Monday, September 12, 2011

The Shaman Speaks

"All comes by the body, only health puts you rapport with the universe."

Walt Whitman, from "By Blue Ontario's Shore"

This quote--which could serve as credo for integrative medicine--is the kind of thing that occasionally reminds me why I went into psychiatry. Beyond the often questionable DSM diagnoses, the vagaries of therapy, and the imperfect biological treatments, what we are after is a state of attunement and acceptance in which a biological being achieves transcendence of the merely physical without, necessarily, any recourse to the supernatural.

It is not the work of poetry to answer all our questions, of course, and one can legitimately wonder what sorts of subjective states, interpersonal relationships, and achievements of meaning must come together to constitute "rapport." But if we say that health is merely the absence of disease (or disorder), if only to trim the ambitions of restless and overweening doctors (and their many accomplices and handmaidens in the behemoth that is the health care industry), it is nonetheless true that it is typical of consciousness to aspire to something more than just the absence of suffering. Perhaps poets pick up about where physicians trail off.

Wednesday, September 7, 2011

Mental Illness Is Whatever We Say It Is

"Psychology, which explains everything
explains nothing,
and we are still in doubt."

Marianne Moore, from "Marriage"

By "we" I don't mean we psychiatrists, at least not primarily, but rather "we the people." Caseness, or the determination of what counts as a mental disorder and what doesn't, is not something we go out and discover in nature; rather, it is a social category arrived at both explicitly and implicitly through cultural debate. The psychiatric profession obviously has opinions about caseness, but these do not go unanswered or unlimited by society at large.

In large part, antipsychiatry critique has been aimed at the extent of psychiatric diagnoses, both the numbers of diagnoses themselves (larger in every succeeding edition of DSM, we are reminded) and of course the numbers of people given those diagnoses. Suddenly it seems as if every other kid has ADHD and/or autism. Recently several psych blogs cited a recent survey claiming that 38% of a European sample suffers a mental disorder in a given year. This included substance abuse and dementia, but nonetheless it seems like a high number (the 5 or 10-year prevalence would be significantly higher).

I think that 38% seems like a high number for reasons both illegitimate and legitimate. Even now there is a tendency, more latent in some than others, to view those with mental disorders as the mad, an appalling but surely very minority group safely stowed away in institutions. The notion that "the mentally ill" walk the streets and even have jobs and families like you and I remains foreign to some. But there is also the real concern that the sick role, a transaction that officially relieves the patient of at least some social responsibility, loses its meaning when used too widely. In that respect, there is too little appreciation of the great variation in severity of mental disorders; just as one may go to an internist for a touch of gastritis or for cancer, a technical psychiatric diagnosis may or may not involve significant disability or the use of the sick role.

Whether medical or psychiatric, diagnosis when applied liberally enough approaches the condition of enhancement. For Freudians neurosis was an inescapable condition of humanity, so at certain times and places (and with sufficient economic resources) to be in analysis did not mark one as "sick" so much as self-aware and ambitious. Similarly, in those older than 85, significant dementia is closer to the rule than to the exception, so statistically speaking the effective treatment (which we don't yet have) of dementia in the very old would in fact qualify as enhancement. And for modern medicine, mortality itself has virtually become a disease (which as the Onion occasionally reminds us, retains its 100% prevalence despite our best efforts). When we seriously discuss mental disorders having a prevalence greater than 50%, we start to consider syndromes that are, in toto, to be expected of the human condition, at least at this place and time.

Enhancement may well be justified, depending on the circumstances. The question is always: is treating any given phenomenon clinically (that is, as a syndrome worthy of specific medical intervention) likely to be helpful (that is, to lead to better functional outcomes, in the case of those problems for which we really do have treatments, or to better understanding of ourselves and others, in the case of those problems that remain intractable)? Or would it be better to consider the issue as a social/moral/cultural/existential difficulty? That is really the question, and not one that neuroscience can shed any light on whatsoever. Biologically, all human capacities appear to exist on dimensional continua, and the point at which we indicate "pathology" or "caseness" is a social and interpretive outcome.

Tuesday, September 6, 2011

The Religion of the Good, Part 2

A recent New Yorker profile of the philosopher Derek Parfit mentioned that the late Bernard Williams once dismissed the ideal of a universally compelling moral code as (I paraphrase) "something you use on the men who come to take you away." Indeed, implied in the "problem of evil" is the conviction (or fantasy perhaps) that if we could only find the right combination for the great moral mystery vault, the ponderous door of error would swing open, releasing a radiance that would burn away the scales from the eyes of the benighted.

I imagine that some religious believers have a similar feeling that if they could only depict or praise God rightly, his existence and glory would be as plain to everyone else as they are to them. The holy grail of thought is the proposition (or grand scheme of propositions) that is as self-evident as 2 + 2 = 4 but as transcendent and as life-changing as the existence of God. That is the constructed idea(l) that we imagine would stop the bad men in their tracks and bring them to their knees. If God does not exist, then it will be necessary to invent (it)--this is the project that is at least implicit in non-relativistic philosophy. As Wallace Stevens wrote, "One day they will get it right at the Sorbonne."

I once read a review by Helen Vendler in which she claimed that the role of the critic is not only (or even primarily) to explain or to justify, but also to celebrate. Similarly, I think that for anyone who reflects seriously about the moral life, explanation and justification go only so far, beyond which point one can only aspire to praise and embody one's views. The barbarians who burn down the monastery are unfazed by the crucifix; likewise, no secular moral system achieves the potency of a talisman. To accept this is also to accept a troubling existential diversity in human nature--other people see the great questions in the same way that I do, except when they don't do so at all. Perhaps the Tower of Babel is the central metaphor for humanity, making us the most atypical species. There is a strain in philosophy that seeks to tear down the tower in favor of a second Garden of Eden, done rightly this time.

The problem is that many men (most of them, alas, have been men) have been sure that they beheld the Truth, and terrible things have been done in the name of Truth. The point is to religiously (in the generic sense) embrace a system of meaning while avoiding clinical or moral insanity. Just as Satanism may be an internally consistent religion, so may there be functioning philosophies of evil (National Socialism, al Qaeda, etc.). We denounce them not because they have no justification (they do have their internal justifications), but because we find them pernicious and repugnant. Our grounds for doing so may be ultimately contingent on the creatures that we evolved to be, but that is the best we can do--we can never escape history by inventing ourselves de novo. By and large, we also happen contingently to find the blues and golds of sea, sky, and sun to be gratifying, and we can only be grateful that we do so. The truth is not given in any simplistic way, but there is also no truth that does not derive, in some fantastically complicated way and filtered through many generations of human consciousness, from our origin.

Monday, September 5, 2011

The Religion of the Good

A couple of weeks ago, in the New York Times philosophy feature "The Stone," Joel Marks confessed his loss of faith in objective morality:

"I thought I was a secularist because I conceived of right and wrong as standing on their own two feet, without prop or crutch from God. We should do the right thing because it is the right thing to do, period. But this was a God too. It was the Godless God of secular morality, which commanded without commander--whose ways were thus even more mysterious than the God I did not believe in, who at least had the intelligible motive of rewarding us for what He wanted us to do." (Italics in original).

Marks goes on to claim that even if we withdraw the quasi-theistic vehemence of our confidence in objective morality, and thus acknowledge the mere contingency of our beliefs, this needn't change our actual practice. We continue to believe what we believe and have the right to advocate our views in accord or in competition with others, but according to Marks, we can never claim that the views of others are wrong, only that they lead to different consequences. Such advocacy would seem able to achieve moral consistency, and not full justification. For instance, Marks notes animal welfare as one of his central preoccupations. Alluding to the basic moral tenet that avoidable suffering is wrong, one may educate others about animals' lives in factory farms, but not add the emotional force of moral disapprobation (which, Marks maintains, may provoke resistance or resentment as much as anything).

I think that this is wrong and that it mistakes human moral development. At a certain level we embrace certain traditions, rituals, and moral standards not because we pretend to ultimate moral justification of them, but because the alternative is chaos. We raise our children to believe that certain behaviors are not merely different from what we happen to do--they are wrong. We watch football rather than soccer by virtue of mere geographic contingency; while we may prefer football, we recognize that this is likely due to acculturation and habituation. But when we say that it is not right to abuse animals, we assert that this true everywhere and for everyone.

Secular morality does therefore partake of the emotional conviction of religious faith, but this reflects its fervor, not its groundlessness, and hence is a mark of strength and not weakness. The "God" of secular morality is an impersonal ideal that we collectively construct, not a personal interlocutor that we discover. There are, of course, many versions of this "God" just as there are many versions of the God of the Christian church (and obviously Islam and Judaism). But I think there can therefore be a fundamental secular referent of the term "Godless," which denotes not merely he who lacks faith in the supernatural, but he who is unable or unwilling to shape his behavior according to moral ideals and/or the suffering of others (conduct which we may designate as psychopathic or evil).

Near the beginning of Terence Malick's "The Tree of Life," the narrator comments that there are those who live in a "state of nature" and those who live in a "state of grace." We live in a "state of nature" insofar as we merely gratify our impulses, even if to the detriment of others, or complacently embrace our (evolutionarily) contingent dispositions. And there is a secular version of the "state of grace" whereby we believe ourselves to be free to (collaboratively) fashion a moral ideal.

The "religion" of secular ethics is prey to the same pathologies as conventional religion, i.e. propensities to rigidity, dogma, self-righteousness, hypocrisy, and exclusion. But it is also offers the same potential for affiliation and transcendence (if not, granted, the same degree of narrative interest or life-after-death consolation). I consider myself agnostic because I do not find any of the world's supernatural deities to be existentially compelling, but my attachment to, say, the Golden Rule (among other moral precepts) does have, as Joel Marks rightly argues, a good deal of faith to it. But inasmuch as there can really be no doubt as to whether the Golden Rule exists, this my attitude could be said to involve love more than belief.