Journeys

I will be traveling much of the next three weeks, so posting will probably be light to non-existent. Happy Independence Day!

Robert Pinsky and the Muse of Psychiatry

Robert Pinsky's fascinating "Essay on Psychiatrists," which surely must be by far the longest published poem in the history of the world that is devoted to shrinks, once inspired me to write a much less felicitous essay of my own. I was surprised to discover today that, well, both "essays"--one a must-read, the other not so much--are fully available online.

This is Pinsky's conclusion (section 21. 21!):

Essaying to distinguish these men and women,
Who try to give medicine for misery,
From the rest of us, I find I have failed

To discover what essential statement could be made
About psychiatrists that would not apply
To all human beings, or what statement

About all human beings would not apply
Equally to psychiatrists. They, too,
Consult psychiatrists. They try tentatively

To understand, to find healing speech. They work
For truth and for money. They are contingent...
They talk and talk...they are, in the words

Of a lute-player I met once who despised them,
"Into machines"...all true of all, so that it seems
That "psychiatrist" is a synonym for "human being."

Even in their prosperity which is perhaps
Like their contingency merely more vivid than that
Of lutanists, opticians, poets--all into

Truth, into music, into yearning, suffering,
Into elegant machines and luxuries, with caroling
And kisses, with soft rich cloth and polished

Substances, with cash, tennis and fine electronics,
Liberty of lush and reverend places--goods
And money in their contingency and spiritual

Grace evoke the way we are all psychiatrists
All fumbling at so many millions of miles
Per minute and so many dollars per hour

Through the exploding or collapsing spaces
Between stars, saying what we can.

This was published in 1975, but not so much has changed, really. One can't expect him to get everything right...Even lutanists had the temerity to despise us? What would guitarists do, crush us like bugs? What "prosperity?" Okay, maybe more prosperous than contemptuous lutanists and snarky poets, but opticians may be a close call...Not really into caroling (is anyone?)...

One of my observations back then was the back-handed compliment at the heart of the poem. Message: psychiatrists are just like the rest of us, no worse, no better. Therefore don't hate them, but why pay to see them really? I've got kids to feed...

Fool Me Once...

"Sir, I have found you an argument; but I am not obliged to find you an understanding."

Samuel Johnson

"Be wise with speed;

A fool at forty is a fool indeed."

Edward Young

A few brief reflections today:

1. Errol Morris has begun an interesting series on anosognosia, which is a lack of knowledge of a deficit or disability (in psychiatry we speak of "lack of insight," or lack of awareness that one has a mental illness). It pertains to a number of specialized neurological syndromes (which may include certain varieties of hysteria), but in a far broader sense it seems to me that it pertains to foolhardiness--the fool is precisely he who is smugly confident that he has all the relevant information or skills that he needs, when he doesn't. Folly is the self-assured ignorance of one's own ignorance. Conversely, an ignorant person could be considered wise if he is aware of his ignorance (the first lesson of Socrates). All organisms have imperfect knowledge and therefore may be considered ignorant, but only human beings can be foolish or wise. This must finally be neurobiological, but with an inescapable moral component.

2. According to a review, in his biography of Marcus Aurelius, Frank McLynn considers the Roman emperor's stoic philosophy monstrous and inhuman inasmuch as it prizes individual virtue and peace of mind over vulnerable care for the external world. I have often thought the same about the Zen attitude of non-attachment, but it occurs to me that these philosophies are meant to be bracing tonics, not to be imbibed in excess. It is said that the only difference between a medicine and a poison is the dose; the same could be said of ideologies.

3. The latest entry in the New York Times's delightful philosophy blog looks at existentialism's subject/object distinction in the context of the pop phenomenon that is Lady Gaga. The point seems to be that Ms. Gaga (?) embraces the objectification of the female form, exaggerates it to an absurd degree, and then flaunts it like a weapon, exulting in her power. Arguably this has gone on for millenia, but never apparently with such gusto or in such over-exposed fashion. Inasmuch as one consciously and authentically objectifies oneself, one also operates more deeply as a controlling subject, but at the price of becoming more broadly an object. It is the plastic surgery conundrum again--does one ultimately do it for oneself or for others? Both, of course, but in each individual case--and presumably cumulatively as well--one effect must prevail.

4. One can run a psychiatric clinic without benzodiazepines or stimulants just as one can run a pain clinic without opiates or an office without air conditioning. That is, one can--human beings lived without these things for most of history and continue to do so in much of the world--but for better or worse this is what we call civilization.

5. I am always warily curious about the patient who was dissatisfied with his last doctor, and not because there aren't plenty of lame doctors around. But when I hear "All he wanted to do was dope me up on medicines," I am tempted to reply, "Sort of like you're trying to get me to do now?" and when I hear "He kept changing my medicine every month," I think, "Sort of like you'll ask me to do next visit?"

Fathering

"It is a wise father that knows his own child."

The Merchant of Venice

In sharing Toy Story 3 with a packed house of the next generation yesterday, it occurred to me that the toys are fundamentally parental figures, not stand-ins for kids, even if they act in a playfully juvenile fashion (as parents are sometimes wont to do). My memory of the first two movies is vague, but I don't recall the biological father of Andy, the boy whose toys these are, playing much of a role. It is Woody who is his father figure, with Buzz and the rest acting as kind of extended family. They belong to Andy, yes, but in the sense of needing to be there for him. It is interesting, and a bit sexist perhaps, that none of the toys occupies a maternal role (although yes, Andy does have an actual mother, and Mrs. Potato Head is grandmotherly I suppose).

The movie is sad because Andy is moving on to college, and outgrowing his toys the way children outgrow their parents, i.e. significantly but not totally. The toys are ageless in the way that adult parents are ageless; between the ages of, say, 30 and 60, adults--and parents--usually don't change dramatically, especially in their children's eyes. Of course, the toys' declared rationale is that Andy needs them, and they are reluctant or unable to acknowledge their need for him, or their need for his need of them. The toys worry that they are obsolete and over the hill--obviously this is a concern of parents, not children.

In recent evolutionary posts I have implied the way in which human beings come to life possessed of an incredible inertia, and yet in our contemporary cultural folly, this is often assumed to be an inertia of stasis, when nothing could be further from the truth. In fact, human beings come into existence embodying an immanent inertia of developmental momentum built up over several billion years. Children are less lumps of clay awaiting molding than they are rushing rivers capable of both cleansing and bowling over anyone in their path.

Much talk of the decline of parenting seems to be in the air; fertility rates are declining most places (although not quickly enough to quell concerns of population-related environmental catastrophe)--the childless seem more numerous than ever before in human history. And studies suggest that parenting doesn't make people happy, quite the opposite. Courtesy of Arts and Letters Daily, Bryan Caplan suggests that parents bring their distress upon themselves in an illusory faith in their own ability to shape their offspring. Basically, our self-imposed pressure is unreasonably high. Numerous studies show that absent frank abuse or deprivation, children grow up to be some permutation of their parents, but not because of specific parenting practices (reading habits, family dinners, curfews, schools, etc.), which don't matter much in the long run, but because they bear their parents' genes. For evolution, propagation is too crucial to entrust to local and contingent parenting practices.

Examining studies purporting to demonstrate the unhappiness of parents, Sonja Lyubomirsky, considers several alternatives. One is that children endow a life with meaning in a way that ultimately matters far more than transient states of satisfaction captured by happiness surveys. Another is the possibility, similar to Caplan's, that parenting is far more difficult and anxiety-provoking now than it has been for most parents in human history. While in most pre-modern cultures parenting was shared by extended family (or indeed "a village"), now it is undertaken primarily by the nuclear family, or all too often, by the single parent. Added to this is the unreasonable sense of parental responsibility for outcomes. I would mention also that today's pace of cultural change generates anxiety; for most of history parents could justifiably assume that their children and grandchildren would inhabit a world very similar to theirs--I can't begin to imagine what sort of world could await my grandchildren.

I am not so cynical as to maintain that most people have children out of a narcissistic urge. Human beings know, of course, that they are not living on through their descendants; rather, they seek to perpetuate values and ways of life that are dear to them--children are votes cast for the future of humanity. I seek to share nature or the arts with my kids not because such things will "improve" them (whatever that means), but because I want them to love what I deem worthy of love, and because I want them to help further a world in which such things have value. There are, of course, other ways to cast votes for the future, through teaching, good works, etc. For better or worse, most human beings crave the materiality of grandchildren.

Explanation and Intervention

"Nature conceals her secrets because she is sublime, not because she is a trickster."

Albert Einstein

In considering causation in his conclusion to The Evolution of Childhood, Melvin Konner writes:

When asked why a teenage boy punches another, we can say that he does so because of:

• the secretion of a neurotransmitter in the amygdala


• in a neural circuit primed by testosterone,


• in response to a verbal insult,


• after a lifetime of frustration and observation of violence,


• given a fetal brain hurt by alcohol,


• and shaped by prenatal androgenization,


• against a background of maleness and individual aggressiveness,


• caused by natural selection favoring male status and self-defense,


• on a phylogenetic foundation of reproductive competition.

None of these explanations contradicts any of the others; in fact, we do not have an explanation until we have all nine levels.

This is an impressive illustration of over-determination, and an integrative understanding of a seemingly simple act. There is the full spectrum from molecular biology to cultural narrative; if a discrete behavior is this complex, how can we hope to answer the question, "Doctor, why am I depressed?" However, because we must be pragmatic creatures, we can't just throw up our hands; we must decide which cause(s) will be most significant for us in terms of possible intervention. However, we may not have sufficient information for such decisions for a few lifetimes yet. Discussing the biochemistry of development, Konner goes on to write:

Now all we have to do is spend a couple of centuries working out the cascade. We will need a very big piece of paper--it won't fit on a laptop screen--but we will eventually draw it, and it will explain everything. Up to a point. Beyond that, there is chance, chaos, and countless outside influences, especially in the flexible realm of behavior. These may make our elegant diagram look like a Jackson Pollock painting. Still, these outside influences are partly lawful, just as Pollock's drips and splatters, a mess to the untrained eye, are strangely ordered and intentional in their provenance. These external forces, like the cascade itself, are powerful, and understanding them better will give us a certain measure of control.

Nevertheless, we now know that it is foremost the cascade that builds brain and behavior, not just in the embryo but throughout development and life; the cascade proposes, the environment disposes. The cascade is the key creative element in the story. So we behavioral scientists might now show our respect for it--and break decisively with a century of disdain--by enunciating a law of psychogenetic inertia: developmental plans in motion will stay in motion according to predetermined guidance unless diverted by outside forces. It is perhaps just another way of saying canalization, and it is hardly as elegant as Newton's first law, but it may serve to remind us that all creatures, children included, come into the world with a plan.

A new human being is like a cupful of water dipped from the Amazon--we may straighten its course here and there, or dredge its bottom, or purify its waters but there is no need for chlorine or a canal.

Heavenly Buddies

"I don't know how to love Him."

Jesus Christ Superstar

"In the end, however naked, tall, there is still

The impossible possible philosophers' man,

The man who has had the time to think enough,

The central man, the human globe, responsive

As a mirror with a voice, the man of glass,

Who in a million diamonds sums us up."

Wallace Stevens, "Asides on the Oboe"

In my current reading (Melvin Konner's The Evolution of Childhood) I came across the sentence, "Religion is largely about relationship" (p. 671). Initially this took me aback as an extraordinary claim (isn't religion also about history, narrative meaning, social tradition, and morality?), but I realized it wasn't, for a couple of reasons. For one, I had implicitly but mistakenly read it in the impoverished sense in which "relationship" is used in contemporary popular culture.

Perhaps this was because in a local show last night the great Iris DeMent, chatting between songs, talked about her 92-year-old mother, who, after watching Oprah on relationships, said something like, "I'm not sure I even know what a 'relationship' means" (she had been married for 50-odd years and borne 14 children). In common parlance "relationship" is inextricably and often trivially tied to romance and dating, generally in the sense of novelty and excitement. In a couple of paragraphs I'll speculate on why that might be.

But Konner was merely stating the obvious in this case in the sense, which I've written about before, that religion is primarily about emotional needs, not metaphysical conviction. God serves vital interpersonal functions on two levels, providing both an idealized, all-accepting Other as well as a real and connected community of believers focused on that Other. While religion obviously is diverse, even a supposedly atheistic "faith" like Buddhism generated over the millenia a massive emphasis upon the figure of Buddha himself, arguably a God-substitute. While a tiny minority of "believers" may view God from an abstract perspective, for the vast majority of believers, religion is intensely personal. In a world of inevitably imperfect relationships (whether with parents, childrens, friends, or lovers), God is infinitely supporting and reliable. In psychoanalytic terms, as many have written, God is a superb "selfobject," the ideal that can also be related to (witness Christ as both God and human).

If the essence of religion is emotional and relational--if we may view it as a boat (an ark?) sheltering people on a threatening sea--it nevertheless requires a metaphysical anchor, that is, the being who is this idealized Other must be held to actually exist. Otherwise the whole enterprise is for naught. And it is this anchor, philosophically very shaky indeed, that has been the focus of most critics of religion over the millenia. But for most believers the intuition of the presence of this perfect Other is so obvious, so strong, so overpowering that it is impervious to argument. One may as well try to convince someone that he is not, in fact, in love with his beloved (perhaps Iago, one of the most despicable characters in all of literature, did pull this off with Othello, but it didn't turn out very well).

If religion were as universal among human beings as, say, language or sexual drive, then that would be end of story (Homo religiosus?). But while the great majority of human beings who have ever lived have been religious in some way, shape, or form despite arguably devastating philosophical objections to belief, it is of course the case that a minority of individuals, both now and throughout history, have been either implicit (i.e. agnostic) or explicit atheists. How do they manage relationships without the perfect partner who is God? Would a therapist in Scandinavia care to comment here?

To get back to Oprah, I wonder if "relationships" are so much the talk of the popular airwaves for the very reason that relationships are harder to maintain than ever. Not only religion, but the family and community have grown progressively more fragmented over the past century or two. Among other things, people turn on Oprah (another selfobject) as they might go to church. The anchor is loose, so the pressure to locate, attract, and keep (!) the "soul-mate" increases. When the Bible palls, family is distant, and the suburban street is empty, there is always eHarmony (or for Wallace Stevens, the poetic ideal). While neo-atheists such as Christopher Hitchens or Richard Dawkins are smugly confident, Nietzsche saw the death of God (as opposed to the Church, a very different animal) as undeniable and inevitable, but also as an immense tragedy for humanity, a tragedy past which we are still trying to feel our way.

Fun with Innuendo

"Even paranoids have real enemies."

Delmore Schwartz (?)

A local Republican candidate for congress has suggested that the gulf oil spill may have been a government plot. He does not claim outright that this is the case--indeed he admits that no facts support his speculation--but he has decided to add the possibility to the national discourse on the matter.

In the same spirit, I would like to take the opportunity, here, to raise the possibility that, as many have suspected, the moon is in fact made of green cheese. Granted, there are no facts supporting this claim (indeed, there may be so-called "facts" contradicting this claim, according to the liberal media), but I have long suspected that, well, the earth's lone satellite is not all that it would appear to be. Open discourse in this country necessitates free debate as regards the composition of the moon, as with all matters, and I hope that this proposal will not provoke any attempts to shut down my First Amendments rights in launching the discussion. In fact, the Obama administration may have found the oil spill to be a useful diversion from the true state of the heavens.

I find it very interesting that the oil spill occurred in the Gulf of Mexico and not next to Obama's home state of Hawaii. Wait, he wasn't born in Hawaii, was he? Well, he vacations there at any rate, and doesn't want oiled beaches on vacation. There are no oil rigs off of Hawaii? No matter. I haven't heard of any oil spills off of Kenya either.

Business as Usual

"Dost thou think, because thou art virtuous, there shall be no more cakes and ale?"

Sir Toby Belch, Twelfth Night


"Lord what fools these mortals be!"

Puck, A Midsummer Night's Dream


"Energy is eternal delight."

William Blake


Last month I did a post on obesity in which I argued that the "heroic" ideal, according to which we expect the average obese person to shed (and keep shed!) the pounds through sheer willpower, is unrealistic. Rather, systemic incentives must compensate for human frailty. I would submit that the same is true of our now daily vilified "addiction" to fossil fuels, now blamed for both climate change and the kind of reckless quest for oil dominating the airwaves.

In a recent column Thomas Friedman suggested that maybe now, in the wake of the calamity in the Gulf of Mexico, we will decide to take drastic action as individuals to reduce our carbon footprint. His article was entitled "This Time It's Different." No, it's not, at least so far as individual, existential, by-the-bootstraps decision-making is concerned.

Human beings on average are wired to appreciate threats and crises that affect them or their kin or close neighbors in a direct and concrete way. Climate change and, notwithstanding ubiquitous images of oiled wildlife, oil spills are too remote and abstract to change daily behavior. Human beings crave energy, whether in the form of culinary calories or fossil fuel horsepower, and we seek to enjoy this energy without its deleterious drawbacks. Like the true addict, we wish not to decrease or cease our use, but to use without consequences.

Fossil fuel consumption will not diminish until its cost to the individual consumer increases drastically, period. The overriding convenience of cheap and abundant energy is like cocaine. Of course, one point of government is to enable us, collectively, to compensate for individual short-sightedness by enacting laws that reflect our wisdom and our better nature. We need innovative energy policy, not holding out hope for individual abstinence from fossil fuels. The argument from individual virtue is the argument for inaction.

Evolve

"Nothing in biology makes sense except in the light of evolution."

T. Dobzhansky

Yes, that quote is overexposed, but some things cannot be given too much honor. I am making my way through Melvin Konner's massive The Evolution of Childhood, which is wondrous as a compendium of biological and anthropological research, but not really recommended except for fans of evolution or psychobiology. For beach reading look elsewhere.

With the exception of the very real possibility of God's non-existence, which finally got through to me around age 17, I would say that no single idea has struck me with so much force as Darwin's theory. Once its awesomely simple explanatory power made itself felt, so many other seemingly unrelated phenomena clicked into place. And evolution endows humanity with the dignity of deep time and deep history. To learn that creationism is true would be like learning that the universe was switched on five minutes ago, containing the illusion of a 13.7 billion year past. As Darwin noted in wrapping up The Origin of Species, "there is grandeur in this view of life," the notion that the living world has boot-strapped its way to its current dizzying variety over 4 billion years on this planet. Each new organism, whether virus or human, is a biological hypothesis unwittingly put forth by the universe.

Perhaps I fell in love with evolution, as it were, through the writings of the archaeologist and poet Loren Eiseley, for whom the barely fathomable past of Homo sapiens held the haunting sublimity of the ocean or of deep space. For him evolution, far from answering all our questions, poses profound metaphysical and moral mysteries. If there is anything that evolution teaches, it is that our species was never inevitable, and represents no culmination. The contingency goes all the way down, and we too shall pass. There is comfort in that. This reassurance removes us (as Plato might put it) from rooms of smoke and mirrors into open sunlight, where we all find ourselves on the same endless plain.

What does evolution mean for psychiatry? Much in theory, perhaps little in practice. A few thoughts as I understand them:

1. Evolution, unlike God, does not care about our happiness. Reproductive fitness is not inconsistent with suffering, which is not to say that suffering is our normative condition.

2. Evolution, unlike God, is not perfect; it merely makes do with the conditions at hand, which leads to very imperfect designs, such as the human lower back, and perhaps, schizophrenia, mental retardation, etc.

3. Evolution operates at the level of the gene, so certain psychological conditions (of anxiety, depression, or mania) may be adaptive at lower intensities but maladaptive when (more rarely) large numbers of predisposing genes congregate in individuals. Much distress results from bad luck.

4. Evolution is always context-dependent, so certain genes (for obesity, ADHD, or substance abuse) only became problematic in environments of high caloric density, literate technocracy, or the easy availability of intoxicants, respectively.

5. Evolution helps with understanding and acceptance, but by virtue of the naturalistic fallacy (the effective is not necessarily the good) it tells us nothing about what we should value for the future. Henceforth we guide our own evolution, however hapazardly. This may be why evolution can seem to mean either everything or nothing: it has the potential to explain all, but in the form of a consciousness that could theoretically turn its back on all that (or so it seems). As a recent review of what the "post-humanists" are up to suggests, this may reflect our brilliance or our ultimate folly. Is accelerated change a threat to human nature, or the truest embodiment of human nature? Beyond a certain point self-transformation is logically and formally tantamount to suicide, is it not? Even the humble bacterium has the wisdom not to reject its own nature. Consciousness is about the always precarious integrity of identity. Would I still know you on the other side of the Singularity? Would I know myself?

Portrait of the Artist

From Helen Vendler's review of the essays of German poet Durs Grunbein, in The New Republic:

Of the titles of these essays, my favorite is "Why Live Without Writing." (It is more compact in German, Warum schriftlos leben: the word schriftlos suggests a desolation that "without writing" does not). When this essay was recently published in the journal Poetry, it attracted the hostility of a reader who took umbrage at Grunbein's respones to the three questions inevitably (says Grunbein) put to poets: "Can you really live off it?"; "How long have you been writing for?"; and ("the trickiest one") "Why do you write?" The reader of Poetry thought that Grunbein was patronizing his audience; but in fact he was exploring why these questions--seemingly so simple--are impossible to answer as the listener might wish. Grunbein wittily turns the question around, offering as a response to "Why write?" the answer "Why not?"

"I don't want to frighten you," he sharply remarks, "but have you thought about what happens to people who aren't artists?" He quotes E. E. Cummings, in The enormous Room, who, when a reader asks, "What do you think people who aren't artists become?" shoots back, "I feel they don't become: I feel nothing happens to them; I feel negation becomes of them." Grunbein points out that the non-artists among us are "always terribly busy but finally disappear...without a trace." The living voice of the artist, in the long run, trumps the transient nvoices of the non-artists of the world.

Grunbein offers three reasons of his own for writing: self-assertion, self-extension, and self-exploration:

In writing, it is one's innermost being that tries to assert itself, paradoxically, by self-exposure...You write...[because without writing], trammeled up in your own limited lifespan, you would always remain incomplete, half a man, so to speak...From which it follows, third and last: you write because the brain is an endless wilderness, whose roughest terrain can be traveled only with a pencil.

(That "endless wilderness" bit is wonderful, to be traveled with a pencil, with a keystroke, with a dialogue).

A Troubled Mind

Twenty years before Kurt Cobain's suicide rocked the music world, the self-inflicted demise of another musician was relatively little noticed. Nick Drake (1948-1974) was an English folk singer and guitarist who released three transcendent records to minimal or no acclaim before dying from an overdose of amitriptyline. He was a perfect Romantic artist, the tormented genius who was too ill-suited to the world to survive, the kind of person who is at once evolution's greatest product and its greatest failure.

It sounds like Drake, reserved and anxious from an early age, grew frankly socially phobic, interpersonally avoidant, and depressed as his short life wore on. Pathologically shy and distant even among family and friends, he obviously sought escape in music and marijuana. His first album Five Leaves Left, produced when he was only 20, was a staggering achievement for a novice. But one of the reasons it failed commercially was his inability or unwillingness to promote the record through touring and interviewing; he knew how good his work was and thought it should speak for itself. Big mistake, at least if one wants to be recognized. And presumably Drake did wish this; largely unable to connect in other ways, he sought to connect through music. When he found his overtures largely ignored by the public of his time, it was a devastating rejection. Ironically, of course, his albums are now commonly honored as among the best of the last century.

Drake's voice is hypnotic in its effect, both dark and delicate, both detached and intimate. His musical world is one of ethereal melancholy. As with Sylvia Plath and some others, it is tempting to experience his work through the prism of his eventual fate--how is it possible to experience such beauty and such sadness at the same time? The first song on his first record, "Time Has Told Me" (which can be heard here), is Drake at his best, a clarion call but at a frequency many cannot hear.

Together Again

As you can see, Blue to Blue posts have been reabsorbed here.

Forwarding Address

I am in fact shutting down Blue to Blue and have returned to Ars Psychiatrica.

Asylum

"He drew a deep breath. 'Well, I'm back,' he said."

(Sam), The Return of the King

For a local book club I read Clifford Beers's A Mind That Found Itself (1908) (available free online here), a famous account of mental illness and its generally appalling treatment in the state psychiatric hospitals of the time. While the style was somewhat stilted and self-important, I found it to be remarkably readable and compelling overall. Beers's style was direct and gracefully free of jargon, which helps to keep the text from seeming dated.

The book was sociologically important for its depiction of abuses of psychiatric patients, of which there were many (of both abuses and patients), and this remains a problem to this day. Psychiatric inpatients present challenges on multiple levels that the modestly trained and motivated staff that the state can afford to pay are not well positioned to deal with.

The grim conditions were expected; what surprised me was Beers's crystal-clear description of his descent into (and intermittent ascent from) madness. He recounted a classic history of bipolar disorder, all the more convincingly because he never applied any technical term to his condition, which is a relief these days when it seems that "bipolar" is cried from the rooftops. He suffered a classic depression with psychotic features (including a textbook Capgras delusion), followed, after his hospitalization, by a prolonged and florid manic syndrome. He perfectly catalogued the physical agitation, reduced need for sleep, and pressure to speak and write. Acutely manic patients can be very trying within the confines of a hospital ward, and while Beers obviously could not be blamed for his conduct, it is clear that he was an immensely difficult patient who unwittingly provoked some of the regrettable treatment he encountered. Lithium would not come along for a few more decades, alas.

Here is his account of euphoric mania:

After all, delusions of grandeur are the most entertaining of toys. The assortment which my imagination provided was a comprehensive one. I had tossed aside the blocks of childhood days. Instead of laboriously piling small squares of wood one upon another in an endeavor to build the tiny semblance of a house, I now, this second childhood of mine, projected against thin air phantom edifices planned and completed in the twinkling of an eye. To be sure, such houses of cards almost immediately superseded one another, but the vanishing of one could not disturb a mind that had ever another interesting bauble to take its place. And therein lies part of the secret of the happiness peculiar to that stage of elation which is distinguished by delusions of grandeur--always provided that he who is possessed by them be not subjected to privation and abuse. The sane man who can prove that he is rich in material wealth is not nearly so happy as the mentally disordered man whose delusions trick him into believing himself a modern Croesus. A wealth of Midaslike dulusions is no burden. Such a fortune, though a misfortune in itself, bathes the world in a golden glow. No clouds obscure the vision. Optimism reigns supreme. "Failure" and "impossible" are as worlds from an unknown tongue. And the unique satisfaction about a fortune of this fugitive type is that its loss occasions no regret. One by one the phantom ships of treasure sail away for parts unknown; until, when the last ship has become but a speck on the mental horizon, the observer makes the happy discovery that his pirate fleet has left behind it a priceless wake of Reason!

Simplify, Simplify

I will ponder color and design over the weekend, but here I must recommend a recent David Brooks column stoutly defending the liberal arts in education. Eschewing grand but airy pronouncements (of the kind frequently found on this blog), Brooks argued that the study of history, literature, and other domains creakily termed "the humanities" gives unique insight into "The Big Shaggy," his term for the deeply complex and wayward aspects of human nature that escape systematizing theories, whether biological, political, or otherwise ideological ("The Big Shaggy" isn't the term I would have chosen, but Brooks is writing for the New York Times, while I'm writing here).

His column nicely encapsulated what I've stood for in life and fought for in my years of clinical work, that is, resistance to the dumbing-down of human experience that is often found in diagnostic systems and, well, simple-minded approaches to minds that, rightly considered, are infinitely complicated. And yet I found myself contrasting that truth with a recent Jon Stewart routine in which he showed multiple clips of Barack Obama, with respect to situations like the gulf oil spill, health care, and the economy, pronouncing again and again to reporters, "It's complicated." Stewart followed this up with appalled exasperation: "Well simplify it!"

This usefully reminds me that human beings, while capable of appreciating complexity (to varying degrees) are alike in needing, especially in times of crisis, forceful and dramatic metaphors that are, yes, simple. So when I am tempted to disdain such words as "depression" or, even worse, "chemical imbalance," that seem to obscure a wealth of nuance with a kind of advertising slogan, I need to remember that such terms help to orient people. While a minority of folks--those who seek out psychoanalysts and English doctorates--may revel in boundless complication, most people are not wired that way. That is not to say that they're stupid or simple-minded; they merely crave contrast and direction. Leadership, whether political or clinical, is about providing these things; by breaking things down into basics, it risks dumbing-down, but the alternative risk is endless equivocation.

It seems to me that the art of medicine, like the art of life, is steering a path between over-simplification and over-complication, making use of metaphors without becoming trapped by them. Indeed, isn't language itself a kind of over-simplification inasmuch as it reduces, to paraphrase William James, the blooming, buzzing confusion of experience to a finite number of limited words? We can only grasp reality by making a narrative out of it, a narrative that necessarily distorts the stuff of experience. Just as we charge Barack Obama with constructing a narrative of the gulf oil spill that usefully but modestly apportions responsibility and possible avenues of action, we would charge a psychiatrist with drawing up a diagnostic and therapeutic narrative that is respectful of its own limitations. Whenever one tells oneself, "It's complicated," one should inwardly reply, "Simplify, simplify," and vice versa.

Happy 100?

I haven't indulged in blogging about blogging for a long time, but I will allow myself this now that Blue to Blue has inched its way to 100 posts over 11 months. However, while I have retained a few core readers (thank you!), overall the readership as reflected in both hits and comments has been smaller than in my first blog Ars Psychiatrica. Reasons?

1. I haven't been as prolific, either in frequency or ambition of posts; it has simply been a more desultory blog overall. For various reasons I haven't devoted the time and energy that I often did last year. However, some Blue to Blue posts have been, I think, every bit as decent as many in the parent blog.

2. While I would hope that most people would visit this sort of blog primarily for textual content, the cool pictures and quotes that often adorned my previous blog have generally been lacking here. All else being equal, people like pictures.

3. Considering style further, I think that the title Ars Psychiatrica, while a bit pedantic, also usefully named the blog's niche in a way that the more inscrutable "Blue to Blue" does not. Also, the midnight blue template, while appealing to me at first, has grown a bit oppressive (or maybe I'm just bored with it).

4. I haven't been as active in reading and commenting on other blogs as I used to be, which affects readership.

5. As Facebook, Twitter, etc. have continued to grow and offer further distractions, maybe fewer people take time for blogs than used to be the case. (?)

6. As compared to its predecessor blog, probably fewer posts here have offered anything like mainstream commentary on psychiatry (again, the niche is less defined).

7. Perhaps the Novalis brand, so to speak, has grown a bit stale. Just as some claim that writers tend to write the same book over and over again, one does tend to revisit the same issues, although hopefully in a spiral more than a circular fashion (theme with variations).

8. In any event, I find myself at another cusp of choosing whether to give up blogging altogether or, on the contrary, to shift gears again and approach things from a different angle. As compared to the past year, I am in a position to devote more attention to writing if desired. I have even considered returning to Ars Psychiatrica (2.0 perhaps), declaring Blue to Blue a finally unsatisfactory detour. Or perhaps I will undertake something else altogether.

On the Perpetuation of Species

Spanning the gamut of online wisdom, advice columnist Carolyn Hax and philosopher Peter Singer weigh in on the advisability of adding to the sum total of humanity. I've long been curious about the ways in which people choose (when they do have a choice, which they usually do) whether or not to have children.

Hax, responding to a letter-writer who asks if her anxiety disorder may be too severe for her to attempt parenthood, replies, in effect, that wanting to be a parent is no justification for becoming one. She advises the inquirer to consider, in light of her own knowledge of what it is to be a child, whether she would want herself as a parent. How drastically different human history would be if this were a precept that were followed with any consistency! Isn't the presumption of fitness for parenthood pretty much wired into the human organism? Indeed, it may be only the seriously depressed or demoralized, like the letter-writer in this instance, who even consciously consider the matter (which isn't to say that most people who choose not to have children do so for reasons of pathology).

Singer reminds us that creating a child is, of course, a portentous act of either good or ill. He alludes to recent philosophical writing that argues that, well, life often isn't the unqualified good we take it to be (I envision The Onion article: "Philosophers discover that life isn't worth living."). And all joking aside, one does occasionally encounter lives that are so chock full of misery and degradation that, really, not only the moral universe as a whole, but also the possessors of the lives in question, would seem to have been better without them.

Half tongue-in-cheek, Singer wonders whether it would be reprehensible for the species to decide that we will in fact be the final generation. After all, there is no categorical duty to procreate; we do not hold the childless to be guilty of some existential failure or infraction. We cannot be held to have a responsibility for vague beings of the future who may or may not exist; we have duties toward the living, that is all. And yet...one could argue that the presumption of a future for humanity, even if one does not have biological children oneself, is so deeply ingrained in the human organism that the horror of apocalypse far exceeds one's own demise. The future of humanity is not an obligation, but it is a hope, or perhaps a faith.

If one were to genuinely doubt the chance for a worthwhile life of one's offspring, then one would implicitly have to question one's own as well. I am surprised that Singer didn't mention The Children of Men, the movie a few years back that showed the depression and desperation of a world without reproduction. Arguably the final generation, whenever its grim day may come, whether in years or in millenia, will be the saddest one of all.

Maxim

A nice poem by Carl Dennis (already online at The New Yorker website):

A Maxim

To live each day as if it might be the last
Is an injunction that Marcus Aurelius
Inscribes in his journal to remind himself
That he, too, however privileged, is mortal,
That whatever bounty is destined to reach him
Has reached him already, many times.
But if you take his maxim too literally
And devote your mornings to tinkering with your will,
Your afternoons and evenings to saying farewell
To friends and family, you'll come to regret it.
Soon your lawyer won't fit you into his schedule.
Soon your dear ones will hide in a closet
When they hear your heavy step on the porch.
And then your house will slide into disrepair.
If this is my last day, you'll say to yourself,
Why waste time sealing drafts in the window frames
Or cleaning gutters or patching the driveway?
If you don't want your heirs to curse the day
You first opened Marcus's journals,
Take him simply to mean you should find an hour
Each day to pay a debt or forgive one,
Or write a letter of thanks or apology.
No shame in leaving behind some evidence
You were hoping to live beyond the moment,
No shame in a ticket to a concert seven months off,
Or, better yet, two tickets, as if you were hoping
To meet by then someone who'd love to join you,
Two seats near the front so you catch each note.