‘The buried emotional tangle in the rag and bone shop’

Veronica O’Keane, Professor of Psychiatry and practising Consultant Psychiatrist at Trinity College Dublin, has her first trade book out now with Allen Lane: ‘The Rag and Bone Shop: How We Make Memories and Memories Make us’. Our editor Jon Sutton fired her some questions.

When Psychologists are asked for the difference between themselves and Psychiatrists, they tend to focus on prescribing rights. From your own perspective, what’s the difference in how you approach the topic of memory compared with Psychologists?

What a big question and one that we don’t ask very often. Starting with the general aspects, psychiatrists co-ordinate care and are by definition pragmatic, more focused on identifying brain pathology, whereas clinical psychologists dig deeper, bringing new insights to the personal aspects of disorders and illnesses, and help the team and the person understand in a way that is unique to the individual patient. Psychologists are very skilled at ‘translating’ whereas psychiatrists are primarily diagnosticians, prescribers and managers. 

In relation specifically to memory, my experience in clinical practice is that psychologists are skilled in understanding subjective problems in the context of the unique memory maps of the individual, and psychiatrists are skilled in differentiating primary memory problems from a cognitive difficulty secondary to psychiatric disorders. But I also see that both disciplines seem to battle away without great insight into the pervasive memory maps of psychotic experiences.

Your metaphors around memory as a neurally coded experience – the flash of lightning that lights up a tree in a storm, the buried rag and bone shop of the past – do you think they are essential in understanding memory as a conscious experience?

Yes, I think so. Our conscious experience of memory is composed of multiple brain processes, many of which are automatically processed but are experienced as a unified whole, except if mentally ill when this unity of conscious experience is broken down. If we want to understand memory, for example the pathological memories of PTSD, we need to encourage awareness of what is automatic, what is lighting up that they are not attending to, the buried emotional tangle in the rag and bone shop. This is really what introspective therapies like mindfulness and CBT teach us: to remove the outer clutter and focus on the underlying experience. 

You write that in writing the book you turned your back on intellectual explanations and eschewed theory. Was that for your own benefit, or that of the audience, or…?

Thank you for pointing out this central aspect of the book. I believe that there is a cognitive bias in conventional attempts to understand the world, yet very few people understand the world or themselves in this way. We need to start with human experience because this is how our brain formulates the world. Second, most theoretical explanations leave non-experts hanging in abstract formulations to which they cannot relate, and that includes also most experts, who stop questioning what it is that they are really exploring. All our understanding starts with experience.

It’s beautifully written, particularly for a first book… and for me I think it emphasises that to write an engaging professional book for a public audience you need to be a bit of a polymath, drawing on literature, film, poetry and art, on patients’ stories, on your own life… Was all that there in your mind from the start, or did one or other aspect come out more strongly during the writing?

Thank you. I didn’t write the book with any planned format: it emerged in this way because of how my memories have formed my way of seeing the world. The journey is a naturalistic one, I hope, for the reader. The mix of arts and science is completely natural for me. There was no mainstream neuroscience when I was doing my medial training, and only a limited piecemeal teaching in the neurosciences when I trained in psychiatry. Although subsequently I did a PhD in neuro-biochemistry, there was no real vision of whole brain function. I knew intuitively that human experience originated in the brain and was drawn to the written and visual arts, music, and philosophy because the humanities describe and emote introspective experience. Did one aspect come out more strongly when writing? The poet has a special place in Irish culture, being traditionally seen as the memoralists of the times. Poetry is reflective and laconic and did emerge more than other art forms.

You draw on fairy tales… do we risk forgetting a lot of ‘folk psychology’ understanding into our mental lives? 

I explain in the book that I was reared in the tradition of fairy tales and they were more real to me, and remain more real for me today, than the religious dogmas that were hammered home to Irish children in the uniform Roman Catholic education of 1960’s and 70’s Ireland. Ireland was a strange mix of catholic dogma and the unconstrained romantic expression of the living arts. I was drawn particularly to the fairy story form probably because it was pre-Christian, it was free from parable and meaning, and it was set in wild nature and local place. I still love the idea of the rag tree, where strips of cloth tied to tree branches, usually a hawthorn, signify a wish, a love, a person who is sick or who has died. There is a rag tree in Trinity College in the centre of Dublin where I work, and when I pass it I see the secret longings, losses and hopes of individual humans.

Changeling babies is a common motif in fairy tales from around the world. The mother believes that her baby has been taken away by the fairies and substituted with a changeling, who usually has a similar appearance. Mother can tell that the baby is not hers, and knows that the fairies are tricking her. Another motif is that the mother is taken away by the fairies and replaced by an identical double. It struck me when treating women with postpartum psychosis that they often had delusions of substitution – that their babies were imposters, that their husbands had been replaced by identical doubles etc – and this triggered memories of fairy stories about changeling babies. In this way I have come to understand the hidden wisdom in ‘folk psychology’ and the real life value of fairy and folk tales as collective memory and wisdom being passed down intergenerationally. These stories make girls aware that bad things happen and to warn them that childbirth is sometimes associated with strange going-ons.  

A central quote is from Louis Bunuel, ‘Our memory is our coherence, our reason, our feeling, even our action. Without it we are nothing.’ Did writing the book increase your fear of losing your memory in later life? Reading it did for me!

I think that everyone who works with the brain – whether a psychologist, psychiatrist, neurologist or neuroscientist – is fearful of losing their ‘mind’. This fear is justified because brain disease, like dementias, erode one’s sense of self. It is also very painful for loved ones, and sometimes clinicians, to observe. 

In relation to non-pathological memory loss – mild cognitive impairment – I’m not terribly frightened about this because our abstract brain, our pattern recognition, improves with age, and more than compensates for memory efficiency. Our acceptance of inevitable decline, in my personal experience, improves with age because of expanding happiness, but perhaps I’m just lucky. When I was your age I was also frightened of cognitive decline.

You write of a memory of the warm summer of 2018, when you ‘swam in the sea and swam in memory’. Do you think it’s possible to have favourite memories that aren’t rich in the sensory aspects from the time? Does adding those details back in improve the memory?

This question involves both the making and the recalling of memories. Yes, I do think that memories need some sensory animation to imprint and this has been well explored in the psychology of salience. It is important to add that sensory experience includes both external – exteroceptive – experience; and emotional – interoceptive – experience. You may light up internally at a relatively insignificant external event – this interoceptive event, the ‘lighting up’ is also a sensory experience. Sometimes we try to really remember how we felt when something happened and this does enrich the memory, it makes the event special because we are really creating a new experience from the memory. 

You write that it is ‘becoming more apparent that brain and mind are one and the same’, yet many psychologists might argue that the underlying biological basis of many mental disorders remains elusive, along with breakthrough medical treatments. Would you not agree? You do say in the postscript that ‘Psychiatry will be last to arrive at this point…’

I do believe that it is becoming apparent that the brain and mind are one and that this is the final frontier of dualism. I think that it is also apparent that the biology – the biochemistry, the neurophysiology, the anatomy, the connectivity – remain largely unknown. We are trying basically to understand processes that are not available to consciousness. Yes, medics can give better treatments to repair pathology in the brain although processes remain elusive. Regardless of whether we will ever fully understand brain processes, it will remain impossible for a human to fully understand their own processes, one’s own mind. To do this one would have to be outside looking in. The best that we can do, and psychology excels at this, is to try, as far as possible, to observe the brain processes of another and help them see their own brains from the outside, as it were. 

Find out more about the book here.

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