Ketamine: An Update

In 2016, I wrote Ketamine Research In A New Light, which discussed the emerging consensus that, contra existing theory, ketamine’s rapid-acting antidepressant effects had nothing to do with NMDA at all. I discussed some experiments which suggested they might actually be due to a related receptor, AMPA.

The latest development is Attenuation of Antidepressant Effects of Ketamine by Opioid Receptor Antagonism, which finds that the opioid-blocker naltrexone prevents ketamine’s antidepressant effects. Naltrexone does not prevent dissociation or any of the other weird hallucinatory effects of ketamine, which are probably genuinely NMDA-related. This suggests it’s just a coincidence that NMDA antagonism and some secondary antidepressant effect exist in the same drug. If you can prevent an effect from working by blocking the opiate system, a natural assumption is that the effect works on the opiate system, and the authors suggest this is probably true.

In retrospect, there were warnings. The other study to have found an exciting rapid-acting antidepressant effect for an ordinary drug was Ultra-Low-Dose Buprenorphine As A Time-Limited Treatment For Severe Suicidal Ideation. It finds that buprenorphine (the active ingredient in suboxone), an opiate painkiller also used in treating addictions to other opiates, can quickly relieve the distress of acutely suicidal patients.

This didn’t make as big a splash as the ketamine results, for two reasons. First, everyone knows opiates feel good, and so maybe this got interpreted as just a natural extension of that truth (the Scientific American article on the discovery focused on an analogy where “mental pain” was the same as “physical pain” and so could be treated with painkillers). Second, we’re currently fighting a War On Opiates, and discovering new reasons to prescribe them seems kind of like giving aid and comfort to the enemy.

Ketamine is interesting because nobody can just reduce its mode of action to “opiates feel good”. Although it was long known to have some weak opiate effects, it doesn’t feel good; all the dissociation and hallucinations and stuff make sure of that. Whatever is going on is probably something more complicated.

The psychiatric establishment’s response, as published in the prestigious American Journal of Psychiatry, is basically “well, f@#k”. Here we were, excited about NMDA (or AMPA) giving us a whole new insight into the mechanisms of depression and the opportunity for a whole new class of treatment – and instead it looks like maybe it’s just pointing to The Forbidden Drugs That Nobody Is Supposed To Prescribe. The article concludes that ketamine should not be abandoned, but ketamine clinics under anaesthesiologists should be discouraged in favor of care monitored by psychiatrists. I will try not to be so cynical as to view this as the establishment seizing the opportunity for a power grab.

What happens now? A lot of this depends on addiction. One way we could go would be to say that although ketamine might have some opiate effects, it’s not addictive to the same degree as morphine, and it doesn’t seem to turn users into drug fiends, so we should stop worrying and press forward. We could even focus research on finding other opiates in a sweet spot where they’re still strong enough to fight depression but not strong enough to get people addicted. Maybe very-low-dose-buprenorphine is already in this sweet spot, I don’t know.

But all of this is going to be shaped by history. Remember that heroin was originally invented (and pushed) as a less-addictive, safer opiate that would solve the opiate crisis. Medicine has a really bad habit of seizing on hopes that we have found a less addictive version of an addictive thing, and only admitting error once half the country is addicted to it. And there are all sorts of weird edge cases – does ketamine cross-sensitize people to other opiates? Does it increase some sort of domain-general addiction-having-center in the brain? I know substance abuse doctors who believe all of this stuff.

Also, should we start thinking opiates have some sort of deep connection to depression? “Depression is related to the stuff that has the strongest effect on human happiness of any molecule class known” seems…actually pretty plausible now that I think about it. I don’t know how much work has been done on this before. I hope to see more.

Source: Ketamine: An Update

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He makes no effort in bed

Suzi Godson

Q My husband is continually surprised that I don’t feel like having sex very often, despite the fact that he does nothing to turn me on. If we try to talk about it, we end up in a blame game. How can I make it really clear that he needs to make an effort to have a good sex life?

A It is so easy to turn the marital bed into a battleground. At first glance, the situation you describe sounds fairly straightforward: you feel aggrieved that your sexual needs are being ignored by your husband. Since he never makes an effort to turn you on, how could he possibly be surprised that you can’t be bothered engaging in sex? And since he never listens when you tell him how you feel, you ignore his pleas for intimacy. Frustratingly, he doesn’t seem to understand any of this, so you are searching for a more explicit way to make your feelings clear to him.

 

Ultimately, it sounds if you are blaming him for your unhappiness — therefore it is his responsibility to fix the situation. While that sounds like a rational argument, it doesn’t sound like a very positive sign for your relationship. Numerous studies have found sexual satisfaction to be a very reliable measure of marital satisfaction, but the opposite is also true; problems within a relationship often manifest as sexual difficulties. Perhaps the feelings you have about sex reflect bigger concerns about how little your husband does for you in general. However, for many people sex is a way of expressing emotional intimacy. Therefore, shutting down such an important line of communication is cutting off your nose to spite your face.

When two people know each other very well, as I presume you do, they become acutely sensitive to shifts in each other’s mood. Partners mirror each other’s emotions and behaviours, which is fine if you are yawning, or giggling, but not so fine if you are fighting. Multiply irritability by two and negative feelings spiral downwards much more rapidly. If you don’t communicate properly, things can progress from bad to worse until one day the relationship becomes so toxic that you might decide that it is over.

Tit for tat is a highly destructive form of communication, but fortunately it is one that is very easy to avoid. All that needs to happen is for you to hold up a white flag and say: “I’m sorry.” Maybe you feel as if you have nothing to apologise for — but that’s not the point. Mutual accountability is the first rule of healthy relationships and being big enough to take responsibility for your part in whatever bad feeling has been polluting your relationship is the quickest way to change the dynamic. When things go wrong between two people, it is very rarely one person’s fault entirely, and it is often a lot easier for the person who has less to feel ashamed of to climb down.

When it comes to sexual relationships, the best way to effect positive change is to do unto others as you would have them do unto you. If you want your husband to be more flirtatious with you, be more flirtatious with him. If you want him to kiss you and tease you and whisper sweet nothings in your ear, kiss him and tease him and tell him what you want him to do to you. Sweetness, playfulness and sexual generosity are contagious behaviours that create love, joy and enthusiastic reciprocity, so instead of giving your husband the cold shoulder, call a ceasefire and make love, not war. You will be much happier.

Religie als therapie

Religie als therapie: ‘We hebben allemaal behoefte aan onze God’

Hij verrichtte pionierswerk naar de verwerking van trauma’s uit de kindertijd. En hij muntte het begrip ‘veerkracht’. Maar één ding heeft hij zijn leven lang onderschat, zegt Boris Cyrulnik: ‘De rol van God.’ Om dat goed te maken, schreef de beroemde Franse neuropsychiater het boek God als therapeut.

 

Religie als therapie: 'We hebben allemaal behoefte aan onze God'
‘Almaar meer jongens en meisjes zijn doodsbang voor de vrijheid waarin ze geboren zijn.’ © iStock

Boris Cyrulnik, die in juli zijn eenentachtigste verjaardag vierde, is wereldberoemd om zijn baanbrekende onderzoek naar traumaverwerking. In 2001 publiceerde hij zijn ultieme bestseller Les vilains petits canards, vertaald als Veerkracht. Daarin bouwde hij verder op de hechtingstheorie van de elf jaar eerder overleden Britse psychiater John Bowlby. Kinderen, zei Bowlby, zijn geprogrammeerd om zich te hechten aan hun ouders of opvoeders. Als die hechting fout loopt, betalen ze daar soms een levenslange prijs voor, in de vorm van angst, depressie, verslaving, relatieproblemen. Volgens Cyrulnik ligt de sleutel voor heling, en misschien zelfs voor herstel van een onveilige of mislukte hechting, op de bodem van de put: onze natuurlijke veerkracht – résilience, in het Frans – is onze beste bondgenoot in de strijd tegen de gevolgen van vreselijke trauma’s als oorlog, incest, terreur, mishandeling of misbruik. Gespecialiseerde therapie kan daarbij helpen.

Boris Cyrulnik, God als therapeut: waarom mensen zich hechten aan een god, Lannoo, 272 blz., 24,99 euro.
Boris Cyrulnik, God als therapeut: waarom mensen zich hechten aan een god, Lannoo, 272 blz., 24,99 euro.

In 2010 had de neuropsychiater een ervaring waardoor hij op dat inzicht zou voortbouwen. ‘In Congo, in een opvangcentrum van Unicef, ontmoette ik kindsoldaten. Het waren zwaar getraumatiseerde jongens. De kracht die zij uit hun geloof putten verraste me’, zegt hij. ‘Een jongen van een jaar of tien zei tegen me, met ogen vol angst: “Ik voel me alleen goed in de kerk.” Het instituut kerk en God leken hem veerkracht te geven. Meteen wilde ik dat fenomeen dieper onderzoeken, met behulp van de moderne psychologie, de neurowetenschappen en de hechtingstheorie. Ik kon niet anders dan vaststellen: God is soms een uitstekende therapeut.’ In 2017 leidde die vaststelling tot het boek Psychothérapie de Dieu, waarvan de vertaling God als therapeut nu uit is.

Ons beeld van God wordt al bepaald terwijl we nog baby’s zijn, schrijft u. Daarbij zullen veel lezers de wenkbrauwen fronsen.

Boris Cyrulnik: Natuurlijk zal geen enkel kind voor zijn twintigste levensmaand een zinnig woord zeggen. Natuurlijk gelooft geen enkele pasgeborene in God. Maar ouders presenteren hun godsbeeld wel aan hun baby. Later zal dat kind hun geloof overnemen; het is eigenlijk een teken van hun wederzijdse affectie. Ook atheïstische moeders en vaders delen hun spiritualiteit met hun kind, alleen is de figuur van God dan vervangen door bijvoorbeeld muziek of literatuur, of door de grote humanistische waarden.

Welnu, het belangrijkste is dat die spirituele link met zijn ouders de interne wereld van het kind voedt, lang voor het zijn eerste woordjes brabbelt. Een kind ontwikkelt zich altijd in een context, en neemt van daaruit gebeurtenissen waar. Door de verhalen van onze ouders over God of het spirituele zijn we, zodra we beginnen te spreken, ook in staat om een wereld te voelen die niet waarneembaar is. We zijn gehecht geraakt aan God zoals we gehecht zijn aan onze ouders: Hij geeft structuur aan ons bestaan – en bij uitbreiding aan onze samenleving.

Hoe rijmt u dat inzicht met de vaststelling dat God de voorbije decennia zo massaal de deur gewezen is?

Cyrulnik: Laat ik het voorbeeld geven van Canada. Generaties lang waren God en de kerk in dat land ontzettend belangrijk, tot daarmee in amper één generatie komaf is gemaakt. De verklaring daarvoor, volgens mij, is dat de staat er de rol van God heeft overgenomen. De Canadese overheid voorziet nu in alles wat een kind nodig heeft: school, bescherming en veiligheid.

Religie als therapie: 'We hebben allemaal behoefte aan onze God'
© ©Julien FAURE/Leemage

Welnu, wij lijken allemaal een beetje op Canada. Hoe beter het ons vergaat, hoe kleiner onze behoefte aan God. Ervaren we vrede, welzijn en welvaart, dan zetten we Hem gemakkelijk aan de kant. Maar: de dag dat we een geliefde verliezen of ons leven aan een zijden draadje hangt, richten we ons, al dan niet ver van de schijnwerpers, met onze smeekbeden naar boven. Op die momenten wordt God onze therapeut.

Dat veel ongelovigen zich nog altijd laten begraven in gewijde aarde is daarvan ook een teken?

Cyrulnik: Zulke rituelen zijn onze bakens, ja. Ze bieden ons troost. Ze zijn belangrijk voor onze psychische gezondheid. Op het moment dat de staat God vervangt, verliezen we een pak van die bakens. Dat verlies van God impliceert ook een verlies aan waarden, ethiek en moraliteit. Dat is problematisch, want hoe meer we ons hechten aan het materiële, hoe egoïstischer we worden. We vergeten dan hoe we moeten samenleven. Een kind leert dan niet langer om rekening te houden met anderen, en empathie wordt selectiever.

Een opvoeding met God kan toch ook tot onvoorstelbare gruwel leiden? Denk maar aan de kinderen van de IS.

Cyrulnik: Zodra een geloofsgemeenschap zich afsluit van de rest van de wereld, wordt het extreem gevaarlijk. In een sekte is er alleen nog empathie voor andere sekteleden. De buitenwereld móét bestreden worden, of op zijn minst genegeerd.

Kijk, de essentie is: we hebben allemaal behoefte aan onze God, maar er zijn vandaag op aarde 35.000 verschillende goden. Ze zijn stuk voor stuk nuttig en noodzakelijk voor alle mensen die in hen geloven: daar moeten we ons bewust van zijn.

Boris Cyrulnik

1937: geboren in Bordeaux

Studie: geneeskunde en psychiatrie aan de Faculté de médecine de Paris

– Is als neuropsychiater verbonden aan de Universiteit van Toulon

– Schreef verschillende populair-wetenschappelijke boeken over psychologie

– Introduceerde in 2001 zijn theorie over veerkracht bij het grote publiek

– Richtte in 2013 het Institut Petite Enfance in Savigny-sur-Orge op, voor de opleiding van hulpverleners en het onderzoek naar de vroege kinderjaren

Veel jonge mensen nemen uiteindelijk afscheid van de God van hun ouders.

Cyrulnik: Dat gold misschien voor uw generatie, maar ik merk dat jongeren vandaag naar de schaapsstal terugkeren, naar de God van hun voorouders en naar conservatieve waarden. Bij christenen, maar vooral bij moslims en joden zie ik die evolutie. Almaar meer jonge moslims hullen zich in kledij die de eerste volgelingen van de profeet Mohammed gedragen zouden hebben. Er worden zelfs bizarre zwempakken ontworpen én gedragen die in Arabische landen verboden zijn, omdat ze in strijd zouden zijn met de islam. En veel jonge joden zien het huwelijk niet langer als een bezegeling van de liefde tussen twee mensen, maar als een manier om onder toezicht van hun rabbijn de samenleving in te richten. Hun geseculariseerde ouders staan daar met open mond naar te kijken. Zij hebben zichzelf moeten vrijvechten van wat zij ervoeren als het juk van het geloof en de geestelijkheid – en nu nemen hun kinderen daar afstand van.

Hoe verklaart u die terugkeer naar God?

Cyrulnik: Praat met leerkrachten op lagere en secundaire scholen, en zij zullen u vertellen dat almaar meer jongens en meisjes worstelen met het huidige gebrek aan structuur in gezin en samenleving. Ze zijn doodsbang voor de vrijheid waarin ze geboren zijn. Ze hebben nood aan houvast, aan autoriteit een duidelijk opvoedkundig pad. Mag het verbazen dat ze dan vluchten in de armen van God?

De neoliberale droom is een leugen | De Volkskrant

 

The neurosurgeon Henry Marsh on why assisted dying should be legalised

Assisted dying is not euthanasia. It is about people making their own free choice that it’s time for their life to end, argues the neurosurgeon and bestselling author Henry Marsh

ILLUSTRATION BY NICOLAS CASTELL
The Sunday Times, 

I first discovered the dishonesty that can be involved in terminal care when I had to care for a man in the final stages of cancer of the colon in the early years of my surgical training. He had undergone an unsuccessful re-exploration of his abdomen for intestinal obstruction and had developed an especially unpleasant complication after the procedure. The anastomoses — the sutured joints we had made between the parts of his intestine that we had cut out — broke down and he developed multiple faecal fistulae through his abdominal wall. In other words, several holes appeared in his abdomen and, through these, faeces steadily oozed out. The smell was truly awful. He had been put in a side room and you had to take a deep breath before going in.

There was nothing we could do to help him. He was wide awake and I am sure that he knew what was happening and that he was dying. He must have seen the involuntary expressions on our faces as we entered his room, steeling ourselves to brave the stench. We started a heroin drip with a pump “to keep him comfortable”, and over a period of many days he died. I had been a doctor for three years by then, but felt utterly unequal to the task of discussing his death with him, partly because we were, in effect, trying to kill him with the heroin, but could not openly say so.

I remember him looking sadly into my eyes as I stood above him, trying to stop myself looking away out of the window, while nurses were carrying out the hopeless task of trying to keep his abdomen clean.

I will never know what he might have said if I had sat down beside him and talked to him openly. Was I frightened that he might ask me to “ease the passing”, as it is called in medico-legal language, and break the law? Was I frightened that I would have to admit to him that that was what I was trying to do? And was he equally frightened of such a conversation? It is always difficult to talk of death to a dying patient, but even now, 40 years later, I feel that I let this man down and was a coward.

There are many ways of dying. It can be fast or it can be slow, it can be painless or painful, it can be horrible, even in the modern age (whatever some palliative care doctors might claim to the contrary) or a peaceful fading away. But only rarely is dying easy, and most of us now will end our lives in hospitals, a few of us in hospices, in the care of strangers, with little dignity and no autonomy — unlike our ancestors, who mostly died in their own homes. Although scientific medicine has brought great and wonderful blessings, it has also brought a curse — dying, for many of us, has become an unpleasantly prolonged and institutionalised experience.

Few of us now will not live into old age, but our bodies and brains inevitably wear out, however much we care for them with exercise, sudoku and healthy diets. Most of us will develop cancer, many of us will become demented. Our ancestors died quickly — usually from infections — and had no choice in their endings. Pneumonia, it used to be said, was the old man’s friend. But medical treatments now keep us alive for much longer than in the past, but often in a debilitated state and at the cost of unpleasant side-effects and prolonged periods in hospital. Not only this, but modern diagnostic technology can now predict our decline and death some time before they come, while we might still be relatively well and independent, whereas our ancestors could continue to live in blissful ignorance, before they succumbed to a short and final illness.

Evolution has equipped us with a deep fear of death, which is surely hardwired into our brains. This fear made sense when our forbears were at risk of dying when young, putting the survival of their children in jeopardy. But how hard should we try to avoid death in the modern age? When the infirmities of old age will have made life a burden for some of us, or when doctors have told us that only dying and little living awaits us? Or if we start to become forgetful and are diagnosed with Alzheimer’s or one of the other remorseless dementias?

Some of us — probably not many — would prefer to bring our death forward in such circumstances. If we are not yet in institutional care, we are always free, of course, to commit suicide, but it is not easy as we have to do it violently — by jumping from a height, cutting our throats, by hanging or asphyxiation, or in the US with a gun, where there are some 20,000 such deaths every year. These unassisted methods are distressing — both for ourselves and for our families.

Rest in peace: the room at the Eternal Spirit clinic, Switzerland, where David Goodall spent his final hours
Rest in peace: the room at the Eternal Spirit clinic, Switzerland, where David Goodall spent his final hours PHILIPP JENNE

In several countries — in particular, the Netherlands, Belgium, Canada, Switzerland, India, six US states and, as of next year, the state of Victoria in Australia — it is not illegal for doctors to prescribe a drug (usually a barbiturate) with which people can bring their life to a dignified and peaceful end. (The claim made in parliament in the recent debate on assisted dying that the drugs used could cause great suffering was a monstrous lie.) Various names have been used to describe this action by a doctor — euthanasia, mercy-killing, assisted suicide or assisted dying.

The word euthanasia is probably best reserved for doctors killing patients without their consent, as happened in Nazi Germany. It is crucial to a proper understanding of the debate about assisted dying (the name I prefer) to understand that the possibility of legal assisted dying applies only to people who have mental capacity, as it is called in the law. It does not apply to people with brains damaged by disease or trauma or old age, who have lost the ability to make rational choices for themselves. So “assisted dying” is not euthanasia — it is not doctors deciding when somebody should die, but about people making their own free choice that it is time for their life to end in peace. Why should we deny ourselves and others this freedom?

As Lord Denning once observed, the prohibition against helping somebody else kill themselves is a little odd. How can it be illegal to help somebody do something that is not in itself illegal? But in the UK, a majority of members of parliament and the British Medical Association (BMA) are implacably opposed to introducing such legislation, even though many opinion polls have consistently shown a strong public majority in favour of it, with only a vociferous minority against it.

A variety of arguments have been presented to defend this oddity, with its denial of human rights, and its consequent and cruel infliction of considerable suffering on many people.

The traditional argument, of course, is religious. God has banned suicide. He has “fixed His canon ’gainst self-slaughter” as Hamlet put it. It is therefore wrong to help people kill themselves. But this is a matter of belief and faith, and people who have such beliefs have no right to impose them in a free society on those who do not share them.

The opponents of assisted dying must find other, often surrogate, arguments. One such argument is that people might be depressed or mentally ill, and not responsible for themselves. But surely this problem is easily dealt with by suitable psychiatric safeguards? There is no evidence from the countries where assisted dying is available that this is a problem. Indeed, applying for assisted dying from the Dignitas clinic in Switzerland is a lengthy and expensive business, requiring detailed medical and psychiatric reports, with many requests being rejected. Similar procedures are in place in all the other countries where assisted dying has been legalised. Obviously, people who are suicidally depressed or psychotic should receive psychiatric treatment and not assisted dying, but it is not very difficult to distinguish between severe depression and a considered wish to bring one’s death forward when faced with untreatable cancer, dementia, motor neurone disease or similar problems.

Another argument is that assisted dying is a slippery slope that will lead to euthanasia, as practised in Nazi Germany, of the old and frail, of the disabled and mentally ill. “There will be death targets,” as one senior politician once put it to me. Somehow or other — the proponents of this argument do not explain how — assisted dying will result in the frail, vulnerable and disabled being bullied into asking doctors to kill them, even though it is not what they want. I do not find this a very plausible scenario.

It is true that assisted dying comes in two forms — the first, in America and Canada and in Lord Falconer’s defeated bill, is that it should only be legal if a patient is expected to die within the next six months. In recent weeks we learnt of David Goodall, the 104-year-old Australian scientist who wanted to end his life as he found that it had become an increasing burden. He had to go to Switzerland, as he did not have a prognosis of less than six months. He spoke very clearly at a press conference about this and of his dismay that he could not die in his own home. His family were in full agreement and, rather movingly, crowdfunding enabled him to fly business class for his last journey to Zurich. In countries such as Holland, Belgium and Switzerland, there is an additional qualification for assisted dying. You will qualify for it if you are faced with a future of intractable suffering. A young English man, for instance, left quadriplegic in a rugby game, opted for death in the Dignitas clinic on these terms, as have several senior English physicians I have heard about who had been diagnosed with early-onset Alzheimer’s. In Holland and Belgium, assisted dying has been granted to a small number of chronically depressed patients who have failed all treatment.

The fierce opponents to Falconer’s bill claimed that permitting assisted dying for people with a six-month prognosis would soon lead to assisted dying for intractable suffering as practised in the European countries, and then, they implied, to mass medical murder.

No evidence is produced to justify this fear, so we do not really need to provide any evidence against it either. But surely it is absurd — why should assisted dying lead to doctors killing their patients against their will? Was Harold Shipman representative of the medical profession? We trust doctors with our lives at the moment — why should the availability of assisted dying suddenly turn them into killers? Brian Rix, one of the great campaigners for the disabled, initially opposed assisted dying when it was being debated in the House of Lords as he feared it would escalate into use against the disabled. But when he himself lay dying shortly afterwards, he wrote a most moving letter to the Speaker of the House of Lords, saying that he had been mistaken and that he had changed his mind.

A different argument is that the legalisation of assisted dying will be used as an excuse to provide less hospice care. This has not been borne out in countries where assisted dying is available. The hospice movement is alive and well in the UK (where, in fact, it originated) and I see no good reason to think that it will not continue to be so.

One of the most widely voiced arguments against assisted dying is that greedy children will bully their elderly, vulnerable parents into asking for a suicide pill so that they can inherit the family silver. I have rarely heard a more ridiculous suggestion. Not only does it show a remarkably poor and patronising opinion of your fellow human beings, it is also — at least in my experience — contrary to what I have usually observed in my own work as a doctor.

More often than not, it is the dying patient who has accepted death, but the family who find it hard to let go. Besides, the simplest of safeguards, in the form of the patient being carefully interviewed by independent specialists (who need not necessarily be doctors) over a number of days or longer, would easily prevent this happening. And surely, if there were such a breakdown of a loving relationship between a parent and their children — something very much against normal human nature — isn’t it rather unlikely that the parent would fall in with his or her children’s attempts to get them to volunteer for suicide? Again, there is no evidence from the countries where assisted dying is legal that this happens.

The final argument against assisted dying is that its availability will frighten vulnerable, dying patients and that therefore the right of people to opt for it should be overridden. I find this argument bizarre. It seems to be saying that legalising assisted dying will make dying patients see hospitals and hospices as little different from death camps and no longer places of kindness and care. It is worth repeating yet again: assisted dying is voluntary and applies only to people with mental capacity. It does not give doctors the power of life or death over their patients in any way whatsoever. Why should dying patients think that it might, when it is clearly stated that it does not?

I have a friend, whose opinion I deeply respect, who is a palliative care doctor. She is opposed to assisted dying, but for none of the above reasons. Her objection is that many of her patients, when they are admitted to her hospice, are in a desperate mental state. They feel obliged to do what they believe is best for their family (ie, kill themselves), even when this might not be what they themselves really want. Furthermore, she feels, families may possibly encourage this (with the best, least selfish intentions) because they look at their parent or grandparent dying of cancer and cannot conceive of the state they are in as being anything other than terrible when, in reality, it is remarkable what people can come to terms with. But this, I would suggest, is not a case against assisted dying, but instead an argument against providing it quickly.

Safeguarding interviews will take time, and during this time the dying can try to achieve some kind of reconciliation with those who will be left behind. The fact remains that the patient’s wishes should ultimately be paramount and some people will nevertheless continue to wish for control over their death, and it is simply wrong to deny them this.

Every time I operate there is some risk that the patient will come to harm, but the risk is justified by the possible benefits. Surely the same applies to assisted dying? Even if — and it is a very big if — a few patients are hastened to a premature end by bullying relatives or callous doctors, which somehow the safeguards fail to stop — might this not be a price worth paying to allow the much greater number of patients who wish their lives to end with dignity to do so? Hospices are often wonderful places, with wonderful staff, but not all of us want to die in them. The campaign slogan of opponents of assisted dying is “care not killing”, but perhaps some of us do not want to be cared for by strangers as our life comes to its end. Perhaps we would prefer to die at home, at a time of our own choosing. As it is, hospice care is available only to a small proportion of dying patients and in the UK rarely to the elderly.

There are two further points to be made in favour of assisted dying other than the a priori case for patient autonomy. In Oregon, where assisted dying has been available since 1997, it is reported that many people who express an interest in assisted dying when they enter hospice care in the event do not take it up. The knowledge that, when the end comes, there will be no risk that it will be very distressing is clearly reassuring. As the Belgian palliative care doctor Wim Distelmans has argued in his book In Pursuit of a Dignified Life’s End, assisted dying should be seen as complementary to terminal care and not in opposition to it. In England, where assisted dying is against the law, many hospices and hospitals nevertheless use escalating terminal sedation for the final phases of their patients’ illness. Increasing doses of opiates, ingenuously justified as symptom relief, precipitate respiratory failure and death. As Distelmans argues, this is no different from euthanasia without consent. Might it not be better if the use of such terminal sedation could be talked about with patients and their relatives, and that the patient had some choice in the matter?

The recent events in Gosport surely show this all too clearly. The risk of abuse is much greater when death is hidden with half-truths and euphemisms than if it is openly discussed with patients and families, as would be possible if assisted dying was legalised.

Hasn’t it been said that only the truth sets us free?

It is clear that the opponents of assisted dying are frightened by it — they argue that if it is legalised in England it will bring out the worst in either patients’ families or their doctors, or both, and lead to abuse. They have produced no evidence to justify this dismissive and negative view of human nature. Is it, perhaps, that their fear has a different, unconscious, root?

It has always struck me as somewhat illogical that the most passionate opponents of abortion and assisted dying usually have religious faith, with a concomitant belief in life after death. Surely, if our lives continue after death, abortion and assisted dying are not absolute evils? Why can’t there be room for compromise — that sometimes suffering can justify bringing a life to an earlier, more dignified end, with a speedier entry — hopefully — to heaven, than if nature, which so often now means intensive medical care, is left to take its course? It is as though they think that assisted dying is cheating — that we need to suffer when dying if our soul is to be reborn. Some even claim that dying is a transcendent experience, but I suspect that any transcendence is enjoyed more by the witnesses than by the dying. Perhaps what drives these people is more their own fear of death than concern for what might be best for the rest of us. In particular, fear of the thought — which is such a threat to their faith — that death might be final after all, with nothing to follow.

Henry Marsh’s Admissions: A Life in Brain Surgery is out now in paperback (Weidenfeld & Nicolson £9)

Astral divorce?

First there was conscious uncoupling. Now the latest trend in splitting up is cutting the psychic ties that bind us to our exes

Dolly Alderton
The Sunday Times, September 10 2017

In the aftermath of a break-up, there are well-worn milestones of recovery, just as there are stages in grief. The drunk text to the ex. The radical new haircut. There’s the moment you realise you’ve dropped a dress size from lying in bed for a month and only eating what’s left in the cupboard; the first misjudged snog with a stranger.

But now there’s a trend to seek a new type of closure — that of the spiritual. These days, break-ups go beyond a simple goodbye to an ex: some venture into Peruvian forests for purging ayahuasca ceremonies, others do cosmic ordering in the comfort of their own home. The latest solution to clearing the mental cobwebs of a bad ex? An “astral divorce”.

SHE ASKS ME THE NAME OF MY EX AND HOW WE MET, THEN NUDGES A BOX OF KLEENEX TOWARDS ME AS I START CRYING
Think of it as the next logical(ish) step to conscious uncoupling, the term famously used by Gwyneth Paltrow to describe the amicable separation from her husband, Chris Martin. “Astral divorces” are a “cutting of ties and contracts” with a past relationship and are performed by psychics. The aim is to rid you of old, residual energy from an ex that may be holding you back and to help move you into a new phase of your life, ready for love again.

As it happens, there’s an ex I haven’t quite been able to shake off, so I decide to see Jane Orr at the Urban Retreat luxury spa in Harrods. I’ve never visited a psychic before, although Orr prefers the term intuitive consultant: “I’m what we call ‘clairaudio’, which means I can hear as well as see pictures. I’m all the clairs,” she says.

Essentially, for an hour of your time and £160, Orr offers a sort of spiritual colonic to get rid of all the bad bits of exes that have stuck to you. I ask her how often she sees someone who is still too attached to a past relationship. “It’s very common. Our whole life is made up of relationships, and our physical body creates an energy field, like a mobile phone signal, that is affected by anybody we interact with. That vibration will stay with you unless you consciously cut it away. That’s what I do as a healer.”

At the beginning of my astral divorce, Orr asks me to shuffle some tarot cards and pick 10 with my left hand. She hangs a small crystal pendulum above one of the cards and tells me a particular archangel is about to move it in a particular direction so she knows who she’s talking to “because otherwise I get the riff-raff”. Throughout our session, she regularly confers with “him” or “them”, who seem to be sitting behind her. At one point, one of them even tickles her nose.

One of the first cards Orr turns over is the death card, which marks a full stop to a situation, not (usually) actual death. For example, if you were about to get married, it might denote the end of singledom. She tells me she sees a very successful American musician who is going to be important for me; she doesn’t know whether he pertains to my romantic or work life.

“Bruce Springsteen?” I say, hopefully.

She asks behind her. “They’re not going to tell me because they say it will freak you out,” she says. Later, I spend my entire bus ride home googling “American male musicians”.

We finish the tarot cards and discuss what she’s read. My astral divorce is beginning to feel more like a conventional therapy session. Orr asks me the name of my ex, how we met, how long we were together and any lessons I learnt from our partnership. She nudges a box of Kleenex towards me as I start crying, something I’m sure she’s seen a lot of in her line of work.

“What I’m also beginning to get brought in is a past life as a nun,” she says. My weeping stops and I burst out laughing. She tells me that this nun had feelings for a priest that she found emotionally overwhelming and frightening. The invisible Greek chorus behind her tells her she needs to “clear the nun”, which will help rid me of my own anxieties about love and commitment. (Later, when I tell a WhatsApp group of my friends about the session, I get a load of messages slagging off the nun. “So out of order of her to ruin your sex life,” one writes.)

Next, I lie on Orr’s massage table and close my eyes, while she takes me on a meditation journey. She tells me she will “pull and cancel” all contracts with the troublesome ex-boyfriend so “only the love and lessons remain”. She also tells me she will send the nun “to the light so she gets healing”, which will “make all the difference”. She asks me to imagine myself in a ball of light and sends me up to “the seventh plane”. I lie in silence for a while and notice a strange dragging sensation from the top of my head.

Afterwards, I do feel lighter somehow. I can’t deny that taking a moment to acknowledge the good and bad of a past relationship and then consciously say goodbye to it is a cathartic experience. Jane admits this is a valuable part of the process: “It’s the classic thing of you writing them a letter, but you don’t post it, you burn it. That can be very powerful. It’s really a question of focusing and externalising the feelings and thoughts so that it’s out, otherwise it’s still going round and round.”

Astral divorce isn’t the only non-traditional method of finding closure in the aftermath of a break-up. Hollie, 28, credits a women-only spiritual event as the moment she moved on from her past relationship. “It involved conscious dancing, a gong bath and going around the room hugging people, which was a personal breakthrough,” she says.

Although she had to suspend her cynicism, the Saturday- night ritual pulled her through her last stage of heartbreak. “All these women were dancing together like idiots, hugging and getting drunk on chai tea — it’s just amazing and weirdly comforting. I strutted home like I was in the I’m Every Woman music video.”

Carmen, 41, tells me she felt so destroyed by a disastrous relationship that she travelled to her ancestral home of Donegal to bury mementos from the relationship at the Gap of Mamore. “It was important for me to do something physical to cleanse the bad love from my life. I think that whatever transformation took place, we need moments in our lives to stop and heal.”

I have a date this Friday, the first one in six months. Before my session with Orr, I was thinking of cancelling. I have no reason to believe this will lead to a new love any more than the years I spent Tinder-dating every weekend.

But as I float out in my ball of light and back into the Harrods make-up hall, I feel more open. I decide to pick a new lipstick for the occasion called, fittingly, Out of Control. It is a timely reminder that in this life we are mainly passengers on a journey of unpredictable chaos, but sometimes it’s soothing to be reminded — be it by a friend, a therapist, a witch doctor or the universe — that we’re heading in the right general direction.

via Dolly Alderton asks: do you need an astral divorce? | Style | The Sunday Times

Olivia Laing, the acclaimed author of The Lonely City, on loneliness, marrying the poet Ian Patterson and the challenge of intimacy

ANNA HUIX FOR THE SUNDAY TIMES MAGAZINE. HAIR AND MAKE-UP: ROSE ANGUS. WITH SPECIAL THANKS TO THE BARBICAN CENTRE
The Sunday Times,

At the age of 39 I was fairly sure I would spend the rest of my life alone. I lived alone, I worked alone. No matter what I did, or who I dated, I didn’t seem to be able to find the relationship I longed for.

I’d first joined the vast ranks of the lonely five years earlier. In 2011, I moved to New York in the wake of a break-up. A new relationship had come to an abrupt end. I’d pinned far too much hope on it, and though lovers had come and gone before, this particular departure left me desolate, my self-esteem on the floor. In a strange city, 3,000 miles from my family and friends, I was rapidly overwhelmed by loneliness.

Being so lonely was agonising. Worse, it felt actively repellent. It didn’t take long to realise that one of the worst elements was the omnipresent shame — the gnawing belief that being lonely was bad and wrong, a humiliating failure that could never be confessed. But the more I thought about it, the more illogical this seemed. After all, millions of people are lonely. Why was it so unspeakable?

Part of the reason I decided to include my own experiences in The Lonely City, my 2016 book about loneliness, was that I wanted to break this taboo. I hoped that by confessing to my least admissible feelings, I might dismantle something of its painful stigma. I wanted to reposition loneliness as a natural human state, part of the everyday texture of our lives, uncomfortable, but not beyond the pale.

Researching the book necessitated delving into psychological studies. Loneliness, I discovered, is caused by a lack of intimacy. It isn’t the same thing as solitude, though they do intersect. You can be lonely and have plenty of friends. You can even be lonely in a marriage. What matters is not the type or number of relationships a person has, but their depth and closeness.

Once I’d understood this, it seemed the least I could do was put my knowledge into practice. I decided I needed to put down more roots. I’d been drifting back and forth between Brighton and New York for two years, unhappy and unsettled. This was the period I wrote about in The Lonely City, and it had to stop.

The people I most liked were in Cambridge and I could afford to rent a tiny house with a garden there. I was still alone. I couldn’t conjure up a partner. Maybe I’d be single for ever, maybe I’d never marry and have children, but I could build myself a warm, companionable, green life, even so.

I moved in January 2013. That first weekend, as I was unpacking in my dank Victorian cottage, a Twitter friend who lived nearby DM’d me with an invitation for dinner. Ian Patterson was a poet and Cambridge don in his sixties. He lived with his wife, the writer Jenny Diski, a few streets east. He was a celebrated cook, and it turned out he’d invited all our mutual friends in the city to a feast of roast pork and chocolate nemesis, all of us squashed around the table in their beautiful book-lined house. It was such a generous gesture to a stranger, such a kind, warm-hearted thing to do.

Ian was nearly three decades older than me, but all the same we quickly became friends. We were both passionate gardeners, and we’d take tours around our patches, pointing out the plants we were most proud of. At some point that first spring, he realised I didn’t have a car, and offered to take me with him on his Sunday trips to Waitrose. He’d make up songs with amazingly dexterous lyrics, weaving the events on the street into impromptu musicals.

One of the nicest things about being friends with someone so much older than me was the perspective it offered. It was obvious from how he spoke about her that Jenny was the love of his life. They’d met when he was 50. I found it so comforting to know that it was OK to be a late developer, that love could strike at any time.

Then, in 2014, Jenny was diagnosed with lung cancer, which she documented in a series of wry, devastating essays in the London Review of Books. In the wake of her death two years later, I saw a whole different aspect of loneliness, the obliterated planet of bereavement. Now it was my turn to repay Ian for his many kindnesses, sitting with him as he worked through the grim bureaucracy of death. The Lonely City was published that same spring. I hoped the book would be useful, but I hadn’t bargained for the intensity with which it was greeted. At readings, I was regularly embraced by tearful readers, often very young, who would tell me about their own struggles with isolation, their fear that there was something uniquely wrong and ugly about them. I became the poster girl for loneliness. Just as I’d hoped, it turned out that craving love and closeness was not a unique failing, but something that we share.

Head over heels: Laing with the poet Ian Patterson at their wedding in August 2017
Head over heels: Laing with the poet Ian Patterson at their wedding in August 2017

Our friendship sustained us both, but it took a very long time to realise I loved Ian. A series of random events gradually nudged us closer together. My landlord decided to redecorate my dilapidated house substantially. I had to move out for three weeks. I went to Ian’s, though both of us were deeply nervous about sharing a space. To our amazement, we fitted together like toast and butter. I’d never cohabited with anyone, not properly. I had no idea that sharing daily life could be so joyous.

I was supposed to move back home, but somehow I never did. The food was too good, the company too jolly. Then Ian had surgery, a knee replacement, which left him needing care for weeks. As I sat beside his unconscious body in the hospital bed, an hour after the operation, his face pale, a blood bag dangling by his side, I realised he was the person I loved most on earth. But I still persisted in thinking we were just the dearest of friends, an odd couple whose minds happened to move in similar ways, who capped each other’s quotations and laughed at the same lamentable puns.

For my 40th birthday I rented a big house in Suffolk for a weekend of celebrations. An hour after I arrived, the man I was seeing texted me to say he wouldn’t, for perfectly good reasons, be able to come. It was Ian who cheered me up, who gave me one of his spotted handkerchiefs to dry my wretched tears. That weekend, I started to realise that I was as responsible as anyone for my own loneliness — that I kept making the wrong decisions, picking people who through no fault of their own couldn’t possibly give me what I really wanted.

Meanwhile, there was Ian, dear and delightful, loyal to his bones. He spent the weekend in the kitchen, making beef fillet and a cake dyed red, blue and yellow like a Mondrian painting that took three days to construct. Sometimes you need love to be presented to you in physical form. Sometimes you need to taste it to really recognise it’s there.

We didn’t just love each other. We were in love with each other. We were the foundation of each other’s lives. We decided to get married that summer. Suddenly there was no time to waste. We sloped off to the register office in Cambridge and tied the knot. I panic-bought an Isabel Marant minidress online; Ian looked sharp in a seersucker jacket and shades. He’d lost three stone since we got together, a combination of happiness and the bionic knee. He danced up the aisle, his face all sheeny with tears. We giggled so much, we set the registrar off too; she said afterwards she’d never laughed in a wedding before.

I was overjoyed, but all the same I found the shift far harder than I could have anticipated. We’re told wedding bells are the end of the story, not the beginning, and it rapidly became apparent that I didn’t know very much at all about what “happily ever after” actually required. After all those years of longing for love, and especially for settled, permanent commitment, I was amazed to discover how difficult it was.

In many ways, solitude had been easy. I didn’t have to think about anyone else. I was at complete liberty. If I wanted to eat muesli for dinner and ignore the washing-up, if I didn’t feel like speaking for days on end, no one else would care, or even know. It’s hardly news for the serially monogamous, but if you get as far into adulthood without cohabiting as I did, multiple emotional skills go unlearnt. Worse, you don’t even know they’re missing.

I was completely unused to living with anyone. I didn’t know how to compromise. I had no idea how to have an argument, and found disagreement so threatening, I kept escalating to shouting within seconds. All the things I’d believed about myself were wrong. I thought I was a peaceful, possibly slightly melancholy person, but it turned out I was practically deranged and appallingly controlling. “Soften your borders” became my mantra. Luckily for me, Ian possessed the magical gift of patience. He’d been married twice before, he had three adult children, he was seasoned at the act of intimacy. I’m sure someone younger or less relaxed would have ditched me immediately. I’m sure it also helped that he could see I was trying, that I really didn’t have a clue. I’d never had to negotiate over even simple things like what to cook for dinner, let alone how to squeeze two households into one in a matter of weeks.

Ian is fanatically tidy, but at 68 he had a house completely stuffed with possessions, as well as 15,000 books. I had a fairly substantial collection of my own. It wasn’t so much a marriage of true minds as a fusion of two libraries. We got rid of so many, we were practically banned from our local Amnesty bookshop and had to dump them at local charities on strict rotation. The weeks of lugging tote bags and boxes felt mildly symbolic; making room for each other as sweaty physical labour.

That first summer of marriage, I started writing a novel at high speed. I wanted to capture what it was like to fall in love when the world was becoming borderline apocalyptic, and I also wanted to explore this strange antechamber to intimacy. I wrote down everything that happened, both in our small domestic life and in the world at large, from arguments over the garden deck to Trump’s tweets during the white-supremacy march in Charlottesville. I was paranoid and terrified, and I wanted to get it onto paper and out of my head.

One of the best things about this weird act of art-making was that I started to see the ways in which I’d been the author of my own past experience, including the loneliness that had dogged me for so long. Loneliness is political, loneliness is caused by social exclusion and stigma. At the same time, there are ways in which avoiding intimacy can be a choice. I knew I was terrified of getting hurt, but I hadn’t realised how this was affecting the kind of relationships I had. I was nearly pathologically afraid of abandonment and so I’d repeatedly picked people who were absolutely incapable of giving me what I needed, to ensure I was never really at risk of substantial loss.

I gave these embarrassing traits to Kathy, the character in my novel. “Finally,” it says in Crudo, “she understood all the aloof boyfriends, the endless appeal of people who were only half there. She’d liked it that way, she’d liked being by herself, kept company by her old pals hankering and craving. She’d liked living in a perpetual adolescence, never having to be responsible for anyone else. Were other people as bad as Kathy? Did they wake up out of it, in shock at their own intractability, their own bad taste?”

I certainly did. I wrote Crudo in seven headlong weeks. All my non-fiction books have taken years of painstaking research. This one was like riding an enormous, horrifying wave. I finished it in Heathrow airport, on my way back to New York. I felt as if I’d come out of a fever, as if I’d coughed up a snake. The world is still just as crazy, but the relationship at least has settled down. It’s calmer now, a little more regularised, a little more steady. But I’m glad I took a cast of those first weeks, that I captured what the tumultuous early days of marriage actually felt like.

I recently did the BBC Loneliness Experiment, a survey that assesses your current levels of loneliness. I was startled to see how much my life had changed, that feelings that had been true for years had disappeared without my even noticing their absence. I don’t feel isolated now. Ian and I talk all the time, chattering like the sparrows that live in next door’s brambles. I always wanted to have a relationship like this, in which you can discuss anything, from the nature of Byron’s limp to how to plant an apple tree.

I do think my years alone helped in some ways. I might have been inexperienced at compromise and care, but on the other hand doing so much on my own did mean I was independent, confident and worldly, that I had no problem doing things Ian still finds alarming, from dealing with solicitors to negotiating strange cities. Working through loneliness also made me come to terms with myself, to touch the bottom and realise I liked who I was. I’m not sure you can have a relationship without that kind of basic affection for yourself. Without it you are always needy, requiring your partner to convince you of your own basic acceptability.

We’re getting married again this summer, a proper fete, with all the people we didn’t have time to invite before. The “save the date” was an Annie Leibovitz photograph of Tony Curtis and Jack Lemmon reprising their characters from Some Like It Hot: two battered old bodies, both in lipstick, Curtis pert in Y-fronts, Lemmon sturdy in a lacy white nightie. They were tightly clutching hands, another odd couple, merrily extending the boundaries of love.

We’ve been picking readings. The one I chose was from the end of Far from the Madding Crowd by Thomas Hardy. It’s when Bathsheba Everdene finally realises she truly adores Gabriel Oak. They have a brilliantly awkward conversation, and then Hardy sets out a sort of philosophy of mature love — the kind that is seasoned, that takes place between adults who have been hurt before, who have been friends first, who know each other thoroughly and who decide to risk their hearts and try again.

This camaraderie is, he says, “the only love which is strong as death — that love which many waters cannot quench, nor the floods drown, beside which the passion usually called by the name is evanescent as steam.” It makes me cry every time I read it, though it’s usually Ian who bursts into tears at the drop of a hat. Being friends with my partner, that feels foundational, a thing I wouldn’t swap for all the world.

My life has changed so drastically in the past year. I still spend a lot of time alone, in my study, as any writer must. I still travel, though nothing like as wanderingly as I did before. If I visit New York now, it’s for a crammed week or two, not great islands of time, and the trips are anyway populated with meetings and friends. Friendship is another thing that’s much easier to manage from the security of a relationship. Because I’m less anxiously reliant on my friends, because I don’t need them so much, I’m more confident, more rooted, less scared to voice divergent opinions, to let myself be seen, which makes the relationships much more healthy.

That isn’t to say fear has been banished entirely. I used to worry I’d never meet anyone and now I live in terror of Ian’s death. He’s the same age as my parents; I know it’s likely that I’ll lose them all at around the same time, a loss so cataclysmic I can barely begin to fathom it. I worry about my sweet husband vanishing into the blind alleys of dementia. I worry about blood clots, bowel cancer, a heart attack, a stroke. When I first met him he had crippling arthritis in one knee, which before the surgery was so bad he couldn’t walk five paces without yelping in pain. At some point the other knee will go too, and our liberty will be restricted once again.

There are more serious concerns. He has two aneurysms, though they are still tiny now. I worry that one could rupture and kill him. I try not to google it too much. He has sleep apnoea, too, the same thing that killed Carrie Fisher. I wake him repeatedly in the night to check he’s breathing. He bats me away with a big paw, mumbling sleepily, “I’m still alive.”

Our best collaboration has been the garden. In a way, I suppose it’s the model of our relationship — carefully enriched and tended by us both, an explosion of flowers followed by quiet fallow periods. We’re in it for life, this marriage, though that might not be the longest stretch of time. We both know what love costs, and what it’s worth. We both know that it doesn’t always come and will most certainly go, but for now, for us, love is the world.

Crudo by Olivia Laing is published on Thursday (Picador £13). Olivia Laing will be discussing her book with Elizabeth Day at the Rialto Theatre in Brighton on Tuesday 26 June. Tickets are available at rialtotheatre.co.uk