Substitution Aids Success

Aging is a script. You are its director. However, chance and fate may make the script unpalatable – or deplorable. With the appearance of chronic illness, patients frequently say “why can’t I do what I love?” The answer most often is to do something else.

The body works through continuous reinvention. Bodies remake themselves all the time. Often the secret to improvement is substitution, whether it’s your brain recreating new information networks following a stroke or a ballplayer with a broken leg undergoing physical rehabiliation. The trick is, if we can, to intelligently regenerate.

Pain, Depression and Addiction

Forgive me for starting with a personal anecdote. Some years ago I developed chronic pelvic pain. Forget my doctors’ hapless attempts to treat my non-existent chronic prostatitis; the national “guidelines” of the illness predicted I would be fully disabled within eighteen months. Pain and the requirement to urinate was pretty much constant, walking was painful. I had given up running some years before when my knees began to hurt, replacing it with walking, biking and exercycling – the principle of substitution possessed precedent. Swimming was about the only activity I could do consistent with my physical therapy, so off to the Y I went.

I don’t like to swim. I’m not good at it. My version of the Australian crawl looks like an over-eager drowning man who has forgotten to breathe. There were other obstacles. Long evening lines of eager swimmers necessitated three individuals to a “lane.” Semi-professionals doing the butterfly regarded the lane as their private territory, leading to ungentlemanly behavior. Lifeguards who acted more as corrections officials (“our orders are not to speak to you”) paced the lanes above and could not be convinced to close drafty windows. Nor were the high levels of chlorine helpful, leading to itching each night and the change in color of my swim trunks from blue to mauve before disintegrating in my fingers. Yet with time my breast stroke became slightly less inelegant, and I found my mind calming through the meditative swift, cooling motion of water. After a year of swimming and PT, I was pretty much normal.

So when a horribly depressed patient with tinnitus arrived, attended by his kind and devoted wife, I figured there were several things to do.

Not that he wanted to do anything – even to watch television. I tried different elements of the four fold path – physical, mental, social and spiritual actions towards well-being – with very limited success. He did not want to move from bed. Getting him to try cognitive-behavioral techniques was unavailing. He refused to reengage socially with old friends, and felt his life without meaning and purpose. Medications made him ill. Tinnitus – and accompanying hearing loss – were the only things he wanted to talk about – or could think about.

Recent studies now are beginning to show how much tinnitus takes up the brain’s information networks, ramifying its effects far, far beyond the auditory cortex. The body indeed is information – but how to get this man well?

He had always loved tennis. Formerly it performed a large role in his physical and social life. When I told him he should just get out of the house and hit a ball against a practice wall, he was incredulous. He used to be a good player. How could he stoop so low as to hit a ball against a wall? It would only make him remember how much he had lost.

It took a long time, but he began to move. He told me he hated the whole idea, but he started hitting the ball regularly. Then, he found he could put it over the net. Later he was convinced to call on an old tennis friend, and to try and hit balls with him – though not play a game.

He’s playing regularly now, and is a lot of fun to talk to.

Replacement as Reinvention

Just as the body is always taking old stuff and remaking it anew, rehabbing and recycling, often we can act the same ourselves. The runner may unhappily become a walker following a knee replacement – but the slowed speed may allow her to meet and befriend people along the way. The man addicted to heroin may replace his addiction with marathon running, spiritual actitions, or as one of my patients did, with overwhelming love for his wife and new family. The dark predictions of physicians may prove unfounded; the physicist Stephen Hawking has outlived his expected demise from ALS by fifty years, and managed to prosecute an affair and leave his wife while paralyzed inside a wheelchair. Biology is endlessly inventive – so are people.

It’s not merely that half a loaf is sometimes better than none. The four fold path – physical, mental, social and spiritual well-being – can provide guidance. Physical treatments often aid mental health. When illness is severe and unremitting, social engagement and elements providing meaning and purpose need to be brought to bear – pretty much most of what medical care could offer until the past century. As T.S. Eliot pointed out, “they also serve who stand and wait.”

Particularly when attending others who are sick and ill. The brain improves through novelty, with necessity the mother of invention. And biological reinvention does more than keep us alive – it can make us well.