By Jon Franklin

Copyright 2000 The News and Observer

 

 

Moira’s mother put the big blue medical tome high on the family bookshelf, well out of her daughter’s reach. But that, if anything, only made it more seductive. For years the book beckoned from its perch until finally the girl was old enough to push a chair over and crawl up on it. Stretching, she could just curl her tiny fingers around the heavy spine of the book.

She wrestled it to the carpet. There it fell open, and for the first time, Moira confronted the woman with only half a face, the man with elephantiasis of the testicles, the grotesquely fused Siamese bodies of Chang andEng.

Guiltily, she closed the book and put it back on the shelf.

But in the world according to Freud, desire and horror are as conjoined as the Siamese twins, and certain things, once seen, can never be unseen. So it wasn’t long before she returned to the shelf, pulled the book down again and revisited the nightmare universe of human suffering.

If the attraction reflected a child’s natural curiosity for all things forbidden and denied, there was also something more. Some important other thing lurked behind the brutal photographs, something too complex and mysterious for a young girl’s mind to resolve. But it was a definite presence. And it seemed to call her.

Time and time again she returned to the book of horrors, absorbing in the process an appreciation for the reality of the bizarre and the sorrows of existence. Slowly, with the passage of years, she could reach the book without the chair. By then she had come to identify the presence in the book. It was the ghost of her natural father.

Her father had died in an automobile accident in March 1964, while training to be a psychiatrist at the Menninger Clinic inTopeka,Kan.He died just as he was undergoing his own psychoanalysis, one of the final requirements for Freudian practice.

Moira had been an infant then, too young to remember his living face. A few years later, her mother remarried and, in deference to her new husband, banished most of the reminders of the old one from her life. Of the man who had ignited her existence, the girl had nothing.

Or almost nothing. Somehow the big blue book with “Anomalies of Modern Medicine” embossed on the spine had survived, and it proved to be enough. The instincts of a child had led the dead man’s daughter to the book. Through it, from across the moat of human anguish, the ghost beckoned.

Again and again she pulled down the book, opened it on the carpet and turned the pages. She read and stared and thought. Finally the book itself waned in importance, and her journey took an abstract, intellectual turn. Still the ghost beckoned, and Moira followed it, deeper into the labyrinth of the mind.

Now, more than a quarter century later, Moira Frierson Artigues has an M.D. behind her name and, as a senior resident in forensic psychiatry at Duke, is an expert on the nature of ghosts. She understands where they come from and what they seek, which is closure. So as her last year of training drew to an end, she laid her father to rest in a way he probably would have approved – by telling the whole story, and what she had learned from it, in the March/April 2000 issue of the North Carolina Medical Journal.

 

Aside from the ghost, Moira’s history was not unlike that of other medical students. She exercised a fierce discipline, worked hard and excelled in her studies. In college, she acquired a degree in English with grades strong enough to qualify her for entry into medical school.

But the ghost was not something that could be put aside. It was there, always, and it was still there when it was time for Moira to choose a medical school, which was not, really, a choice. Her father had gone to the Medical University of South Carolina, and so would she.

The ghost was strong there, as she had known it would be. As she hurried from class to class, she could not help but be aware that her feet trod the same ground her father’s had. She made time to inspect the school’s historical records and, discovering where his class had studied, she visited the buildings that still survived. One of them now served as a cancer center. His old dorm, where he had slept, had been converted to a “wellness center.”

“I would go there a lot,” Moira recalls. “I would think about him a lot as I was walking around campus. You know … gosh, what was he like?”

Though most medical students were inclined toward clinical research, it was the library that attracted Moira. She proved to have a talent for using the databases, the heart of the modern medical library.

In her father’s day, the great master database of medicine had been stored in the form of inked impressions on paper, the paper bound with thread into volumes containing endless lines of authors, titles and places of publication. The “Index Medicus,” as the volumes were collectively called, took up whole shelves of the library.

Databases were a remarkable creation, unquestionably superior to what had come before. The “Index Medicus” was still there, of course – the heavy books with matching bindings, sitting side by side on a low shelf. But few people consulted the old index anymore; it was too tedious and, anyway, the information to be found there was mostly obsolete.

Still, Moira noticed them. Old things, gone but not forgotten, fascinated her; they were a counterbalance, somehow, to the relentless newness of science. Inevitably, she was pulled to the medical history section of the library, and the evolution of medicine became a component of her education.

She was especially intrigued by the way medicine’s development reflected that of the broader culture. Despite the lore that held doctors separate and aloof, cultural history and the development of medicine were so intricately intertwined as to be inseparable. This was especially true for her father’s specialty, psychiatry.

He had been a Freudian, almost by definition. The entire American culture was Freudian during the ’50s and early ’60s – doctors, scientists, artists, politicians, everyone. John Steinbeck’s darkest novel, “East of Eden,” had been structured upon Freudian assumptions about sociopathology. In the real world of clinical medicine, the Freudian couch was all that stood between the seriously psychotic patient and shock treatment or lobotomy.

Moira’s father had lived at the end of this era, though, and it didn’t much survive him. Not long after his death, the drug chlorpromazine, better known by its trade name Thorazine, revolutionized assumptions about the mind. Chlorpromazine could actually change the way a person thought. It quelled the hallucinations of many schizophrenics and set the stage for the revolution in psychopharmacology and the de-institutionalization of mental patients.

So Moira’s world, she discovered, was fundamentally different from her father’s. Her own education took place in a professional culture in which the mind was seen as a biopsychological engine – an engine which, when it failed, posed a problem in psychochemistry. Freudian therapy, with its endless 50-minute hours of talk, seemed almost quaint by comparison. It was common for modern psychiatrists to deride psychotherapy with a snorted observation that no Freudian had ever cured schizophrenia.

This was true, of course. And yet … as Moira tried to visualize her father and his state of mind, she could only think of him as a compassionate man, with a deep curiosity about the human condition. What else would have drawn him into so desperate a field as psychiatry, one of the lowest-paid of all medical specialties?

Where, in the psychopharmacological wave that had inundated talk therapy, had such compassion gone? Were communication and caring really pass”?

Moira was not alone with this thought. Many of her generation of medical school students were uneasy with the reductionistic assumptions of prescription-pad psychiatry. There was no doubt that drugs were a key tool in healing sick minds, but … were they sufficient?

To Moira, the mind was above all an engine of relationships. It needed to communicate, to interact with other minds. In that case, human contact had to be at least as essential to mental health as the balance of neurotransmitters and receptors.

Such thoughts made the ghost seem increasingly compassionate, cast him almost as a defender of some gentler faith.

But to a medical student, of course, such philosophical and personal ruminations were secondary to survival. Survival was study. Biochemistry, immunology, pathology and the landscape of the heart, kidneys, liver and brain had first call on Moira’s energy. The ghost was very much there, but he lurked in the background.

Then one day, while working in the library, she found herself standing in front of the old “Index Medicus.” The ghost, always latent in her mind, stirred restlessly.

The question formed almost of its own volition:

Had he ever published anything?

Quickly, she found the proper volume, laid it on a table and opened it. Her fingers, larger and stronger now than the ones that had once reached for the embossed blue volume, were no less inquisitive. They flipped the pages rapidly, then slowed. Her eyes ran down the columns, finally coming to rest on the name she was looking for.

Douglass Bewley Frierson, M.D.

There were two entries, one in 1959 and one in 1961. Moira rushed to find them and make copies.

They were only case reports, a mere single page each, but to her they were deeply significant. They had an anthropological quality, almost, testifying to the passage long ago of another, kindred spirit and intellect.

What they said, though, was unsettling. Both involved experiments with drugs. One of the drugs was chlorpromazine.

She read it over and over, letting it sink in.

Like it or not, it put the ghost in a far different light. Her father, whatever he was, had been no romantic defender of the Freudian faith. He had, in fact, been tinkering with the stuff of revolution.

This intelligence subtly shifted Moira’s universe, spawned a new set of questions about who Dr. Douglass Bewley Frierson had been. What force would have compelled a Freudian to flirt with what, in the hindsight of a generation, was the dogma of the enemy?

The answer could come from only one place: history. She intensified her research, concentrating on that moment of schism when the Freudians had split from the psychochemists. What had it been like for a Freudian to live in her father’s time?

And so Moira’s odyssey in search of her father translated into ever greater intellectual effort, and at every step her intellectual growth was accompanied by a deepening of emotional growth. She frequently pulled out her copies of her father’s papers and read them again. Slowly, as she exhumed the context in which they were written, their meaning swam into focus. As that happened, the copies she had made of those papers metamorphosed into talismans. When the time came to apply for a residency atDukeUniversityMedicalSchool, she took them with her.

The more she became intimately familiar with the scientific literature of her father’s time, the more she could see, beyond the stiff language, the human reality of the people.

It had been a terrible time for psychiatry. The nation’s mental institutions were packed with patients. For every psychiatrist, there were hundreds, sometimes thousands, of sick, needy people. Many of them were confined to the locked back wards, all but forgotten by their families and never expected to leave. They screamed and jabbered, and some were frozen in catatonia. Their progress, if any, was calibrated in terms of how difficult they were for the staff to manage. Families and psychiatrists looked with hope at insulin shock and lobotomy.

The more she studied this period, the more complicated it became. Her father’s generation of psychiatrists suffered not just for lack of tools but also for perspective – so sometimes, in their attempts to improve the situation, they made the problems worse. Freudians of the day, for example, believed schizophrenia was caused by the family and, in particular, by “bad mothering.” That only increased the burden of guilt already shouldered by the schizophrenics’ families.

For Moira, the try-anything desperation was exemplified by a book she discovered that Linus Pauling had written in the ’60s. “It was modestly titled “A Cure for Schizophrenia,” she would recall much later, in an interview. “If I remember correctly,” she said, “one of the things he advocated was beating the patient.”

Chlorpromazine showed up almost unbidden. At the time Moira’s father was experimenting with it, most psychiatrists thought of it as a tranquilizer, and they used it on back-ward patients to make them easier to manage. “In those days,” Moira said, “the idea that brain chemistry modulates the way we think was unheard of.”

The attendants who worked in mental hospitals didn’t have time to actually listen to the people they took care of. It was years before they began to notice that patients who got chlorpromazine didn’t just have quieter hallucinations … many of them no longer hallucinated at all.

Once the anti-psychotic action of the drug was discovered, there was a wholesale rush to drug treatment.

In hindsight, chlorpromazine had many therapeutic inadequacies and a number of serious side effects, Moira said, but given the historical context, chlorpromazine was in fact a miracle. Along with the tricyclic antidepressants, it opened new possibilities for effectively treating the mentally ill. Much later the fluoxetine, or Prozac, class of drugs was safer and more effective still. It was no wonder that the prescription pad had replaced the couch.

The more Moira understood her father’s era, the more she appreciated her own education. Her view of mental illness was informed by a revolution in brain science that makes the knowledge at her father’s disposal look primitive.

Then, during her residency, another dimension shifted. Moira had always thought of her father as an older, wiser man. But she was older now than he had been, and she also had more clinical experience.

And so the story remained true to the basic Freudian mantra that lives proceed in circular narratives, endless sagas in which each episode, in closing, creates the beginning of the next one.

By the second year of Moira’s residency, it was all much clearer.

Psychiatrists were a quarrelsome lot, with a destructive tendency to divide into warring camps. The nature vs. nurture issue was especially divisive. Psychotherapy was dominant in the earlier decades of the 20th century, and the psychotherapists made the rules. When chlorpromazine appeared, the scale tilted dramatically in favor of biology. What went around had come around, and in the decades that followed, psychoanalysis was marginalized.

In the tradition of all feuds, defeat led to victory and victory led to excess. In the case of the ascendancy of biopsychiatry, she charged in her journal article, “The success of medication has led to a simplistic view of treatment, a ‘dumbing down’ of psychiatry.

“Psychiatric residencies today teach only a bare minimum of psychoanalysis and the techniques of psychotherapy,” she complains, “though in recent years a long string of studies have shown that relationships as well as drugs have an impact on the physical properties of the brain.” Presumably, she added, experiences trace a much finer pattern than drugs, which affect all of the brain at once.

“Instead of viewing biological and psychoanalytic models as opposed to one another,” she wrote, “I believe that psychiatrists today could improve their treatments by using both medications and psychotherapy. This would also integrate the factors that make psychiatry a fascinating field: hard science alongside thought and behavior.”

She is not alone in her opinion. Her cohort of psychiatrists is much more inclined to consider the brain an engine of both chemistry and experience. The result, Moira says, is a trend back toward psychoanalytic treatment – not instead of drugs, but in addition to them.

The obvious equation, Moira says, is that if chemistry can alter behavior, then behavior must be able to alter chemistry. But it was difficult to prove until recently, and the introduction of, for example, modern brain scanners. Now, a spate of recent scientific studies have provided psychotherapists with ammunition that is likely to accelerate the renewal of their power.

“There is plenty of evidence that psychotherapy works in borderline personality disorder, in combination with drugs, in schizophrenia,” she says. “The point is, why should we devalue that part of a person’s medical treatment?

“The historic swings between nature and nurture have been radical, and they are not needed. … We’re all talking about the same thing. We’re talking about how a person experiences their life, essentially, and I don’t think there’s a reason to make those distinctions … and when you do, you divorce yourself from a body of material that can be helpful to you in treating someone.”

A clearer view:

As for her father, she knows him better now.

“I see him,” she writes, “as a young man intrigued by a fantasy of idealized psychiatry, amalgamated from images in the popular media. … I see him as an inquisitive and curious person, training at a time when amazing discoveries about psychopharmacology lay just around the corner.

“He undertook the care of very difficult patients without the tools available today. I see him as a man of moral courage and generosity, familiar with the psychoanalytic and the biological aspects of his profession, undergoing his personal analysis at the same time he was writing case reports about the new psychotropic drugs. He recognized that his chosen profession was at a watershed in history. The future must have looked exciting.”

And so the epitaph was written and engraved in the pages of a medical journal, bearing witness to another Freudian truth, that intractable emotional sorrows can be resolved by intellectual insight. Father and daughter were connected by history, like Siamese twins, he standing at a moment of schism and she at a moment of reunification. The chasm is closed, the wound is healed, the story is ended, and the ghost no longer beckons.

Which leaves only one loose thread: Where, now, is the big blue book of horrors?

The question seems to catch Dr. Moira Frierson Artigues by surprise. A shadow crosses her face, and then she shakes her head slowly.

“I don’t know whatever happened to that,” she says. “I wish I did.”

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