Sunday, October 23, 2011

Renewing of the Mind (Part 1) Phil 4:5-7

I've recently been more and more interested in Psychiatry and specifically in Cognitive Behavioral Therapy (CBT). I’ve had several intriguing conversations with Jeffrey Schwarz (who showed the brain changes that occur with CBT) and I’ve studied under David Burns (most famously of Feeling Good) and his TEAM therapy. CBT as I understand it, essentially focuses on intentionally practicing certain thoughts. The idea is that many mental illnesses are at their core an irrational belief which leads to a habit of bad thinking. If this irrational belief can be identified, confronted with rationality, and then finally ousted through practice of right thinking, there will be some healing. Essentially, the theory asserts that you can choose your thoughts, and so by indirect consequence, you can choose your moods. If you think depressing thoughts, you will wind up depressed. If you think pleasant thoughts, you won’t. The role of the therapist is to help teach a person to identify the irrational thoughts and practice rational ones.

[Now please note: this is what I have learned from two specific thinkers in CBT. CBT doesn’t strike me as a standardized orthodoxy, so these observations might not be true elsewhere, and as I am only a neophyte, it might not even be true here.]

I was reading in Philippians yesterday and chapter 4 really jumped out at me because it seemed that Paul in the First Century had figured out CBT. This will begin a long-running series on Psychotherapy in the Bible. I’ve had the thought before, but decided “here” was as good a place as any to start. If you have other passages that speak to this question, please let me know and I’ll (eventually) write about them. I’d be interested to collect these from other traditions, literature and philosophy. So if you’re a Shakespeare scholar, send some passages my way. Or if you know about parallel passages in the Koran, please let me know.
5 Let your reasonableness be known to everyone. The Lord is at hand; 6 do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. 7 And the peace of God, which surpasses all understanding, will guard your hearts and your minds in Christ Jesus. (Philippians 4, ESV)
The sections starts off with “reasonableness,” and moves immediately to anxiety. The alternative to anxiety is prayer with thanksgiving. The immediate consequence of this thankful prayer is the peace of God. And this peace itself becomes a defense of both the heart and the mind.

One of the major ‘irrationalities’ that cause anxiety is the desire to control. What if I fail that test? It’s Friday night and I’m out of town; what is she doing right now? I don’t know everyone at the party; what if they don’t like me? I’m speaking in five minutes; what if I say something stupid? What if the plane crashes? Everyone has the temptation to fall into these anxious thoughts. What does Paul advise? Pray. Give it to God.

What does that do? It helps you realize that it’s in God’s hands, anyways (everything is, after all). Kneeling before the Throne Room of the Universe, one feels humble; not the big shot who has something to prove. And then when one rises from prayer, and walks out of the Throne Room, one realizes that one was just in the THRONE ROOM OF THE UNIVERSE. What problem could possibly concern Heaven? And what problem could possibly concern one of its citizens?

Also, we can’t forget the thankfulness. No matter how bad things get, every Christian can open his prayer with: “Thank you Father, for life and breath and salvation.” Though every once in a while you get a man like Job, most can go a lot further than that prayer. Most can be thankful for family, health and even wealth. Most have some hint of nature (sun or stars or sky if nothing else) that they can be thankful for.

Paul tells us to pray a lot. He tells us to practice this set of thoughts and attitudes. And when we do this, we’ll be armored from further assault to both heart (emotions) and mind. Exactly in agreement with CBT, Paul says that something you practice by conscious effort (prayer) will be a guard against future perturbation of mood (“heart”) and thought (“mind”).

So let’s imagine our first character, overwhelmed with feelings of anxiety for an upcoming exam. He is anxious probably because he’s grasping onto his pride and playing out the worst case-scenario in his mind, over and over again. He’s imagining getting the test back, with a big “F” on it, and his having to take the course again, and lose his scholarships, and be ridiculed by friends, and have to go home and tell his parents, and not get into medical school, and, and, and… Now let’s let him pray:
Father, I thank you for life and breath and salvation. I thank you that you have given me the opportunity to study at this wonderful school, that you’ve given me friends that believe in me and a family that loves me. Thank you for this beautiful day, the warm sun and calm green trees. I lift up this exam to you. I have been diligent in my preparation; I have studied what I have studied and done all that I can. And so now I pray that you give me success. Passing this exam will ultimately help me serve your children by entering medical school. Nevertheless, not my will but yours be done: I trust that you will be with me and will do what’s best for me, be it to fail this exam or to pass. Amen.
 If our young friend prays this prayer (or others like it) for 15 minutes a day, he’ll have a lot harder time stressing out about the exam. It’s in God’s hands. He’s accepted the possibility that he might fail, but he’s not worried about that either. On top of it all, he began with gratitude; even this alone will put him in a better mood than when he started.

The pattern of Philippians 4:5-7 is brilliant and powerful:
1. Begin with being reasonable.
2. Don’t worry.
3. Instead, pray and be thankful.
4. This will guard your heart and mind.

Monday, October 17, 2011

New-found Freedom to Think in Medical School

Last week I had a conversation with one of my attending physicians. His critique of my presentation was the only thing I would ever be praised for before: exhaustiveness. “What lab data do you want? What do you think is relevant?”

It’s a question I haven’t really had to answer before. I’m used to being asked, “What’s the bilirubin?” Or listing off all the values in the complete metabolic panel. But which to I think are presently relevant? Well, I’m not really sure. I’d have to think about it.

To think about it

That’s exactly what is finally being asked of me. Not “Memorize this” or “Learn this physiology” but finally, “Figure out this clinical problem.” Of course, all the memorizing and learning is necessary for there to be any problem solving. But there has been an abrupt change in the focus.

In our Practice of Medicine course, we would sometimes take 4 hours to go through a single case. Many of the exercises involved creating comically exhaustive differential diagnoses or similar tasks. Criticism would be mainly for being not exhaustive enough. Of course this exercise in recall is useful in helping us learn the common conditions associated with symptoms, but it’s still just recall. Now I have been asked to vet the list myself.

I have been waiting for two years to hear someone say “Think!” I’m no longer evaluated purely on conformity to a rubric, on my ability to list off everything that might possibly cause jaundice ever. It’s objective, to be sure. But it’s not all that doctors actually do. Doctors think. And when they tell other doctors what they’re thinking, they do not behave like patients with head trauma, with comatose brains, vomiting up (and possibly aspirating) undigested information.

For medical training, the beating heart of the medical student, with its passions and emotions, was put into arrest so that we could be “objective.” The medical student reports the information without passion or emotion (for these, of course, would “cloud” judgment). As a result, his verbal presentation is given in a monotone voice with exactly as much life as his heart has that is as flat as his EKG. But to become a real doctor, the student’s heart must be shocked back to life. He must take on bias, bias for his patient and for truth). He must start to care about what the diagnosis is. He must care enough to argue for his patient, to defend his view on the diagnosis, and to persuade others that he is right. No longer are patients presented as a list of facts; they are presented in a story.

And only human beings, alert and oriented with beating hearts, can tell stories. And they do tell stories. Doctors tell stories. And medical students should pay attention, for this will help them to emerge from the stasis that their first two years have put them into.

It’s never pleasant receiving criticism. But the criticism I got last week shocked me back to life. It was liberating! I could and I should behave like a real doctor now, not just a mindless, heartless medical student. I hope that my mind remains alert and my heart stays beating.

Sunday, October 9, 2011


Blogs are funny things and because you are publisher, editor and author, a personal blog is always “The Number One Source For What I Happen to be Thinking About” (to use the words of one of my favorite bloggers, BradleyWright). Right now, I am thinking about writing, and specifically (because I like to think about me a lot) my writing. This is the 200th Arena-Man post. And this week, the 10,000th visitor visited. A vast majority of this traffic was since I started posting consistently in January (and, I think, this was the wrong webpage for many a poor Googler). I might meta-blog too much (i.e. blog about blogging). But it’s my blog, so I can meta if I want to.

I’ve recently been approached by a few friends and acquaintances and thanked for my thoughts or for encouragement via Blog. I’m usually not quite sure how to feel about it. Firstly, it’s a bit startling to realize that real people actually read my stuff. When I spit out a few paragraphs on this or that subject, apparently it might actually have implications. It’s also strange to know that people are in my head; by my writing, I have opened the window of my soul and let strangers peep in. This creates an unusual sort of relationship: one that is unidirectional. And I suppose this has always been true of writing. The thoughts or ideas or visions of one person are transformed into black ink on white paper (or in your case, photons from a monitor) which are sensed by the retinas of another, and translated back into an idea. You send paper by mail, data by internet, and ideas by writing.

Writing allows for worldview to be shared. It allows the eyeballs through which one person understands the world to be shared by others. But unlike conversation, the relationship is unidirectional. The reader gains something from the writer, but the writer learns nothing of the reader (except, usually, how many companions he has; that is, the number of books sold, page-views, etc). And this has traditionally been the only way.

But the Internet has allowed for a new paradigm. It has allowed for readers to directly interact with the writer, and in real time. Not only does the writer transmit his ideas, but readers can reply with their reactions. Requests for clarification, challenges, encouragements. The little “comments” box at the bottom of posts and the “share” button of Facebook allows for conversation. It allows aspiring writers to express themselves in a single line or several. It allows those who want to transmit the ideas they agree with to their friends. And it allows enemies (real or philosophical) to engage directly. It allows for strangers from around the world to sit down to a cup of tea and discuss ideas like neighbors and friends, or to debate in chivalry, like esteemed opponents.

As you might know, discussion on deep questions is one of my favorite things to do. I get so excited when I find out someone has initiated a discussion; someone has become that first commenter, that first person to step out of the anonymous crowd into the Arena. Consider the discussion that took place when I discussed Fairy Tale Romance. I was so encouraged to hear from people I hadn’t talked to in forever. And I learned something from them. What had been a theory in my head could be interpreted in light of others’ experience. A discussion on Scientific Faith and on Alexandra Wallace have been electric, and in both cases, my argument was challenged, clarified, and through the conflict, strengthened.

I realize that writing is something I really enjoy and really want to get better at. And it makes me happy that what has been a hobby of mine has been an encouragement to others. Thanks for reading! I hope to hear from you in the comments.

Tuesday, October 4, 2011

Beauty Fast

Sterile floors. Sterile hands. Sterile computers. Sterile people. White walls. White ceiling tiles. White tile. All illuminated by fluorescent white lights. Straight halls, every room like every other. Uniforms. Doctors: Blue scrubs, white coats. Patients: hospital gowns (with open back). Beeping monitors. Beeping pagers. Beeping intercom. Beeping, beeping, never-heeded, never-ceasing beeping! An arms race of volume and pitch! No music, not even in doctors’ voices. They are flat and sharp like scalpels. No touch but through breathless gloves. Dry hands, chapped by alcohol sanitizer. And the smell. The musty smell of the hospital interrupted only by periodic nasal stabs by the alcohol on the way in and out of every room. And the occasional whiff of urine or feces or vomit. These are the ingredients of the Hospital Aesthetic.

And so after six days of this, I was hungry, but not for food. I was hungry for something else. My soul needed a drink. I needed transcendence.

I went to church and two lines into the first song, I was struck by the beauty and truth of it and I shed a tear. I felt great joy because of a story that was told. I felt deep humility and power in Communion. I returned home and, it being Sunday and a beautiful day, I had an overwhelming and unexplained urge to go for a bike ride. So I hopped on my bike and rode a few miles down the road. I thought of beautiful places on campus and then biked to them to take in more beauty.

The straight lines and curves of the Stanford arches towered above me, showing me my smallness. The tiny little leaves whirled around me, showing me my greatness. The tan brick, blue sky, yellow sun, green trees, black road, white clouds. The smell of dirt and a thousand thousand plants. Wet hands from sweat, unwashed and greasy from the bike. The bright sun, so bright I had to squint. A full spectrum of light, to make the bluish bulbs of the hospital seem silly, like the photocopy of a diamond. The sun showed through in beams and streaks, through the canopy of the endless oaks.

I ate the experience of today like a starving man. My eyes drank in the light like a lost man drinks an oasis. When I had finished, I was rejuvenated. I had taken my fill. And I am ready to endure another week of sterility.

The body withers away if it lacks food; the immune system weakens, the strength fades. What about a soul? What would happen to a person who is starved of transcendence, who never sees beauty, who never sees something so beautiful that it brings tears? Could this weaken a soul (psyche) as starvation of food weakens a body? What happens to our psychic immune system when we are not properly nourished?