Bedlam

Macbeth: Canst thou not minister to a mind diseased;

Pluck from the memory of 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 needed a psychiatric referral and not a brush-off; we know how he turned out (well, psychiatry was a bit green in 1600).

1. Nassir Ghaemi, M.D., a prominent name in academic psychiatry, writes a thoughtful blog at Psychology Today. In his last few posts he has started to explore the issues stemming from the recent well-known scandals of psychiatric research and pharmaceutical companies. As one would expect, the reality is neither one of money undermining everything of value in the profession nor one of open, public-spirited firms working for nothing but the common good. I still need to write my post on this topic (yes, avoidance has its uses).

2. Courtesy of Arts & Letters Daily, I see that Paul McHugh, M.D. has written a useful conceptual and historical review of the concept of hysteria, a famous shapeshifter in both psychiatry and medicine (hysterics are as likely, if not more so, to visit non-psychiatrist physicians as psychiatrists). Basically, hysteria results from the intersection of individual vulnerability and suggestibility with the prevailing winds of groupthink at any time pertaining to what constitutes legitimate illness or illness behavior.

3. Have you nursed a lifelong dream to work in a state psychiatric hospital? If so, it is commendable, because good people are definitely needed. However, before signing up you might want to look at this hair-raising account of life as a social worker in a hospital in a state located somewhere between Virginia and South Carolina. Did you think that snake pit, cuckoo's nest, etc. were safely of the 1950's and 1960's? Think again. If you're going to become seriously mentally ill, be sure to arrange excellent insurance beforehand.

This account is not typical, fortunately, arising as it does from regrettable adventures in mental health care reform. It is amazing that forty years after the great deinstitutionalization of the 1960's (the effort to move the teeming masses of then-much-larger state psychiatric hospitals into outpatient community programs), we still can't get this right, apparently through lack of funding and organizational mismanagement.

And this occurs in a nation that, before the recent economic plunge at any rate, was apparently the most prosperous in both absolute and relative terms in the history of the world. Mental health care reform appears to be where good intentions go to die. Is the economy booming? Then mental health can spare some funding. Is the economy tanking? Then mental health is going to have to tolerate some cuts. What was that about a society being judged by how it treats the most vulnerable?

Strung Out

Heroin be the death of me

Heroin, it's my wife and it's my life

Because a mainer to my vein

Leads to a center in my head

And then I'm better off than dead

The Velvet Underground

"An orgasm is nature's pale imitation of heroin."

Unattributed (if anyone knows source let me know)

Psychology Today blogger Stanton Peele, Ph.D. has a post proposing, according to him, the seven most addictive "substances," from cocaine (least) to, believe it or not, love (most). I won't quibble with his ranking per se, but since many people ask whether one can be addicted to such things as shopping, food, the Internet, and sex, it brought to mind how we go about defining addictions.

The problem is that the very concept of addiction is controversial and philosophically problematic, touching on great questions of free will, emotion, and even spirituality. Most of this is beyond the scope of this post (and, it must be said, beyond the scope of this amateur philosopher), but it seems safe to say that addictions are never entirely chosen nor entirely determined. They always hover somewhere in between, and it's hard to get one's mind around that (sort of like the uncertainty principle of quantum mechanics on a psychological level, perhaps). It is simple-minded to claim that willpower is absolute, but with addictions there is always room for choice ("Do I stop by the liquor store on the way home? Just two won't hurt.").

When we say that someone has a "conventional" addiction to something like nicotine or alcohol, we mean that the direct neurobiological effects of the substance are, if not removing, at least significantly impairing a person's capacity to avoid the substance. If a person stopped smoking three days ago and , feeling intense craving, gives in and takes a smoke, do we say that he was absolutely compelled (against his will) to do this? Well, no, but we think he has diminished volition--because of biological withdrawal effects--as compared to someone, say, who takes a smoke after being abstinent for a year.

We have a great deal of evidence now, from neuroimaging and other sources, that substances of abuse powerfully affect brain pathways. The conundrum is: how do we get form there to inferences about free will? After all, it is pretty likely that, say, flying into a rage is accompanied by certain neurobiological changes as well. If someone looks at me the wrong way and I take him down (I have not, generally, been known to do this), what keeps me from saying that "my brain made me do it?"

There would seem to be two answers to this, one biological and one sociological. Biologically, the question is how specific and how intense the neurochemical changes are as compared to what one might think of as a "normal" pleasurable experience (such as a walk on the beach, an enjoyable concert, or even sex). The more specific and prominent these changes are, the greater reduction in free will we might expect.

The sociological answer would seem to be that society, over time, develops, one hopes, a more refined consensus about what can reasonably be expected from individual behavior. It is reasonable to expect people not to fly into a murderous rage; it is not reasonable to expect all people at all times to be able to stop smoking at will without biological and other cessation strategies that may reduce hindrances to their free will.

Which brings us to the questionable "addictions" to sex, the Internet, and even food. The problem is that these activities just may not override the brain's volitional system in the same way that nicotine, etc. do. After all, just as a thought experiment, suppose that I enjoy reading books; I may even read them, at times, to cope with life's slings and arrows. In fact, I enjoy reading books so much that if I were prevented from reading them for a day or two, I could deal with it, but if it went on for much longer I would start to miss them, would become mentally restless, and would overall feel less happy. Would I be in "withdrawal" from a book "addiction?"

Similarly, if a materialistic person suffers a major financial hit, is he in withdrawal from a money "addiction," or if a "workaholic" is obliged to reduce his hours, does he suffer from "work withdrawal?" We may jokingly say yes, but we shouldn't really mean it.

To return to my example, what if I felt compelled to read so much that I neglected family and work responsibilities? (Note to wife if reading this post: please do not comment here). And after all, inasmuch as reading is pleasurable for me, it is probably associated with release of endorphins and other neurobiological changes at some level. The problem is that these changes are not above and beyond the evolutionary normal pathways that dictate our values and how we choose to attend to them. I would be overindulging in reading not because of an addiction, but because I was repeatedly choosing to do so (as emotional distraction or whatever).

There may be interesting gray areas. One might think sex would be one--after all, sex is arguably, in a purely biological sense if nothing else, one of the most focused, intense, and "rewarding" experiences we are naturally equipped to have. But the operative word here is "naturally," as nothing is evolutionarily normal if not sex. For eons societies have expected individuals to govern their sexual impulses without appeal to anything like a sex addiction clinic.

A true gray area could conceivably be video games and other virtual experiences. As these grow in intensity and engagement, perhaps they could stimulate the brain's reward systems in a way that may be beyond the evolutionary pale, such that cyberdetox would be necessary. Ars Psychiatrica does make for compelling reading, I know, but generally speaking the Internet doesn't appear yet to have reached that point.

None of this is to say that overindulgences in food, sex, or the Internet aren't problems; they certainly can be. But the issue, which may well be amenable to psychotherapy or other means of amelioration, is the individual's basic system of emotional self-regulation, not an "addiction."

Future Shock

"Telephone, n. An invention of the devil which abrogates some of the advantages of making a disagreeable person keep his distance."

Ambrose Bierce

It's interesting to think about the future, but also dismaying, as the futurologist, much like the psychiatrist, is almost certainly destined to be mistaken. But it's irresistible. William Faulkner wrote that not only is the past never dead, it's not even past. The same could be said about the future--in a metaphysical sense perhaps nothing exists except now, this precise moment, but in another sense all past and future are always with us.

The Pew Internet and American Life Project concerns itself with such things and has released results of a survey of technological thought leaders and muckety-mucks regarding what the Internet and wireless communications in general may be like in 2020. The issues explored include the form and extent that these are likely to take, the implications for privacy and security, and the possibility that these technologies may enhance social tolerance and therefore social harmony over time. Also considered is the likely growth in virtual realities (or "reality augmentation") as a part of everyday life. (All those books I've read, and I never realized I was engaging in "reality augmentation").

In 2020 my kids will be 21 and 18. I find it a constant struggle to manage what I, for lack of a better term, call their "screen time" (which in our household includes television, computer, or handheld games). At their current ages, at any rate, they can't seem to comprehend why I would want them, every now and then, to spend a little while with a book or playing outside. So it is a kind of neurological "eat your vegetables" sort of thing.

There are of course people who allow their children very little or even no "screen time." That is a bracing sort of philosophy, but I wonder about the implications in a world that will only become more filled with screens. Fast food restaurants increasingly have televisions going, as do doctor's offices and any other public place where waiting is likely. Is keeping kids away from screens anything like keeping them away from germs or allergens?

Will people be happier in the future? If you believe the forecasts, people will only get more and more connected, at least in the virtual and wireless senses, and we know that social support can only be a good thing. However, such a world would also expose us constantly to the sight of others who may be more well-off or happy than we are, which could be bad (we know that relative goods--compared to what others enjoy--are more significant for happiness than their absolute number).

Neuronarrative today has an interesting post, an interview with brain and aging expert Gary Small, M.D. about neurological implications of some of these technologies.

Archimboldi

Ay, in the very temple of Delight

Veil'd Melancholy has her sovran shrine,

Though seen of none save him whose strenuous tongue

Can burst Joy's grape against his palate fine;

His soul shall taste the sadness of her might,

And be among her cloudy trophies hung.

Keats

I don't use the term "mind-blowing" very often; or if I do, this time I really mean it. As I touched down on page 893 of Roberto Bolano's astonishing and sprawling 2666, I couldn't remember the last time I was so far into a book before realizing that it was a great one. That may sound like faint praise, as if it were merely slow to warm up, or it grew on me, or whatever; the actual literary impact is prodigious, as if one stretched Ravel's circling crescendo Bolero to a tome nearly the size of War and Peace.

Bolano (I still can't manage the tilda in his name, which is lame of me), the Chilean expatriate who lived in Mexico and later in Spain, died in 2003 at only fifty, the victim apparently of hepatitis C contracted from earlier heroin use. Since then he has become a posthumous literary superstar in the English-speaking world as his last novels are being translated. This book was included among the 10 most notable works of 2008 by the New York Times (Jonathan Lethem's review is here), and here is a useful post on it by Chekhov's Mistress.

A poet who reportedly turned to novels in his last years to support his family, Bolano was writing against time in this crowning work, and it shows, not at all in any sloppiness, but in the propulsive force of its sentences. I had the sense that Bolano was racing ahead, turning around now and then to urge haste, as I rushed to catch up to him before he got out of sight. The work contains everything expected of epic--family, love, sex, crime, war, politics, history--but in the most surprising contexts and contortions.

The framing device of the book, comprising five large, semi-autonomous and linked sections, is the fictional, extremely reclusive, and floridly pseudonymous German novelist Benno von Archimboldi. The appallingly dark heart of the book is the horrific epidemic of "femicides" occuring in Santa Teresa, Mexico, supposedly a fictionalized version of Ciudad Juarez (the real-life, drug culture-related mayhem of which is chronicled here). For three hundred pages Bolano provides a harrowing litany of women, many of them prostitutes but many factory workers or waitresses, who turn up raped and mutilated, dumped in ravines and beside desert roads. Many of them go unclaimed, and the police, whether inept or corrupt, can't make any progress in solving the crimes.

The intertwined themes of the book are beauty--the sheer indulgent delight of story--and horror--the reign of apathy in the face of absolute evil. Like all great literature, it aims to find redemption amid desolation and loss. Bolano's style strikes me as an improbable cross between Hemingway and Proust; individually, his sentences are flat, dispassionate and often wry, but their cumulative effect is noble, sweeping and reflexive, like a bird circling above a great expanse. The result is at once gritty and, at times, grandiloquent. Here is Bolano, grimly, on men and women:

Ingeborg laughed too. Then she began to talk about the way some women were attracted to men who killed women. About the high regard in which woman-killers were held by whores, for example, or by women who chose to love without reservations. In Reiter's opinion these women were hysterics. But Ingeborg, who claimed to know women of the sort, believed they were just gamblers, like cardplayers, more or less, who end up killing themselves late at night, or like the habitues of racetracks who commit suicide in cheap rented rooms or hotels tucked away on back-streets frequented by gangsters or Chinamen.

Here he is, using the very wide-angle lens, on nature:

"All this light is dead," said Ingeborg. "All this light was emitted thousands and millions of years ago. It's the past, do you see? When these stars cast their light, we didn't exist, life on Earth didn't exist, even Earth didn't exist. This light was cast a long time ago. It's the past, we're surrounded by the past, everything that no longer exists or exists only in memory or guesswork is there now, above us, shining on the mountains and the snow and we can't do anything to stop it."

Here he is describing Archimboldi's style, which captures his own as well:

The style was strange. The writing was clear and sometimes even transparent, but the way the stories followed one after another didn't lead anywhere: all that was left were the children, their parents, the animals, some neighbors, and in the end, all that was really left was nature, a nature that dissolved little by little in a boiling cauldron until it vanished completely.

Bolano's way is narrative abandon, but crucially tempered by the constraints of mortality and human frailty. The book's first section recounts the quest of four European literature professors for the elusive Archimboldi whom they both love and specialize in. The academic life is depicted in all of its alternating profundity and vacuity. The long middle of the book, set in arid Mexico, is also a narrative desert; like a plant that struggles vainly to sprout despite lack of rain, the story can't seem to escape the squalid nightmare of Santa Teresa's murderous culture. But the last section, a chronicle of Archimboldi's amazing, bewildering life, erupts in narrative ingenuity, with one story found to be encased within another in a way that put me in mind of The Arabian Nights. The best word for this book is narrative plenitude, without superfluity.

That last section brings all of the book's disparate characters together, but not in a physical sense or even in a thematic one, unless one counts the detached contingency with which people, across continents and decades, come together--for a book, for love, or for murder--and then drift away into the murk of time or forgetfulness. The story comes to an end, like life, with finality but without resolution.

Read it; no review can give a sense of it. I am encouraged to find a contemporary novel this good. The holidays may not require great literature, but January definitely will. The solstice is less than a week away.

Noises in the Attic

Alas, how is't with you,
That you do bend your eye on vacancy,
And with th'incorporeal air do hold discourse?


Gertrude

(Illustration by Adolf Wolfli, hospitalized for psychosis in Berne, Switzerland from 1895 until his death in 1930).

Auditory hallucinations are the darndest thing. We all have our moments in life obviously, and I think that my own experiences plus a willing imagination can provide at least a vague idea of what it might be like to undergo a good number of the clinical syndromes I see. Can I know exactly? Of course not, as some patients like to point out, but that is always the case between two people (can they know exactly what it is like to be me?). Like any decent doctor or therapist, I make the effort and continually check in with the person in question to see how my imagined approximation is holding up.


Voices are tough though, as I have never experienced anything like them. The ominous creak upstairs, the pillow in the dark mistaken for something else, yes, but voices are something else entirely. I doubt that dreams provide any semblance of waking hallucinations. I can only imagine that they are disturbing at the least and potentially terrifying. My lack of experience makes me all the more curious about what it might be like to have them, so I hope that imagination gives empathy a needed boost.


Voices are most commonly associated with schizophrenia, but they constitute psychotic symptoms that may occur in various other conditions: severe depression or mania, substance abuse or withdrawal, and various neurological disorders such as dementia and delirium. Visual hallucinations can occur along with voices, but the former are more commonly seen in "organic" conditions such as substance withdrawal and delirium. Atypical voices can occur with borderline personality disorder or post-traumatic stress disorder. Not long ago I saw someone with voices that, she volunteered, had names. This is unusual, and given her history of severe abuse, it may suggest dissociative identity disorder (the same as "multiple personality disorder").


If someone hears the voice of a loved one who has died, this is considered normal. Similarly, hearing the voice of God is normal if such is culturally appropriate for the person and not accompanied by psychopathology. It is also possible, although perhaps rare and certainly not well understood, for some people to have random and isolated auditory hallucinations without having a psychiatric or neurologic condition.


Like much in psychiatry, the heterogeneity of auditory hallucinations is impressive. Most commonly they are strange (i.e. not sounding like anyone known to the patient) and derogatory. That is, they utter insults, often using profanity. Somewhat less commonly, they issue commands, sometimes bizarre and sometimes threatening.


But auditory hallucinations can be quite subtle, and in those cases it is hard to know how aggressively to go after them (particularly when they aren't obviously distressing to the patient). Someone may hear faint voices but be unable to make out what they are saying (this is often described as hearing a barely audible conversation in an adjoining room). They may hear noises that don't seem "real" (i.e. generated by the physical environment) but that aren't voices. Some people hear music; this seems to occur with the elderly more often. Some of this may be more likely with the relative sensory deprivation of hearing loss.


When it comes to true schizophrenia, there is nothing quite like seeing someone in the grip of a first psychotic break, or in the months thereafter. There is a distinct air of dismay, bewilderment, and consternation. The patient appears at once puzzled, confused, and afraid. I am often surprised that patients and their families are not particularly focused on the diagnosis--it is as if they know already at some level. I give it to them anyway as gently as I can (or remind them as the case may be) and emphasize manageability of symptoms with treatment.


The psychotherapy of psychosis involves education and intentional self-distraction among other things. People in the grip of voices sometimes wander long distances away from home, as if they are being hounded. It takes them a while to learn and to believe that they don't have to listen to the voices, that the voices, despite their threats, are actually powerless to hurt them or anyone else. People who have lived with schizophrenia for years become relatively accustomed to voices, although they can obviously still be upset and agitated by an exacerbation.


While recent studies have suggested that older antipsychotic drugs (like haloperidol (Haldol)) are every bit as good as newer ones, in my experience the newer ones are better tolerated in a subjective sense. Patients are more willing to take them. The metabolic side effects (weight gain and diabetes) can be a major problem.


In the ten years since residency I have never accepted drug company gifts or support of any kind. So my drug preferences are based on what I read in the literature and my experience with patients. Risperidone (Risperdal) is my favorite antipsychotic to start with; it seems to balance solid effectiveness with good tolerability. I found out the other day that 30 doses of generic risperidone 3 mg was only $46; I was surprised, that almost approaches affordability.


Olanzapine (Zyprexa) has the worst metabolic side effects on average, but its efficacy is impressive; it is often a reasonable option for those having major insomnia and who are thin (to start with). Unfortunately it is exorbitantly pricy. Quetiapine (Seroquel) is well-tolerated, but as it too can cause weight gain (and is very expensive too), so is often prescribed too loosely for insomnia and anxiety (in the absence of psychosis). Aripiprazole (Abilify) is a decent alternative because it produces less drowsiness and weight gain, but not uncommonly it generates unpleasant akathisia (a restless feeling).


The other day at our small clinic 37 patients received their monthly or bimonthly antipsychotic injections (they are for people who cannot or will not keep up with taking pills daily, but these kinds of shots are voluntary). I heard that Risperdal Consta now comes with a smaller needle for deltoid rather than gluteal use; I suppose that is an improvement. I imagine it must hurt though.

Grand Inquisitor

The heart asks pleasure first

And then, excuse from pain --

And then, those little anodynes

That deaden suffering;

And then, to go to sleep

And then, if it should be

The will of its Inquisitor

The liberty to die.

Emily Dickinson

Several items caught my eye today. It is dark and stormy here, with the potential for sudden catastrophic death looming over the landscape (okay, there's a tornado watch); so forgive the theme of menace.

1. On the brightest note, I was alerted to a comprehensive listing of psych-related blogs at "101 Fascinating Brain Blogs" at Online Education Database. It includes all the well-known ones but also many I wasn't aware of (oh, and it commendably includes Ars Psychiatrica).

2. Art Blog by Bob yesterday featured "The Scream" and several other works of the evidently dysphoric painter Edward Munch (painter of today's illustration here as well). Check it out.

3. For any readers in Kentucky I happened upon a Scientific American article about the United States Narcotic Farm (or Narco) near Lexington. From 1935 until 1975 the huge facility housed many of the nation's criminal addicts, which included some prominent names over the years. It was the setting for a great deal of addictions research involving the prisoners, although toward the end the C.I.A. and others apparently developed concerns that research involving both L.S.D. and less than fully informed consent may have been going on. The article includes a slide show and alludes to a documentary about Narco that would be very interesting.

4. Also in Scientific American is an article on schizophrenia and its relation to language. Schizophrenia is an enormously complex illness and we are far from understanding it, but given the prevalence of auditory hallucinations in the disorder, links to language function have long been a focus. Apparently genes related to language are increasingly suspected in schizophrenia, which may be a casualty of our species' very rapid brain growth over the past million years or so. It is odd to think of such a devastating illness deriving from the same developmental pathway leading to, among many other things, the great poets.

5. The New England Journal of Medicine has an editorial on the current status of physician-assisted suicide in the United States, now legal in both Oregon and Washington state after the latter recently approved it by a decisive 58-42 margin. With 6.7 million people, Washington is twice the size of Oregon and will be an interesting test of the law.

As the article documents, the procedure in Oregon has not drawn the multitudes that were originally feared. From 1998 through 2007 only an average of 34 patients per year carried out the procedure. The law requires two physicians to independently confirm that a patient is both terminally ill and competent to make the decision. As one would expect, the most common diagnosis was terminal cancer. The "physician assistance" usually involves prescription of barbiturates, which the patient apparently must administer himself.

No psychiatrist is required to be involved, although consultation with one is encouraged if there is any suspicion of depression or questionable competence. However, the article notes that no psychiatry consultations were made in 2007, and only 12% of cases involved consultations in the nine previous years.

I have pretty firm opinions on most issues, but this is one I struggle with. We know that suicidal ideation in general is much, much more likely to be related to a mental disorder (most commonly depression, substance abuse, or schizophrenia) than not, and we are familiar with concerns arising from end-of-life suicidality that may stem from inadequate palliative care or fears of being a burden on family members.

A philosophical question in psychiatry is whether suicidal ideation can be anything but a manifestation of disorder. The arguments pro and con are complex and beyond the scope of a blog post (Courtney S. Campbell wrote a heftier review of the issues in The New Atlantis), but I personally believe that it is possible for a terminally ill person, afflicted perhaps with irreversible physical or mental decline, to desire death without being considered clinically depressed.

However, considering the finality of suicide, and the issues of subtle or not-so-subtle suggestion or coercion that can arise, I wonder sometimes if we're making it too easy, too comfortable to make such an existentially stark decision. It may be hard for a psychiatrist to say, but it is a conscious being's inherent right to commit suicide. If someone tells me he's going to, then I will commit him to a hospital or otherwise take steps to prevent him. But if he doesn't tell me or anyone else, then no one is going to stop him.

The question is: why does he think he has a right to get someone else to help him? Some decisions are meant to be excruciatingly difficult and painful; that often means they shouldn't be made at all, or if they are made, certainly not with nonchalance. I think there is some risk to any society of allowing people to go too "gently into that good night." To me this seems the wisest and most conservative approach.

Where Liberals Lurk

And if you gaze for long into the abyss, the abyss gazes also into you.

Nietzsche

I got to thinking about political dispositions in the mental health professions when I read a recent post by D. G. Myers in A Commonplace Blog. He tries to account for the great preponderance of political liberals in academia, particularly in humanities and social science departments, which is well-documented and has apparently been the case for a long time. I'm not sure I quite agree with his claims, but they are worth reading here (plus a couple of comments from yours truly).

Another group that is predominantly liberal-leaning is mental health professionals. I have remarked about this before and am quite sure that I have seen surveys supporting it, but with limited time and database access I am unable at the moment to summon citations (I welcome suggestions by anyone who knows of any, even if they don't support my supposition). I am not saying that this professional political bias is obviously either good or bad (and certainly not that a liberal therapist is better than a conservative one), but I'm curious as to why it may be. I am not aware of this kind of trend in health care professionals in general (if anything, physicians are popularly associated with more conservate viewpoints on average, although I don't have data for that either--after all, this is a hobby, not a job).

In thinking about this I was reminded for some reason of Jonathan Haidt's work on morality and political worldviews (links to which can be found here). Haidt, a psychologist who has also written extensively on happiness, has argued that both liberals and conservatives place high value on moral and ethical considerations, but that they tend to appeal to different sources of moral significance.

Briefly, Haidt maintains that moral considerations can be divided into five domains, which he describes as: harm/care, fairness/reciprocity, ingroup/loyalty, authority/respect, and purity/sanctity (and he postulates evolutionary roots for each of these). In general meaning these terms are fairly self-explanatory. His central point is that modern ethical thought in the West (which has been the foundation of liberal politics) has focused, disproportionately perhaps, on the first two domains, which pertain to issues of individual autonomy, the well-being of the self, and particularly justice.

According to Haidt, conservative thought does not disregard the domains of harm/care and fairness/reciprocity, but it tends to give equal weight to the other three domains, which relate to the need for collective restraint and clear boundaries of appropriate behavior. For example, political dissent even in tense wartime conditions, which is a basic value of liberalism, is suspect from a conservative point of view due to appeals to loyalty and respect. Liberals and conservatives often cannot agree on a particular issue not because one group is more ethical or even more clear-thinking than the other, but because their moral foundations are different. As a psychologist Haidt is just trying to explain, not to justify; I don't know if he is right, but the categories make intuitive sense to me.

So why would mental health professionals lean toward the harm/care and fairness/reciprocity domains? A possibility that comes to mind is that we tend, on average, to work with people who have been socially marginalized as a result not only of direct illness effects but also of often very powerful social stigma. Autonomy and self-determination are precisely what they struggle with; too little self and not too much (in the true sense of the term) is the issue.

We keep seeing the David half of countless David and Goliath confrontations, so perhaps it is natural for us to be critical of prevailing trends and to stick up for the little guy. Somewhere I read once that the mad are the absolute poor, for they have lost even their minds. And as Myers points out with respect to academia, once a political slant gains ground in a subculture, it often grows more marked with time as members tend to recruit more of their own into the discipline.

Of course, most liberal therapist-types are liberal well before they become therapists. And with respect to the five moral domains, we still have a lot to learn about how people, through whatever vagaries of biology and culture, develop the "courage of their convictions." And these five factors presumably interact with five other factors, those commonly used for psychological profiles (OCEAN: opennness (vs. conventionality); conscientiousness (vs. laxity); extraversion (vs. introversion); agreeability (vs. contentiousness); neuroticism (vs. lack thereof)).

For instance, I have always had a strong aversion to violence, whether toward animals or human beings. What seemed squeamish or even weak to a 13-year-old has become an attribute that I do not apologize for (although I would be a really pathetic Marine). And I have long had a regard for authority that is not, so to speak, excessive. So presumably both psychological and moral factors account for what I do for a living.