Dasha Kiper was once on track for a Ph.D. in psychology, but she became weary of the abstract and theoretical world of academia, finding herself to beDasha Kiper was once on track for a Ph.D. in psychology, but she became weary of the abstract and theoretical world of academia, finding herself to be more interested in grounded, real-world work with people. During her graduate-school years, she looked after an elderly Holocaust survivor who suffered from dementia, viewing this “as an opportunity to observe how a person fights to preserve his sense of self, even as a neurological disease was eroding it.” Kiper ended up becoming the consulting clinical director of support groups for an Alzheimer’s organization. She now facilitates meetings for family members and friends who care for dementia patients. Long an admirer of neurologist Oliver Sacks’s methods of clinical observation, emotional engagement with, and affection for his patients, she has modelled her approach to working with people on his.
In her professional role, Kiper regularly hears caregivers confess to feelings of guilt over the intense frustration and anger they feel dealing with their loved ones. These people know that the brain of a dementia patient doesn’t fire on all cylinders, yet almost all get sucked into arguments and power struggles with the impaired person, feeling compelled to present “the facts” to one who seldom comprehends and almost certainly won’t remember them, even if there is the occasional flicker of understanding. Caregivers are ashamed of their lack of composure—or what Oliver Sacks identified as the indispensable “compassionate detachment” one needs to assist the neurologically handicapped. Kiper began to wonder if the frustrating caregiver-patient interactions she kept hearing about might be due to something other than mere impatience.
In this excellent book, permeated by her warm intelligence, she focuses on the psychology of dementia caregivers, the “invisible victims of the disease,” who “unwittingly become part of the madness” and even mirror the irrationality and distortions of their charges. Based on cognitive and neuroscientific research, insights from literary fiction, and her own experience, Kiper proposes that much of the difficulty caregivers face in dealing with patients is due to the default setting of the healthy brain, which operates with a number of cognitive biases and philosophical intuitions. For one thing, we humans are wired to regard others as having the ability to learn, incorporate new information, be self-reflective, and maintain a continuous, essential core self. This perspective prevails even when we know we’re dealing with those whose cognitive faculties have been drastically diminished.
Kiper effectively uses case studies of caregivers she’s worked with to explain (among other things) why (1) we cannot remember that dementia patients forget; (2) family members take so long to recognize the disease; and (3) it’s so hard to change our knee-jerk, emotional reactions to the cognitively impaired person. She also explores the defenses that the mind uses to cope with the chaos and confusion that dementia wreaks.
As might be expected, a consideration of how memory works is a major focus of the book. Kiper points out that the distinction between the impaired and normal brain is not as clear-cut as one might think. Typically, functioning memory is not a one-to-one correspondence with reality, nor is it designed for accuracy. In fact, memory doesn’t actually exist to serve “objective” reality, but rather to create meaningful narratives about who we are. None of us can retain all the details about what we experience. Normal subjects have compensatory strategies to offset the memory loss that naturally occurs, relying on the employment of concepts, categorizations, and generalizations. In short, our minds summarize. Later, when we retrieve a memory, we’re not actually “summoning” a previous event but “reconstructing” past experience based on some elements of what happened, on a general sense of what might have happened, and on our current beliefs and feelings. The way normal memory works affects how we view and interact with Alzheimer’s patients.
Another basic principle about mental function that Kiper regularly returns to is that the brain’s objective isn’t “to be wise or right or even reasonable, but to conserve energy.” So much of how we think and behave is done on automatic pilot. Citing psychologist Daniel Kahneman’s book Thinking, Fast and Slow, Kiper says our usual effortless, automatic mode of “fast” thinking, which forms immediate impressions by recruiting intuitions, biases, and assumptions, gets us into trouble with the Alzheimer’s patient for whom many of these assumptions no longer apply. It’s difficult for a harried caregiver to switch in the moment to the “slow,” more deliberative thinking mode that dealing with a dementia patient requires.
Kiper’s book is a rich and fascinating one. I’ve barely scratched the surface here. While it’s not of the self-help genre, Travelers to Unimaginable Lands is certainly a helpful, instructive, and accessible book—not only for caregivers who can’t understand their erratic and irrational behaviour (never mind forgive themselves for it), but also for those interested in the unconscious brain processes that govern the ways we think and act....more
Veronica O’Keane has been a practising psychiatrist and researcher for over thirty-five years. She has worked in both England and Ireland and has particular expertise in the diagnosis and treatment of post-partum psychosis and depressive illness. She explains that when she was training, Freudian theory and therapeutic technique dominated the field of psychiatry, but that from the late 1990s on discoveries in neuroscience have shed light on the biological underpinnings of mental illness. In The Rag and Bone Shop she provides case studies of psychiatric patients she has cared for over the years, reflecting on their illnesses—from anorexia and borderline personality disorder to mania and schizophrenia—in light of discoveries about brain anatomy, circuitry, and the neurophysiology of memory. Psychologist William James’s observation that the study of abnormal mental function can help us to better understand what is normal resonates strongly for O’Keane, forming the bedrock of her book. In addition to her own clinical experience with mentally ill patients, she draws on the findings of psychologists, philosophers, neurosurgeons, and researchers—historical and current—and on the literary works of greats from Samuel Beckett to Virginia Woolf, who, she declares, were highly observant and even prescient about the workings of the brain.
Rich in detail, fascinating, and informative, O’Keane’s book is ambitious, possibly too much so. (I think the forays into physics and folklore, for example, could quite safely be cut.) Early on, she writes that she is interested in the question of memory. However, her work ranges well beyond that subject, her stated focus seemingly ironically forgotten. I found the title, taken from Yeats, rather misleading. O’Keane invokes “the rag and bone shop of the heart” in her discussion of the prefrontal cortex and insula of the brain, regions which interpret and regulate our emotional responses to the external and internal worlds. Since the book is about so much more than these areas of the brain, I would have liked to see a more general and inclusive title.
I read an uncorrected proof provided by the publisher. It was abundantly clear that the text was still in its own “rag-and-bone” form—that is, still in need of a fairly significant clean-up. There were numerous distracting typos, dangling modifiers, pronoun agreement and reference problems, punctuation issues, and many baggy, ungrammatical sentences. Since the material is fairly dense and complex for the lay reader, I do hope the prose undergoes a rigorous editing. I would especially love to see someone correct O’Keane’s tendency to refer to research subjects, not in the expected plural—i.e., as “rats”, “monkeys”, or “babies”—but in the singular, as proper nouns. Her writing about how seven-month-old babies learn that their parents are separate people is particularly grating and awkward: “If Baby is left alone too long or if they are not soothed . . . difficulty in forming trustful relationships may start” and “About eighteen months later Baby begins to become aware of themself.”
I have no doubt that O’Keane’s subject matter would fascinate many. Having said that, I think some expert revision and editing are in order before this book is sent out into the larger world.
Many thanks to Allen Lane/Penguin for providing me with a digital ARC in exchange for an honest review....more
Dr. Karl Deisseroth is a Renaissance man: He is a psychiatrist with a special interest in autism and treatment-resistant depression; he has a Ph.D. inDr. Karl Deisseroth is a Renaissance man: He is a psychiatrist with a special interest in autism and treatment-resistant depression; he has a Ph.D. in neuroscience; and he is a professor of bioengineering at Stanford, where he spends much of his time running a lab. His interactions with patients who are challenged by a range of psychiatric or neurological issues raise provocative questions and inform his work in the lab. He’s also a lover of literature, which he regards as important for “understanding patients” and which can “at times provid[e] a window into the brain [that is] more informative than any microscopic objective.” Deisseroth is a proponent of cross-fertilization between disciplines—the humanities, engineering, and various scientific fields. Ideas and influences from unexpected directions can be transformative, he says, and if science is too biased towards solving disease-related questions, innovation is curtailed. Projections reflects its polymathic author’s philosophy. It’s a rich, fascinating, and exciting amalgam of stories of patients with particular psychiatric diseases and symptoms, including mania, paranoia, multi-infarct dementia, autism, borderline personality disorder, eating disorders, and depressive illness. The narratives are offered with the view that the broken can provide insight into the unbroken—abnormal function helps us understand what is normal. Deisseroth’s book also contains elements of personal memoir and scientific expository writing about genetics, evolution, and the role that a technology called optogenetics can play in exposing the complex neural circuitry and components involved in certain emotional states and diseases.
Unlike other medical specialists who can use a range of diagnostics—including blood work and imaging—to home in on and identify disease, psychiatrists are reliant on patient history and clinical presentation. Deisseroth writes: “The challenge of trying to perceive and experience unconventional realities from the patient’s perspective is the heart of psychiatry, working through the distortions of both the observer and the observed.” To practise well, he intimates, psychiatrists have to have a measure of self-awareness. They must be careful not to over-identify with patients and be mindful not to ascribe their own emotions or experiences to those they are treating. Sometimes, however, psychiatric diagnoses can be reached when the clinician notes the feelings a patient evokes in him. For example, in dealing with borderline patients, who are “maestros” at eliciting emotion in others—bringing forth powerful positive or negative feelings that approach patients’ own intense states—Deisseroth has found it useful to be attentive to the “rising tingle” up his back “in that sensation of defensive rage that we feel in our skin when personal boundaries are violated.”
Physicians are trained to see brains as biological objects. With psychiatric illnesses, however, the organ itself is not obviously damaged, and there are few explanations for why patients are suffering and what their diseases mean in a biological sense. A new technology called optogenetics (much of it developed in Deisseroth’s own Stanford bioengineering lab) is changing that. This technology allows scientists to see specific nerve cells firing as well as activity patterns in brain “circuits” created by the “projections”—the axons (extensions or threads)—of neurons across the brain.
Optogenetics involves taking genes responsible for making light-responsive proteins from such microorganisms as ancient algae and delivering them to specific neurons in laboratory animals, usually mice. Amazingly, this genetic material can be carried to its target by a virus. Once it reaches the intended nerve cell, the microbial DNA provides instructions so that the mammalian neuron can now produce a light-sensitive protein called a rhodopsin. Later, scientists can administer laser light to the transformed neuron by means of thin flexible fibers of glass (fiber optics). The genetically-altered lab animal’s neuron fires in response to that light—it’s excited or inhibited. Throughout the process, the animal brain is left intact; researchers are able to study the components that give rise to neurological function without taking the system apart. Deisseroth’s team has also developed and employed another technology called hydrogel-tissue chemistry, which helps to turn the normally dense and opaque brain into a state which permits light to pass through freely. This allows high-resolution visualization of the physical components of certain brain functions and emotional states.
Deisseroth explains early in his book that optogenetics technology has allowed scientists to learn that emotional states typically involve several brain areas. (Knowledge gained through this method may ultimately lead to treatments for afflictive states.) Anxiety, for example, begins in a region of the brain called the bed nucleus of the stria terminalis (BNST), an extension of the amygdala (a part of the brain involved with experiencing emotion). Threads from the BNST radiate out and activate several other brain areas. One projection travels to the parabrachial nucleus in the pons, which is part of the brainstem. When activated, this area increases the breathing rate of an anxious individual. The risk aversion (fearful avoidance) we see in an anxious person is controlled by a different thread, one travelling from the BNST to the lateral hypothalamus. Finally, the negative feeling or “valence” associated with anxiety is handled by a third projection, which extends to the ventral tegmental area, a part of the mammalian brain’s reward-and-motivation network.
Projections is organized around patient stories. Deisseroth walks the reader through the symptomatology of each condition, what is known about its genetics, and the ways in which optogenetics has shed light on what is going on. The author often considers the social context in which the patient’s illness has developed, whether it be the ruptured early family life of a borderline patient or the state-sponsored persecution of a patient from a Uyghur community in China. I appreciated his reminder that “nothing in biology makes sense, except in the light of evolution.” If something does not matter for survival, it disappears. It’s very possible, then, that what we now consider psychiatric illness once served a purpose. For example, the elevated state of being that we see in mania may have allowed some people to lead others in past times of existential threat; the euphoria of the manic individual may have uplifted and inspired his fellows. The decreased need for sleep, the abundant energy, and the intense commitment to projects may have served ancient societies well in times of migration or rebuilding. On the other hand, humans may have had periods during which the conservation of energy was critical for survival. The roots of depression may lie there.
Deisseroth acknowledges that there are ethical concerns about how new technologies like optogenetics are used. Neuroscience can target specific cells and connections to make animals more or less aggressive, defensive, energetic, sexual, social, hungry, thirsty, or sleepy. To what extent might these findings ultimately be applied to transform dysfunctional or suffering humans? Which changes are socially and morally acceptable and which are not? Deisseroth opines that the scientific community has a duty to explain its work to the general public, who must become engaged in the discussions about how new neuroscientific technologies are applied.
I am grateful to Random House for approving my Net Galley request for an early review copy of Karl Deisseroth’s book. It is one of the most stimulating works I’ve read in some time. I think other motivated readers interested in the workings of the brain will find it very rewarding, too....more
Early in her book on outbreaks of mass psychosomatic illness around the world, neurologist Suzanne O’Sullivan observes that “disease impresses people;Early in her book on outbreaks of mass psychosomatic illness around the world, neurologist Suzanne O’Sullivan observes that “disease impresses people; illness with no evidence of disease does not. Psychological illness, psychosomatic and functional symptoms [that is, symptoms which indicate problems with how the nervous system is working] are the least respected of medical problems.” She proceeds to look at cases in various countries, including Sweden, Kazakhstan, the Miskito Coast of Central America, Columbia, (the US embassy in) Cuba, Guyana, and small-town USA. Many of these cases involve children and teenage girls, and most involve people on the periphery of the dominant culture: ethnic minorities and groups suspicious of the government or caught between two worlds, the traditional and the modern.
Drawing mostly on anthropology, social psychology, and philosophy, the author makes a strong case for the ways in which society and culture shape illness and the means by which extreme symptoms, which can’t be attributed to physical pathology, communicate important messages about conflicts within a group or culture. O’Sullivan says mass hysteria/conversion disorder/psychosomatic or neurological disorder—the phenomenon goes by a variety of interchangeable names—are as “real” as disease in which there is discernible abnormality in the body. She rightly rejects Cartesian mind-body dualism, pointing out that “mind” is a function of the brain, that it too is created from biology and is “not an intangible independent entity.” However, she does not explain how the minds/brains of groups of people actually create illness—that is, how problems with the functioning of their nervous systems cause mass hysteria. There is vague, unsatisfying mention of neural circuitry and of patients paying too much attention to the “white noise” of their bodies, misinterpreting that noise, perseverating on symptoms observed and reinforcing their misinterpretations. It is not clear how all this ties in with the mass events that O’Sullivan is interested in. Noticeably lacking is a discussion of the mechanisms of social contagion. Also absent are footnotes and sources.
While I found The Sleeping Beauties an interesting and stimulating read, it was not a wholly satisfying one. Thank you to Net Galley and the publisher for providing me with a digital ARC....more
“I had forgotten one of the most important lessons my job had taught me. There was no one truth, there was no one story. Instead there were, behind ev“I had forgotten one of the most important lessons my job had taught me. There was no one truth, there was no one story. Instead there were, behind every case, just webs of messy lives. To look for the truth in a case was to forget my role. It was my responsibility to guide those who came my way as best I could through the law and its systems, with humanity and empathy. It was my job to give them, as far as I was able, what they wanted. And I must try to do this even when what they wanted was not always, in the end, actually justice.”
Sarah Langford is a barrister, a court/trial lawyer with a particular passion for criminal law. In this collection of eleven cases from magistrate and crown courts, Langford tells the stories of a wide variety of people she represented—among them: a young offender who chronically burgled badly; a man charged with gross indecency for “cottaging” (engaging in sex in a public lavatory); a Bangladesh-born, non-English-speaking young wife whose violent husband seeks to gain custody of their young child; an 18-year-old possible pedophile; and a 22-year-old mother, herself the daughter of chaos and dysfunction, who has already had one child taken away and now stands to lose her newborn son.
Langford’s book is mostly both entertaining and educational. The cases read like short stories with fully fleshed-out characters, psychological insights, and often suspense. Legal terms are usually seamlessly incorporated and explained within the main body of the text, but the reader can also check footnotes, which provide more detailed information.
The reader learns how the courts work, how a case is processed, and something about the daily life of barrister, who is not only responsible for properly representing clients’ stories and interests, but also an interpreter, a social worker, psychiatrist, educator, and even a parent at times. Langford’s ethical dilemmas, emotional responses, her wrangling with her own more shameful reactions to clients and their stories are laid out honestly for the reader to consider. Langford is an intelligent and likeable guide whom I enjoyed spending time with.
CanadianReader
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