Friday, November 20, 2009

Caged Animals

"The fault, dear Brutus, lies not in our stars, but in ourselves, that we are underlings."


I've never found it easy to answer the occasional but predictable question, "Why did you become a psychiatrist?" but a succinct, if not simple, response is evoked for me by a Psychology Today blog post by Dr. Mark Goulston. Bluntly entitling his post "Maybe You're Just Wrong," he claims that for some people he works with--especially those with no major Axis I mental disorder--he gives them the option of being labelled ill on the one hand, or in mincing-no-words fashion, "psychologically flawed and emotionally immature" on the other. In the former case, psychotherapy and possible medication may be indicated, whereas in the latter case, some kind of education or training may be called for.

What this speaks to for me is the ever-present question: to what degree must or can we take responsibility for our lives and identities? There is no life without suffering, that's for sure; without being lugubrious about it, it is clear that on the scale of a moment, a day, or a lifetime, existence not infrequently doesn't turn out the way we seem to feel that it should. Why is that? I went into psychiatry not in order to relieve the most suffering in any kind of generic sense; it is impossible to quantify suffering, of course, but maybe I could do more good by working in a soup kitchen or by becoming a hedge fund manager and then donating the majority of my income to charity.

No, I went into psychiatry to try to relieve a particular kind of suffering, that associated with the "mind-forg'd manacles" that prevent us from being as psychologically or emotionally free as we might. There is an odd little Arcade Fire song called "My Body is a Cage." Well, the mind is a cage too, obviously, and this is a troubling notion only if one thinks freedom could possibly be infinite. All are limited by temperament and disposition, although to be sure, some have cages that are far more spacious and pliable--and in far closer proximity to other cages--than others.

The fundamental premise of medicine is that we are not wholly responsible for our own suffering. The sick role is a socially sanctioned kind of forbearance granted to incapacity, stemming from a recognition that it is deeply unjust to pretend that "the cage" isn't there. However, it is equally unjust--in an infantilizing way--to carry on as though another's cage is more restrictive than it has to be.

In his blog post Goulston claims that most of his clients prefer to be considered wrong--and responsible for their own plight--rather than innocent victims. I wish I had his confidence in human nature (personally I think Dostoevsky's Grand Inquisitor was more on the money). Obviously these people aren't paying him with insurance, which would require a listed diagnosis. And I refer to them as clients rather than patients for a reason.

Goulston sets out the free will conundrum in stark terms, which is why the piece struck me, but clearly he constructs a false opposition. For psychiatric care, if it is enlightened, should always endeavor to seek a fair balance between the claims of responsibility and "the natural shocks that flesh is heir to." After all, situations either of absolute responsibility or the absolute lack thereof are very rare. Life is continually lived in a state of partial--and never precisely known--responsibility. And science does not help much with this. Free will is profoundly social and political, relating to what one ultimately must answer for (to hypothetical others). In that sense there is no one Free Will, but a multiplicity of free wills in different social contexts.

So for instance, it is common for a depressed person not to take of himself. He doesn't exercise or eat healthfully, he gains weight, he isolates himself and loses friends, and perhaps even loses his job because he doesn't drag himself to work on time. To what degree is he responsible for his plight, as opposed to being a victim of the medical condition of depression? Arguably science cannot answer this question. To be sure, ever more sophisticated brain scans may show that depressed brains are different in certain ways than non-depressed brains, but inasmuch as psychology stems from neurobiology, such brain scans could theoretically also show differences between, say, lazy and selfish brains as opposed to motivated and selfless brains.

I would argue that responsibility in this case--in all cases--is a pragmatic construct. What helps this person to function better--varying degrees of encouragement, stigma, and penalty (e.g. unemployment) on the one hand, or direct support and perhaps biological intervention on the other? Of course it is likely to be a combination of the two. The depressed person may be given supportive therapy and even medication, but there is also an expectation that he will exercise and socialize more to improve his own lot. Medical and psychiatric care should aim to balance the sick role with social expectation, the latter being mirror image of social responsibility. What does it mean though to "function better?" Ah, the question of how life ought to be lived is beyond the scope of this post--or this lifetime most likely.

I've been curious about the emergence in recent years of "life coaching," "job coaching," etc. Does this stem from a lingering stigma of therapy, or does it derive from a desire for therapy that is more actively interventional? However, if one is primarily "wrong" and not "sick," then a better metaphor may be teaching or even tutoring. A "coach" implies that life is a sporting event to be won or lost, whereas life perhaps is better approached as a skill, like piano-playing or any other. Well no, life surely isn't so straightforward as that--composing may be the better metaphor. Or since this is my post and I have no head for musical composition (as opposed to appreciation), I'll say writing. Yes, life as writing.


Anonymous said...

There's a certain freedom in knowing the limits and substance of your cage. Believing you can be an infinitely free-range hen--insofar as all possibilities of hen-ness are available to you--enslaved to no murderous chicken/egg industry and humans thereof, when in actual fact you're just a delusional battery egg-laying hen fated from birth and circumstance to be nothing but, is a dismal state of hen/human existential affairs.

There's nothing wrong with cages - whether born into, thrust into, or acquired through free will/s.
Cages are the condition of individualities. Every choice in life is another cage; another expression of freedom's finitude. I would say freedom is the capacity to en-cage oneself on one's own terms.

Cages are homes, not prisons. Permanent and impermanent in varying measures and parts. They catch the fall-out from our nuclear lives. They bend and resist in response to the fluxions of life. They are the means of our ends, the ends of our means, the meaning we give. They exist beyond responsibility.

Cages always seem to be greener on the other/other's side. But are they?

Retriever said...

Haven't read the piece you linked to yet, but liked your reflections.

As far as a cage? I think that a good psychiatrist can tell when a prisoner is never going to get out on their own, and in fact will die of discouragement, or rage so violently against the gaolers that they come to harm.

For a depressed person, the psychiatrist is far more than the legal drug pusher or the life coach. I don't like the idea of a life coach any more than I like the model of social work as one who knows better counselling (bullying) another to do what they "ought" to. Because if someone else tells you what to do (even if right) one can avoid responsibility, blame the advice giver when it turns out badly, or balk and self sabotage as a way of expressing rebellion etc.

The model I like is really the Count of Monte Cristo. The shrink is the prisoner next door, who has the great good fortune to have a map and some knowledge that will help the prisoner first escape and then find their way (if they work hard, and have a lot of luck and/or GOd's help) to a far better life. The first and most important task is to reawaken hope.

However, this is perhaps most appropriate for depression. Or for people who are genuinely beset by difficult life circumstances.

The people with horrible character defects, bad to the bone, whatever, aren't as familiar to me.

One other incredibly important role of the psychiatrist is close to that of a priest or spiritual director and involves a) convincing a person (usually a manic or psychotic person) that they need help, that the shrink is not out to get them, and b) encouraging them to get treatment repeatedly as necessary, manage their life. This may initially be purely for the sake of the people around them (when a sibling is manic they feel wonderful and it's just the rest of the family who are boring clods trying to weigh them down), but ideally a good shrink can reach and motivate person to find the ways in which managing a difficult mood or thought disorder will actually improve their life too.

It's especially necessary, ironically, in the hard core chronic mental illnesses that people nowadays consider treatable only by meds. Because the meds are inadequate, often stop working, or have such vile side effects. I have one relative who died after over 50 years of rapid cycling bipolar disorder who could not and would not stay on meds because of their awful effects, but who never found a doctor who could encourage her and (yes) cheerlead and help her develop insight into those aspects of her personality that complicated her illness. I have another relative who is heading down the same route, who has already sufferend 32 years in a similar manner....has never met a single shrink she has any use for. This seems sad to me.

It's awe inspiring on the rare occasions when the meds work. But usually they do a half assed job and it's the quality of the doctoring that can make all the difference at certain key junctures.

As far as the distinction between people who are really ill or just need to shape up, I think all of us are a bit of both. When I was studying to be a minister, we were taught that our mission in congregations was to comfort the affflicted, and to afflict the comfortable. I think it's a pretty good description of a psychiatrist's vocation also. The care of hearts and minds their common task. Tho obviously each expert at a different kind of care.

Anonymous said...

An example of what you have referred to as the 'epistemological quagmire' that obtains. Writing (expression, the act of thinking, acting itself, controlling expression, mediating feeling etc) and reading (interpretation, rewriting, listening, etc) are useful tropes (limited as all models and maps and conceits) since the cages we wander between are barred or meshed or webbed with syntax.

Anyway, good to see another post and such an elegant piece of writing.