Happy Happy, Joy Joy

"Most people are about as happy as they make up their minds to be."

Abraham Lincoln

Abe was typically pithy when he supposedly said or wrote this, but even he may have nodded in this instance, for it reflects a simplistic and misleading conception of what happiness might be. It came to mind after the media buzz generated by a study about happiness and social networks. The study suggested that those individuals rated highest in happiness (by a "standard measure" of the same) were most likely to have broad social networks of similarly happy people.

The first thing that is apparent is the stunning obviousness of this "finding," like so much of social science research. I mean, who could have guessed that happy people are not usually recluses, or surrounded by miserably negative folks? It is much like another shocking recent study suggesting that television watching is usually inversely proportional to happiness. It also confirms what every disaffected teenager has suspected: the popular "in" folks really are different.

Well, I suppose the study may show that schadenfreude, by means of close-up exposure to the unhappy, is not the best route to happiness. To be sure, when I ask people what (if anything!) they have found helpful about a recent psychiatric hospitalization, I am surprised that the response often involves their apparently gratified awareness of others who are even worse off than they are. But this may suggest that it is primarily the distressed who may be helped by acquaintance with the even more distressed; happiness may enjoy a magnanimity that unhappiness cannot afford.

Of course, people have debated what happiness means for thousands of years. I guess the contemporary question is whether one can be seriously, lastingly unhappy without also meeting criteria for depression. We have decided that bereavement, as well as other various disappointments in life's natural course, is distinct from depression, but is unhappiness that occurs for no particular reason anything other than depression?

In this business we talk about someone being "euthymic," or free of significant depressive or manic symptoms. But this is a fairly sterile term, and it seems like happiness ought to be something more, perhaps a spiritual sense (secular or not) that one's life is headed in a meaningful trajectory. Yet happiness is not inconsistent with pain and suffering; indeed, we might say that unhappiness is suffering exacerbated by a sense of meaninglessness. So can one be happy and depressed at the same time? How about happy and dysthymic? I'm not sure.

I hope this blog has already established that medications are not my chief personal or professional interest, although in light of escalating psychiatry/pharma scandals, I think I may list a separate disclaimer indicating my near-total lack of interaction with drug companies over the years. And clearly there are things one can do on one's own or in psychotherapy to improve one's mood and likelihood of happiness.

One of those things is increasing one's proximity to other people, preferably happy people. One of the cruel vicious circles of depression, however, is that people, particularly happy people, do not generally relish the company of seriously unhappy people (that may be one way they stay so happy). At the risk of sounding excessively wry here, I suppose that unhappy people ought to seek out the company, at least, of those somewhat less unhappy than they are, thus ratcheting up their own happiness potential ever so slightly. Thereby one might progressively advance closer to the shangri-la of the truly happy.

A significant hitch can occur when the most negative people in one's life, the ones potentially most detrimental to happiness, also happen to be one's family, friends, or associates. There is always the possibility that, like a substance abuser needing to avoid triggers, one could need to break free of a toxic influence. Problematically, this study suggests that if you want to become or remain happy, you ought to avoid the unhappy like the plague. I guess the naturalistic fallacy, the notion that what (contingently) is the case ought in fact to be the case, is the basic hazard of science.

But there is also the risk that unhappiness, like depression, can come to be seen as primarily a lifestyle choice and not what it is, an extremely complex interaction of biology and behavior. The risk of Lance Armstrong stories is the notion that anyone ought to be able to overcome cancer if they only try hard enough; the parallel risk with this kind of study is the notion that we can safely blame the depressed because they "choose" their unhappiness. In this business, if it's simple, it's almost always wrong.

The Year in Music

The man that hath no music in himself,

Nor is not moved with concord of sweet sounds,

Is fit for treasons, stratagems, and spoils.

The motions of his spirit are dull as night,

And his affections dark as Erebus.

Let no such man be trusted. Mark the music.

Lorenzo, The Merchant of Venice.

I am no musician, but I am an avid listener and I know what I like. If you couldn't care less, please feel free to stop reading now. What follows is outrageously opinionated, and for all I know could potentially offend many.

Overall I didn't find 2008 to be as remarkable a musical year as 2007, but maybe that was just me. Listed below are some records that I found to be notable, for better or worse; it is by no means comprehensive, as between work, family, blogging, and reading, I have time to sample only a fraction of even well-known releases. I may have overlooked some great ones and would like to hear about them if so.

To get relative disappointments (for me) out of the way, I found several of the year's heralded albums to fall a bit flat. R.E.M.'s Accelerate was competent and featured their signature sound in an ununusually focused and lively package, but overall they seem like a band that, ever since the prodigious Automatic for the People, just hasn't had that much more to say.

Two new and ballyhooed acts, Fleet Foxes and Vampire Weekend, seemed striking at first, but after a couple of listens they started to sound a bit twee and contrived. This was particularly the case with Vampire Weekend's quasi-African rhythms--this sort of thing was done a long time ago, and much better, by the likes of Peter Gabriel and Paul Simon.

Two interesting middling successes (I can't bring myself to call them failures) were My Morning Jacket's Evil Urges and The Raconteurs' Consolers of the Lonely. Evil Urges is one of those works that is highly proficient and eclectic but ultimately leaves me indifferent, and without a clear understanding of what the band is about. Perhaps it is possible to be too proficient and eclectic, when one goes out of one's way to leave one's showily ingenious mark on as many musical styles as possible within one album (is it really a good idea to try to impersonate both Prince and Wilco on the same record?). As for The Raconteurs, their album was vigorous and contains some tremendous riffs (with Jack White it could hardly be otherwise), but I found it to lack the endearing whimsicality of the White Stripes.

For me the most overlooked record of the year was Kathleen Edwards's Asking for Flowers. She combines a hauntingly wistful voice and a softer, more feminine Neil Young sound. Musically the record is a huge advance over her more work(wo)manlike first two efforts. There isn't a weak song on it, and she is one to watch.

January saw Cat Power's second album of covers, Jukebox. What is it with her and covers? Maybe she just prefers performing to songwriting. Well, with her voice it doesn't matter--she can sing nursery rhymes if she wants to. It is one of the great natural voices for both indie and blues, and owing to her well-documented history of emotional vicissitudes, I'd like to think that my profession may have played at least a miniscule part in keeping the voice singing. The one new tune, the Dylan homage "Song to Bobby," is spectacular, as is her remake of her own prior song "Metal Heart."

Portishead's Third was another tour de force for the somewhat lugubrious group. Plenty of bands are dark--last year's Boxer by The National, which everyone seemed to find stupendous, was dark, but in a droning sort of way that I found, even after multiple listenings, to be about as interesting as a cold drizzle. But Third is dark in a way that sounds variously magisterial and slightly deranged, if that possible; it is at once anxiogenic and uplifting. For me "The Rip" was one of the sublime songs of the year.

I can't make up my mind about Jenny Lewis's Acid Tongue. Like Evil Urges, it seems to suffer from a scattered eclecticism, but since it is her voice, it doesn't seem to bother me as much. The title song is Lewis at her absolute best, while "The Next Messiah" is ambitious if nothing else. Some of her songs are so sweet and direct (like some on Rilo Kiley's first record) that it can be hard to decide whether they are merely saccharine schlock, or whether they are so much so as to be actually subversive (in which case one can relish the beauty without guilt; as I think Nietzsche wrote somewhere, it is possible to be superficial out of profundity). She does make one think (among other things), and that is more than many pop musicians manage.

I'm not sure if I can get used to the "new" Lucinda Williams on Little Honey, which virtually all reviewers saw as a much sunnier work, for better or worse, than her usual. The voice and spunk are still there, but some of the pathos is missing ("My Little Honeybee," for all its energy, seems finally crass, although perhaps that is ageism on my part since I might give the ditty a pass in a performer two or three decades younger). Of course, there's no matching the successive heights of Car Wheels on a Gravel Road and Essence, where she had a kind of anguished gravitas.

Well, I could go on, but I am opined out. Please let me know what I overlooked, or which of my judgments is most egregiously mistaken.

Spicy Southern Gothic

(No, not that spicy; this is a wholesome blog).

Is there a way to find the cure for this implanted in a pill

It's just the name upon the bottle, which determines if it will

Is the problem you're allergic to a well familiar name?

Do you have a problem with this one if the results are the same?

The White Stripes, "Girl, You Have no Faith in Medicine"

What care the Dead for Winter?

Themselves as easy freeze --

June Noon -- as January night --

As soon the South -- her Breeze --

Of Sycamore -- or Cinnamon --

Deposit in a Stone

And put a Stone to keep it Warm --

Give Spices -- unto Men --

Emily Dickinson (excerpt)

1. A psychiatrist close to me met a new patient to the clinic, a young man with a documented history of schizoaffective disorder, one day after his discharge from the hospital. Faxed hospital records describe the admission, but the patient was asked what, in his view, led to the hospitalization. "Too many spices," was the mumbled reply. Further questioning failed, alas, to illuminate this response ("spices" did not mean drugs, which, atypically, were not involved in the case).

Hearkening to a libertarian streak, the doctor's spontaneous response was, "Well, if the man prefers a bland diet, who am I to object? Are we as a society going to compel him to consume spicy food?" Perhaps the patient's figurative implication was that "the world is too much with us," and that we confront too much, too fast in this, perhaps literally, maddening culture. Perhaps this man was sane in an insane place.

Perhaps, but the hospital record suggested that this cute academic formulation wasn't the whole story, so prescriptions were duly written and the fellow shuffled back out into the extravagantly seasoned world of ours. Another reminder that psychiatry, warts and all (more every day if you watch the news), seems to be a necessary evil.

2. My commute goes between barren tobacco fields and crumbling barns, that rural part of old Dixie in which seeing the Stars and Bars openly blazoned is by no means beyond the pale (interestingly though, not only this state, but this county went for Obama, albeit very narrowly). I moved here from a slave-owning but Civil War border state, and it intrigues me to speculate on the subtle cultural differences between the two states, both a hundred and fifty years ago and now. I've been reading Doris Kearns Goodwin's Team of Rivals, which title has suffered overuse in recent weeks; the Lincoln bicentennial is just two months away.

At any rate, the other morning I saw an old black hearse sitting off in a field, with a small American flagpost affixed to the driver's side window. I wasn't sure whether this was some kind of political commentary, or someone's idea of a joke, or what. Maybe I should bring my camera next time; then again, maybe I should just keep on driving by.

Feline Farce

There have been myriad queries (okay, one or two) about the lamentable cat situation (chronicled here November 23). Pictured at right is an actual Novalis cat at risk of villainous entrapment (did I mention...? ha ha). (Due to a technical glitch, illustration later removed).

One additional cat was trapped, although it actually wasn't one of ours, but rather a stray (we think) we had seen lurking around the neighborhood for a while. My wife pleaded for its release, as it would have faced sure euthanasia at the animal shelter. The neighbors relented, and the stray was pardoned (although I haven't seen it since, so I wonder).

It turns out that the neighbor wife's cat phobia (stemming from a past "bad experience") is the issue, as well as the teenaged son's fear of having a cat scratch up his pristine new car. My first car was a 1975 Dodge Dart--I was more worried about making it across intersections without stalling than about domestic cat defacements. But I did not bring up that "bad experience."

Water guns were proferred and declined. Neighbors agreed to withdraw traps so long as steps are taken to limit feline prowling. As a gesture of good will (and a kind of neighborly placebo), we agreed to erect a privacy fence in the back that will at least keep that neighbor out of sight, out of mind (with pleasure), both for the cats and for us.

I point out that we were actually, without knowing it, offering the neighbor wife free therapy, in the form of graduated exposure, for her cat phobia. In a better world, our friendly felines would gradually have infiltrated their yard, stamping out their rodents and gently marking their territory, and, no catastrophe ensuing, neighbor wife would have been won over to their charms: cure effected. But as usual, psychiatry's efforts go unappreciated.

I tried to think of a proper cat-trapping poem to dignify the occasion; the corpus in that category being limited, I could only choose Rilke's great and terrible "The Panther" (translated by Robert Bly):

From seeing the bars, his seeing is so exhausted

that it no longer holds anything anymore

To him the world is bars, a hundred thousand

bars, and behind the bars, nothing.

The lithe swinging of that rhythmical easy stride

which circles down to the tiniest hub

is like a dance of energy around a point

in which a great will stands stunned and dumb.

Only at times the curtain of the pupil rises

without a sound...then a shape enters,

Slips through the tightened silence of the shoulders,

reaches the heart, and dies.

On Psychiatric Overdiagnosis

Consternation and derision greeted the recent Archives of General Psychiatry study that suggested that large numbers of American college students have mental disorders. Every once in a while psychiatrists like to assert that a large proportion of the population needs nothing so urgently as, well, to see a psychiatrist as soon as possible, and it gets everyone in an uproar. Psychoanalysts used to be good at this, but it works just as well for the DSM system. Rather than quibble over numbers, I have a few general comments.

Psychiatrists seem to have the idea that they are the ultimate arbiters of diagnosis. They aren't; the society in which they practice is. Now, psychiatrists do have more expertise than the average person on the street when it comes to mental functioning, but some wisdom is not the same as omniscience. The psychiatric profession--explicitly via the DSM, implicitly via aggregrated clinical habits--submits proposals as to what should constitute mental disorder. However, it is the society at large, contingent upon public attitudes and financial resources, that ultimately decides what the purview of psychiatry will be.

The analogy that comes to mind is the distinction between military tactics and defense policy. As the famous quote goes, war is too important to trust to the generals. In the case of democracy at least, a society decides (by virtue of the government it elects) the general kind of defense policy it will pursue. The military is entrusted with the mission of carrying out those military goals. But the military does not set defense policy--in a democracy at least. To be sure, military personnel have opinions about defense matters that, due to their expertise, should be given particular attention, but they do not have the final say.

To stretch the metaphor to a breaking point, the problem is that the "war on mental illness" (would that be like the "war on drugs" or the "war on terror?") is not a coordinated campaign, but rather comprises endlessly complicated guerrilla tactics carried on in many thousands of consulting rooms. Psychiatrists have their "marching orders," a plan of what is to be accomplished and what is or is not appropriate in carrying out that plan, in the form of, say, FDA recommendations, the DSM, and the nebulous concept of "standard of care," but due to professional privilege it is easy for psychiatrists to become vigilantes. They become so sure of their power and, granted, so honestly aggressive toward "the enemy" (mental disorder, recall, not the patient), that they exceed appropriate bounds. When psychiatrists try to be Batman, things go awry.

When a soldier or even a general becomes insubordinate or even undermines the mission in subtler ways, he can be removed. When individual psychiatrists commit malpractice, of course, they can be removed in a way too. But there is no easy feedback system for influencing the profession as a whole when it has strayed too far. Economics can accomplish this, and did so when society essentially decided that it could not pay for long-term psychoanalysis for anyone who wanted it.

Psychiatry, like the Republican Party, may be venturing farther into the wilderness. Criticism of diagnostic and prescribing trends, along with high-profile pharma cases rocking academic psychiatry, has put the profession out of step with "mainstream America." Psychiatry needs to understand that while people at all ages have varying degrees of mood instability and impulse control, not everyone wants to classify these differences along a diagnostic spectrum. People want to have the freedom to be odd or even imprudent even if it may do them harm; they want the freedom to screw up without having to see a psychiatrist. Lack of "awareness" and "access" can be real issues, but when psychiatrists focus on them excessively they can lose sight of the fact that some people just do not desire their services. Psychiatry seems to think, "If only they knew us better, they would like us--what's not to like?" Hmm.

For the foreseeable future there will be enough truly unambiguous psychopathology to keep the profession plenty busy without having to go stir up diagnoses. None of what I've written is meant to romanticize very real depression, bipolar disorder, schizophrenia, and yes, personality disorder and substance abuse, for which psychiatry is alas, quite necessary. But overall mainstream psychiatry is looking a lot like the party of Delay, Bush, McCain, and Palin. Let's see, whom else can I offend?

Lugubrious Lucubrations

If you're down he'll pick you up, Doctor Robert

Take a drink from his special cup, Doctor Robert

Doctor Robert, he's a man you must believe,

Helping everyone in need

No one can succeed like Doctor Robert.

Lennon/McCartney

Psychiatry is mostly unlike the rest of medicine, for better and worse, but it seems to me it has some things in common with my (admittedly distant) understanding of what a pain specialist does. If any of the latter happen to read this, set me straight.


1. Mental disorders, like pain syndromes, are often correlated with objective factors, but they are nonetheless fundamentally subjective and therefore frequently misunderstood and vulnerable to stigma. Diagnosis is therefore ambiguous and liable to being contested.

2. Both mental disorders and pain syndromes may get better with the mere passage of time. Watchful waiting is always an option.

3. Conservative treatment methods (psychotherapy/physical therapy) should be considered first.

4. Both mental and pain disorders are at risk of settling into chronic pernicious syndromes (often in a mutually reinforcing way).

5. Medication treatments in both carry the risk of addiction, sometimes iatrogenic. This can create tension in the clinical relationship.

6. In both psychiatry and pain medicine, simple cases are rare because primary care physicians have already taken care of most of those.

7. Both mental and physical distress are sensitive to suggestion and placebo (or nocebo) effect, both cultural and medical.

8. The treatments are broad in their effects and not specifically pegged to diagnosis; therapy is therefore more empirical and pragmatic than theoretical.

9. The aim is not cure, but rather symptomatic management either indefinitely or until the episode gets better on its own.

10. Both physical pain and emotional distress, beyond a certain point, threaten to become all-encompassing and to monopolize consciousness.

11. Both physical and emotional pain are necessary and at times even advantageous, but one can have too much of a good thing.

12. People may be growing less stoic, more sensitive to both physical and emotional distress in contemporary culture. There is a straight line between aspirin and Prozac.

Cool (or at least cooler than we thought)

We are stardust

We are golden

And we've got to get ourselves

Back to the garden

Joni Mitchell

And yet, except for us,

The total past felt nothing when destroyed.

Wallace Stevens, from "Esthetique du Mal"

The New York Times has a mind-bending article today about new theories of the early Earth. Some geologists are thinking that our planet cooled down rather faster than was previously thought, meaning that life may have gotten started, not as soon as conditions allowed, but perhaps only after a few hundred million years beyond that point.

Based on apparently abstruse calculations, it is also thought that soon after the Earth coalesced 4.5 billions years ago it was struck by a Mars-sized object (not Mars, but something roughly the size of Mars)--much of the extruded vaporized material came together as...the moon. In the several hundred million years after that cataclysm, the Earth is thought to have been struck, perhaps on four different occasions, by objects more than 200 miles in diameter; the energy released by each collision would have evaporated the oceans. How cool is that? What a show that would have been. It's probably a guy thing.

This morning I came upon a line in the book I'm reading (2666): "The scarred moon still shone in the sky." It is easy to forget that the Earth's surface has been ravaged even more than the moon's, but we have had the benefit of the extreme makeovers of plate tectonics. Planetary plastic surgery; the moon is a crone, the Earth remains a debutante.

Oh, there was also an article about doctors behaving badly (mostly surgeons of course). It took 4.5 billion years to produce...what?