Waking Up, Episode I: The Deconstruction of Me
As many of you know, I've had dogs for over 20 years, and I now have a Cane Corso named Juno. Going on dog walks in the evening after dinner is one of the highlights of my day. Silence, being outside in nature (we live by a creek that is great to walk along), being with my pal, and time to reflect and wonder have been a core part of my daily mental health routine.
Most nights, I walk the same route, which includes walking by a house that my wife Lea and I always loved the look of - sort of a mid-century modern craftsman style home dating from the 1950s. We repeatedly commented on how, with a little renovating and TLC, the place could be reborn into a new home while maintaining its core identity.
Sure enough, it went up for sale, and soon the renovation started. It turned out to be much more than a renovation. It was essentially a teardown of the entire home above ground while leaving the foundation below ground level, followed by a rebuild on top of the old foundation.
The original ground-level layout of the home stayed the same.
Then, over 18 months, a brand new home was constructed on top of the original layout and old foundation. The finished house is almost the same shape and size as the original, but it is new, and it's beautiful.
Why am I telling you this story? Because when I "elected" to go to Hazelden for prescription narcotic addiction, I figured I was going to go there for a quick remodeling job - repair the cracks in the wood and walls, put on a fresh coat of mental paint, put the couch and chairs back in, light a fire in the fireplace, and have a seat at the game of living again.
Boy, was I wrong.
Being a physician, I was "enrolled" in the health professions track, which meant 3 months of incarceration. Normal people (addicts) typically are in treatment for six weeks in the regular program (kind of like an undergrad program), where the emphasis is on the core 12-step program. Physicians get another 6 weeks in a kind of graduate-level program.
Why? Because it takes more time to deprogram and reprogram highly programmed physicians.
When my three kids drove off that freezing cold and sunny early March day leaving me standing alone in the "welcome" lobby at Hazelden, I felt like Jason Bourne in The Bourne Identity when, after massive sleep deprivation and having his head repeatedly submerged under water, Dr. Hirsch calmly and matter-of-factly asked, "Will you commit to this program?"
My answer? Yes, sort of.
I had no idea that the 55-year-old home inside my own head — that thing I call me, the me I talk to all day long, the house of me built over so many years by the programming from my childhood, adulthood, and surgical career — was about to be torn down to its bare foundation like the house in my neighborhood, leaving me raw, exposed, and totally lost.
My Locus Coeruleus Tries to Kill Me
The teardown of Michael Maddaus started with narcotic withdrawal. I suspect many of you may have heard how hard it is to withdraw from narcotics as I had, but I had no idea....
My brain is on fire, but even though it's out of gas, the fire rages on. It's as if I'm strapped to a gurney with an IV infusion of industrial-strength doses of amphetamines, 24 hours a day for six days straight.
You may be familiar with the hormone epinephrine produced by the adrenal gland. Epinephrine is the fight-or-flight hormone released in response to threats or stress. In the brainstem, there is a minuscule spot called the locus coeruleus that is sort of like the brain's own adrenal gland that produces norepinephrine, the cousin of epinephrine.
Though it's minuscule, the locus coeruleus has a massive impact on our mood, alertness, and levels of anxiety, and just like Amazon, it can deliver norepinephrine anywhere in your brain instantaneously through the dense web of neurologic delivery routes it has spread throughout the 3 pounds of 100 billion brain cells that make you, well, you.
Norepinephrine, produced by the locus coeruleus, creates our mental alertness and anxiety. But here's what's interesting: it turns out the release of norepinephrine by the locus coeruleus is regulated by our own endogenous opioids —endorphins—the natural narcotic-like substances in our brains.
And get this: endorphins are released with exercise (runner's high) and with the practice of gratitude (more on this in a future post), which leads to less norepinephrine being delivered by the Amazon delivery monster to all those brain cells throughout your brain. That's why both exercise and gratitude make you feel calmer, more relaxed, and in a better mood, just like narcotics.
So my itty-bitty locus coeruleus had been drenched with narcotics for over a year, which kept the door of the locus coeruleus warehouse of norepinephrine closed and its Amazon delivery system shut down.
This is the dreadful Catch-22 that people addicted to narcotics fall into over time. At the beginning of your narcotic love affair, all is wonderful. You take them, you feel great for a bit, then it's done. But in as little as four weeks of taking narcotics regularly, there is a buildup of undelivered norepinephrine packages in the locus coeruleus Amazon warehouse. And if the narcotics don't show up on time to keep the gates closed, the brain gets flooded with norepinephrine packages.
So 24 hours after your last dose of narcotic, the neurologic garage doors open, and those Amazon norepinephrine delivery trucks roll out en masse and dump their norepinephrine packages throughout your brain.
Massive, crippling anxiety ensues. You feel like you're having a panic attack 24/7. The solution? Take some narcotics.
Rinse, repeat, rinse, repeat, day after day, as you descend into a hellish lack of agency over the monster.
What starts out as a small love affair slowly morphs into a grotesque, dysfunctional relationship with the drug, just like having become head over heels infatuated with someone, only to find out later, once the drug wears off, that you have stepped into a relationship from hell where you endure the day-to-day hell of the other person for the hope of a return to the early, radiant promise of a love paradise.
In love and in drugs, you can end up feeling trapped, and you are physiologically, until you either have the courage to end it yourself, or circumstances end it for you, as in my case.
So now, being in treatment, off the stuff, and with no hope of relief, the neurologic garage doors broke open. The Amazon delivery trucks started delivering all those built-up norepinephrine packages with ruthless efficiency.
For 6 days, I only slept in small catnaps, day and night. By the end of the whole mess, I was starting to become paranoid and started imagining things due to the profound sleep deprivation.
The other debilitating symptom: hideous muscle contractions. You could actually watch my bicep (if so inclined) ball up into a knot all on its own, over and over and over, again and again, every 10-15 minutes, 24 hours a day. Sometimes it was my calf, then bicep, then my tricep, then my quadriceps....the muscle contracted so hard at times that it hurt.
It was living fucking hell.
A brief moment for a little contrast check: keep in mind that just 10 days before my withdrawal nightmare I was a full professor, endowed chair, vice chair of the department, program director, blah blah blah, with a beautiful home on a creek in Minneapolis with a bathroom stocked with L'Occitane skin and hair products from France.
Now I'm just another miserable addict in rehab in the middle of withdrawing from narcotics, sleeping in a room with a 21-year-old alcoholic kid, and sharing a bathroom with three other guys (2 more from an adjoining bedroom) that had a small, grimy tub without a plug.
The lack of a fucking plug mattered a lot because the only relief I could get from the muscle contractions was to soak in a very hot bath for 10 minutes, and even then the relief only lasted for 30-45 minutes. I resorted to using a washcloth to plug the drain. All night, I either lay in bed, took a bath, or wandered the halls of the institution to keep the contractions at bay, cycling between the three activities.
Grit and Trauma
But (full disclosure - I am about to pound my ever-so-slightly puffed-up chest a bit), I maintained discipline. I was housed in a building called Cromwell, an old building with a small kitchenette, a TV area, shared bedrooms (mine with a 21-year-old alcoholic on his fifth tour of the place), and an outside area for smoking cigarettes.
There was a strict protocol we addicts had to follow during the 6-week undergrad program. For every meal, we (all the Cromwell inmates) had to gather as a group by the door and, once everyone was accounted for, walk as a group to the cafeteria for meals. We also had required lectures that all the inmates in the entire place had to attend every day in a large auditorium, and we all had a housekeeping assignment. Mine was to vacuum the floor of the TV room and the common area every morning.
My small point of pride in all of this mess is this: during my entire 3 months there, every man (Cromwell was an all-male building) withdrawing from narcotics caved in to the misery and stayed holed up in their dark rooms in bed for days. They never went to lectures or did their little assigned housekeeping jobs.
Me? I did what Winston Churchill admonishes us to do: "If you're going through hell, keep going." I stayed with the program and did my assignments. I vacuumed every morning (in general, I like to vacuum – I even vacuumed carpets full time for a year after the Navy in the 52 story IDS office building in Minneapolis, and I now own two top-of-the-line Miele vacuums), I went to every lecture and group session, even though my head flopped back and forth like a beached carp as I fell in and out of 20 second comas.
Though I was (and still am) proud of my endurance and grit, looking through the Learning Retrospectoscope, it appears that there may be a bit (maybe more like a lot) of what psychologists call "maladaptive behavior" going on.
I recently listened to a fascinating Peter Attia podcast with Jeff English, a psychologist who works at The Bridge (a residential program in Kentucky for folks with, essentially, trauma induced "maladaptive behaviors,") in which English noted that children in dire, trauma laden circumstances tend to go one of two directions: they either sort of psychologically curl up and become more submissive and try to avoid the hell by becoming invisible, or they push against things with an enormous amount of grit.
My teen years were a trial of psychologically traumatic events: parental alcoholism, abandonment, emotional abuse and neglect, and violence. My path was the grit path. I stole cars, broke into places, rebelled endlessly, ran away from home in stolen cars to California and Florida - the list goes on. But it was the same delinquency grit that propelled me to go from not being able to add fractions to getting into medical school and graduating AOA and into the best academic surgical training programs.
English talks about the tree of trauma in our lives: the roots are the wounding experiences, and the branches are the manifestations of the wounds, which are the survival strategies we used in the past to disconnect in an effort to keep ourselves from being vulnerable.
English lists five roots of the psychological trauma tree (note that these are most often related to our parents or caregivers when we were children, but that they can happen with anyone in our life or at any time in our life):
- Abuse - something happened to you - physical or emotional abuse that we all can identify.
- Neglect - something failed to happen for you, like a boy who is being bullied at school day after day, and every day he comes home somewhat sullen and off, but the parents or caretakers fail to notice his demeanor because they are so driven, busy, and successful. Note that intention (by the parents) is not necessary for neglect to occur.
- Enmeshment - this is a boundary violation - a form of emotional incest with mom or dad. The child becomes the best friend and confidant of the parent, which happens much more in "successful" families where outcomes and expectations are celebrated and not the journey. The kid has to either get on board with the program, or else rebel.
- Abandonment - there are all sorts of abandonment scenarios: death, physical desertion (mom picks up and leaves out of the blue to never come back), seasonal (military deployment, prison, parental separation and rejoining), and of course, a huge one, emotional abandonment (the person is there, but not really there for you) as in the child being bullied.
English notes that in his house growing up, they did anger. It was not ok to be sad, so he was abandoned emotionally in this subtle but profoundly impactful way.
English said something profound about abandonment that I think needs serious highlighting: "When you abuse me, you abandon me." - Tragic Events - death of a parent or sibling.
The thing with all of these psychological trauma tree roots is that it comes in two general flavors - vanilla and chocolate - big T trauma, and little t trauma. Big T traumas are the obvious big events like the death of a parent, physical or sexual abuse, or suicide attempts like my mother's. Little t trauma, on the other hand, is like death by a thousand paper cuts, like the boy being bullied example above, or my "step-father" Ralph barking in a tone drenched with contempt, "you're eating us out of house and fucking home" everytime he saw me open the fridge door.
The deal with either big T or little t trauma is that it registers as a moment of perceived helplessness, which activates the limbic system, and then stores the event in your memory (like the hand on the hot stove). We all respond differently to big T or little t trauma, but the underlying commonality in the way we respond is that it is an attempt to disconnect or keep ourselves from being vulnerable.
Take the grit thing. My response to the vulnerability of being a child and "betrayed" over and over again by my mother and her husband, Ralph, was to escape to the streets and into mayhem, and then pull out as much grit as possible to forge a path out of the hellish landscape life had painted for me. It was to prevent me from the dangers of being vulnerable and at risk in the past, and now the protocol was activated in Hazelden as I am vacuuming the floors in a sleep-deprived stupor.
Another example from the podcast. A kid is in his room when he hears his father abusing his mother. He comes out, peeks, and sees his father holding his mother up against the fridge with her arm locked behind her back and hears her say, "You're going to break my arm!" The kid runs into the biff and pretends to be throwing up and starts making puking noises to get the father to stop.
Lesson learned. Dad is mad or starts to hurt mom, the kid pretends something is wrong, like being sick, to get it to stop. The skill learned? Deception and lying. Then, as an adult, when his limbic system gets triggered by anything remotely similar or related, it will activate the deception and lying file stored in his brain.
Thus, a brilliant survival skill learned as a kid turns into a "maladaptive behavior" which can become a character defect later in life.
So this young, innocent boy, through no fault of his own, is profoundly vulnerable to the generational hell of a series of maladapted human ancestors who are now locking him up in their ancestral prison of maladapted behaviors. He masters the skill of lying and deception to protect his mother and to protect himself from the massive vulnerability of seeing his mother being hurt and abused.
So, later in life, past the big T or little t traumas, these brilliant survival skills can become liabilities that surface in four ways:
- Codependency: an outer reach for inner security. Because I can't draw that security from inside of me, I have to get it from something or someone else.
- Addiction - and not just to narcotics or alcohol - grit, ambition, work, anger - and they all go back to the root of the tree - trying to keep the little boy or girl safe by protecting them from being vulnerable. It becomes a situation where the thing that you do, the survival skill used as a child (drugs, work, ambition, grit, anger) to disconnect to avoid being vulnerable, morphs into a thing that you cannot not do (take a moment to digest that phrase fully - do you have a "thing" that you cannot not do like I did with grit?
- Attachment issues - we humans are wired and created for belonging and connection for our survival, and when the efforts or desire for belonging and connection are thwarted by trauma, the effort to connect and belong becomes neurologically coupled with fear.
Not good. It can lead to anxious attachment (the more of me I give to you, the more I expect from you), avoidant attachment (not giving the other person all of you), and disorganized attachment (a mixed bag of getting someone close to us, then needing them to back off).
It is worth repeating: these "maladaptive behaviors" or skills we develop in response to big T or little t traumas are an attempt to disconnect or cope with that moment of vulnerability that rocked our mental world and then gets stored permanently in our limbic system to be opened in the future when needed for protection.
The neurological wiring of the "maladaptive behavior" or survival skill is so deeply embedded in the walls and structure of our brains (miles of well-myelinated neurologic paths formed over time) that the force of the "maladaptive behavior" takes over in the future, without your awareness, automatically. You think your reaction to a situation is "normal," but it's not.
There was a time, I hate to admit, that I would have said bullshit to this stuff. In my mind, the events were done and gone, and I thought I had managed to breach the surface of the dark waters of hell that I had been swimming in as a young boy and teen and into the fresh air and daylight of freedom from the past.
Boy, was I wrong.
The weird thing about all this? When you are an adult and these "maladaptive behaviors" surface in the face of some trigger that activates the old protective file, you often think that your response or behavior is the result of the current stimulus. In other words, you can be completely unaware that your behavior in the present is actually a resurrection of the old vulnerability survival skill - it is like a vampire coming to life again.
Case in point? Me. After I was out of Hazelden, I was, as required, seeing my psychologist, Sarah, weekly. Sarah was my assigned psychologist at Hazelden, and I continued to see her after my discharge. She is an incredibly kind, patient, and insightful person that kept bugging the shit out of me about my mother and the impact of my past on my current world.
Kudos to her for putting up with me and my relentless resistance to thinking there was any connection between my mother, my past, and my present self. I wanted none of it, because in my mind, it was over and done with. Out of sight and out of mind.
Until one day, about 6 months after I got out of Hazelden. As English correctly notes, "our biggest trauma triggers are those closest to our hearts," and that is so true. My wife Lea used to be able to trigger the living hell out of me, and the triggering stimulus was usually some form of rejection. But the thing about Lea is that she can state such rejections in a very direct way.
As in "No!"
Me, I go for the "I would love to - I'm sorry sugar, but right now I gotta finish this, can we in about an hour? I love you."
It is hard to explain the sensation of being triggered, but it was like having an emotional shade drawn down over my mind. I could see it happening as I descended into a state of literally being shut down. The emotional texture and my mood would become a monotone grey, like a dark, cloudy day that saps your energy and drive, and it was covered by a searing layer of resentment and a feeling of betrayal. This whole mental state of affairs could stick around a full 24 - 48 hours until I finally recovered from the physiologic storm.
As English said on the podcast, "what's hysterical is historical." The betrayal file stored in my limbic system from mom's relentless alcoholic relapses and emotional abandonment was getting activated by the present, by my wife Lea. Sure, she may be blunt in her rejections, but my physiological reaction was way out of proportion to the stimulus.
The proof, the nail in the coffin that put the damn vampire in its place, came one day about six months after I was discharged from Hazelden, when I was standing by the stairs talking to my daughter Maya. The day before, we had made a plan to go to lunch together. Maya is like me - gentle and careful with her words, and we have an extremely close and psychologically safe relationship.
Maya said, very casually, and like it was no big deal (which it wasn't), "Pa is it ok if we skip lunch today?"
I was standing at the top of the stairs as the Betrayal File got loaded into my brain RAM and as the same old emotional shade was drawn down over the light of my mind. I was full-on triggered. I said "sure" with a little crack in my voice, walked downstairs, went into the laundry room (I go there to collect myself when stressed or triggered), and folded clothes. There, folding the towels, I finally realized that Sarah was right.
My old friend, the mommy Betrayal File stored in my limbic system that served me well as a young boy, is alive and well, and is getting in the driver's seat of my life and taking me places I don't want to go to.
It brings to mind this quote from Anthony De Mello: “How could you go about creating a happy, loving, peaceful world? By learning a simple, beautiful, but painful art called the art of looking. This is how you do it: Every time you find yourself irritated or angry with someone, the one to look at is not that person but yourself. The question to ask is not, ‘What’s wrong with this person?’ but ‘What does this irritation tell me about myself?'"
Same deal with the Grit File stored in my limbic system. The grit skill I learned as a teen and reinforced so magnificently as a surgeon, the grit that served me so well to get out of the hell hole I was in and that led me to become an incredibly successful thoracic surgeon against all odds had became a liability to me when I found myself burned out, in physical pain, lonely, and not fulfilled.
To me, the Grit File was THE was the way out of any difficult situation.
I picked up a phrase from Jeff English in the podcast that I love: Can you stop doing what you cannot not stop doing. In my case, this means; can I not heed the call of my activated Betrayal and Grit Files when they are not serving my best interests or the best interests of other humans in my orbit?
This is the mental inflection point of change. You realize something about your reactions and behavior, you see it, you cannot deny it, but can you choose to do the hard work of creating new neurological files to stop doing the thing that you cannot not stop doing? In other words, can you develop the mental muscle, one rep at a time, of a new response.
It was time for me to loosen the power of these trauma files stored in my limbic system, and the first stage was full-on acceptance (acceptance will set you free again!) of their presence and the truth that they exist. That alone was wildly liberating. I was finally awake and free of the yoke, the trance, of cause and effect.
I also had to learn how to remind myself of what was really going on when I get triggered, to breathe correctly to reduce the sympathetic activation, and to be kind to myself.
No more "just get over it." Now I get over it, but without the unnecessary irritation, anger, and sense of betrayal.
This shit works.
I am convinced that so many of us have these big T and little t trauma files stored in our limbic system from our past (even from incredibly caring and stable families). The mistake that I and so many others make is to dismiss as inconsequential, seemingly small but highly emotionally valenced events, as "no big deal" and to "just get over it."
I do believe that there is a time and place to just "get over it," but like all things, this requires experience, knowledge, and discernment - i.e. wisdom, something that can be built, like a house, over time.
I have said, again and again, that things are good until they are not. I now prefer the way Annie Duke, the author of Quit: The Power of Knowing When to Walk Away, frames it: The opposite of a great virtue is a great virtue.
Grit is a great virtue, and the opposite, knowing when to dump the grit and have the grit to quit, is also a great virtue.
Getting over things is a great virtue, and its opposite, embracing our emotions and our human struggles, is a great virtue.
Like so much in life, it all depends.
Next up, the start of the remodeling on top of the foundation.
P.S. In this post, and in others I have written, I refer to being in Hazelden as being incarcerated, and the folks in treatment as inmates. I use these words intentionally because they represent my mind and thinking at the time. Recall that I was voted least likely to succeed by my fellow inmates. I was bitter, angry, and resentful at life in general. I was a mess.
What I want to say is that Hazelden saved me. To this day, I cannot believe how kind and caring the people who work there are. It blows my mind that they had the compassion and stamina to work with someone like me when I showed up on their doorstep.
I have fond and warm memories of the relentless patience and kindness of so many people there, which actually brings tears to my eyes. One small example: when I was roaming the halls in the middle of the night, withdrawing (we were not to be anywhere but in our rooms), they assigned someone to hang out with me. She tagged along with me as I roamed, offering small kindnesses to me here and there, but most of all, she did what David Brooks calls Accompany - she was just with me, making it a little less hellish to be so alone.
I will be forever indebted to so many people who worked there: Sarah, my psychologist, who tolerated my rigidity and frustrations with grace and compassion; Steve Delisi, the incredible psychiatrist, who understood me as a physician and who would push back on my thinking to see new perspectives (a master clinician); Fred (the oracle of Hazelden), who was part of the graduate program and had seen it all and was a fount of wisdom; and so many others.
From the bottom of my heart, I thank you all.
Feedback with a thumbs up or down is greatly appreciated, or drop an email to me michael@michaelmaddaus.com.
