The Pain of Neverland

One goal in my work is to provide insight into maladaptive patterns in the way people go about their lives; one goal with the blog will be to take a look at the more obvious examples of psychodynamic principles as they play out in society.

I wrote this introduction to readers of the Healthcare Professionals Network shortly after the tragic death of pop icon Michael Jackson. As I mulled over a topic and listened to the news reports, I realized that my professional experiences come together in such a fitting way in regard to his life and death that I had to make reference to the tragedy; I apologize for being opportunistic.

I am a psychiatrist with a psychodynamic approach to diagnosis and treatment. One goal in my work is to provide insight into maladaptive patterns in the way people go about their lives; one goal with the blog will be to take a look at the more obvious examples of psychodynamic principles as they play out in society. The unconscious mind lives in a fantasy world of ‘primary process thinking’ where constraints from time, money, and other ‘buzz-kills’ of mature thought wield no power. We each have our unconscious fantasies, often at conflict with the limitations imposed by adult reality. Michael Jackson was in many ways a man living in a ‘primary process’ world, a ‘Peter Pan’ who never had to mature and face the facts, too wealthy and famous for anyone to stand in his way and say ‘you can’t have a merry-go-round—Grow up!! I will add the important caveat that I never met him, never even met someone who met him, so this is all just a guess. But we do a lot of guessing in psychodynamic psychiatry, so the point is still worth discussing.

My second connection with the Michael Jackson story is that I have significant experience with opiate dependence, and the relationship between opiate dependence and the treatment of chronic pain. I expect (another educated guess) that opiates played a role in Mr. Jackson’s death. I know too well the world of desperate addicts who consciously or unconsciously manipulate others to keep drugs available and keep sickness at bay. And like many physicians who deal with chronic pain, I know the pressure one feels when a patient has paid money in order to receive respite, and complains of aches and pains from years of dancing, spinning, jumping, and kicking—a world that surely left Mr. Jackson with osteoarthritis and chronic pain. Michael Jackson, I would surmise (sounds better than ‘guess’), developed the misguided but common notion that narcotics were appropriate and helpful for such aches and pains, when in reality they are only a seductive pathway to misery and desperation, as tolerance demands higher and higher doses of the narcotics and dependence prevents going without the drugs for longer than a few increasingly-miserable hours.

But there is more. I am Board Certified in Anesthesiology (having taken the Boards back in the days of lifetime certification!) and I worked as an anesthesiologist and pain doc for almost ten years. I pushed a large amount of Diprivan (Propofol) ‘back in the day’, making me more of an expert than many of the TV docs who I heard refer to the milky induction agent as a ‘sleeping medicine’—kind of like calling Fort Knox a ‘piggy bank.’ And the final reason for my connection with Michael Jackson is perhaps the most significant reason: I know how to moon walk. This last point alone puts me in a very select group of physicians—and was, I would again guess, the reason I was given the opportunity to write this blog.

I cannot promise that every blog post will come together in such a fascinating way (just say it—oh puh-leaze!!), but my general approach will be to try to remind the field of psychiatry that even as we learn more about brain function, and even as we develop better medications to treat psychiatric illness, psychiatry will always be a field concerned with the mind. I have a PhD in neuroscience and was, in the 1980s, a ‘grind and bind’ guy; tearing up rat neural membranes, spinning them down, and measuring the binding qualities of various radio-labeled chemicals, so I know the temptation for seeing the brain as a mass of chemical and electrical signals. But no understanding of neurochemistry will come close to explaining the thoughts and emotions of Michael Jackson, particularly in his last days, when he wanted so badly to turn off his brain that he resorted to using an anesthetic induction agent to quiet his thoughts at the end of the day. I have to wonder: were there no nice thoughts to focus on, to help tolerate the nighttime awake? Diprivan hurts when it is injected, and patients often wince in pain as they drift off to sleep in the operating room. But apparently the alternative was even more painful… which brings us back to an interesting thought.

As I said earlier, we all have our unconscious, primary-process fantasies. Some of us fly; I used to have wonderful dreams of jumping so high that I was nearly flying, and in a primary-process world it never hurts to land. Some have fantasies of limitless riches, or perfect love. But a person who had perhaps the best opportunity to live in the world of fantasy—in a world where people only say ‘yes’, and where pet monkeys are only a phone call away—was unable to tolerate such an existence. Why would that be? There is surely an important lesson for all of us in the tragic story of the boy living in Neverland; an ‘aha experience,’ or a moral to the story. I won’t spend any more of our time musing about the answers, since my answers would surely be different than yours. But the fun thing about psychodynamic psychiatry is that there is always a lesson, a story, or an ‘aha experience’ there for the taking for all of us, if we look for it.

I look forward to talking with you again.