, Adso, and those prepared to die for the truth, for as a rule they make many others die with them, often before them, at times instead of them.”

Umberto Eco, writing with imagination, scholarship and eloquence crafted a story that reminds us of the dangers and cruelty of dogma, that "insane passion for the truth.”  And he reminds us of the necessary corrective power of laughter and humor.

In another time and another place philosopher Isaiah Berlin warned, “It is a terrible and dangerous arrogance to believe that you alone are right . . .”   I couldn’t have said it better.  Umberto Eco did.

Medicine and Philosophy

“It is a lame creature who calleth himself a physician and he be void of philosophy and know her not.”  (Paracelsus, 1493—1541) 

My formal background in Philosophy consisted of one undergraduate Intro to Philosophy course, which was the most numbingly boring class I ever took.  I was assigned two papers for that class, one on Hobbes and one on Kant. The only all-nighters I ever pulled in college, were writing those awful papers.  I agonized over those papers, knowing as I wrote them that they made no sense. I recently reread them. They still make no sense.  Yet, I got an A in the class which only confirmed for me, at the time, that Philosophy was a lot of bull.  Philosophy was off my radar for many years thereafter.

It was during my psychiatry residency, I realized there was a gap in my education, a gap that my background in science and in psychology could not fill.  I wanted to better understand my patients.  I wanted to know the degree to which my patients had no choice but to do as they did. Was their behavior determined?  Where there is no choice, there can be no blame. Or, did they have choice, free will?  Where there is choice, there is accountability.  And I wanted to be consistent.

I wanted to know more about the mind and the brain.  How does thinking arise from matter?  I wanted to know more about human nature.  Are we inherently good or evil or neither?  I wanted to understand how we know what we know.  What can we know for certain?  What makes for a good and meaningful life?  An ethical life?  After all, as Socrates admonished, “the unexamined life is not worth living.”  My interest in philosophy was rekindled.

This winter I will be back in the classroom, teaching a new course, Medicine and Philosophy, to a group of senior medical students.  For most of them, it will be their introduction to philosophy. I will look back on the experience of my introductory course and try not make the same mistakes. My task ahead is to make philosophy as meaningful, interesting and exciting to a group of skeptical medical students, as it is now for me.

The introductory class I’m planning will not be a historical survey of philosophy nor will it be taught didactically.   My class will be constructed on two premises. First, everyone is a philosopher.  Second, philosophy is not passive, it is an activity.  In class, we will do philosophy.

Everyone is a philosopher.  Some just need help putting their beliefs, their values and their opinions into words. The first task in class will be for each student to begin to articulate their philosophies. Once that has begun, we will proceed with the work of philosophy.  I will provide some basic tools, tools that date back 2500 years to the time of Socrates and Plato, and they will be asked to critically examine, refine and sharpen their thoughts.

The over-arching goal of this course Medicine and Philosophy is for students to develop and expand their critical and creative reasoning, and along the way, learn to apply the critical and creative thinking of philosophy to sound medical practice.  I want no student physician in my class to ever be accused of being a lame creature, void of philosophy.

Philosophy comes from the Greek roots phylos meaning to love and Sophia meaning wisdom. I will teach a class about wisdom and hope they love it as much as I.

That’s lesson plan one.  Only fifteen more to go.

An Educational Challenge

Several years ago, I taught a course on parent guidance to a group of child psychiatry Fellows.  This was a bright group of students, all of whom were in their 4^th or 5^th year of post-doctoral training. 

I assigned them a task.  I asked them to pretend to write an advice column for a parent magazine, a 400- to 500-word column, sharing their views and opinions in response to parent inquiry.  For their first column, I asked them to respond to a parent seeking advice about spanking. 

A week later, I collected their columns.  I read them and, for the most part, thought they were dull and mediocre.  My wife read them and thought there was something not quite right about them.  After doing some investigation, she discovered that 7 out of 8 papers were written almost word-for-word from articles found on-line. 

Initially I was angry and disappointed.  I let the students know that if they had been on faculty, they would have been fired for plagiarism.  If they had been in a graded course, they would have failed. 

The students thought I was being unfair.  After all, if I had asked them to write a column about the side-effects of Paxil, wouldn’t they have Googled side-effects of Paxil in order to get the information?  I tried to explain that they were comparing apples and oranges. I didn’t ask for a recitation of facts about spanking. I asked them to articulate an opinion, their opinion. 

As I talked more with the students, I began to understand why they struggled with my task.  I was reminded that they worked in a high-pressured academic environment in which time was short and demands excessive.  Some admitted to going on-line as a short-cut, a time saver. I was reminded that much of their science and medical education, preceding my class, was done on computer while trying to learn massive amounts of information. It was their reflexive response to seek out the right answers on-line.  I was reminded that these students functioned in an environment where they were under constant supervisory scrutiny. They were afraid to be wrong. To be creative and original was to risk being wrong. 

As a teacher, that class was an awakening.  I became aware of a potentially serious educational pitfall. For many years, my student’s education had not encouraged the formulation and expression of opinion.  They had neither the experience nor the confidence to put their own thoughts into words and think that it could be okay. 

I have shared my cautionary story with teachers of all grades and levels, reminding them that, in this age of information, we must conscientiously teach critical and creative thinking.  Every student deserves time to think, to play with ideas, to develop opinions.  No right or wrong.  Computers off.  No Googling allowed.

Letting Go

“Do not go gentle into that good night.

Rage, rage against the dying of the light.”   (Dylan Thomas, 1914—1983) 

Bad advice from poet Dylan Thomas.  I want these next however-many-year’s journey into that good night to be gentle and relatively quiet, no raging.  I’m trying to successfully navigate old age.  So far, for me, aging is not about rage.  It’s about “letting go.” 

Physically, I must let go.  There has been a slow and steady progression of body parts and functions that don’t work as well as they once did, and I’ve let go of the hope that they’re going to get better.  Joints ache.  Reflexes are slower. Healing and recovery take longer. Sleep is lighter, naps are more frequent and energy declines.  Through all this I have recognized an important new sense of self. I am not my body.  I’m merely housed within this aging and sometimes inconvenient structure. 

The first draft of this blog I write while resting in bed, with a pair of crutches at my side.  I have a small tear of my right lateral meniscus.  There was no trauma to my knee, no past injury.  I just took a bad step.  I have degenerative changes in my knee, ‘degenerative’ being a brutally frank word for the erosive physical toll of old age. Now, with my new bad knee, I will let go of those activities that might cause further damage to the joint.  I can still be active and mobile.  I can walk, cycle, swim, and most importantly fish. 

Materially, I am letting go. I’m getting rid of ‘stuff’.  A few years ago, we moved from our home in St. Louis, to a townhouse apartment in Kansas City.  In the process, we let go of 2 trucks worth of extraneous furniture and other assorted items.  I don’t miss any of it.  In fact, it was quite liberating to let go of so much unneeded baggage.  There is very little I don’t already have that I need or want. I am ready to get rid of more. 

Professionally, I’ve let go.  With retirement, I let go of 35 years of clinical practice.  I no longer use the skills I acquired over so many years of life experience. I let go of the respect and dignity that came every day, walking into the office, being greeted by my title, Dr. Boxer.  I let go of the security of a paycheck. 

But letting-go has its upside.  In the years prior to retirement I let go of any concerns I had regarding evaluations and the expectations of my employers.  I went to work and did it my way.  With retirement, I let go of paper work, bureaucracy, liability and the morning alarm clock. 

Psychologically, I let go of dreams, of all that I once thought that I could do or become.  In my youth, in my residency, I wanted to be the best. I half-jokingly hoped that one day they would speak of Freud, Jung and Boxer.  All-in-all, I am proud of what I accomplished professionally, but my lifework will remain relatively anonymous. 

But for a very sore knee, I am not unhappy. With every letting-go, there is a bit of grieving, but that’s followed by the calm of acceptance and gratitude.  And my life remains uninterruptedly blessed with loving and understanding family. 

How do I prepare for the ultimate letting go, the journey into that good night?  By grieving if needed, followed by acceptance and gratitude, followed by letting go when I must. No raging.

Connect Four

In an otherwise high-tech world, the most important piece of equipment in my office was a $10 game of Connect Four.  For over thirty years, I used that game to help with diagnosis and with therapy. 

For those who may not be familiar with the game, Connect Four is played on a grid, 6 slots vertically and 7 slots horizontally.  By taking turns dropping checkers into one of the slots, the goal is to get four in-a-row, much like tic-tac-toe.  What makes it an ideal game for office use is that the rules are simple, the set-up is easy, it appeals to a wide age range, and the game can be played, completed and repeated in a few minutes. 

Children of all ages enjoy the game. Even before children are old enough to understand rules, they love to dump out the checkers and watch them scatter. Children, a bit older, and able to tolerate a modicum of delayed gratification, learn to replace the checkers in order to dump them once again.  At yet another stage, children not only replace the checkers, but do so in patterns such as stripes or alternating patterns.  Now that they’ve entered in to this cognitive world of planning and patterning, they seem to derive more pleasure from what they have created than from the act of dumping. 

School age children, approximately ages 6 through 8, are ready to take a major developmental step forward and learn the rules of the game.  For some children, especially those who are very oppositional, this may be the first time that rules are heard not as restrictions, but in a positive context.  Rules make the game possible. Without rules, there is no game. 

With the game, there are social lessons.  How to follow rules.  How to take turns.  How to be patient when it is not your turn.  How to be gracious in winning and gracious in losing.  If a child broke the rules, cheated, I didn’t get angry or berating.  It was a learning opportunity.  “Okay,” I said.  “You can do that with me, but how would you feel if I did that?” or “How would you feel if a friend did that when you were playing?”  “How would a friend feel if you did that with them?  Would they still want to be your friend?” 

With the game, there are cognitive lessons.  How to slow down and to look at options.  How to use words to assess the choices.  How to discern better and worse decisions. How to predict better and worse results.  If a bad move was made, I didn’t pounce upon my patient in victory, “Aha, now I got you!”  I would say something like, “Look carefully at your move.  Why is that not a good move?”  “If you go there, where am I likely to go?”  “What would be a better move?” Then I allowed them a do-over.  As we played, I observed if they learned from past mistakes.  I asked them to put into words their strategy.  Eventually, I asked them not only to articulate their strategy, but could they figure out mine. 

A coach is a motivator and a teacher. When I played games in the office my role was to coach. The goal was never about becoming an expert at Connect Four. The goal was to give children experience and practice in social engagement, decision making, slowing down, paying attention, using words to assess, making good choices and considering consequences.  Through this and many other board games, and with a bit of coaching assistance, children can acquire social and cognitive skills, important for their future success.

Being Thirty

Ah, but I was so much older then, I’m younger than that now.”  (from My Back Pages, by Bob Dylan)

The most difficult years of my life, unquestionably, were my thirties.  In my twenties I was dating.  I was in med school and then residency.  I was a doctor.  I was beginning to make some money. I felt very grown up. Little did I know. 

In my thirties I was buried in an avalanche of grown-up responsibilities, challenges and associated stresses.  I was now married. I had young children demanding of my time, energy and resources.  I had a home mortgage and all the unanticipated expenses associated with home ownership.  I was no longer in training and was just starting out in my career. 

It was a time when there was too little time to get everything done.  I had to make compromises.  Often, I felt I was doing a half-assed job at work alternating with doing a half-assed job at home.

There was constant fatigue and irritability.  My wife and I often called these times “the damage control years.”  The goal was to muddle through as best we could, do or say nothing stupid or damaging to our relationship and live with the mantra that “this too shall pass.”

It was around this time when I also became aware of my parents’ limitations as they entered in to their senior years.  They didn’t have all the answers and wisdom which I once attributed to them.  They didn’t have the same energy and resources to give as they once had. They were not so available to come to the rescue.  I had to reconcile that despite my burdens, they had lives and needs of their own.

As hard as my thirties were, they were not without good times and joyous occasions.  And, however difficult the problems seemed at the time, I can look back and see that they were rites of passage, no more than ‘first world problems’.   My thirties were an important piece of my life’s journey, a necessary and inevitable piece of becoming fully adult.

And sure enough, with my forties came calmer times. The kids were now older and in school.  Once children could sleep through the night, so could I.  Energy improved.  Mood improved.  I felt confident and competent in my career.  There were fewer financial surprises. There was even some occasional time for leisure; reading, fishing and vacations.

Now, it’s my children’s turn to take on the difficult challenges of new marriage, new home, young family and new career.  When I’m around them I feel their stress, not without experiencing some post-traumatic stress of my own.  I also understand that they will have to come to terms with the increasing limitations of this aging and all-too-fallible parent.  I can’t take away, nor do I wish away, their responsibilities, challenges or stress. After all, this too shall pass.  I wish them successful damage control and muddling through over these next years, so that by the time they are forty, they too can emerge competent, confident and fully adult.