Today’s guest, Dr. Samuel Pauker, is someone near and dear to me. He guided and directed my recovery from mental illness. I personally benefited from his caring and dedication to the well being of his patients.
Dr. Pauker is on the clinical faculty of Weill Cornell University Medical College and Assistant Attending in New York Columbia Presbyterian Hospital. He is on the faculty of Columbia University Center for Psychoanalytic Training and Research and has a private practice in New York City. He has been treating and aiding patients since he graduated from the University of Pennsylvania Medical School in 1979.
He co- authored one of the first books on what to expect in marriage with his wife, Miriam Arond, The First Year of Marriage: What to Expect, What to Accept, and What You Can Change for a Lasting Relationship.
With the onset of my panic attacks I was directed to a local psychiatrist who did an intake in about twenty minutes and sent me on my way with a prescription for some medication in hand. I had a very negative reaction to the medication and I was desperate to find the help that I knew I needed. I wanted the top psychiatrist. My aunt, Mrs Shana Schacter, a very respected psycho therapist recommended Dr. Pauker. He was the best thing that happened to me in that period of hopelessness and helplessness.
Dr. Pauker’s intake was almost three hours long. I remember how he asked me to explain what I was feeling and what was wrong. He listened and then he asked me more questions and then he began to explain to me what I was experiencing. His next step was to tell me that I could overcome this debilitating darkness and live a real life once again. Dr Pauker explained the treatment plan along with the reason for each type of medication.
“”The kind of work I do is psycho-therapeutic psycho-pharmacology. I listen to the patient’s own depiction of their symptoms. Each symptom may be buried in a story and each story is unique to that individual.”
“Dr. Pauker, I still remember that day. The amount of time you took gave me the hope that you would understand. You asked so many questions to make sure that you would be able to properly diagnose me. When I left your office, I had a feeling that I would get well. It gave me so much strength. During the depths of my panic attacks I reached back to that initial visit and found the ability to cling to hope.”
Dr. Pauker explained, “One of the hallmarks of depression is the inability to believe in oneself, life or see any positivity. Depression is like a sine wave, it waxes and it wanes. One day a patient can feel good and thinks, ‘Hey, I’m doing much better, I’ll set up appointments for tomorrow.’ But tomorrow arrives with a wave of dread and those appointments are not able to take place. I warn my patients that it takes three months to get to a place of an even keel.”
“Years ago we had medication that was 80% effective for 80% of the patients. I felt like a charlatan telling patients, ‘Yes, I have what it takes to make you well.’ The patient used to be hospitalized for three months. We could monitor closely the ups and downs. Today the medicines are more fine tuned, better and we have many options at our disposal. In the beginning weekly follow-up is necessary to keep tabs on how the patient is reacting to the medication and if there is an improvement.”
“When a patient arrives at my office they are often in a desperate state. If nirvana is 0 and 10 is hell, the typical patient will come at a 7,8,9, or even 10.
At that point I need to medicate the patient to bring them down to a 4.5, or 6. Then the patient is capable of doing the next part of the recovery program. I explain to them that they need to get involved in yoga, meditation, or cognitive behavior therapy. It is the only thing that will save them. Initially they need the medication to calm the waters so they can swim to shore. But they need to do the inner work to really heal.”
“In the beginning people have depressed thoughts and they say ‘I don’t want to be on drugs forever. I tell them, ‘You don’t have to be on forever. The limit is 50 years. It says so right here on the box.’ Either they look at me like I am crazy, which makes them feel good, that I’m the crazy one and not them, or they are capable of seeing the humor and for the first time in a long time, it brings a smile to their lips.”
“The medication is only to do away with the debilitating effects of the depression so that real change can take place in the person by practicing yoga, meditation, prayer or the like.”
He then further elucidated, “There is a colossal difference between mourning and depression. When a person mourns they will be crying one moment and then their thoughts will bring them to a funny memory and they will laugh out loud. They experience both emotions. In depression it is one long, steady line of down. They can’t experience any positivity.”
“Family that are struggling to care for a relative in a depressive state will eventually be worn out. Depleted. I tell residents if a person’s family is at a point where they have no more to give, it is a clinical sign that their family member needs to be hospitalized for a maximum of 9 days. Then there is a 9 day window for the patient to be diagnosed and the family to take a deep long breath. A treatment plan needs to be put into place during those 9 days, including medication and follow up. It is only the beginning of the recovery.”
“Depression is treatable. It isn’t appropriate for any stage of life. It is deep, it is dark and it is unrelenting. Mourning is appropriate, depression isn’t.
There are people who have a milder form of depression, dysthymia. The person functions but is carrying a heavy weight on their shoulders and always walking on the cloudy side of the street. They can ride the crest of the wave when things are good, but the tiniest thing turns from a molehill into a mountain. One out of every three people walk around with mild depression. When someone with dysthymia loses a loved one then they are in danger of falling into a real depression. They cannot mourn. One cannot mourn when depressed. A depressed person is always playing the same thing over and over again in their head. It never ends. During mourning one plays over things and learns from them and internalizing the new insight. A depressed person will feel a need to suffer. ‘How can I go on with my life if this person did not live?’ One loses faith with the good and forgiving G-d and maintains belief in an angry and accusatory, killer G-d.”
“Many years ago I was in the Peace Corps. I was based in the Philipines with very little medication at my disposal. One day a farmer came to me and he was depressed. I got hold of some anti-psychotic pills and they worked for him. Word got around that I had helped him and all of a sudden there were lines of people waiting for me. What I didn’t know was that the local shaman had given his authorization and so the people believed that I could help them. I ran out of medicine. I was giving them cough medicine because that is what I had. This shaman saw that I was buckling under the load of the numbers of people so he removed his sanction and they stopped coming. It was their belief, their hope that had helped them.”
“There are not enough psychiatrists to treat all the people who are suffering from depression. Any person who has suffered from mental illness and has come out of it, serves as a beacon of light to others. They are deputized. The people who have come through it are the front line of defense and will be asked by those suffering, ‘How did you do it?’ ”
“Anxiety and depression are linked together. There is an anxious component, ruminative and negative. There is a difficulty to have positive thoughts. There are signs like difficulty sleeping and loss of appetite and enthusiasm. If one thinks negative thoughts they will be anxious. They may also be depressed. If one’s anxious thoughts go further, then the adrenalin of the anxiety will block the feelings of depression. When people begin the treatment for depression, some will get extremely anxious. We treat the anxiety and then the patient will become aware of their depression and say, ‘Doc, I am so depressed.’ The medication did not make them depressed, it just unmasked the hidden depression. We need to treat the patient through this depression. It may call for an increase in anti-anxiety medication, which can be risky and we must keep close tabs on the patient.
The patient must be made aware of what’s going on. We treat straight through until the depression lifts.”
Dr. Pauker is finishing a new book about body, mind and soul which should be out in the next few months. In it he discusses the connection and the effects of one on the other. “Depression can be close to 100% curable with close to 0% side effects. But medication is the beginning. Then one must also go the psycho-therapeutic route to understand oneself. As you walk your biological gradient back , you will see there are things that can only walk through a psychological gradient, like CBT or yoga, a mind/body gradient.”
“In yoga one creates an artificial stress and then you learn to breathe deeply and relax. One teaches themselves that when in stress, the automatic response is to relax and this in turn shifts the mental state.”
“Psycho-spirituality, the real meditative state, has these luminous aha moments. These might be the core of the therapeutic healing process.”
The tips that Dr. Pauker recommends to someone who is living with a loved one who is suffering from mental illness, but does not want to do the work, and does not want to go down with the ship are:
Point out – don’t get into a battle over it. If you find yourself repeating the same thing three times in a row in an escalating voice – back off! They heard you, understood you and part of themselves agrees with you, or they wouldn’t put up a defensive wall. Instead, agree with them and this makes it harder to disagree with you. ‘You have a good point there. I’m going to think about that.’ Leave them holding air, not your neck.
What you can say is ,’You seem unhappy’. No frontal attacks. Then the spouse might say, ‘I am unhappy, because you are constantly (fill in the blank)’ Then you could say, ‘I agree, but I’m noticing that you are unhappy. Maybe you want to get a consult.’
You don’t have to be consistent. On one occasion you can hit them over the head and say, ‘You’ve been miserable to live with,’ and on another say, ‘Gee, you look so unhappy.’ Internally there is a part of the other person that wants to get well. You want to get the message across to that unconscious part that wants to get help. Don’t get nihilistic and think your voice isn’t getting heard. Go by the rule that by the 14th time your voice will be heard. Don’t give up!
Dr. Pauker sees hope through the prism of conscious and subconscious.
It depends on the situation. A woman who is dating a guy who can’t commit, may be best served by knowing the reality of the situation. He won’t do what she wants unless he sees her back leaving.
“A person with terminal cancer is best off acknowledging the situation and using the time they do have to the hilt, knowing that their time is limited.”
“Early in my career I saw myself as somewhat of a charlatan telling patients that I will fix them. while knowing I only had an 80% chance to help 80% of the problem.”
“ I have a good reputation and people come to my door. But their belief is bigger than me. Medicine moved into the shamanic. We go to a doctor because we want to believe he is going to be a healer.”
“It is much more than putting them on my shoulders. I just sit in between. The medicine is for real; it is not a placebo. Their belief is not just in the doctor, it’s in the institution. I try to shuttle the two institutions, pharmacology and psychology. I don’t know much about herbal medicine, but there are more people who rely on that then rely on conventional medicine. The patient can read up about it and they can have some feeling of control over it. They don’t have to rely on us.”
I don’t know how to sufficiently express my gratitude to Dr. Pauker who saved me when I was drowning in the depths of depression. He gave me hope and permission to heal. The medication got me to the point where I was able to begin the work that I needed to do in order to make a real change and find my way to wellness in mind,body and soul. We must always remember that pharmacology can numb the pain, but to actually heal one must do the work in order to reach true wellness. A psychiatrist can’t wave a magic wand and give out pills to take away the source of the pain; he can only prepare the ground for us to till and plant seeds of hope.
Thank you for walking me through the process, giving me clarity, hope and a sense of comfort; a feeling that I was not alone and a sense that it was okay to not be okay.
You can reach Dr. Pauker at email@example.com.