Another DSM-5 revision seeks to collapse “alcohol dependence” and “alcohol abuse,” two separate diagnoses, into “alcohol use disorder.” Where DSM-III defined addiction in terms of dependence (clearing the whiff of conversion and transience that surrounds alcoholism and alcoholic), alcohol use disorder reconceives addiction more explicitly as a brain disease, even as it spreads open a diagnostic spectrum. If it feels like the culmination of a blame-conscious trend in the nomenclature, the fine-tuning of alcohol use disorder’s criteria is potentially infinite. On the table now is the removal of alcohol-related legal trouble from the checklist (since state laws differ about things like drunk driving, it is seen as an unreliable marker) and adding alcohol craving. Consensus on what constitutes “craving” is already proving elusive, which might indicate why it was left off the list for so long. An Australian study published in Addiction, a scientific journal, and presented at the conference suggested that adopting this new classification would lead to a 60 percent increase in diagnoses; in the United States that number has been estimated at up to twenty million newly diagnosed addicts.
Because a second DSM diagnosis often accompanies their addiction problem, substance abusers offer a stark example of how close psychiatry remains to its predicament of a century ago, where symptoms and diseases refuse to separate and assume their proper order. Did the anorexic stop eating because she was depressed, or did malnutrition cause her mood to plummet? Was depression a response to stress or molecular mutation? Was a gene marker for compulsion turned on by circumstance?
The Greek idea that personal identity derives from what we do and how we are perceived has been adjusted for an inward-facing culture: you are what you have, and you have what you do. Instead of reckoning with the world, reckoning with your illness is the path to self-discovery. But what if owning your ADHD and responsibly re-upping your Adderall scrips is actually hindering the passage into self? What if we are masking the mysterious cause of so much spiritual and emotional suffering by calling it a psychiatric disease? What if we never stopped being what we do, and that’s the better part of the problem?
Separating symptoms from disorders—those who feel depressed from those who are depressed or have depression—according to a keenly intuitive discretion is the clinician’s job. As waves of psychiatrists forsake traditional forms of talk therapy in favor of the lucrative prescription-writing business, the issue of causality recedes from “a philosophical problem with no defined answer,” as one conference presenter put it, to an afterthought defined by default, once a drug treatment is found to suggest that a mental illness is based in bio-pathology. But psychiatry’s sibling worship of science is critically flawed: the biological basis of disease is self-evident; it doesn’t need to be proven. At stake is the cause—of diabetes, of heart disease, of lupus. Only by understanding a cause can cures be determined and vaccines developed. It’s why cancer treatments are so brutal and imprecise. It’s why my thirty-six-year-old uncle, an immunologist, died of a heart attack after sloppy radiation treatments for lymphoma weakened his brachial artery. We still don’t understand cancer’s causes, so we do battle with its effects. By turning to science to prove the existence of sadnesses, compulsions, darkened or deluded minds, and disordered behavior our own experience has already confirmed, we are denying a complexity of self that only language and the continuum of lived experience can contain.
Allen Frances thinks money and hubris have corrupted the APA, that it can no longer be trusted to define the terms of mental health. “They overvalue what they think they know,” he told me. “There’s a certain lack of humility for the great unknown, particularly with the impact of this new neuroscience.” Frances doesn’t believe there’s a new wave of reactive pathologies and takes a question about that possibility as an opportunity to reiterate that the one thing that hasn’t changed in the last twenty years is clinical psychiatry—certainly not based on anything brain scans have turned up so far. So why change its handbook?
“Once you write the book, it can be easily distorted,” Frances said, “and you have no control over it. We had every reason to think that autism would not become an epidemic, that ADHD would not become an epidemic, because we did cautious—fairly cautious things. And that thing blew out of control.” He paused. “These suggestions, they slope the curve of normality.”
When I told Frances that post–DSM-IV autism numbers have altered my thinking about having children of my own, his answer was immediate: “I don’t think you should have children for other reasons, but autism isn’t one of them.” He looked away. “The world’s too crowded.”
* * *
It was fixing to rain on Waikiki. Having checked out of my hotel and blown off the conference’s final-afternoon dregs, I had eight hours and nothing but beach until my flight back to Los Angeles.
It was like breathing wet T-shirt on the strip, so I headed into one of the nearby outlets—a Billabong, if you must know—with nothing in particular in mind. This used to be a fairly safe option. The part of the retail world not geared toward my concrete desires, which were finite and never extended far beyond food, travel, and clothing, was busy proposing possible aspirations, which were infinite, and involved things like hair extensions, handbags, and expanding every part of my physiognomy I wasn’t obsessed with shrinking. No part of it was not interested in some present or future part of me. We existed in a kind of mutually reinforcing harmony that way.
Inside the store, carefully curated indie-punk-ska fusion droned from corner speakers and a backwash of sand covered the floor. The salespeople appeared as polished preadolescents, and within a minute two of them had addressed me as ma’am. Except for the sand, which I may have imagined, all of these things have happened before. At some point, though, while moving between rack after rack of what suddenly looked to me like clothing designed for sub-life-size sculptures made by intelligent aliens working from rumors of the human form, I realized what was happening. Determined to drop myself from this thing’s greatest height, I pulled a fitted, many-pouched jacket and what looked to be a reasonable pair of cargo pants from their hangers and headed for the changing room.
I can’t really describe what happened next, except to say that I faced the inconceivable, and it was not cool.
* * *
I took the only retail job I’ve ever had during a summer at home in Toronto, after my first year in New York City ended with what I came to describe as a nervous breakdown.
I had always been curious about that phrase. It sounded both mysterious and meaningless—the refuge of Victorian romantics, maybe, or the girls at my grade school who went around, to my voluble scorn, proudly announcing their PMS. And yet there was nothing else to call it, and no way to leave it unnamed. Symptoms: incapacitating loneliness, exhaustion; extreme susceptibility to common viruses, anemic chest pains. Onset: sequoia slow, then all at once.
A couple of times a week that summer I walked over to the high-end boutique where a friend of a friend had offered me a twelve-dollar-an-hour gig doing inventory and stocking shelves. The boutique, since deceased, exemplified a new kind of retail: the concept of the old general store rarefied to scale. They sold their parent company’s boot-cut jeans and plush peacoats alongside towels in unexpected colors and designer stemware; Italian kitchen implements mingled with seasonal-print pajama bottoms.
I had asked to stay mostly in the back, where I stacked seat covers and reorganized shelving units filled with scented candles and camisoles. Too much time in public, with people I didn’t know, felt dangerous. There was this hideous fragility. An incident in a sandwich shop had left me in a heap on the bathroom floor. For weeks, even small unkindnesses spelled chaos. I appreciated the calm of the stockroom, where I could bring order to the merchandise, stepping onto the floor now and then to watch the show. I was grateful for a place to go.
Cracking up meant asking for help. Deciding that I had, in fact, cracked up was liberating in this regard. Dreading my own company, all summer I foll
owed family and friends from room to room, auditing weekend trips and errands to the hardware store as though they might save my life. I tried therapy, briefly, but it was too late for that. It was too late for a thumbs-up in the dike.
At its core it was a problem of context. Flailing around inside my own poorly defined limits, I had lost my place. The rituals of youth no longer mark our passages with any authority. We reach maturity any number of times—biologically, religiously, legally, academically, socially—before the age of twenty-one, but the imputation rarely sticks. The world will not be informed of your various arrivals, the world informs you. It probably always did, though multiplexity means better hiding places, more ways for the contingencies of time to splinter into crisis. It seems obvious to me now that tribal coming-of-age rituals are often designed to be searingly painful so they won’t leave any doubt. Because cut as many ribbons, engrave as much parchment, pound all the Jäger shots you like, the long and largely spouseless, childless, asset-free stretch of one’s twenties and thirties is not the ordered march into adulthood it has been.
And so, at some point, the options are made plain. The longer you wait to address them, the more basic they become. The world informs you and then you must decide. Slowly, sometimes moment by moment, small choices about whom and how to be beget bigger ones—shading in background, scaling out the continuum; striking out villains, fleshing in the overlooked—until the story begins to tell itself, with a fully fledged hero at its center. Here’s the gist: at twenty-nine, I broke down and became a woman.
Because the boutique was near a cluster of office buildings and a grocery complex, at lunchtime it teemed with working women. Wearing bright pedicures and the face of drift, they moved absently about the floor. It’s one of the most private rituals you will see a woman conduct in public: eye contact is discouraged and conegotiation strictly peripheral. Crossing domains—kitchen to bathroom, beauty to fashion, work to home—the women reached out blindly, caressing a crystal decanter, briefly adjudging a mandoline, letting the synthetic but reasonably silklike fabric of a peach-colored blouse slip through their fingers as they passed.
“They don’t know what they want,” the store manager shrugged one afternoon, after I remarked on her deft brokering of the sale of a three-hundred-dollar leather jacket. “You just have to tell them.”
I think of that summer in the stockroom when I see those women now—when I see us—arms outstretched, passing through the material world in a waking trance. I wish I could tell her what she wants. I wish I knew.
* * *
The sky was pouring as I hurried out of Billabong, youth officially over, and ran toward an open, sheltered structure on the beach. I sat at the third of its seven stone picnic tables, where one muttering woman was quickly replaced by another—a Hawaiian for a blonde. At the next table five men were playing bridge. The blond woman pulled a woven mat from the green milk cart fastened to a set of wheels and spread it out on the ground behind me.
“You gotta be in by nine, out after six,” said the bald, mustached man with the Carolina accent. “New house rules.” The men murmured. “But you know what? I’m gonna break ’em.” He giggled like a Nick Ray delinquent, a real juvie. The blond woman in the pink floral dress pulled white wool and needles from the pink-and-black plastic suitcase beside her crate and began crocheting an infant’s skullcap. The chess game at a far table had attracted a crowd.
A gaunt, shirtless guy in orange shorts changed tables every fifteen minutes, bicycle in tow. The Hawaiian with the dangling cigarette and HANG LOOSE trucker hat had placed a blue cushion between his butt and the stone slab. A stringy blond hustler blew through the shelter, talking up a designer-sneaker windfall. The bridge club ignored him and he skittered away, sorry for their loss. The Hawaiian snorted, “Wasn’t he the one with the coffee yesterday?”
I had been sitting there for about an hour when a shoeless man with bursting-blue eyes and a badly scabbed face and hands took a seat directly across from me. His thick head of eggshell-white hair was well combed with pomade on one side, but mussy and crusted with bird shit on the other. He was small and shambling with bright, vaudevillian features and hid a minibottle of vodka in his right hand. We looked at each other for a second or two.
“I am des-per-ate,” he announced, watching me. “I am desperate … for some intelligent conversation.” It was a great opener and he knew it. I smiled, setting down my pen, and inquired as to how I had qualified for the job.
“You have no computer,” he said, waving over my belongings. “You have a notebook, and a pen—longhand, that’s the way to go.” I laughed by way of agreement. There suddenly seemed an awful lot to laugh about.
“Everybody has a story,” he said with a topic-changing rap of the table. “I’m an alcoholic. What’s your story?”
I told him I’d bet there was more to it; he shrugged, then said that he used to be a writer too. Is that so? It is, he said, for a show called Cheers—maybe I knew it? I laughed—again—and said maybe I did. After some prodding he recounted the best joke he ever wrote, a slow burn for Sam Malone involving a gas station, nasty cologne, and a botched seduction. The punch line eluded me but I gave it up anyway. He was a Vietnam combat veteran, he mentioned in passing. He used to edit fiction for hire.
“Have you ever tried to write a novel?” he asked, spreading both hands out and dividing the space between them into three with his left one. “I show them what they’re doing wrong, almost like a schoolteacher.”
I wanted to know what happened in California; he only grew maudlin about the money Ted Danson had shrugged off for one last season of Cheers—a decades-old refusal still at the forefront of all the things he couldn’t understand. Patricia Richardson—same thing. And to think, she wasn’t even that well known.
“Not much to look at. Nothing up here,” he said, cupping his hands over his chest. “She should have taken the twenty million and run.” He shook his head. Who wouldn’t? He talked about Andy Ackerman and David Angell, the Cheers producer who was on American Airlines Flight 11: “We lost him.”
My companion went on quickly, with no time for follow-ups, tacking in a new direction when I asked for more detail. He was a gambler—twenty-one and Texas Hold’em, mostly, and followed a show called Poker at Night, where a woman—again, not much to look at—had just cleared close to a million dollars. He confused the show’s name but remembered the exact number: $930,000. He’d never bet more than eighteen hundred.
From there it was back to comedy. “I’m not a racist,” he said, naming off his favorites—Woody Allen, the Marx Brothers—“but these are all Jews. They’re the best at comedy: you just can’t beat ’em.”
When a friend at the next table offered a sandwich from the ABC Store across the street, the man squeezed my arm as he stood to leave. I asked his name—still dazed by his absurdly improbable appearance and hoping he might hang around—but couldn’t make out his reply. I asked again, and he frowned.
“I’m fay-mous!” he sang, shuffling past. “Everybody knows me.”
About an hour later, when I rose to leave, the man in the inside-out, oatmeal sweatshirt was too far gone to talk. He had sent his friend back to ABC for more vodka. The bridge game had broken up, small bills were exchanged, parties dispersed. I told him I wanted to say goodbye and thank him for the conversation. Would he give me his name? I don’t know why but I was stuck on it.
“What would you want with me?” he asked miserably, propping his head in both hands. “I’m a piece of garbage.” I said it wasn’t true and pushed a piece of paper with my e-mail on it in front of him. Again, I don’t know why. He’d mentioned having an e-mail address but it was submerged in vodka by then. A young black man watching from two tables over gestured for me to come speak with him. He had heard the city was sending out homeless relief—was I it?
Who winds up in Hawaii? Statistically, it has one of the ten lowest rates of depression in the country. It was named America’s happiest state for the
third year in a row in 2011, according to something called the Gallup-Healthways Well-Being Index. Statistically, alcohol hospital admissions are trending downward, while methamphetamine use has seen a 20 percent spike. Hawaii is in the top tier of drug users with “unmet treatment needs.” Its rate of patients admitted to the ER with secondary psychiatric problems has doubled in the last fifteen years. These are the numbers.
“You really want to talk to me?” The old man seemed wistful, as though I’d just fanned out Danson’s millions. I said I did. What was his name? With his head hanging low, he began grappling blindly with his wallet. I stood puzzled, then pained, by his objective. At length he pulled out a pristine twenty-dollar bill and lifted it into the space between us. I said no—please. No, thank you. I squeezed his arm. And goodbye.
* * *
Just to the left of the picnic shelter is the Waikiki strip, ever streaming with tourists carrying ABC bags on their way to their next meal, or purchase, or rest in between those two things. To the right is the beach, where a family of three, a toddler and her parents, were camped for the day. All afternoon a ritual played out: The little girl let out an icy scream each time her father returned her to the ocean, sometimes permitting submersion, sometimes not. Always she reserved the right—between burying her face in his neck and turning to contemplate the waves—to reconsider. You didn’t need to hear her cries to know them: Don’t let go of me, Daddy! Daddy—don’t let go! You heard him too: Button, have I ever?
Beyond the family is shoreline, then a stone breaker. Beyond that are dozens of surfers, small and silhouetted, like penguins riding on personal floes. They wait and wait and intermittently rise up. Finding their footing, they stand like inukshuks on the horizon, under a perfect ceiling of cloud. One at a time they crouch and twist with the waves, more than human, bypassing the human altogether. Beyond the surfers are the sailboats, beyond them the warships, and beyond those the thin, levitating line between sea and sky.
This Is Running for Your Life Page 19
