Sunday, November 30, 2008

Breathe In, Breathe Out

The mind is its own place, and in itself
Can make a heav'n of hell, a hell of heav'n.

Satan, Paradise Lost

A miserable day in the East, and I chose to face the holiday-shopping hordes, unbowed by cold rain and recession. I drove around for hours in search of the lump-of-coal megastore. In vain.

One must cleanse the palate before a Monday.

"I have no name;
I am but two days old."
What shall I call thee?
"I happy am,
Joy is my name."
Sweet joy befall thee!

Pretty joy!
Sweet joy, but two days old.
Sweet joy I call thee:
Thou dost smile.

William Blake, "Infant Joy"

Evil: The Leftovers

"Come, you spirits

That tend on mortal thoughts, unsex me here,

And fill me from the crown to the toe top-full

Of direst cruelty! make thick my blood;

Stop up the access and passage to remorse,

That no compunctious visitings of nature

Shake my fell purpose, nor keep peace between

The effect and it!"

Lady Macbeth

Or should it be "Leftovers: the Evil?" At any rate, moral outrage, like revenge, is probably a dish best served cold.

When I think about the Mumbai murderers, I realize that indignation, in its simplifications and its threatened demarcations of "us" and "them," can be too pleasurable for our own good. But Scott Simon's commentary at NPR agrees, vis a vis evil, that some acts are so heinous that no adjective will better serve. As he points out, for the truly evil, there are no innocents; in that sense, perhaps evil is itself a theory of human nature (a theory that, despicable in itself, views human beings as inevitably despicable).

Ironically, these Mumbai horrors feel worse than suicide bombings (even those that, like 9/11, killed far more people) because they were so much more cold-blooded and required sustained, ongoing deliberation. The suicide bomber must of course massively rationalize his act, but he knows that he won't be around to witness the suffering and mayhem he generates. Accounts in Mumbai agree that these people went out of their way to kill indiscriminately at point-blank range--the old, the young, women, men, it didn't matter. Consider how much effort it surely must have taken to suppress any stirrings of empathy as the killers methodically went from room to room. These actions were evil in a very intellectual sort of way.

That these acts presumably had political ends makes them no less evil. I used to think that the routine denunciations of such atrocities by the President and other heads of state was fairly absurd, stating the obvious. But I'm starting to think that nothing can be taken for granted morally any longer, and the world needs these "routine" restatements of what the civilized realm holds to be justified or unjustified. If we want to "despise the sin, not the sinner," that is fine with me. Evil is the ultimate diagnosis, I suppose, so let us label behavior, not persons. But let us label certain kinds of behavior unambiguously and not bring in extenuating factors of upbringing, biology, or political ideology.

A recent book I need to pick up is the philosopher Susan Neiman's Moral Clarity (her Evil in Modern Thought of a couple of years ago was both accessible and illuminating). Without resorting to simple-minded dichotomies, we need guidelines in a world of increasing moral murk, in which the more we know, or think we know, about the infinite complexities of culture and biology threatens to generate Hegel's "night in which all cows are black."

I am no Jonathan Swift (1667-1745), but his epitaph has been on my mind lately:

Hic depositum est Corpus
Huyus Ecclesiae Cathedralis
Ubi saeva Indignatio
Cor lacerare nequit,
Abi viator.
Et imitare, si poteris,
Strenuum pro virili
Libertatis vindicatorem.

Translated by William Butler Yeats as:

Swift has sailed into his rest,
savage indignation there
cannot lacerate his breast.
Imitate him if you dare,
world-besotted traveller,
He served human liberty.
Addendum 11:39: It occurs to me that evil is the obscene negative, in the moral realm, of what God is in the metaphysical realm. It seems that both must exist, even if, disappointingly, as sociological necessities.

Saturday, November 29, 2008

Time Out of Joint

"Demand me nothing; what you know, you know:

From this time forth I never will speak word."


We have had a month of relative, even sentimental political hopefulness, and a few days of giving thanks. Now the moral rhythm, as well as recent events, demands a return to the tremendous subject of human evil. (Ho Ho Ho to you too, dear reader, by the way; well, okay, I never was asked to be Santa Claus at work, I always wondered why).

The immediately infamous incident of the hapless Wal-Mart worker trampled to death during a pre-dawn Black Friday shopping stampede was enough to get me brooding (okay, it doesn't take much). Not only did the initial pressure of the mob lead to the appalling turn of events, but individual shoppers reportedly resisted attempts to clear the area for rescue efforts and for the sake of at least minimal dignity owed toward the dead. It is hard to think of a more grotesque reflection of contemporary capitalist consumption; may those shoppers relish their plasma TV's in complete moral equanimity! As commentary on our economy, it is a visceral, freakish and microcosmic counterpart of the recent Wall Street mayhem. Our culture satirized itself perfectly. I hear Sweden is awfully June and July.

I've always been interested in the way psychology has struggled to deal with the hulking fact of human depravity. We try to stow it away in little boxes like psychopathy, antisocial personality disorder, and situational and contextual predispositions to malfeasance (see Walmart, stampedes). The poets and artists have been much better, recognizing that this is, along with love, one of the great subjects. Shakespeare's Hamlet, King Lear, and Othello derive much of their irresistible, infernal power from the central fact of nefarious humanity. It doesn't make for very pleasant drawing room conversation, however, and perhaps not for proper blogging, I don't know. So many other things are easier to talk about.

Moral indignation can be a very strong human emotion, and one that very likely has deep evolutionary roots. Particularly outside of the United States (well, and China), capital punishment is politically incorrect, but it can be surprising how often relatives of murder victims not only clamor for the death penalty, but want to be present when it is carried out. Reportedly one of the ten Mumbai terrorists was taken alive. How we wish he could provide some eloqent window into the darkness of those deeds! Unfortunately he will probably be, like Iago, morally mute; evil cannot ultimately justify itself, but neither does it have to.

The child psychoanalyst Melanie Klein postulated that we experience evil in ourselves first but, unable to bear it, project it upon others, in what she called the "paranoid-schizoid position" of infancy; for the baby, the Other is either all good (breast available) or all bad (breast withdrawn). She argued that moral complexity develops in the "depressive position," in which we recognize the Other as, inevitably, an amalgam of good and evil (it is "depressive" because the rage that, one hoped, could eradicate the Evil Other would also, it turns out, eliminate the Good Other as well; moral complexity is difficult and therefore disheartening).

But evil, like beauty, artistic capacity, or love is distributed unequally among individuals and, arguably, among cultures and epochs as well. Freud, famously shaken by the epic brutalities of World War I, was driven to postulate the "Death Instinct" as an explanation for the darker regions of our nature that he felt he had previously not adequately accounted for. This formulation turned out to be one of the most controversial and least substantiated of his provocations (and with Freud, that's saying a lot), but it does embody a psychological attitude that, I think, we don't have a good name for. It is the confrontation, not of the primitive babe, but of the average adult, with the moral abyss. Moral outrage we might call it, or moral disappointment. Or perhaps it is a kind of moral grief, a mourning of an ideal of human nature; of course, we know that idealists fall, hard.
Okay, no succumbing to the "spirit of gravity," but I also know I won't be setting foot in Walmart this holiday season. Actually, I am always surprised by how many patients mention trips to Walmart as a virtually pathognomonic stressor; no experience seems to set off a smoldering panic disorder, or sometimes something worse, so reliably. Of course, is this "mere" faulty anxiety, or rather the canary in the coal mine, a tell-tale sign of deep evolutionary wisdom?
"Keep up your bright swords, for the dew will rust them."

Wednesday, November 26, 2008

Wishful Thinking

Edward Munch, The Sun (1912)
(Giving thanks four months in advance).

At the earliest ending of winter,
In March, a scrawny cry from outside
Seemed like a sound in his mind.

He knew that he heard it,
A bird's cry, at daylight or before,
In the early March wind.

The sun was rising at six,
No longer a battered panache above snow...
It would have been outside.

It was not from the vast ventriloquism
Of sleep's faded papier-mache...
The sun was coming from the outside.

That scrawny cry--It was
A chorister whose c preceded the choir.
It was part of the colossal sun,

Surrounded by its choral rings,
Still far away. It was like
A new knowledge of reality.

Wallace Stevens, "Not Ideas About the Thing but the Thing Itself"

Tuesday, November 25, 2008


"They have been at a great feast of languages, and have stolen the scraps."

Love's Labour's Lost

The New Republic features a review of a history of scrapbooks in America. In the Table of Contents the topic didn't initially draw my interest, but I found myself reading it and am glad that I did. Like many hands-on pursuits, the endeavor may have waned in recent years, but it has a wider history and extent than I was aware of. I never did keep a scrapbook per se, although I have been an inveterate collector of various things, this side of hoarding I hope.

The article brought to mind the strange hybrid identity of the weblog, even though I was surprised that the author didn't make the obvious connection to blogging. People blog for myriad reasons, of course, including the advancement of political points of view, academic arguments, or quasi-professional self-expression or activism. And the blog has features of a public, or in the case of anonymous bloggers, semi-public, journal, that is, a record of personal events or observations.

But blogs also often serve as digital scrapbooks, asserting both general value and individuality, often in non-verbal ways. Both blogs and scrapbooks take what may seem to be personal or cultural ephemera (in one case, digital, in the other, paper) and lend them some permanence. Some are more personal and some are more generally cultural, but all are declarations to the world: "I am a person; this is what I care about." The implication is usually, as Mr. Rogers might say, "Wouldn't you like to care about it too?" It has been said that most writing, most art in general, bears an element of seduction, in a sense far more broad and subtle than the erotic. As a hybrid journal/scrapbook, the blog is like this too, reaching out and documenting items that are somehow poignant, compelling, or lovely, and expressing the hope that someone else out there will agree.

In terms of style, few things in a blog are incidental or accidental. Given the finite number of templates available (for those of us too cheap or time-pressed to use custom platforms), I am continually amazed by the diversity of verbal and pictorial worlds in the blogosphere. The basic template; the ratio of text to image; the tone, frequency, and content of posts all convey an unmistakeable individuality (even if pseudonymous). Even a blog that, like a therapist's office, might aspire to seem "neutral" would in fact convey far more. Of course, some blogs are endearing, some plain, some downright offputting.

The amazing thing is how the Internet has leveled psychological barriers to self-exposure. How many people would walk down the street asking random people to look at their journal or scrapbook? Not many, but the blogosphere is a virtual street in which those "random" people are in fact in search of scrapbooks to look at. If ebay enables the exchange of merchandise, and datings services enable relationships, the blogosphere enables a weird kind of communal digital scrapbook that both reflects and refracts the world in real time.

Breaking...Local Cat named Best in World

In a nice segue from last post, I am astonished to learn that I live within a half hour of the Best Cat in the World. Santos, a one-year old black Persian that is originally from Venice but now lives in north Raleigh, beat out 729 feline competitors to take the Cat Fanciers' Best in Show in Atlanta. Santos reportedly sleeps on blue silk pillows in his own room and has a serious catnip habit. After this big win he might be able to have some girlfriends. Details here.

Sunday, November 23, 2008

You Be the Judge--Please

Presumptuous maid! with looks intent

Again she stretched, again she bent,

Nor knew the gulf between.

(Malignant Fate sat by, and smiled)

The slippery verge her feet beguiled,

She tumbled headlong in.

"Ode on the Death of a Favorite Cat"

Thomas Gray

Good fences may make good neighbors, but they are mere nuisances to felines. I need feedback on this post, to settle an urgent question of practical ethics, in the general area of neighborhood pet management. Our neighbors are cat-intolerant, and this has generated friction. We are aggrieved--do we have a right to be?

We possess a number of cats that is well above the mean, but still in the single digits and still, I would argue, short of the threshold of pet-hoarding pathology (all were shelter cats or strays). Most of the cats stay in the house, but all are free to come and go, and while they generally stay in the immediate vicinity, they sometimes feel the need for more extended perambulations. Our cats are typically well-mannered, and most of the neighbors whom they have visited have expressed pleasure in having made their acquaintance.

A month or two after having moved into the neighborhood, the fellow next door, with whom we had had minimal contact (it is a rural area, and he keeps to himself), came over and politely mentioned that at least one of our cats had ventured onto his deck, and that his wife is allergic to cats. I had never heard of cat allergy being triggered by a cat passing through the back yard, and I mumbled something about the difficulty of constraining the movements of felines. I told him we'd keep an eye out for cats in his yard, and that he should feel free to shoo them away (in point of fact, I had never actually seen a cat in his yard--if anything they seem to prefer the yard on the other side of us--but I didn't doubt that it had happened once in a while).

We heard nothing else from them, until a few days ago we got a call from the county animal shelter about one of our cats--it had been caught in a trap set out by our good neighbor. The cat was unharmed, but of course there was a fee to reclaim our cat, and this time of year one hates to think of a cat stuck in a trap for whatever period of time it might take for someone to realize it is there. This time the complaint, per the animal shelter, was that paw prints had been found on the neighbor's car.

My point of view is that roaming cats are very much like barking dogs--they can be annoying to those who don't care for them, but they are just a price of living in proximity to other human beings, who tend to like to keep animals of some sort. Actually, I can't imagine how a cat or two walking through the yard is even remotely as annoying as a back yard dog that won't stop barking. The cats do not tear up plants or otherwise destroy property. The worst they could conceivably do is leave a bit of fertilizer behind, although they usually do that in the litter boxes or in the woods behind our house. Ours are certainly not aggressive in any way (they are all healthy and up to date on their shots).

Obviously with respect to law our neighbor has a right to trap any animal on his property that he doesn't want to be there. But with respect to ethics and social convention I think this is a ridiculous situation. Is the onus really on us to keep all the cats in the house so that none of them might venture past the property line? Oh, how I hope this fellow decides to get a dog--I have sensitive ears!

Friday, November 21, 2008


When I was probably around 11 years old, my family stopped by Cape Canaveral on a vacation. At that time, which just preceded the inception of the Space Shuttle program, the mighty legacy of the Apollo program still lingered over the place. Human beings venturing onto other worlds, braving the void: this was the stuff of science fiction and, then, science fact. I understand the financial limitations of space endeavors, given all we face on earth, but neither the Space Shuttle program nor the robotic probes to distant planets vies with human exploration in terms of what really inspires us.

I cannot recommend too highly In the Shadow of the Moon, last year's superb documentary on the original moon landing. Featuring many of the early astronauts (excepting, notably, Neil Armstrong), it conveys the incredible wonder--and barely acknowledged terror--of those first forays into the universe. It is hard to know how that compared with other epochs of human exploration. Countless explorers have ventured across land and sea, at times when failure and death were real possibilities, but all earthly wildernesses feel like home compared with space. The void is emphatically not the natural place for us, lacking everything in which we evolved as animals.

Some have wondered about the psychological impact upon prospective astronauts to Mars as the earth ceases to be visible world in space and shrinks to merely another, if faintly blue, "star" in a black sky. This perspective is routine in science fiction, but perhaps nothing is more easily written than done. Costs and technical challenges limit manned (or womanned) space exploration, of course, and astronauts have obviously and notoriously been lost before, but perhaps the risk of human beings dying, not in fiery explosions which are bad enough, but freezing or suffocating on a cold, dark world beyond recourse, also gives one pause.

This post has taken a gloomy turn, when I intended the opposite. I know: Barack Obama will revive NASA and perhaps SETI as well! Yes we can! Millions of years from now some alien intelligence, intercepting our broadcasts across the deeps of space, will reach 2008 and wonder, "Wow, who was that guy, and why did everyone love him so much?" His (alien) Republican neighbor will mutter, "Just another liberal."

Thursday, November 20, 2008

Nothing Doing

1. The resounding warnings about overuse of antipsychotic drugs in kids seems analogous to their questionable use in the elderly with dementia. In both cases there are dreadful situations (out-of-control kids and out-of-control "seniors," I suppose the current euphemism is) and the implied question, "Doctor, is there nothing that can be done?" To be sure, sheer habituation, as well as intellectual laziness--the failure to consider situational or behavioral factors--play a role, but there is also the inability for so many doctors to say, "Well, no, I suppose nothing can be done, nothing medical anyway." This is not, of course, new--as much as we like to complain about the state of things now, throughout history the foolish audacity of doctors knew no bounds (think of all the bloodletting, mercury, etc.).

2. The humbling reminder of the "organic" roots of Gulf War Syndrome (see John Grohol's post yesterday) is another installment in the centuries-long debate over psychosomatic illness. The battle lines, so to speak, are always shifting. I've never done much VA work myself, but during my medical education and training in the 1990's Gulf War Syndrome ranked up there with fibromyalgia and chronic fatigue syndrome. Indeed, Elaine Showalter's 1997 book Hystories included the former along with entities such as alien abduction syndrome and satanic ritual abuse, phenomena fueled by media hype and mass hysteria. Of course, what makes this business so fiendishly difficult is that the revelation of organic roots for such issues still in no way rules out psychological and sociological overlay in individual cases. But it is a perfect example of the always questionable assumption that medically unexplained symptoms must therefore be psychological.

3. Dear Prudence at Slate responds today to someone (apparently with schizophrenia) writing about a family wanting to perform an exorcism on him or her. This is more lurid than what I usually hear, but nothing is more common in stories of mental illness than the incomprehension and condescension of even well-intentioned family. "Get out more," "Think positively," etc. These recommendations have a grain of wisdom, of course, but usually reflect a total lack of understanding of mental illness as opposed to, say, a transient emotional funk.

4. Emily Dickinson poems and Seinfeld episodes have this in common: both are extremely pithy, and relevant examples of both can be found for any life circumstance. So a comment from last post brought this one to mind:

They say that "time assuages," --
Time never did assuage;
An actual suffering strengthens,
As sinews do, with age.

Time is a test of trouble,
But not a remedy.
If such it prove, it prove too
There was no malady.

(A stoicism out of step with our times, perhaps with any time).

Tuesday, November 18, 2008

Gallows Humor

I recommend this New York Times article about humor (or the lack thereof) in psychiatry. I think psychiatrists tend to be serious not only out of respect toward patients and their experience, but also because the profession does not yet enjoy the (self-)respect that would allow it to laugh at itself. Sometimes drawing too much attention to the absurd, however tempting it might be, is not a wise (career) move.

That reminds me, I need to reread Thomas Pynchon's The Crying of Lot 49, one of the great ones, if only for the character of Dr. Hilarius, who among other absurdities, calls his patients in the middle of the night just to see how they're doing (and also to try to enroll them in an LSD study). In fact, I wish I could rename this blog "Dr. Hilarius"--would Pynchon emerge from seclusion to sue me I wonder?

Not long ago I read a comment on another blog that speculated on whether a mental disorder can be considered "terminal." I think the answer is an emphatic no, but the reasons why are curious (they do not include: "Because our treatments are so great."). Like other doctors, we see a number of people with chronic and severe problems that are unlikely to get a great deal better. In fact, a significant percentage of what we see is at least somewhat resistant to treatment (if something gets better quickly and completely in this business, it probably would have gotten better on its own).

We do not enjoy anywhere near the same prognostic science that, say, oncologists do though. And it isn't only a matter of science; it is a matter of semantics and ethics. When we say that someone is terminally ill, we presumably mean that, no matter what he does, biology will take its course within an arbitrarily limited period of time, six or twelve months or whatever. Mental disorders are not like that, of course. We speak of supportive treatment in psychiatry, but not of palliative care.

Like, say, dentists and pain specialists, psychiatrists tend to concern themselves more with quality of life than with mortality. Suicide is a tragedy whenever it happens, but in terms of sheer volume it is dwarfed by mortality from other causes and by the overall scope of mental suffering that goes on. Mental disorders more commonly kill in less spectacular fashion; people die younger than they otherwise would have because they don't take care of themselves, or drink or smoke, or whatever.

Reduced life expectancy is not exactly the same as having a terminal illness, but it is also not the same, say, as dying with "incidental" prostate cancer, in which an eighty-year-old man's histological quirk had nothing really to do with the timing of his demise. So I obviously never tell anyone they have a terminal psychiatric diagnosis. "Chronic" is the much more appropriate term, and diabetes is the medical parallel I most often use. Like diabetes, many mental disorders will not go away, and may reduce life expectancy and even quality of life, but can be usefully managed over time.

There is, of course, another reason why no legitimate psychiatrist would come out and pronounce a mentally ill person's condition as "terminal." One could only do so out of knowledge that life would end suddenly and unexpectedly in the near future as a result of the mental illness. We know what that means. This would not only presume knowledge we don't have, but could also amount to a self-fulfilling prophecy. So I worry that when people speak of "terminal" psychiatric cases, they're seeking permission. And that would be no laughing matter.

Lincoln/Obama, Once More

The historian Garry Wills has usefully outlined the comparisons and contrasts between Lincoln and Obama. There is the external parallel, both hailing from exotic backgrounds (Obama, of course, with the Kenya-Hawaii-Indonesia connections, and Lincoln coming from abject poverty in backwoods Kentucky, exotic in its own way) and adopting the state of Illinois as adults. Both saw themselves as outsiders until, perhaps somewhat to their own surprise, they "made it" in the ultimate political fashion.

But Wills argues that the deeper similarity is temperamental and interpersonal. They have had in common a quietly high intelligence that is deliberately downplayed, not out of any lack of ambition or confidence, but out of discretion and political astuteness. This led both to be underestimated, arguably to their benefit. The main difference between them, in terms of personality, appears to be Obama's narrower emotional range, lacking both Lincoln's disposition to melancholy and his perhaps compensatory storytelling hilarity. Obama is capable of wry humor, but he is no comedian. If anecdotal history is accurate, Lincoln may be one of the few Presidents who, were he brought back today, might be able to give Letterman, Stewart, et al a real run for their money.

Sunday, November 16, 2008


1. It has been a busy weekend, with company; it feels rude to absent oneself, for more than a little while at any rate, to blog.

2. Terrible storms here Friday night. After a loss of telephone, cable television, and Internet access, what would be the interval after which a normal person might grow restless and dysphoric?

3. I can't recall where I saw it recently (if it was on your website, my apologies), but the best phrase for the post-election letdown may be postpartisan depression. Of course, we're no more postpartisan now than we were at the "end of history" in the 1990's.

4. Probably my all-time favorite blog title is Languor Management (my life in two words); the site also has a terrific poem in its November 14 post.

5. An article noted by Arts & Letters Daily chronicles the haplessly isolated population of Greenland, apparently drawn by the inevitable pull of mineral and oil wealth. I had no idea it was such a hotbed (so to speak) of psychopathology; apparently 20% of teenaged girls there have attempted suicide. Psychiatry to the rescue! Very often the best professional advice is: get out while you still can. Mastering the obvious since 1848.

6. Holiday reading: Robert Bolano's 2666 is suddenly the literary event of the year, perhaps the decade (one review is here). Haven't read him; may have to now. (If anyone out there knows how to produce the tilda here, please let me know).

Friday, November 14, 2008

Deus Absconditus

"Here's a truck stop instead of St. Peters."


1. In an article in Slate Paul Bloom considers reasons why atheists may or may not be less happy, or less "nice," than believers. As background to his piece, it bears noting that a great deal of research has looked at whether religiosity has any protective effect against mental illness. As one might expect, the results are mixed and depend a great deal upon how one defines religiosity. In general, the ritual associated with religion, and in particular the communal support of church (synagogue, mosque, etc.), seems to matter more than belief in metaphysical or religious dogma per se. And as always, correlation does not imply causation: while religious practice may alleviate psychopathology, it may also be the case that those who are less impaired by mental or emotional symptoms to begin with are also more likely to be religiously inclined. It is always hard to pinpoint where vicious, or virtuous, cycles get started.

Bloom reviews evidence that atheists in the United States tend to be less charitable and less happy, on average, than their faithful peers. There is, of course, a long debate over whether belief in God is ultimately necessary to shore up ethics (Dostoevsky: "If there is no God, then everything is possible."). Bloom points out that belief in God may have the psychological effect of feeling perpetually watched; if one feels always under the gaze of an Other, one is more likely to behave in ways morally accepted by the social group. Indeed, some evolutionary psychologists have suggested that this may have granted survival advantage to groups comprising religiously inclined members over the ages.

However, Bloom notes that in other, much more secular societies, such as Denmark and Sweden, lack of religious belief appears to be much more compatible with both happiness and ethical behavior (indeed, with respect to crime and other social parameters, Danes and Swedes are much better behaved than Americans on average). Bloom suggests that the difference is that in the United States, organized religion, although diverse in terms of denomination and ideology, nonetheless dominates communal activity.

That is, non-believers in the United States are, implicitly or explicitly depending upon circumstance, excluded from communal sources of support. American atheists may be less happy on average because they live in a predominantly faithful society. The obvious analogy here would seem to be homosexuals, who (particularly males) have higher rates of diagnosed mental illness than heterosexuals; this seems much more likely to be the effect of social discrimination and exclusion than of any inherent factors.

2. Correspondences:

I held a Jewel in my fingers
And went to sleep --
The day was warm, and winds were prosy --
I said "Twill keep" --
I woke -- and chid my honest fingers,
The Gem was gone --
And now, an Amethyst remembrance
Is all I own --

Emily Dickinson

I think I lost it
Let me know if you come across it
Let me know if I let it fall
Along a back road somewhere
Money can't replace it
No memory can erase it
And I know I'm never gonna find
Another one to compare

Lucinda Williams

(Car Wheels on a Gravel Road is one of those sublime albums in which no note seems misplaced or superfluous, and to which I never tire of listening).

Whence comes the all-too-common preoccupation with some precious thing, place, or experience that has been irrevocably lost? Call it the Romantic/neurotic gene.

3. I noted with amusement this morning that The Eagles' current gig is the "Long Road out of Eden" tour. Am I alone in finding this more than a little pretentious for a rapidly aging supergroup that hasn't come up with anything new and remarkable for decades? Maybe they were looking for an artful way of noting that their best years are long gone.

Thursday, November 13, 2008


"We are in great haste to construct a magnetic telegraph from Maine to Texas; but Maine and Texas, it may be, have nothing important to communicate."


Just in the past day I've come across three reminders of how Internet activity has increasingly become an assumed aspect of personal identity, for better or worse (when it makes news, it's usually for the worse). In two local stories, teachers in Charlotte were disciplined for making derogatory remarks about students on Facebook, while an investigation is under way to determine whether Durham police officers made slurs against Barack Obama on Myspace pages. Of course, these individuals did not take precautions to shield their comments from general viewing; it reminds me of people listening to headphones who speak at obliviously high volume.

Nationally, the unprecedented scrutiny of potential applicants to higher level jobs in the Obama administration includes documentation of any and all past Internet activity, including "handles" or alter egos employed. (I'm withdrawing my application for Surgeon General in protest; a psychiatrist as Surgeon General--can you imagine?). This offers a useful reminder that anonymity on the Web is never absolute.

It makes me wonder--should this blog be mentioned on my CV? Is it a public sort of hobby, or quasi-professional, or a hybrid? When I decided a while back to link my name to the site, I determined not to write anything that I would not, in principle, be willing to see printed in the local paper. And in the work I currently do, this sort of thing is not likely to come up much with patients. But if I were to be in private practice at any time in the future, I wonder how my approach to the issue might change, and whether I would notify patients ahead of time of blogging activities or just deal with it as it might come up.

Wednesday, November 12, 2008

Whiling Away a No-Show

Perhaps the art of life comes down to steering between cynicism and sentimentality. You have to get the tone right. So here's one of each extreme.

"Irony might be defined as disgust recalled in tranquillity."

Theodore Dalrymple (with apologies I suppose to Wordsworth).

Me, disgusted?

Also, an acquaintance of mine will become a decade old later this month. A weighty achievement. Here is Billy Collins's "On Turning Ten."

ECT Reminiscences

There are so many melodramatic frissons surrounding the phenomenon and experience of electroconvulsive therapy that it is worth discussing the procedure soberly and straightforwardly. After eight years I stopped administering the treatment last year, but not because of any appalling epiphany: as with most aspects of ECT, the reality is more prosaic than the myth.

I stopped because the practice of ECT (particularly in solo fashion) is time-consuming, tedious, and emotionally draining; I was ready to do something else. It can also be very rewarding, not in the sense of reimbursement (not very good, which is why ECT services are hard to find in some areas), but because at least a subset of severely ill people can be significantly helped by ECT. As a non-practitioner now I can write this with no conflicts of interest, unless one wishes to dismiss these reflections as exercises in retrospective self-justification (if so, so be it).

Like many treatments in psychiatry, ECT is both overused and underused. It is overused because there are some conditions that don't respond well to ECT but that are so refractory that both patients and doctors grow desperate. It remains underused because available antidepressant treatments, both medications and psychotherapy, persist in being only mediocre in their effectiveness. Severe and treatment-resistant depression remains a scourge, and for many ECT offers the only way out (to my mind suicide is not a way out).

The biggest drawback of ECT is not side effects, but rather, on average, modest and sometimes time-limited efficacy. To be sure, it is better than medications, but in some cases that is not saying much. And responses to ECT are as heterogenous as depression itself. Some people have a curative course of ECT and do well for two or three decades before another episode. Some people improve signficantly but relapse within weeks. Others, a minority fortunately, do not improve at all.

In the course of eight years I heard far more complaints about residual depressive symptoms than about side effects. The latter do occur, and headaches and short-term memory loss can be reasons not to proceed with ECT. These days this decision is almost always made on a voluntary basis; forced ECT is rare in this country, although in some cases (e.g. catatonia) it can be necessary and life-saving.

Those who advocate a complete ban on ECT or who argue that its use is always illegitimate have no understanding of severe depression. People who have the concentration and motivation to blog about this issue are not likely, in the course of that activity at least, to be in the kind of depressive episode that would prompt consideration of ECT. For eight years I had more referrals than I could handle of those who had lost virtually all capacity for energy, pleasure, or reasonable function, and who had already tried available psychotherapy and medication treatments. Not all, but some at least, ended up being very grateful for ECT. I can honestly say that no one I treated said they regretted ever having the procedure; maybe they were just sparing my feelings though.

ECT is a woefully inadequate procedure, and like, say, chemotherapy, it must be superseded eventually by something more...civilized. But the desperate times of both depression and cancer can call for desperate measures at times.

Monday, November 10, 2008

Web Withdrawal

I'll be off on a little Veterans Day camping jaunt, offline, for a couple of days. If you see someone curled up by the side of the road, it might be me, going through an Internet version of sensory deprivation. (Not really, it'll be okay--hopefully even pleasant).

Sunday, November 9, 2008

Evil Not Otherwise Specified

"And I looked, and behold a pale horse: and his name that sat on him was Death, and Hell followed with him."


Enough for now with the rational exuberance of the election; let us be grimly realistic. The New Yorker this week has an intriguing look at the phenomenon of the psychopath, which, as the article reminds us, means "suffering soul." This brings up the obvious question of whether they themselves do in fact tend to suffer, as opposed to those who come in contact with them.

Those who, like me, do not work in forensic or correctional settings generally encounter antisocial types who are in distress of some kind (i.e. they present voluntarily for treatment). However, it seems to me that they are usually more perturbed by the social consequences of their actions than by those actions themselves. That is, they do, much like a severe substance abuser, seem to recognize at some level that they are not "right," at least not normal, but the distress comes about as a result of legal, financial, and social results of their behavior, which in itself they often find, of course, to be quite gratifying (or as we say in the business, ego-syntonic).

For instance, I saw a guy not long ago who was superficially quite pleasant and engaging but who professed to have committed a number of highly violent acts over the years, some of which had come to the attention of the legal system, some not. On one level, he seemed to exhibit remorse for this, but he was also at great pains (so to speak) to impress me with the magnitude of his potential for violence (he was affable with me and I did not feel directly threatened in any way). He said several times, "I don't want to hurt people," but at other times he acknowledged that hurting people sometimes gives him great pleasure, and he made a point of insisting that those whom he had victimized in the past had deserved it in some way.

This man did seem dysphoric, but I'm not sure that it was necessarily related to his antisocial style (he may have bipolar disorder as well). As the aforementioned article mentions, it is quite possible for psychopaths to function successfully and without obvious suffering. Psychopaths are not inevitably violent, and in settings such as business, law, or politics they may decide that it is in their best interests not to be, but the hallmark of the condition is that this decision is based purely on self-interest, not on true conscience.

A few decades ago, cultural explanations for the formation of antisocial individuals were dominant, reflected in the term "sociopath." The pendulum has very much swung back to neurobiological explanation. To be sure, many psychopaths have awful and abusive childhoods, but that may be due as much to genes shared with their parents as to any direct result of traumas endured (after all, most people abused as children do not become psychopaths).

Brain imaging is the reigning trend now for insight into behavior, but it's hard to know how this ultimately relates to whether we treat antisocial actions as freely willed or as imposed by psychopathology. After all, we know that all subjective experience and overt behavior originate in the brain in some fashion, and the precise location and nature of this--whether the amygdala or some other region lights up on functional MRI--is of questionable relevance to legal theories of responsibility. Of course, such theories ultimately reflect social consensus, and as brain imaging and other neurobiological techniques become more commonplace in the public eye, the trend over time may favor determinism over free will.

But there is a strong visceral resistance to viewing certain kinds of violent or predatory deeds as inevitable or merely biological. This may not be rational in a strictly scientific sense--as myriad philosophers have argued, from the point of view of the universe (or the ultimate functional MRI machine), all thoughts and behaviors are determined by the brain. However, our revulsion toward the psychopath is highly rational as itself a product of evolution.

One can imagine that genes favoring psychopathy may have survived over the eons because in some contexts they may confer survival advantage. In some situations ruthlessness and comparative lack of conscience, particularly when coupled with prudence, can be remarkably helpful. However, this has had to struggle against competing genes that have favored the social cooperation and trust that bound successful groups together over evolutionary time. Groups cannot function if more than a tiny fraction of its members are psychopaths.

A severely moralistic view of antisocial behavior has therefore, for both biological and social reasons, itself seemed inevitable so far. Whether psychopaths will continue to be "corrected" in the criminal justice system as they are now, or rather according to a mental health paradigm a la A Clockwork Orange (this remains science fiction, as no effective treatments for psychopathy currently exist), is based more upon social decree than upon science. It's for the voters to decide; the neurobiologists and the moralists will make their respective cases over time. The ultimate referendum: is the serial killer evil or sick?

Friday, November 7, 2008

The Case for Obama (Seriously)

King Lear: Dost thou know me, fellow?

Kent: No, sir; but you have that in your countenance which I would fain call master.

King Lear: What's that?

Kent: Authority.

Why have we hired Barack Obama for what The Onion called, half-seriously perhaps, "the worst job in the world?" We obviously did not hire him for his executive experience; rather, his appeal depends on leadership qualities, judgment, and temperament.

Obama inspires without having to rely on empty demagoguery or the "cult of personality." People are tired of the extreme partisan rancor that has taken over national politics for the past 15 years or so (I'm happy to admit that Democrats have contributed to this as well, but in my opinion less than Republicans). Obama has charisma and obviously uses it to achieve his aims (and he needed it to help win the election), but if anything he constantly downplays this characteristic. Recall that a year ago he was often criticized for being dry, aloof, and "professorial." As I've written before, unlike most politicians, Obama does not seem to need the adulation of the masses, but rather views it as a necessary means to political ends.

Obama is like Bill Clinton in that he is both charismatic and wonkish--he really does have a meticulous interest in getting things done; he is more pragmatist than ideologue. Unlike Clinton, he is also highly disciplined. He is a leader who inspires people to work their butts off for him, and as his flawlessly run campaign suggests, he is good at spotting talent. But he panders less than most politicians (it's probably impossible to get elected without pandering at all). After all, in his speeches he has spoken of personal sacrifice and "tightening our belts"--how long has it been since we heard that?

In terms of judgment, it is hard to overstate the significance of Obama's early opposition to the Iraq war in 2002, at a time when this was a minority opinion and a politically risky one. The war is finally wrapping up, and it has been overshadowed by the economy as has everything else, but it is good to remember that, despite the final "success" of "the surge," the war overall was the greatest tragic blunder of the Bush presidency. From the vantage point of 2002, Obama could have been disastrously (for his political prospects) wrong, but he wasn't.

In terms of general administrative skills, Obama endured, with remarkable grace and resilience, what may have been the longest (22 months) and most grueling single political campaign in American history. His operation was huge, involving all fifty states and, of course, hundreds of millions of dollars. The people he chose to run it did so with admirable unity and efficiency. Can even this huge campaign operation automatically be extrapolated to the massive extent of the federal government? Of course not, but it is a promising sign. Part of what we're after is sheer competence; after all, the Bush administration was so dismaying not merely because of ideology but also because of ineptitude (see Iraq War, Katrina response, etc.). And sure enough, in his first days Obama is not staffing his White House with eager but green 20-somethings; rather, he is looking to experienced political figures for wisdom. Also, how much foreign policy experience did Governors Clinton and Bush have when they took over?

I was slow to warm to Obama. A year ago I was saying that Hillary Clinton would make a better acting President (although I never did think she could win the general election--too much baggage). And until recently I had always had some admiration for John McCain (the last eight years would have been much different, and in a good way, if he could have bested George W. Bush in 2000). Indeed, as recently as a few months ago I was fairly complacent about the election because I figured we would get a decent administration regardless of the outcome.

But McCain's erratic behavior in the closing months, and his willingness to take the low road with negative campaigning (even if it wasn't as negative as it could have been), was alarming to me. It is good to remember that there really was no truly conservative choice this election season. Indeed, the Bush administration has been so objectionable because it hasn't been conservative; it has been radical, in its unilateralism, its extreme economic policy, and its disregard for consensus. McCain's increasing coziness with these Bush trends over the past couple of years, coupled with his "maverick" status, made me wonder what the heck he might do if given the most powerful position on earth? Palin was the last straw--not a "maverick" choice but rather a radical and reckless one--and showed me that McCain had finally gone around the bend. In fact, I try to avoid ageism, but his erratic behavior overall made me wonder, in a neurobiological sort of way, what exactly was going on in that 72-year-old brain.

In terms of experience, one can always revisit the example of Lincoln, who technically had less experience than Obama when elected. Lincoln probably was a risky choice at the time and could have turned out to be a disaster (why not just let the South go and leave slavery for the next generation?). But people clearly saw qualities in him that promised exceptional leadership and judgment. I'm definitely not saying Obama is another Lincoln, and he could certainly fail, or be a very qualified success like Bill Clinton. But I would argue that from the vantage point of the current time, he is overall the least risky, and the most favorable, choice we have.

Thursday, November 6, 2008

Uneasy Lies the Head

Let me have men about me that are fat;
Sleek-headed men, and such as sleep o' nights.
Yond Cassius has a lean and hungry look;
He thinks too much; such men are dangerous."

Julius Caesar

1. As I consider the myriad "horse races" of the election season, it's easy to see Obama as a political version of Secretariat, running away from the pack at Belmont (the charming video of that race, easily found on Youtube, features the awestruck announcer famously proclaiming the great equine "a tremendous machine!" as he comes down the stretch).
2. Overshadowed by all the other election hubbub was the vote by the state of Washington to legalize assisted suicide for the terminally ill (joining Oregon, the Netherlands, Belgium, and Switzerland). As a psychiatrist who fervently values dignity and self-determination but who is all too aware of the distorting influences of even subtle depression, I have always found this a particularly tough issue to make up my own mind about. It is similar to my ambivalence about capital punishment; to point out the obvious, the very irrevocability of death casts a pall over even the strongest sense of the right. If it is possible to quote this in a broadly secular sense, the words of Oliver Cromwell come to mind: "I beseech you, in the bowels of Christ, think it possible you may be mistaken."
3. Speaking of the "bowels of Christ" (and Cromwellian insurgencies), Kay Hagan usurped Elizabeth Dole's North Carolina Senate seat despite Dole's immediately notorious campaign ad trying to smear Hagan's alleged association with the "Godless Americans" PAC. A Hagan-sounding voice at the end of the absurd spot cried out, hysterically, "There is no God!" The apparently devout Hagan objected vehemently to the misrepresentation of her piety, but nowhere around here did I come across any umbrage over the deeper implication, that to be "Godless" (it sounds even worse than "atheist") is in itself to be on a par with pedophiles or terrorists. I truly think that a woman, and then eventually a homosexual, will be elected President before an openly atheistic person could be considered.
4. I've always wanted to visit Alaska: so much space, so few people, the incredible terrain. The more I hear about Governor Sarah Palin and convicted felon Senator Ted Stevens, the more curious I become. In a collective expression of "up yours!" Stevens was apparently just voted back to Washington by the good people of Alaska, although that required a state-wide vote of only about 106,000 people (Obama could get that every time he held a rally). Nothing is more ironic than Palin touting the virtues of "real Americans." When I think of the latter, Anchorage doesn't, somehow, come immediately to mind. No, I still want to visit Alaska some day precisely because it is the Other in so many respects.
5. The other day I revisited Obama's vaunted 2004 Democratic National Convention speech. It was as great as I remembered, but I was struck by how very young he looked then. In current appearances he looks, to my eyes, ten years older; hopefully some of that is a transient effect of fatigue. The man is going to have to be strong. He is the first "celebrity" President since JFK, but that is a much more life-consuming role now than it ever was. Except for the occasional jaunt to Camp David or whatever, a celebrity President, unlike your regular celebrity, can't take refuge in eccentric isolation or furtive trips to rehab. Think of what happened to Bob Dylan when he felt the weight of a generation's hopes (okay, later he still managed Blood on the Tracks and Desire, not bad). To be sure, Bush got away to Crawford a great deal, but I don't think many noticed he was gone.
6. If one word could capture my association of Obama and our politics it would have to be intellectual and political class, not in the economic sense but in the sense of subtlety (without vacillation), self-respect (without smugness), and sophistication (without supercilious elitism). Mistakes will be made, but one hopes they will be earnest ones, rather than the boorish ones of the past eight years.
7. If anyone is Obama's Presidential "father" it is Hillary Clinton. The year-long inferno of the primary race singed off any weak or superfluous parts and completed his transformation into the ueber-politician (in the best sense of the word). If he were like most of us, he would, knowing how very much he owes her (and the dream of hers that was consumed in the same blaze), avoid her like the plague. I was afraid he might select her as running-mate just to show himself and the world that he is not like that. Fortunately he was so much not like that he could forgo advertising the fact, and instead could pursue his primary ambition. Similarly, he was merely being himself when he felt able to take the time to visit his dying grandmother without making a political issue of it. Like most geniuses, he supersedes distractions, including, and most importantly, psychological ones.
(The program is acting up and won't allow proper spacing, which is driving me crazy. All I can think of on short notice is to use some bold type for contrast--sorry).

Wednesday, November 5, 2008

Fiat Lux

"The worst lack all conviction
While the best are full of passionate intensity..."

Yeats (paraphrased)

It is disorienting to have a national leader who is curious, articulate, and gracious toward those with different views. It is like waking up with 10 more IQ points--and better manners besides.

I'm sure many are having similar reflections this morning, but in my 39 years the only two other instances of such profound change I can remember feeling in my gut this way were the break-up of the Soviet Union and 9/11.

I hope my children can grow up with eight years of this.

Tuesday, November 4, 2008

North Carolina "battleground" Dispatch

1. On rural roads down here one sees almost exclusively McCain/Palin signs; in the cities, of course, not.

2. Some 2.6 million people in North Carolina voted early, roughly 40% of registered voters.

3. It is chilly and rainy in central North Carolina this morning, but there was still a one hour wait at my rural precinct when it opened at 6:30 A.M.

4. At the end of the long line when polls opened, out by the parking lot, a fellow was handing out "sample ballots." They were ballots, alright, but except for the presidential race, which was unmarked, all of the other races were marked Republican. A handwritten note at the bottom helpfully explained that the marks reflected the "constitutionally correct" positions on several issues. When I emerged an hour later, he was gone.

5. Voter name and address were requested and were checked off in the book, but no I.D. of any kind was required. On the basis of such casual procedures the near future of the free world is decided...

Monday, November 3, 2008

Reality is Prodigy

"'Yes, we wait for the stroke of doom,' said Faramir. And they said no more; and it seemed to them as they stood upon the wall that the wind died, and the light failed, and the Sun was bleared, and all sounds in the City or in the lands about were hushed: neither wind, nor voice, nor bird-call, nor rustle of leaf, nor their own breath could be heard; the very beating of their hearts was stilled. Time halted."

The Return of the King

"'Whilst the last members were signing it,' wrote Madison, 'Doctor Franklin looking towards the Presidents chair, at the back of which a rising sun happened to be painted, observed to a few members near him, that painters had found it difficult to distinguish in their art a rising from a setting sun. I have, said he, often and often in the course of the session, and the vicissitudes of my hopes and fears as to its issue, looked at that behind the President without being able to tell whether it was rising or setting: But now at length I have the happiness to know that it is a rising and not a setting sun.'"

Miracle at Philadelphia

Sunday, November 2, 2008

Vox Populi

"Reason may mislead us; experience must be our guide."

John Dickinson (of the Constitutional Convention)

In a few days we can finally think of something besides politics, but not quite yet.

1. Perhaps the greatest casualty of a for-the-ages McCain upset on Tuesday, after of course one Barack Obama, would be the credibility of countless pollsters and pundits, who have with rare near-unanimity virtually crowned Obama before the fact. In fact, I guess both polling as a "science" and political commentary as an art would be set back a fair piece if so many agreeing polls, and pols, could turn out to be wrong. Reliability (i.e. consistency and reproducibility) without validity (i.e. accurately describing the world as it is) gets you nowhere. If McCain wins, even psychiatrists will be able to hold their heads high for a change--around pollsters and pundits at any rate.

2. A couple posts ago I wondered about the nature of delusion. The ever helpful NYT features this article reviewing the strangely opposite (although equally vitriolic) political universes of Fox News and MSNBC. I wonder if the two channels in fact demarcate the limits of those political interpretations of this campaign that could be called, by consensus, within the normal range (and quite a wide range it is). Perhaps to be to the right of Fox, as to be to the left of MSNBC, is to exceed the two standard deviations that begin to raise the eyebrows of people like me (if, as ever, there is "functional impairment" as we say).

3. I was thinking more about the literary skills of Presidents, and it occurs to me that the last century or so has been a long relatively unlettered stretch (I'm no presidential historian though--where is Michael Beschloss when you need him?). Of the founders, Jefferson and Madison were writers and thinkers of the highest order. Another peak occurred with Lincoln and Grant (whose Civil War memoirs enjoy critical esteem).
Theodore Roosevelt and Woodrow Wilson were literary types who wrote extensively, although little that I know of that is of lasting general interest. After that, I can think of little except Kennedy's Profiles in Courage, but that book, even more than Obama's Dreams From My Father, is widely suspected to have had major ghostwriter input. I'm looking forward to seeing what the George W. Bush Presidential Library will have on display.
If anyone knows of other examples of superior Presidential writing I would be curious to know them.