Thursday, August 28, 2008

Dostoevsky's Dream

To switch from Chekhov to Dostoevsky is to enter a different experiential universe. Dostoevsky is best known for his novels, of course, but he also wrote a few great short stories, among them "The Dream of a Ridiculous Man," which can be read here (with so much on the Internet, why did I recently haul hundreds of pounds of books over hundreds of miles?). Like many of his stories, it is about moral depravity and redemption.

Dostoevsky's views of depression may make us a little uncomfortable these days inasmuch as they seem of have moral implications. The "Ridiculous Man" certainly seems depressed--he's frankly miserable, sees nothing more of value in the world, and plans a suicide. Amid his brooding he ignores the frantic pleas of a distressed little girl in the street. But after he leaves her behind he has a dream that transforms him, or so we are asked to believe.

Dostoevsky seemed to have a problem with the Enlightenment, or at least with any simple confidence that rationality and scientific knowledge will improve the human condition. At the end of this story he (or rather the narrator) writes, "The chief thing is to love others like yourself, that's the chief thing, and that's everything...The consciousness of life is higher than life, the knowledge of the laws of happiness is higher than happiness--that is what one must contend against. And I shall."

It seems that one could divide most people into two basic camps, one claiming that what we most need is "out there" awaiting discovery and the other maintaining that what we most need is right under our noses and that we need merely to recognize it and make use of it. I think that Tolstoy and Chekhov are more typically "Western" writers inasmuch as they were more of the former camp (Chekhov thought sick people needed a doctor, not "love"). The hard thing, of course, is to keep one foot planted in each camp.

But Dostoevsky's narrative "point" is well taken, since supremely rational philosophers have labored for thousands of years now to locate a foundation for morality that goes "deeper" than contingent human solidarity. And like Nietzsche, he saw consciousness as the basic source of humanity's often morbid condition. It is ironic, though, to use the highly self-conscious experience of literature to remedy the pathologies of, well, self-consciousness. Was he following Blake's dictum that "If the fool would persist in his foolishness, he would become wise?" Perhaps Dostoevsky meant that at its best, literature does not comment on life, it creates life, or a form of it anyway.

Tuesday, August 26, 2008

New for DSM-V? (Part 2)

Kids these days...One of my early interests in psychiatry was the influence of culture upon identity and psychopathology. I was fascinated by the notion of "cultural syndromes," not those from the antipodes that are rarely encountered here, but rather those operating under our very noses, and therefore potentially very common and yet overlooked. Two factors operate here, one being evolutionary psychology, and the other being historical exceptionalism, the idea that we are living in social and technological circumstances that are truly unprecedented. Of course, every generation in history has thought of itself as special in some way, but some have been more special than others. Here are five relatively novel factors from contemporary times and their speculative effects on "evolving" human psychology:

1. Changes in family structure: The rise of divorce, the increase in couples choosing not to marry, and unprecedented mobility have, many sociologists have argued, decreased the average strength of social ties and support, leading perhaps to increased prevalence of depression and borderline personality features (witness the rise of eating disorders, cutting, etc.).

2. The fragile, coddled self: As Christopher Lasch so trenchantly argued in The Culture of Narcissism from the 1970's, the emphasis upon surfaces so characteristic of late capitalism, along with the rise of the self-esteem movement in education and society generally, may have increased the prevalence of narcissism, in both expansive and depleted varieties.

3. Be careful what you ask for: While poverty and income inequality remain serious problems, on average Americans over the past few decades have lived in the most prosperous and globally influential society in history. Also, the increasingly ubiquitous media feeds images of extreme wealth into everyone's television and computer screens. Some argue that the result is "affluenza," a syndrome of entitlement coupled with the collapse of social and cultural value into economic terms.

4. The distracted, virtual self: While this area remains hugely controversial, concerns persist that the ubiquity of television and Internet has promoted distractibility and impatience on the one hand and incuriosity and self-absorption on the other. The diagnostic quagmires of ADHD and autism come into play here. Related issues are the rise of "multitasking" and the decline of reading and even intellectual standards in general. And when attention is consumed with filtering an onslaught of external stimuli, there is less interest and energy left for introspection.

5. Sexuality and the body: The unprecedented access to pornography enabled by the Internet, along with the mainstreaming of plastic surgery, have challenged traditional meanings of sexuality in relationships as well as the relation of the self to "its" body. Whether this is empowering or degrading depends very much, of course, on whom you ask. And as the self comes to be more completely conflated with the body, it may be no surprise that in psychiatrists' offices a somatic solution (for "chemical imbalance") is more often sought.

It seems to me that what all these trends share is a decentralization of value, in which the self must steer (or be steered in childhood) through a wilderness of increasingly media-driven and competing ideologies and interests. Decadent times, for better or worse...

Monday, August 25, 2008

Those Melancholy Poets

This Humble Blogger has been tied up with travel, moving, and getting the kids into a new school year, so for now I'll briefly resort to a poem, "Having it Out with Melancholy," by Jane Kenyon. Recommended to me by a former patient with quite severe and chronic depression, it is one of the best poems I've read about "the black dog."

Kenyon apparently suffered primarily from depression, although according to an essay I once read by her husband, the poet Donald Hall, there were manic phases as well. Ironically (or not) she died of leukemia when she was only 48.

This poem features the strange and harrowing intimacy the melancholic has with an disease that is not a passing affliction--not the spring allergy season, not even the breast cancer that may possibly be eliminated--but rather a lifetime partner of sorts. There are some wonderful lines. "You taught me to exist without gratitude" reflects the all too common view of depression as a failure of character, and also illustrates the reality of depression as a blight upon a state of native health. One has to "learn" not to be grateful for what the non-depressed person takes for granted, an appreciation of the basic fact of life. Indeed, for the depressed, "the pleasures of earth are overrated."

For me the heart of the poem is section five, "Once there was light," in which the speaker, in a temporary reprieve, feels an unaccustomed and transcendent unity with humanity, a unity that is violated all too soon by the return of what is later called "the unholy ghost." The depressed are singled out; their condition is nothing if not solitary. And yet the poem ends with another momentary respite, in which the speaker witnesses a bird's "bright, unequivocal eye." Like that eye, the cruelty of depression is inscrutable, but that it exists in nature (that same nature that most poets find so compellingly beautiful) certainly is "unequivocal."

I would never suggest this poem to anyone with a relatively new diagnosis--it might terrify or even mislead--but it may offer succor to anyone who has learned to live with "the black bile" over the long term.

Saturday, August 23, 2008

New for DSM-V? (Part 1)

Thanks to Arts & Letters Daily, I see that psychiatry has continued its bold foray into nosology (here's one pun I never thought I'd have the opportunity for), in the form of a study by two (reportedly) eminent researchers into the prevalence of rhinotillexomania (that would be nose picking). Apparently this survey indicates that such behavior is highly prevalent among teenagers, as it has been found in previous studies to be in adults, and as with virtually any other behavior, a certain subset of human beings apparently pushes it to the point of "psychopathology" (pain, bleeding, etc.).

Unless this news story was a hoax (in which case the joke is on this psychiatrist), is there any better illustration of the intellectual bankruptcy of contemporary psychiatry? Are there too many academics with too much time on their hands? Maybe someone can conduct a study to find out.

Thursday, August 21, 2008

Pithy Poem of the Day

As a lover of aphorisms, and as someone fascinated with issues of free will and identity (an interest only spurred by psychiatry of course), I couldn't resist this short Goethe poem (which I came across in Alex Ross's The Rest is Noise):

No one can know himself,
Detach from his self,
Yet he tries to become every day
What is finally clear from the outside,
What he is and what he was,
What he can and what he may.

If one can get past the quaint 19th-century emphasis upon "he," it is clear that this is a profound glance at the ambiguities of the free and the determined. All the subjective struggle that is at the heart of life (how to live, what to do?) merges in the end with the inevitable. And in a profession that, drawing from Socrates's infamous "Know thyself," prizes self-examination, it is worth remembering that we can never fully succeed at this (or if we did, we would in fact be fully detached, viewing ourselves as biological machines). In fact, Goethe supposedly said at some point, when the topic of self-knowledge came up (and I'm paraphrasing), "Heaven forbid that I should know myself." He meant to exaggerate, of course, but all the same some mystery must remain at the core of who we are.

Wednesday, August 20, 2008

Thou Shall Return Phone Calls

Before dismounting from my high horse, I will add a ninth rule for psychiatrists (but stopping short of an Old Testamentish ten):

9. Return phone calls. One of the most common complaints I hear from patients about their previous psychiatrist(s) is the failure to return phone calls--and not merely to do so in a timely manner, but rather to do so at all. I can't imagine doing this, any more than I can imagine just not showing up for work. I understand that, except for those private docs able to bill (and collect!) for phone calls, these interruptions of the work day seem to represent unpaid work. But it seems to me that just like the office space and furniture, time spent on phone calls should just be considered a cost of doing business, part of overhead. Of course, there are occasional patients who abuse the right or privilege to reach their doctor by phone, but those cases can be dealt with individually. Sometimes I think that if one wanted to do well in a private practice, a willingness simply to return calls promptly and politely would put one ahead of the game.

Okay, that's it.

Tuesday, August 19, 2008

Rules for Psychiatrists

Not long ago the NYT reproduced some "rules for doctors" devised by Dr. Rob in his blog "Musings of a Distractible Mind." They are worth reading, and I pondered what some rules for psychiatrists might be; at the risk of being presumptuous, I offer some off-the-cuff thoughts:

1. Even for "med management," take the time (it needn't take long) to get a sense of the patient's unique life story--its stages, its successes and failures, its hopes and goals. Doing so will help him or her to feel more understood, and it should help make the interaction more interesting to you (if it doesn't, this may be a hint that you're in the wrong specialty). I think of this as a mini-biography, distinct from diagnostic formulation.

2. Given the still very ambiguous state of psychiatric diagnosis, spend less time on hair-splitting (bipolar II vs. bipolar NOS?) and more time on what has pragmatically been helpful for the patient over time.

3. Regarding patients who seem rather annoying or downright detestable, in addition to trying to figure out how much this implies about the patient as opposed to the psychiatrist, actively try to find something to like about the patient. If you can't find anything at all, someone else probably ought to be treating him or her.

4. Be alert and don't be naive, but also don't assume you are a mind-reader as regards suspicions of "med-seeking," functional complaints, or whatever. Studies suggest that no one group of people, including psychiatrists, is better at detecting lies than any other. Take the patient's reports at face value until you have uncontrovertible evidence not to.

5. Be on the lookout for "psychopharmacological Calvinism." Substance abuse is real, and it can of course be iatrogenic, but it is also the case that benzodiazepines and stimulants are uniquely helpful for substantial numbers of patients. "Med seeking" is actually a misnomer; if you knew a particular medication to be helpful for your symptoms, wouldn't you "seek" it as well?

6. If the patient can't afford the medication, you're wasting everyone's time.

7. Take side effects seriously. Use every opportunity you can to reduce numbers of medications and dosages--but some people really do seem to need five drugs.

8. Regarding psychiatry's ability to intervene significantly in disorders over time, the discipline is still where medicine and surgery were perhaps a century ago. While the patient must have hope, beware of overconfidence and excessive expectations (particularly since these days the patient often comes in with the latter already). Diagnosis, prognosis, management, solidarity, comfort: these should be possible, even when treatment and potential for recovery are quite limited.

Okay, soapbox complete. I'm open to subtractions and additions.

Monday, August 18, 2008


I've been reading Atmospheric Disturbances, a debut novel about, apparently, Capgras Syndrome, by one Rivka Galchen, a youngish woman described on the jacket flap as having both M.D. and M.F.A. (whether psychiatry-trained or not I don't know). Featured in a moderately enthusiastic New York Times review, the book is a first-person narration by a late-middle age (or so I gather) New York City psychiatrist, Leo Liebenstein, who suddenly believes one day that his younger Argentinian wife, Rema, has been replaced by an impostor.

Inasmuch as the book involves Argentina and includes a number of philosophical themes related to identity and perception, it has raised inevitable comparisons to Borges (indeed, Peter Kramer, in an ambivalent review in his blog, suggested that the novel may have worked better as a short story). In the NYT review the book was described as "brainy," and to me that is the basis of both its occasional virtues and its deeper flaws. The prose seems too brainy, and is chock full of clever and overly literary turns of phrase as well as obscure allusions. And since this is a first person narration, it is not really believable; no one talks or thinks like this. Liebenstein never really seems real or worth caring about; he seems, well, rather like a young woman thinking and writing really hard for an MFA seminar.

The story does contain a number of ingenious variations on the theme of the double (and it's making me want to go back and reread Dostoevsky's The Double as well as Dr. Jekyll and Mr. Hyde). Naturally, the dynamic between Leo and Rema raises likenesses of Capgras Syndrome to the more mundane process of falling out of "love" (or at least the erotic phase thereof) with someone; suddenly a prospective or actual partner, while technically the same (a simulacrum, the term frequently used in Atmospheric Disturbances), seems totally different. One of the epigraphs of the novel, by Gilles Deleuze, ends with "The beloved expresses a possible world unknown to us...that must be deciphered." Does erotic love end, and mutate into something less titillating, when the beloved is in fact more or less deciphered? And reading the book reminds one that our own identity, that we like to think of as more or less stable, is in fact made up of myriad overlapping doubles; this morning I am a Doppelganger of sorts of myself as I was yesterday (almost precisely the same, but not quite).

As a psychiatrist narrator Liebenstein never really comes alive, as I said, and in fact he is positively annoying: friendless, self-involved, straining to be clever. Most dissappointingly given the fictional scenario, he himself doesn't make the basic observation that he is struggling with a Capgras Syndrome. Could a psychiatrist lack insight this completely?

This happens to be the second "Capgras novel" in the last couple of years. Richard Powers's The Echomaker featured a man who suffered a head injury in an accident and developed the Capgras delusion about his sister; overall that was a much more impressive and believable account. Galchen certainly shows potential, and Atmospheric Disturbances is intriguing as an effort at psychological and philosophical fiction, but the result is mixed.

Thursday, August 14, 2008

Talking Heads' Talking Cure

The great Talking Heads song "No Compassion" begins this way:

In a world
Where people have problems
In this world
Where decisions are a way of life
Other people's problems they overwhelm my mind
They say compassion is a virtue,
But I don't have the time.

There is a surely a tension--in medicine, in psychiatry, in this society--between an insistence on personal responsibility and accountability ("decisions are a way of life") on the one hand and the recognition of suffering and human weakness on the other. Do people truly and fully "decide" to be overweight, to be alcoholics, to smoke, to be depressed, or to "make poor choices" (that wonderful wastebasket phrase for people screwing up their lives for no clear reason we can ascertain), or does some corner of their brain, or even better, some pernicious aspect of their environment, essentially hijack the process and "decide" for them? I don't know the answers, of course, but I have long thought that the central art of medicine is seeking some balance between responsibility and compassion. At the end of a particularly bad day a later lyric might come to mind:

My interest level is dropping, my interest level is dropping
I've heard all I want to, I don't want to hear any more

In contrast somewhat to other specialties, the challenge of psychiatry is probably more emotional than intellectual and technical (we don't have procedures for the most part, and we don't have to worry so much about renal physiology, but compassionate acceptance of those with mental disorders, yes, that is not trivial).

Wednesday, August 13, 2008

Patient Consumers

I have moved into a work setting where there is much talk of "clients" and "consumers" in lieu of "patients" as those seeking mental health care (Shrink Rap recently alluded to this time-honored issue). I'm no Latin scholar (the title of this blog notwithstanding), but my understanding is that "patient" derives from the Latin referring to one who suffers or endures some condition, and not necessarily with any connotation of passivity or subordination.

It seems to me that suffering is the key concept here. A consumer utilizes goods or services in a discretionary sense, and one could argue that this could include even "somatic services" such as a manicure, a massage, or even (illegally in most places of course) sex. A client is in need of someone, such as a real estate agent or an attorney, for representation or guidance in a potentially complex social or financial interaction. But a patient is someone who is either actively suffering or under threat of potential suffering and death in the future; in the latter sense we are all of course "patients" at some time or other.

To be sure, one could argue that someone presenting for an annual physical may not be actively suffering at all (until the rectal exam), but however much we might try to talk about "wellness," it remains the case that doctors' offices make people nervous because they are reminders of vulnerability and mortality. Doctors (including, indirectly at times, dermatologists, radiologists, and, yes, psychiatrists) are entrusted with matters of life, death, and suffering, so I would argue that anyone interacting with a physician in a professional setting is in fact a "patient."

Psychotherapists of various kinds occupy an interesting middle region here. Certainly people who consult psychotherapists are in some kind of distress, more so on average, presumably, than those who consult real estate agents or attorneys. And some cases of psychotherapy are so existentially intense (or the symptoms involved so severe) that patienthood seems appropriate (after all, therapists are called upon at times to hospitalize people, and it sounds ridiculous to talk of consumers or clients being committed to the hospital). However, some cases of psychotherapy (for instance, marital counseling) may be sufficiently narrow, and sufficiently bordering on what some might consider "problems of living," that "client" may be a suitable term.

I for one think that "consumer" is never appropriate in clinical contexts--save that for the accountants and insurance companies. To refer to patients as comsumers is to minimize their distress, both actual and potential; it is to imply that they are suffering no more than someone stopping by the convenience store to consume a six-pack.

Tuesday, August 12, 2008

Chekhov Revisited

I've been rereading more Chekhov--this guy was so good it's scary. In just the last two stories I've come across both ends of the affective spectrum, and both illustrate his subtle approach to the interplay of psychopathology and social context. "A Dreary Story" (you have to have literary nerve to give your stories titles like that) is about an aging professor who has become deeply embittered and alienated from his profession, his family, and indeed all that he used to hold dear. The prospect of his death, which can't be too far away, is both terrifying and eerily pleasurable. He is tired and isn't sleeping well--is this a geriatric depression? If so, it is a fascinating look at how depression drains the world of value. But we get the impression that this fellow may always have been a prickly and curmudgeonly sort--is this rather the ungraceful aging of a depressive and irritable temperament? (Where did I once come across the comment that in old age people are very much as they were when they were younger, only more so?).

"The Black Monk" features a cerebral and intellectually ambitious student who, while visiting the estate of his future father-in-law, appears to have a manic episode in which he hallucinates "the black monk." But this manic episode is subtle--he sleeps little and seems to take ecstatic pleasure in the luxuriant summer beauty of the rural estate and in the love of his future wife. It is only when he hallucinates more regularly, and becomes convinced that this madness is the mark of distinction setting him apart from "the common herd," that we realize that we have entered for sure the realm of psychopathology. He spurns his wife and father-in-law, and their reaction is interesting: they realize he is mentally ill and therefore not fully responsible for his actions, but since there is no real treatment available (this was in the 1890's), they cannot help but resent his actions. In Chekhov, as in real life, personal freedom and responsibility, versus the lack thereof, always remain murky, although ultimately we must always choose when to view ourselves and others as either agents or as victims. Most important, in his work psychopathology is never a simple natural kind, but is inextricably tied into a network of personal and social meaning. The question is always: where does the person end and the illness begin, and is it even proper to think the two can be separated?

Monday, August 11, 2008

Voting for Values

Since there has been no end to pop psychologizing about John Edwards, I can't resist the impulse to weigh in, not about him individually but about why the issue matters and should matter. After the obvious question of why he would or could do such a thing (when will they learn?), what seems to puzzle most commentators in the media and blogosphere is why a "private" issue like adultery should have any bearing on a person's fitness for public office. The answer is that a president, or at least the president in a culture like ours, is not only, or even primarily, an administrative technician, but rather is elected to represent and embody the nation's values.

"Why can't we be more like Europe?" a number of commentators have asked. They argue, accurately, that the blatant lying (Edwards's "tabloid trash" denial) is necessary only because of the allegedly absurd sexual standard and public nosiness about the same. Why can't politicians be free to fornicate in peace so long as they are breaking no laws and performing their public duty? The answer is that for the president at least, a crucial part of the public duty in question is respecting the value system of the majority (so long as it does not oppress the minority).

Unfortunately perhaps for liberals (and I am to the left of center), the majority of Americans deem fidelity in marriage to be a crucial value to be upheld in the public sphere. And not only fidelity in marriage--it would seem that while we may be ready for a biracial or a female president, we're probably not ready for a single president (even if there were convincing evidence that he or she wasn't gay). A single and childless presidential candidate would not, and could not, be seen to share the values of the majority. For the same reason, an atheist or homosexual could not be elected president. These limitations may change of course, as more people choose not to get married, procreate, or go to church, but that lies in the future. For now, spouse, children, and church must be in the political picture for national office, thanks to democracy. Again, I'm not saying it should be this way, but it is.

Sunday, August 10, 2008

Order and Mayhem

Yesterday I finally saw The Dark Knight, apparently one of the last people to do so since its release just a couple of weeks ago. The media coverage of the film, along with the tragically real Heath Ledger connection, reached new heights of absurdity, but in this case I surprise myself by finding it warranted. This is the first comic book movie I've seen in which the niftiness factor and the visual artistry took a back seat to the sheer evil of the villain; it is the first one I've seen that transcended camp and succeeded in being genuinely disturbing. This Joker is a reasonable pop psychological depiction of true psychopathy, as opposed to more conventional forms of villainy stemming from ambition, greed, or even the lust for domination. This Joker desires mayhem for its own sake and revels in the infliction of pain; as he convincingly states, the one thing human beings cannot tolerate in their interpersonal understanding is chaos, which is the ultimate inscrutability. What we cannot stand above all is an absence of pattern. This Joker is all surface and no core, and we are given no traumatic biography to account for his nature: it just is. As in the case of Iago, we are deprived of the comfort of (supposed) explanation.

Is psychopathy, like suicide, one of the unique risks of consciousness? Do other primate species have anything corresponding to psychopathy? No celebrity watcher, I know nothing about Heath Ledger (I never even saw Brokeback Mountain), but one can't help but speculate that playing that Joker could prove the last straw for someone laboring under a particular psychological burden.

Back in the real world, in China, chaos erupted on an individual scale despite unprecedented measures to ensure total order and predictability. I have no idea why the Chinese man in question, described as a 47-year-old factory worker who was divorced and apparently without a current permanent address, fatally stabbed an American (the father-in-law of the men's volleyball coach) and then leaped to his own death. Was he depressed and angry, or disgruntled, or paranoid and delusional? It goes to show that the potential for chaos, however remote, is the price of freedom. Certainly cultures, as much as individuals, vary in their tolerance of chaos.

Thursday, August 7, 2008

Poetic Suicide

There is an interesting suicide poem, "Trouble" by Matthew Dickman, in the current The New Yorker. When one steps back and considers enough suicides, by different means in varying circumstances, it starts to seem dangerously anthropological in a way, as if suicide is just a behavior that self-conscious entities exhibit on occasion. People speculate about elephants and whales sometimes yielding voluntarily to death, but few things separate human beings from the rest of the animal world more starkly than suicide. Consciousness (or at least some neurological proclivity of which consciousness is an epiphenomenon) must have had major survival advantages over evolutionary time in order to outweigh suicide.

One alarming fact about psychiatry in the modern era (the past fifty years, when psychotropic medications have been more widely available) is the minimal impact on the suicide rate, which has hovered around 30,000 annually in the United Status for quite some time. Clearly there is much that we do not understand about suicide. Suicide has a grip on the social and historical imagination that far outweighs its actually impact on mortality; obviously one is much more likely to die of heart disease, cancer, or even an accident than from "self murder." In psychiatric practice it is striking to see the wide continuum of suicidal thinking and behavior. Of course, it is a truism that virtually all "normal" people occasionally have the thought of suicide cross their minds, particularly on a really bad day, but one useful boundarly marker of the grim realm of depression is a qualitatively different attitude toward suicide, which takes the form of a wan indifference to the attachments and rewards of life. Before one can pursue death one must first abandon life. As the conclusion of this poem suggests, this temptation must be resisted. Why? As every parent tells their children, "Just because."

Wednesday, August 6, 2008

Med Managers

In this month's issue of Archives of General Psychiatry, an article documents a decline of visits to psychiatrists involving psychotherapy, from 44.4% in 1996-97 to 28.9% in 2004-05. To anyone in the field this is about as surprising as the weather forecast in August (as of last evening, "It's going to be another hot one").

There are three issues pertaining here, and two of them--the overall continuity and quality of care delivered to patients, and the economics involved (some argue that treatment split between therapist and prescriber leads to more overall visits and therefore more expense)--receive the most attention, properly so. But the third issue, hardly trivial, is the satisfaction or lack thereof of being a psychiatrist. It is hard for me to imagine that undiluted medication management, particularly done at the q 15 minute pace that is increasingly standard, could be anything but a mind-numbing grind, an evil necessary only for paying the bills (particularly the ever larger student debt burdens of new physicians). Think about it--at this point, and for the foreseeable future, psychiatry enjoys neither the scientific specificity nor the treatment efficacy (except maybe in the case of ECT) of other specialties. If there is no time to engage with patients' stories, how many people realistically would want to do this?

Tuesday, August 5, 2008

Dylan as Medical Humanist

From Bob Dylan's "Open the Door, Homer"

"Take care of all your memories,"
Said my friend Mick
"For you cannot relive them
And remember when you're out there
Tryin' to heal the sick
That you must always
First forgive them."

The sick are sure to have committed at least one of two sins: either reminding us, the well (for now), of our own vulnerability or mortality; or having brought on or exacerbated their illness through their own action or inaction. This is true of mental illness above all, giving rise to the stigma we all know so well.

When Dylan finally gets his Nobel it will be for lyrics like this.


If a psychiatrist/therapist were to read only one poet, I would propose Dickinson, who takes in the exaltations and debasements of human experience like no other. But if one could read only one fiction writer, I can think of none better than Chekhov, who contrastingly explores the great and ordinary middle range of humanity. They complement one another well, Dickinson covering the remote ends of the bell curve and Chekhov covering the wide middle. In fact, Chekhov's persona--unpretentious, exacting, detached, unsparing yet humane--is exactly what one might hope for in a great therapist and diagnostician of the soul. "Ward 6" is a dismaying, even terrifying exhibit of the perils both of madness and of the medical profession, but I wish that every medical student and therapist in training could read it.

But there is no Chekhov story that is without its humble yet transcendent insight. This morning I reread one called "The Teacher of Literature," and at the end I had the wonderful thought that "This isn't fiction at all, this really happened just so, and I was merely a fly on the wall." It had the two necessary ingredients of great literature: strangeness (different century, alien culture) and absolute fidelity to reality.

Monday, August 4, 2008


Regarding the purview of psychiatry, there is always the option of delimiting it to the classic syndromes: schizophrenia, bipolar disorder, and severe major depression. Fencing these off from the messy domains of anxiety, substance abuse, and personality disorder is certainly tempting. Indeed, sometimes it seems we suffer from category mistakes, and that problems of living are no more psychiatric than, say gun control issues are medical. Heart attacks kill people, and so can nuclear weapons, but that doesn't mean that both are equally the bailiwick of the medical profession. Similarly, depression and unhappiness both cause psychic distress, but they are not equally psychiatric. What is the discipline, though, that deals specifically with problems of living as opposed to mental disorder?

Sunday, August 3, 2008

Bandaged Moments

What better place to start than Emily Dickinson, the Vincent Van Gogh of literature where the intersection of psychopathology and genius is concerned? It is hard to think of many other writers of her stature who suffered such psychological impairment over such a long period of time. This is not to "pathologize" her or to detract from her very high rank, it is merely to state the obvious.

Of perennial interest, Dickinson is the subject of a new book by Brenda Wineapple, which chronicles the relationship between the poet and Thomas Wentworth Higginson, her literary mentor of sorts and at times reluctant correspondent over many years. It is hard to think of a more representative mid-19th century American figure than Higginson, who was an abolitionist and a liberal and literary clergyman. But he was utterly conventional in ways that must have placed him in a different experiential universe than Dickinson at times.

Dickinson wrote plenty of tortured lyrics, of course, but some are breathtakingly simple, straightforward, and lovely:

The earth has many keys.
Where melody is not
Is the unknown peninsula.
Beauty is nature's fact.

But witness for her land,
And witness for her sea,
The cricket is her utmost
Of elegy to me.

Past is Prologue

Is psychiatry worth doing, and if so, why and how? I suppose those questions are the point of this blog. The last few years haven't been very kind to the profession. The diagnostic system remains an object of derision to many, the medications have become ever more suspect in terms of both safety and efficacy, and sleaziest of all, more and more psychiatrists have been discovered to be in bed with pharmaceutical companies. And it hasn't only been individuals whose integrity has been questioned--psychiatry's leading professional organizations and journals (and by implication its methods of research and publication) have come under increasing suspicion.

So the point of this blog is to explore what remains vital and worthwhile in the field, and to my mind that requires drawing on broader traditions, of history, philosophy, religion, and the arts. Any psychiatrist ends up being asked countless times why he or she chose such a peculiar and, to some, appalling line of work. Perhaps psychiatrists get this more often than other therapists because of an assumption that the former, had they wanted to, could have become "real doctors." At any rate, one answer for me is that in medical school psychiatry seemed to have a breadth far surpassing other disciplines; instead of poring over laboratory results or doing the same procedures over and over again, psychiatry seemed to offer a chance to engage with some of the great questions in life: the distinctions between health and illness, the nature of happiness, the definition of the worthwhile life. Particularly in the context of psychotherapy, the field seemed the most flexible and genuine, and the least coldly clinical. Being at risk of being called a shrink for the rest of one's life, or of being coolly dismissed by surgeons (or heck, by family physicians, who may be glad to be one discipline up from the bottom of the totem pole), seemed a modest price to pay for more authentically interesting work.

I can certainly say that I still would choose no other branch of medicine, but the field seems flatter and narrower than it once did. I know that some of this is due to the kind of acculturation that anyone goes through--much of it is "old hat" to me now. But in the case of psychiatry it goes further, I think, largely because of the inexorable pressures of economics. It is not only the case that psychiatrists very rarely do therapy any more--that change has been going on a long time now. But in my experience people, both inside and outside of medicine, are increasingly surprised if a psychiatrist has anything at all insightful to say about anything beyond medication issues. I think that trend has to be resisted. Anyone who is not only diagnosing people with mental illnesses but also prescribing mind-altering medications should strive to have the broadest (dare I say wisest?) view possible of the endeavor. And this is not merely for the benefit of the patient--it should make the activity much more interesting to the psychiatrist as well.

So I will comment on ideas, cultural trends, and the arts as they influence psychiatry and are influenced in turn. I claim curiosity more than I claim expertise or comprehensiveness, and I welcome comments, objections, and suggestions.