Orion Rising

Like needles infinitely thin
And infinitely cold,
Relentless stars resist the dawn
And pierce the restive mind.

Too beautiful for us, those suns
Recede. Before they fade
They cast the Hunter's lying form:
I cannot not see Him.

But could we travel there, his limbs,
His helm, his mighty sword
Would shiver mockingly apart
As Betelgeuse conspired.

In all the universe Orion exists
Just here, beholden to blinding human need.

Two More

I've never been much of a poetry writer, and until recently I hadn't set my hand to one in some fifteen years. I'm not sure why I've felt inclined lately (although I can guess).

I've also never been a big fan of formal rhyme, which in unskilled hands can lapse into the sing-songy, stilted, and sentimental. Thus this attempt in sonnet form:

Daughter's Day

Girl rides her horse with childlike gravity;
Defiance thereof, perhaps, makes her rejoice
To cross this paradise of grass and trees
In summer's silence but for the crickets' noise.

It never will be simple like this again:
The girl and animal, a space to share.
She brushes Princess Star and looks within
The foreign eyes, interpreting their stare.

The horse's muteness sobers and puzzles her;
She seeks to draw her into consciousness.
About the lives of others we can infer,
Propose, conjecture, extrapolate at best.

She parses difference, intuits "same,"
Explores, enlarges, and learns the limits of "tame."


And this one indulges my weakness for the subjective sublime, and for a very conventional pun:

Carolina Beach

Boy hurls himself against the surf, as sun
And sea contend on the ribboned anvil of rock,
Or tiny rocks, the sand, the earth ground down
Into flowing stone. The boy is one
Of mine, a drop of sea-stuff bound in bone
And sinew, fired by solar elements,
Warmed to the point of restless self-regard.
We came from there, I think, correct myself--
Not we, but bits of matter did congregate
In acts of whimsy, once, until the game
Developed needs, demands, to be gratified
Or denied. The water waits with awful patience,
Inscrutably, for what I do not know.
The sea is self-estranged; its progeny
See its depths as alien, visceral.
The ocean swallows the sun, in dreams at least.
But I think otherwise: the sea will boil
Five billion years from now, when all are gone.
But now I watch my son, scorched by our star,
But cooled by salty spray from the abyss,
Stand before a towering wave, which swats
Him flat onto the river of scraping stone.
He rises, laughing: son is victor, now.

Bumps in the Road of Science

From Edward Mendelson, The Things That Matter: What Seven Classic Novels Have to Say about the Stages of Life (2006):

In the early nineteenth century the most up-to-date and modern psychological science was phrenology, the pseudoscience that identifies your emotional and moral character by mapping the bumps on your skull, in much the same way that more recent pseudoscience traces your voluntary actions back to the unchosen, involuntary workings of selfish or altruistic genes. A university chair in phrenology was established at Glasgow in 1845, and Charlotte Bronte, like most of her contemporaries, took it for granted that phrenology was valid science; Jane Eyre is conscious of her "organ of veneration" when Helen Burns recites Virgil, and observes on Rochester's forehead "an abrupt deficiency where the suave sign of benevolence should have risen," and Rochester observes in Jane "a good deal of the organ of Adhesiveness." But for Charlotte Bronte, phrenology was merely a familiar feature of her intellectual landscape. Marian Evans [George Eliot] took it far more seriously as a new instrument of knowledge that called for her active participation in it. At the time she was translating Strauss's Life of Jesus, she arranged to have a full phrenological analysis made of herself, based on a plaster cast of her cranium, and the preparations for the analysis included shaving her head.

A Playground, Once

This is mine:

They climb the ropes with small, determined fists,
Delighting in the planetary pull.
Unknown children play in parallel;
The lives of others mean everything and nothing.

The sun, benignant, violates the dark,
Burning color into bewildered sight.
A train's whistle sounds, its anchored tracks
Forlornly straight, its body massively wrought
As it pushes past our gratuitous idyll.

The beasts are absent, but for a wheeling bird
Or vigilant squirrel; the animals are gone.
We have made this land our own, have scoured
It clean but for this empty green expanse;
Kids play in the vacuum of myriad other springs.
The creekside walnuts bear witness, their boughs aloft.

Recall it just like this, no matter what
Happens, this is the way it was this day.
They grow now in the harsh glare of change,
But storied shadows, specters of memory,
Sit silently far off, and watch and wait.

Total War (?)

"War is the continuation of politics by other means."

Clausewitz

Frank Herbert in today's New York Times both laments the dearth of public interest and support for the wars in Afghanistan and Iraq and suggests that such lack puts in question those wars' very reason for being. Wars? War is one of those words (like "love" perhaps) that is misleadingly applied to a vast spectrum of human activities.

Horrific tragedies for military families continue, but I would submit that Iraq and Afghanistan elicit little more than a yawn from most of the public these days because these conflicts have become too remote and too abstract for most to fully appreciate (in this respect they may be similar to global warming and health care). I think I am no Pandora in reminding that 9/11 was eight years ago; that's twice the duration of U. S. involvement in World War II. No further attacks have occurred on American soil. Unlike Germany or Japan seventy years ago, Al Qaeda simply does not pose a sufficiently concrete threat to American survival, whether directly or by distortion of the global order, to provoke an unequivocal response.

To be sure, the risk of further attacks has by no means been removed, but the "war on terror" is no more a true war than the "war on drugs" or the "war on poverty" were true wars; it is a failure of metaphor. The adversary is no state, but rather an enormously complex cultural system, and perhaps "police action," notoriously applied to the Korean War if memory serves, most accurately applies to Iraq and Afghanistan.

Herbert marvels that only one percent of the U. S. population is directly involved in the military effort to protect the country, at this point against Al Qaeda. But this ceases to be surprising if one views the work in Iraq and Afghanistan as analogous to police work. After all, the work of the police is really never done; there never is any end point at which the crime rate is reduced to zero. The idea is to reduce the risk to the public to an acceptable level. That is really all the military can hope to do at this point in Afghanistan. The police protect all of us, but only a tiny fraction of the public is actively involved in policing. Is this fair? Apparently so, inasmuch as police work is voluntary and rewarded with respect and honor, if also by substantial risk.

I wish "war" would be used only for serious conflict, that threatening the actual integrity of nation states. Some other term, "police action" if nothing else will serve, should be used for more measured responses. If we really thought that Al Qaeda posed an irrefutable risk to our national survival (by means of weapons of mass destruction presumably), would we post a few tens of thousands of soldiers in the wasteland of the Afghanistan/Pakistan border? No, we would institute a draft and flood the region with, I don't know, half a million or more soldiers, reduce the rocks there to smaller rocks, and flame out cave by hidden cave, as we did in Pacific islands on the road to Japan. The national will is not there because the perceived threat is not there.

To be sure, this could change tomorrow with an audacious new attack. But the risk of prevention in military matters, like prevention in, say, psychiatry or policing (Minority Report anyone?), is that one can make things worse in trying to make them better. I am not recommending pulling out of Afghanistan, as if I had expertise to do so, but I wish we could stop calling it a war, as if clear victory were possible. Deaths are parallel and appalling tragedies wherever they occur, but at this point the death of a soldier in Afghanistan has more in common with the death of a state trooper in the line of duty than it does with a death on the beach on D-Day.

Novalis

It's odd that I've never gotten around to sharing some of the real Novalis (1772-1801). Talented aphorists are a rare breed, from the transcendental (Emerson) to the empirical (Samuel Johnson) to the mordant (Oscar Wilde). Novalis's fragmentary style suited his tuberculosis-shortened life. As I was looking over a recently rediscovered volume, I was struck by some of these (all from Novalis: Pollen and Fragments, translated by Arthur Versluis):

"We seek above all the Absolute, and always find only things."

"The insignificant, mundane, raw, loathsome and ill-bred becomes through witticism alone fit for companionship. It is as if these were intended only as jokes: their destined aim is to be a joke."

"Humanity is a humorous role."

"The most ingenious insight is discerning the proper employment of insight."

"Each individual is the midpoint of an emanation-system."

"Where children are, there is a golden age."

"All enchantment is an artistic madness. All passion is an enchantment. An alluring maiden is an actual sorceress, inasmuch as one believes in her."

"A character is a completed, refined Intention."

"Bias and attachmentn are for the imagination what fog, blinding light, and colored spectacles are for the eyes."

"The higher something is, the less it overturns--rather, the more it strengthens and corrects."

"Play is experimenting with chance."

"All that is visible rests upon the invisible--the audible upon the inaudible--the felt upon the unfelt. Perhaps thinking rests upon unthinking."

"Every word is a word of incantation. Whatever spirit is called, such a one appears."

"Paradise is strewn over the earth--and therein become unknown--its scattered lineaments are bound to coalesce--its skeleton is bound to become enfleshed. Regeneration of paradise."

"Completed speculation leads back to nature."

"One could call every illness an illness of the soul."

"Poetry must never be substantive, but rather always only wonderful."

"Earnestness must glimmer cheerfully; jokes must glower soberly."

"Whoever has no sense of religion, must nevertheless have something in its place, which is for him what religion is for another--and therein originates much contention."

Enough Already

"The greatest part of a writer's time is spent in reading, in order to write: a man will turn over half a library to make one book."

Samuel Johnson

"As good almost kill a man as kill a good book: who kills a man kills a reasonable creature, God's image; but he who destroys a good book, kills reason itself, kills the image of God, as it were in the eye."

Milton, Areopagitica

The last couple of years have involved a good deal of packing and moving, into and out of homes and offices. Books do not travel particularly well. They are weighty, they are easily nicked on the corners, and their myriad shapes and sizes seem designed to fatally vex their efficient packing into boxes. The other day, gazing upon such boxes stacked in closets, their contents accessible only in theory, I was seized by an impulse to purge the library. Last year I had conducted a purge, but this would be a larger one.

How many books does one need, particularly in the age of Kindle and the Internet, where many of the classics in particular are perennially available if one doesn't mind reading from a screen (granted, a big if)? And if one does suddenly crave a particular book, it is only a click and a day or two away. In my current demesne I have roughly 50 bookshelves worth of space divvied up among a number of bookcases of various sizes, and their contents leave perhaps half again as many books in boxes. Grossly estimating an average of 20 books per bookshelf, I gauge my library at around 1500 volumes. This doesn't sound as many as I may have thought, but due to upgrades made over the years most of these are hardbacks or substantial paperbacks.

I am no Thomas Jefferson, obviously, but he has always been a figure of fascination for me as for many others, and not least because of his famous library. His ideal was the erudite and cultured pastoral gentleman, and for most of human history, of course, if you wanted to live far from the city, you had to bring your culture with you. That he certainly did (thanks in part I suppose to slave labor). I read that he had between 9000 and 10000 volumes, a staggering number now, and a stupendous one then. But when the young Library of Congress was burned by the British in 1814, he sold over 6000 of his books to restock the institution. Presumably he realized that one man, no matter his genius or the flow of visitors to his doorstep, could not possibly make regular use of 10000 books.

One person can't make regular use of 1000 books either. But there are a substantial minority that I do dip into again and again, if only to revisit a chapter or look up a phrase. There are a number that I love for their sheer physical beauty; the arts books obviously fall in that category, but many others do too. And of course a number arouse various kinds of nostalgia, because they were gifts from special people, or because they bring to mind a certain phase of life or state of mind. Someday a 1000 book collection may be a veritable antique in the house--that day may come sooner rather than later--but no matter how prodigious the Internet becomes, a stocked bookcase will always mean the life of the mind to me.

These books have been amassed at a fairly regular pace over the past 25 years, with spurts here and there as cash flow permitted. For many years I couldn't get enough, and disdained the very notion of the public library. Why would I give a book my time--than which commodity nothing arguably is more precious--if I didn't want to keep it with me? It was bad enough that I couldn't hold onto periodicals. But there comes a point where even words and ideas can become clutter, and I don't have Jefferson's Monticello--or his slaves--to best store and manage this library.

So after several hours of sifting (yes, one's hands can become sore from the sheer handling of books), a dozen boxes--probably some 200-300 volumes--are going, whether to used book stores or wherever they can find a home. They range from genre fantasy from the mid-1980's to philosophy and professional books from just a couple of years ago that left me underwhelmed. A few of them, bought already well-used 20 years ago, will find no home, and of course the used-book stores won't take them all. How are dead books best disposed of? With fall coming on, we could use some extra fuel for the fire pit out back which the kids love. But no, not that.

Is Humor Possible in Psychiatry?

I just have a few moments before heading off to my (perpetually solemn) work, but at the risk of seeming to protest too much, I thought I'd dash off a few thoughts on humor and its hazards in psychiatry as raised by the last post.

The theory of humor is famously unfunny, but it seems to me that amusement can arise from: our common vulnerability to physical circumstance (slapstick), the humbling of the high and mighty and the pretentious (satire), and the sheer delight of ambiguity (puns).

The general humor of medicine, such as it is, owes most to satire inasmuch as doctors are viewed as (and really are) self-important. However, psychiatry is more subject to smirking precisely because of the ambiguity of its practices. Thus the myriad on-the-couch cartoons of The New Yorker are funny precisely because psychoanalysis is an ambiguous endeavor (this humor is also safe inasmuch as the patients there are viewed as well-to-do worried well). However, from the point of view of stigma, one could argue that psychoanalysis is in desperate straits as a profession; can it afford such lampooning?

There are a number of problems that are not funny because they are both serious and unequivocal: schizophrenia, dementia, mental retardation, severe depression, etc. However, when, as yesterday, when I see a new patient who has diagnosed himself with adult ADHD, I smile wryly to myself not because ADHD is not a real and serious condition, but because it has become so faddish and so ambiguous. Senility used to be faintly amusing until it became better appreciated how devastating dementia really is. Similarly, drunkenness is becoming less amusing over time as the gravity of alcoholism is better appreciated.

Arguably bipolar disorder is in a class by itself in this respect inasmuch as, in its severe forms, it is an appalling and potentially fatal disease, but it continues to defy proper understanding, as reflected in the ongoing controversies over its diagnosis and treatment. If I sometimes roll my eyes at bipolar disorder, I am doing so not due to its sufferers, but due to my and our own incomprehension of what is really going on. I will grant that, given the epistemological quagmire, humor may be best avoided, but prudence does not always prevail.

So in my humble opinion the Onion piece was funny on multiple layers. It was a kind of behavioral pun, in which Obama's roller coaster ride in politics and public opinion was suddenly cast in the absurd new light of a mood disorder. It was absurd, and therefore funny, precisely because we know that Obama doesn't have bipolar disorder (if he suddenly did, it would cease being funny). And given Obama's lofty status ("The One"), there is a pleasure in puncturing the pretension, even for one of his supporters.

So as a politically-interested psychiatrist, I was naturally amused not because the piece somehow made fun of bipolar patients, but because it showed the fallibility of our own diagnostic practices in a political context. I can well understand, of course, that someone with clear-cut bipolar disorder might view the Onion piece rather differently. After all this analysis, it ceases being funny, but that fact in itself is mildly amusing.

Bipolar Barack

Some time ago I wrote a post that questioned the practical feasibility of electing a U.S. president with openly diagnosed bipolar disorder. I caught some flak for that, but I have changed my point of view only today, thanks to this mind-blowing story by The Onion. This changes everything. Vice-President Biden is helpfully diagnosed as well at the end of the first clip. If President Obama starts to put on a lot of weight, we'll know why. (No, this is not a cheap shot at bipolar disorder; it's merely hilarious).

Delusion?

Delusion? -- No!

In atmosphere almost too heavenly
Pure for nourishment of earthbound
Bone, or bone-borne flesh, I stood,
At last past sweat and swink, at crag-edge. Felt
My head swell like the sky that knew
No distance, and knew no sensation but blueness.

In that divine osmosis I stood
And felt each discrete and distinct stroke
Of the heart as it downward fled--
Cliff, cleft, gorge, chasm, and, far off,
Ravine cut in the flattening but still high glitter
Of earth. I saw afar the peek-a-boo of some stream's gleam.

Mind plays strange tricks on us.
One moment I felt the momentous, muscular thrust
Skyward of peak, then the thumb-and-forefinger twist
Of range on range. I entered in.
Was part of all. I knew the
Glorious light of inner darkness burn
Like the fundamental discovery.

Yes, stretch forth your arms like wings, and from your high stance,
Hawk-eyed, ride forth upon the emptiness of air, survey
Each regal contortion
And tortuous imagination of rock, wind, water, and know
Your own the power creating all.

Delusion? -- No! For Truth has many moments.

Open your eyes. Who knows? This may be one.

Robert Penn Warren

The Great Game

The other day I was reading an article on Siberia that mentioned the region of Kamchatka, and for some reason this took me back, Proust-like, to my first experience of that hyperborean locale. I speak, of course, of the exquisite game of Risk (or as my old version had it, Risk!), the Parker Brothers game of gleeful world domination that, I was surprised to see, is fifty years old this year.

To play Risk was to enter a world geography both ruthlessly abstract (nations and states replaced by entities such as Central Europe and Eastern United States) and intriguingly off-kilter (a world in which Ukraine was as large as South America, and the menacing Cold War U.S.S.R. was replaced by puzzling regions such as Ural, Yakutsk, Irkutsk, and, yes, Kamchatka). The graduated hues of the board (North America a staid mixture of yellow and brown, Europe a pellucid series of blue, Asia a murky and clotted melange of green) provided an understated yet kaleidoscopic backdrop. Whimsical touches included a whale spouting in the Arctic, a pair of dolphins off of Africa, and a stately ship of the line in the Indian Ocean.

I recall many a languid summer afternoon spent with this game. Our version, from the 1970's I assume, still had the sturdy wooden cubes as game pieces, with elegantly rounded oblong pieces representing consolidated forces. These pieces had both a simplicity and solidity totally lacking in the inevitably plastic substitutes which followed in ensuing versions of Risk. Our set was from an age more prodigal and generous than the current time can apparently afford to be.

I always thought Risk entailed a pleasing balance between strategy and the vagaries of fortune embodied in the dice. A conservative mood--a determination that one was simply, if uninterestingly, going to win this time--dictated an aspiration for North America, which commanded large territories relatively easy to defend. But one could only do that a couple of times before yielding to the temptations of more baroque enterprises: a Napoleonic seizure of Europe despite its vulnerability on all sides, or a Mongolian sweep across the vast Asiatic plains, perhaps sneakily originating in Australia.

There was a definite, if guilty, pleasure in observing one's forces gathering inexorably for an invasion, and exultation as red sixes came up again and again in dice-battle. An evolutionary rush occurred as blue or black or green armies rolled across territories. More delicious still were those rare episodes in which one's beleaguered smaller defending army, Thermopylaean perhaps, might repel or fatally weaken a monstrous invading force. Numbers and strategy usually won out, but for short periods of time, as in life, luck mattered.

A game of the 18th and 19th centuries, and of childhood. Simpler times, twice over.

Vox Populi

"The voice of the intellect is a soft one, but it does not rest until it gains a hearing."

Freud, "The Future of an Illusion"

The health care debate is dispiriting, and not only because the Democrats' handling of the issue has been inexpert. The celebrated town hall format is primarily a test of who can yell the loudest within view of the most media amplifiers. More than ever I'm convinced that most Americans are not ready for health care reform.

A generation or more has become accustomed to access to whatever test or treatment they (oops, I suppose I should say "their physicians") want, regardless of the actual evidence for its effectiveness, and for the majority of those who do have medical coverage, the 40 million plus who don't are a statistic, not a tragedy, and certainly not worth endangering the system for.

Shocking, isn't it, that anyone could propose putting a price on life? Life is infinitely precious. We would pour untold billions to treat the loudest town hall crier. No limits--for those brazen enough to seize the wealth that is. If none is left over for those who were too busy or distracted to make the meeting, well, that's the American way.

The Hippocratic injunction to "First, do no harm" is being aired a great deal. True, but if one adheres to this too closely, one never does anything. Any intervention carries the risk of harm. And there would be harm, or at least perceived harm, in the event of health care reform, inasmuch as some people, both patients and doctors, would no longer be able to pursue indisciminate testing and treatment.

Politicians aren't able to highlight this unpalatable fact, of course, just as weight loss programs steer clear of the cruel realities of diet and exercise. We spend too much money on health care, and we do so inequitably. Redressing this would indeed involve lifestyle changes, hunger pangs, and sore muscles from time to time. We're not ready to change--yet.

I get tired of signs saying "Don't touch my health care." In many cases the gray-haired person holding the sign has Medicare precisely because the government does touch his health care in a generous sort of way as it is. "His" health care is being funded by my taxes. And for those with private health insurance, their care may be paid for by my premiums. After all, I'm healthy overall and don't use many benefits. Isn't the whole concept of insurance tantamount to (gasp) socialism? Maybe we should rewind eighty years and stipulate that people can have as much unregulated health care as they want, but only what they can pay for out of their own pocket. Now that would steer well clear of socialism, even if people would be dying in the streets.

Questions of populism also arise from an NPR article describing a website aiming to publish patients' ratings of their doctors. Actually I think this is generally a good thing, but mainly because it would enable patients to avoid the relatively few really subpar physicians out there. Obviously most doctors, as with all human pursuits, occupy a large middle range of good-enough-but-not-great, and patient surveys are unlikely to make fine distinctions here.

I have a certain horror of statistics, but I suppose it may be more accurate to throw out the lowest and the highest ratings of a given physician; the former could just be from a crank who didn't get the Xanax he wanted, while the latter could be from a patient who got on famously with the doctor because their kids go to the same school. Truly bad doctors usually share the same kinds of vices: they don't listen, they are rude and arrogant, and they don't exercise good judgment. A patient should beware of looking for a kind of popularity contest that could reveal the "very best" doctor in his area; he should content himself with finding the good-enough doctor who will do an able job.

There's that idea again: not the best care (at all costs), but good enough.

Lessons in August

School is starting up. I don't know why this poem came to mind:

The Ball Poem

What is the boy now, who has lost his ball,
What, what is he to do? I saw it go
Merrily bouncing, down the street, and then
Merrily over--there it is in the water!
No use to say 'O there are other balls':
An ultimate shaking grief fixes the boy
As he stands rigid, trembling, staring down
All his young days into the harbour where
His ball went. I would not intrude on him,
A dime, another ball, is worthless. Now
He sense first responsibility
In a world of possessions. People will take balls,
Balls will be lost always, little boy,
And no one buys a ball back. Money is external.
He is learning, well behind his desperate eyes,
The epistemology of loss, how to stand up
Knowing what every man must one day know
And most know many days, how to stand up.
And gradually light returns to the street,
A whistle blow, the ball is out of sight,
Soon part of me will explore the deep and dark
Floor of the harbour...I am everywhere,
I suffer and move, my mind and my heart move
With all that move me, under the water
Or whistling, I am not a little boy.

John Berryman

Summer Camp Alternative

I had not thought death had undone so many.

T. S. Eliot (after Dante)

Forget Chuck E. Cheese's, forget the pool (well, we did that yesterday)--this morning I hauled the seven-year-old to the sprawling cemetery here where we're visiting. He was all for it, actually; since we moved to the country a year ago he has been intensely curious about the small church cemeteries that dot the landscape (he heard the word as "memories" for a while). And two of my grandparents are there.

For a seven-year-old, his acquaintance with death is probably typical. A couple of family pets, and then a few months ago two great-grandmothers who essentially died, as was formerly and quaintly said, of "old age." So the reality has touched him, but not so closely or so viscerally that a cemetery would be best avoided. And this one is a lovely place, strewn with flowers and anchored with numerous massive old trees ("I know that one's a sequoia!").

Notions of status come early and naturally to Homo sapiens. "Look how big that is, they must have been rich!" The diversity of names, dates, family constellations, and monument styles were remarked upon. "This many people have died?" Yes, in a medium-sized city over a couple of centuries. No questions, fortunately, about postmortem biology. I haven't been able to convince him that ghosts aren't real, but he felt secure with the sun high in the sky.

He was looking for those who had fallen in battle, and was impressed by the cleanliness and symmetry of the military section. The monument of Henry Clay towers over the others, although it is barely visible among the equally lofty trees surrounding it. "That must be the biggest grave in the world!" No, surely not--what is? The Great Pyramid, I suppose, although maybe the Taj Mahal, if it does in fact constitute a grave, is the most lovely.

The biggest disappointment was our inability to find any stones featuring "rip," and I had to break it to him that R. I. P. is rarely found outside of cartoons and Halloween displays. Popular media has a step on the Grim Reaper himself.

The Cool Web

It occurred to me that this poem's title is a double-entendre in the perpetually hip Internet age, but the meaning works either for words or for websites. I've spent much of my life among words, but I go through stretches in which my faith in them flags and I crave reality (and resent the postmodern notion that there is no reality outside of our words and concepts). Wallace Stevens put it another way in "The Motive for Metaphor."

The Cool Web

Children are dumb to say how hot the day is,
How hot the scent is of the summer rose,
How dreadful the black wastes of evening sky,
How dreadful the tall soldiers drumming by.

But we have speech, to chill the angry day,
And speech, to dull the rose's cruel scent.
We spell away the overhanging night,
We spell away the soldiers and the fright.

There's a cool web of language winds us in,
Retreat from too much joy or too much fear:
We grow sea-green at last and coldly die
In brininess and volubility.

But if we let our tongues lose self-possession,
Throwing off language and its watery clasp
Before our death, instead of when death comes,
Facing the wide glare of the children's day,
Facing the rose, the dark sky and the drums,
We shall go mad no doubt and die that way.

Robert Graves

Who Are You Calling Fat?

"I have a certain alacrity in sinking."

Falstaff


A survey suggests that the majority of Americans are not convinced that they are as fat as health experts say they are, or at least, they don't seem very alarmed about it. 82 percent said that obesity is either no problem or only a mild problem for themselves or their families. I don't know if they were asked whether obesity is a problem for other people and their families; my guess is that the numbers in that case would come out differently. But clearly this is out of step with the near-panic of many health experts over the epidemic of obesity.

This is the perennially interesting question of who gets to define what an illness is. Obviously opinion polls don't settle purely scientific questions. I believe I've seen multiple polls suggesting that the majority of Americans do not give full credence to the theory of evolution. While this fact is fascinating on cultural and sociological grounds, it detracts nothing from the validity of evolution itself.

The question with obesity is whether the poll in question reflects mere denial of the prevailing metabolic state, disbelief in the alleged health effects of obesity, or a declaration that whatever those effects might be, most folks don't care enough to tackle the problem. It hasn't helped, of course, that there has been significant ambiguity about health effects; while morbid obesity clearly hastens mortality, it is far from completely settled, so far as I know, that obesity in the moderate range shortens life span.

Obviously there are other ways obesity may be detrimental, primarily through increased morbidity, that is, suffering related to arthritis, diabetes, or other secondary conditions. These complications arguably increase health care costs. Obesity is problematic in other miscellaneous and logistical ways, for instance, even by increasing consumption of jet fuel for higher passenger payloads. None of this is to comment in any way on the causes of obesity, or the locus of responsibility, merely the consequences.

So the poll results may just reflect ignorance--people just don't understand, or don't want to understand, the social impact of obesity. But what if, at some level, they do, but they don't deeply care enough to label it a problem? Certainly in psychiatry, lack of insight is a common predicament--individuals with alcoholism or schizophrenia often enough can't or won't grant that they have a problem. But in those cases we stipulate that if they were placed before a jury of their peers, so to speak, or before a hypothetically rational person, they would be found to have a problem.

Alcoholism and schizophrenia do not reach epidemic status; it is easier to see the outlier as "disordered." But what happens when the outliers become the majority--can they define their putative disorder out of existence, or at least redefine it so that it again becomes a minority state? For instance, one could imagine a redefinition of morbid obesity as obesity, period, and what we now call moderate obesity, within a new and broader normal range. Even if such a change reduced average life span, the majority consensus would be a repudiation of the designation "illness" or "problem." There are, after all, values other than health-related values.

Yes, maybe technically the doctor makes the diagnosis, but if the "patient" doesn't consult the doctor, or even if he ignores the doctor's advice, is there still an "illness" or a "problem?" If the majority of patients were to do this, maybe not. In the country of the blind, the seeing man is king. But in the country of the overweight, the lean man is...malnourished. In a patient population of the contentedly curvaceous, the alarmed doctor is...alarmist.

Silliness

Two bits of nonsense that I just came across:

1. The Huffington Post reports that the husband of Diane Schuler, the woman who caused the horrific crash in New York that killed eight people, vehemently denies that she had an alcohol or substance abuse problem. Evidence of high levels of cannabis was found in her system, her alcohol level was 0.19 (more than twice the legal limit), and a vodka bottle was found at the scene. And the accident occurred in the early afternoon.

Her husband referred to medical problems she suffered from that may have "caused her" to drink excessively that day (although the fact that she was quite alert with that alcohol level suggests that her tolerance, and therefore her regular use, was quite high). If it could be shown that her alcoholism was secondary to diabetes, it would revolutionize psychiatry. It's an appalling event all around, but in this case denial (by proxy) knows no bounds.

2. A post by the usually astute KevinMD, in discussing the risks of physicians treating celebrity patients, alludes to a study that reportedly found that celebrities are 17% more narcissistic than the general population. Not 15% as previously thought. Presumably this was found either by hooking folks up to a new and improved narcissometer, or by a serum levels of self-regard.

A possible limitation of the study was that levels of narcissism were "pinpointed" by narcissistic researchers.

Are these lead-ins to the coming triumph of DSM-V?

Vignette

A young guy with no psychiatric treatment history comes in for his second visit. After some initial pleasantries:

I: "How did the medication go?"

(Sheepish look). "Well, I got the prescription filled, but then I got scared and threw it away."

(Later in session, he): "You went to school for ten years to do this?"

"Yeah, it seemed like longer at the time."

(Later in session, he): "Is your job hard or easy?"

"Mumble, mumble, mumble."

Now I can't get it out of my head. Is it dishearteningly hard, or is it laughably easy? I discover that there is no objective way to gauge this. By how many years it takes to obtain society's assent to do it? By how one feels at the end of the day? By "outcome measures?"

What a comedian.

The Rest of the Story

"How sharper than the serpent's tooth it is to have a thankless child."

Lear


I haven't been inspired to write here the past couple of days, yet here I sit, typing. Why? Because writing is what I have to do; if it weren't here it would be somewhere else. The standard advice for writer's block, or even writer's procrastination, is to sit down, stare at the blank (screen), and write something, anything. As Lear also said, "Nothing will come of nothing." But out of something, something else may come. Granted, this write-at-all-costs mantra was pre-Internet; the adage was never to write something, anything for instantaneous, theoretically global release.

I've always been fascinated by the attractions and repulsions that operate between people--animal magnetism, as it were. Obviously a lot of what folks like me do professionally is to commiserate, if nothing else, with people for the slings and arrows of romantic entanglements. Those are interesting enough, but arguably parent-child relationships are more powerful in the end. Partners come and go, but parents, siblings and children are for life.

Except when they aren't. I'm always intrigued by family secrets of distancing and estrangement. Siblings who grow up sharing so many intense experiences during impressionable youth may turn out to live totally different lives, perhaps to have little to say to one another, perhaps to squabble bitterly over the inheritance or worse. Through what mysterious genetic and social unfoldings does the black sheep acquire his hue?

I've noted before that parenting gone bad seems to engender some of the worst suffering one sees. The divorced father who can't see his children. The dumbfounded mother who sees her boys turn into drug addicts and criminals. And then there is the puzzling torture of the child who won't communicate at all.

I see one every once in while, a middle-aged father or mother whose child is incommunicado. They may seem harmless enough--a woman whose chronic depression may have made her emotionally unavailable to her children, or a man whose alcoholism and workaholism may have left family scars. Their child (or sometimes all the children, or sometimes one child and not the others) not only won't maintain a relationship, but supposedly won't even grant a reason why. Calls and letters not answered, and no forwarding address. The silence is more exquisitely painful than any denunciation.

Was there some unspeakable atrocity of abuse? Most things in life may be atoned for if undertaken with sufficient sincerity, but perhaps not all. Or is this a case of an unforgiving child who has embraced the path of ruthlessness? How much "honor," in the Ten Commandments sense, is owed to the dishonorable mother or father? To the merely inadequate mother or father?

Family secrets. In encountering a person one confronts a subjective world unto itself, and yet there are parallel worlds giving onto a mutual universe. The "history" one obtains one is merely one volume of a potentially infinite library that is a family. The empty chairs in the office may speak alternative volumes. Their would-be occupants may sit in other, similar offices, next to other, similarly empty chairs.

Autres Temps, Autres Moeurs

More from Darwin's The Voyage of the Beagle (November 22, 1832):

Animals are so abundant in these countries, that humanity and self-interest are not closely united; therefore I fear it is that the former is here scarcely known. One day, riding in the Pampas with a very respectable "estanciero," my horse, being tired, lagged behind. The man often shouted to me to spur him. When I remonstrated that it was a pity, for the horse was quite exhausted, he cried out, "Why not?--never mind--spur him--it is my horse." I had then some difficulty in making him comprehend that it was for the horse's sake, and not on his account, that I did not choose to use my spurs. He exclaimed, with a look of great surprise, "Ah, Don Carlos, que cosa!" It was clear that such an idea had never before entered his head.

-----

During the last six months I have had an opportunity of seeing a little of the character of the inhabitants of these provinces. The Gouchos, or countrymen, are very superior to those who reside in the towns. The Gaucho is invariably most obliging, polite, and hospitable: I did not meet with even one instance of rudeness or inhospitality. He is modest, both respecting himself and country, but at the same time a spirited, bold fellow. On the other hand, many robberies are committed, and there is much bloodshed: the habit of constantly wearing the knife is the chief cause of the latter. It is lamentable to hear how many lives are lost in trifling quarrels. In fighting, each party tries to mark the face of his adversary by slashing his nose or eyes; as is often attested by deep and horrid-looking scars. Robberies are a natural consequence of universal gambling, much drinking, and extreme indolence. At Mercedes I asked two men why they did not work. One gravely said the days were too long; the other that he was too poor. The number of horses and the profusion of food are the destruction of all industry. Moreover, there are so many feast-days; and again, nothing can succeed without it be begun when the moon is on the increase; so that half the month is lost from these two causes.

Airy Nothings

In The New Republic Jerry A. Coyne coolly dismantles another instance of fuzzy theological thinking, this time Robert Wright's The Evolution of God (unread by me). According to this and other reviews of the book I've read, Wright argues not only that religion has become globally more beneficent and tolerant over historical time (a questionable enough claim), but also, without venturing to affirm that God does in fact exist, suggests in myriad hedging ways that it certainly looks as though he could exist, inasmuch as humanity is supposedly following the Golden Rule more often as the centuries pass.

Folks never tire, it seems, of trying to adduce evidence, whether scientific, historical, or sociological, for God's real existence. Kierkegaard--and many others besides I'm sure--had a lot to say about the folly of this undertaking. If you're going to believe, fine, but do so as a leap of faith, and stop saying that science suggests anything about the nature of God. There are a number of things in life that science per se can't help us with (such as how to live, what to do), but what it does do--explain the nature of material reality in testable fashion--it does very well indeed. There are things science can't explain yet, such as how the universe came to be, but science as of 1800 couldn't explain viruses either.

Not having read Wright's book, I obviously can't say much, but it seems to me that if humanity is becoming somewhat more peaceful and pro-social over time, it is less likely due to some kind of divinely inspired evolution than to the simple fact that the planet is getting a lot more crowded, and it's a lot harder than it ever was to swing one's elbows without hitting a neighbor. Folks could tolerate six-shooters on the frontier, but not nuclear weapons (or excessive carbon dioxide emissions) down the street. It's becoming more apparent as history passes that humanity resides not in a fortress, but in a boat. We can't allow ourselves to use up the fish or shoot up the hull.

Seeking to use science to buttress religion is precisely a lack of faith. I personally wouldn't care for any God who would allow (her)self to be captured in the nets of science.

Doctor's Orders?

A couple of quasi-medical links worth noting...Karen Houppert in Salon considers the factors that may have led to a schizophrenic woman, Otty Sanchez, to not only kill but consume parts of her newborn baby. In accounting for why Sanchez reportedly was off of her meds (and according to the article claimed to have been hearing voices telling her to do the deed), Houppert suggested that a doctor probably told her to stop taking them due to breastfeeding. Say what?

It is not for me to comment on Sanchez's specific case beyond saying generally that it is overwhelmingly more likely that she was off of her meds because, in the case of schizophrenia and other severe and persistent mental illnesses, non-compliance is more the rule than the exception. When one considers that the disorders in question often involve poor self-insight, and that the medications are often extremely expensive and have significant side effects, non-compliance ceases to be surprising. I have no idea whether she was even in active treatment around the time of her pregnancy or delivery, but by the time the baby was born the only potentially life-saving intervention would have been social services intervention to ascertain her mental status and fitness for motherhood at the time.

Houppert commendably offers a view of "killer moms" as desperate and hopeless women rather than as amoral monsters. However, in our contemporary glorification of maternal instinct it is easy to overlook the fact that infanticide, far from being unnatural, has in fact been a routine practice in numerous "primitive" cultures in various times and places. While the practice seems to make no evolutionary sense at first blush, it actually does inasmuch as infanticide usually happens when a mother (often a particularly young one with poor social and financial support) feels overwhelmed and unable to raise the baby safely. In that case, it makes evolutionary sense for the mother to punt, so to speak, and preserve her own well-being as she can live on to reproduce again. This is obviously not to condone a heinous deed (murder and rape are "natural" as well), but it is to argue that it is not inherently psychologically puzzling.

In another vein of risky behavior, a local story looks at the persistent popularity of tanning beds despite new data suggesting that they dramatically increase the lifetime risk of skin cancer. However, a 78-year-old woman in the article justifies her habit (I have never had the pleasure of visiting a tanning salon, but I never would have expected to encounter the 70-and-over crowd there).

The reasons for this practice are interesting. Some just thumb their nose at medical recommendations, which is a useful reminder that there are values in life apart from cautious self-preservation. Tanning salon operators (who might be said to be biased) maintain that their services are actually healthful inasmuch as they provide vitamin D in a controlled fashion (according to the article some folks actually arrive with doctors' notes advising them to get more vitamin D).

There is also the fact that while skin cancer is common, and undoubtedly more common with tanning bed use, it is also an eminently treatable cancer in most cases when caught early. I don't mean to trivialize it, but apart from the rare melanoma, your average skin cancer is not, say, pancreatic or ovarian cancer.

In an overview of biotechnology's effects on the human body, William Saletan in the New York Times points out that many current and developing medical interventions seek to compensate for risky behaviors, from overeating to running on bad knees. So my inference is that advances in the diagnosis and treatment of skin cancer may have the eventual paradoxical effect of boosting tanning salon profits.