Ars Psychiatrica

The Thousand Natural Shocks

2012-01-21T13:02:00.000-08:00

John Gray argues that Freud is out of fashion these days owing to his basically tragic view of human nature, according to which we are fundamentally conflicted creatures condemned to interpersonal (and intrapersonal) struggle. The point, to Freud, was to learn to live productively with that state of affairs--no "chicken soup for the soul" here! Full social and personal harmony and ultimate existential consolation are ideals we cannot achieve, so our best and only redemption is to learn to do without them.

Personally I happen to find this aspect of Freud appealing, much more so at any rate than his overweening dogmatism or his far-fetched psychosexual speculation. But if Freud was in fact a modern Stoic, his decline in influence and popularity merely reflects the fact that stoicism as a way of life has never been a mainstream ethos, at least in Western civilization. We'll be waiting a long time to hear a presidential candidate declare that his favorite philosopher is Epictetus. Whether wisely or not, human nature seems to crave more than what some of the more dour tenets of psychoanalysis can provide.

In a similar vein, Daniel Smith in the Times wonders (having trouble with the hyperlink function, sorry) at the persistently high level of anxiety in western culture, which objectively speaking is one of the more successful societies in history. Even the poor in the United States enjoy levels of material comfort unimagined by all but the most wealthy in most past eras. Whereas we experience "stress," the countless generations of history endured miseries of labor, climate, poverty, the random death of children due to infectious disease. This goes to show (unless we want to assume that our forebears experienced their lives as appalling affliction) that beyond a visceral baseline, suffering is never objective or absolute, but rather relative to our expectations, for ourselves and relative to others.

Nature and Conservatism

2012-01-18T16:02:00.000-08:00

In the Times Richard Friedman, M.D. questions the widely debated evolutionary origins and/or advantages of depression. While happiness may not have been selected for survival advantage over the eons (emotional hypersensitivity, paranoia, and compulsivity have their uses in certain environments), he reminds us of the naturalistic fallacy, that is, we shalt not derive an ought from an is. We do not hesitate to decry genocide, bacterial infection, or "nature red in tooth and claw" even though such phenomena are eminently natural.

Theoretically there is nothing, not even cheesecake or Youtube, outside of nature (there is only one reality after all), but practically human beings have always distinguished between realms of culture (that which we believe we have some power to modify) and nature (about which, like the weather, we can only ultimately talk and not do anything). And one doesn't have to be a tree-hugger to acknowledge some sublimity of nature as the realm from which we came and which remains ultimately beyond us. Insofar as nature has accomodated the evolution of human beings over a million years (and of life in general over several billion years), it constitutes a kind of metaphysical cradle that we do well to rock only gently. It is a comfort to know that countless galaxies are beyond the capacity of humanity to despoil. Confronted with nature's nearly infinite array of figurative knobs and levers, we eagerly push this or switch that, but it still remains quite possible that human civilization will drive life on earth into an ecological ditch over the next millenium. The birth of consciousness may turn out to have been a tragedy for the biosphere--or not.

And yet one does commit the naturalistic fallacy every day, every moment, as life itself is the fundamental is from which we derive the ought. Nietzsche's ideal of the "eternal recurrence," the willingness to live one's life over again, in every inevitable detail and infinitely many times, is the absolute expression of the naturalistic fallacy. Some fallacy. If the ought has no connection to the is, where else could it come from?

In The Beginning

2012-01-11T18:27:00.000-08:00

As I read about the physicists' dismay at the possibility of our "accidental universe" amid myriad possible universes, I am puzzled over what we expect to find, ultimately, in so-called fundamental particles or laws. After all, what physical law could be so fundamental as to entail the existence of something rather than nothing?

The human mind has two explanatory needs, one for cause-and-effect and the other for narrative meaning, but it seems to me that both of these cannot be satisfied at the same time. Science does a marvelous job of explaining the behavior of matter within the range of conceivable human experience, but as we pursue cause-and-effect into the remoteness of time and abstraction, science leads to infinite regression. At a certain point, neither the Big Bang nor the infinite multiverse suffices as explanation; one can only say that there is something rather than nothing and that is that. We don't know why.

Narrative accounts on the other hand may gratify the basic emotional need for explanation, but then science goes out the window. There is something rather than nothing because God is in all places and all times--on this view a warm glow of necessity takes the place of the implacably arbitrary.

We have evolved as both calculating and valuing creatures, but these local faculties, while estimable in the human milieu, bear diminishing power into the deeps of space and time.

The Shaman Speaks

2011-09-12T08:47:00.000-07:00

"All comes by the body, only health puts you rapport with the universe."

Walt Whitman, from "By Blue Ontario's Shore"

This quote--which could serve as credo for integrative medicine--is the kind of thing that occasionally reminds me why I went into psychiatry. Beyond the often questionable DSM diagnoses, the vagaries of therapy, and the imperfect biological treatments, what we are after is a state of attunement and acceptance in which a biological being achieves transcendence of the merely physical without, necessarily, any recourse to the supernatural.

It is not the work of poetry to answer all our questions, of course, and one can legitimately wonder what sorts of subjective states, interpersonal relationships, and achievements of meaning must come together to constitute "rapport." But if we say that health is merely the absence of disease (or disorder), if only to trim the ambitions of restless and overweening doctors (and their many accomplices and handmaidens in the behemoth that is the health care industry), it is nonetheless true that it is typical of consciousness to aspire to something more than just the absence of suffering. Perhaps poets pick up about where physicians trail off.

Mental Illness Is Whatever We Say It Is

2011-09-07T13:09:00.000-07:00

"Psychology, which explains everything
explains nothing,
and we are still in doubt."

Marianne Moore, from "Marriage"

By "we" I don't mean we psychiatrists, at least not primarily, but rather "we the people." Caseness, or the determination of what counts as a mental disorder and what doesn't, is not something we go out and discover in nature; rather, it is a social category arrived at both explicitly and implicitly through cultural debate. The psychiatric profession obviously has opinions about caseness, but these do not go unanswered or unlimited by society at large.

In large part, antipsychiatry critique has been aimed at the extent of psychiatric diagnoses, both the numbers of diagnoses themselves (larger in every succeeding edition of DSM, we are reminded) and of course the numbers of people given those diagnoses. Suddenly it seems as if every other kid has ADHD and/or autism. Recently several psych blogs cited a recent survey claiming that 38% of a European sample suffers a mental disorder in a given year. This included substance abuse and dementia, but nonetheless it seems like a high number (the 5 or 10-year prevalence would be significantly higher).

I think that 38% seems like a high number for reasons both illegitimate and legitimate. Even now there is a tendency, more latent in some than others, to view those with mental disorders as the mad, an appalling but surely very minority group safely stowed away in institutions. The notion that "the mentally ill" walk the streets and even have jobs and families like you and I remains foreign to some. But there is also the real concern that the sick role, a transaction that officially relieves the patient of at least some social responsibility, loses its meaning when used too widely. In that respect, there is too little appreciation of the great variation in severity of mental disorders; just as one may go to an internist for a touch of gastritis or for cancer, a technical psychiatric diagnosis may or may not involve significant disability or the use of the sick role.

Whether medical or psychiatric, diagnosis when applied liberally enough approaches the condition of enhancement. For Freudians neurosis was an inescapable condition of humanity, so at certain times and places (and with sufficient economic resources) to be in analysis did not mark one as "sick" so much as self-aware and ambitious. Similarly, in those older than 85, significant dementia is closer to the rule than to the exception, so statistically speaking the effective treatment (which we don't yet have) of dementia in the very old would in fact qualify as enhancement. And for modern medicine, mortality itself has virtually become a disease (which as the Onion occasionally reminds us, retains its 100% prevalence despite our best efforts). When we seriously discuss mental disorders having a prevalence greater than 50%, we start to consider syndromes that are, in toto, to be expected of the human condition, at least at this place and time.

Enhancement may well be justified, depending on the circumstances. The question is always: is treating any given phenomenon clinically (that is, as a syndrome worthy of specific medical intervention) likely to be helpful (that is, to lead to better functional outcomes, in the case of those problems for which we really do have treatments, or to better understanding of ourselves and others, in the case of those problems that remain intractable)? Or would it be better to consider the issue as a social/moral/cultural/existential difficulty? That is really the question, and not one that neuroscience can shed any light on whatsoever. Biologically, all human capacities appear to exist on dimensional continua, and the point at which we indicate "pathology" or "caseness" is a social and interpretive outcome.

The Religion of the Good, Part 2

2011-09-06T13:28:00.000-07:00

A recent New Yorker profile of the philosopher Derek Parfit mentioned that the late Bernard Williams once dismissed the ideal of a universally compelling moral code as (I paraphrase) "something you use on the men who come to take you away." Indeed, implied in the "problem of evil" is the conviction (or fantasy perhaps) that if we could only find the right combination for the great moral mystery vault, the ponderous door of error would swing open, releasing a radiance that would burn away the scales from the eyes of the benighted.

I imagine that some religious believers have a similar feeling that if they could only depict or praise God rightly, his existence and glory would be as plain to everyone else as they are to them. The holy grail of thought is the proposition (or grand scheme of propositions) that is as self-evident as 2 + 2 = 4 but as transcendent and as life-changing as the existence of God. That is the constructed idea(l) that we imagine would stop the bad men in their tracks and bring them to their knees. If God does not exist, then it will be necessary to invent (it)--this is the project that is at least implicit in non-relativistic philosophy. As Wallace Stevens wrote, "One day they will get it right at the Sorbonne."

I once read a review by Helen Vendler in which she claimed that the role of the critic is not only (or even primarily) to explain or to justify, but also to celebrate. Similarly, I think that for anyone who reflects seriously about the moral life, explanation and justification go only so far, beyond which point one can only aspire to praise and embody one's views. The barbarians who burn down the monastery are unfazed by the crucifix; likewise, no secular moral system achieves the potency of a talisman. To accept this is also to accept a troubling existential diversity in human nature--other people see the great questions in the same way that I do, except when they don't do so at all. Perhaps the Tower of Babel is the central metaphor for humanity, making us the most atypical species. There is a strain in philosophy that seeks to tear down the tower in favor of a second Garden of Eden, done rightly this time.

The problem is that many men (most of them, alas, have been men) have been sure that they beheld the Truth, and terrible things have been done in the name of Truth. The point is to religiously (in the generic sense) embrace a system of meaning while avoiding clinical or moral insanity. Just as Satanism may be an internally consistent religion, so may there be functioning philosophies of evil (National Socialism, al Qaeda, etc.). We denounce them not because they have no justification (they do have their internal justifications), but because we find them pernicious and repugnant. Our grounds for doing so may be ultimately contingent on the creatures that we evolved to be, but that is the best we can do--we can never escape history by inventing ourselves de novo. By and large, we also happen contingently to find the blues and golds of sea, sky, and sun to be gratifying, and we can only be grateful that we do so. The truth is not given in any simplistic way, but there is also no truth that does not derive, in some fantastically complicated way and filtered through many generations of human consciousness, from our origin.

The Religion of the Good

2011-09-05T13:00:00.000-07:00

A couple of weeks ago, in the New York Times philosophy feature "The Stone," Joel Marks confessed his loss of faith in objective morality:

"I thought I was a secularist because I conceived of right and wrong as standing on their own two feet, without prop or crutch from God. We should do the right thing because it is the right thing to do, period. But this was a God too. It was the Godless God of secular morality, which commanded without commander--whose ways were thus even more mysterious than the God I did not believe in, who at least had the intelligible motive of rewarding us for what He wanted us to do." (Italics in original).

Marks goes on to claim that even if we withdraw the quasi-theistic vehemence of our confidence in objective morality, and thus acknowledge the mere contingency of our beliefs, this needn't change our actual practice. We continue to believe what we believe and have the right to advocate our views in accord or in competition with others, but according to Marks, we can never claim that the views of others are wrong, only that they lead to different consequences. Such advocacy would seem able to achieve moral consistency, and not full justification. For instance, Marks notes animal welfare as one of his central preoccupations. Alluding to the basic moral tenet that avoidable suffering is wrong, one may educate others about animals' lives in factory farms, but not add the emotional force of moral disapprobation (which, Marks maintains, may provoke resistance or resentment as much as anything).

I think that this is wrong and that it mistakes human moral development. At a certain level we embrace certain traditions, rituals, and moral standards not because we pretend to ultimate moral justification of them, but because the alternative is chaos. We raise our children to believe that certain behaviors are not merely different from what we happen to do--they are wrong. We watch football rather than soccer by virtue of mere geographic contingency; while we may prefer football, we recognize that this is likely due to acculturation and habituation. But when we say that it is not right to abuse animals, we assert that this true everywhere and for everyone.

Secular morality does therefore partake of the emotional conviction of religious faith, but this reflects its fervor, not its groundlessness, and hence is a mark of strength and not weakness. The "God" of secular morality is an impersonal ideal that we collectively construct, not a personal interlocutor that we discover. There are, of course, many versions of this "God" just as there are many versions of the God of the Christian church (and obviously Islam and Judaism). But I think there can therefore be a fundamental secular referent of the term "Godless," which denotes not merely he who lacks faith in the supernatural, but he who is unable or unwilling to shape his behavior according to moral ideals and/or the suffering of others (conduct which we may designate as psychopathic or evil).

Near the beginning of Terence Malick's "The Tree of Life," the narrator comments that there are those who live in a "state of nature" and those who live in a "state of grace." We live in a "state of nature" insofar as we merely gratify our impulses, even if to the detriment of others, or complacently embrace our (evolutionarily) contingent dispositions. And there is a secular version of the "state of grace" whereby we believe ourselves to be free to (collaboratively) fashion a moral ideal.

The "religion" of secular ethics is prey to the same pathologies as conventional religion, i.e. propensities to rigidity, dogma, self-righteousness, hypocrisy, and exclusion. But it is also offers the same potential for affiliation and transcendence (if not, granted, the same degree of narrative interest or life-after-death consolation). I consider myself agnostic because I do not find any of the world's supernatural deities to be existentially compelling, but my attachment to, say, the Golden Rule (among other moral precepts) does have, as Joel Marks rightly argues, a good deal of faith to it. But inasmuch as there can really be no doubt as to whether the Golden Rule exists, this my attitude could be said to involve love more than belief.

Captain America

2011-07-25T17:40:00.000-07:00

"The denial of moral absolutism leads not to relativism, but to nihilism."

Paul Boghossian, "The Maze of Moral Relativism"

I never thought I'd see a decent Captain America film in my lifetime, but this time Marvel has managed brio without ponderousness. When I was into comics in the 1980's, Cap was, it must be said, my favorite. While I enjoyed a number of titles, he eschewed the smart-alecky goofiness of Spider-Man, the self-involvement of the X-Men, and the contrived contortions of the Fantastic Four; sober but spirited, he was neither the hipster Batman nor the staid Superman (that George Washington of superheroes).

In the 1980's, shrouded by the forgetfulness of his reading public, Captain America bore little resemblance to the "old-growth superhero" (in A. O. Scott's memorable phrase) of the 1940's. Making up in steadfastness for what he lacked in flamboyance, he merely did his workaday thing month after obdurate month. In the new movie he reclaims a bit of the Nazi-slugging romance (Red Skull always was the villain par excellence, implacable and inscrutable without being ridiculous, compared to which Darth Vader was a clown).

Needless to say, Cap also embodies American exceptionalism as well as the absolute injunction to act morally. As Boghossian compellingly argues in his piece, if one wishes to avoid believing in nothing, it is logically necessary to believe in something. For the non-psychopath there is no evading moral dialogue (or in the case of comic book films, moral combat).

Eccentrics

2011-07-24T13:59:00.000-07:00

Leon Wieseltier at The New Republic is the rare prophet with subtlety, arguing with great ingenuity but always in opposition, whether to thoughtlessness, smug certitude, or superficial sociability. He is the rare intellectual insider who dares to be deeply and skeptically unfashionable; as such, he steers a tight course between the curmudgeonly, the lugubrious, and the devastating.

In his most recent piece (not available online except to TNR subscribers), he uses the metaphor of birds that sing at night (because they can't get a tune in edgewise in the growing cacophony of the urban day) to lament his growing disconnection with the insulted and humiliated of the world:

"Not long ago I surprised myself with the embarrassing thought that I no longer know any lonely people...But I am cut off from the ones who are cut off, from the disconnected and the un-networked (our technology of communications is supposed to have made such marginalizations obsolete, but I do not believe it: our culture is filling up with evidence of the lonely digital crowd), the ones who lead lives of radical solitariness, of aloneness without appeal, with no bonds to console them and no prospects to divert them, who struggle for stimulation and expression, whose beds are deserts, whose phones almost never ring, who march through their difficulties without any expectation of serendipity or transcendence. Their absence from my experience makes me feel disgracefully narrow."

This is a brave admission, and an acknowledgement by Wieseltier that he is, despite himself, one of the elite. But as one who gets to know many such people (as many physicians and most social workers do), I see a risk in extolling the lives of the disaffected and alienated. There seems to be romanticizing here, as of the overlooked poet scribbling in his garret, the anchorite glorying in his desert cave, or the oppressed dissident in the labor camp. Wieseltier seems to be claiming the inherent dignity of suffering, and while there is that, does this mean we should be any less assiduous in our struggle to alleviate distress? Suffering has the potential to lead to wisdom, but arguably in actuality it most commonly does not.

The prophet (whether secular or religious) is always positioned somewhere between the eccentric and the crank. The eccentric lingers "away from the center" of human experience, but can still engage in dialogue with a significant part of his fellows, whereas the crank has been cut off, as when a man goes into the desert for transcendence but never makes it back to relate the tale.

The Elegaic Mode

2011-07-18T14:05:00.000-07:00

For W. G. Sebald, the modern world, a composite of contemporary detritus and forlorn nature, is a kind of forme fruste of the historical human condition. Sebald was a past-intoxicated writer, and in The Rings of Saturn a ramble through southeastern England yields disquisitions on Joseph Conrad, herring fisheries, imperial decline, and the silkworm industry. The entropy is inescapable. Here are a few choice quotes:

(On fishermen): "I do not believe that these men sit by the sea all day and all night so as not to miss the time when the whiting pass, the flounder rise or the cod come in to the shallower waters, as they claim. They just want to be in a place where they have the world behind them, and before them nothing but emptiness."

(On the writer Michael Hamburger): "Perhaps we all lose our sense of reality to the precise degree to which we are engrossed in our own work, and perhaps that is why we see in the increasing complexity of our mental constructs a means for greater understanding, even while intuitively we know that we shall never be able to fathom the imponderables that govern our course through life."

(On Thomas Abrams, who devoted his life to a minute reconstruction of the Temple of Jerusalem): "In the final analysis, our entire work is based on nothing but ideas, ideas which change over the years and which time and again cause one to tear down what one had thought to be finished, and begin again from scratch."

(On the melancholy of medieval weavers): "It is difficult to imagine the depths of despair into which those can be driven who, even after the end of the working day, are engrossed in their intricate designs and who are pursued, into their dreams, by the feeling that they have got hold of the wrong thread."

(On the destructiveness of civilization): "Like our bodies and like our desires, the machines we have devised are possessed of a heart which is slowly reduced to embers. From the earliest times, human civilization has been no more than a strange luminescence growing more intense by the hour, of which no one can say when it will begin to wane and when it will fade away."

If as many say, we now live in the Anthropocene era, in which the activities of Homo sapiens directly affect planet-wide processes, why can't we regard humanity with kindness, as we might regard any natural force? Just as a levee is meant to withstand the flood, one's mourning, indignation, and even resentment are meant to withstand and, if possible, to divert the human flood from that which one holds dear.

That (Self-) Blaming Feeling

2011-06-28T13:58:00.000-07:00

"Why, worthy thane,
You do unbend your noble strength to think
So brainsickly of things. Go get some water,
And wash this filthy witness from your hand."

Lady Macbeth

In a compelling argument for the congruence of brain and mind, and the ethics that ought to follow therefrom, David Eagleman maintains that blame derives from a misguided and outmoded belief in free will. He claims that blame is basically backward-looking, implying that one could and should have done differently (than one just did). But when we face up to monism and the brain-as-mechanism, we realize that, after the fact, there is nothing to do but acknowledge that given the conditions that prevailed at any past time, one could not in fact have acted differently.

Eagleman argues that shame and blame are not, in fact, very good at modifying behavior, and what we need is a more rational and forward-looking attempt to achieve desired outcomes, in ourselves and others. A la B. F. Skinner, he proposes that we approach brains as we would approach engines or computers that are on the blink. Both sticks and carrots may be necessary to shape desired behaviors, but they should be undertaken in a dispassionate way, free of messy or reckless vindictiveness.

There is nothing inherently objectionable about his advocacy of what he calls "the frontal workout," that is, an updated biofeedback project whereby one might learn (or teach) better control over impulses. But he might have said more about the phenomenology of guilt and blame, which are, after all, very deep aspects of human experience. These are very distinct and familiar subjective phenomena, and arguably they are far from arbitrary or nonsensical.

Blame is the social group's means of imposing its norms, and blame works most effectively when it is internalized as guilt and shame. Blame is a deterrent, plain and simple. And as is so often the case, it works best when it is involuntary (when blame is reflected on too carefully, one arrives at Hamlet). This is not to say that shame and blame are generally good things, merely that they are natural (and many perfectly natural human behaviors are odious). However, even in Eagleman's handyman-of-the-brain world, some impetus and motivation for change must exist, and I don't know whether that motive would come from unless from those primeval emotions of guilt and shame. They merely exist in healthy and in pathological forms. Guilt and shame may seem to be primarily about the past, but really they project forward into the future; like pain, they are the brain's message to itself: That didn't go well, so try something different. Blame and guilt are modes of moral (self-)argument.

And in a follow-up to the recent post about reading, the literati are a bit atwitter about Philip Roth's declaration that he has stopped reading fiction. In a Salon article Laura Miller speculates that inasmuch as fiction provides insight into character and human subjectivity, perhaps some do reach a point at which they have all the insight they need. After all, the novel isn't called the novel for nothing, and some readers do believe there is nothing new under the sun. But then again, one could paraphrase Samuel Johnson and say that "He who is tired of fiction is tired of life."

The Tree of Life

2011-06-26T12:03:00.000-07:00

Solitude from mere outward condition of existence becomes very swiftly a state of soul in which the affectation of irony and skepticism have no place...After three days of waiting for the sight of some human face, Decoud caught himself entertaining a doubt of his own individuality. It had emerged into the world of cloud and water, of natural forces and forms of nature. In our activity alone we find the sustaining illusion of an independent existence as against the whole scheme of things of which we form a helpless part.

Joseph Conrad, Nostromo

Terence Malick's The Tree of Life consistently defies expectations of coherent narrative, instead implanting myriad images implacably in the mind. One could be haunted by this film. As David Thomson wrote in his review in The New Republic: "Less than a framework of story, we have a situation, and this is itself not just fair, but an enlightening novelty. Most of us do not feel that we are living stories (at least not until later); we believe we are getting on with a situation."

As the movie's epigraph from Job suggests, the situation is one of inevitable suffering and loss, albeit experienced in a perpetual haze of existential glory. The tone of the work is continually exalted, which probably accounts for its controversial and varied reception. For those predisposed to its message, irony is silenced; the sacred is always a puzzle to the intelligentsia.

The situation in The Tree of Life, is, most mundanely, that of a family in 1950's Texas, but really Malick is concerned with the situation of human life and its vexed relation to life, broadly considered. Much has been made, both derisively and respectfully, of Malick's depiction of the history of the universe and the pre-human earth (dinosaurs even!), but I'm not sure why. Narratively, this is merely the use of a very wide-angle lens, and a salutary use at that--there is more to heaven and earth than is dreamt of in Manhattan. Indeed, a few aerial shots of early hominids would not have been out of place. Psychologically, the "family romance" may seem endlessly interesting, but neither man nor woman lives by interpersonal relationships alone. There is that which preceded us and that which will outlast us.

In the first few minutes of the film, as we get our first impressionistic views of the O'Brien family, a female voice-over poses the contrast of nature and grace, asserting that the way of nature is domination and self-indulgence, whereas the way of grace is care and endurance. Much of the film unforgettably documents the necessity of nature--deep space, inscrutable water, arboreal visions, scathing light, barren rock, towering glass and steel--but the realm of grace is uniquely human. Consciousness is dualistic not in substance (body and soul, brain and mind) but in moral experience, in what we have no option but to choose.

Only human beings, in all of life that we know of, can fail the test of grace, and we see the risk and stakes of such failure in the boy, Jack, of 1950's Waco and the contemporary man, Jack (a ravaged Sean Penn). Violence and predation antedated humanity by many millions of years, but only with the first glimmer of consciousness did the storyline of Cain and Abel come into the world. We see it in the boy Jack's sullen resentment of his father and his acts of petty boyhood mayhem (breaking windows, mistreating frogs, stealing lingerie). Similarly, only humanity is prey to despair, of which contemporary Jack appears to be a classic example, suffering Kierkegaard's "sickness unto death."

Some reviews I've read seemed to infer that the culminating beach scene was some kind of Rapture-like representation of the end of the world, but to me it seemed a symbolic depiction of redemption, as Jack somehow breaks through his granitic alienation. The idea and the ideal of the sacred presume that amid seemingly endless tawdriness or trauma there are still spaces and times of grace if we can only find them.

Drill Imagination Right Through Necessity

2011-06-25T06:35:00.000-07:00

Play

Nothing's going to become of anyone
except death:
therefore: it's okay
to yearn
too high:
the grave accommodates
swell rambunctiousness &

ruin's not
compromised by magnificence:

that cut-off point
liberates us to the

common disaster: so
pick a perch--
apple branch for example in bloom--
tune up
and

drill imagination right through necessity:
it's all right:
it's been taken care of:

is allowed, considering

A. R. Ammons

Missing

2011-06-19T09:42:00.000-07:00

"How can one transmit to others the infinite Aleph, which my timorous memory can scarcely contain?"

Jorge Luis Borges

Some time ago Linda Holmes at NPR wrote a wonderful piece observing that, by virtue of sheer plenitude of space and time, each of us is destined to miss out on the vast majority of whatever it is we love in life. Far from being a downer, it is comforting and even self-transcending to realize that no matter how assiduous or dynamic one may be, there are just more people to meet, books to read, films to see, or sunsets to witness than any one life can manage. It is a reminder that even if, as the cliche goes, the world is much shrunken owing to the speed of travel and communication, one can divide infinity many times over and still be left with infinity. To live a lifetime is to gaze upon an ocean of experience, yet be allowed to dip one's hand in the water only once.

One consequence of having a large "physical" library (as opposed to having a Kindle sitting unobtrusively on the table) is that the many hundreds of tomes mutely gaze outward, as if in reproach of my all-too-human forgetfulness. My eight-year-old has asked before, "Daddy, why do you have all of these books if you can get them all on the computer?" One reason is that my recall isn't what it once was, and my library is one kind of living personal record. Many volumes I do dip into now and again--a poem here, an essay or short story there--but how many, realistically, will I live to reread altogether?

For some 20 years--roughly, from 15 to 35--I was a prolific reader, of all genres, but particularly fiction. You know: the canon, the great books (and many that were not-so-great). While I still read, of course, typical life circumstances have much reduced the time available for it. Whether by coincidence or not, I find myself less patient with fiction, and more given to non-fiction, than used to be the case, but I continue to fight that. Proust I feel sure I will live to reread, all 3000 pages. But the 1000 pages of Les Miserables? Probably not. Much of Dickens I hope to reread, but probably not Barnaby Rudge. Recently I read Harold Bloom claiming that rereading Samuel Richardson's Clarissa was a great priority. Really? I've never read Richardson even once. Do I need to read him before expending time on rereading Jonathan Swift? And should I do that before, or after, I brush up on American history?

Inasmuch as there is nothing outside of reality, fiction is merely a peculiar branch of non-fiction, reality's myriad conscious self-reflections. Per Stendhal, a novel is a mirror carried along a main road, but it is a puzzling kind of mirror, with surprising concavities and convexities. Fiction seeks reflections that reverberate and recreate reality in microcosm, a la Borges's Aleph. A successful work of art achieves a unity that symbolically reproduces the completeness of reality. Non-fiction is always a magnifying glass, if not a microscope--clarity is purchased at the expense of breadth. Fiction is a necessarily distorting mirror, since any simple mirror or magnifying glass capable of capturing everything we care about would have to be as large as the universe itself.

The stakes are high in the arts--the potential payoff is high, but when fiction seriously fails, it is upsetting, because it is as if reality itself is being mocked or even maimed. Bad non-fiction is like a lie, which is bad enough, but bad fiction is like blasphemy. I forever vacillate between Plato--who saw the arts as begetting deceptive images (among the myriad shadows on the wall of the cave), distractions from the pursuit of truth--and Aristotle, who argued that poetry at its best reveals necessary truths, while history merely documents contingencies. Perhaps it is just a matter of epistemological and existential focus, the iris of the inquisitive mind.

Is Psychiatry Like Acupuncture?

2011-06-15T16:49:00.000-07:00

As I've discussed a few times here, this is the worst of times for antidepressants and other psychiatric medications; considering questionable efficacy and likely side effects, their popular esteem is at a low ebb. This makes them...a great deal like various alternative medicine treatments that remain highly popular and widely used (and paid for) despite the disdain of evidence-based medical critics.

In The Atlantic David H. Freedman discusses the persistent popularity of alternative medicine and its unlikely cohabitation with conventional research even at the Mayo Clinic and other hallowed institutions. He points out that while medicine made its reputation in the first half of the twentieth century with the significant (if not complete) conquest of infectious disease, its efforts to extend its domain to the kinds of chronic diseases that plague us today (diabetes, heart disease, cancer, Alzheimer's disease) have been frankly disappointing. What, exactly, has medicine done for us lately?

Psychotherapy and psychiatric medication have been targets of critical and cultural derision on the part of many for decades, yet millions of patients seem to derive some kind of healing experience from the pill or the couch, as the case (and the personal inclination) may be. The same could be said of the masses flocking to chiropractors, homeopaths, and, yes, acupuncturists in defiance of the conventional medical wisdom. We spend years in medical school learning about physiology, when practically speaking, healing arguably has more to do with constructing a healing ritual than with one's board scores. The "chemical imbalance," absurdly oversimplified though we hold it to be, may be like the acupuncturist's "lines of force," a necessary if fictional semantic scaffold on which to mount a clinical encounter. The shaman lives!

History of a Suicide

2011-06-06T10:34:00.000-07:00

"I perceive I have not really understood any thing, not a single object, and
that no man ever can,
Nature here in sight of the sea taking advantage of me to dart upon me and
sting me,
Because I have dared to open my mouth to sing at all."

Walt Whitman

In puzzling over an unexpected suicide (and how many suicides are not, at some level, surprises?), we often ask empirical questions, as a detective might. How did this come about? Who or what is the primary culprit? But arguably the challenges suicide poses are chiefly existential and interpersonal, not factual. That is, the suicide, in rejecting life itself, dissents from values that we hold very dear.

And the question of "How could we not have known?" is more relational than epistemological. That is, suicide reminds us of the perturbing basic inscrutability of human relationships. If we do not know something so basic as whether someone is suicidal, what do we really know about them? That's why psychotherapeutic relationships can be the most intimate of all--not obviously in a physical sense, but in an existential one. The therapist often hears things that no one else in a person's life hears.

I just finished Jill Bialosky's History of a Suicide, which considers the suicide of her younger sister Kim some twenty years ago at the age of 21. It is a worthwhile and reflective addition to the suicide memoir shelf, but Bialosky is, like many, preoccupied with questions of causation. The problem is that completed suicide is complex and rare (relative to the numbers of the depressed); why would we expect suicide to be any more fathomable or predictable than other atypical behaviors, such as murder or sudden religious conversion? If we had the technology or insight to predict individual suicides, what other behaviors might we be able to foretell?

Bialosky seeks out a suicide specialist who tellingly conducts a "psychological autopsy," as if we can answer the dilemma of suicide using the tools of pathology. Unsurprisingly, a number of potential contributing factors come to light: a family history of mental illness and even suicide, a father who abandoned the family and ignored or rejected Kim, a depressed and withdrawn mother, an abusive boyfriend, and alcohol and drugs. This list is noteworthy for its obviousness and for the fact that every one of these things is objectionable in its own right even apart from any possible relation to suicide. The things we might do to reduce suicide risk--maintain family integrity, shore up communities, limit drug use, and increase awareness and treatment of depression--are things that we ought to be doing anyway. These influences ultimately tell us nothing, because we do not know which is necessary or sufficient.

The other thing that suicide teaches is how little we sometimes know of ourselves. It appears that a certain fraction of suicides, at least the final determination to act, are impulsive. If we could interview completed suicides after the fact, I suspect that a significant number would express surprise, if not dismay, that they actually went through with it.

Who Needs Psychiatrists?

2011-06-05T13:14:00.000-07:00

I have seen a medicine
That's able to breathe life into a stone,
Quicken a rock, and make you dance canary
With spritely fire and motion, whose simple touch
Is powerful to araise King Pippen, nay,
To give great Charlemain a pen in's hand
And write to her a love-line.

All's Well that Ends Well

The criticisms of contemporary psychiatry are coming fast and furious now, and not just from the fringe any more. Cheryl Fuller at Jung at Heart refers to a review by Marcia Angell of three recent anti-psychiatry volumes (of which I have read Daniel Carlat's Unhinged and Robert Whitaker's Anatomy of an Epidemic, but not Irving Kirsch's The Emperor's New Drugs). And while it's not specifically about psychiatry, an American Scholar article by Harriet Washington documents the discouraging corruption of medical research and publishing by so-called Big Pharma.

The mounting charges are of the most serious kind, and warrant a full-on response from the profession (which this blog post does not aspire to be). To very briefly summarize, the basic effectiveness of antidepressant drugs (and to greater or lesser extents, all psychiatric medications) is increasingly dubious as the integrity of research purportedly showing their efficacy is called into question. Critics maintain that for decades (antidepressants came into general use in the 1960's), thousands of psychiatrists (and of course other physicians as well) and millions of patients have prescribed and taken non-therapeutic compounds based on an underestimation of the placebo effect.

As for neurobiology, critics point out, correctly, that there is no evidence for any specific "chemical imbalance" that antidepressants allegedly alleviate. However, this is not the crux of the issue, for other central nervous system agents (e.g. anticonvulsants and anesthetics) have mechanisms of action that remain somewhat mysterious. And depression is in fact correlated with specific neurobiological states, but only because every psychological state--falling in love, undergoing religious conversion--can only be based in the brain. The question is not whether any given psychological phenomenon has a biological correlate (of course it does); the question is whether said phenomenon is best understood and potentially modified in chemical as opposed to other (psychological, interpersonal, social) terms.

It is one thing to claim that antidepressants are overblown and oversold; it is quite another, of course, to claim that they are useless or even pernicious. For instance, Robert Whitaker's arguments can lead only to the conclusion that antidepressant drugs should be expunged from the earth, and that psychiatrists are either unwitting or cynical quacks for prescribing them. And of course, as psychologists and social workers have taken over much of the psychotherapy territory that used to belong to psychiatry, the profession's identity has been ever more given over to psychopharmacology. After all, Freud didn't think psychoanalysts needed to be physicians, and there is no evidence that psychiatrists make better therapists than those with other degrees, so absent real results from biological treatment, why does psychiatry exist, exactly, beyond a function as a research program?

As someone who has, regrettably, long recognized the limitations of existing drugs but who still prescribes them, what do I believe? And can what I believe be remotely legitimate inasmuch as my current livelihood (by no means opulent in doctorate-level terms, but reasonable) depends on these medications having a role? Intellectual honesty demands that if one has a pressing self-interest in believing something, one should subject that belief to fierce and insistent criticism. There is no sin greater than tendentiousness.

This discussion derives from the valorization of the randomized, placebo-controlled trial as the ultimate arbiter of medical outcome, very much at the expense of individual clinical judgment. After all, many hold that clinical judgment is subjective and idiosyncratic, and therefore open to bias and not to be trusted. If all that needs to be known about medications can be inferred from statistical trials, than anyone (such as Whitaker, a journalist) can know more about them than a physician. Indeed, on this view only the non-physician can accurately appraise medical treatments because his view is not warped by self-interest. And yet there is considerable question as to whether patients (or "patients") in rigidly controlled research studies are truly representative of real-world clinical encounters.

What, then, do I believe? I believe, with the Buddhists, that life is suffering (but not only that); the long history of humanity is one of untold miseries of anxiety and depression that were either merely endured (there being no other choice) or compensated for by relationships, religion, art, or alcohol. Like the agonies of even routine childbirth or the ravages of even typical old age, mental disorders have always been part of the human condition; only relatively recently have we tried to modify them. One can make an argument that all of these things should, again, be merely endured, but I don't think history has a rewind button. Yet the expectations regarding mood and anxiety have exceeded all bounds, as has the expectation that one has some right to reach ninety with sound mind and body.

I believe that existing drugs do not counteract specific or discrete physiological processes, but (like psychotherapy) are nonspecific mental balms. SSRI's and benzodiazepines are to mental distress as NSAID's and opiates are to physical distress, that is, they are often disappointing and attended by sometimes dismaying side effects, but millions of patients have found them of some use. I believe that in a modest way they reduce suffering, by no means always or even often, but on average. I believe this on the basis not of research studies, but of my clinical experience and that of many others. And the day I stop believing that is the day I will stop prescribing.

Who Needs Narrative?

2011-06-01T07:34:00.000-07:00

Arguing for the psychological uses of narrative, Bill Benzon at The Valve distinguishes the "autobiographical self" (i.e. identity over time) from the "core self" (i.e. one's integrated psycho-physiological state at any given time). He claims that the "core self," influenced as it may be by intense situational and physical factors (he uses hunger and sexual desire as examples), not to mention its transient nature, threatens to disrupt the autobiographical self. He suggests that narrative (he specifically mentions "play-acting" and "storytelling") usefully provides an overarching frame within which to understand and evaluate our dispositions and behaviors over time.

The account leaves out a lot of course (for instance, it would seem that temperament straddles both kinds of self). And his case seems a bit extreme--as if even a starving man would look back on his life as having been little more than an ultimately unsuccessful quest for food--but there may be something to it. After all, someone in a deep depression may view much of his past "through a glass darkly" in a way that lightens considerably when the episode relents. And obviously the two selves affect each other reciprocally and continuously.

Staying with Benzon's schema, it would seem that psychological distress occurs in two varieties. Unhappiness is a malady of the autobiographical self, a dismayed sense that one's story has somehow gone awry through vicisitudes of sensibility or circumstance. One seeks in a therapist a kind of narrative catalyst that will open up unimagined possibilities, including the often profound possibility of actually being listened to and perhaps even understood. Dysfunction of the core self manifests as symptoms that may actively impede functioning. There is considerable overlap between the two, but arguably we resort to psychotropic medication inasmuch as symptoms appear to be beyond the power of narrative to reframe. But nothing is more frustrating than to try to treat unhappiness with meds or to tackle narrative-resistant symptoms with more narrative. Diagnostic confusions and controversies arise from the difficulty of distinguishing symptoms from unhappiness.

It occurs to me that like certain other phenomena such as religion and even music, narrative broadly considered (that is, interest in all stories whether contained in books, film, gossip, or hearsay) is hard to explain because it is very widespread but not truly universal. Some faculties, such as hunger and thirst, are obviously ubiquitous because their absence is not compatible with life. Others, such as basic senses or sexuality, are not imperative for individual life but are so typical of the species that their absence is uncontroversially deemed pathological.

Inasmuch as existence is necessarily temporal, some interest in narrative is presupposed, even if only speculation as to where the next meal will come from. But sophisticated narrative--that is, at least at the level of communal folk tales--has, like religion, been found to exist in virtually every human society. And yet just as there is a reliable minority of individuals who are irreligious, there are of course people here and there who are relatively free of the narrative bug, who may be more invested in other domains of experience (facts, ideas, bodily experience, etc.). If religion and narrative truly are central to (individual and species) human identity, then how is it that even a (non-pathological) small minority more or less escape their purview? Perhaps diversity itself is such a powerful evolutionary engine that it constantly throws out alternatives to the prevailing cultural trajectory, suggesting of course that those faculties we view as indispensable are actually contingent.

Human Experience

2011-05-30T17:28:00.000-07:00

"(We) occupy landscapes of values--worlds made up not of quantum lattice structures, but of opportunities and obstacles, affordances and hindrances."

Alva Noe

The full 13.7 post is here and worth reading.

I think that this, the sensation of swimming in a sea of significance(s), whether noxious or gratifying, is a major reason I wound up a psychiatrist. It is no wonder that our species yields paranoids and creates deities to worship. We do not generally perceive the universe as what it would be without us--that is, a constellation of infinite facts--but rather as a shifting drama of desire and revulsion, of affirmation and repudiation.

You (Don't) Say It's Your Birthday

2011-05-24T17:52:00.000-07:00

Happy birthday, Bob.

Alex Ross posted some favorite lines.

There is something about Dylan--the musician, the poet, the cryptic cultural figure-- that is gratuitously compelling. If grace were to exist, it would feel something like listening to Dylan, to that "thin wild mercury sound" of 45 years ago.

It seems miraculous that he is still alive, both literally and figuratively.

Favorite line? At random:

"Well, the comic book and me, just us, we caught the bus"

Postscript

2010-11-22T16:35:00.000-08:00

One more thing. I ended a bit abruptly a month ago, yet I recently came across two links that encapsulate the blog's preoccupations so fittingly that I cannot resist tying this last speculative bow.

The Wittgenstein scholar Peter Hacker explains that philosophy, unlike science, does not add to our knowledge of reality; rather, it examines the conceptual schemas through which we consider reality. Formal science is extremely successful in the relatively narrow task of documenting external reality, and it brooks no competitors; but arguably everything we most care about exists outside of science's purview. I particularly liked his comment that science yields an aggregate of facts that can be transmitted from generation to generation as a kind of epistemological bolus, whereas philosophy--like the arts--must be perpetually recreated.

Hacker also assails the prevailing scientistic fetish for neuroscience, arguing that from the point of view of real human priorities, it is the unified human agent that counts, not his or her brain and its myriad parts. "My amygdala made me do it" is not so different from "My soul made me do it." The moral self must take ownership of its concepts and its actions, not hide from them by ascribing them to the brain. Neuroscience may increasingly give us the capability to tinker more viscerally with our own experience, but this is nothing but the means to an ever debatable end. Science is nothing but a method, and one which can never identify the life most worth living. The latter can only be arrived at biographically and culturally, through lived experience, dialogue, and contingency. Everything that is not a fact exists in the vast penumbra of narrative.

Andy Martin looks at the overlap of autism and philosophy, arguing that both phenomena (endeavors? conditions?) involve a basic inability, or perhaps unwillingness, to fathom seemingly transparent communications. He suggests a tension between a philosophy that seeks to eradicate or solve conceptual confusions and one that accepts their inevitability. The latter is what always drew me to philosophy and to literature, which to me constitute the infinite project of outlining and marveling at the fundamental riddles of (inter)subjective experience. Consciousness is interesting not despite, but precisely because, imperfect understanding cannot be avoided. A philosophy or a science that proposes to eliminate conundrums is oppressive and must be resisted; a refusal to fully understand or be understood is a kind of assertion of freedom.

However, philosophy should not be sheer mystification. Language is the most powerful tool ever devised, and as such it can never be totally under our control; to some degree it always has a life of its own. Its spontaneous complexity is luxuriant and life-giving, as I have said, but it is well-known that metaphors can become stifling vines threatening to choke off light and space. Philosophy is fundamentally a linguistic pruning operation, lopping off conceptual excresences that threaten our narrative well-being.

Philosophical, that is, moral and aesthetic truths can never be as unambiguous as scientific ones, but they achieve a certain pragmatic objectivity because, well, human beings are so constituted that we need certain standards that are not lightly or trivially modifiable. Where does psychology fit? Like medicine, psychology derives from science a sense of realistic empirical boundaries of what may be technically achieved, but its aims must arise through personal and cultural narrative philosophy.

And that really is all I have to say for now.

Finis

2010-10-19T17:43:00.000-07:00

"Now my charms are all o'erthrown,
And what strength I have is mine own,
Which is most faint."

Prospero

In the Times Judith Lichtenberg examines altruism, in particular the fact that it seems impossible to isolate pure unselfishness, uncontaminated by all self-interested motives (even if only the often unconscious satisfaction of having done good). But she argues that altruism is no less desirable, individually and socially, for all its imperfections; indeed, a flawed, all-too-human altruism is the best we can hope for in this world, that is, at all.

It seems to me that the wish for unsullied altruism is parallel to the fantasy of an absolute free will, untrammeled by ambivalence, weakness, or material considerations. The totally free and altruistic act would, of course, be the act of God, not of human beings.

That seems like a fine note upon which to end this blog, which has now run for more than two years and 400 posts. A blog has no natural ending apart from the demise or sheer exhaustion of its author. I find that I have said all that I have to say in this format, and nothing would remain here but the recycling of old themes and, of course, gawking at the baubles of the Web as they flash by. I have arrived at that definite point marked not by ambivalence or by frustrated block, but by dispassion--it is time to move on.

If Emerson was right that life consists of what a man (sic) thinks about all day, then this blog has been a reasonable record of the past two years of my life. Many posts have been tossed off, but many have been thoughtful, carefully wrought and even alarmingly personal, especially to any perceptive readers out there. It has been a transitional time, befitting a blog I suppose.

Other projects await. I will need to prepare for a Grand Rounds presentation a few months hence (a late echo of the academic life), and I am getting closer, finally, to starting a private practice, which will take considerable doing. Any additional post here in the future would be a link to a possible different kind of blog, a more professionally discreet and decorous one that might support a practice.

Thanks to readers--be well.

A Score of Scores

2010-10-17T13:09:00.000-07:00

"Thus the whirligig of time brings in his revenges."

Twelfth Night

As mundane commemoration of this blog's 400th post, a few points on the infinite Web:

1. After I read this profile of Arvo Pärt, I went back and listened again to the wonderfully haunting "Tabula Rasa." It's spookily spiritual, scarily good, and perfect for Sunday Halloween this year. Music comes in two basic varieties: that which sets you in motion, and that which makes you more still.

2. The Atlantic on the unnerving unreliability of medical research. I have not been to a primary care physician in a dozen years, and barring any new or unusual symptoms, I hope to extend that streak far into the future (do not try this at home).

3. Melvin Konner on the likely primeval advantages of currently unfashionable distractibility and hyperactivity.

4. I happened to see three great local productions of Shakespeare comedies (Twelfth Night, As You Like It, A Midsummer Night's Dream) over the past two weeks. His comedies, entertaining though they are, are ultimately more disturbing than even the depths of Lear or the black hole of Iago because they show us the arbitrariness of erotic attachment. I was wondering why Macbeth wasn't making an appearance in the season of ghouls and goblins, but Viola, Olivia, Orlando, Rosalind, and Demetrius & Co. are finally more frightening than Lady Macbeth. Never look to Shakespeare for consolation--even the funhouse mirror does not flatter in the end.

5. The comedy club last night was uneven. Beyond a certain point, raunchiness is to true humor as bathos is to pathos; both are varieties of sentimentality, and failures of feeling. But okay for Saturday night.

The Haunted Future

2010-10-16T05:24:00.000-07:00

"An apple serves as well as any skull

To be the book in which to read a round,

And is as excellent, in that it is composed

Of what, like skulls, comes rotting back to ground."

Wallace Stevens, from "Le Monocle de Mon Oncle"

I've never gone in much for ghosts, but I'm reconsidering this after reading Leon Wieseltier's meditation on the presence of the unseen. He is writing about historical and cultural memory, but to be sure, there are myriad ghosts of the non-supernatural variety if we would just open our eyes and see them. Wieseltier writes, "Ghosts are the natural companions of estrangement; the invisible officers of tradition, of all the valuable things that have been declared obsolete but, in some stubborn hearts, are not obsolete. It is one of the fundamental properties of the human that the absent may be more significant than the present."

Humanity has always been locked in life-and-death struggle with its various ghosts. Monotheism sought to displace the ghosts of sky, sea, and mountain in favor of one great ghost-in-chief (of all absences, perhaps the one most present). The Enlightenment and modernity routed the fairies and ghouls of cave, dell, and stream. Perhaps the third great usurpation has been the perennial presentism of ubiquitous 24/7 Internet media, whose blinding glare renders the pre-millenial past ever more faint.

Memory, both personal and global, comprises legions of ghosts, as does the written word. Perhaps even the spoken word commemorates that which has passed--as Nietzsche wrote (and as the ever elegaic Harold Bloom was fond of quoting), "That for which we find words is something already dead in our hearts. There is always a kind of contempt in the act of speaking." In other words, we never quite catch up even to the present moment, much less the future.

I think that I have always had to work hard to free myself of ghosts. I have often felt like Frodo when the Ring was on his finger: reality dimmed and retreated and he found himself in a parallel or superimposed shadow world. At any given moment or situation, it is difficult to remind myself that "this, here is reality," for I know that "this, here" can only be the most miniscule excerpt of Reality, an atom in the universe. The ghosts vastly outnumber the living, beyond measure.

Internet media is interesting inasmuch as it locks us into a perpetual present, yet also displaces us from an actual present. The hordes of Blackberry and Facebook-checkers are not entirely "there," but they also are not haunted in any meaningful way; they are not afflicted by ghosts, rather, they and their living interlocutors are in a kind of Limbo. All virtualities are not created equal, and I prefer mine to have a history.

And then there are other specters, of alternative selves (and the persons-to-ghosts those selves would have encountered or even conceived) that occupy the paths not taken. There are ghosts of the future, those beings we think we or those we love might become. As James Surowiecki writes, procrastination can be a way of fending off or at least questioning such spirits.

Procrastination can be a manifestation of mere bewilderment or self-doubt, in which case it may help to break down a daunting or nebulous project into smaller, more concrete, and more practical stages. But as Surowiecki notes, procrastination may reflect a more basic instability in motivation, as identity is somewhat fluid and we can never be entirely sure that we will want tomorrow what we want today. He also reports--news flash!--that, believe it or not, human beings are ambivalent creatures beset with inner conflict (apparently economists and behavioral psychologists are just finding this out).

Inasmuch as it represents skepticism about distant, abstract goals in favor of more short-term rewards, procrastination may be a malady peculiar to modernity. Indeed there is a double-whammy here since complex societies demand deferred gratification at the same time that pleasurable and instant distractions grow more abundant. But there is a more fundamental existential issue. We often put things off because we are not yet sure of their value, and hope that the passage of time will clarify it, so that we can decide which among the plethora of "ghosts of the future" may become real.

Slacker Humanity

2010-10-13T16:49:00.000-07:00

"I have a kind of alacrity in sinking."

Falstaff

The generally wise Theodore Dalrymple ponders the not-so-heroic motivations of Homo sapiens. His musings imply, to me, a few possibilities:

1. People often make the cardinal mistake of assuming that other people--whether of a different nationality, epoch, or faith--are very much like them. In fact, it pays to approach people as an anthropologist would, assuming nothing.

2. People are motivated by rather short-term factors operating in their local environments, which is why folks are far more worked up about, say, the economy than about such things as climate change or Afghanistan, which at this point represent relatively nebulous and distant threats.

3. Once people reach a certain level of comfort in their lives (and perhaps it isn't a very high level) they are significantly complacent about working harder. That may be why unemployed Americans stand by as undocumented immigrants take low-paying jobs and why the average American is not alarmed about China or India gaining some kind of competitive advantage.

4. As Dostoevsky's Grand Inquisitor claimed, people on average crave comfort and security more than freedom. Or rather, just as the alcoholic, deep down, wants not to stop drinking but to be able to drink without adverse consequences, most people want freedom without responsibility or the possibility of failure.

5. All of this is to say that humans are first and foremost mammals. We are energetic and ambitious except where complacency and the conservation of energy (often wrongly and pejoratively miscast as laziness) prevail, which is frequently.

Real Happiness

2010-10-12T15:35:00.000-07:00

"Hope is itself a species of happiness, and perhaps, the chief happiness which this world affords."

Samuel Johnson

Happiness has been a hot and trendy topic in psychology for a while now. Philosopher David Sosa explores the concept by contrasting it with the experience of mere pleasure; using Robert Nozick's famous "brain in a vat" thought-experiment, he argues that happiness must consist in "human flourishing," which, while somewhat question-begging, does imply that human beings finally crave reality as a field of action, and not merely the kind of virtual subjectivity provided by, say, drugs (or of course the Internet, which is now a more plausible instance of virtuality than Nozick's 1974 chemical one). We stand in deep need of a real external world; the solipsist may think he is happy but he is not.

Sosa's argument suggests that happiness may be more objective than subjective, that is, an individual may not be the best judge of his own happiness. And the degree to which we can control our own happiness is forever in question. According to ancient Stoics and Zen Buddhists, we have the capacity to manage our own consciousness to the point of invulnerability to external accident. But skeptics of many stripes have disagreed, claiming that grave losses or hurts may seriously impair happiness.

Perhaps, to paraphrase Shakespeare's Malvolio, some are born happy, some achieve happiness, and some have happiness thrust upon them; happiness is some kind of interaction of temperament and luck. As today's illustration suggests, I happened to be in Washington, DC over the weekend. Surely George Washington led one of the happiest of lives, and not because he was consciously exultant: a middling Virginia planter and mediocre military man, his character coupled with happenstance propelled him to a truly charmed position in an insurgency apparently destined for greatness.

Happiness is not only not congruent with pleasure--it may be compatible with considerable suffering. Did Abraham Lincoln have a happy life? While he was a jovial sort at times, and an ambitious man who surely knew his own magnitude, he also suffered grim depressions, presided over national mayhem, and died grievously. And yet the scale of his moral achievement, as well as his lasting status as the most beloved of presidents, confers an indisputable happiness upon his life, just as the verdict of history renders Mao Tse-Tung's an unhappy life even if the tyrant died serenely at peace.

Is depression consistent with happiness? I think it depends on severity in a way that is comparable to the experience of pain. Many with chronic, low-grade distress, whether emotional or somatic, may achieve a certain detachment from their affliction that affords scope for happiness. Similarly, episodes of severe melancholy or pain, when transient, may be "happily" endured. But depression is unique among maladies in that a sense of hopelessness is itself a cardinal symptom, making it one of the chief obstacles to happiness.

Yellow Bile

2010-10-10T17:34:00.000-07:00

Guildenstern: The king, sir --

Hamlet: Ay, sir, what of him?

Guildenstern: Is in his retirement marvelous distempered.

Hamlet: With drink, sir?

Guildenstern: No, sir, rather with choler.

After an email I sent about a mutual patient complaining of irritability, her wise therapist commented to me on how many more patients she had seen with anger issues in recent years. She wrote, "My belief is that we are witnessing a 'cultural disorder,' with skewed attachments, a sense of entitlement, a lack of accountability, and a crisis of conscience." I too have been surprised by how many patients present with not only dysphoria, but with barely contained annoyance over the conditions of their lives.

Considering how many patients present with symptomatic behaviors of rage episodes and "going off on people," anger per se is surprisingly uncommon as a cardinal diagnostic symptom in psychiatry. As always, it all depends on context. General irritability may characterize depression, mania, or ADHD. Men in particular seem to react with defensive rage when threatened by anxiety. Borderline, narcissistic, and antisocial personality disorders often involve an inability to modulate indignation and temper.

A Times article discusses the occurrence of bullying at ever early ages (think Kindergarten), attributed speculatively to controlling, snarky parents as well as a general media culture valorizing materialism and mean-spiritedness. After several decades of sociologists decrying the disconnectedness, narcissism and entitlement of up-and-coming generations, are we seeing the fruits in an increasingly thin-skinned populace, in both clinical and political terms? Is resentment mutually amplified by the man on the street, virtual and media alter egos, and the much vilified political establishment? Indignation and claims of victimization are everywhere and are thereby cheapened.

Is It Depression?

2010-10-05T14:34:00.000-07:00

"When I use a word," Humpty Dumpty said in a rather scornful tone, "It means just what I choose it to mean--neither more nor less."

Lewis Carroll

I took the title of this post from a drug ad I saw today, a question that, contrary to its originator's intent, yields no clear answers. What kinds of answers does someone seeing a psychiatrist seek, and will she get them? (For complex and controversial reasons, it is epidemiologically more likely to be a she, although that leaves plenty of he's too).

Someone seeing a doctor for chest pain wants to know two main things: one, is this a potentially mortal threat, and two, what can be done for it? The cardiologist can resort to a number of physical exam findings and (more likely these days) tests to answer these questions. What is at issue is: what underlying biological process does the pain reflect?

The psychiatrist's function is not much like this. If presented with someone with depressive symptoms, it is true that there are occult medical syndromes (such as, say, hypothyroidism, vitamin B-12 deficiency, or pancreatic cancer) that could be responsible, but these etiologies are vastly outnumbered by idiopathic depressions. The patient may want to know: is this caused by a "chemical imbalance," or by relationship problems, or by a history of abuse? One may speculate or construct a narrative around this, but is impossible to know for sure.

So if a psychiatrist is usually unable to identify underlying pathophysiology, what can he/she provide? Context. A large part of psychiatry is the proper use of the sick role--people present with ambiguous symptoms that are often the target of stigma in the community at large, and the question is: am I merely weak, or am I losing my mind, or is something else going on? While the psychiatrist has limited appeal to diagnostic tests, he can call upon wide experience with persons exhibiting similar symptoms (for this reason, it is extraordinarily scary to be a neophyte in psychiatry, because one has neither firm science nor experience as backing, only clinical supervision).

The granting of the sick role and the understanding and compassion involved can be quite powerful. The psychiatrist "mans" the gateway of mental disorder, conveying seemingly contradictory messages: you are merely human and therefore vulnerable like the rest of us, and so not beyond the pale, yet to a greater or a lesser degree you are more impaired than the average person. Beyond this, there is really only management of symptoms, as I have written before, in the way that a pain specialist manages symptoms. This may take the form of dynamic understanding, or cognitive reframing, or medications, but none of these is directly treating a clear-cut disease process.

In other words, when someone presents saying "my chest hurts," the appropriate next questions are, "What is really wrong with me and how can it be fixed?" When someone presents with "I am depressed," she has usually diagnosed herself. There is a sense in which one cannot be mistaken about one's own depression any more than one may be mistaken about being in pain (subjectivity prevails here). The questions that follow are: "How does my experience compare with others you have encountered; is there hope for me; and how can this be managed?"

Identity Crisis

2010-10-05T07:44:00.000-07:00

Christine O'Donnell has a new ad in which she not only distances herself from witchcraft, but also boldly (and baldly) asserts, "I am you." Really? So politicians are now inserting themselves not only into my living room but into my very psyche? Obviously she meant that she is like me or shares my values (which she doesn't), but the difference between simile and metaphor is significant here. I'm spending the morning repairing my boundaries.

Mad Scientists at Work

2010-10-04T14:15:00.000-07:00

"I have neither the scholar's melancholy, which is emulation; nor the musician's, which is fantastical; nor the courtier's, which is proud; nor the soldier's, which is ambitious; nor the lawyer's, which is politic; nor the lady's, which is nice; nor the lover's, which is all these: but it is a melancholy of mine own, compounded of many simples, extracted from many objects, and indeed the sundry contemplation of my travels, in which my often rumination wraps me in a most humorous sadness."

Jacques, As You Like It

Most psychiatrists can't go a week without hearing the "guinea pig" comment from a patient alarmed by the all-too apparent imprecision of the enterprise. Problem is, it would be bad enough if treatment were up in the air; the reality is that diagnosis itself is often in flux. Two links--Mitchell Newmark, M.D. at Shrink Rap and Joe Westermeyer, M.D. in the green journal--illustrate nicely the yawning gulf between theory and practice when it comes to the art of the shrink.

Patients (and insurance companies) often crave DSM-type diagnosis for the sake of clarity, but such categories often do not usefully guide treatment. Both psychotherapeutic and biological interventions, strangely, can be both more general and more idiosyncratic than by-the-book diagnoses would suggest. After all, many of the most basic psychotherapeutic stances--Rogerian acceptance and cognitive reframing just to name two--apply across numerous diagnoses. The same may be true of medications--"antidepressants" are used to treat not only depression, but multiple anxiety disorders as well as eating disorders.

In this sense, two seemingly contradictory propositions may be said to be true: every case of depression is alike, and no two cases of depression are alike. The former may as well be the case when it comes to biological treatment, or rather, it is merely the case that depression exists on a spectrum of severity which dictates the aggressiveness (but not the basic type) of intervention. But it is just as true that when it comes to the fine-tuned approach to the patient (including, but not limited to, formal psychotherapy), myriad developmental and personal variables guide treatment far more than DSM diagnosis. Another way of putting this is that despite decades of attempts to make the DSM more specific, individuals within a category (whether schizophrenia or borderline personality disorder) are still more different than they are similar.

I think of evaluation and treatment as situated among three axes: severity, symptoms, and idiosyncratic history. The most basic question is: how impaired is the individual, and what extremity of intervention is called for? The first issue, whether evaluation or treatment is required at all, has already been answered, by the patient or someone close to him/her, by the time the clinician is on the scene. The second issue is whether biological intervention is likely to be helpful. In select cases, the third issue is whether inpatient or residential treatment is indicated.

Individuals are driven to treatment by symptoms, and once it is decided, if it is decided, that biological intervention is appropriate, it is shaped by symptoms more than by diagnoses. Yes, there are a few major categories helpfully kept in mind--primary psychotic disorder, depression/anxiety, bipolarity, substance abuse, and ADHD (or other cognitive impairments)--but those suffice for general formulation so far as biological treatment is concerned. When it comes to general and psychotherapeutic approaches, the unique idiosyncrasy of the patient is the chief guide of treatment.

As Dr. Newmark points out in his post, psychiatry remains profoundly different from the rest of medicine, where diagnosis is everything, in this respect. If a patient presents with chest pain, it is supremely important to know whether it is due to a heart attack, aortic dissection, bronchitis, pulmonary embolus, gastroesophageal reflux, or costochondritis, because each of these calls for clearly distinct treatments. Psychiatry is not like that. Deciding whether a person's diagnosis is depression, bipolar disorder, or schizophrenia will suggest moderate differences in treatment, but the latter will derive more from specific symptoms and personal background. This goes to show that psychiatry remains far more art (or "art") than science. The research-powers that be have yet to persuade the practitioner otherwise.

Doctor Death

2010-09-27T18:11:00.000-07:00

"Will you tell us when to live, will you tell us when to die?"

Cat Stevens

The execution of Albert G. Brown, Jr. in California has been delayed not only because of legal concerns, but also due to dwindling supplies of sodium thiopental. In my eight years of doing ECT we often had to switch back and forth between methohexital and thiopental (both barbiturates) because for whatever reason national supplies recurrently ran short. Why I wonder?

I remember that the morning of Timothy McVeigh's execution some years ago was an ECT day, and incredibly, the anesthesiologist involved (not one I usually worked with fortunately) commented before the patient was asleep that pre-ECT drugs and lethal injection drugs are similar (big differences: ECT involves supplemental oxygen and therapeutic effect; execution, not so much). When it comes to surgical types, the stereotypes are generally true.

The article mentions, to morbid and comic effect, the assurances of the spokesperson of California's Department of Corrections that adequate thiopental was available "to stop Mr. Brown's heart." Absurdly, the drug's maker then objected that its product was not "indicated for capital punishment."

Capital punishment is ultimate faith in the power of the state, which makes the conservative case for it puzzling. Execution is misguided for the same reason that suicide is misguided--in both cases death's finality overlooks the perennial possibility of human errors of judgment, whether of culpability or of the value of one's own life.

In any case, making execution into a quasi-medical procedure is a mockery. If we will celebrate death and its deterrent effect, let us haul out the gallows and the guillotine.

Becoming Who You Are

2010-09-27T17:07:00.000-07:00

Sean Wilentz's Bob Dylan in America (excerpt here from The Daily Beast) is a worthy review of that force of nature, offering not a comprehensive examination (which will some day run to many volumes), but a series of deep core samples, as it were, taken from representative phases of Dylan's tortuous and protean career.

Dylan's story is a half-century version of Seinfeld's "show about nothing," that is, he is the trickster irrationalist, the artiste supreme, resisting every categorization. He is about nothing but sheer exuberant creativity, following his own quiddity, throwing off songs as a fire throws off sparks. For him there is only history, human nature, and the music driving the flower through the green fuse. He speaks endlessly but does not answer questions (as such, he is a kind of ultimate counter-example to psychiatry, or perhaps rather a competitor, the great blank screen and arch-therapist).

In parallel, D. G. Myers at A Commonplace Blog neatly identifies the dilemmas of religious toleration vs. tolerance. A deeply religious man to judge from his writing, he points out that all theological justification is logically circular, and there is no arguing first principles; in a process that apparently remains mysterious, one finds oneself either inside or outside of a belief system. So religious toleration is the recognition that one has nothing to fear from other faiths outside of coercion and violence.

What do Dylan and religion have in common? For me, it is the realization that there is finally nothing outside of nature, attachment, and seduction. I mean the latter not in any manipulative sense, but in the sense that not only art, but also persuasion and reason, are attempts to beckon others hither, to say, "Look at this wondrous state of being, if only it could be realized."

Why This Psychiatrist Isn't Practicing Psychotherapy

2010-09-27T14:07:00.000-07:00

In expectation of their forthcoming book, the Shrink Rap folks did a post soliciting inquiries about psychiatry. Predictably, among them was: why aren't more psychiatrists doing psychotherapy? There are a number of ways to answer this, the simplest and least sophisticated being: shrinks are increasingly co-opted by Big Pharma and choose big bucks over introspection and integrity. That happens, of course, but it isn't the whole story.

Another way of looking at it is just the division of labor. People tend to get better at what they spend a lot of time doing. In recent decades huge numbers of psychologists and social workers entered the therapy arena, and not only do they often do therapy as well as a psychiatrist could--often they do it better. Why don't internists offer physical therapy, or detailed nutritional counseling? Because there are specialists who offer those services. Yes, they do offer them somewhat cheaper than an internist could or would offer them, but the more important point is that those specialists get really good at what they do.

To assume that psychiatry without formal psychotherapy (of the explicitly defined, 50-minute variety) is nothing more than pill-pushing is a warped and shrunken view of the medical role. The medical dimension of psychiatric practice has its own healing frame and ritual, the management of which calls for nuanced understanding of human nature and diagnosis; that is, psychiatry should offer a unique professionalism. Psychiatry without psychotherapy should not be confined to the peddling of antidepressants any more than internal medicine without physical therapy or nutritional counseling should be defined by the peddling of muscle relaxants or oral hypoglycemics.

As Freud himself believed, an M.D. after one's name does not endow one with unique therapy skills. As a psychologist reminded me years ago, people tend to do what they are trained to do. And as a commenter responded to a previous post on this topic (I can't seem to find it, so I paraphrase), people tend to practice what they believe. That is somewhat limiting (there are a lot of things I believe in more than in psychiatry, but it is necessary to pay the bills), but more or less true. I practiced ECT for years, but I don't "believe in" ECT more than in therapy. There is also, crucially, the matter of personal fit.

There are a lot of good therapists out there, and there are a lot of primary care physicians able to offer an SSRI (for better or worse) for transient or mild conditions. But people seem to have a hard time finding intelligent psychiatrists to offer, if nothing else, prognosis and understanding if typical treatments don't seem to work. One can have and apply a knowledge of the history, sociology, and philosophy of mental disorder without feeling the need to provide formal psychotherapy. I have done the latter in the past, and perhaps I will do it again, but for the time being it is more interesting in the abstract than in actuality.

The Solitary

2010-09-22T14:34:00.000-07:00

"In a soulmate we find not company but completed solitude."

Robert Brault

Briefly, The Atlantic features a story on Donald Triplett, the now 77-year-old who was the original child diagnosed with autism by Leo Kanner. After him, I suppose, le deluge.

One can only marvel at the complexities of this diagnosis, which rival those of schizophrenia. In both cases, is this a diagnosis unique to modern times? In contrast to mood disorders, which have demonstrably always been with us, it is difficult to find clear traces of schizophrenics and autistics in the historical record. Did they merely elude the spotlight of history, ekeing out obscure lives in remote farms or urban hovels? Or is some relatively recent pathogen, toxin, or environmental poison at work?

Does autism represent merely aberrant wiring, the vulnerability of a vastly complex process to contingent errors? On the face of it, autism (like schizophrenia) would seem likely to have caused a major fitness disadvantage to our ancestors (Donald in the article lacks not only offspring, but any history of girlfriends). Or does autism merely represent the severe form of gene associations that in milder forms may have generated unusual social respect in evolutionary times past? And as with ADHD, autism has no place to hide in hyper-social, hyper-competitive societies. Anxious suburban settings strive to emulate the more relaxed small-town acceptance and support enjoyed by Donald Triplett. One could also ask, inasmuch as he does not appear to be unhappy, whether he is "disordered" at all.

America's Most Wanted (Doctors)

2010-09-20T17:53:00.000-07:00

The dogs may bark, but the caravan moves on. Just when I had carried my graduate school application to the mailbox (do they still accept paper?)--I heard the market for Wallace Stevens studies is strong--I see that, according to an update in Psychiatric Times, I may not want to give up my day job quite yet.

It is striking that as many critics deride the profession and its tools, its real-world prospects grow apace. Indeed, the treatment of children, now most controversial, is precisely where the best jobs are. Why I wonder? Pharmaceutical behemoths stoking demand? Post-imperial, recessionary American malaise? Perhaps it is also related to the increasing pressure on primary care doctors, who just can't handle the huddled masses of the unhappy.

Murray Bail's The Pages

2010-09-19T06:03:00.000-07:00

In Murray Bail's The Pages (NYT review here), two women, one a philosopher and the other a psychoanalyst, drive into the Australian hinterland so that the former may appraise the unknown work of a reclusive self-styled philosopher who has died, leaving his work in disarray in the austere corrugated steel shed where he labored for years.

So far the story itself sounds austere, but Bail's short novel is told briefly and impressionistically. Within the framework of the mystery of Wesley Antill, of his life and his life's work, philosophy and psychology as competing ways of being and knowing are set in relief.

That Bail, previously unknown to me but clearly an assured and sophisticated writer, trots out certain well-worn stereotypes makes me wonder if he didn't do so knowingly, as if defying the stigma of stereotyping or implying that there is more truth in such than we would care to admit. For we meet the flaky psychoanalyst, who has affairs with married men (and at least once in the past, with a client) and who manages to come across as both curious and self-absorbed. Her ambivalent friend is the detached, vaguely awkward, Aspergers-ish philosopher. Both of these are juxtaposed with the tough, taciturn ways of the sheep farmers (Antill's brother and sister) whom they meet on their errand.

Of course, philosophy and psychology do not exist in simple contrast or parallel. Philosophy is seen to have crucial emotional and biographical functions, whereas psychology makes truth claims, all too often unexamined. But Bail is obviously not interested here in academic arguments, but in philosophy and psychology as differing ways of being in the world, which Bail strikingly links to the physical environment:

Hot barren countries--alive with natural hazards--discourage the formation of long sentences, and encourage instead the laconic manner. The heat and the distances between objects seem to drain the will to add words to what is already there. What exactly can be added? "Seeds falling on barren ground"--where do you think that well-polished saying came from?

It is the green smaller countries in the northern parts of the world, cold, dark complex places, local places, with settled populations, where thoughts and sentences (where the printing press was invented!) hae the hidden urge to continue, to make an addition, a correction, to take an active part in the layering. And not only producing a fertile ground for philosophical thought; it was of course an hysterical landlocked country, of just that description, where psychoanalysis itself was born and spread.

It would appear that a cold climate assists in the process. The cold sharp air and the path alongside the rushing river.

In Bail's telling, here and elsewhere, philosophy (even if it is thoroughly naturalistic) has an otherworldly aspect; that is, it can only deal with deeply human problems, yet it seeks to distance itself from its human roots, becoming suspicious of language itself and attempting to break into some situation of truth above or beyond. It thrives in barren (mental and physical) landscapes, whether everything extraneous is put aside. It is unclear whether the enterprise is heroic or pathological. Elsewhere he writes:

"Too much light is fatal for philosophical thought." But some light is necessary.

That is, philosophy is about clarity, but total illumination lays bare the questionable motives of philosophy itself. Philosophy can only seek its own justification as a cat chases its tail. Yet one comes away from the book with the impression that psychoanalysis, while stemming from an honorable impulse to know oneself, is forever losing its way in acts of self-indulgent navel-gazing in cluttered, verbose interactions. Like I said, stereotypes--there it is, that idea again.

This is an intriguing fly-by view of philosophy--see its towering peaks and desert expanses--and psychology--see the buildings crowded into the hillsides, with people busily moving to and fro. Overarching it all is a book like this, the work of the imagination.

Is Science Interesting?

2010-09-17T09:21:00.000-07:00

(The above purports to be a Chinese periodic table; if the characters instead express sentiments hilarious or profane, the more fool me).

Over at 13.7 Ursula Goodenough eloquently makes the case for scientific understanding as a civic and spiritual duty--it is not enough that we admire or respect nature, as individuals we must know how she ticks, at least in basic terms. She recognizes that such knowledge not only doesn't always come naturally or easily--often it is actively resisted. And yet she is not primarily interested in science as a means to technology.

It seems to me that curiosity is to science what speech is to the written word. Curiosity is spontaneous and natural, whereas science is part of culture and must be taught to successive generations. And while humans are inherently inquisitive about the physical world, we tend to be most curious about those environmental aspects that affect us most directly, and even so, our interest in social matters of love, violence, power, and gossip is often stronger still.

Is science necessary, any more than the invention of writing was necessary, or are both these merely contingent? Verbally and scientifically literate cultures are not superior to oral and pre-scientific ones, or if we consider them so, it is only because that is the water that we swim in. The most straightforward importance of science is its enabling us to manipulate the physical environment; when we wring our hands about the state of math and science education in this country, this is no high-minded spiritual concern, but rather worry that other nations may develop competitive technologies ahead of us.

I think that beyond the salience of science as means to other ends, it offers two other enticements, one spiritual and the other, for lack of a better term, I would call the human pleasure of puzzle-solving. These sometimes contrasting satisfactions shed light on different cognitive styles.

Science performs certain spiritual functions in relation to the physical world, functions pertaining to origins, essences, regularity, and plenitude. Science teaches us, in a manner dependent on logic and replicated experiment and not dogma, that there is far more to reality than what our immediate senses may perceive, from the microscopic to the cosmic and to the extent and variety of the living world. Science reassures insofar as it shows that reality obeys laws rather than whimsy, endowing the universe with a sublimity beyond that achieved by art or religion. However, beyond a certain point, details do not matter so much; I can appreciate the grand implications of evolution without a thorough acquaintance with the development of snails over two billion years.

The spiritual offerings of science go only so far. Over the years I have often had an intense interest in science, but I never felt a temptation to become a scientist. I majored in chemical engineering and then chemistry before realizing that I was not enough of a puzzle-solver to do science. I found scientific research to be soul-crushingly dull.

Many people (fortunately) take delight in how things work, either mechanically or verbally. They get a kick out of Rubik's cubes, crossword puzzles, or detective stories. My mind never really worked that way--I am naturally drawn to semantic, verbal, emotional and narrative insights. Neither mindset is superior, and I'm sure it's no evolutionary accident that human nature encompasses these two ends of a spectrum.

To be sure, I "got" science well enough to get into and through medical school without a problem, and it is wondrous that a biological system generates the insights I'm interested in, but the existential condition of suffering is what engaged me in the first place; the mere details of neuroscience are not, finally, compelling. That is, neuroscience does provide self-knowledge, but it is not the primary or even the best source, and it says nothing about how one should live.

And yet one might object: isn't psychiatry or psychotherapy like puzzle-solving? Not really. Yes, it is about pattern recognition, but it is not about arriving at a final aha! moment at which all the ambiguities drop away and nature stands revealed. Psychological treatment is an amalgam of personal history, emotional hermeneutics, and biotechnology in the service of existential goals and values.

Goodenough makes excellent points in her piece, but I think she protests too much. As a scientist and a puzzle-solver, she is baffled that many are not similarly wired. She ascribes it to some degree to fears of reductionism, but I think this applies only to a few scientific issues, such as evolution or neuroscience inasmuch as many see them as opposed to God or the soul.

Otherwise science is a specialized and contingent preoccupation. I am glad that I understand that plants grow not because spirits in the ground are telling them to, but because they convert solar energy into carbohydrates via photosynthesis in their leaves. However, the precise chemical equations involved, unless or until they are practically imperative for me to know, I am content to leave to the scientists.

The Dragon's Hoard

2010-09-15T15:34:00.000-07:00

"Man is hungry for beauty. There is a void."

Oscar Wilde (via review by Arthur Krystal)

I always thought of dragons, the greatest and darkest creatures of Faerie, chiefly as collectors and connoisseurs, not primarily as plunderers or marauders. Their treasures would be rich, strange, and obscure, gained as much by study and ingenuity as by brute force or fire. The trove under the mountain promised a hidden plenitude.

As I think more about Paul Bloom's How Pleasure Works, and his theory of the "life force" embodied in art works and artifacts, it occurs to me that this life force really consists of attachment, to a transcendent Other that is an artist or other cathected individual. The memento is a repository of attachment. If money is about power and freedom, collected items are about connection and the gravity of history.

In Plato's "Symposium" Socrates presents a theory of erotic love as a deficit state, as the craving of an inherently incomplete entity. Aristotle wrote that the solitary man is either a beast or a god (and I don't think he saw men as gods). No matter how we attempt to defend against it, need is the default state of humanity. This need is best satisfied by relationships, but even those with abundant relationships maintain a system of stored attachments in the form of memorabilia, whether in the form of photographs, letters, books, or other valued items.

Having a romantic connotation of the dragon's hoard from childhood, I found it jarring for a while to hear of hoarding as a hallmark of pathology. How indeed does one shape and prune one's network of keepsakes? This is a deeply personal art. Just as, per Samuel Johnson, one should keep one's friendships in constant repair, so should one maintain one's personal record of attachments.

This art is distinguished by discrimination. Just as we are dismayed by those who would cast away every book, photograph, and card, we are appalled by those who cast away nothing. Just as he who loves everyone arguably loves no one (in particular), so he who keeps everything has become blind to relative value. In the case of hoarding the "life force" has become clotted and stagnant; a natural need has defeated its own purpose. If Thoreau was right that one is wealthy in proportion to what one can do without, it is also the case that human beings are those animals in need of apparent superfluity.

Entitlements High and Low

2010-09-15T09:11:00.000-07:00

James Ledbetter at Slate describes the explosion of Social Security Disability Insurance coverage in recent decades, to the current rate of 4% of the potentially working population, as high as 6% in some states. The two most common kind of conditions covered? Mental disorders and musculoskeletal injuries (think lower back pain), both of which are notoriously elastic. Both are often quite real and severe, but surely these soaring disability rates are driven by non-clinical factors as well.

I work at one clinic at which virtually all the patients (or "consumers" as they are designated in the community mental health setting) either have disability status or are assiduously seeking it. They openly compare notes on how best to get a "crazy check" and to retain it long-term (patients often resist reduction or removal of medications in the belief that it may make them appear less disabled). Before they learn the system they are surprised to learn that I am not directly involved in the process--Social Security has its own protocol for determining disability. The bar is set apparently high--people are often turned down multiple times over a period of years, but repeated appeals especially with legal support usually seem to succeed, and once attained, disability is rarely lost, at least in the population I see.

Obviously many warrant disability support whatever the circumstances. But even among the questionable ones it is no simple matter of conscious malingering. Between $500 and $1000 per month isn't much, but it compares well with full-time minimum-wage work, which is the best that many disability candidates could hope for. And as Ledbetter mentions in his piece, disability rates may reflect long-term weakness in the job market that could be worse than feared. If someone with any mental symptoms whatsoever is chronically unable to find a job, his/her natural inference may come to be that s/he is disabled by those symptoms. Certainly I have seen this deduction at work (so to speak) in many young, quite able-bodied men in rural areas who have lost once abundant construction jobs. I was pleased to see that Ledbetter also produced the argument (as I did in a post last week) that increasingly technical jobs may be out of reach of a greater fraction of the labor pool.

Meanwhile, at the other end of the socioeconomic spectrum, NPR's health blog, citing a JAMA study, looks at reasons why doctors accept pharmaceutical company perks despite well-known concerns about conflicts of interest. The most common reason appears to be that they believe that they deserve them. This sounds familiar from my years of trying educate residents and medical students about the ethical issues involved. The latter just could not compete in general with their conviction that as they were working hard and--at that point in their careers anyway--not mind-bogglingly well-compensated, they were in fact entitled to a free lunch. One man's entitlement is another man's just deserts (or just desserts as the case may be).

The suppression of freeloading is the ultimate evolutionary game of whack-a-mole.

Little Thoughts

2010-09-13T15:54:00.001-07:00

I am steering clear of Big Thoughts today; sometimes one just has to write something, anything.

1. Whenever I despair of psychiatry's approximations, I am consoled by economics. Am I the only person who wearies of the endless liberal/conservative tug-of-war on taxes? Really, wouldn't one think that in 2010 it should be possible to empirically determine the optimal tax rate in terms of effect on economic stability and growth? No? And people are surprised we haven't figured out depression?

2. It is official, according to Thomas Friedman and David Brooks: the United States is in a national funk, 300 million slackers with respect to the values that made this country great. Is this surprising? Having achieved the greatest prosperity in the history of the world, and lacking a coherent antagonist (Islamic terrorism is more akin to organized crime than to an Evil Empire), complacency sets in. It is human nature. Is it necessary that not only the 20th, but also the 21st, be American centuries? When can we mutate into a more temperate version of Canada?

3. Paul Bloom's How Pleasure Works (Bob's review here) is an entertaining if unchallenging stroll through his pet theory of "essentialism," the human tendency to believe in and attach to unique and individual identities as opposed to interchangeable sets of properties. I particularly enjoy his discussions of objects such as artworks or even random possessions of celebrities that retain the transferrable "life force" of their originators. The collector (and bibiophile) in me loves this: one accumulates loved objects as a reservoir of life force, a tide that in the case of hoarders gets out of hand.

4. Check out Douglas Coupland's amusing "Dictionary of the Near Future"--I particularly like his "pseudoalienation" (technology as an intensification of the human, alas) and two varieties of melancholy.

Conundrums and Credulity

2010-09-12T04:33:00.000-07:00

A couple of recent links usefully examine the empirical and moral implications of religious belief. Tim Crane considers the ambiguous relation of faith and evidence, pointing out that while a demanding need for evidence for God is seen to reflect a fragile faith, it is nonetheless the case that religion collapses without a crucial intersection between the supernatural and the historical record.

John Cottingham, reviewing books by Mark Johnston and Andre Comte-Sponville (unread by me), suggests the paradoxical moral effects of specific belief. His review reminds us that belief in a personal God, with its implied promises of salvation and heavenly reward, cannot escape entirely the taint of idolatry and self-interest. The highest, most heroic spirituality would be that which conducts itself as if God existed while relinquishing any actual belief that this is the case. That is, the truest Christian, even if it could somehow (impossibly) be conclusively demonstrated that Jesus Christ was merely a man, would go on just as before.

However, Cottingham argues, in a way that is probably familiar to readers of this blog, that without the existential anchor of actual theistic belief, religion loses all specific content and disintegrates into well-meaning but empty notions of the life force. And worse, he claims that the project of a fully secular ethics is ultimately doomed, that without the foundation of communal faith underlying Western civilization, the elaborate complexities of Locke, Kant, etc. have no binding force.

This introduces a paradox of morality: so long as it is buttressed by a personal God (who by implication may dole out rewards and punishments), it is primitive and tribal in nature, but if God is jettisoned, morality becomes metaphysically optional. Cottingham clearly prefers the former as the lesser of two evils. Of those who, like myself, are non-believers yet do not routinely indulge our worst impulses, he would presumably say that we are either merely timid or are ungratefully coasting on a sense of decorum stemming ultimately from the Western faith we profess to be unmoved by.

I guess I see secular morality as a historically novel trend, as unprecedented in our ancient evolutionary history as, say, scrupulous regard for the welfare of animals or acceptance of antipodal human beings as something other than targets for conquest. I think that the emotional roots of religion are biologically deep, but that they can find other soil than historical theism. After all, the historical specificity of faith accentuates the paradox of religious tolerance: if a Christian truly believed that a Muslim's tradition were as valid as his own, he would have no compelling reason to remain a Christian. Instead, he consents to respect the Muslim point of view, but for reasons of social concord that lie outside of faith itself; for monotheistic gods are inherently jealous.

But to return to Crane's point about history and faith, it is important to recall that belief cannot avoid being mediated through and through, as the crucial roles of Scripture and the Koran reveal. When I say that I do not believe in Allah or the Christian God, I am really saying that I do not believe that the assembled writings of various Middle Easterners of 1300 or 1800 years ago reveal anything more than compendia of hearsay. It is not God that I disbelieve in; it is a specific historical product of deeply fallible humanity that I disbelieve in. Similarly, those who profess to believe actually subscribe to a particular and all-too-human historical tradition, in the absence of which religion sublimates into a vapor of vague feeling.

It could also be said that I (presumptively perhaps) await the one and true religion, which will come after all of these false starts. I propose a return to the Egyptians, those worshippers of cats and of the sun.

The Analogy with Education

2010-09-09T05:23:00.000-07:00

Briefly and speculatively this morning, at a friend's behest I've been reading Robert Whitaker's Anatomy of an Epidemic, another entry in the thriving anti-psychiatry industry. I am still early in the book, but so far it is, for its genre, a sober attempt to answer the question of why, after decades of intensive research, the problem of mental illness and its attendant disability appear to be, if anything, worse than ever. A hypothetical answer came to me when I read Robert J. Samuelson's suggestion about educational reform in Newsweek.

Samuelson observes that the United States has been in educational "crisis" for decades now, yet despite the application of massive resources and large numbers of teachers (and immeasurable pedagogical ingenuity), average academic performance has not significantly budged. He makes the not very politically correct claim that the problem is no longer the educational system, it is the students, or at least the kinds of students that the culture at large now produces. He adduces two factors: the increasingly anti-intellectual and autonomous culture of adolescence, and the huge increase in educational access in an increasingly technological and sophisticated society. In a nutshell, the educational system increasingly aspires to wring blood from a stone.

Human beings naturally vary in cognitive skills, concentration, etc. and for most of human history only a minority of the population endured extended formal schooling. The past generation or so has been the first experiment in population-wide education, and it could be that the system is coming up against natural human variability. In the past those who, whether due to lack of opportunity or aptitude, could not obtain extensive education were able to find niches in agricultural or other basic functions that are now increasingly occupied by machines. In an economy increasingly requiring advanced and specialized skills, niches are more competitive and harder to come by. Thus the uneducated are, relatively speaking, more disabled than in times past.

It could be that mental disorders, except perhaps for the most severe forms (the exact boundaries of which are still not determined), are not so much discrete entities as they are one end of the bell curve in terms of parameters such as mood, anxiety, attention, and reality testing. They may be analogous to learning disabilities inasmuch as deficits in stress tolerance, mood stability, and sustained attention increasingly place persons at greater disadvantage. Contemporary society is not so much provoking these problems as it is making them more apparent, that is, revealing natural human variability in the same way that, say, a basketball camp highlights differences in jumping ability. Because these capacities are complex and developmental, they are not easily modified.

Just as in centuries past, the academically challenged found niches, so those with anxiety and mood disorders may have been able to gravitate to settings that accomodated their symptoms. They found rural occupations permitting distance from people; they found solace in church; they were able to obtain support from family. But in our more mobile and dispersed society, the only jobs available are often intensely stressful, requiring constant contact with people even if only on a telemarketer's line. Individuals who used to rely on family increasingly have to resort to official disability status. It is not the case that psychological disability is new or unprecedented--it is just that there is nowhere for it to hide.

ADHD is obviously the place at which educational and psychiatric challenges intersect, and to my mind it is the perfect example of a hypercompetitive, ambitious post-industrial society illuminating natural and evolutionary variation in a human cognitive capacity, in this case attention and impulse control. The fact that distractibility, like the ability to metabolize (then scarce) calories parsimoniously, was adaptive for much of human evolution, does not unfortunately mean that it is adaptive now. The effort to suppress obesity, like much of psychiatry, may be an instance of cultural evolution, one that appears to have a lot of bumps in the road.

The Perfect Game

2010-09-06T04:02:00.000-07:00

For the holiday, just a nod to David B. Hart's passionate paean to baseball, which he, tongue only obliquely in cheek, proposes as the most uniquely American contribution to culture, one that differs in kind and essence from those more cramped sports lumped together as "the oblong game:"

All of this, it seems to me, points beyond the game's physical dimensions and toward its immense spiritual horizons. When I consider baseball sub specie aeternatis, I find it impossible not to conclude that its metaphysical structure is thoroughly idealist. After all, the game is so utterly saturated by infinity. All its configurations and movements aspire to the timeless and the boundless. The oblong game is pitilessly finite: Wholly concerned as it is with conquest and shifting lines of force, it is exactly and inviolably demarcated, both spatially and temporally; having no inner unfolding narrative of its own, it does not end, but is merely curtailed, externally, by a clock (even overtime is composed only of strictly apportioned, discrete units of time).

__________________

No other game, moreover, is so mercilessly difficult to play well or affords such a scope for inevitable failure. We all know that a hitter who succeeds in only one-third of his at-bats is considered remarkable, and one who succeeds only fractionally more often is considered a prodigy of nature. Now here, certainly, is a portrait of the hapless human spirit in all its melancholy grandeur, and of the human will in all its hopeless but incessant aspiration: fleeting glory as the rarely ripening fruit of overwhelming and chronic defeat. It is this pervasive sadness that makes baseball's moments of bliss so piercing; this encircling gloom that sheds such iridescent beauty on those impossible triumphs over devastating odds so amazing when accomplished by one of the game's gods (Mays running down that ridiculously long fly at the Polo Grounds in the 1954 World Series, Ted Williams going deep in his very last appearance at the plate); and so hearbreakingly poignant when accomplished by a journeyman whose entire playing career will be marked by only onen such instant of transcendence (Ron Swoboda's diving catch off Brooks Robinson's bat in the 1969 series).

___________________

I am not nearly as certain, however, that baseball can be said to have any discernible religious meaning. Or, rather, I am not sure whether it reflects exclusively one kind of creed (it is certainly religious, through and through). Its metaphysics is equally compatible and equally incompatible with the sensibilities of any number of faiths, and of any number of schools within individual faiths; but, if it has anything resembling a theology, it is of the mystical, rather than the dogmatic, kind, and so its doctrinal content is nebulous. At its lowest, most cultic level, baseball is hospitable to such a variety of little superstitions and local pieties that it almost qualifies as a kind of primitive animism or paganism. At its highest, more speculative level, it tends toward the monist, as a consistent idealism must.

Science Run Amok

2010-09-04T13:38:00.000-07:00

Every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good; and for this reason the good has rightly been declared to be that at which all things aim.

Aristotle (trans. W. D. Ross)

Over at Edge, Sam Harris writes on science as it may apply to morality. He raises many compelling issues, but his piece exemplifies the grievous attempt to extend the relentless rigor of science beyond its rightful purview. If nothing else, the article is worth reading for its sheer effrontery (leave aside the moral debates of three thousand years, it's really rather simple!).

Harris argues that the force of science may be brought to bear on the problem of morality in three respects, not only anthropologically (documentation of actual ethical practices), but also as regards the ends of morality (which he stipulates as the well-being of conscious creatures), and surprisingly the art of persuasion, that is, bringing the benighted into the orbit of the empirically right-thinking.

His method is to claim that since the methods of science (i.e. evidence, consistency, parsimony) depend on consensus, and morality depends on consensus, then they are parallel endeavors; that is, normative moral phenomena--the ways one should live--are objectively true or false in the fashion that physical states of affairs are true or false. In other words, one may dissent from scientific methods (appealing, presumably, to revelation or intuition) just as one may opt out of moral claims, but to do so, Harris implies, is to place oneself beyond the pale. He also draws an analogy with economics, suggesting that just as goods and services may (theoretically) be generated and distributed in an objectively optimal manner, so is there a neutral calculus of human well-being.

The problem is that one may recognize many modes of human well-being without falling into the mire of moral relativism. To be sure, we are not entirely adrift in ambiguity. It is uncontroversial, for instance, to suggest that the citizens of Switzerland are better off in absolute terms than those of North Korea, just as it is safe to say that Bach is superior to Kate Perry. However, these are extremes, and most moral distinctions are more subtle. Are Americans better or worse off on average than Germans? Is Bach superior to Schubert?

The real problem for Harris appears to be what to do with the outliers, that is, those unreconstructed folks who fall in with creationism, or those societies that do things like execute adulterers. But the problem is that those with whom we disagree do not generally object to human well-being; they merely assess it differently. Those who oppose abortion or even stem-cell research believe that a society in which post-conception Homo sapiens are not disposed of is, on the whole, a desirable one. Muslim societies that discriminate against women or execute adulterers believe that they do so for the average benefit of all. Even Hitler believed that he was adding to the sum total of moral goodness (of the human beings who mattered to him). Can the methods of science, as opposed to moral consensus, really prove otherwise?

If so, there would presumably be some foolproof method, as yet undiscovered, of ascertaining comparative well-being. Are Californians better off than New Yorkers? How about men and women? Doctors and lawyers? The very notion is absurd.

Unsurprisingly, given the ambit of this blog, the matter may be best approached through the lens of psychopathology. In the various realms of fact, of morality, and of aesthetics, there are those with whom we merely disagree and those who are indeed beyond the pale. For instance, the evidence supporting the human contributions to global warming is strong, such that those to disbelieve are suspect and perhaps perverse, but nothing more. However, those who hold that the moon landing was faked or that Barack Obama was born in Kenya are, properly speaking, delusional in the sense of the cultural fringe.

Similarly, Auschwitz and North Korea are examples of psychopathy and megalomania, respectively, both of which may be held to be forms of moral delusion. In contrast, those who object to abortion or secularism are those with alternative moral views. Except in jest, there is no such thing as aesthetic delusion, although it seems to be ubiquitous.

The problem with applying the authority of science to moral and aesthetic realms is twofold. First, the external world exists independently of us, and is has certain characteristics and laws that we come to understand more or less accurately. Science is supreme here--no other technique for fathoming external reality comes close. However, ethics and art are not external to us--they are generated by us, and are found after the fact to be more or less admired or salutary. In science consensus as to method is the means to an end, but in matters of morality and art it is consensus through and through.

The second problem is that science leads inexorably to technology; understanding here implies the power to control and manipulate. And unfortunately the history of trying to engineer consensus in morality and art where it does not naturally exist is not propitious. For when we apply technological methods not to external reality but to human reality (ourselves), strange things start to happen. Yes, human beings and societies have a material reality that is subject to science, but that reality also supersedes and frames the very undertaking of science. Ethics and art are not technical problems to be solved but perennially unfolding realities to be experienced. The moralist and the artist are gardeners, not machinists.

On Antidepressants

2010-09-01T06:55:00.000-07:00

Macbeth: Cure her of that.

Canst thou not minister to a mind diseased,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?

Doctor: Therein the patient

Must minister to himself.

Macbeth: Throw physic to the dogs, I'll have none of it.

The other day I was reading an account of Mozart's final hours, in which he lay wracked by fever and pain, still idiopathic to this day. When the doctor arrived, he prescribed cold compresses. If that good medical man had any notion of what he was dealing with, what might it have been like to attend to one of the greatest composers in the history of the world and to be able to do nothing better than cold compresses? (Of course, it is thought that his life may have been iatrogenically shortened by previous blood-letting as well).

I've been reading Thomas Hines's Architecture of the Sun, a history of modernism in southern California, in which various people moved to that region upon medical recommendations of a more salubrious climate. Those were the days, when a prescription for sunlight, dry air, and palm trees was respectfully viewed as deep medical wisdom! A doctor's word could relocate people across continents.

The history of medicine is a weird amalgam of ignorance and authority, incapacity and power. Even through the millenia in which the practical (positive) effects of medicine were minimal, doctors nonetheless occupied a crucial social locus of judgment and prestige.

Physicians now fight for space in a more crowded arena, but some of their outsized influence remains. For better or worse, a diagnosis from a psychiatrist often carries more weight than one from a therapist. When patients need temporary time off from work or apply for disability, the paperwork seeks the opinion of the physician, not the therapist, nurse practitioner, or physician's assistant. The physician still wields the gavel of the sick role most vigorously.

But if, as the commenter to the previous post suggested, the primary function of the doctor must be the relief of suffering, what happens when the doctor's tools are in fact too weak to accomplish this, or what is more complicated, what happens when the effect of those tools is owing to their wielders' social power rather than to any inherent properties (i.e. the placebo effect)?

Much has been heard of late about the dubious effects of antidepressant drugs, an issue that can only give any psychiatrist serious pause. This issue has been raised many places, and this post is not intended as a literature review, but Sharon Begley's Newsweek article may be as good a summary as any. If antidepressants are truly no better than placebo, then a scientific fraud on an unprecedented scale would have been perpetrated over the past half-century, and there would be something seriously rotten in the state of psychiatry.

I believe, of course, that antidepressants have real effects, otherwise I could not do my job in good faith. This belief could be deemed meaningless inasmuch as I have self-interested reasons of both professional standing and financial stability for holding it, and the human capacity for self-deception is unfortunately vast. But there are of course scientific reasons to doubt ambiguous drug trials, chief of which is the fact that many patients (or "patients") enrolled in drug studies are not representative of real clinical settings. Their disorders tend to be milder and more pure (i.e. uncomplicated by other diagnoses), and the very fact of their willingness to participate in a drug trial may heighten their response to placebo.

So, what do I believe about antidepressants based on 15 years of prescribing them to many hundreds if not a few thousand individuals in various settings? I believe that they are imperfect drugs that too often fail to work--my ECT experience alone would tell me that. I believe that antidepressants treat symptoms of still mysterious illnesses; they do not target the illnesses themselves. They are non-specific, affecting a broad spectrum of emotional response and anxiety level; in that sense they are more like what David Healy, in The Antidepressant Era, referred to as tonics than like magic bullets (think aspirin, not penicillin).

I believe that antidepressant effects are stronger, relative to placebo, the more severe and sustained depression or anxiety is. For mild and transient conditions they are often useless (thus the irony of the moral panic over Prozac-based emotional enhancement). I believe that people (prodded by drug advertising and cultural momentum) rely on them too much on average. Social and psychological interventions should be tried first.

But I refuse to believe, broadly and scientifically, that antidepressants are indistinguishable from placebos. For one thing, within the pharmacopeia there are a few drugs that I think of as internal placebos (buspirone or hydroxyzine, anyone?) having little effect beyond a hope and a prayer. But the mainstream antidepressants aren't like that, and while I know that the placebo effect is powerful and still not well understood, I have seen too many unimpressionable people with dramatic and sustained responses, and too many impressionable types who fail to improve, to believe that there is no physiological effect.

On what may seem like a trivial note, I haven't researched the literature, but many pet owners and veterinarians attest to the effects of Prozac, etc. on neurotic cats and dogs; can that merely be a mass phenomenon of placebo effect by proxy?

Confessions of a Psychopharmacologist

2010-08-30T05:48:00.001-07:00

Half of the people can be part right all of the time,

Some of the people can be all right part of the time,

But all of the people can't be right all of the time.

I think Abraham Lincoln said that.

"I'll let you be in my dreams if I can be in yours."

I said that.

Bob Dylan, "Talkin' World War III Blues"

The other day a new patient referred to the "psychopharmacologist" he used to see in the major metropolis he used to call home. It occurred to me that just as the Moliere character learned that all along he had been speaking in prose, for the past year I have been functioning as a psychopharmacologist, although without the presumably higher fees that that slightly pretentious title might attract. It does sound better than medication manager.

In this role I do not, if only for my own sanity, regard people as merely bundles of symptoms or diagnoses; I do my best to understand them as whole individuals, with the often brute realities of medical morbidity, economic desperation, social chaos, and family dysfunction that generally color their lives far more than any psychological subtleties do. But in the clinics where I work, almost all patients are required to have either a psychotherapist or a case manager in addition to medication visits, so tending to compartmentalize like humans do, they soon associate me with an important but very circumscribed role.

Why have I drifted away from psychotherapy, apart from the inertia of now well-recognized market forces? I think a recent Psychology Today post by Michael Bader, D. M. H., provoked by the already notorious Daphne Merkin article in the Times, helps to explain why. A self-described psychoanalyst, Bader dissents from what he views as the insular, navel-gazing propensities of organized psychoanalysis. His piece should be read firsthand, but basically, he accuses psychoanalysis of emphasizing the often endless exploration of theory and nuance while neglecting practical measures that may relieve suffering.

I took Bader's argument to be directed not only at psychoanalysis per se, but at any open-ended psychotherapy that valorizes ambiguity and self-knowledge over any specific notions of outcome as conventionally considered. The natural rejoinder to this is that Bader has erected a straw man, that any good psychoanalyst will include pragmatism in a sensible course of treatment, and that only a tiny minority practice in the purblind, cloistered Manhattan fashion described in Merkin's article. I would be curious to hear the reactions of any therapist readers (and you know who you are).

Even though I have never had formal psychoanalytic training (although I have been widely exposed to its tradition and rationale) and do not currently practice psychotherapy, I felt a guilty twinge of recognition, for the kind of infinitely curious investigation of uncertainty that Bader assails is exactly the kind of process that I find interesting, and the deeper and the more ambiguous the better. Give me understanding over mere symptom relief any day. However, it seems to me that that sort of depth psychology has been threatened less by medications than by competing therapy models (and perhaps by changes in sensibility characterizing the culture at large).

The view from here is that psychotherapy is ever more associated with time-limited, evidence-based, measurable cognitive and behavioral procedures. I am the first to say that these pursuits help many people, and I support them absolutely. Look at the self-help aisle--the majority of folks seek basic recipes for meaning and contentment in life. The trouble is that from a practitioner's standpoint, I have no interest whatsover in the simple, sunny platitudes of cognitive-behavioral therapy, the well-worn ruts of the seven secrets of highly effective people or whatever.

If or when I do set up my own practice eventually, any psychotherapy I would undertake would be openly in disregard of any simplistic symptomatic outcomes, and indeed would not profess to "treat" any DSM mental disorder. The impractical is merely another name for that which is worth doing for its own sake. Who am I? How to live? What to do? These are the questions I find interesting in psychotherapy. That is not to say that one should self-indulgently wrap oneself in a cocoon of existential stupor. Proximate measures of well-being underlie higher-order inquiries. Eat well, sleep well, exercise. But these things are common sense. I am intrigued by those things that aren't common sense.

Daphne Merkin may have been unfair to those analysts. They offered her profound experiences of self-exploration; what she was seeking was symptomatic improvement. Those contrasting expectations should have been made clear. Psychoanalysis above all treats...a hunger for psychoanalysis and all that it entails, and there is nothing whatsoever wrong with that. Any person's suitability for psychoanalysis depends far more upon intellectual disposition (i.e. faith and steadfastness in the process) than upon diagnosis.

If or when I return to providing psychotherapy, it will be based on unpredictable contingency, much as life is. Yes, a therapist must have expertise, a certain self-awareness and wisdom, including firm boundaries, but beyond that the endeavor floats on a sea of uncertainty. I do share Freud's tragic view of life. Short of that, I will continue to work on biological modification of the brain, the means of which I will tackle next post.

Just Because

2010-08-29T04:19:00.000-07:00

Some say they're goin' to a place called Glory and I ain't saying it ain't a fact

But I've heard that I'm on the road to purgatory and I don't like the sound of that

Well, I believe in love and I live my life accordingly

But I choose to let the mystery be

Iris Dement

I have in mind a couple of posts on psychotherapy and meds, but for today just another piggyback on NPR's excellent 13.7 blog, where Ursula Goodenough posts on matters of ultimate questions. Her last name, while not in fact made up for this post, is eminently suitable and must have had an effect on her formative development (unless, oops, it is her married name).

Her post about her own "covenant with mystery" is interesting in its own right, but I was particularly struck by her quote from an unnamed contributor to a listserv at the "Institute on Religion in an Age of Science," for the comment expresses, more clearly and succinctly than I have achieved, the ecology of belief:

While theism per se may seem irrelevant from several perspectives, the impulse underlying it is not. The concept of a personal God is one way of envisioning the ultimate source or organizing force of all that is. Many feel this image has flaws. But unless an alternative is adopted in its place, the absence leaves a Big Question, and gaping holes in understanding/belief are uncomfortable. I agree that understanding or appreciating Reality does not require Theistic causality. But, until a naturalist perspective can offer some type of image of the ultimate that can both be grasped and feel right, it will remain lacking in something essential.

As Goodenough notes, there is an irreducible subjectivity to belief, relating to how it makes one feel; it is a deeply personal matter, as much so as the kind the person one falls in love with. For agnostics, theism does not "feel right," whereas for believers it does, or at least it feels right enough. Similarly, for me naturalism feels good enough, but I recognize that this puts me in the distinct minority, both historically and currently (and perhaps futuristically as well).

Today's loud atheists, the Richard Dawkinses and Daniel Dennetts of the world, are good scientists and philosophers but poor psychologists. Projecting their mentalities upon mankind, they would deprive the majority of their spiritual bread while putting in its place something that, for that majority, tastes of ashes.

I think it was Emerson who wrote somewhere that the genius believes that what is true of himself is true of all humanity. Yes, there is overlap between genius and narcissism, but it is only partial.

Truth and Popularity

2010-08-24T16:14:00.000-07:00

The last comment provoked some thoughts which probably warrant a new post. What is the relation of truth/value and popularity? The impulsive answer is none at all; indeed, the very test of moral integrity resides in its indifference to polls, in political terms. However, I don't know that it's that simple.

It's obvious that physical/scientific truth bears no relation to popularity; if global warming is primarily the result of human activities, this will be the case even if only 5% of the population believes it to be so. In contrast, I would suggest that advocates of both moral and aesthetic truth do aspire to majority confirmation, but crucially over the (very) long term.

I think it was the ancient Greek Solon who reputedly said, "Call no man happy until he is dead," by which he meant not that death brings happiness (although that is certainly one interpretation), but that a life can only be judged in its totality, when all the results are in. An otherwise blessed or virtuous life can go seriously sour in its final years, just as an otherwise benighted life can see redemption toward the end. Similarly, moral and aesthetic values may be measurable only over the lifespan of the human species.

At any given point in time, Homer or Shakespeare enjoy fewer readers than, say, John Grisham or Dean Koontz, but in addition to the fact that the former enjoy much more sophisticated literary apologists than the latter, their readership is multiplied over the generations. In terms of sheer cultural influence, readership over time matters more than mass readership within a short period; I can't imagine what the "value multiplier" might be--perhaps 1 million readers spaced out over a century matter far more than 100 million readers concentrated in a year. So while at any given time a taste for Homer would have to be considered a minority or niche interest, in the grand scheme of literary influence it is very much a mainstream taste. Aesthetics is a popularity contest, but those amassing "hits" or publishing figures today are likely the hares who will lose out by far to the turtles in the end.

Similarly, while an avid support for human rights may have been a minority position in Hitler's Germany, in the prevailing context of moral thought, it is now the majority position. There are certain moral convictions--equality for women, gay rights, vegetarianism--that, considered from the point of view of world history, remain very much minority views, but the hope is that over the very long term of centuries of millenia, these will become dominant opinions. When George W. Bush stood by his decision to invade Iraq, he may have been thumbing his nose at contemporary popularity, but he was wagering that in the much larger court of future historical and public opinion, he would be vindicated (we'll see).

As the cliche goes, from the standpoint of science, a tree falling in the forest does make a noise even if no one is there to perceive it. The interesting question is: does a moral conviction hold true even if it doesn't attain its majority? Take the equality of women for example. Many of us adhere to this position even though it has been violated throughout much of history as well as in the world today; but as I said, we hope and intend that in the future of humanity it will become a default moral value. But what if human life had been abruptly ended in, say, the year 1800 by a massive asteroid? Could it be said that the equality of women was somehow a "true" moral value for Homo sapiens even if it had scarcely been observed by the species up until that time?

I think this is true primarily from the point of view of logic. Inasmuch as we are rational creatures, we admire consistency in moral views. So if a premise of one's moral system is that human beings should be treated equally in terms of basic rights, then the equality of women and minorities is logically implied whether or not human beings are around to recognize this. So even if civilization were ended by an asteroid tomorrow (or if Republicans took over the country in perpetuity), gay rights may still be logically valid as an implication of the values reflected by the Constitution. However, this is arguably a formal and somewhat empty triumph. When we press our moral views, we aim not only to persuade our current peers, but also to set precedents that may contribute to crucial influence over time.

So when we argue values, whether moral or aesthetic, the stakes are large--we lobby for the kind of human world we hope to see instantiated in the future. If only a few will join us now, we hold out hope that we may campaign for coming generations. A scientist who feels certain that he has arrived at the empirical truth on a certain matter may be blissful in the knowledge even if it is not much appreciated. But an artist or moralist, while he may tolerate contemporary disdain, must--if he is not solipsistic--be disappointed to know that his vision would be relatively rejected not only now, but also in perpetuity. But I see this, in the best cases, not as an issue of narcissistic admiration, but as one of shared respect for a human ideal. Even those artists closest to schizoid pathology make a bid for connection to future readers. Emily Dickinson did not publish for the most part...but left her poems to be found. Franz Kafka bid his works be burned...but did not burn them himself.

Piscivores

2010-08-22T13:33:00.000-07:00

"...until everything

was rainbow, rainbow, rainbow!

And I let the fish go."

Elizabeth Bishop, from "The Fish"

There is a book out that purports to demonstrate that fish feel real pain, which is not a mind-boggling surprise. At Salon Linda Kernohan discusses her vegetarian vicissitudes, including occasional ambivalence about fish, experiences that are pretty similar to my 18 years of meat-avoidance. The main difference is that I never aspired to veganism--it always struck me as too fanatical and puritanical and, ironically, as a kind of denial of the intricate web that we cannot help sharing with other creatures.

To live is to do damage, even if it is to the insects trodden unawares underfoot. There is also the fact we all benefit, as eventual patients, from animal-related medical experimentation. We affect animals by doing anything that emits carbon. It is disingenuous to suppose that in any aspect of our lives we do no harm. That is no argument, of course, to abandon harm-reduction.

I think vegetarianism turned me off on pure philosophy forever. Let me explain. When I first encountered Peter Singer's Animal Liberation in my early 20's, his arguments seemed so prodigious, and ultimately so irrefutable, that I was converted and remain so to this day. However, it didn't take long to realize that not only friends and family, but the vast majority of the human race, remain unmoved by such arguments. I am hard-pressed to think of any other routinely accepted behavior that has such little ethical justification. (Friends and family remain non-vegetarian, which I fully accept of course, and I do not foist my diet upon my children).

The only competitor to meat-eating as mainstream ethical violation may be the blithe acceptance of vast swaths of absolute poverty by prosperous first world citizens, of which I am every bit as guilty if not more so than the next person, so my ethical achievement, such as it is, is selective. Interestingly, Peter Singer has written passionately and prolifically about that issue too. At any rate, these examples convinced me of the relatively small role that justified reasons play in human conduct. So much the worse for philosophy, which always sends me back to religion, literature, and psychology, that is, to the constellation of contingent human needs, among which formal ethics constitutes only a minor part.

Kernohan's vegetarian experience is interesting in a couple of respects. She mentions not missing meat, so it's not as if her day-to-day life is some kind of triumph of self-denial. I recall enjoying meat twenty or more years ago, but it does not feel like a privation. Like her, I eat fish rarely, maybe once every month or two, and it's hard to say why. Maybe it is knowingly wicked self-indulgence (vice on a very small scale indeed).

Kernohan also raises the intriguing issue of depression and vegetarianism, in this case wondering whether subtle dietary deficits could affect mood in ways we don't yet fully understand. However, while she acknowledges other factors that of course may be related to depression, I wonder if she has it backwards. That is, could a depressive tendency and a certain moral and emotional squeamishness predispose to vegetarianism? Who knows, maybe not only vegetarianism, but political liberalism as well, could for some be outgrowths of Melanie Klein's depressive position, a morbid intolerance of suffering? As Nietzsche wondered, if one is virtuous at all, is one virtuous from a position of strength or from one of weakness?

Sunday School

2010-08-22T03:39:00.000-07:00

"The whole of existence frightens me," protested the philosopher Soren Kierkegaard; "from the smallest fly to the mystery of the Incarnatiion, everything is unintelligible to me, most of all myself." By contrast, the evolutionary reductionist Ernst Haeckel, writing in 1877, commented that "the cell consists of matter...composed chiefly of carbon with an admixture of hydrogen, nitrogen and sulphur. These component parts, properly united, produce the soul and body of the animated world, and suitably nourished become man. With this single argument the mystery of the universe is explained, the Deity annulled and a new era of infinite knowledge ushered in." Since these remarks of Haeckel's, uttered a hundred years ago, the genetic alphabet has scarcely substantiated in its essential intricacy Haeckel's carefree dismissal of the complexity of life. If anything, it has given weight to Kierkegaard's wary statement or at least heightened the compassionate wonder with which we are led to look upon our kind.

"A conviction akin to religious feeling of the rationality or intelligibility of the world lies behind all scientific work of a high order," says Albert Einstein. Here once more the eternal dichotomy manifests itself. Thoreau, the man of literature, writes comopassionately, "Shall I not have intelligence with the earth? Am I not partly leaves and vegetable mould myself?" Or Walt Whitman, the poet, protests in his Song of Myself: "whoever walks a furlong without sympathy walks to his own funeral drest in a shroud."

Loren Eiseley, from "Science and the Sense of the Holy"

Unanswerables

2010-08-20T08:20:00.000-07:00

"The mystical is not how the world is, but that it is."

Wittgenstein

Marcelo Gleiser at NPR's 13.7 blog speculates about the ultimate inability of science to explain the first cause of the universe. The fact that there is something rather than nothing may not be a demonstrably empirical matter. I suppose the three great and still unsolved questions are: the origin of the universe, the inception of life, and the development of consciousness. Many have suggested that our minds may not be structured to solve some puzzles, ever.

Of the three, it seems to me that in the long run biology itself, the coming into being from the lifeless muck of self-replicating and eventually self-assembling organic systems, will be the "easiest" to account for. And I think that over time, even if it takes centuries, we will arrive at a decent understanding of how neural networks generate subjectivity, although the specifics of individual subjectivity will always retain some obscurity inasmuch as a particular consciousness is epistemologically a self-enclosed system (i.e. no outside agent could fully understand what it is to be me without in fact becoming me and in the process ceasing to be himself).

But the source of reality itself is a totally different kind of question, and one that may not in fact be scientific at all. For me the strangeness of the matter is that I can't even imagine what an explanation for the universe would look like or how it could possibly be satisfactory. One possibility is that the universe (or rather some grand multiverse from which our universe sprang) has always existed. But somehow I find this kind of infinite regress distasteful. In fact, infinity itself is distasteful except in the abstract.

However, neither am I happy with the notion that the universe had a specific origin, before which or outside of which there was truly nothing (such that "before which" or "outside of which" have no meaning inasmuch as time and space do not exist outside of the universe). The human brain evolved with assumption of limits and of agents. Theistic accounts of creation, while intellectually unsatisfactory in all sorts of ways, nonetheless are easier to relate to. It is somehow emotionally easier to imagine that a stipulated God has simply always been than that a neutral multiverse has always been. I'm not sure why this would be so.

I have the same problem, actually, with space. That is, it is equally disturbing to imagine the universe as spatially infinite as it is to imagine that it would be even theoretically possible to arrive at a physical point beyond which there is non-being. That suggests that time and space are simply limiting frameworks of my contingent mind. So speculating about why the Big Bang happened or where it came from may be like aspiring to stare directly (without mirrors, etc.) at the back of my head.

No, I haven't been getting high or reading Heidegger. But philosophy is a kind of willful stupidity, the refusal to accept the obvious as obvious. To ask why reality not only follows abstract physical laws, but also exists at all (which is not required by those laws) is something like asking how one knows reality is "out there" at all rather than a mere dream or illusion of consciousness; both questions vainly seek for something within experience to justify the basic condition of experience at all. And with that one leaves the desert of philosophy for an oasis of common sense, and the weekend.

Emerging Adulthood

2010-08-18T16:01:00.000-07:00

What's to come is still unsure:

In delay there lies no plenty;

Then come kiss me, sweet and twenty,

Youth's a stuff will not endure.

Twelfth Night

The Times today has a long article on "emerging adulthood" (the tweens), increasingly advocated as a newly normative stage of psychological development. It is the ever more de rigueur period in which twenty-somethings "find themselves," bouncing in and out of jobs and relationships, moving back home, etc. It struck me because of the similarities with "new" psychopathological syndromes, such as increasingly mainstream obesity, (adult) ADHD, soft bipolarity, etc.

One similarity is the jostling of neuroscientific and cultural explanations. On the one hand, brain scans suggest that the pre-frontal cortex continues to develop until age 25, so why shouldn't we expect emotional and cognitive development to be an adventure until that time? Well, there is the fact that throughout much of the world and throughout history, sociological maturity kicked in well before age 25, that is, "emerging adulthood" is a phase that many have apparently been able to skip when needed.

The piece suggests that "emerging adulthood" may actually be an artifact of prosperity; basically, twenty-somethings lollygag around because they can, because they live in the most well-off nation-state in the history of the world, and their parents are willing and able to indulge them. To be sure, this is a mixed blessing: too much promise and too many choices can be burdensome. As I have argued before, the vices of the rich are now the vices of the middle class, who are rich beyond the dreams of avarice compared with most human beings who have ever lived. And yet we try to use neurobiology to justify this sociological state of affairs. It is the brain that adapts to the environment and to society, not vice versa.

And yet this needn't be a pejorative development. Life span is increasing, reproductive technologies augment the opportunities for child-bearing, and the retirement age may eventually be 70 or 75, so what is the hurry, exactly, to settle into the grind of work and children? The crucial change is in attitudes and expectations--the stigma of living with one's parents until age 30 is not so biting. Some sort of cultural tipping point has occurred, which may or may not have anything at all to do with neurobiology. This is allegedly about normal psychology, but it parallels metamorphoses in psychiatric diagnosis. We collectively decide what is normal, then look to science to try to justify the decision.

If Mama Ain't Happy...

2010-08-18T13:21:00.000-07:00

What's the ugliest

Part of your body?

What's the ugliest

Part of your body?

Some say your nose

Some say your toes

But I think

It's your mind

Frank Zappa and the Mothers of Invention

"Since You Asked," Salon's advice column, features a strikingly detailed case of adult children trying to manage a parent's mental illness, in this instance severe anxiety and somatoform disorders superimposed upon baseline character pathology.

What is frustrating of course is the apparent lack of information and insight provided by psychiatry. The woman in question has no insurance, which in our benighted "health care system" renders her up a creek to begin with. To be sure, late-life anxiety and personality disorder are tough to treat--benzodiazepines can be risky, and rigid resistance to therapy is common. But one would have thought the family at least could have obtained a prognosis and suggestions for containment and harm-reduction, which psychiatry must be able to provide if nothing else.

Cary Tennis's "advice," such as it was, was unusually muted in this case: basically, deal with it (you will find the strength somehow) or don't deal with it (cut her off). Maybe he should have suggested that they plant themselves in a shrink's office and refuse to leave until they get an answer. As I've increasingly come to think recently, realistic prognostication is a lost art in psychiatry.

Much has been written about medicine's futile attempts to stave off inevitable death. Psychiatry is not directly involved in that fight, but it has its own counterpart, a perpetual stalling action in which medications and therapists are thrown at refractory symptoms willy-nilly in the notion that some day, somehow, either placebo effect or spontaneous remission will kick in. And perhaps they will, but patients and families should be told up front about the likelihood of that actually happening. Oops, honesty of that sort might disrupt the very placebo effect that one holds out hope for. So one can only steer between pessimism and disingenuousness.

Diagnosticism

2010-08-18T06:49:00.000-07:00

Premodern umpire: "I call 'em as they are!"

Modern umpire: "I call 'em as I see 'em!"

Postmodern umpire: "They ain't nuthin' 'til I call 'em!"

(Attribution?)

In the current Psychiatric Times Ronald Pies, M.D. pooh-poohs the proposed diagnosis of "hypoactive sexual desire disorder" (I can't find an online link for it yet). I hold no brief for that particular problem (sounds like enhancement to me), but I found his article notable for his suggested approach--the "desert island test"--to defining mental disorder.

Specifically, Pies maintains that a disease is one which would cause both distress and incapacity with respect to even the kinds of basic survival functions needed for castaway solitude. Even apart from the objection that such isolation would provoke serious emotional problems in most people, it seems like an awfully restrictive model. For all mental disorders are exquisitely sensitive to stress and crucially contingent upon context, and for Homo sapiens, stress and context are primarily interpersonal. I can think of any number of severe schizophrenics, bipolar folks, and of course substance abusers who--again, if they could tolerate the loneliness--might function surprisingly well on a desert island.

Pies's model is an example of a common desire to clarify the bounds of psychiatric diagnosis by distinguishing endogenous from "merely" situational syndromes; the difficulty is that people cannot be fully understood apart from their situations. But it brings to mind the notion of mental disorder as one that impairs evolutionary fitness; this is an idea that aims to get at some primal ideal of (healthy) human nature, one free of all the dross of contemporary cultural pressures and expectations. Again, the problem is that human beings evolved as deeply social creatures, so the impact of social and cultural context is inextricable from human nature.

In an effort to dismiss mere cultural consensus as a source for psychiatric diagnosis, Allan Horwitz and Jerome Wakefield write in The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder:

Moreover, when concepts of disorder are equated with whatever conditions are called disorders in a particular group, the possibility of scientifically evaluating and critiquing these concepts is lost. Also lost is the commonsense understanding that a culture could be wrong in its judgments about disorder. For example, the Victorians were wrong in believing that masturbation and female orgasm were disorders, and some ante-bellum Southerners were wrong in holding that runaway slaves were suffering from a mental disorder. But if disorders are just culturally relative conditions, then we cannot explain why these judgments were wrong, because those diagnoses did indeed express the values of their times. (p. 219)

This seems like a fine bit of epistemological panic to me, as if the lack of scientific evidence leads inevitably to mere relativism. What if diagnostic guidelines are rooted not in science, but in the same kind of rigorous and argued (but not incontrovertible) consensus that prevails in, say, ethics and law? After all, slavery and sexism also expressed the values of the 19th century, but we can firmly believe and argue that they were deeply wrong. Diagnostic guidelines are in fact made up as we go along, but only in the same way that the courts "make up" the law as they go along, that is, based on reasoning and rooted in prevailing cultural values. In fact, psychiatrists are something like judges, applying precedent to the circumstances of a unique case. Similarly, an umpire's calling of balls and strikes is inherently subjective, but it is a practice situated in accepted guidelines for the strike zone.

Attempting still to keep diagnosis tidy, Horwitz and Wakefield write:

Problematic mismatches between human nature and current social desirability such as adulterous longings, male aggressiveness, or becoming sad after losses are not in themselves disordered. For example, it may be fitness enhancing in our culture not to have tastes for fat and sugar, but that does not mean that people who have such tastes are disordered; that is how we were designed to be, due to conditions that existed when we were evolving. (p. 220)

They seem to imply that such entitites as ADHD, obesity, and substance abuse are therefore cultural pathologies or toxins, having nothing to do with individually diagnosed disorders. However, they immediately go on to qualify this:

However, sometimes environmental conditions that are too different from what is evolutionarily expected can produce real depressive disorders because people were not naturally selected to function in such settings. Modern warfare, for example, leads many soldiers to develop mental disorders that persist far beyond the immediate combat situation because the human brain was not developed to function under such conditions. (p. 220)

It is hard to see how a situational background like war is more productive of individually diagnosable disorders than, say, the easy availability of abundant calories. Is the implication that obesity is merely a personal choice, whereas trauma is not?

There is a real biology of differences of emotional responsiveness, interpersonal relatedness, stress resilience, etc. just as there is a real physics of a baseball's trajectory over the plate. Technologies of biology and physics can modify these processes with greater or lesser success. But what we define as pathology or as balls and strikes can never be a matter of science; it is a matter of reasoned consensus.

Human biology and human nature are not equivalent concepts; human nature also includes culture and consciousness and is therefore self-modifying and self-questioning. The laws of biology are universal, but the contents of biology--what kinds of organisms actually exist at any given time--are contingent. Similarly, there are sociological "laws" of diagnosis inasmuch as pretty much all human cultures have implicit or explicit categories of health vs. sickness, but the contents of those categories may justifiably vary across times and places. Diagnostic categories are not entities we discover, they are entities we decide on.

Why do people keep trying to ground nosology in science? Perhaps because ours is a fractious and often fractured culture, such that consensus is very difficult to achieve, and in psychiatry there is no body with the authority of the Supreme Court. Some diagnoses are straightforward--severe and persistent mental illness is no more conceptually ambiguous than, say, murder (which isn't to say there is no ambiguity at all). Views of the proper bounds of ADHD or depression, in contrast, may vary as much as if not more than views of abortion or gay marriage--in all of these cases there is no account that is eternally or "scientifically" valid; there are merely competing claims of harm vs. an ideal of the good.

Monday Moralisms

2010-08-16T06:59:00.000-07:00

Just a few tenuously linked cogitations (or cogitated links) today:

1. Paul Kingsnorth laments the watered down sort of environmentalism that focuses on sustainability, which inevitably means sustainability of...humans with their self-absorbed, energy-wasting ways. The apparently true environmentalism that values the natural world for its own sake seems forever in retreat. However, nature in itself is nothing but a human value. Outside of Homo sapiens, nothing in nature would blink if tomorrow the moon slammed into the earth. I always think of Wallace Stevens: "Except for us the total past felt nothing when destroyed."

This it not technically true, as we think pretty strongly that a range of non-human organisms have sentient awareness. But we ourselves are such linguistic beasts through and through that, in large part, if it isn't at least potentially articulated in some way, it isn't fully real. Human beings evolved to care about human values, which includes nature, but only in competition with other values.

Some people like their nature mediated. Henri Rousseau, who painted the image above, drew his inspiration not from traveling to the tropics, but from the local zoo. Similarly, I have enjoyed so many nature programs on the Serengeti over the years that I think an actual safari would be a letdown, and not just because of all the other cheesy tourists perched atop jeeps pointing at the non-plussed zebras. Imagination fruitfully expands reality. For better or worse, earth is the human planet until we're gone. The discovery of life elsewhere in the universe, even if it isn't "intelligent" (or perhaps especially if it isn't intelligent), might be a great comfort to some: life existing beyond our capacity to despoil it.

2. The media (the cardinal manifestation of the very human capacity for mass hysteria) doesn't do environmentalism many favors. For weeks we heard that the gulf oil spill was a kind of toxic stake thrust into the heart of oceanic nature. We heard that it may never recover. What do we hear now? That most of the oil is gone and scientists are having to work hard to demonstrate any clear-cut damage to the ecosystem. When people develop alarm fatigue from this sort of thing, is it any wonder that skepticism over global warming persists?

3. Allen Frances, M.D. in the Times decries the possibility of treating normal grief reactions with antidepressants. It is an indication of the bizarre two-sidedness of psychiatry that half of the commentariat complain about psychotropic medications not working, while the other half fret that they may work too well for the wrong indications. Of course, people have been obtaining benzodiazepines and other sedatives for grief symptoms for decades.

This is a great example of the importance of context, and why brain scans and rating scales ultimately play a small role in making diagnoses. For a diagnosis is not primarily about biology or symptoms, it is about the human meaning of what is going on. A psychiatrist who denies a patient an antidepressant for normal grief is acting as a kind of arbiter of interpersonal and cultural well-being.

4. Sharon Begley at Newsweek discusses research suggesting why irrationality may have been favored by evolution. Reason evolved not to arrive at disinterested truth, but to persuade others of a point of view (Nietzsche's truth as a "mobile army of metaphors"). And arguably "disinterested truth" is the most convincing point of view of all. We evolved as promiscuous, murderous sophists--how then has moral progress been possible? Can psychology explain that I wonder? Is reciprocal altruism all there is? If truth is ultimately pragmatic, it ceases to do its work once we see it as merely pragmatic; disinterested truth is the fiction in which we must believe in order to sidestep nihilism. One must willfully overlook the contingency of one's values in the way that a batter at the plate must forget about everything except the pitcher.

5. Dave Pell at NPR considers technology and how it can distract us from "the big picture," which in his case involves atrocities going on in Afghanistan. It made me wonder though, what is this "big picture" that people talk about? Is it more like a painting, or a photgraph, or a collage? Is it a composite of all the "little pictures?" For some people the big picture is philosophy, for others science, for others religion. Of course, the picture can get too big, right? From the perspective of the universe or infinity, nothing less than totality matters. I suppose the art of living is the art of perceptual focus, of arriving at the "just right" picture.

Where the Wild Things Used to Be

2010-08-10T11:14:00.000-07:00

The other day my eight-year-old asked, "Daddy, what does 'integrity' mean?" My heart warmed--it was a Norman Rockwell moment, my chance to impart one of the primary virtues. I tried to explain it in an age-appropriate way, and asked why he inquired? "Oh, it's also a brand of alarm system." (After having moved on from a great enthusiasm for natural disasters, his current preoccupation is with smoke and fire alarms and other indicators of incendiary mayhem and transgression). More Jackson Pollock than Normal Rockwell. Hopefully he'll remember that it's not just a brand name.

This came to mind when I read Anne Applebaum's Slate post on ADHD in literature, specifically embodied by Tom Sawyer and Huckleberry Finn. It has been many years since I first read of their adventures in oppositional defiance, but she seems about right that while Mark Twain doubtless romanticized their naughtiness, they lived in a time far more tolerant of disobedience, distraction, and disregard for academic achievement. Or maybe "tolerant" is the wrong word: it was an age that left more space, both physically and psychologically, for such things.

In Madness and Civilization and other works, Michel Foucault argued that around the middle of the last millenium, when the first glimmers of the Enlightenment appeared, Western civilization began to become distinctly less hospitable toward mental disorder. The mad, who for centuries had wandered more or less unmolested along the margins of society, came to be seen as a greater threat to new priorities for the order and management of populations. Previously seen as harmless or perhaps even as alternative sources of vision, the mad were increasingly perceived as a menace.

I wonder if the escalating pathologizing of ADHD features could represent a second great phase of this "civilizing" process, if unfocused energies and scattered cognition present challenges to a logocentric society that are more subtle than those of mania or psychosis, but ultimately intolerable nonetheless. As Hanna Rosin straightforwardly argued in The Atlantic, the culture and the economy increasingly valorize and reward calm, structured, meticulous, and persistent verbal order, all of which may be more commonly found in women, on average, than in men.

It is not only the case that expectations for order are higher, that there are far more moving pieces, so to speak, in a post-industrial information society. Technology also amplifies any specific potential source for disorder, via means such as automobiles, firearms, the Internet, or in the case of rogue terrorists, nuclear or biological weapons. It is like not only building a bridge far longer than has ever been attempted before, but also in unprecedented water and weather conditions. The cognitive inefficiencies of ADHD, which often of course entail great creativity, may come to be a cultural luxury for which we have to fight to maintain space (the playgrounds and natural parks of human cognition perhaps).

Knowing and Being Known

2010-08-08T09:35:00.000-07:00

"There is nothing so practical as a good theory."

Kurt Lewin (?)

I can't resist commenting on Daphne Merkin's New York Times article on her (mis)adventures in therapy, not specifically because of its implications for her or for psychoanalysis, but because of general issues it brings to mind regarding diagnosis and levels of understanding.

On a human level the piece intrigues mainly with its idiosyncratic portraits of Merkin's successive therapists; taking full advantage of the writer's prerogative, she turns the tables by pigeonholing them (this one is dowdy, this one seedy, this one aloof, etc.) just as they would aspire to pigeonhole her. However, the surprising yet perhaps telling thing is that she doesn't actually document them pigeonholing her, that is, there is almost no discussion of diagnosis beyond the vaguest of terms: anxiety, depression, neurosis.

It is not my role her to speculate on Daphne Merkin, who is a brilliant writer. But any decent clinician is going to have one diagnosis come to mind when she discusses having poor boundaries, chaotic relationships, one therapist who comments on her difficulties with navigating emotional proximity, and at least one episode of severe regression when given free rein to explore her childhood issues. And yet there is no discussion of diagnosis or its extension, prognosis; that is, what pattern exists here and how might it unfold over time?

Merkin seems surprised herself at how little overall clinical effect her perpetual "life in therapy" has had, not least because while some of her therapists were clueless and unhelpful, others were deeply empathic and understanding. Indeed, she felt very understood by and very attached to at least a couple of them, and yet nothing seemed to change for her overall, at least in the way she was hoping for. What is going on here?

This question also came to mind when I read Cheryl Fuller's most recent post on obesity which, while making no explicit reference, followed and seemed an implicit response to my most recent post here. Her eloquent post, decrying allegedly simplistic overgeneralizations, was a plea for deep understanding of the individual experience of obesity. It brought to mind what I see as a tension between empathy and theory (or diagnosis) as ways of knowing that have different but complementary purposes.

Empathy is, of course, a fine-grained attunement to an individual's emotional state and history, an engagement with a truly unique sensibillity and life trajectory. This is obviously a form of knowledge, and may be likened to other forms of perception that are sui generis: a singular Picasso, or a sunset whose precise configuation of color and shadow will never be precisely repeated anywhere or at any time. Human beings have a powerful need to understand and to be understood in this way, which is the way of love, friendship, ethics, and aesthetics. It is what most people think of as the ends (i.e. the goals) of human life.

However, the whole point of theory and diagnosis is to overlook endless idiosyncratic differences and to identify how entities and processes may be alike, not how they differ. This kind of classification has three purposes: it enables us potentially to know how phenomena may develop over time, how we may go about modifying them, and on a more abstract level, how "it all fits together." The former two aims are those of science, while the latter aim belongs to spirituality. These things are necessary because a universe of irreducible uniqueness is also a universe of chaos (and also a universe without language, which also intrinsically glides over differences; a language could do full justice to individuality only if it had as many words as there are entities).

A good theory (or diagnosis in medicine) should either either lead to effective interventions or to a recognition of the necessary limits of treatment, i.e. prognosis. A theory that aids in neither altering nor predicting outcomes is useless. But there are different levels of explanation with corresponding different levels of treatment. For instance, we lack an ultimate theory of obesity, that is, an explanation of who gets fat and why, but we have a more proximate theory: obese people become obese because more energy is absorbed through their stomachs than their bodies expend as energy. Therefore one can intervene at that level of explanation through bariatric surgery (the ethical and cultural considerations of which I'm not touching here).

To come back around to Daphne Merkin's quandary: as presented in her article at least, the diagnostic/theoretical system has failed her on multiple levels. For while psychoanalysis has never been accused of neglecting theory, and the practices she describes imply a theory, this is never made explicit to her. While there may be passing and perceptive interpretations, no therapist ever comes out and says what may be wrong with her.

There is also a problem with prognosis. If I see someone who has seen a dozen other doctors over decades without success, then there are three possibilities (listed in ascending probability): the diagnosis is wrong, the diagnosis is right but not every possible treatment has been tried, or the condition is untreatable. Merkins's therapists never seem to consider that the diagnosis may be one that is not amenable to classical analysis. Or even if they consider this option but reject it, they are undeterred by the failure of a dozen of their colleagues in the past. Why? Perhaps because in psychoanalysis idiosyncrasy plays such a primary role that there are as many different treatments as there are individual therapists. The last option is that her therapists know that the treatment will not work in any conventional sense but view it as a kind of palliative care. This seems to be Merkin's own take on it; by the end she is not hopeful of any real progress, but life in therapy seems at least slightly less intolerable than life without.

So medicine and psychiatry need both levels of understanding: the empathic and the theoretical. If the latter unopposed is crude and callous, the former unopposed is static and ineffectual. Theory enables us to manipulate the world (including our own bodies) to our own ends, while empathy enables us to decide what those ends will be. When it comes to psychiatry, as I have written here in the past, flaws in treatment are far less grievous to the profession than flaws in diagnostic understanding. As perpetual debates over psychoanalysis and the DSM-5 demonstrate, our map of the human psyche still has wide swaths of empty space, offering limited guidance to those lost on the way. Our minds so often rush to treatment options (how do we get there from here?) that we often skip a crucial orientation step (where are we exactly?). Psychiatry will be waiting for its GPS for a long time. When we finally get it, let's not become overly dependent on it...

If Thine Eye Offend Thee...

2010-08-04T14:25:00.000-07:00

"Has it ever struck you that there's a thin man inside every fat man, just as they say there's a statue inside every block of stone?"

George Orwell

As the national obesity rate continues to creep higher, Cheryl Fuller at Jung at Heart speculates about the deeper meanings, if any, of obesity. As she notes, there is a natural human craving for a smoking gun, a prime mover: a gene, an archetypal childhood experience, a cultural imprint, anything. It is a craving not to be satisfied, as it increasingly appears that weight is a complex result of human identity, no easier isolated and explained than, say, intelligence. It is the outcome of natural (and individually variable) gratification, energy expenditure and environmentally available calories.

Fuller notes that the inferred role of volition is central to obesity, and this combined with its unavoidably public aspect, makes it a virtually unique target of social judgment in our society. Most other objects of discrimination are either agreed to be unchosen (race, gender) or can be more or less concealed (sexual orientation, substance abuse). As a slender person who was fat through adolescence, I have always felt like a bit of an oddity in the great obesity debate. So I thought I would share how my attitudes toward food and lifestyle have developed over time. Crucially, I claim no personal merit or superiority for the experience--it could as easily be said that the weight was lost for me (by developmental genetic change, etc.) as that I lost it and kept it off. And indeed, as I think back on it now, I think that it was not so much an exertion of willpower as it was taking steps to minimize the need for willpower. Or I may have just "grown out of it." But aspects of the process suggest to me what might have to happen for a person to beat obesity.

My family history for obesity is I suppose moderate; some have had it (not morbidly), some haven't. I was basically born fat and remained that way to varying degrees until around age 17. I was not morbidly obese--certainly there were bigger kids--but it was significant enough to affect juvenile social relations, self-esteem, athletics, etc. Especially in my early teen years I went through many diets that were miserable and only transiently if at all successful. But I loved food dearly, a wide variety of foods, and it was painful to deprive myself of things I loved. I heartily disliked exercise, not least because I was out of shape.

When the change came, it came in stages and not as the result of some conscious plan. The first step was my first job at age 15, a newspaper route that, due to the inconvenience of stopping the car every 50 feet, I did on foot and, increasingly, at a run. Suddenly I had daily exercise that I did not have to force myself to do; willpower was removed from the picture. For while I loved food, I also loved having spending money, so I effectively had no choice but to exercise.

I had the paper route for only a couple of years, but I tried to adopt attitudes toward physical activity that would seem automatic, not requiring constant deliberation (the dreaded willpower). I take elevators only to ascend or descend five floors or more. Unless frankly fatigued, I try not to sit when I can stand, and not to be still when I can pace and fidget. I have never much cared for running, swimming, or biking, but found in walking a daily activity that suited my meditative disposition and that eventually came to seem indispensable. I am restless and uncomfortable when unable to take at least a short walk in a day.

But in terms of my psychological stance toward food, I think the more far-reaching change was that, somehow, food ceased to be for me the source of gratification that it once was. This is captured by the cliche "Eat to live, don't live to eat." In a process that seemed to be unconscious at the time, I "decided" that food would no longer be a major source of pleasure to me. I decided that certain foods (pancakes, doughnuts, elaborate desserts) would be largely off-limits to me--they became gratuitous, no longer worth the risk. It helped when, a few years later, I became vegetarian for ethical reasons, a change that in itself dropped the last ten to twenty pounds that I needed.

This has not been culinary asceticism per se. I still love chocolate, ice cream on a summer day, fresh bread, etc. But I no longer relish these things in the sense of arranging my life around them, that is, they are incidental. I will pick them up when convenient, but I don't go out of my way for them and do not relish them in the way that I might relish a piece of music or a book. Food beyond that needed for sustenance is just not a significant part of my life.

As I said, I do not claim any particular merit for this or any implications for any other persons; I merely describe how it seems with me. It is not something that I take smug pleasure in. The point is that it does not require prodigious or prideful effort; it flows naturally. It is well known that genes are not once and for all, that is, they wax and wane throughout the life cycle unpredictably. Perhaps as an adult I merely enjoy some genetic dispassion for high-calorie foods, whereas as a child I suffered the opposite. Certainly I have other vices--on any given day it would be easier for me to forgo food as opposed to caffeine or Internet access.

Alternatively, as Cheryl Fuller might speculate based on her blog post, perhaps it became psychologically intolerable for me to remain fat, such that the joy of eating, long gone from my life, was not too high a price to pay. I think that many people, and certainly not only the obese, delight in food as one of the basic pleasures of animal life and are not willing to give that up. So when a person desires thinness but does not achieve it, it reflects not weakness, but an unwillingness to pay the often steep price demanded. There is a major trade-off involved. And people should not be blamed for their choices (unless they expect others to pay the costs of those choices). The complication is that what appears as a choice may not always be so (does a nicotine addict "choose" to keep smoking? yes...and no). The unsuccessful dieter thinks that he can deprive and exert himself for a few months before reverting to the status quo, when the reality is that he must alter his basic worldview: he must fall out of love with food.

It is often pointed out that eating cannot be considered a true addiction because it is not possible to abstain from eating. That is true, but it is possible to abstain from a certain degree of gratification in eating. To my mind, this is the kind of lifestyle overhaul required to beat obesity, analogous to the alcoholic avoiding bars or hard-drinking friends. While this is a matter of choice, it is not a simplistic matter of weakness vs. strength or willpower. Willpower is the alcoholic sitting in a bar all evening long and not taking a sip--no one expects that to work. One cannot avoid food, but one can avoid food as pleasure. Just as an alcoholic must look at a bottle and see poison, someone wishing to lose weight must look at food and see not a sumptuous feast, but rather a necessary evil. And obviously it is crucial to construct compensatory gratifications, whether sensuous or intellectual.

The Mumbo Jumbo Men

2010-08-03T06:40:00.000-07:00

"Well, if it's a symbol, to hell with it."

Flannery O'Connor (of the Eucharist)

According to a local story, notoriously nefarious atheist Daniel Dennett's latest kick is, apparently, publishing case reports of religious hypocrisy (once again, the consistency of human behavior is shockingly cast into doubt). A United Church of Christ campus minister at Duke does not believe in "the cosmic guy in the sky," instead holding, according to the reporter, that:

God is a process of mysterious cosmic creativity that makes for greater love and justice. He thinks of God as a force working within human beings and nature, and he sees his role as trying to imitate that divine character whose greatest exemplar is Jesus.

For better or worse, I'm a pretty abstract person, but I've always been at a loss to understand what this sort of thing means. Is it Spinoza's pantheism, a congruence of nature and God? Or is it more like The Force? (There is deep wisdom in popular culture if one only knows where to look for it). Is the "cosmic creativity" also behind, say, evil (no creation without destruction)? Or is that just what makes it so mysterious?

To paraphrase something Stanley Fish once wrote, I've never been sure that religion is something that one can subtract God from and still have something left. That's why I'm not convinced that Buddhism is a religion--a profound and culturally powerful tradition of thought and practice, yes, but not a religion.

Once the possibility of the supernatural drops out, call it a fellowship, or a philosophy seminar, or a therapy group, but not a church. In fact, the minister described in the story is essentially doing pastoral therapy, that is, trying to respectfully manage belief systems in a way that is beneficial by secular standards.

And yet...there is an undeniable sense of the sacred and sublime, experiences that must be psychological, yet cannot be viewed as merely psychological. That is, they denote not the supernatural, but their essence vanishes when fussily isolated and manipulated by instrumental reason ("Let go, Luke!"). Art, love, the natural sublime, ethical practice, and (the absence of) God fall in this category of willed acceptance (the acceptance of the need for acceptance as it were), the willing suspension not of disbelief per se, but of reductionism and radical skepticism. The sacred is found where Reason averts its gaze, not for the sake of gratification or chaos, but of a greater good. It is the paradox of the mind trying to stay out of its own way, of glories glimpsed only out of the corner of the eye.

Whatever You Say, Doctor

2010-08-02T06:40:00.000-07:00

"The brain that is innately fearful and angry has been selected for by evolution."

Allan Hobson

"My holy of holies is the human body, health, intelligence, talent, inspiration, love and absolute freedom--freedom from violence and falsehood, no matter how the last two manifest themselves."

Chekhov

Two years ago tomorrow appeared the first post of this peculiar A. P. blog; 361 posts later, it still seems as good a rationale as any. Happily, I have little more to say about the activity of blogging itself--it is an intellectual hobby, full stop.

I am forever casting about for serviceable metaphors for what it is that psychiatrists do. Well, psychiatrists are doctors--what do they do? Arguably they have a dual role, one scientific/technological and the other dramatic/emotional. Taking the latter first, the clinical encounter is a carefully scripted and staged act of caring which grounds the endeavor in the aim of healing rather than, say, exploitation. And yet it cannot be only drama; medicine functions legitimately only if there is real technical know-how beyond the layman's scope that doctors are privy to. The two act in concert to produce a clinical outcome.

It is the technical basis that Daniel Carlat has, to some scandal, questioned in his recent book Unhinged. If the science of medicine comprises diagnosis and treatment, both come under intense scrutiny in that volume. As the "debate" over DSM-V has grown into the kind of ad hominem free-for-all that would seem typical of the U. S. Congress, psychiatric diagnosis is considered by many to be as much hearsay as real science. And as alleged technical breakthroughs like vagus nerve stimulation and transcranial magnetic stimulation have turned out to be relative duds, some of psychiatry's most powerful somatic treatments remain at the level of mid-20th century technology. Carlat concludes that psychiatrists should no longer have to be physicians by training--the implication is that our technology, such as it is, does not justify it.

Undeterred, Henry Nasrallah, M.D. extols the "futurology of psychiatry," laying out the technical revolution that is just around the corner--we have been hearing that for 25 years, but this time it's apparently for real. I think of a sonorous voice from my childhood: "Gentlemen, we can rebuild him; we have the technology." But while other physicians are replacing knees and stenting coronary arteries, psychiatrists are...prescribing Valium. But Lee Majors looking mellow for an hour wouldn't have made for much of a show--even in the 1970's.

Granting the profession's shortcomings yet decrying the infighting and self-doubt, Ronald Pies advocates the "prescriptive bond" as the essence of the medical mission of psychiatry (one that, presumably, could not be performed by psychologists with prescribing privileges). Basically, he is writing about the drama of the white coat, that is, a seemingly trivial prescription has the history and authority of several millenia of medical tradition behind it. The caduceus. The Aura of the Doctor. And yet what good is that if the prescription is for sugar pills, or for something that may do more harm than good?

I think of the psychiatrist as a weird hybrid of the philosopher, the priest, the legislator, and the pharmacist. All of these must grapple with inherently ambiguous and contentious issues corresponding to crucial human needs. All must deal with the man on the street, whose opinions on these matters often exceed all in intensity if not in wisdom. But what ensues when the community loses faith in the shaman is...debates like these. Everyone feels he knows best about his body and what to put into it, about right and wrong, about God, about what policies to enact. And yet society sees fit to appoint "experts" for these roles not really befitting the title of "expert." Psychiatrists should not be glorified druggists, but those with enough perspective and wisdom to usefully frame human suffering. In that sense, pace the futurologists, there will be "nothing new under the sun."

Concerning Natural Religion

2010-07-30T17:07:00.000-07:00

The pensive man...He sees that eagle float

For which the intricate Alps are a single nest.

Wallace Stevens, from "Connoisseur of Chaos"

Two recent links set out the basic aims of religion--Ron Rosenbaum, in a welcome apologia for agnosticism (as opposed to blustery atheism), points out that science has never (yet) delivered on the central question of: why is there something rather than nothing? Marcelo Gleiser, over on NPR's commendably cosmic 13.7 blog, proposes death (i.e. the valorization of life) as a basis for a transcendent spiritual ecology. Basically, how did we get here, and why do we have to leave so fast?

In the currently popular effort to bridge science and religion, Gleiser seeks some universal principle within human nature and religious impulse that will supersede differences. And yet, if one can forgive mere contrariness, it occurred to me: what if the most universal principle of human religiosity is in fact diversity of belief? What if that which "unites" us is actually our tendency to form "our" worldviews in opposition to "theirs?"

Much research in evolutionary psychology, echoing millenia of intuitive observation of human nature, suggests that human beings may be wired for "us and them" thinking, for thinking in binaries, for forming "in" groups and "out" groups. We define ourselves by contrast, for better or worse (we may think it is mainly the latter, but in evolutionary terms it may be otherwise). Male vs. female. White vs. black. Old vs. young. Liberal vs. conservative. Rich vs. poor. Yankees vs. Red Sox.

This needn't mean that humanity is doomed to internecine nastiness, but it does suggest that populations will tend to resist conformity of thought. Wouldn't it be nice to rise above the science vs. religion debate? Sure, just as it would be great if Republicans could pal around with Democrats, or if Protestants and Catholics could agree to bury doctrinal differences.

History arguably consists of the vicissitudes and machinations of contrasts. The now generally mocked "end of history" forecast in the 1990's was apparently premature. Why do we mourn the declining diversity of culture or language, yet celebrate the notion of religious diversity merging into some fuzzy "reverence for life?" The latter risks both the incommunicably idiosyncratic and the coldly abstract; successful religions generally depend on persuasive personal narratives that bind communities together.

In other words, religion is not contingently parochial, it is necessarily so, presupposing the community of those who "get it" versus those who don't. And agnostics and atheists define themselves in opposition most of all; arguably belief preceded disbelief. If a totalizing belief system were ever to take over the earth, whether it be the Catholic Church, a Muslim caliphate, or an atheistic regime, then the next day heresy would break out somewhere. Unless or until the seemingly unanswerable questions are answered, incompatible belief systems will persist, which should be okay.

The Age of Anomie?

2010-07-26T08:31:00.000-07:00

"Message: I care."

George H. W. Bush

The mad have always been with us--convincing descriptions of severe mood disorders in particular exist from antiquity. But neuroses and "problems of living," or at least the recognition thereof, are largely inventions of modernity, as set forth by Ronald Dworkin in his account of what he calls "the caring industry." His article is not brief but presents some fascinating arguments and warrants careful reading. I have time for only a short summary and response here.

As Dworkin describes, since the 1950's a massive population of therapists of every stripe and, now, "life coaches," has sprung up to manage emotional issues that until then had been the domain of traditional peer groups, lines of authority, and cultural connectedness. The rise of mobility and suburbanization and the decay of natural communities began this trend, which was reinforced and hastened by the social turmoil of the 1960's and onward. Therapists do the work (or try to) that used to be done (if it was done at all) by families, neighbors, and the clergy.

So far this is pretty familiar territory--Dworkin documents the increasing ubiquity of the caring industry in the military, the schools, and everyday life. He points out that while the 1950's are often recalled as a calm before the storm of contemporary upheaval, the decade was, beyond its infamous conformity, actually marked by a deep malaise, reflected in its moniker as "the Age of Anxiety." It was as if the plunge into collective and rapid social and technological change, still a few years off, could nonetheless be glimpsed and feared.

But Dworkin's more creative and radical claim is that, presumably in response to the civilization-wide catastrophes of the two world wars, people in the West at mid-century underwent a profound change in their emotional engagement, one that we still haven't recovered from. He suggests that for the better part of a millenium, love had grown as an ideal in personal, religious, and national life. But the extent and depravity of the world wars showed that love stops at the nation-state and cannot be extended to humanity as a whole; the implication is that love is not only insufficient for global security, it is positively dangerous, and an unaffordable luxury, inasmuch as it fosters tribalistic nationalism in a nuclear age.

The consequence was that people have tended to grow more detached and cynical in their attachments. Much of the residual lure of love, intensified by the entertainment industry, has come to reside in individual erotic connection, upon which more and more seems to ride even as it becomes more fragile. Dworkin argues that people have largely given up on the organic, intense, but volatile attachments to natural peer groups in favor of cooler, more easily manageable relationships obtainable from therapists in finely titrated 50-minute increments. It is an elaborate theoretical version of the therapist-as-friend-substitute claim.

There is much that could be said in response to this fascinating version of history. First, while he does not come out and say so, Dworkin's elegaic tone certainly evokes some Golden Age when people were happier--is that really the case? While he suggests that the masses are lonely and miserable, most surveys of Americans at any rate show that the majority consider themselves basically happy (I am aware of the myriad nuances surrounding a fraught construct such as happiness). To be sure, attachments are not so simple, so monolithic, or so geographically given as they long were, but are they worse? Perhaps they are more dynamic, more flexible.

For some reason Dworkin refers primarily to the traumas of the war-ridden early 20th century, but it seems to me that the nuclear age contributed more directly to civilization-wide angst. For 65 years now the possibility of nuclear holocaust has been a gun held to the head of humanity, and it has not gone away, even if we don't so much envision a Soviet premier with his finger on the button. For those so inclined, the environmental threats of recent decades have added to the perceived risk of the earth being ruined beyond repair. These things, it seems to me, could sap social trust and confidence more than the legacy of the trenches and the Holocaust, horrible though they were.

Dworkin maintains that people utilize "the caring industry" on a massive scale because they have grown more sad and alienated. However, by this argument, one could argue that people use air conditioning because they have grown hotter than people of previous centuries. The latter would of course be wrong, but one can make a case that psychotherapy is not so much a response to cultural calamity as it is just another modern innovation that people find useful and reassuring. The comparison to air conditioning may sound trivializing, but it isn't entirely far-fetched; after all, in heat waves such as we are having now in my part of the world, AC does save lives, even if for most it "merely" adds to quality of life.

It is true that air conditioning has made people less tolerant of the heat, just as automobiles make people on average less tolerant of exercise. But these are side-effects and trade-offs that the majority seem willing to make. And the relative softness and sensitivity of modern populations are arguably consequences of unheralded prosperity--there is a bit of a princess-and-the-pea phenomenon whereby the better off on is, the less tolerant one becomes of imperfection. Most people in history had no need of therapy because they were too busy trying to stave off starvation and disease.

Modern psychotherapy arose in Europe in the 19th century, which on that continent on average was a time of great prosperity; suddenly there was a larger middle class with the time and disposable income to worry about the kinds of "problems of living" that traditionally could be "suffered" only by the rich. It is significant then that psychotherapy really took off in the U. S. in the 1950's, which, while it was a time of war weariness and nuclear anxiety, was also in economic terms the start of a globally novel degree of economic well-being.

Despite its inequalities (more stark in recent years), over the past half-century the U. S. has been, in sum, the most prosperous nation in the history of the world, so arguably its vices--the breakdown of the family, the hypertrophic media and entertainment industries, the rise of obesity, and yes the "triumph of the therapeutic"--are largely ailments of prosperity. But these ailments are very real, and attended by real suffering--just ask the morbidly obese. The caring industry may be an inevitable result of liberal capitalism. As a culture, it may be that we have become less trusting, and perhaps even less loving, than our great-grandparents, but arguably we are also more knowing and less naive.

Medicine and Metaphor

2010-07-25T07:46:00.000-07:00

It seems as if the honey of common summer

Might be enough, as if the golden combs

Were part of a sustenance itself enough,

As if hell, so modified, had disappeared,

As if pain, no longer satanic mimicry,

Could be borne, as if we were sure to find our way.

Wallace Stevens, from "Esthetique du Mal"

To judge from the vituperative comments section of his blog, Daniel Carlat, M.D. is now apparently the Most Hated Psychiatrist in America, having offended fellow shrinks and patients alike by being honest. In his recent book, Unhinged, he bravely and forthrightly discusses the obvious, i.e., that we don't know nearly as much about the brain and about psychotropic medications as we would like, and that psychiatrists don't do psychotherapy nearly as much as they used to.

Until we have a full neurophysiological and philosophical understanding of consciousness, we will lack a complete understanding of psychotropic drugs, whether marijuana or Thorazine. Deal with it. We don't even have a full grasp of sleep, which is one of the most basic behaviors in the animal kingdom. Do we fully fathom how anesthetics work? And yet we submit to them, and to trust people to cut into our bodies while doing so. Can someone tell me exactly how the experience of pain works, and therefore how Tylenol is effective?

Indeed, one of the commenters on Carlat's blog likens psychotropics to aspirin, and I think that is an apt comparison. In all of medicine, psychiatric conditions are most similar to pain syndromes, and psychiatrists are most similar to pain management specialists. In both cases we have an imperfect account of underlying pathophysiology, but the resulting distress is clear, so we do our best to alleviate it. The DSM is a bit of a red herring; in their everyday work most psychiatrists treat symptoms.

There are of course legitimate philosophical debates about the proper place of pain in life, and no doubt we have become less tolerant of both physical and psychic distress in contemporary times, but the whole enterprise of medicine is predicated on the supposition that suffering is not inherently redemptive (it is a shame that Nietzsche lives on in the public imagination mainly with "What does not kill me makes me stronger," which is plainly wrong, or at least very selectively true). If patients come to a psychiatrist looking for a one-time fix or an indisputable explanation, they will likely be disappointed. But I would suggest that they're looking for someone who will understand and validate their suffering and offer some relief.

Any decent doctor should know that pharmacology and other technological interventions have their limitations and drawbacks--insight and behavior change should be attempted first, just as they should before, say, considering bariatric surgery for obesity. The psychiatrist's message should amount to: "I see that you are hurting. You're not alone and you're not a freak; I have seen a lot of people with similar problems. It's not your fault. I can't completely explain where your pain comes from, but I know of some things that could help."

Unless they are of the tiny minority subject to involuntary commitment, folks are free to avoid psychotropic drugs just as they may choose to steer clear of analgesics, but they shouldn't condemn those who find them helpful. The problem, as I've written here many times, is not that mental illness doesn't exist or that psychotropic drugs don't work even for symptoms (they unequivocally do, although not as completely or as often as we would like); the problem is that psychiatry has been far too confident and grandiose in its claims of diagnostic specificity and treatment efficacy.

People see psychiatrists who declare that their Major Depression is as clear and unambiguous as appendicitis might be, and that Prozac will definitely be the solution. But the majority of patients we see present with symptoms more like chronic back pain than like appendicitis. In a perfect world we would have a full understanding of back pain, such that it could be eliminated directly (or--gasp--tolerated) rather than treated with clumsy analgesic regimens. But that is a heroic ideal, not the world we live in. We need more realistic expectations, which is what Dr. Carlat has tried to supply in his blog and his book. As someone once said (oh right, Buddha), life is suffering, and since the dawn of civilization human beings have fermented, distilled, and smoked whatever they could get their hands on in an effort to tinker with flawed consciousness, and psychiatry, like pain management, is an attempt to undertake this in a way that is, yes, civilized.

The Soul, Explained

2010-07-24T15:01:00.000-07:00

"Why, look you now, how unworthy a thing you make of me! You would play upon me, you would seem to know my stops, you would pluck out the heart of my mystery, you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet cannot you make it speak. 'Sblood, do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me."

Hamlet

In the latest entry in the Times's philosophy blog, Galen Strawson trenchantly outlines both the inevitable logic gainsaying free will and the practical necessity supporting it. Rationally and scientifically, free choice can only be a mirage: a decision of what to do must stem from what one is. But what one is must in turn result from an interaction of genetic composition and environmental context; there is no room in the causal chain for some kind of ex nihilo self-creation. How can one be responsible for one's biologically and culturally contingent dispositions?

Interestingly, Strawson answers this by appeal to a novelist (Ian McEwan), who suggests another way of looking at free will, as that for which one is obliged to accept ownership. This reflects the central sociability of free will; ownership is an inherently social concept, and the conviction of free will that attends consciousness is an evolutionary means of modulating individual behavior. Free will involves that for which we must answer before our peers; human groups cannot function insofar as individuals disown their own conduct. Free will is therefore a matter of reason and language; a choice is always accompanied by at least an implicit self-justification before a virtual tribunal (this is internalized with varying degrees of integrity as conscience). From the vantage point of science, free will is a fiction, but practically speaking only the fatalistically depressed and the psychopathic disavow personal choice. Free will is located not in neurobiology, but in sociology--no emotions are more fundamentally interpersonal than guilt and shame. The mythical human being raised by wolves, without human contact or language, is by definition unfree.

So free will is located not in the brain, but "in" the group or human culture. What does this imply for the soul? I would argue that just as free will is not some kind of metaphysically magical legerdemain, the soul is not some kind of ethereal "stuff" existing separate from the brain. But the soul is not merely another name for the brain. Rather, the soul is massively distributed, consisting of vast networks of social and experiential contacts (another name for it would be "identity" or "the self").

My soul, like anyone's soul, does contain my irreducibly subjective experiences, but beyond that it entails every kind of relationship I have ever had, the work I have done, the influences I have taken in or given out. And crucially the soul has a history and a rationally supported system of values, both of which depend upon language. This is why animals, who presumably have moment-to-moment conscious subjectivity, do not have souls (that doesn't mean we should eat them though). Infants do not begin to develop a soul until language acquisition begins, and arguably the severely demented have largely lost their souls (both groups are still deserving of care and respect not only because they can still feel pain, but because regard for them is part of our souls). Having a soul is not like being pregnant--it is a matter of degree and diversity (although from the point of view of human rights and dignity, we consider all Homo sapiens to be fundamentally ensouled).

So the soul is not some kind of mysterious stuff, it is a network of ideas and relations. Most people's souls die when their bodies die or within a generation or two, but some souls live on in perpetuity, like Plato's or Muhammad's or Shakespeare's. Hitler's soul, regrettably, will have a very long life. Similarly, if we inquire about the identity of some country, the United States for example, it is obviously true that the U.S. consists of a certain part of the land mass of North America plus the bodies of some 300 million inhabitants as well as their various artifacts and structures. However, the U.S. is not merely these material conditions; for better or worse, its identity comprises a history and a system of ideals--all of this goes to make up its collective soul.

People almost universally have an intuition, whether right or wrong, that they are something beyond their bodies and brains, and in the sense in which I am speaking they are right. For the soul depends crucially upon actually lived history and relations with widely dispersed persons and phenomena. My soul contains not only my body/brain, but also my family, my profession, the Big Bang theory, the Andromeda Galaxy, the Louvre, and countless other entities. And my understanding of my soul requires that these things really exist, that they are not merely phantom firings of a deluded nervous system. The soul is very much a developmental beast: what I did yesterday defines my current soul much more than what I did twenty years ago.

Even though, from a scientific standpoint, I could not have ended up (in this universe anyway) with any other soul than the one I have, I conduct myself in explicit or implicit view of others with whom I share a mutually negotiated system of values, such that I feel obliged to keep my soul in what I consider to be the best possible condition. As with anyone, results may vary. And at times one maintains the soul with an eye not so much toward the currently available group as toward a stipulated or ideal community.

Psychology of the Artist as a Young Man

2010-07-24T13:31:00.000-07:00

Inspired by current local conditions, I picked up Heat Waves in a Swamp, an exhibition volume on the works of the visionary American watercolorist Charles Burchfield (1893-1967; his Four Seasons is above). Discussing Burchfield's decision to remain in small-town Ohio and then rural western New York rather than going for the bohemian big-city life, Dave Hickey writes:

First, he was far from a genuine rustic, enamored of his isolation. His daily life was that of a cosmopolitan intellectual who has isolated himself, as a secret drinker might, to conceal his weakness. In Burchfield's case, this weakness was his bond with the landscape of his youth, a place that, for Burchfield, was less beloved than genetically imprinted--like the promise of water on a baby duck--that was less a theatrical setting for his art than an inextricable, mysterious extension of his selfhood, or he an extension of it. Over the years, I have tried to put a name to this particular malady. Many authors, writers, and performers have suffered from it. It is characterized by a shift of centeredness. The ground shifts and the barrier between ourselves and the world disappears. We feel ourselves to have become possessed--to have become an extension of the world, a particle in that whirlwind. The self is obliterated in this instant. The effect is akin to Stendhal's syndrome, to the wooziness we feel when we are captured by pictorial illusion. It is akin to dancing, to the loss of self that accompanies our giving ourselves up to the music. I call it the curse of the soft self--the unwilling dissolution of one's identity into its environment. It is the malady of painters, writers, actors, musicians, and critics. It always brings with it the terror of not being able to reassemble one's identity int he wake of having lost it.

I found this to be remarkably perceptive, and I think I can help Hickey out with the name of the peculiar malady: schizoid personality, of which this passage is an apparently unknowingly evocative description. The schizoid type's instinctive human craving for connection is in conflict with a hypersensitivity toward physical and emotional contact; what is feared is smothering, intrusion, definition by others. The world as it is is too much with them; the self is perpetually under siege. The modus operandi of the schizoid person is withdrawal into an internal world of imagination and intellectualization (William Blake's "I must create my own world or be enslaved by another man's"). Schizoids are lovers of distance, which Burchfield apparently found far from the hip, crowded art scene. As Nancy McWilliams writes in Psychoanalytic Diagnosis (1994):

The most adaptive and exciting capacity of the schizoid person is creativity. Most truly original artists have a strong schizoid streak--almost by definition, since one has to stand apart from convention to influence it in a new way. Healthier schizoid people turn their assets into works of art, scientific discoveries, theoretical innovations, or spiritual pathfinding, while more disturbed individuals in this category live in a private hell where their potential contributions are preempted by their terror and estrangement. The sublimation of autistic withdrawal into creative activity is a primary goal of therapy with schizoid patients.

Mad Scientists at Work

2010-07-23T11:32:00.000-07:00

I have a new hero after reading a profile of neuroscientist and writer David Eagleman:

Eagleman rejects not only conventional religion but also the labels of agnostic and atheist. In their place, he has coined the term possibilian: a word to describe those who "celebrate the vastness of our ignorance, are unwilling to commit to any particular made-up story, and take pleasure in entertaining multiple hypotheses."

Sign me up--I want to be a possibilian.

The "guinea pig" complaint is far and away the most common one I hear about previous psychiatrists (and I'm sure it is said about me by those patients who move on to other prescribers). A new medication is tried every month, seemingly willy-nilly, without a sense of an overall framework or plan. A psychiatrist, plainly, is no auto mechanic. Psychotherapy, truth be told, really is a neverending experiment, but medication somehow is supposed to be different.

We know a vast amount about the effect of medications over large populations, but idiosyncratic variation in drug response remains too great to predict outcomes for individuals. In that sense medication reactions are almost like an extension of the assessment process. Treatment, diagnosis, and prognosis become one. Medication trials obviously don't give the same kind or precision of information that a brain MRI will give a neurologist, but they are very informative of a patient's dynamics and likely outcome.

The problem of prognosis is fundamental to psychiatry. Neurologists, even though they often can do relatively little about sometimes appalling diseases (MS, ALS, Huntington's Disease), nonetheless enjoy a greater stature than psychiatrists because, even if they can't do more, they know more. A patient would obviously prefer to get well, but if he can't get well, he wants to know what the future holds so that he can wrap his mind around it and plan accordingly.

There are of course crude measures of prognosis: general intelligence, education, financial and social support, and the presence or absence of past hospitalizations, suicide attempts, personality disorder, and substance abuse. But on a more subtle level, in psychiatry prognosis declares itself only over time, as the myriad variables involved in a mind interact with unique life circumstances. The physiological systems generating identity, behavior, and other aspects crucial to psychiatry are far more complex and unpredictable than those giving rise to, say, motor or sensory control.

The milder or more subtle a condition is, the harder prognosis can be to pin down. I can no more predict how a low-grade dysthymia will behave over decades than I can predict when a person might get married, or how much money they'll be making ten years from now. This isn't to say that I can't predict at all, but such prognostications are based as much on common sense (the past tends to predict the future, etc.) than on any grand professional expertise. Since I'm not allowed to keep a crystal ball in the office, I'm limited to indirect measures of understanding.

Maybe more psychiatrists should aspire to be possibilians, to "celebrate the vastness of our ignorance" rather than pretending to more knowledge than we actually have. Prescribing a medication isn't like performing an oil change--it is accompanying a patient in an experience of self-discovery. Physicians differ from drug dealers in that the substances we purvey, by social contract, must have minimal standards of safety, uniformity, and usefulness. In addition, we are expected to be wise and discerning students of human nature. Beyond that, things get interesting.

Calling Sir Galahad

2010-07-22T17:49:00.001-07:00

"Nothing will come of nothing: speak again."

King Lear

An older fellow presents with chronic depression, personality disorder, social isolation, medical problems, and a deeply ingrained sense of bitterness and entitlement. However, he is highly intelligent, erudite, and possessed of an acidic, acerbic wit, making a session with him a bleakly endearing clinical approximation of reading Samuel Beckett.

He declares that while he has no imminent plan or intent, he deems it "92%" likely that within five years he will be dead "by my own hand." And yet, two minutes before the end of our meeting, he asks whether I know of any wisdom that he ought to keep in mind if or when the suicidal bug should bite him in the future. Interesting bit of intellectualization, that.

Ah, for a transcendent mantra that could tear the scales from the suicide's eyes and show the world in all of its eminently worthwhile glory! I'm thinking of a phrase that, when uttered, would silence the most raucous city street and bring the mighty to their knees, that would be like a compound of: the Holy Grail, the ultimate Om, fragments of the True Cross, the Philosopher's Stone, the meaning of Zen, the Ark of the Covenant, the Fountain of Youth, the proof of the existence (or non-existence) of God, the proof that Shakespeare wrote (or did not write) Shakespeare, the Theory of Everything, a perpetual motion machine, the Aleph of Borges, and the One Ring of Sauron (which, recall, did not permit its wearers to die).

But alas, that fantasy is akin to keeping a tower upright by proposing to blast it perpendicularly into space, when in reality its supports are far more prosaic, comprising deep-seated attachments between stone or steel and the earth from which they came. And of course that's what the request entailed: attachment, not anti-gravity thrust. "We'll talk about it next week."

The Heart of the Matter

2010-07-20T16:23:00.000-07:00

"It's hard to make that change

When life and love

Turn strange

And old."

Neil Young

Hats off to Dr. Rob at Musings of a Distractible Mind, who muses (of course) on suffering and the ends of medicine. Every now and then it is good to look up toward the remote (and ultimately inaccessible) peak at whose base one labors. To switch metaphors, each morning we march out upon the beach, brooms at the ready, braced to sweep back the tide. Physicians should know their Sisyphus. Heroic? Not usually. Futile? One hopes not. For some it seems to be the worst possible profession, except (a la Churchill) for all of the others.

David Foster Wallace Lives

2010-07-19T10:03:00.000-07:00

Life, friends, is boring. We must not say so.

After all, the sky flashes, the great sea yearns,

we ourselves flash and yearn,

and moreover my mother told me as a boy

(repeatingly) 'Ever to confess you're bored

means you have no

Inner Resources.' I conclude now I have no

inner resources, because I am heavy bored.

People bore me,

literature bores me, especially great literature,

Henry bores me, with his plights & gripes

as bad as achilles,

who loves people and valiant art, which bores me.

And the tranquil hills, & gin, look like a drag

and somehow a dog

has taken itself & its tail considerably away

into mountains or sea or sky, leaving

behind: me, wag.

John Berryman, "Dream Song 14"

This poem, by a suicide who was also the son of a (paternal) suicide, came to mind as I was thinking more about David Foster Wallace. Even now, nearly two years later, I occasionally come across reflections on his demise, the shock and dismay of which still linger in the reading community. It occurs to me--as I'm sure it has occurred to many although I haven't actually seen mentions of it--that Wallace was the Sylvia Plath of this generation, the literary light snuffed out by the Black Dog.

There are obvious differences: gender, genre, and age--while Plath was only 30ish, Wallace was 46, and it's possible that his best work was already behind him in any event. But why did his suicide generate more consternation than the deaths of, say, Nathanael West or Albert Camus by motor vehicle at similar ages?

The inspirational quote by Wallace cited in Retriever's post of yesterday struck me perhaps because I had recently come across a very different sort of Wallace quote; the contrast of the two pretty much sums up the conundrum of genius and madness. The quote I mean was in Daniel Carlat's Unhinged (about which more eventually I'm sure), apparently an account of depression from a Wallace story:

You are the sickness yourself....You realize all this...when you look at the black hole and it's wearing your face. That's when the Bad Thing just absolutely eats you up, or rather when you eat yourself up. When you kill yourself. All this business about people committing suicide when they're "severely depressed": we say, "Holy cow, we must do something to stop them from killing themselves!" That's wrong. Because all these people have, you see, by this time already killed themselves, where it really counts....When they "commit suicide," they're just being orderly.

This is pretty grim and implacable stuff. Does anyone know a good joke? But really, black as it is, it is a spot-on description of severe depression. The difficulty of separating the illness from the self. The relentless but narrow logic of self-destruction. And Wallace is right in implying that suicide is merely a (final) symptom, and obstructing the symptom without addressing the disease is arguably unhelpful. Pre-empting a suicide is not in itself a solution to anything except insofar as it enables attention to underlying pathology.

In his book Carlat refers to Wallace in arguing that psychiatry still has a long way to go in terms of effective treatment. It is interesting that in the past decade or two, both the explosion of antidepressant advertising (especially on television) and the controversy over widespread medicating practices have fostered the notion that antidepressants are powerful drugs. That may have been part of the Wallace surprise--while people on the street still understand on some level that suicides still happen, the notion that in 2008, twenty years after the introduction of Prozac (the threat of which was thought to be that of making too many people "better than well"), a writer of the caliber of Wallace would go and kill himself seemed, well, so 19th century, or at least, so 1963.

Wallace and Plath also had in common the fact that neither suicide was, in purely clinical terms, surprising. Both had been hospitalized and had received ECT earlier in their lives. Plath was on an early antidepressant, and Wallace had been on many of them, including the monoamine oxidase inhibitor Nardil. I don't know the details of their treatment, but it appears they had plenty of it. While terminal cases are common (indeed inevitable, right?) in all areas of medicine, terminal psychiatric cases remain frustratingly abstract--we do not have the ominous scans, biopsies, or lab results that provide the paradoxical balm of the inexorable. Oh yes, we get a feeling that a certain case isn't likely to end well, but all we can do is fight on, calling the prognosis "guarded."

Suicide continues to shock, even as understanding of depression grows; a stigma persists. It is deemed "selfish" and demeaning, and that is on the whole probably a good thing. It keeps some people, I think, from reaching the point of no return. For as Wallace's quote argues, past that point, there is no weighing of potential alternatives, there is only a sense of overwhelming necessity, no more resistible than gravity. That is why involuntary commitment exists--logic has failed.

Just as suicide was long considered a sin against God, it continues to be seen by some as a sin against Life. The suicide rejects what most of us hold most dear, and there may even be a trace of egoism in this view, on two levels (not only "How could he consider himself too good for this world?" but also "How could he not want to be part of a world that contains...me?"). In social terms, suicide threatens to startle the horses in the street as the saying goes. I'm capable of viewing depression as medically as anyone, but this moral dimension means that depression will never be as simple a matter as diabetes--the former's sinister distant cousin is acedia, or willful blindness of the true light. As many have noted, the psychiatric/therapeutic office has an element of the confessional.

One-Sided Conversations?

2010-07-18T15:52:00.000-07:00

"And there's some evil mothers, well they're gonna tell you that everything is just dirt."

Velvet Underground

My great reader Retriever adduces a fine David Foster Wallace quote and suggests the necessity of worship--of something, anything--even among atheists. I agree--agnostics/atheists shouldn't hold themselves to be above reverence or the idea of the sacred. Worship is humility before the sublime coupled with self-acceptance, existing as spiritual experience.

I would argue that what distinguishes the agnostic/atheist is not worship, but rather prayer, that is, the lack thereof. Prayer is the essence of theistic religion because, no matter how subtly it is undertaken, it presupposes the existence of a divine respondent "out there," and one with a personal understanding of and care for human beings. If, as I wrote on a few posts ago, religion is chiefly about relationships, then prayer expresses those relationships. The title of Retriever's post--"Who do you worship?" (italics mine)--reflects this exactly. The essence of religion is faith in an unseen interlocutor.

Atheists are not inherently nihilistic or hopeless; as their name suggests, they are properly considered "godless," unpersuaded by the myriad contingently cultural conceptions of supernatural agency. They needn't be against God; they merely have no convincing philosophical or personal experience of (her), so they feel it makes sense to live their lives under the assumption that (She) does not exist. An atheistic may, in the broad sense, worship many things (ideals, humanity, objects of beauty), but s/he worhips noone, that is, no person or specific stipulated agent.

As usual Emily put it well:

My period had come for Prayer --

No other Art -- would do --

My Tactics missed a rudiment --

Creator -- Was it you?

God grows above -- so those who pray

Horizons -- must ascend --

And so I stepped upon the North

To see this Curious Friend --

His House was not -- no sign had He --

By Chimney -- nor by Door

Could I infer his Residence --

Vast Prairies of Air

Unbroken by a Settler --

Were all that I could see --

Infinitude -- Had'st Thou no Face

That I might look on Thee?

The Silence condescended --

Creation stopped -- for Me --

But awed beyond my errand --

I worshipped -- did not "pray" --

The Stars, Like Dust

2010-07-17T13:11:00.000-07:00

"If our titles recall the known myths of antiquity, we have used them again because they are the eternal symbols upon which we must fall back to express basic psychological ideas."

Mark Rothko

"Twelve hundred miles its length and breadth,

That four-square city stands.

Its gem-set walls of jasper shine,

They're not made by human hands."

Iris Dement

This afternoon I enjoyed the Whitney Museum's exhibition of Charles Burchfield, a latter-day William Blake of small-town America, whose watercolors blaze with a similar spiritual energy (above is his "Sphinx and the Milky Way").

And I couldn't have said it better, as regards plenitude and significance, than this blog post by Adam Frank. Size matters. An atheist could be defined as one who finds all existing conceptions of God to be inadequate.

Still On Vacation

2010-07-15T02:25:00.000-07:00

We are stardust.

Billion year old carbon.

We are golden.

Caught in the devil's bargain

And we've got to get ourselves back to the garden.

Joni Mitchell

In their sheer magnitude, extremes of urbanization return humanity to the fold of natural history: the closest we can come to the pullulating condition of the sea and stars, featuring oppositions of emptiness and plenitude. Even here, of all places, there is nothing outside of nature.

On Vacation

2010-07-14T03:09:00.000-07:00

No End of Books

2010-07-10T13:18:00.000-07:00

"I...had always thought of Paradise

In form and image as a library."

Jorge Luis Borges, "Poem of the Gifts"

"My library

Was dukedom large enough."

Prospero, The Tempest

If Thoreau was right that one's wealth may be measured by how much one can do without, that is, the smallness of one's needs rather than the mass of one's possessions, then the Internet and Kindle, etc. are making readers rich beyond the dreams of avarice. As the (then) seven-year-old put it recently, "Daddy, why do you have so many books in the house? Don't you know that you can read books on the computer?"

And yet Nathan Schneider, among many others I'm sure, claims a role for books going well beyond the textual information they contain. For him they are a "theater of memory," a personal (and collectively, a cultural) record of imaginative and intellectual development. And David Brooks argues that books, in contrast to the chaotically egalitarian Internet, embody standards of intellectual hierarchy and wisdom.

What of print culture will survive? Not physical newspapers, surely. For many years a faithful newspaper subscriber (and long ago a delivery "boy"), I am now appalled that, daily, countless trees are sacrificed, and countless gallons of gasoline burned, so that bundles of paper may be dropped on porches to be briefly perused before passing (one hopes) to the recycling bin, when the same information may be transmitted by the energy cost of turning on the computer for a few minutes. To be sure, this information should be paid for, and it remains economically perplexing that one has access to so much free information online.

While not a hoarder per se, I used to stockpile magazines and journals (no more). Will weeklies and monthlies survive in paper form, if only for doctors' offices? They would seem to have a better chance than newspaper, but probably not, still, a good chance. Their value does not significantly transcend the textual information they contain.

What of books then? I have been considering another winnowing of my library--what is indispensable in paper form? Three categories, I would argue. First, and most straightforwardly, are the art, photography, and graphic design books, which are frank objects of beauty in their own right. Second, there are books of, one might trivially and misleadingly say, "sentimental" interest, that is, books that, when they catch my eye on the shelf, evoke a memorable experience of imagination or thought in my life (ranging from the relatively picayune, such as Stephen R. Donaldson's Thomas Covenant series, read in the summer of 1982, to quasi-respectable professional works of recent years). Third are the classics, however considered, that is, those texts that embody such value for me that at any given time I wouldn't want to have to depend on anything beyond visible light for the reading of them, and certainly not upon electrical power, Internet access, or the vicissitudes of any electrical device. Once acquired, a book provides near-perfect freedom which, short of frank theft of destruction, cannot be taken away.

Books will survive in some form for the same reason that, even in the age of reproduction, original art and live performance survive: as bodily creatures, we crave and require more than just information. We need tactile experience. Books will become fewer and more expensive, and people will become far more selective in what they choose to shelve, but they will survive. What will vanish into readable cyberspace will be the teeming fields of routine fiction and fact, texts that are diverting or useful for a month or a year. Those that prove their worth to following generations will pass into paper. For those who care about such things, personal and cultural libraries will remain anchors of intellectural and imaginative memory and identity. Like churches, museums, and parks, books will persist, even in diminished numbers, as quasi-sacred artifacts of thinking bodily creatures.

The Analog Life

2010-07-09T16:44:00.000-07:00

"The formula for my happiness: a Yes, a No, a straight line, a goal."

Friedrich Nietzsche

Not long ago I wrote a post contrasting ambiguity and clarity; this came to mind today in response to a video by Dan Ariely that was on Arts and Letters Daily. His point was that online dating is less helpful than it could be because it sorts people by digital, searchable characteristics (think height, religious affiliation, etc.) when our actual experience of others is far more subtly graded: analog.

Indeed, personal sensibilities can be (digitally!) grouped into the analog and the digital. The former sees nothing but continua and shades of gray, while the latter craves contrasts. Think yes and no, good and evil, male and female, liberal and conservative, young and old, rich and poor, sick and well. The mind variably demands and abhors such simplifying, absolute goalposts as frames for experience.

Literature is analog; psychology is digital. Psychoanalysis is analog; medical-model DSM-IV psychiatry is digital. History is analog; politics is digital. The tension between humility and conviction: both seem to be necessary.

Ghost in the Machine

2010-07-03T16:36:00.000-07:00

Or: the metaphysics of childhood. (Paraphrased) actual conversation:

Seven-year-old: Daddy, how could Sandman [a Spider-Man adversary] survive since he's just made out of sand? I mean, wouldn't he need internal organs (sic)?

Me: Yes he would, that's why he's just make-believe. That's why ghosts aren't real either [seven-year-old clings fervently to a belief in the supernatural].

Seven-year-old: But ghosts are invisible.

Me: So, they would still need internal organs, wouldn't they?

Seven-year-old: No, Daddy, ghosts are made out of the afterlife (sic).

It never ceases to amaze me that matter has evolved to the point of deeming its own role in consciousness to be dispensable in this way. Sort of like ascending a tower and kicking the ladder away--the view is excellent, until one gets hungry or restless...

Journeys

2010-06-28T05:55:00.000-07:00

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

2010-06-23T17:16:00.001-07:00

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...

2010-06-22T13:49:00.000-07:00

"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

2010-06-21T16:45:00.000-07:00

"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

2010-06-20T15:56:00.001-07:00

"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

2010-06-19T07:45:00.000-07:00

"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

2010-06-17T16:29:00.000-07:00

"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

2010-06-16T16:33:00.000-07:00

"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

2010-06-14T12:10:00.001-07:00

"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

2010-06-13T16:45:00.000-07:00

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

2010-06-13T13:57:00.000-07:00

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

2010-06-13T04:31:00.000-07:00

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

Forwarding Address

2010-06-12T18:07:00.000-07:00

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

Asylum

2010-06-12T16:59:00.000-07:00

"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

2010-06-11T17:48:00.000-07:00

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?

2010-06-09T06:32:00.000-07:00

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

2010-06-07T15:59:00.000-07:00

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

2010-06-07T15:14:00.000-07:00

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.

Really?

2010-05-29T16:57:00.000-07:00

"Fortunately analysis is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist."

Karen Horney

Alan Schatzberg, M.D., outgoing president of the APA, has presented a solution for what he sees as a major problem besetting the DSM-5 process, that is, excessive coziness with the common folk and their darned opinions:

"One thing we ought to consider is using more technical language. Our cardiology colleagues don't talk about heart attacks but use the term myocardial infarction. Hematologists are not attacked for including leukemia in their nomenclature, and they wouldn't think of giving it up for "way too many white cells disorder" (WTMWCD)! Why shouldn't we follow their lead? To my view, bulimia would be a better term than binge eating disorder. The latter was attacked by a prominent psychiatric critic as suggesting he could be diagnosed with the disorder after a heavy Thanksgiving dinner. Our language should indicate the severity of the possible impairment. Simiarly, temper dysregulation in children sounds too much like temper tantrums. They are not the same, but the use of the language is problematic. We need to be more serious about our terminology. In the end, we will get it right."

Yes, this is what ails contemporary psychiatry, the lack of abstruse terminology that will mystify and impress the hoi polloi (which wouldn't be a bad term for a mental disorder, come to think of it). Time to haul out the Latin and German dictionaries. American psychiatry's cardinal sin has been false modesty, and an unwillingness to stick its fingers into as many pies as possible. We need to be more aggressive in educating the purblind populace about the grave severity of their mental states, crying out for the local psychiatrist. We need to exaggerate the degree of our actual knowledge, for the good of our patients of course.

What is noteworthy about myocardial infarction, though, and countless other terms from other disciplines, is the useful work that the names do in indicating specific and potentially modifiable pathophysiology (in this case, the death of cardiac muscle cells). Unfortunately it's hard to think of a single psychiatric diagnostic term that has that level of specificity. Are neurologists wringing their hands over the term stroke, which seems to enjoy both wide general use and a meaningful clinical designation?

This sounds like the kind of throat-clearing that might lead a psychiatrist to wear a white coat, which is about as useful on a shrink as it is on an accountant. Not really, of course, as perhaps a white coat would helpfully accentuate the placebo effect, as would the casual use of dumbfounding (if insignificant) expressions like amygdalar aberration, or hippocampal ischemia, or limbic encephalopathy. (Unless the patient starts laughing). Yes, melancholia sounds way cooler than depression, but apart from those of us who enjoy cool words, what would the former accomplish beyond self-importance?