Who Holds the Clicker?

Mario Delia Grotta is 35 years old, with a shaved head and a tattoo of a rose on his pumped left shoulder. He wears gold rings on three of his beefy fingers and a gold chain around his neck. His neck is as thick as a thigh, and strong, and beneath the skin lie the raised ridges of what look like veins but are really wires from his surgery. He’s the kind of guy you might picture on a Cessna 140, speeding down the highway with no helmet, or in a bar in a working-class Italian section of town in the afternoon, a cigarette wedged in the corner of his lip and a shot glass full of something amber. He is the kind of guy who looks tough and would seem, on first appearance, to swagger his way through the world, but that is not true of Mario. For the past 14 years, Mario has had such severe anxiety that, three years ago, his psychiatrist, Ben Greenberg of Butler Hospital in Providence, R.I., suggested psychosurgery, or what, in the current medical climate, is now being labeled neuro-surgery for psychiatric disorders. Mario couldn’t stop counting and checking. In his attempts to ward off panic, rituals consumed 18 hours of his days. Fearful of dirt, he had to take three showers. He searched for symmetries. His formal diagnosis was obsessive-compulsive disorder, which is just a fancy way of saying scared. Was the car door locked? Did he count that up correctly? The French call obsessive-compulsive disorder mania de doubte, a much more apt title than our clinical OCD; mania de doubte, a phrase that gets to the existential core of worry, the difficulties of gracefully giving up the ground, opting instead for a clenched, demonic doubting that overrides evidence, empiricism, plain common sense. For Mario, life was crammed into a single, serrated question mark.

Since 1935 at least, psychosurgery has been used to treat anxiety disorders like OCD and its close cousin, melancholy, but it has always involved destroying neural tissue. It has involved cutting whole nerve tracts between here and there, taking down the phone lines. Forty, 50 years ago, any benefits people derived from the knife were perilously balanced against the flattening of feeling and the blanching of their personalities. Now, however, this is no longer true. Pacemakers for the brain, originally developed to treat movement disorders in Parkinson s patients, are beginning to be used on some of the most intractable but common psychiatric problems: anxiety and depression. Still highly experimental and available only to patients for whom every other available treatment has failed, the implants nevertheless suggest a time in the not-too-distant future when there may be options other than drugs for both those disorders. Given the current suspicions regarding the safety and efficacy of SSRIs (selective serotonin reup-take inhibitors), we need those other options. Soon, we may have a whole new cure on our hands, and in our heads.

Unlike psychosurgeries of the past, this cure does not necessitate cutting. Neural destruction is out, and in its place are prosthetics for the brain, or implanted electrodes. When correctly programmed, the electrodes emit a constant current that, theoretically, jams pesky brain circuits, the ones that say you suck you suck you suck or oh no oh no oh no. This idea made sense to Mario. His experience of illness was one of a terrible loop-de-loop, a kind of cognitive incontinence; something had to stop the stuttering rush. So he said yes to surgery. He said yes in part because he knew, if he didn’t like the neural implants, he could simply have them removed. The same cannot be said, of course, for the lesions of lobotomy.

In fact, neural implants are not new; they are merely being revived. Among the first researchers to experiment with the use of implants in the treatment of psychiatric cases was Robert Heath, who implanted over 100 electrodes in patients over a series of six years. This was back in the 1950s, when psychosurgery was still an industry. Heath was a handsome man with a spade-shaped beard and elegant hands, and he worked at the Tulane University School of Medicine, which was not far from the back wards of Louisiana’s mental hospitals and prisons, places of high, coiled wire; black, lacy grates; and unremitting sunlight. Heath took criminals, slit open their skulls, dropped electrodes down deep inside them, and then, with the use of a handheld stimulator, waited to see what would happen. Here’s what happened: Heath discovered that electrodes placed in the medial fore-brain bundle, otherwise known as the septal area of the brain, produced feelings of intense pleasure, while electrodes inserted into the tegmentum made a man enraged. Electrodes placed just so in the amygdala produced feelings of fear or its alternate, calmness, depending on the setting. Writes Heath, “The possibility of ameliorating or even curing psychiatric conditions through the use of these implants is vast.” Heath, along with José Delgado at the Yale University School of Medicine, found that they could stimulate and snuff anxiety with the small flip of a switch: they could take shy animals and make them social, and take social animals and make them shy; they could induce fear and reduce fear. And it all seemed so easy. Heath treated a homosexual man by implanting an electrode in his pleasure center and then having him watch movies of heterosexual encounters, and within 12 sessions, he was a newly made man. The patient proved it to Heath by sleeping with a prostitute on a hot Louisiana night, when even the walls were sweating, and he was successful.

Neural implants were significant right from the start, not only because they provided hope for the clinically distressed, but also because they, in part, changed the way we collectively thought of the brain. Prior to Heath and others before him, like Wilder Penfield and Paul Broca, many people believed thoughts and emotions were carried by blood through our heads via hollow tunnels. Once researchers like Heath demonstrated, however, that you could prod a tiny piece of cortical tissue and get a specific response—a taste of prune in the mouth, a smear of yellow in the air—Broca’s theory of localization was confirmed. This was a major mind shift, the brain now a series of discrete centers that, when wiped out, could cause tremendous loss and, when stimulated, could make many things froth forth.

Neural implants were abandoned in the 1960s, when the antipsychiatry movement first formed and, with it, came the discovery that governmental agencies like the CIA were experimenting with the new technology, in part, by funding Robert Heath. The CIA hoped to use the implants for what they called psychobiological weaponry, an idea that, once made public, fell fast out of favor. The implants were resurrected in 1987, however, when a French neurosurgeon operating on a Parkinson’s patient discovered that, if he touched the patient’s thalamus with an electrical probe, the patient’s shaking stopped. Several years after that serendipitous discovery, neural implants were approved by the FDA for the treatment of essential tremor, dystonia and some forms of pain. But something else was being observed, as well. Those implanted Parkinson’s patients—some of them brightened right up. Many experienced mood changes or felt their worries go away. It appeared the circuits controlling physical shaking were somehow connected to mental quaking, as well. “It’s how a lot of medicine happens,” says neurosurgeon Jeffrey Arley, Ph.D., M.D., of the Lahey Clinic in Burlington, Mass. “It’s by extrapolating backwards. Someone then has to have the chutzpa to say, ‘Gee, maybe we ought to try this for certain psychiatric problems.’ You believe it’s worth the risk. You don’t know until you try it. Someone has to say, ‘Gee, we can do this.’”

And someone did. Some small groups of psychiatrists and neuro-surgeons, in the early 1990s, began to talk amongst themselves. Psychosurgery had a very bad rap, so they spoke softly. One of their primary questions: Where, precisely, in a psychiatric patient, would one put the electrodes? Can you pinpoint mental illness as you can pinpoint Parkinson’s, with millimeter accuracy? The answer is no. “It took 10 years to find the target with Parkinson’s,” says Ben Greenberg. “At this point we are probably two or three years into that process. We will find the circuitry involved in (psychiatric) conditions. I think it’s going to happen.”

Neural implants for the treatment of psychiatric disorders is highly speculative, hit and miss, but that’s a risk you might want to take if your life is racked with pain. “We want,” says Dr. Helen Mayberg of Emory University, “we want more than anything, to find that sweet spot and go there.”

Mayberg and many others in her field talk about the sweet spot. And, at the same time as they covet this sweet spot, they fear being reductive and are quick to say that it’s all more complicated than simply pinpointing a tiny target; targets, after all, are linked to other targets.

What happens here affects the gravity over there. But that doesn’t mean there isn’t localization.

“My sense,” says Dr. Jeff Arley, “is that there are fairly discrete areas tied into some of the emotions.” Based on the work of Heath, it seems that pleasure has its places.

If it’s so possible to induce, say, pleasure or motivation, then why aren’t scientists simply aiming to override people’s psychic pain by searching for and stimulating their pleasure centers? This kind of question makes people in the field extremely uncomfortable. “We don’t want to get people high,” says Don Malone of the Cleveland Clinic. But in the face of such severe suffering, maybe we should.

Surgery also carries risks. “For one thing,” says Harold Sackheim of the Kolb Psychiatric Institute, “there’s a 1 percent to 2 percent chance of seizures, a 20 percent chance of infection, so if you can get relief without invasive surgery, you might want to pursue that other avenue first.”

Pills. That’s the other avenue we supposedly should pursue first. But should we? We take so many antidepressants that, last summer, British scientists found Prozac residue in England’s drinking water. For all our consumption, though, enough mental-health professionals now think antidepressants—which purportedly pose a suicide risk, especially in the first five weeks of use—are dangerous enough to warrant a black-box warning on the labeling. Perhaps more compelling, and far less contentious, are National Institute of Mental Health data suggesting that antidepressants leave a staggering number of users without any relief at all. “We have searched and searched,” says depression researcher Dr. William Burke of the University of Nebraska School of Medicine, “for the holy grail, and we have never found it.” That’s true. The often overlooked fact, according to Harold Sackheim, is that a full 30 percent of people are not helped by medication, not helped at all, not a whit, not a bit, and that translates into 42 million people without a salve for their suffering. The fact also remains that, of the 70 percent who are helped by antidepressants, only 30 percent of those are helped robustly; the others get some symptom relief and limp along. It’s not a pretty picture. There are no pretty pills.

Mario, who has tried more than 40 different kinds and combinations of medications, knows this all too well. When, three years ago, Dr. Greenberg first suggested surgery, Mario’s wife was eight months pregnant. He couldn’t stop counting and checking. For him, even with a death rate as high as 1 percent to 2 percent, the surgery to implant the chip was well worth the risk.

On a Friday in early February 2001, Mario woke up next to his wife. Instead of going off to work in the parish church, where he rubbed crucifixes until the gold gleamed, he went instead to Rhode Island Hospital, where surgeons were suiting up for his case. Was he scared? A week or so earlier, in preparation for his surgery, Mario had gone to a tattoo artist and had had the Chinese sign for child branded into his forearm. “If I didn’t make it, if I never got to see my daughter be born, then at least I would have this tattoo,” he says. “Child. With it on my arm, I knew I could go to the grave with some meaning.”

Now in the O.R., Mario is given a light sedative. His head has been shaved. The surgeons’ choices of brain targets are guided by the results of past lobotomies and cingulotomies and which lesions brought with them relief. The problem is that all sorts of lesions have attenuated anxiety and depression in desperate patients, lesions to the left or right, up or down, here or there. Without a single sweet spot, the possibilities are disturbingly numerous. No one in their right mind gets on a ship if the captain isn’t sure where to steer. Of course, that’s the point. Psychiatric patients who have this surgery are no longer in their right minds. They get on board because this is their last lifeboat.

At Butler, the doctors put the implants in the anterior limb of the internal capsule. However, other neurosurgeons in the past have favored the cingulate gyrus; still others, the sub-caudate nucleus. Helen Mayberg’s target is slightly behind Benjamin Greenberg’s and Don Malone’s. “We chose the anterior limb,” says Malone, “because that’s where the electrodes fit the best,” a comment slightly unnerving because it reveals the somewhat arbitrary nature of how these decisions get made.

As for the results, it’s early, but in a sample of about 40 patients, Greenberg and his colleagues have seen a 50 percent reduction in severe anxiety symptoms. Some people experience a complete remission. Others get more partial relief. As for depression, there have been about 15 implantations worldwide, with many more scheduled for later this year and next. Has it worked with melancholia? No one’s ready to give specific numbers, but there’s an unmistakable air of guarded optimism about the results. In an interview last March, Helen Mayberg, who claims she was the first ever to use DBS (deep brain stimulation) for depression, said, “So far the results for depression are extremely encouraging. We are very excited.”

Doctors like Greenberg and Malone and Mayberg are anxious to separate current-day psychosurgery practices from the practices of the past, when ice-pick-like instruments were thrust up under open eyes, and blades were swished through the brain. These doctors want you to know they are not lobotomizers, not lobotomizers, not lobotomizers, and indeed, there are significant differences between the carefully crafted surgeries of today and the recklessness of the past. But some facts remain the same. There is a gruesome quality to any brain surgery. The drill is huge; its twisted bit grinds through bone, making two burr holes on either side of the skull while, beneath a sheet, the patient’s body shakes.

It took surgeons about four hours to make the two holes in Mario’s skull. Mario remained awake through all of this, and he was consistently questioned. “Are you okay? Are you alert?” His head was held in place by a steel halo that screwed into his skull at six spots. The operating room was cold, despite the relentless, surgical sun. The surgeon threaded two 1.7-millimeter wires through the burr holes, wires on which the tiny aluminum electrodes were strung. Picture it as ice fishing: There is the smooth, bald lake, the hole opening up, dark water brimming like blood around the aperture, and then the slow lowering of string, the searching, searching, for where the fish live.

After several hours, the surgeons had the electrodes in place, nestled in the internal capsule. Mario could feel none of this because the brain, the seat of all sensation, has no sensory nerves. Next the surgeons implanted two cigarette-sized battery packs beneath Mario’s shoulders, under the skin. Wires run from the packs, up under the neck, to the implants themselves. The packs, controlled by remote computer and telemeter, power the electrodes when the switch is flipped, when the dial is turned high or low, on or off. Mario lay there, waiting.

He would have to wait a while. Psychiatrists do not turn the electrodes on right after surgery. That happens three weeks later, when the swelling in the head has gone down, when the bruised brain has had a chance to heal itself. Three weeks later, the burr holes sealed with skin, Mario would come back, and they would wave the handheld telemeter over his body, and the wires would leap to life.

With the re-emergence of neural implants, the only malleable and reversible form of psychosurgery—you can turn it up or down, on or off, take it in or out—coupled with high-tech imaging devices and stereotactic equipment that allows for impressive precision, psychosurgery is poised to make a comeback, to step from the pall cast by the early lobotomizers into a circle of respectability and, more importantly, of possibility. Now a patient can potentially reap the very real benefits bestowed by psychosurgery without having to undergo the dulling personality changes associated with broad, frontal-lobe ablation and the irreversibility of a lesion.

However, psychosurgery’s potential comeback is not only due to the new flexibility of its treatments. Its also likely rooted in our growing, collective realization regarding the limitations of drugs and our frank disenchantment with the companies that make our medicines. Not only do we know that SSRIs now have black-box warnings and that 30 percent of sufferers get no relief at all, we also now know that Americans spend billions of dollars a year on psychiatric medications. We know that the companies producing these drugs claim the high costs are necessary for research and development, and yet very few truly original drugs have come down the pipeline. Most are what the industry calls “me-too” drugs, slight variations of the older drugs still on the market.

This past year, the public learned that drug companies selectively publish only the studies with favorable results, a serious lie by omission. We have learned how drug companies court physicians at conferences by paying for posh hotel rooms and other high-end goodies. We have seen companies like GlaxoSmithKline push their sales reps to sell medications—neurontin comes to mind—for uses that are almost entirely untested. How can you trust a pill if you can’t trust its progenitor?

The first modern-day psychosurgeon was the Portuguese neurologist Egas Moniz, who won the Nobel Prize in 1949. Around that time, psychosurgery came to our side of the sea, where it was adapted with all-American fervor. Dr. Walter Freeman went from clinic to clinic, inserting ice-pick-like instruments, plucking patients who kicked and screamed their way to the table. There were no internal review boards, no ethics committees, no concern with patient consent, no solid scientific studies backing the work itself, but only fervent testimonials from patients like Harry Drucker, who claimed in 1938, in a magazine called The Coronet, “Psychosurgery cured me.”

And it did cure some people, or tweak their lives for the better, but the cost was sometimes huge, and the damage to human dignity could be appalling. This is no longer necessarily the case. Current-day psychosurgeons have taken extreme efforts to separate themselves from the shady past. In order for Mario to be eligible for neural implants, he not only had to have tried and exhausted every available pharmacological option at either optimal or above-optimal doses, but also to have undergone at least 40 hours of behavior therapy and submitted to six rounds of electroconvulsive therapy. His case was reviewed by one internal review board and one ethics board. “We don’t want to repeat the mistakes of the past,” says Greenberg. “We want to be sure this therapy is not only not used indiscriminately, but that it is reserved for the group of people who have failed trials of everything else.”

Why? After all, when you take a drug, you are perhaps altering your brain in ways as or more profound than neural implants do. When you take combinations of drugs, as many psychiatrically ill people do, you put yourself at risk for medication-induced Parkinson’s and a whole raft of other serious outcomes. “That’s true,” says Greenberg. “Look, I agree with you.” But his agreement won’t cancel out caution. The past does not feel far away.

After three weeks, the swelling in Mario’s brain had gone down, and he went back to Butler to have his implants turned on. This was pay day. Or not. So far there are only about 50 implanted psychiatric patients in the world. Mario was the first American.

Mario went to Ben Greenberg’s office. The men sat facing each other, Greenberg with a briefcase on his lap. He snapped it open and, using the computer inside plus a handheld telemeter, turned on the implants by remote control. Mario remembers the exact moment they went on. “I felt a strange sadness go all through me,” he says. Greenberg’s fingers tap-danced on the keys. There was a click, and the sadness went away.

Says Steve Rasmussen of Brown University, “With DBS, the thing has a certain immediacy to it. You can change behavior very, very rapidly. On the flipside of it, there’s a danger, too. This really is a kind of mind control. You know what I mean?”

This is the rare admission, the sudden slip in these doctors’ carefully crafted accounts of their experiments. For the most part, they insist this has nothing to do with mind control or social shaping; they are simply psychiatrists targeting symptoms. But, of course, that’s too simplistic. Anytime a psychiatrist tries to tweak a patient’s mind, he is doing it in accordance with social expectations. Symptoms always exist in a cultural context that defines whether they are “good” or “bad.” In this sense, psychiatrists are the long arm of the state, and if that arm is actually in your head, it could be too close for comfort.

Click click. Mario felt a surge inside of him. There. Right there. Greenberg closed down the computer. Later, outside, Mario peered at the world turned on, turned up, and indeed, it did look different: the cheerful, lime-green grass; the yellow-throated daffodils. He began to walk and then walked faster. He couldn’t seem to stop. “You’re like the Energizer bunny,” his wife said to him. Everything was great. The sun was like a lemon drop up there in the blue bucket of a sky.” I felt revved,” Mario says.

Mario is not the first person to become a little too happy on the wire. “That’s one of the dangers,” says Greenberg. Don Malone, also a DBS psychiatrist, says, “We don’t want hypomania. Some patients like that state. It can be pleasurable. They’ll tell you to keep the current right there. But this is just like having a drug prescription. We decide how much, when and how.”

That’s a little creepy. Because it’s not the same as with a drug prescription. A patient can decide to take no drugs or five drugs. A patient can split his drugs with his spouse, feed them to the dog, put them in ice cream or applesauce, or just switch psycho-pharmacologists. Despite prescription regulations, there is tremendous freedom in being a pill-popper. But not so for those with implants. Psychiatric patients are wired in a way over which they have little to no control. And herein lies one of the problems. True, no one is dragged to the operating table in terror any longer. No one is cut without exquisitely careful consideration. Instruments have been honed; imaging devices, advanced. And yet, the informed consent psychiatrists now take such care to secure is neither entirely informed nor entirely consenting. Because a patient does not, cannot, fully understand or appreciate the degree to which, after the surgery, he or she will live at the flip of the doctor’s switch. Once a month, they must travel from wherever they live—Ohio, Mexico, Florida—for what are called “adjustments.” Adjustment decisions—turning the implants up or down, altering the “stimulation parameters”—reflect how the patient scores on a paper-and-pencil test of symptom intensity. The patient’s subjective report is taken into account, but the final and, ultimately, complete control lies with the treatment provider.

“Who holds the clicker?” asked one doctor at the annual neuro-surgery conference this past June.

The answer from neurosurgeon Rees Cosgrove of the Massachusetts General Hospital: “The doctor has that, yeah. Yeah.”

Mario’s good mood continued. For days, he considered himself possibly cured. He had obsessions and compulsions, but they were smaller now, overshadowed by the grand energy that had come to saturate his existence. Then his daughter was born. They took the baby home. Her name was Kailly. She was a textbook-perfect baby: She screamed; she shat; she drooled; her entire, unregulated being a little vortex of chaos. Mario changed her diaper, saw the golden smear of shit and, in his heart, backed way up. His mood dipped. He had a terrible time feeding the baby. Sometimes it took him so long to give her her breakfast that it would be time for lunch and he’d have to start all over again. The baby, strapped in the high chair, screamed, squash all over her mouth. Wipe that up. Right away. He was better, yes, but not enough. No, not nearly, nearly enough.

Mario went back to see Greenberg. For the first month after surgery, he saw him every day. Greenberg snapped open the briefcase and turned this up and this down. He fiddled here and there. Over a span of time, with Mario reporting the waxing and waning of his symptoms, Greenberg eventually got the setting right. Each time the setting was changed, Mario felt that peculiar wash of sadness. Then he evened out. He began to pick up dirty things. It was, at last, okay.

Now when Mario talks about that time, his early days of recovery, tears come to his eyes. “It was like a miracle,” he said. “I still have some OCD symptoms, but way, way less. Drs. Greenberg and Rasmussen saved my life. Sometimes they travel to conferences together on the same plane. I tell them not to do it. It makes me very nervous. Who would adjust me if the plane went down? No one else in this country knows how to do it. It’s like the president and the vice president traveling together.”

As for the future of neural implants, some neurosurgeons see in them the potential to treat a wide variety of psychiatric problems, from eating disorders to substance abuse to schizophrenia. And as these devices gain in popularity, so, too, will the ethical issues that stick to them like barnacles. Because despite the extremely cautious way neurosurgeons and psychiatrists are going about using the implants in the treatment of anxiety and depression, and despite their impressive results, there are still some who oppose the work, and even those who are its advocates admit they are treading on tricky ground. Beyond issues of informed consent, there continue to hover fears, tired but persistent, that, if this intervention fell into the hands of the state or overworked prison systems, it might be used as a management device. Despite the fact that both of these things did happen in the last century, it seems unlikely they will happen again, if only because the researchers involved are so carefully guarded against that possibility. Neurosurgeon Rees Cosgrove, at that annual meeting of neurosurgeons in June of 2004, said, in an effort to caution restraint, “I do not think we will have another opportunity to do this. So if we do not do this right and carefully and, you know, properly, I don’t think it will come back.”

And then there are other potential ethical problems. Cosgrove himself says, “It’s easy for any good neurosurgeon to do this right now. That’s the dangerous part. It’s easy.” And if it’s easy, what will stop neurosurgeons, both mercenary and curious, from performing these operations on a public clamoring for relief? Will there come a time when these implants will be used for the treatment of milder forms of mental illness? And why shouldn’t they be? To take the inevitable step forward, what will stop people from pursing these implants for augmentation purposes? Cosgrove describes a patient who, after implantation, became more creative.

But we’ve heard much of this before, in the great Prozac better-than-well debate, and 17 years after Kramer’s influential book, people do not seem better than well. The promise of Prozac has faded, taking with it many of our souped-up fears, and chances are, thankfully, neural implants will prove to be just as disappointing.

However, a few ethical problems seem hard to get around. Some scientists question the very premise that despair can be localized. But perhaps the simplest conundrum is this: DBS for psychiatric disorders is very experimental. There are no animal models of DBS for anxiety or depression, so these forays into the human brain are largely unguided, despite all the high-tech equipment. Said Cosgrove at the 2004 meeting, “One of the important, outstanding issues for deep brain stimulation is that we are not clear what the optimal targets are. We don’t even know what the optimal stimulation parameters are, and we don’t know what the long-term effects are. … It’s not so simple as we make it out to be.”

But for Mario, it is simple. “I’ve had a hard life,” he says. “My parents got divorced. My father died. I broke my foot. I have OCD.” He pauses. “But I have been helped.”

A long time ago, in the 1950s, Drs. Rune Elmquist and Ake Senning developed the first implantable cardiac pacemaker, and they anticipated so much publicity that they did it at night. Now cardiac pacemakers are as common as grass. Will there come a time when neural prosthetics will be just as banal? Will we ever view the brain free of the awestruck intensity that now informs our vision? After all, no one says much when a woman has her ovaries out, thereby losing estrogen and progesterone, or when an aging man takes testosterone, despite the fact that these hormones, produced in glands outside the brain, have as fierce a role in the formation of our selves as any gray matter. Some might even say neural pacemakers and the psychosurgeries from which they sprang have and will continue to play a pivotal role in both our understanding and acceptance of the brain as just another organ, part of a system so interconnected that one segment cannot be valued more than any other. Some might also say, however, that the brain will always be the final frontier, the acme of exploration, because in no other place is there the potential for a surgeon to so acutely and immediately make memories evaporate, dreams rise, fingers freeze, hope sputter. The argument could be made that we are not entirely our kidneys but that we do live entirely within the circle of our skulls.

For Mario, this is all armchair philosophizing, irrelevant to his situation, and he is right. “I don’t care what it means,” he says. “I care that I’m better. I’m not all better, but I’m better.” His wife is now pregnant with their second child, and he carries with him pictures of his 3-year-old daughter. The daughter is beautiful. She wears tiny, gold hoops in her ears. She and Mario play together all the time. They play “tent” in the morning, climbing under the bed sheets, where it is dark, where the 6 a.m. light barely filters in. He shows her shadow puppets. A bird flies. See, a spider. This is the church; this is the steeple; open it up, and here are the people. His wife showers; water hits the walls with a sound like static. Outside, cars roar on the roads. Under the sheets, so close to his daughter, Mario can hear her breathe; he can kiss her; he is not afraid to hold her hand. Some might say Mario has agreed to a strange sort of bondage, but Mario doesn’t think so. He would say he has been freed enough to love.

About the Author

Lauren Slater

Lauren Slater is a psychotherapist and writer. She has received awards including a National Endowment for the Arts fellowship and a Knight Science Journalism fellowship at MIT; her work has also appeared in The Best American Essays.

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