The Impossible Profession

In a nice segue to the last post, and with a thanks to Retriever (since the current New Yorker hasn't quite arrived at the house yet), it was a pleasure to read Louis Menand's take on psychiatry's discontents. It is probably the best single overview of the profession's vexing ambiguities that I have seen; it's all there--the diagnostic quibbles, the ideological clashes, the greedy pharmaceutical companies.

Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.

It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).

Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.

There is much more to be said, but this is a lunch hour post.

Complementary Cultures

"One could divide humanity into two classes: 1) those who master a metaphor, and 2) those who hold by a formula. Those with a bent for both are far too few, they do not comprise a class."

Heinrich von Kleist

I was struck by a passage from Rebecca Newberger Goldstein's 36 Arguments for the Existence of God in which Jonas Elijah Klapper, the breathtakingly bombastic caricature-of-a-humanist, offers the following riff:

"But, no, I'm not impressed by the slide-rule mentality. I remain unimpressed with the mathematical arts in general. What are the so-called exact sciences but the failure of metaphor and metonymy? I've always experienced mathematics as a personal affront. It is a form of torture for the imaginatively gifted, the very totalitarianism of thought, one line being made to march strictly in step behind the other, all leading inexorably to a single undeviating conclusion. A proof out of Euclid recalls to my mind nothing so much as the troops goose-stepping before the Supreme Dictator. I have always delighted in my mind's refusal to follow a single line of any mathematical explanation offered to me. Why should these exact sciences exact anything from me? Or, as Dostoevsky's Underground Man shrewdly argues, 'Good God, what do I care about the laws of nature and arithmetic if, for one reason or another, I don't like these laws, including the "two times two is four?"' Dostoevsky spurned the hegemaniacal logic, and I can do no less."

It is ludicrous, and it bespeaks a pride bordering on the Satanic ("Better to reign in Hell than to serve in Heaven"), but it does contain the kernel of a point. It brings to mind William Blake's objections to Newton and certain excesses of the Enlightenment: "I must create my own system or be enslaved by another man's." Also Dickinson's "Tell the Truth but tell it slant." Is meaning ultimately a matter of temperament?

I thought also of Consilience, in which Edward O. Wilson argues that there is no aspect of experience, including the supposed mysteries of morality, art, and religion, that, in theory at least (whether we as a species can or will ever know and understand enough to grasp it all is a different matter), cannot be accounted for by objective (i.e. scientific, broadly considered) understanding. Subjectivity may, like ultraviolet light or atoms themselves, be a phenomenon we can never perceive directly, but one that will eventually be found to follow certain laws.

Wilson's book was published in 1998, when postmodernism more of a force to be reckoned with, but I was struck by his approach to the postmodernists' insistence upon decentered, contextual meaning (Nietzsche's notion of truth as a "mobile army of metaphors"). He quotes a passage by George Scialabba:

Foucault was grappling with the deepest, most intractable dilemmas of modern identity....For those who believe that neither God nor natural law nor transcendent Reason exists, and who recognize the varied and subtle ways in which material interest--power--has corrupted, even constituted, every previous morality, how is one to live, to what values can one hold fast?

To this Wilson answers:

"How and what indeed? To solve these disturbing problems, let us begin by simply walking away from Foucault and existentialist despair...To Foucault I would say, if I could (and without meaning to sound patronizing), it's not so bad...The true will be sorted from the false, and we will understand one another very well, the more quickly because we are all of the same species and possess biologically similar brains."

This is a mind-bogglingly optimistic sort of monism, in which the ancient histories of individual and cultural difference melt away in the radiance of the one objective eye of the "view from nowhere," in contrast to the sheltered, shadowed, and limited perspective of the "view from somewhere," that is, from where (and what) individuals find themselves to be.

However, as a psychiatrist I am intrigued by an element of diagnosis in Wilson's view, his suggestion that beyond a certain point, the hand-wringing of threatened nihilism cannot be logically answered (any more than the specters of suicide or unequivocal delusion can be logically answered). It can only be denied and rejected as moral pathology, as toxic to the range of human potential that has been the consensus of human beings across cultures and ages. Has anyone considered "nihilism" for DSM-V?

Yet Wilson throws a bone to those grappling with nihilism:

"Nevertheless, here is a salute to the postmodernists. As today's celebrants of corybantic Romanticism, they enrich culture. They say to the rest of us: Maybe, just maybe, you are wrong. Their ideas are like sparks from firework explosions that travel away in all directions, devoid of following energy, soon to wink out in the dimensionless dark. Yet a few will endure long enough to cast light on unexpected subjects."

But getting away from pathology per se and focusing on psychological understanding, it is important to see Romantics as one end of the continuum of epistemology, the other end being the Classicists I suppose. Epistemology can't be understood apart from human needs. The fictional Klapper, no less than Blake, Kierkegaard, or Dickinson, is saying, "I need something that your Enlightenment, your 'consilience,' can't provide." It is only when this need--for ambiguity that is--becomes so overwhelming that it cannot be reasonably satisfied that it becomes nihilistic psychopathology. For it must exist in tension with the complementary human need for order, which has its own well-known pathologies.

Wallace Stevens nails the ambivalences of the Romantic mindset in "The Motive from Metaphor:"

You like it under the trees in autumn,

Because everything is half dead,

The wind moves like a cripple among the leaves

And repeats words without meaning.

In the same way, you were happy in spring,

With the half colors of quarter-things,

The slightly brighter sky, the melting clouds,

The single bird, the obscure moon--

The obscure moon lighting an obscure world

Of things that would never be quite expressed,

Where you yourself were never quite yourself

And did not want nor have to be,

Desiring the exhilarations of changes:

The motive for metaphor, shrinking from

The weight of primary noon,

The A B C of being,

The ruddy temper, the hammer

Of red and blue, the hard sound--

Steel against intimation--the sharp flash,

The vital, arrogant, fatal, dominant X.

Just as human cultures over the millenia may have gained from the tension between piety and apostasy, they have likely been enriched by complementary needs for fact and metaphor, reality and fantasy. Yes, there is literally nothing outside of reality, and metaphor is "merely" a subcategory of fact, but Homo sapiens is so constituted as to need its Romantic consolations. Eliot ("Humankind cannot bear very much reality") and Nietzsche ("It is only as an aesthetic phenomenon that existence and the world are justified") had it right. Good riddance to metaphysical dualism, but as for psychological and cultural dualism(s), not so fast.

The Hidden God

"The absence of God will bring you comfort, baby"

Rilo Kiley

Rebecca Newberger Goldstein's 36 Arguments for the Existence of God is an at times clunky novel of religious theorizing as it plays out in academia and Orthodox Judaism (as novels of ideas go, I'll stick with Dostoevsky and Mann), but the jewel of the book is its philosophical appendix, a compendium of 36 arguments for the existence of God followed by their convincing refutations. In this analytic tour de force, theistic justifications are systematically dismantled. However, the disproof of the final argument (The Argument from the Abundance of Arguments) ends as follows:

Few people rest their belief in God on a single, decisive logical argument. Instead, people are swept away by the sheer number of reasons that make God's existence seem plausible--holding out an explanation as to why the universe went to the bother of existing, and why it is this particular universe, with it sublime improbabilities, including us humans; and, even more particularly, explaining the existence of each one of us who know ourselves as unique conscious individuals, who make free and moral choices that grant meaning and purpose to our lives; and, even more personally, giving hope that desperate prayers may not go unheard and unanswered, and that the terrors of death can be subdued in immortality. Religions, too, do not justify themselves with a single logical argument, but minister to all of these spiritual needs and provide a space in our lives where the largest questions with which we grapple all come together, which is a space that can become among the most expansive and loving of which we are capable, or the most constricted and hating of which we are capable--in other words, a space as contradictory as human nature itself.

Yes, that's it. Logically, these refutations are relentlessly persuasive, but I can't imagine them having any effect upon believers, because belief rests upon existential need and emotional disposition. However, one can imagine those who, contrarily, disbelieve not merely out of a respect for logic, but because belief in a God who, to judge from the evidence of the world, could just as easily be sadistic as benevolent is best avoided. History may be more consistent with the cruel God of the Old Testament than with that of the New; is it really desirable to be trapped in the universe, beyond death even, with an omnipotent being with questionable or at least inscrutable motives?

In/Out

"All my daydreams are disasters

She's the one I think I love

Rivers burn and then run backwards

For her, that's enough"

Uncle Tupelo, "New Madrid"

I read Michael Benson's Far Out a while back, a compendium of the latest stunning images from the Hubble telescope, ranging from relatively nearby nebulas (a mere few thousand light years away) to the dimmest specks of galaxies whose light, 13 billion years old, streams oh-so-faintly to us from the dawn of the universe.

The images are truly spectacular, nature writ very large and very distant. But as Benson notes, they are images that, while reflective of reality, are not those that could be captured by that very imperfect instrument, the human eye. He even quotes Blake's immortal line, "If the doors of perception were cleansed, everything would appear as it is, infinite."

Science fact defeats science fiction. Of the universe beyond, say, Mars (or according to President Obama's recent decree, beyond perhaps the International Space Station), you just can't get there from here. The distances defy belief, and the glorious pictures merely tempt. Either we are alone amid unimaginable vastness, or there are likely myriad other intelligences whom we can never contact or perceive across the gulfs of space and time. Either possibility seems absurd. Someone said (was it Wittgenstein?) that if a question has no good answers, that means it wasn't a good question. We are at the limits of human cognition.

The books drove home for me the utter distinction between Godly and Godless universes. In the times and places when I have been able to hold the concept of God seriously in view, the universe seemed very small: just God and us (or me), in a metaphysically tiny room. But subtract God, and the the universe is dumbfoundingly vast, and unimaginably empty. Is there a happy medium between claustrophobia and agoraphobia? The tightrope of sanity maybe.

(What does Uncle Tupelo have to do with astronomy? A mystery).