Friday, January 14, 2011

Paranoia & Hope In Tucson

In the days following the Tucson tragedy, gun sales in AZ — particularly the 33-round magazine for the Glock 9mm — have skyrocketed. Gregg Wolff, owner of "The Glockmeister" gun store in Phoenix, opined that his customers are worried the government is going to outlaw the Glock’s 33-round magazine so there is a rush to get them before that could happen. So much for hope in the Desert State — or anywhere else in the Land O'The Armed and the Home O'The Dangerous. If this is (fair & balanced) resignation to... whatever, so be it.

[Vannevar Bush Hyperlink — Bracketed NumbersDirectory]
[1] Meditation On Paranoia — Peter D. Kramer
[2] Memorial Service Remarks — President Barack Obama

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Fanning The Flames Of Paranoia
By Peter D. Kramer

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Like everyone else, in the wake of the killings in Tucson, AZ, I've been thinking about paranoia. I have worked with the disorder for the whole of my psychiatric career. Early in my residency, at Yale, I was identified as "good with paranoids." I doubt that I began with any special talent. The claim that I did allowed colleagues during residency to avoid these patients and send them my way.

Diagnosis was less critical then, 30-odd years back, but the people I treated probably had paranoid schizophrenia, bipolarity and what is now called delusional disorder, formerly paranoia. My favorite was an annoyed and critical woman who said that CIA agents had damaged her car ignition and then followed her everywhere on the bus, so that she could not travel to see me — and why should she, since I was probably part of the conspiracy? When the Blizzard of 1978 swept through New England, I was held over at the Connecticut Mental Health Center — actually, I had managed briefly to get away and had used cross-country skis to return on the empty New Haven streets. At her appointment time, there, all alone, was my beleaguered patient, sitting on the molded Eames chair in the darkened hallway, waiting for her opportunity to give voice to her suspicions.

The experience in my training years made me comfortable with paranoia. As a result, I have always had one or two paranoid patients on the roster in my private practice here in Providence, RI. I should stress that no one I see resembles Jared Lee Loughner. I travel a good deal, and I can't leave the covering doctor with potentially violent patients. When my patients have schizophrenia or related conditions, they tend to be the most accomplished, most reliable, and nicest people to suffer these terrible afflictions. Their needs are serious enough.

Not much specific is known about how to treat paranoid patients. Generally, they don't come in hoping to lessen their delusions, which can be wholly convincing to them. They want relief from depression or insomnia — or from an employer who has insisted they get help. Their mood symptoms may respond to medication, and they may even become less isolative, but generally the system of thought does not budge. After months of trials of different drugs, the patient will be less agitated and less pained but still solidly convinced that he is being watched and threatened. Always, too, there are prices to be paid in terms of medication side effects.

Paranoia the disease and paranoia the symptom are something like orphan conditions, understudied and therefore subject to untested remedies. You can go to a large general psychiatric meeting and not find a single lecture on the topics. Current research techniques have opened windows onto autism and schizophrenia; those good beginnings have led to funding for further studies. Paranoia simply has not been the subject of "scientific opportunity." The condition is probably highly heterogeneous, in terms of what can cause it, and no one has found a way in.

My paranoid patients throw me back on skills I learned early in my training, when the efficacy of psychotherapy was never in question and the use of medication was a sign of desperation on the part of the doctor. We sit and talk. I try not to make matters worse. (One of my mentors stressed that in the face of paranoia, empathy consists in not offering strikingly accurate insights.) Once we have established what therapists call a working alliance, I will try to induce the tiniest wakening of doubt about conspiracies. I consider this effort crucially important, but it is fraught with difficulty. I lose patients over it; seeing that I don't accept their premises, they flee. Others stay and become heartbreakers. They slide ever further into their delusions. I conduct a rear guard action, trying to slow the march toward ever greater certainty about the dark forces.

If I cannot induce doubt, I try to make clear to the patient that others do not believe as he does. Likely he will lose his job if his beliefs emerge even in subtle fashion — and it is critical for him to keep his job, however humble. If a supportive family is available — and sometimes it is not, since genetics play their role — that safe haven can be of enormous help to patients. But my focus is generally on employment. Work is where skills count, where you can be valued despite your quirks. Work is where, if you are lucky, people will come to know and like you over time, even if you are "hard to live with." Work is where you can interact with people without having them intrude.

Beyond the workplace, another source of unobtrusive connection (so I find) is radio. Television serves, too, as does the Web, but to a lesser extent. I have written elsewhere about how a quite troubled patient with no interest in cars found solace in the company of hosts Tom and Ray Magliozzi when she listened to "Car Talk." Over the years, that program has charmed various of my paranoid patients. I see "Click and Clack" as co-therapists; they demonstrate a relaxed way of responding to life's inevitable frustrations. On the whole, public radio has this reasonable tone. I don't love it when patients spend the morning in bed listening to NPR, but there are worse influences. I certainly have had many patients who are mesmerized by the rant media and the politicians they feature and who come in wanting to discuss the outrage of the moment. I find that attachment less reassuring.

Because of what he is accused of doing, Loughner is an unsympathetic, even a horrifying figure. But Loughner's efforts to find work struck a responsive chord in me, as a clinician. According to the Wall Street Journal, Loughner had asked posters to an online forum, "How many applications... is a lot?" He had listed 21 retail outlets he had approached, including Domino's Pizza and Wendy's. He said he had lost or left jobs at Peter Piper Pizza, Quiznos and others. Although Loughner was disturbed, he did not at that point sound like an utterly alienated man — rather, one looking for acceptance somewhere. The attempts to study at Pima Community College also suggest some remnant of openness to social integration.

What did Loughner watch or listen to? We do not know. The Web and the media contain ideas as extreme as anyone might want. According to Newsweek, Loughner posted anti-government writings and videos based on the views of the right-wing conspiracy theorist David Wynn Miller. Did more mainstream media influence Loughner? Did fear- and hate-mongering pundits or politicians play a role?

Respected colleagues and columnists have been quick to say no. Shall we give Fox News, Glenn Beck, Sarah Palin and the others a quick pass? It is true that the biology of mental illness has its own imperative. But along with most other people, I do imagine that in a general sense social forces can mute, inflame or redirect impulses. That's what the time in the clinical office is about, in part: the use of interpersonal influence to moderate or channel emotions. Much political speech has the same aim.

The work that I do makes me suspect that creating a hysterical political environment has its costs. Many writers have commented on the corrosive effects of casual references to violence, along with the demonization of public figures and the glorification of gun ownership. I want to add a further consideration, implicit in the others, but worth separating out: tolerance, in the public sphere, for paranoia itself.

Two days before the shooting spree in Tucson, Brian Williams asked House Majority Leader John Boehner whether he would confront the claim that Barack Obama is not a natural-born citizen. In measured tones, Boehner gave a coy response: Hawaii's word is good enough for him, but it is not for him to tell others what to think. Watching the clip when it first aired, I thought, that stance must be risky, using a wink and a nod to leave the door open to patent falsehoods. I meant risky politically, in every sense. After all, the birther claim is a true conspiracy theory, dependent on the premise that government institutions are abetting a complexly plotted fraud.

When they argue their case that the plots they discern are real, paranoid patients arrive armed with examples of views more outlandish than their own. After all, my patients do not deny Darwinism or global warming. If they claim that the president of the United States is a conspirator secretly intent on socialism, it's a sign that they are far down a sad road. The public embrace of implausible beliefs creates a context of credulity. For my purposes, journalists and politicians who countenance conspiracy theories are the opposite of co-therapists; they are enablers. They stand as exemplars of a mode of being that scorns doubt, celebrates grievances, and reframes ordinary disagreements as indicators of sinister intent.

In the context of demonization and demagoguery, this embrace of paranoia helps to compose a politics of constant rage. It is convenient and convincing to say that no particular public figure is directly implicated in Loughner's actions. But I wonder whether finally the imputation of some responsibility is so easy to shed. Ω

[Peter D. Kramer is the author of Listening to Prozac and, most recently, Freud: Inventor of the Modern Mind. He practices psychiatry in Providence, RI, where he is Clinical Professor of Psychiatry at Brown University. Kramer received an A.B. from Harvard College with high honors in history and literature. He also received an M.D. from the Harvard Medical School.]

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Memorial Service, January 12, 2011
McKale Center on the University of Arizona campus
Remarks By President Barack Obama

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To the families of those we've lost; to all who called them friends; to the students of this university, the public servants gathered tonight, and the people of Tucson and Arizona: I have come here tonight as an American who, like all Americans, kneels to pray with you today, and will stand by you tomorrow.

There is nothing I can say that will fill the sudden hole torn in your hearts. But know this: the hopes of a nation are here tonight. We mourn with you for the fallen. We join you in your grief. And we add our faith to yours that Representative Gabrielle Giffords and the other living victims of this tragedy pull through.

As Scripture tells us:

There is a river whose streams make glad the city of God,

the holy place where the Most High dwells.

God is within her, she will not fall;

God will help her at break of day.

On Saturday morning, Gabby, her staff, and many of her constituents gathered outside a supermarket to exercise their right to peaceful assembly and free speech. They were fulfilling a central tenet of the democracy envisioned by our founders - representatives of the people answering to their constituents, so as to carry their concerns to our nation's capital. Gabby called it "Congress on Your Corner" - just an updated version of government of and by and for the people.

That is the quintessentially American scene that was shattered by a gunman's bullets. And the six people who lost their lives on Saturday - they too represented what is best in America.

Judge John Roll served our legal system for nearly 40 years. A graduate of this university and its law school, Judge Roll was recommended for the federal bench by John McCain twenty years ago, appointed by President George H.W. Bush, and rose to become Arizona's chief federal judge. His colleagues described him as the hardest-working judge within the Ninth Circuit. He was on his way back from attending Mass, as he did every day, when he decided to stop by and say hi to his Representative. John is survived by his loving wife, Maureen, his three sons, and his five grandchildren.

George and Dorothy Morris — "Dot" to her friends — were high school sweethearts who got married and had two daughters. They did everything together, traveling the open road in their RV, enjoying what their friends called a 50-year honeymoon. Saturday morning, they went by the Safeway to hear what their Congresswoman had to say. When gunfire rang out, George, a former Marine, instinctively tried to shield his wife. Both were shot. Dot passed away.

A New Jersey native, Phyllis Schneck retired to Tucson to beat the snow. But in the summer, she would return East, where her world revolved around her 3 children, 7 grandchildren, and 2 year-old great-granddaughter. A gifted quilter, she'd often work under her favorite tree, or sometimes sew aprons with the logos of the Jets and the Giants to give out at the church where she volunteered. A Republican, she took a liking to Gabby, and wanted to get to know her better.

Dorwan and Mavy Stoddard grew up in Tucson together — about seventy years ago. They moved apart and started their own respective families, but after both were widowed they found their way back here, to, as one of Mavy's daughters put it, "be boyfriend and girlfriend again." When they weren't out on the road in their motor home, you could find them just up the road, helping folks in need at the Mountain Avenue Church of Christ. A retired construction worker, Dorwan spent his spare time fixing up the church along with their dog, Tux. His final act of selflessness was to dive on top of his wife, sacrificing his life for hers.

Everything Gabe Zimmerman did, he did with passion — but his true passion was people. As Gabby's outreach director, he made the cares of thousands of her constituents his own, seeing to it that seniors got the Medicare benefits they had earned, that veterans got the medals and care they deserved, that government was working for ordinary folks. He died doing what he loved — talking with people and seeing how he could help. Gabe is survived by his parents, Ross and Emily, his brother, Ben, and his fiancĂ©e, Kelly, who he planned to marry next year.

And then there is nine year-old Christina Taylor Green. Christina was an A student, a dancer, a gymnast, and a swimmer. She often proclaimed that she wanted to be the first woman to play in the major leagues, and as the only girl on her Little League team, no one put it past her. She showed an appreciation for life uncommon for a girl her age, and would remind her mother, "We are so blessed. We have the best life." And she'd pay those blessings back by participating in a charity that helped children who were less fortunate.

Our hearts are broken by their sudden passing. Our hearts are broken — and yet, our hearts also have reason for fullness.

Our hearts are full of hope and thanks for the 13 Americans who survived the shooting, including the congresswoman many of them went to see on Saturday. I have just come from the University Medical Center, just a mile from here, where our friend Gabby courageously fights to recover even as we speak. And I can tell you this — she knows we're here and she knows we love her and she knows that we will be rooting for her throughout what will be a difficult journey.

And our hearts are full of gratitude for those who saved others. We are grateful for Daniel Hernandez, a volunteer in Gabby's office who ran through the chaos to minister to his boss, tending to her wounds to keep her alive. We are grateful for the men who tackled the gunman as he stopped to reload. We are grateful for a petite 61 year-old, Patricia Maisch, who wrestled away the killer's ammunition, undoubtedly saving some lives. And we are grateful for the doctors and nurses and emergency medics who worked wonders to heal those who'd been hurt.

These men and women remind us that heroism is found not only on the fields of battle. They remind us that heroism does not require special training or physical strength. Heroism is here, all around us, in the hearts of so many of our fellow citizens, just waiting to be summoned - as it was on Saturday morning.

Their actions, their selflessness, also pose a challenge to each of us. It raises the question of what, beyond the prayers and expressions of concern, is required of us going forward. How can we honor the fallen? How can we be true to their memory?

You see, when a tragedy like this strikes, it is part of our nature to demand explanations — to try to impose some order on the chaos, and make sense out of that which seems senseless. Already we've seen a national conversation commence, not only about the motivations behind these killings, but about everything from the merits of gun safety laws to the adequacy of our mental health systems. Much of this process, of debating what might be done to prevent such tragedies in the future, is an essential ingredient in our exercise of self-government.

But at a time when our discourse has become so sharply polarized — at a time when we are far too eager to lay the blame for all that ails the world at the feet of those who think differently than we do — it's important for us to pause for a moment and make sure that we are talking with each other in a way that heals, not a way that wounds.

Scripture tells us that there is evil in the world, and that terrible things happen for reasons that defy human understanding. In the words of Job, "when I looked for light, then came darkness." Bad things happen, and we must guard against simple explanations in the aftermath.

For the truth is that none of us can know exactly what triggered this vicious attack. None of us can know with any certainty what might have stopped those shots from being fired, or what thoughts lurked in the inner recesses of a violent man's mind.

So yes, we must examine all the facts behind this tragedy. We cannot and will not be passive in the face of such violence. We should be willing to challenge old assumptions in order to lessen the prospects of violence in the future.

But what we can't do is use this tragedy as one more occasion to turn on one another. As we discuss these issues, let each of us do so with a good dose of humility. Rather than pointing fingers or assigning blame, let us use this occasion to expand our moral imaginations, to listen to each other more carefully, to sharpen our instincts for empathy, and remind ourselves of all the ways our hopes and dreams are bound together.

After all, that's what most of us do when we lose someone in our family — especially if the loss is unexpected. We're shaken from our routines, and forced to look inward. We reflect on the past. Did we spend enough time with an aging parent, we wonder. Did we express our gratitude for all the sacrifices they made for us? Did we tell a spouse just how desperately we loved them, not just once in awhile but every single day?

So sudden loss causes us to look backward — but it also forces us to look forward, to reflect on the present and the future, on the manner in which we live our lives and nurture our relationships with those who are still with us. We may ask ourselves if we've shown enough kindness and generosity and compassion to the people in our lives. Perhaps we question whether we are doing right by our children, or our community, and whether our priorities are in order. We recognize our own mortality, and are reminded that in the fleeting time we have on this earth, what matters is not wealth, or status, or power, or fame — but rather, how well we have loved, and what small part we have played in bettering the lives of others.

That process of reflection, of making sure we align our values with our actions — that, I believe, is what a tragedy like this requires. For those who were harmed, those who were killed — they are part of our family, an American family 300 million strong. We may not have known them personally, but we surely see ourselves in them. In George and Dot, in Dorwan and Mavy, we sense the abiding love we have for our own husbands, our own wives, our own life partners. Phyllis — she's our mom or grandma; Gabe our brother or son. In Judge Roll, we recognize not only a man who prized his family and doing his job well, but also a man who embodied America's fidelity to the law. In Gabby, we see a reflection of our public spiritedness, that desire to participate in that sometimes frustrating, sometimes contentious, but always necessary and never-ending process to form a more perfect union.

And in Christina... in Christina we see all of our children. So curious, so trusting, so energetic and full of magic.

So deserving of our love.

And so deserving of our good example. If this tragedy prompts reflection and debate, as it should, let's make sure it's worthy of those we have lost. Let's make sure it's not on the usual plane of politics and point scoring and pettiness that drifts away with the next news cycle.

The loss of these wonderful people should make every one of us strive to be better in our private lives — to be better friends and neighbors, co-workers and parents. And if, as has been discussed in recent days, their deaths help usher in more civility in our public discourse, let's remember that it is not because a simple lack of civility caused this tragedy, but rather because only a more civil and honest public discourse can help us face up to our challenges as a nation, in a way that would make them proud. It should be because we want to live up to the example of public servants like John Roll and Gabby Giffords, who knew first and foremost that we are all Americans, and that we can question each other's ideas without questioning each other's love of country, and that our task, working together, is to constantly widen the circle of our concern so that we bequeath the American dream to future generations.

I believe we can be better. Those who died here, those who saved lives here — they help me believe. We may not be able to stop all evil in the world, but I know that how we treat one another is entirely up to us. I believe that for all our imperfections, we are full of decency and goodness, and that the forces that divide us are not as strong as those that unite us.

That's what I believe, in part because that's what a child like Christina Taylor Green believed. Imagine: here was a young girl who was just becoming aware of our democracy; just beginning to understand the obligations of citizenship; just starting to glimpse the fact that someday she too might play a part in shaping her nation's future. She had been elected to her student council; she saw public service as something exciting, something hopeful. She was off to meet her congresswoman, someone she was sure was good and important and might be a role model. She saw all this through the eyes of a child, undimmed by the cynicism or vitriol that we adults all too often just take for granted.

I want us to live up to her expectations. I want our democracy to be as good as she imagined it. All of us — we should do everything we can to make sure this country lives up to our children's expectations.

Christina was given to us on September 11th, 2001, one of 50 babies born that day to be pictured in a book called Faces of Hope. On either side of her photo in that book were simple wishes for a child's life. "I hope you help those in need," read one. "I hope you know all of the words to the National Anthem and sing it with your hand over your heart. I hope you jump in rain puddles."

If there are rain puddles in heaven, Christina is jumping in them today. And here on Earth, we place our hands over our hearts, and commit ourselves as Americans to forging a country that is forever worthy of her gentle, happy spirit.

May God bless and keep those we've lost in restful and eternal peace. May He love and watch over the survivors. And may He bless the United States of America. Ω

[Barack H. Obama was born on August 4, 1961, at Kapi'olani Maternity & Gynecological Hospital (now called Kapi'olani Medical Center for Women & Children) in Honolulu, Hawaii. Obama was elected President of the United States of America in 2008. He graduated with a B.A. in political science from Columbia University and received a J.D. (magna cum laude) from the Harvard Law School.]

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