Waiting

"We make out of the quarrel with others, rhetoric, but of the quarrel with ourselves, poetry."

Yeats

Elizabeth Bishop was an orphan, an alcoholic, and a lesbian, and a 20th century poet with a lofty reputation. Her mother was institutionalized when Bishop was a young child, and the two barely met thereafter; she struggled variably with depression and drink for most of her life. She lived in Brazil for many years, and she was famously a close friend of the (often floridly) bipolar poet Robert Lowell. For whatever reasons of style and temperament, her work is not generally a personal favorite of mine, but I do like a few of her pieces very much, including "In the Waiting Room," found here.

It is characteristic of Bishop that she tries (in this case successfully) to wring poetry from one of the least exotic of experiences: a child waiting in a dentist's office. The setting is effective as a grounding metaphor for childhood, at least as it can seem at times. There is the waiting for some experience at once mysterious, ominous and necessary; cryptic sounds and glimpses of adult activities come through the window. One feels constrained and restless--there is no going in until one is called, and yet there is no point in leaving, as one will only have to come back eventually.

The poem records a crucial moment of self-awareness, associated with the almost anthropological self-distancing embodied in the National Geographic magazine. The child's reflections mark an epochal psychological advance, from the sui generis but often monstrous egotism of early childhood to the shared world of maturity. Most striking is the potentially depressing specificity, the contingency, of what and how human beings are, seen in wide perspective ("Why should you be one, too?). For the very young child all things seem possible--an infinite number of open doors seem to beckon. For the slightly older child, who has had even a premonition of the experience in this poem, a very large number of open doors may remain, but the difference between infinity and "very large" is, well, infinity. It is a hard lesson: no, not everything is possible. Also: sure, you are "different," but not different, rather, you are merely one of many. It is a small step from this to the shock of mortality:

The waiting room was bright
and too hot. It was sliding
beneath a big black wave,
another, and another.

Arguably some adults are not as mature as the child in this poem. And while such moments of alienation can occur to anyone, arguably they are more frequent in melancholics; one definitely gets the sense that this is a "sensitive" (and precocious) child.

However, the major consolation of the limitation and vulnerability of adult humanity is compassion: we care (most of us anyway) because we know what it is to really hurt. That is why very young children can seem so cruel--they don't yet grasp vulnerability. To me the most important lines in the poem are these:

How had I come to be here,
like them, and overhear
a cry of pain that could have
got loud and worse but hadn't?

Until one reaches those lines it may not be obvious that the setting of the dentist's office, while ominous, is ultimately a place of healing. Inhuman nature is full of cries of pain that get "loud and worse." What we (should) most strive for in ourselves and in our shared community is the determination to prevent as much suffering as possible (that reminds me--I still need to register to vote after my recent move). Surely dentists agree--figuratively at least--with Katherine Hepburn's comment in The African Queen that "Nature is what we were put on earth to rise above."

Gentlemen, we can rebuild (her)...

"O that this too too solid flesh would melt,
Thaw, and resolve itself into a dew..."

Hamlet


"I know that I would die if I could come back new."

Wilco

We have the technology. Sherwin Nuland has written an intriguing review in The New Republic of a look at contemporary cosmetic surgery: Anthony Elliott's Making the Cut: How Cosmetic Surgery is Transforming Our Lives. Business is booming of course, particularly in Asia, where self-enhancement offers are folded into exotic vacation packages. Nuland describes the ways in which the predominance of celebrity culture has dovetailed with traditional marketing techniques (e.g. satisfying desire while simultaneously stimulating the desire for more) to make cosmetic surgery more mainstream than ever before. He makes the important point that such procedures are less about individual or idiosyncratic vanity than they used to be; rather, they are about simple consumer behavior on the one hand (youthful appearance as commodity) and a somewhat grim need to keep up with the Joneses on the other (age discrimination in many occupations is very real).

I checked out http://www.cosmeticsurgery.com/ to see what I might be able to afford, I mean, to get a sociological look at what's out there. In addition to the standards, and some intimate bits I'll pass on here, I was surprised to see "calf augmentation" (hate those skinny calves), buttock implants (oh my), and something appallingly called Brazilian Butt Lift Autologous Fat Transfer (my God!). Actually, derriere enhancement is apparently quite the thing in some circles, as a fascinating Slate slide show illustrated. One should not dismiss this sort of thing out of hand; one of the most hilarious moments in Seinfeld (and of course also one of the most deeply moving) was a Calvin Klein executive's comment, vis a vis Kramer, that "His buttocks are sublime!" (Episode: "The Pick")

It occurs to me that while in many occupations the appearance of youth, at least, may be advantageous, medicine and psychotherapy are exceptions to this. In fact, many novice physicians and therapists wouldn't mind looking a decade or two older for their patients, if for no one else. Nuland's review mentions women bringing in pictures of Angelina Jolie to guide their plastic surgeons. What ambitious young analyst would mind a resemblance at least to The Master (and while you're at it, doc, can you surgically graft a cigar to my hand)? Heck, even some callow female analysts-in-training might not mind a little bit of the Freud facial structure (beard optional).

The "deep" question, of course, is how much do we have ownership of our own identity? "Ownership" bears a wicked double meaning, both moral and economic, in this context. And at what point does the desire for self-enhancement become tantamout to self-loathing, an inability to accept what one contingently is? At what point does cosmetic surgery become self-mutilation (strangely enough, by proxy of the surgeon)? And if we do allow our identities to come under the sway of social demands and market forces, is this any worse than the fundamental contingency that our inborn identity already has by virtue of evolution?

If we recognize at some point that we are being gradually remade by our culture ("extreme makeover" indeed), albeit in more gradual and subtle form than was the case for Blade Runner's Rachael, how is this different than the growing realization in today's biology that our emotional and moral lives are more specifically shaped by evolution than we were aware of? Whether we are shaped by God, by evolution, or by the cultural pressures of other humans, the strange tension of self-consciousness and freedom remains. The basic difference, I guess, is that we trust God and evolution to be benign and neutral, respectively, whereas we cannot be so sure that others are not subverting us for their own ends.

Philosophically it turns out to be pretty much impossible to show when we are ultimately (that is, metaphysically) free; however, it is much easier to know those cases when we are not, e.g. when we are implicitly or explicitly controlled by others. In feminist theory there is talk of "deformed desires," as if one cannot possibly freely choose something that also happens to be desired of one by other people or by society at large. When a woman goes the cosmetic surgery route, or even when a woman decides to leave her job and raise the kids, who is really in control, she or subtle or not-so-subtle social forces? We seem to develop indivdual and social narratives of identity that provide the best kind of answer we can hope for. If the fundamentals of humanity are self-consciousness, language, and technology, then one might say that even if we "enhance" ourselves beyond easy recognition, we remain human, all-too-human (the essence of human identity is...the fact that our identity is always open to question).

But (!), a more basic question remains--should I in fact be worried about my buttocks?

Temporary Like Achilles

"The thin-lipped armorer,

Hephaestos, hobbled away,

Thetis of the shining breasts

Cried out in dismay

At what the god had wrought

To please her son, the strong

Iron-hearted man-slaying Achilles

Who would not live long."

W. H. Auden

I wish I had a cheerier post for a Friday, but I must recommend a painful but poignant New Yorker profile of Travis Twiggs, an Iraq war veteran with crippling Post-traumatic Stress Disorder (PTSD). It makes particularly troubling reading for anyone of the opinion that that war was ultimately unnecessary and unhelpful. In this election season, the mass and complexity of things can make power seem very abstract and distant, but stories like this one (as well as, in a very different way, the current financial crisis) restore to executive power its awful specificity and concreteness.

Some have argued that PTSD was largely a political concoction of Vietnam veterans and feminists. I think that is taking it too far; the diagnosis is the real deal, but as is all too often the case in this business, we end up spying too many nails for our diagnostic hammer. PTSD may be divided into two major categories, the first involving the generic shock of loss (the sudden death of a loved one; a natural disaster) and the second involving the revelation of human depravity and violence (war; rape and sexual abuse). Arguably the former merely detonates a latent predisposition to depression and anxiety--this can be quite severe and needful of treatment, but it does not capture the essence of what sets PTSD apart.

The core trauma of PTSD is a raw, unshielded experience of the worst that human nature has to offer; it erodes social trust and the hope that one can, after all, be at home in this world. I have often thought that Hamlet's problem is not merely the sudden loss of his father, but rather the betrayal by his uncle and his mother and the realization that Evil and moral weakness are right here, in those he thought he could trust most of all. In the New Yorker article it is suggested that PTSD may be best considered as an injury rather than a "disorder." That seems right, but it is an injury both psychological and neurological.

Travis Twiggs is described as highly confident, conscientious, and idealistic as regards the military mission. He was reportedly tormented by guilt over the loss of two men under his command, and offended by the lack of public support for the war. Just as PTSD related to rape or abuse is less about sex than about moral violation, war-related PTSD may be less about mortal terror than about the degradation of one's belief in humanity's ability to get things right. Like depression, PTSD involves the loss of what Wallace Stevens referred to as the task of poetry, giving "to life the supreme fictions without which we are unable to conceive of it."

On that note, let's go out and have a great weekend! And make sure you're registered to vote...

(Some Blogger technical glitch is preventing me from optimizing paragraph spacing; my regrets).

Psychosis Really is a Different Country

Now, too much of nothing
Can make a man feel ill at ease.
One man's temper might rise
While another man's temper might freeze.
In the day of confession
We cannot mock a soul.
Oh, when there's too much of nothing,
No one has control.

Bob Dylan, from "Too Much of Nothing," 1967


After a few years of a mixed outpatient and ECT practice dealing mostly with the depressed and anxious, I have moved into an outpatient position with a significant number of patients with psychotic disorders (a population I worked with a great deal on an inpatient basis some years ago), and I had forgotten how strikingly different the two experiences are.

With depressed patients, the suffering is more palpable and focused; light and air seem to be sucked out of the room. With patients with refractory anxiety, there is the alarming impression of a fire that cannot be put out. There is no doubt that the chronically mentally ill (those with schizophrenia and severe bipolar disorder, whom I'll refer to as CMI) suffer, but it is a suffering more of privation than of pain per se. To be sure, there is the unique anguish of the young person with a "first break," but this is composed largely of dread, distrust, and perplexity. But most CMI patients suffer less from their specific positive symptoms than from their limitations, from lives unlived, aspirations given up, jobs lost, and relationships broken. It is not for nothing that schizophrenia was called "dementia praecox."

The frequent lack of insight introduces strange twists into the therapeutic relationship. It is hard to say that doctor and patient are working together when they can't agree on the nature of the problem, or even whether there is a problem (perhaps the doctor and the long-suffering family can be said to be working together). In fact, doctor and patient can seem to occupy parallel realities, in which the same facts--chronic problems functioning and recurrent state hospitalizations--are interpreted in opposite ways. It is interesting to try to come up with rationales for remaining in treatment for those patients who cannot be convinced that there is a problem (because you just seem to do better on medication, because otherwise you might have to go back to the hospital, because your mother will kick you out otherwise).

With the most severely impaired, those with no insight whatsoever, one is working less with the actual patient's self (which has been deformed almost beyond recognition) than with an idealized substitute of the same, a hypothesized rational self that would in fact desire a coherent value system and meaningful relationships. But there is an argument for maintaining a high threshold for this kind of substitution--one doesn't have to be besotted with antipsychiatry to stipulate considerable latitude to be mad.

And then there are the rare cases of possible misdiagnosis. Confirmation bias in psychiatry can be overwhelming--once "borderline personality disorder," "substance abuse," or "schizophrenia" appears on a chart, it may be impossible to root out even if inappropriate. The more typical case, of course, is the patient who sees nothing wrong, but whose history screams otherwise. But there are families who can abuse the petition and involuntary commitment system, and there are patients whose episodic and atypical recreational drug reactions may be misdiagnosed as schizophrenia.

A while back I saw a young woman who may have fit either or both of these categories. She had been discharged from the state hospital on low-dose Prolixin decanoate, but I could not credit the latter for her absolute lucidity which seemed utterly out of step with her diagnosis (the hospital records I had mentioned only vague "symptoms" like "belligerence" and "uncooperativeness"). Her occasional marijuana use and her conflict with her mother seemed more prominent than any psychotic process. So one occasionally picks out one who has been "sane in insane places."

Executive Poet

Yes, the year is failing, but on this last day of summer let's honor the sun once more, in the form of Wallace Stevens's delightful (and self-confident) lyric "Nomad Exquisite:"

As the immense dew of Florida

Brings forth

The big-finned palm

And green vine angering for life,

As the immense dew of Florida

Brings forth hymn and hymn

From the beholder,

Beholding all these green sides

And gold sides of green sides,

And blessed mornings,

Meet for the eye of the young alligator,

And lightning colors

So, in me, come flinging

Forms, flames, and the flakes of flames.

The parataxis of this poem--the repetition of phrases and words for emphasis--lends it a Biblical, majestic sort of cadence. The restatement of "immense dew" and "green sides" creates a tableau of vast fecundity, one which, in the form of the "angering" vine, is disturbing in its very intensity, much like the talent of the flame-flinging poet. We have the impression of a massive vitality that both creates and destroys. Stevens, who lived in New England for all of his 76 years (1879-1955) and wrote many fine poems featuring icy northern landscapes, traveled to Florida regularly on business and clearly relished the contrasts between the irrepressible tropics and the austerities of snow and ice. Compare "Nomad Exquisite" with his much anthologized "The Snow Man:"

One must have a mind of winter

To regard the frost and the boughs

Of the pine-trees crusted with snow;

And have been cold a long time

To behold the junipers shagged with ice,

The spruces rough in the distant glitter

Of the January sun; and not to think

Of any misery in the sound of the wind,

In the sound of a few leaves,

Which is the sound of the land

Full of the same wind

That is blowing in the same bare place

For the listener, who listens in the snow,

And, nothing himself, beholds

Nothing that is not there and the nothing that is.

Here we are in a completely different universe of feeling and perception. Unlike the "beholder" of "Nomad Exquisite," who is energized and engaged by the vital landscape, the "listener" here is rendered "nothing himself."

Wallace Stevens was a highly unusual poet for three reasons. First, he was a very late bloomer, publishing his first book of poetry at 44 and doing much of his best writing well into his sixties. Like music and mathematics, poetry at the highest level is usually a young person's game. Second, Stevens's day job--a vice-president of Hartford insurance company (no starving artist he)--seemed almost defiantly philistine. In many ways his professional work was his public face, and he wrote poetry discreetly on his own time. Maybe the folks at AIG should have read more verse.

The third thing that sets him apart is that particularly for a major poet, his life was remarkably, and outwardly at least, serene and free of overt psychopathology. Of course he had his "issues"--he was quite reserved and arguably even schizoid to a degree (he was uncomfortable in public situations to the very end of his life), and his marriage was cool and distant for many years--but his biography is remarkably free of the exotic travel, frenzied mood swings, and tumultuous love affairs that have filled many famous poets' lives. While his poetry is Romantic in many ways, his life most assuredly was not, at least from the point of view of external incident. He is surely the most unbohemian world-class poet this country has had; being so socially conventional, he was a most unconventional poet, and I for one find that refreshing.

Celebrating Seasonal Affective Disorder

Here we go again, into what is for some people a six-month affective tunnel of sorts. It's as good a time as any to revisit the Dickinson staple:

There's a certain Slant of light,

Winter Afternoons --

That oppresses, like the Heft

Of Cathedral Tunes --

Heavenly Hurt, it gives us --

We can find no scar,

But internal difference,

Where the Meanings, are --

None may teach it -- Any --

'Tis the Seal Despair --

An imperial affliction

Sent us of the Air --

When it comes, the Landscape listens --

Shadows -- hold their breath --

When it goes, 'tis like the Distance

On the look of Death --

It has just been this equinoctial week that the evening light has angled in just so, illuminating the bark of the trees in a way that announces the ongoing death of the year. The obscuring haze of summer evaporates, allowing the startling blue of sunset to limn the trees just so. This is captured by the opening of Sylvia Plath's "The Moon and the Yew Tree," lines that blew me away when I first read them:

This is the light of the mind, cold and planetary

The trees of the mind are black. The light is blue.

It is absurd, is it not, that in winter (in the northern hemisphere) the earth is actually closer to the sun than in summer, appalling, is it not, that a subtle angling away from the source of all life here is enough to plunge the planet into darkness? A religious metaphor perhaps...

Postmortem

I don't keep up with contemporary fiction like I ought to, and David Foster Wallace was one of those names I've seen referred to countless times without ever having read the man's work. I may have to remedy that, morbidly, after his recent death from reported suicide. I probably don't have time for his 1,000+ page magnum opus Infinite Jest, but I may have to find his aptly titled story collection Oblivion. So "the black dog" claims another creative genius.

There is good reason to try to appreciate a book in its own right without reference to the author's biography, but some particularly salient facts are sometimes hard to keep out of awareness, and an author's medical history and cause of death qualify. After all, Flannery O'Connor's works certainly take on a new dimension of meaning in light of her painful struggle and early demise from lupus, and reading Albert Camus might be a somewhat different experience if he had died in bed at 90 rather than having been struck by a car in his 40's.

Suicide threatens to overshadow an author's work to the point of obscuring it, although as depression comes to be viewed more as a legitimate disease, this effect seems to be lightening some overall. But it is hard to read Sylvia Plath, for instance, without having some background cognizance of the legend that her suicide helped to create. I think that for those in love with words and stories the suicides of writers are ultimately humbling: words can do only so much.

Kids These Days

The New York Times just ran a long profile of childhood bipolar disorder, by Jennifer Egan; it is a judicious account that makes for compelling reading (although Furious Seasons does not agree). While alluding to the usual suspects in trying to explain the growing prominence of bipolar disorder in the past decade or so--the influence of pharmaceutical companies, the possible confound with ADHD, or even mere diagnostic imperialism of sorts--the article raises the possibility that something else may be going on.

When I graduated from residency about a decade ago, there was active resistance from many mental health clinicians, myself included, to the spread of bipolar diagnoses (in adults as well as children and adolescents). This was not only due to the fact that Lilly, for instance, was aggressively marketing Zyprexa for mania at the time, although that certainly played a role. I think the strongest feelings emerged when the question involved differentiating bipolar disorder from borderline personality disorder. A number of clinicians I worked with felt that borderlines proudly sported the bipolar "badge" in an effort to explain (away?) their problems while trying to minimize their own responsibility. There was also a sense that slipshod clinicians might be getting too lazy to differentiate depression from bipolar disorder (if you treat everyone with mood stabilizers, then you don't have to worry about makes anyone worse with antidepressants alone).

Around that same time there was growing interest in bipolar disorder and creativity, led by Kay Jamieson's noteworthy work on poets and other writers. So there was a sense in the air that bipolar was somehow chic and indicative of some kind of distinction. Romanticizing depression takes some work, but romanticizing mood swings and impulsivity seems to come naturally. But I think the unmistakeable trend now is a wider acceptance of the "bipolar spectrum," including conditions milder than classic mania that still warrant mood stabilizers.

Egan's article mentions the possibility that the increase in bipolar disorder diagnoses in children may not merely be due to increased attention to and recognition of symptoms, but may in fact reflect a higher risk in many children due to "assortative mating." That is, our society with its unprecedented mobility (in which Internet dating now plays a role), people may be unconsciously be seeking out (and finding!) partners with whom they may share some bipolar susceptibility, however subtle. I had not considered this theory before, but it makes sense. One wonders--would this not apply equally to ADHD? If moody people feel comfortable around other moody people, might not distracted people prefer the company of other distracted people? Is this another respect in which our culture's almost limitless smorgasbord of choices may have its drawbacks?

If we really are producing children who are, on average, more genetically at risk for bipolar (and other) disorders, it will be interesting to see how they come to present as adults. Unfortunately, the article features well-meaning psychiatrists whose strategies of medication trial and error come across as somewhat random and haphazard, which alas, remains the standard of care in dealing with such persistently mystifying illnesses.

Ironically given the alleged superiority of newer drugs, a brand-new American Journal of Psychiatry study (abstract only with public access) fails to show superiority of either Zyprexa or Risperdal over molindone in a group of children and adolescents with psychotic symptoms. I have never even seen a patient on molindone in 15 years of clinical work; maybe I should hasten to change that (not many molindone drug reps running around I guess). My clinical career happens to overlap roughly with the past 15 years' worth of messages from industry and expert opinion about second generation neuroleptics: now the message seems to be Never mind!

ADHD Addendum

As if to corroborate the last post, Marc Bousquet writes about the popularity of Ritalin and other stimulants on college campuses. The increase in ADHD diagnoses in colleges and professional schools, as well as the illicit sharing of meds for the same issues, may result from the confluence of three factors:

1. As a college degree comes to seem more and more indispensable for even basic economic success, a greater fraction of the population at least attempts to get one. This includes, however, many who are not particularly suited, either intellectually or motivationally, to do the work.

2. As mentioned last time, all of us, but particularly young people, increasingly live in a culture of perpectual distraction.

3. A combination of grade inflation and "winner takes all" competitiveness spurs people to do what they feel is necessary (in a way exactly parallel to doping in sports).

One problem with all this, of course, is the stigmatization of those who indisputably do struggle with ADHD. But in terms of the diversion of meds on campus, it seems that this may be more of an ethical and cultural issue than a substance abuse issue per se. After all, apart from legal ramifications if caught, is the occasional (i.e. once or twice per month) use of stimulants for cramming or paper-writing or whatever really going to have identifiably detrimental effects on a person's life (i.e. withdrawal, inability to function at work or relationships, etc.)? From a purely substance abuse perspective, it would seem to occupy the same gray area as the occasional (i.e. once or twice per month) use of marijuana.

Interesting times...

Tomorrowland

Those interested in both the history of psychiatry and the vagaries of diagnosis are always wondering whether it is merely our perceptions that are changing, or whether the stuff of human experience is actually changing in its own right, whether due to the headlong metamorphoses of technology and society, or to genetic changes, or what have you. Arguably three diagnoses prompt this question more than any other: autism, attention deficit/hyperactivity disorder (ADHD), and bipolar disorder (particularly in children). Several recent articles revive these questions.

1. Gregg Easterbrook reviewed evidence suggesting that there could be a link after all between autism and, not vaccines, but rather television in early childhood. The study in question suggested that a rise in autism rates correlated with rises in cable television development in the early 1980's. This is far from conclusive, and no causation has been proven, but it it yet another reason to limit TV especially during those early years.

2. In two pointedly titled articles, "Is Google Making Us Stupid?" by Nicholar Carr and "On Stupidity" by Thomas H. Benton, marked changes in learning and intellectual styles of those growing up in the first Internet generation are considered, and not favorably for the most part. These two writers echo many other educators and cultural observers in claiming that young people in particular, compared to those who matured before the digital onslaught (Internet, Ipods, cell phones, etc.), exhibit a number of characteristics that make serious academic work problematic and that raise concerns about the future capability of both individuals and society as a whole.

In particular, they argue that students today tend to be incurious and intellectually complacent on the one hand and academically entitled on the other, which can be a toxic combination. They can be impatient with the slow work of reasoning and argumentation, tending instead to appeal to relativism and the importance of their own feelings. They are, of course, easily bored and easily distracted. As a group they tend to be rather passive and to require a good deal of external structure.

These are, obviously, speculations and should not be carelessly generalized; these two authors also acknowledge that young people today also have skills that no prior generation has had, and that there are different valid ways of learning and thinking. But overall there is a real concern that superficiality and a lowering of intellectual standards are growing issues.

For psychiatrists this may be relevant in two ways. One is the growing prominence of adult ADHD, particularly in those who were never diagnosed with the disorder in childhood. People are actually starting to talk about true "adult onset" ADHD; it doesn't seem too much of a stretch to suppose that the digital environment could tip susceptible individuals into that kind of symptom cluster.

The second issue may be the status of psychotherapy versus psychopharmacology. For years of course people have expressed concern about the explosion of antidepressant prescribing. One reason for this--in addition to other likely reasons such as the economics of psychiatry, and the influence of pharmaceutical companies--could be a gradual shift in the median cognitive styles of those seeking (and providing) treatment. Psychoanalysis depended in its heyday on large number of prospective analysts and analysands with a seemingly endless appetite for self-exploration and hard intellectual and emotional work. The up and coming generations may expect a much quicker payoff and to have less interest overall in introspection itself.

Are we witnessing a significant shift in "human nature" itself as we become more intimately associated with digital technology? Any opinions out there?

This post is getting too long, so I will consider bipolar disorder next time.

Sarah Palin, Wonder Woman, and late Shakespeare: Tempest in a Teapot

I am no McCain supporter, but I have to acknowledge that the selection of Sarah Palin was a stroke of genius (even if an accidental one). Palin brings to mind two literary domains: Wonder Woman and late Shakespeare. The former is fairly obvious: the unheralded transformation of a seemingly ordinary Diana Prince into a superhero, the bracelets deflecting (media) bullets, the golden lasso (supposedly) enforcing the pronouncement of truth (i.e. rooting out corruption). There is even an invisible airplane: the state-owned one that Palin keeps saying she sold on ebay. And the sex appeal, despite the schoolmarmish persona, is undeniable, as has been noted (Linda Carter anyone?).

But seriously, I would suggest that Palin's appeal has less to do with sex than to a different and powerful family dynamic, that of father and daughter. Let's face it, before her selection McCain was looking old, crabby, and out of touch--a man with a storied and honorable past, but a has-been (even apart from his perceived continuity with the Bush administration). Palin's attractiveness, energy, and spunk do not make him seem virile (he is, alas, too old for that), but for his political chances that is just as well; instead, she makes him seem younger, softer, and yet protective, even paternal.

As others have noted (citations not available, sorry), the father-daughter dynamic is a powerful one in Shakespeare's late phase, foreshadowed perhaps by the harrowing story of King Lear and Cordelia. This is manifest in his late "romances" such as The Winter's Tale and Pericles and culminated in the relationship between Prospero and Miranda in The Tempest. In these stories the father represents wizened experience, and even wisdom of a kind, to be sure, but experience tainted by weariness and a touchy and impulsive egotism. The naive goodness of Cordelia and Miranda challenges the tired cynicism of Lear and Prospero. While the latter clearly represents necessary authority and order, the former embodies freshness of vision and (especially given the implicit fertility of woman) hope for the future; in short, daughters bring redemption from a fallen state. While many of Shakespeare's young women are plenty resourceful (think of Rosalind), they do bring a tenderness to moderate the sternness of men. Interestingly, mothers of adult children in Shakespeare are usually either conspicuously absent or harshly problematic (where is Gertrude, I mean Hillary in all of this?).

Keep in mind here that the majority of voters are not dispassionate analyzers of political positions; in the bewildering contemporary media environment, it takes more time and energy to educate oneself about the truth of the issues than most people are willing or able to devote. Rather, most voters develop a vague gestalt about which ticket seems to best embody their values and judgment. In Palin's selection, McCain at least gave the impression of an openness that belied his crusty antiquity, and the subsequent media barrage endowed her with the vulnerability that compensated for her potentially abrasive resilience. She is a debutante, enjoying still the virtues of youth but capable of entering the wider world. In terms of policy, she may be a disaster, but in terms of reading the dynamics of gender and the generations, her selection was a masterful move. Realizing that family dramas matter and that cortical reasoning is overrated, the Republicans know their Freud better than Democrats do. The powerful family dyad of McCain and Palin arouses associations that are not primarily prurient, but rather sororal and filial. Hamlet and Polonius, that is, Obama and Biden have their work cut out for them.

Wait, did I write Hamlet? Perhaps I should write Othello, for there is that other factor that we had supposedly gotten past. But maybe not; given the racial dynamics here there's nothing like a Desdemona figure to get people thinking...

Twilight Zone

Speaking of extraterrestrials, I would probably be more likely to hear from one than to hear from the "hospitalists" taking care of any patient from this clinic. Information can neither penetrate nor escape from the black box that is the inpatient psychiatric unit. Do these doctors open novels at any random point and start reading? Wouldn't they like to know what has gone before?

There is no coordination; patients lurch from one psychiatrist to another, as a kind of great roulette wheel of medication trials. For the hospitalist, the patient, in an almost metaphysical sense, did not exist before the admission, and will not exist afterward (until he or she almost inevitably returns sooner or later). How the patient will afford extremely expensive medications is not even considered, because it's not the hospitalist's problem. The hospitalist's problem is to get the patient out of there, however possible. Strangely, on the contemporary psychiatric unit time means both everything and nothing, the former inasmuch as the whole endeavor is a race against time (to free up a bed, to maximize insurance cooperation or whatever) and the latter inasmuch as biographical past and future cease to have much meaning.

Grrr!

Extraterrestrial Sublime

I lament the waning of the days this time of year, but the consolation is...the return of night, which, being an early riser, I almost manage to avoid altogether June through August at this latitude. But the premature dusks of September rouse me out of what is, after all, a kind of solar solipsism, and offer a reminder of the great Absence--largely empty and without obvious succor--that is the rest of the visible universe.

But what if Absence were to become Presence? Gazing at the stars more clearly in the cooler, drier air, I think of some great science fiction, supreme among which in the genre I'm thinking of, alien contact, are 2001: A Space Odyssey and Solaris. Both novels are excellent, but the films, unusually, are even better (I'm thinking of the luminous Russian version of Solaris by Tarkovsky, not the execrable Soderbergh remake). I like Close Encounters of the Third Kind and Contact as well, but these have an element of kitsch compared to the former exemplars.

In 2001 and Solaris the "aliens" in question (I use quotes because in the former work the aliens can only be inferred, not perceived, and in the latter story it is never clear whether the planet Solaris really counts as alive) are neither menacing nor cuddly; rather they are transcendently inscrutable (the utterly blank obelisks of 2001, like the planet Solaris, do not disclose their secrets). And yet they do engage with human beings in most exceptional ways.

In a paper perhaps never to be written, I would someday like to discuss how 2001 and Solaris offer a most compelling vision of alien contact as a truly religious experience. For those who find most earthly deities "human, all too human," these aliens are what one might expect a God to be, that is, truly beyond our understanding; "It" does not look like us in the least or deign to speak our language. And yet these alien forces are not merely strange--they do interact with human beings. In the case of 2001, this takes the form of the metamorphosis of humanity into something other (we know not what); in Solaris, the (living?) planet disturbingly yet wondrously reflects elements of the human mind, a process which in itself offers self-understanding and change.

I would argue that these are manifestations of basic religious experience, in which a transcendent power beyond our ability to grasp nonetheless "speaks" to us, finding us worthy, or potentially worthy if not actually so (idealization/mirroring for the self-psychological fans out there). What if God arrived and not only didn't look like a man (or even a little green one), but took a form we couldn't even recognize? True religious experience, however it may be found, combines an acceptance of the human with an impatience with the merely human. This verges on the logically incoherent, which may be why spirituality runs the risk of being crazy-making. Wallace Stevens put it better:

And they said to him, "But play, you must,
A tune beyond us, yet ourselves,
A tune upon the blue guitar
Of things exactly as they are."

Okay, time for some earthly pursuits--run a few errands, catch a little NFL. Maybe get the telescope out later...

The Liberal Elite

I have listed some great poems and films, some of them with "psychiatric" themes and some of them merely favorites (the poems are linked to text).

Annals of Risible Results

Theodore Sturgeon is quoted as declaring that "Ninety percent of everything is crap." That sounds about right with respect to a number of things, and of nothing is it more true than psychiatric research. Nothing demonstrates the pre-scientific nature of psychiatry better than the clinical irrelevance of the great majority of studies published even in the top journals. Until we achieve at least a basic understanding of the great issues of the mind--mood, memory, consciousness--we spend our time on pointless epidemiology (if all you have is a tape measure, then measure everything in sight), irrelevant biological minutiae, or far-fetched speculation (the latter is my metier actually). Psychiatry is a singular medical specialty inasmuch as virtually no published research has any specific implications for everyday clinical work.

Two of the top journals this month illustrate this once again. Archives of General Psychiatry, as usual, is so aridly biological, and so remote from clinical reality, that no real pretense of relevance is even attempted. The American Journal of Psychiatry, once again confirming the obvious, features studies on the relationship or lack thereof between parental depression and the psychopathology of children. To the surprise of no one, the studies suggest that the children of depressed mothers are more likely to have problems themselves. To some surprise, they also suggest that paternal depression has no impact. But the problem is that none of the results achieved should change anything we ought to be doing already. To consider the status and well-being of parents in the course of evaluating a child (and vice versa) should be common sense. And should anyone take the claim about fathers so seriously as to leave them out of the family evaluation? Of course not.

This is not to say that psychiatric research is irrelevant, period. It is largely irrelevant to today's clinicians, but it may be quite relevant to other researchers, who in several decades perhaps, will in fact produce clinically relevant research (just as studies, and treatments, developed decades ago continue to guide practice today). Scientifically, a psychiatrist today may be on par with an internist or surgeon practicing a century ago.

Literature and the Cocktail Hour

Deluged by Tropical Storm Hanna today, a good day for blogging I suppose...Not long ago I came across a good quote: "Alcohol makes other people more interesting." At the time I took this to mean alcohol in the perceiver (so true), although it could of course mean alcohol in the perceived as well (somewhat true). As with any psychotropic substance, though, there is clearly a dose-response curve such that beyond a certain point, alcohol does the opposite.

It occurred to me that literature, or the arts in general, may act in the same way. Nietzsche famously wrote that "we have art so that we don't die of the truth." Could he have also written "so that we don't die of boredom?" Sometimes I think that a love of the arts is like a deficiency--wouldn't it be nice if the world just as it is, without all these...ornamentations, were enthralling, engaging, and lovable enough?

The Neglected Novella

I've added a list of some of the best "psychological" novellas or short novels (in my opinion). The novella is defined in various ways, but I've chosen works between 50 and 150 pages in length. This genre sometimes seems lost between the better known and populated realms of the short story and novel, but in my experience the novella often seems "just right" in both depth and focus. Its length is adequate for a deep portrayal of character, but it must avoid the various digressions that characterize the novel. Perhaps not coincidentally, the amount of time it takes to read a novella is on par with that needed to see a play or a movie. I've started with some fairly obvious ones and will add more as they occur to me.

Romanticism and Running Mates

Notice that this is not titled "Romance and Running Mates," but the notions are related obviously. I just finished rereading Penelope Fitzgerald's wonderful 1995 novel The Blue Flower, the historically based story of the German poet Georg Philipp Friedrich Freiherr von Hardenburg (yes, Novalis). The heart of the story is Novalis's "love at first sight" for young Sophie (she was just 12 when they first met), a child who, in the eyes of all of his family and friends, is dull, undistinguished, and totally unworthy of him. But until her crushing death from tuberculosis three years later, he maintains that he sees something in her that no one else can, and he calls her "my Philosophy."

Arguably there are two basic approaches to love, and in most cases of course they are combined in some measure. One is Novalis's utterly subjective, "in the eye of the beholder" kind of attraction that seems based on some kind of unconscious affinity (which in other eras and places might be called metaphysical or transcendent). The other might be formulated as the match.com theory, in which one approaches a potential mate much as one might hire an employee (or seek an employer?), with a no-nonsense eye toward the prospective correspondence between mutual needs, skills, and attributes. The former is Romantic and visionary, the latter Classical and pragmatic.

I make no claim to know what was going on with the selection of Sarah Palin as John McCain's running mate, but the pick was both impulsive and visionary, depending upon the bias of the commentator. While she obviously had to meet minimal political standards, her specific credentials were less important than a visceral affinity McCain likely felt with Palin, a kinship that he hoped would be shared by others. In the week since she was introduced, the political air has been thick with nothing less than Eros--as could be said of both John F. Kennedy and Barack Obama, she is the politician who is young and compelling enough to inspire other than purely patriarchal or matriarchal impressions. In this age of raw sexual reductiveness, it is interesting to observe a public pull of Eros without the all too frequent pull of pornography (vice-presidential vetting question: Does anyone anywhere have nude pictures of you?). Like Reagan, she is the Republicans' "blue flower," or at least the closest to it that can be found outside of the imagination. (I still prefer that she lose however).

One Hit Wonder

I'm interested in stories that touch on the peculiarity of the aspiring healer's role, and most specifically those that address the shamanistic aspects of the therapist's predicament. The three stories known to me that take on this theme most powerfully are Chekhov's "Ward 6," Nathanael West's "Miss Lonelyhearts," and a relative unknown, Mary Ladd Gavell's "The Rotifer." Gavell's clinically detached, yet sublimely melancholy story first became known to me (and to a wider readership in general) by means of 1999's John Updike-edited The Best American Short Stories of the Century.

Gavell's personal story, described here, is intriguing in several respects. While not medically or psychologically trained, she did serve as managing editor for the academic journal Psychiatry from 1955 until her premature death from cancer in 1967. She wrote a number of short stories, but apparently made little effort to have them published, and none did appear in her lifetime. But after her death Psychiatry, which did not as a rule publish fiction of course, did publish "The Rotifer," which ended up selected for 1968's The Best American Short Stories. From there Updike picked her unknown name to join the much more reknowned ones of the century. After that exposure, several years ago a volume of her other stories (as yet unread by me) was finally released.

"The Rotifer" contains three haunting episodes featuring the gulfs that separate people, and the consequent challenges not only of reaching out to help others, but of connection itself. The young woman narrator, in a science class exercise, muses on the utter impossibility of relating to the microbe (the rotifer) in any meaningful way; in an effort to free the creature from some algal obstruction, she nudges the slide and, of course, disrupts that entire microbial universe.

Later, in the course of historical research into the personal archives of a 19th century family, she finds herself attached to, and concerned about, a young boy who, more than a century before her birth, was sent off to boarding school and, in the archival record at least, never heard from again. She comes to extrapolate these disjunctions of scale and time to interpersonal relationships in general and, with sad consequences in a third episode, finds herself unable to reach out to her family even when no obstacle other than her own resignation seems to exist.

It is fascinating to think of Mary Ladd Gavell, fifty years ago, editing technical psychiatry papers during the day and coming home (after tending to her household and children no less) to compose an alternative, parallel take on the same "psychiatric" phenomenon, the contingent and bittersweet coming together and sundering of lives.