Thursday, January 8, 2009

Impossible Profession

I mean impossible in the good sense, of course. Time is limited tonight, so I enthusiastically recommend a fine brief commentary I came across today on the strange, agnostic difficulty of psychiatry. Written by Rachel Dew, M.D. in the American Journal of Psychiatry, it is by a psychiatrist and intended primarily for other psychiatrists, and it conveys nicely the mind-boggling nature of the undertaking.

The piece speaks for itself, but no blogger can resist a few comments. When Dr. Dew claims psychiatry as "the hardest specialty," I assume she means "hard" in a moral and not a simplistically cognitive way. For the very reason that so much ambiguity does still prevail in psychiatry, there is not nearly as much of the kind of mental calisthenics--the grand connect-the-dots-game involving obscure diseases, symptoms, and physical and lab findings--pertaining to much of the rest of medicine.

If much of medicine is, cognitively and sometimes physically, a kind of triathlon, perhaps with elaborate obstacle courses thrown in, then psychiatry might be more akin to...meditation. Obviously aspiring to mindfulness, psychiatry at its best tries to slow things down, to notice things otherwise unnoticed, to accept an emptiness at the heart of things without giving in to despair. It attends to suffering, knowing that pain often cannot be eliminated but that pain need not be shrouded in affliction.

Psychiatry is not just that, obviously. There are a number of things we do know, even if only in a pragmatic and not a metaphysical or in a purely scientific way. No triathlon perhaps, but one can meditate while walking.

In addition to the inherent difficulty here, there is the added complication that, these days especially, many patients show up to psychiatry looking for a triathlon (to watch, that is). Increasingly, practicing psychiatry is like offering a meditation class in which people keep showing up, asking "Where does the race start?" Well, I don't know, but tell me what you're looking for.


Anonymous said...

Unknown unknowns aren't so bad. It's the known unknowns that torture the puzzle into a diabolical insoluble enigma, while the known clowns just fool around waiting to be shot.

Retriever said...

Very good post, especially the paragraph on meditation and suffering. These words of Dietrich Bonhoeffer's in a completely different context (waiting to be shot for his part in the plot against Hitler) also address this ache balanced against a growing knowledge of who is holding one fast in this so painful world.

This poem captures some of what it means to try to minister to people when uncertain of self, mission or even whether one has seen and heard aright. I think it also expresses some of what your profession is up against.

Who am I? by Dietrich Bonhoeffer

Who am I? They often tell me
I used to speak to my warders
freely and friendly and clearly,
as though it were mine to command.

Who am I? They also tell me
I bore the days of misfortune
equally, smilingly, proudly,
like one accustomed to win.

Am I then really all that which other men tell of?
Or am I only what I myself know of myself?
Restless and longing and sick, like a bird in a cage,
struggling for breath, as though hands were
compressing my throat,
yearning for colors, for flowers, for the voices of birds,
thirsting for words of kindness, for neighborliness,
tossing in expectation of great events,
powerlessly trembling for friends at an infinite distance,
weary and empty at praying, at thinking, at making,
faint, and ready to say farewell to it all?

Who am I? This or the other?
Am I one person today and tomorrow another?
Am I both at once? A hypocrite before others,
and before myself a contemptibly woebegone weakling?
Or is something within me still like a beaten army,
fleeing in disorder from victory already achieved?
Who am I? They mock me, these lonely questions of mine.
Whoever I am, Thou knowest, 0 God, I am Thine!

Novalis said...

Thanks for the poem.

John J. Coupal said...

Your header for this piece brings to mind Janet Malcolm.