Saturday, August 25, 2012
Saturday, January 21, 2012
The Thousand Natural Shocks
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.
Wednesday, January 18, 2012
Nature and Conservatism
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?
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?
Wednesday, January 11, 2012
In The Beginning
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 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.
Monday, September 12, 2011
The Shaman Speaks
"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.
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.
Wednesday, September 7, 2011
Mental Illness Is Whatever We Say It Is
"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.
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.
Tuesday, September 6, 2011
The Religion of the Good, Part 2
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.
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.
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