The Thousand Natural Shocks

John Gray argues that Freud is out of fashion these days owing to his basically tragic view of human nature, according to which we are fundamentally conflicted creatures condemned to interpersonal (and intrapersonal) struggle. The point, to Freud, was to learn to live productively with that state of affairs--no "chicken soup for the soul" here! Full social and personal harmony and ultimate existential consolation are ideals we cannot achieve, so our best and only redemption is to learn to do without them.

Personally I happen to find this aspect of Freud appealing, much more so at any rate than his overweening dogmatism or his far-fetched psychosexual speculation. But if Freud was in fact a modern Stoic, his decline in influence and popularity merely reflects the fact that stoicism as a way of life has never been a mainstream ethos, at least in Western civilization. We'll be waiting a long time to hear a presidential candidate declare that his favorite philosopher is Epictetus. Whether wisely or not, human nature seems to crave more than what some of the more dour tenets of psychoanalysis can provide.

In a similar vein, Daniel Smith in the Times wonders (having trouble with the hyperlink function, sorry) at the persistently high level of anxiety in western culture, which objectively speaking is one of the more successful societies in history. Even the poor in the United States enjoy levels of material comfort unimagined by all but the most wealthy in most past eras. Whereas we experience "stress," the countless generations of history endured miseries of labor, climate, poverty, the random death of children due to infectious disease. This goes to show (unless we want to assume that our forebears experienced their lives as appalling affliction) that beyond a visceral baseline, suffering is never objective or absolute, but rather relative to our expectations, for ourselves and relative to others.

Is Psychiatry Like Acupuncture?

As I've discussed a few times here, this is the worst of times for antidepressants and other psychiatric medications; considering questionable efficacy and likely side effects, their popular esteem is at a low ebb. This makes them...a great deal like various alternative medicine treatments that remain highly popular and widely used (and paid for) despite the disdain of evidence-based medical critics.

In The Atlantic David H. Freedman discusses the persistent popularity of alternative medicine and its unlikely cohabitation with conventional research even at the Mayo Clinic and other hallowed institutions. He points out that while medicine made its reputation in the first half of the twentieth century with the significant (if not complete) conquest of infectious disease, its efforts to extend its domain to the kinds of chronic diseases that plague us today (diabetes, heart disease, cancer, Alzheimer's disease) have been frankly disappointing. What, exactly, has medicine done for us lately?

Psychotherapy and psychiatric medication have been targets of critical and cultural derision on the part of many for decades, yet millions of patients seem to derive some kind of healing experience from the pill or the couch, as the case (and the personal inclination) may be. The same could be said of the masses flocking to chiropractors, homeopaths, and, yes, acupuncturists in defiance of the conventional medical wisdom. We spend years in medical school learning about physiology, when practically speaking, healing arguably has more to do with constructing a healing ritual than with one's board scores. The "chemical imbalance," absurdly oversimplified though we hold it to be, may be like the acupuncturist's "lines of force," a necessary if fictional semantic scaffold on which to mount a clinical encounter. The shaman lives!

The Solitary

"In a soulmate we find not company but completed solitude."

Robert Brault

Briefly, The Atlantic features a story on Donald Triplett, the now 77-year-old who was the original child diagnosed with autism by Leo Kanner. After him, I suppose, le deluge.

One can only marvel at the complexities of this diagnosis, which rival those of schizophrenia. In both cases, is this a diagnosis unique to modern times? In contrast to mood disorders, which have demonstrably always been with us, it is difficult to find clear traces of schizophrenics and autistics in the historical record. Did they merely elude the spotlight of history, ekeing out obscure lives in remote farms or urban hovels? Or is some relatively recent pathogen, toxin, or environmental poison at work?

Does autism represent merely aberrant wiring, the vulnerability of a vastly complex process to contingent errors? On the face of it, autism (like schizophrenia) would seem likely to have caused a major fitness disadvantage to our ancestors (Donald in the article lacks not only offspring, but any history of girlfriends). Or does autism merely represent the severe form of gene associations that in milder forms may have generated unusual social respect in evolutionary times past? And as with ADHD, autism has no place to hide in hyper-social, hyper-competitive societies. Anxious suburban settings strive to emulate the more relaxed small-town acceptance and support enjoyed by Donald Triplett. One could also ask, inasmuch as he does not appear to be unhappy, whether he is "disordered" at all.

Entitlements High and Low

James Ledbetter at Slate describes the explosion of Social Security Disability Insurance coverage in recent decades, to the current rate of 4% of the potentially working population, as high as 6% in some states. The two most common kind of conditions covered? Mental disorders and musculoskeletal injuries (think lower back pain), both of which are notoriously elastic. Both are often quite real and severe, but surely these soaring disability rates are driven by non-clinical factors as well.

I work at one clinic at which virtually all the patients (or "consumers" as they are designated in the community mental health setting) either have disability status or are assiduously seeking it. They openly compare notes on how best to get a "crazy check" and to retain it long-term (patients often resist reduction or removal of medications in the belief that it may make them appear less disabled). Before they learn the system they are surprised to learn that I am not directly involved in the process--Social Security has its own protocol for determining disability. The bar is set apparently high--people are often turned down multiple times over a period of years, but repeated appeals especially with legal support usually seem to succeed, and once attained, disability is rarely lost, at least in the population I see.

Obviously many warrant disability support whatever the circumstances. But even among the questionable ones it is no simple matter of conscious malingering. Between $500 and $1000 per month isn't much, but it compares well with full-time minimum-wage work, which is the best that many disability candidates could hope for. And as Ledbetter mentions in his piece, disability rates may reflect long-term weakness in the job market that could be worse than feared. If someone with any mental symptoms whatsoever is chronically unable to find a job, his/her natural inference may come to be that s/he is disabled by those symptoms. Certainly I have seen this deduction at work (so to speak) in many young, quite able-bodied men in rural areas who have lost once abundant construction jobs. I was pleased to see that Ledbetter also produced the argument (as I did in a post last week) that increasingly technical jobs may be out of reach of a greater fraction of the labor pool.

Meanwhile, at the other end of the socioeconomic spectrum, NPR's health blog, citing a JAMA study, looks at reasons why doctors accept pharmaceutical company perks despite well-known concerns about conflicts of interest. The most common reason appears to be that they believe that they deserve them. This sounds familiar from my years of trying educate residents and medical students about the ethical issues involved. The latter just could not compete in general with their conviction that as they were working hard and--at that point in their careers anyway--not mind-bogglingly well-compensated, they were in fact entitled to a free lunch. One man's entitlement is another man's just deserts (or just desserts as the case may be).

The suppression of freeloading is the ultimate evolutionary game of whack-a-mole.

The Analogy with Education

Briefly and speculatively this morning, at a friend's behest I've been reading Robert Whitaker's Anatomy of an Epidemic, another entry in the thriving anti-psychiatry industry. I am still early in the book, but so far it is, for its genre, a sober attempt to answer the question of why, after decades of intensive research, the problem of mental illness and its attendant disability appear to be, if anything, worse than ever. A hypothetical answer came to me when I read Robert J. Samuelson's suggestion about educational reform in Newsweek.

Samuelson observes that the United States has been in educational "crisis" for decades now, yet despite the application of massive resources and large numbers of teachers (and immeasurable pedagogical ingenuity), average academic performance has not significantly budged. He makes the not very politically correct claim that the problem is no longer the educational system, it is the students, or at least the kinds of students that the culture at large now produces. He adduces two factors: the increasingly anti-intellectual and autonomous culture of adolescence, and the huge increase in educational access in an increasingly technological and sophisticated society. In a nutshell, the educational system increasingly aspires to wring blood from a stone.

Human beings naturally vary in cognitive skills, concentration, etc. and for most of human history only a minority of the population endured extended formal schooling. The past generation or so has been the first experiment in population-wide education, and it could be that the system is coming up against natural human variability. In the past those who, whether due to lack of opportunity or aptitude, could not obtain extensive education were able to find niches in agricultural or other basic functions that are now increasingly occupied by machines. In an economy increasingly requiring advanced and specialized skills, niches are more competitive and harder to come by. Thus the uneducated are, relatively speaking, more disabled than in times past.

It could be that mental disorders, except perhaps for the most severe forms (the exact boundaries of which are still not determined), are not so much discrete entities as they are one end of the bell curve in terms of parameters such as mood, anxiety, attention, and reality testing. They may be analogous to learning disabilities inasmuch as deficits in stress tolerance, mood stability, and sustained attention increasingly place persons at greater disadvantage. Contemporary society is not so much provoking these problems as it is making them more apparent, that is, revealing natural human variability in the same way that, say, a basketball camp highlights differences in jumping ability. Because these capacities are complex and developmental, they are not easily modified.

Just as in centuries past, the academically challenged found niches, so those with anxiety and mood disorders may have been able to gravitate to settings that accomodated their symptoms. They found rural occupations permitting distance from people; they found solace in church; they were able to obtain support from family. But in our more mobile and dispersed society, the only jobs available are often intensely stressful, requiring constant contact with people even if only on a telemarketer's line. Individuals who used to rely on family increasingly have to resort to official disability status. It is not the case that psychological disability is new or unprecedented--it is just that there is nowhere for it to hide.

ADHD is obviously the place at which educational and psychiatric challenges intersect, and to my mind it is the perfect example of a hypercompetitive, ambitious post-industrial society illuminating natural and evolutionary variation in a human cognitive capacity, in this case attention and impulse control. The fact that distractibility, like the ability to metabolize (then scarce) calories parsimoniously, was adaptive for much of human evolution, does not unfortunately mean that it is adaptive now. The effort to suppress obesity, like much of psychiatry, may be an instance of cultural evolution, one that appears to have a lot of bumps in the road.

Emerging Adulthood

What's to come is still unsure:

In delay there lies no plenty;

Then come kiss me, sweet and twenty,

Youth's a stuff will not endure.

Twelfth Night

The Times today has a long article on "emerging adulthood" (the tweens), increasingly advocated as a newly normative stage of psychological development. It is the ever more de rigueur period in which twenty-somethings "find themselves," bouncing in and out of jobs and relationships, moving back home, etc. It struck me because of the similarities with "new" psychopathological syndromes, such as increasingly mainstream obesity, (adult) ADHD, soft bipolarity, etc.

One similarity is the jostling of neuroscientific and cultural explanations. On the one hand, brain scans suggest that the pre-frontal cortex continues to develop until age 25, so why shouldn't we expect emotional and cognitive development to be an adventure until that time? Well, there is the fact that throughout much of the world and throughout history, sociological maturity kicked in well before age 25, that is, "emerging adulthood" is a phase that many have apparently been able to skip when needed.

The piece suggests that "emerging adulthood" may actually be an artifact of prosperity; basically, twenty-somethings lollygag around because they can, because they live in the most well-off nation-state in the history of the world, and their parents are willing and able to indulge them. To be sure, this is a mixed blessing: too much promise and too many choices can be burdensome. As I have argued before, the vices of the rich are now the vices of the middle class, who are rich beyond the dreams of avarice compared with most human beings who have ever lived. And yet we try to use neurobiology to justify this sociological state of affairs. It is the brain that adapts to the environment and to society, not vice versa.

And yet this needn't be a pejorative development. Life span is increasing, reproductive technologies augment the opportunities for child-bearing, and the retirement age may eventually be 70 or 75, so what is the hurry, exactly, to settle into the grind of work and children? The crucial change is in attitudes and expectations--the stigma of living with one's parents until age 30 is not so biting. Some sort of cultural tipping point has occurred, which may or may not have anything at all to do with neurobiology. This is allegedly about normal psychology, but it parallels metamorphoses in psychiatric diagnosis. We collectively decide what is normal, then look to science to try to justify the decision.

Where the Wild Things Used to Be

The other day my eight-year-old asked, "Daddy, what does 'integrity' mean?" My heart warmed--it was a Norman Rockwell moment, my chance to impart one of the primary virtues. I tried to explain it in an age-appropriate way, and asked why he inquired? "Oh, it's also a brand of alarm system." (After having moved on from a great enthusiasm for natural disasters, his current preoccupation is with smoke and fire alarms and other indicators of incendiary mayhem and transgression). More Jackson Pollock than Normal Rockwell. Hopefully he'll remember that it's not just a brand name.

This came to mind when I read Anne Applebaum's Slate post on ADHD in literature, specifically embodied by Tom Sawyer and Huckleberry Finn. It has been many years since I first read of their adventures in oppositional defiance, but she seems about right that while Mark Twain doubtless romanticized their naughtiness, they lived in a time far more tolerant of disobedience, distraction, and disregard for academic achievement. Or maybe "tolerant" is the wrong word: it was an age that left more space, both physically and psychologically, for such things.

In Madness and Civilization and other works, Michel Foucault argued that around the middle of the last millenium, when the first glimmers of the Enlightenment appeared, Western civilization began to become distinctly less hospitable toward mental disorder. The mad, who for centuries had wandered more or less unmolested along the margins of society, came to be seen as a greater threat to new priorities for the order and management of populations. Previously seen as harmless or perhaps even as alternative sources of vision, the mad were increasingly perceived as a menace.

I wonder if the escalating pathologizing of ADHD features could represent a second great phase of this "civilizing" process, if unfocused energies and scattered cognition present challenges to a logocentric society that are more subtle than those of mania or psychosis, but ultimately intolerable nonetheless. As Hanna Rosin straightforwardly argued in The Atlantic, the culture and the economy increasingly valorize and reward calm, structured, meticulous, and persistent verbal order, all of which may be more commonly found in women, on average, than in men.

It is not only the case that expectations for order are higher, that there are far more moving pieces, so to speak, in a post-industrial information society. Technology also amplifies any specific potential source for disorder, via means such as automobiles, firearms, the Internet, or in the case of rogue terrorists, nuclear or biological weapons. It is like not only building a bridge far longer than has ever been attempted before, but also in unprecedented water and weather conditions. The cognitive inefficiencies of ADHD, which often of course entail great creativity, may come to be a cultural luxury for which we have to fight to maintain space (the playgrounds and natural parks of human cognition perhaps).

The Age of Anomie?

"Message: I care."

George H. W. Bush

The mad have always been with us--convincing descriptions of severe mood disorders in particular exist from antiquity. But neuroses and "problems of living," or at least the recognition thereof, are largely inventions of modernity, as set forth by Ronald Dworkin in his account of what he calls "the caring industry." His article is not brief but presents some fascinating arguments and warrants careful reading. I have time for only a short summary and response here.

As Dworkin describes, since the 1950's a massive population of therapists of every stripe and, now, "life coaches," has sprung up to manage emotional issues that until then had been the domain of traditional peer groups, lines of authority, and cultural connectedness. The rise of mobility and suburbanization and the decay of natural communities began this trend, which was reinforced and hastened by the social turmoil of the 1960's and onward. Therapists do the work (or try to) that used to be done (if it was done at all) by families, neighbors, and the clergy.

So far this is pretty familiar territory--Dworkin documents the increasing ubiquity of the caring industry in the military, the schools, and everyday life. He points out that while the 1950's are often recalled as a calm before the storm of contemporary upheaval, the decade was, beyond its infamous conformity, actually marked by a deep malaise, reflected in its moniker as "the Age of Anxiety." It was as if the plunge into collective and rapid social and technological change, still a few years off, could nonetheless be glimpsed and feared.

But Dworkin's more creative and radical claim is that, presumably in response to the civilization-wide catastrophes of the two world wars, people in the West at mid-century underwent a profound change in their emotional engagement, one that we still haven't recovered from. He suggests that for the better part of a millenium, love had grown as an ideal in personal, religious, and national life. But the extent and depravity of the world wars showed that love stops at the nation-state and cannot be extended to humanity as a whole; the implication is that love is not only insufficient for global security, it is positively dangerous, and an unaffordable luxury, inasmuch as it fosters tribalistic nationalism in a nuclear age.

The consequence was that people have tended to grow more detached and cynical in their attachments. Much of the residual lure of love, intensified by the entertainment industry, has come to reside in individual erotic connection, upon which more and more seems to ride even as it becomes more fragile. Dworkin argues that people have largely given up on the organic, intense, but volatile attachments to natural peer groups in favor of cooler, more easily manageable relationships obtainable from therapists in finely titrated 50-minute increments. It is an elaborate theoretical version of the therapist-as-friend-substitute claim.

There is much that could be said in response to this fascinating version of history. First, while he does not come out and say so, Dworkin's elegaic tone certainly evokes some Golden Age when people were happier--is that really the case? While he suggests that the masses are lonely and miserable, most surveys of Americans at any rate show that the majority consider themselves basically happy (I am aware of the myriad nuances surrounding a fraught construct such as happiness). To be sure, attachments are not so simple, so monolithic, or so geographically given as they long were, but are they worse? Perhaps they are more dynamic, more flexible.

For some reason Dworkin refers primarily to the traumas of the war-ridden early 20th century, but it seems to me that the nuclear age contributed more directly to civilization-wide angst. For 65 years now the possibility of nuclear holocaust has been a gun held to the head of humanity, and it has not gone away, even if we don't so much envision a Soviet premier with his finger on the button. For those so inclined, the environmental threats of recent decades have added to the perceived risk of the earth being ruined beyond repair. These things, it seems to me, could sap social trust and confidence more than the legacy of the trenches and the Holocaust, horrible though they were.

Dworkin maintains that people utilize "the caring industry" on a massive scale because they have grown more sad and alienated. However, by this argument, one could argue that people use air conditioning because they have grown hotter than people of previous centuries. The latter would of course be wrong, but one can make a case that psychotherapy is not so much a response to cultural calamity as it is just another modern innovation that people find useful and reassuring. The comparison to air conditioning may sound trivializing, but it isn't entirely far-fetched; after all, in heat waves such as we are having now in my part of the world, AC does save lives, even if for most it "merely" adds to quality of life.

It is true that air conditioning has made people less tolerant of the heat, just as automobiles make people on average less tolerant of exercise. But these are side-effects and trade-offs that the majority seem willing to make. And the relative softness and sensitivity of modern populations are arguably consequences of unheralded prosperity--there is a bit of a princess-and-the-pea phenomenon whereby the better off on is, the less tolerant one becomes of imperfection. Most people in history had no need of therapy because they were too busy trying to stave off starvation and disease.

Modern psychotherapy arose in Europe in the 19th century, which on that continent on average was a time of great prosperity; suddenly there was a larger middle class with the time and disposable income to worry about the kinds of "problems of living" that traditionally could be "suffered" only by the rich. It is significant then that psychotherapy really took off in the U. S. in the 1950's, which, while it was a time of war weariness and nuclear anxiety, was also in economic terms the start of a globally novel degree of economic well-being.

Despite its inequalities (more stark in recent years), over the past half-century the U. S. has been, in sum, the most prosperous nation in the history of the world, so arguably its vices--the breakdown of the family, the hypertrophic media and entertainment industries, the rise of obesity, and yes the "triumph of the therapeutic"--are largely ailments of prosperity. But these ailments are very real, and attended by real suffering--just ask the morbidly obese. The caring industry may be an inevitable result of liberal capitalism. As a culture, it may be that we have become less trusting, and perhaps even less loving, than our great-grandparents, but arguably we are also more knowing and less naive.

Hippocrates and the Hangman

"Many that live deserve death. And some that die deserve life. Can you give it to them? Then be not too eager to deal out death in the name of justice, fearing for your own safety. Even the wise cannot see all ends."

Gandalf, The Fellowship of the Ring

Granted, when it comes to the question of capital punishment, those on death row tend in their character to be more like Gollum (for whom Frodo desires death in this Tolkien quote) than like Socrates faced with the hemlock in Jacques-Louis David's famous painting. And it is noteworthy as regards the quote that contemporary America endeavors to give (deserved) life to those fated to die every bit as aggressively as it seeks to give (deserved) death to those otherwise fated to live after committing heinous crimes. In this respect capital punishment is a grim mirror image of the out-of-control medical-industrial complex. Even the wise...

This came to mind after a recent local story in which the Supreme Court of North Carolina decided (4-3!) that the state medical board cannot in fact discipline physicians who participate in executions (i.e. by monitoring vital signs to insure that the inmate is "not suffering"). Death sentences, which had been on hold for a couple of years because of this question, can presumably start up again.

It took me years to decide where I came down on the question of the death penalty. I used to be for it, as I've always had a healthy respect for evil as a real force in the world, and as Tolkien wrote, in terms of abstract justice there are people who have done things so awful that they deserve to die. However, in an odd parallel to the question of the possible rationality of suicide, I think that the absoluteness of death precludes, in practice, the ethically justifiable intentional taking of life for any reason but direct and obvious self-defense (any society-wide deterrent effect of capital punishment is debated, and is definitely not direct and obvious).

Capital punishment, like suicide, is a declaration that this particular person's life cannot be considered worth living; in an execution the state effectively commits suicide on another's behalf, conflating vengeance and penance. In this sense it is richly ironic that those on death row are not permitted to commit suicide, and indeed may not be considered "competent" for execution if they are suicidal. Both execution and suicide are acts of dreadful certainty: "By the permanence of this act I affirm that I (or we, the state) cannot possibly be mistaken, that things could never come to be different, whether through additional evidence or altered perception." Playing God, indeed, although to do so with someone else's life is rather different, isn't it, than to do so with one's own?

What physician would want the job of monitoring an execution? I suppose it could be a deeply ethical act, inasmuch as the about-to-be-executed are, by definition, those who have had every human right stripped from them--except for the right to freedom from inflicted physical agony. Another irony, as Atul Gawande's recent New Yorker article painfully described, is the regular use of long-term solitary confinement, which arguably inflicts emotional distress far more horrific than the physical pain someone could undergo during lethal injection. What is the difference? Well, there are media and family representatives observing an execution, but in a solitary cell, not so much. Very discreet.

I always come back to Oliver Cromwell's (paraphrased) admonition, "I beseech you, in the bowels of Christ, consider that you may be mistaken." Suicide means blinding oneself to the possibility of the ultimate error. Execution leaves this possibility open, but removes the option of ever rectifying it. Eventually the civilized world will view capital punishment much in the way it views slavery, as beyond the pale (much of the world does already actually, we just haven't joined it yet).

(Moon) Pie in the Sky

A world of made
is not a world of born--pity poor flesh

and trees, poor stars and stones, but never this
fine specimen of hypermagical

ultraomnipotence. We doctors know

a hopeless case if--listen:there's a hell
of a good universe next door;let's go

E. E. Cummings


After considering human enhancement over the weekend, it seems fitting to reflect on its evil alter ego, cultural degradation, on a Monday. I had long meant to get around to Saul Bellow's Mr. Sammler's Planet, but taking it on the cruise ship was a deliberate exercise in incongruity, sort of like schlepping Madame Bovary to a boxing match, or packing "Notes Toward a Supreme Fiction" for an outing to Chuck E. Cheese's. But its theme of cultural decadence seemed somehow appropriate in the sybaritic surroundings, and Bellow's coruscating prose served as a model in miniature for the blazing Caribbean sun that, ultimately, was its progenitor.

Mr. Sammler's Planet was discussed in a typically trenchant post by D. G. Myers at A Commonplace Blog; it is easily the most entertaining and thought-provoking novel about a basically crotchety character that I have ever read. Published in 1970 and set in New York City, it is the story of the Holocaust survivor and general avatar of Old World culture Artur Sammler and his deep dismay amid a society that seems to have cast aside all cultural, material, sexual and scientific restraint. The very first paragraph frames the book well:

Shortly after dawn, or what would have been dawn in a normal sky, Mr. Artur Sammler with his bushy eye took in the books and papers of his West Side bedroom and suspected strongly that they were the wrong books, the wrong papers. In a way it did not matter much to a man of seventy-plus, and at leisure. You had to be a crank to insist on being right. Being right was largely a matter of explanations. Intellectual man had become an explaining creature. Fathers to children, wives to husbands, lecturers to listeners, experts to laymen, colleagues to colleagues, doctors to patients, man to his own soul, explained. The roots of this, the causes of the other, the source of events, the history, the structure, the reasons why. For the most part, in one ear out the other. The soul wanted what it wanted. It had its own natural knowledge. It sat unhappily on superstructures of explanation, poor bird, not knowing which way to fly.

I love that last part--Freud in a nutshell, no? Or inasmuch as Freud himself aspired to be the ultimate explainer, this is perhaps the narrative and aesthetic riposte to Freud, and the whole modernist and Enlightenment project.

The classically deracinated, alienated man, Sammler finds himself in a world he barely recognizes. Obviously he interacts with what, biologically, are other Homo sapiens, but some kind of cultural speciation seems to have taken place--by means of his transit across the Atlantic Ocean and the 1960's--such that he no longer feels he is among his own kind. There has been a transvaluation of values, embodied in the general kooky flakiness of his own daughter and in the appalling children of his nephew and New World benefactor. Common sense appears to have drained from the world. All of this occurs against the backdrop of the time's fervent enthusiasm about the moon landing and mankind's presumed cosmic destiny. As all eyes turn toward the heavens--and away from the earthly decay all around--the irony, perhaps even the pathos, is rich.

I highly recommend the book--Bellow's best in my opinion except perhaps for The Adventures of Augie March.

Bellow's book came to mind when I was reading Thomas Mallon's article in The Atlantic about prospects for sending (unmanned) spacecraft to other solar systems. Around the same time that Sammler had appeared, when progress of the space program paralleled growing awareness of overpopulation and environmental destruction, the anthropologist Loren Eiseley had published The Invisible Pyramid, which evinced similar ambivalence about human restlessness. As a writer long fascinated both by humanity's mercurial ambition over the eons and by the wider natural world, Eiseley couldn't help being alarmed and saddened by the tremendous environmental threat posed to the latter by the former. As a somewhat bitter metaphor for space exploration he proposed the tendency of some fungi to shoot spores randomly into the air when their own life cycles and locales are exhausted. On this account humanity's perennial sense of Manifest Destiny is not so much heroic as cancerous.

What does it say about us if the essence of human nature is to change its own nature, that is, to have no essence? Doesn't that mean that consciousness is basically destructive, or should we say creative? Is self-enhancement a rejection of the self (death, in effect), or its natural developmental trajectory (greater life)? Is space exploration a rejection of the earth, or the fulfillment of a promise that evolved on earth? We must accept ourselves, yet we must change. Paradox.

Times A-Changin'

Maybe, or maybe not. Here's Samuel Johnson on "blogging" in 18th-century England (courtesy of Peter Martin's biography). Sound familiar?

(Writing of the proliferation of independent printers) "If we consider chiefly the state of our own country, [it] may be styled with great propriety The Age of Authors...The province of writing was formerly left to those, who by study, or appearance of study, were supposed to have gained knowledge unattainable by the busy part of mankind; but in these enlightened days, every man is qualified to instruct every other man."

(Writing on the pressure of frequent deadlines) "He that condemns himself to compose on a stated day, will often bring to his task an attention dissipated, a memory embarrassed, an imagination overwhelmed, a mind distracted with anxieties, a body languishing with disease: he will labour on a barren topic, sill it is too late to change it; or in the ardour of invention, diffuse his thoughts into wild exuberance, which the pressing hour of publication cannot suffer judgement to examine or reduce."

I have read before that newly prevalent coffee houses in Johnson's era helped to spur the development of literary culture, caffeine promoting attention and perspicacity more effectively than the psychotropics available in taverns and alehouses. Fast forward to contemporary neuroenhancement, whose prime time status is attested to by Margaret Talbot's review of the phenomenon in The New Yorker.

Talbot interestingly profiles college students who, unmedicated, might lapse into indie slackers, but who seem to fire on all cylinders thanks to Adderall, as well as new agey scientific gurus who swear by Provigil. She covers all the usual objections to widespread and off-label use of such agents: the pressure of technocratic conformity, the emphasis upon focused productivity at the expense of serendipitous creativity, and of course known and unknown adverse physiological effects. But she seems to conclude that the practice is roughly analogous to plastic surgery, that is, regrettable perhaps, but likely not illegal or even necessarily unethical.

The enhancement issue occupied my mind a great deal a couple of years ago and yielded a couple of published papers, but here I would say only that neuroenhancement does differ from plastic surgery inasmuch as the former affects not only one's attributes, but also one's capacity or inclination to reflect upon those attributes. If someone without ADHD is in some hyper-focused state due to Adderall or Ritalin, this state may in itself vitiate his ability to consider whether this is a good thing (just as, similarly albeit more dramatically, an actively inebriated person is not well placed to appreciate the virtues of sobriety). It is as if a plastic surgery procedure were to directly (and not just indirectly) make one even more superficial and other-directed than one already was.

For the psychiatrist, it is also somewhat quaint to hear talk of these agents as being fraught with prodigious impact and potentially hazardous effects, when the issue for many folks with real ADHD is less likely to be side effects than limited efficacy.

The Sage

I'm starting to think that being an advice columnist would be a cool hobby--you get to read all kinds of fascinating, intimate letters from strangers, generate pithy observations on life and proper conduct, and you don't have to worry about after-hours calls or malpractice insurance. Advice-peddling is to psychotherapy what, say, homeopathy is to mainstream medicine. Both respond to the same basic needs.

For a while I've followed "Dear Prudence" (Emily Yoffe) at Slate, and only recently did I start Cary Tennis's column at Salon. Their differences are striking; advice columnists have their own styles, I suppose, as therapists do. Prudence is blunt, wry, and worldly; she does not tolerate fools and the self-indulgent gladly. Her replies are succinct and no-nonsense. Tennis is more reflective, tentative, and speculative, engaging in poetic flights of fancy to get a point across. I wish I could be more like Prudence, but by nature I'm more like Tennis.

A frequent admonition heard (and inevitably, parroted) during my training was that psychotherapy does not involve giving advice. I guess there are two reasons for this: the latter may undermine agency and personal responsibility, and it very likely oversimplifies irreducibly complex situations. But advice columnists perform valuable functions, acting as moral arbiters and as amateur psychologists. Many of the dilemmas prompting advice-seeking involve uncertainty about what is appropriate in myriad life situations, usually involving relationships or personal ethics. If psychotherapy is ultimately about self-understanding, advice-giving emphasizes propriety and practical wisdom.

The problem with advice-giving is that one is almost always going on painfully limited information. Whenever I read a letter the therapist in me instantly has a thousand questions about how some pathetically dysfunctional family or relationship got to be that way. If depth psychology is about reveling in (potentially infinite) complication, time-limited and cognitive-behavioral therapies aim to simplify, as advice-giving does. What I would love to know is whether the letter-writers ever derive any benefit from the replies they receive--it would be nice to have later updates on particularly juicy or precarious situations.

Men Failing to Thrive

In The New Republic Sherwin Nuland reviews Mark S. Micale's new book on the history of hysteria in men. Yes, it exists, but seems to have been hiding in plain sight over the millenia.

As yet another horrific mass shooting occurs (New York state this time), it occurs to me that this is a uniquely male breaking point. Other appallingly violent behaviors, such as serial killing and suicide attacks, are carried out by females in a minority of cases. I'm sure there must be one somewhere, but I cannot spontaneously remember an example of a female walking into a public place and starting to shoot. Why is this? And it brings up the classic mad vs. bad conundrum. Is a "random" mass shooting like a tornado--a force of nature very difficult to predict precisely--or is it an act of the purest evil? Can it be both at once?

Unemployment is soaring here (fourth in the country as of February 2009). How do you make a man depressed, particularly in a rural area? Take away his manufacturing or construction job, leaving him with lots of time on his hands, to do either nothing or to mind the kids while his wife ekes out a secretarial position. In a couple of months, repossess his car (and no mass transportation out here). In a few more months, foreclose on his house so that his family has to move in with his in-laws. By now he'll be unable to afford the pain clinic where he has been treated for back injuries sustained in those manufacturing or construction jobs. Oh, and he has a 9th grade education, so if he's going to retrain it's going to take a long time, and where will the money come for that, exactly?

I'm not sure that SSRI's have been studied in this population. SSRI's--did I mention, take away his sexual function?

Strange the places human misery washes up in the wake of a distant explosion of greed and fiscal ineptitude...

It's Not You, It's Me

"This is the cultural moment of the narcissist," writes amateur (in the best sense of the word) psychologist Emily Yoffe (her "Dear Prudence" advice column in Slate every Thursday is not to be missed). Problem is, that has been true for at least the past thirty years--Christopher Lasch's acclaimed and acute The Culture of Narcissism appeared in 1979, at the end of the "me decade."

Yoffe's piece is a generally accurate and entertaining popular overview, although I would fault it for suggesting that the narcissist himself usually suffers much less than those around him. To be sure, there are the so-called "oblivious" narcissists who are often high-functioning leaders in politics, business, or other fields, and everyone seems to adduce Bill Clinton as an example although as a psychiatrist I'm not ethically allowed to do that (i.e. diagnose celebrities).

But the central point of narcissism is that the grandiosity and lack of empathy both reflect and attempt to compensate for grievous weaknesses in the self, manifested by painful self-absorption and a gnawing sense of emptiness. These so-called "hypervigilant" narcissists are constantly on the lookout for the validation they desperately crave, and lacking which, they often collapse into despondency or primitive rage.

Limited time today, but my pet theory about many of our current ills, narcissism as much as obesity, is that they are the ironic result of society having achieved levels of average prosperity undreamed of by most people for most of history. And it is the capitalistic prosperity itself--the leisure time, the preoccupation with management and appearance, the endless craving for a new external satisfaction--that is responsible, and not any particular political choices made in recent decades. For most of our history the sheer pressure of work and survival protected us from narcissism. Narcissism is a luxury we seem willing and able to afford, even if it doesn't usually make us happy.

Addendum: Just now I found a most emblematic article, courtesy of good ole Arts and Letters Daily, about the woes of contemporary women who are dissatisfied with their lot no matter how rich, well-wedded, or stocked with cherubic children they may be. I won't say this reflects narcissism per se, only the kind of anomic ennui of contemporary success that I mentioned before. The piece also observes, strangely, that men, in comparison, seem content with their lot. I must not know male psychology like I thought I did...

No Grade Inflation Here

NAMI (National Alliance for the Mentally Ill) has released a follow-up report card for states' systems of mental health care. As compared to the 2006 report, unsurprisingly, little has changed overall, and the national average remains a D. No state got an A.

These states got B's: Connecticut, Maine, Maryland, Massachusets, New York, Oklahoma

These states got F's: Arkansas, Kentucky, Mississippi, South Dakota, West Virginia, Wyoming

I do public psychiatry only part-time, and I don't mean to wax sanctimonious, but if you're disadvantaged to start with, and have a mental illness on top of that, but you do happen to be living in, on average, the most prosperous nation in the history of the world, one would hope that you could look beyond the local jail or emergency room to obtain decent help. As a society we obviously have other priorities.

State-by-state grades in 2006 and 2009 are here.

The Sky's the Limit

Falstaff: Now, Hal, what time of day is it, lad?

Prince Henry: Thou art so fat-witted with drinking of old sack, and unbuttoning thee after supper, and sleeping upon benches after noon, that thou hast forgotten to demand that truly which thou wouldst truly know. What a devil hast thou to do with the time of the day? Unless hours were cups of sack, and minutes capons, and clocks the tongues of bawds, and dials the signs of leaping-houses, and the blessed sun herself a fair hot wench in flame-coloured taffeta, I see no reason why thou shouldst be so superfluous to demand the time of the day.

Henry IV

Courtesy of Arts & Letters Daily (again), I see Mary Eberstadt's review of the curious cultural trajectories of food and sex over the past few decades. For the first time in human history, Western societies have offered virtually unlimited access to those two primal goods to most of their populations. Her review is lengthy but interesting (I was going to write fascinating or even titillating, but I don't want to wax immoderate here). Think of it as an edgily romantic runup to Valentine's Day.

As she notes, throughout most of human history food consumption was limited by natural scarcity (and by harsh social punishments of theft), while sex was constrained by biological deterrents (like kids, and syphilis) and social sanctions. Beginning around the 1960's, thanks to technological advances and liberalizing attitudes, all of these barriers started to give way. How have we handled this unprecedented access?

Gluttony was of course one of the seven cardinal sins, but post-medieval societies didn't get too worked up about obesity, which was rare and, if anything, a sign of economic prosperity (the reverse is true now, as obesity is inversely correlated with rising socioeconomic status, not least because the relatively poor are more likely to consume cheap and concentrated calories and less likely to have access to safe and convenient exercise options).

As many have noted, the obesity epidemic is the classic disease of civilization, in which cheap and abundant food meets evolutionary tendencies to store fat for next year's famine. What is surprising, as Eberstadt notes, is the advent of remarkably puritanical attitudes about food choice and body weight over the past few decades. I would suppose this represents a confluence of three factors (in addition to the status factor just mentioned): the mainstreaming of animal rights concerns, an increasing awareness of environmental impacts of food production, and the ever more apparent price tag of food and other behavioral choices (since the health care system is always shifting costs in some way, my neighbor's Big Mac could wind up being my insurance premium).

Eberstadt has an alternative and intriguing notion, although I'm not sure I buy it. As food has acquired more moralistic connotations, sex as we all know has generally done precisely the opposite over the past half century. Eberstadt seems to suggest that as the sexual revolution has continued to careen widely, most recently into an explosion of Internet pornography, we may be transferring some of our (currently politically incorrect) anxieties about sex onto food. That is, we feel a "natural" need to rein in our impulses, and in the current cultural climate it is easiest to do this with diet. It's an intriguing idea, even if just speculative psychobabble on her part; perhaps some kind of hard-wired self-restraint can be culturally bypassed only for a while or only at a price.

Eberstadt also cites a body of research showing the allegedly deleterious effects of pornography and more lenient sexual habits in general. Some of it seems questionable; for instance, when she argues that married folks have better financial and health outcomes than singles, this obviously doesn't show that marriage was the causative factor rather than mere correlate. She is more convincing when discussing the effects of the sexual revolution upon children, mediated not least by the predominance of divorce. So go sow some wild oats, then procreate--in that order (just as stereotypes are often true, cliches became cliches for a reason).

The Sense of an Ending

This being the Martin Luther King, Jr. holiday here in the States, I was going to extend my Pre-Inaugural Poetry Break for another day, but a typically unsentimental commentary by Stanley Fish in the Times warrants notice. Fish has long advocated for the self-sufficient, thought-for-thought's sake status of the humanities in education; that is, a la Harold Bloom, he decries any notion that the humanities make us "better" people in any broad or conventional way, but he sees this as their great merit, that they are (in ways that I would view as quasi-spiritual) ends in themselves and not means to (allegedly greater) social ends.

He likely still thinks this about the general nature of the humanities, but he has decided that their place in the contemporary university is all but gone, except for a view lonely redoubts that he quaintly terms "museums." Universities are increasingly blatant in their roles as essentially customer-friendly vocational schools, aiming to endow students with the "skills" necessary for "today's economy." Because the arts, literature and philosophy do not obviously or simplistically provide such skills, they are increasingly dispensable and barely even demand lip-service.

So I am reminded not only of my post of a few days ago, in which reading in general threatened to become an "arcane hobby," but also of a couple of trends in medical education. One is the inevitable erosion of psychoanalytic and, in a wider sense, humanistic thought on psychiatry and psychiatric education over the past twenty years or more. This is convincingly analogous to the process Fish describes.

The second and ironic evolution or, rather perhaps, reaction, has been the attempt to restore interest in narrative to medical education and discourse. This quixotic project, in which I played an exceedingly obscure role in the past, seems a bit like trying to open a lending library inside a video arcade, but stranger things have happened. Yet in general the sense is that we have entered a more crass and mercantile age--but this too shall pass, even if after our lifetimes. Meanwhile, enclaves of enlightenment will go on.

But, for the poem I had in mind for today, befitting this final day of a dank, dim, and dispiriting age in American politics, I summon that sour, dour Californian Robinson Jeffers (1887-1962):

Shine, Perishing Republic

While this America settles in the mould of its vulgarity, heavily thickening

to empire,

And protest, only a bubble in the molten mass, pops and sighs out, and the

mass hardens,

I sadly smiling remember that the flower fades to make fruit, the fruit rots

to make earth.

Out of the mother; and through the spring exultances, ripeness and

decadence; and home to the mother.

You making haste haste on decay: not blameworthy; life is good, be it

stubbornly long or suddenly

A mortal splendor: meteors are not needed less than mountains: shine,

perishing republic.

But for my children, I would have them keep their distance from the

thickening center; corruption

Never has been compulsory, when the cities lie at the monster's feet there

are left the mountains.

And boys, be in nothing so moderate as in love of man, a clever servant,

insufferable master.

There is the trap that catches noblest spirits, that caught--they say--

God, when he walked on earth.

(Note: poem format, but not content, altered to fit blog platform).

If this republic was "perishing" in 1925, what is it now--darkest undead? Is resurrection possible, by degrees? Perhaps eight years will suffice.

Bedlam

Macbeth: Canst thou not minister to a mind diseased;

Pluck from the memory of a rooted sorrow;

Raze out the written troubles of the brain;

And with some sweet oblivious antidote

Cleanse the stuff'd bosom of that perilous stuff

Which weighs upon the heart?

Doctor: Therein the patient

Must minister to himself.

Macbeth needed a psychiatric referral and not a brush-off; we know how he turned out (well, psychiatry was a bit green in 1600).

1. Nassir Ghaemi, M.D., a prominent name in academic psychiatry, writes a thoughtful blog at Psychology Today. In his last few posts he has started to explore the issues stemming from the recent well-known scandals of psychiatric research and pharmaceutical companies. As one would expect, the reality is neither one of money undermining everything of value in the profession nor one of open, public-spirited firms working for nothing but the common good. I still need to write my post on this topic (yes, avoidance has its uses).

2. Courtesy of Arts & Letters Daily, I see that Paul McHugh, M.D. has written a useful conceptual and historical review of the concept of hysteria, a famous shapeshifter in both psychiatry and medicine (hysterics are as likely, if not more so, to visit non-psychiatrist physicians as psychiatrists). Basically, hysteria results from the intersection of individual vulnerability and suggestibility with the prevailing winds of groupthink at any time pertaining to what constitutes legitimate illness or illness behavior.

3. Have you nursed a lifelong dream to work in a state psychiatric hospital? If so, it is commendable, because good people are definitely needed. However, before signing up you might want to look at this hair-raising account of life as a social worker in a hospital in a state located somewhere between Virginia and South Carolina. Did you think that snake pit, cuckoo's nest, etc. were safely of the 1950's and 1960's? Think again. If you're going to become seriously mentally ill, be sure to arrange excellent insurance beforehand.

This account is not typical, fortunately, arising as it does from regrettable adventures in mental health care reform. It is amazing that forty years after the great deinstitutionalization of the 1960's (the effort to move the teeming masses of then-much-larger state psychiatric hospitals into outpatient community programs), we still can't get this right, apparently through lack of funding and organizational mismanagement.

And this occurs in a nation that, before the recent economic plunge at any rate, was apparently the most prosperous in both absolute and relative terms in the history of the world. Mental health care reform appears to be where good intentions go to die. Is the economy booming? Then mental health can spare some funding. Is the economy tanking? Then mental health is going to have to tolerate some cuts. What was that about a society being judged by how it treats the most vulnerable?

Grand Inquisitor

The heart asks pleasure first

And then, excuse from pain --

And then, those little anodynes

That deaden suffering;

And then, to go to sleep

And then, if it should be

The will of its Inquisitor

The liberty to die.

Emily Dickinson

Several items caught my eye today. It is dark and stormy here, with the potential for sudden catastrophic death looming over the landscape (okay, there's a tornado watch); so forgive the theme of menace.

1. On the brightest note, I was alerted to a comprehensive listing of psych-related blogs at "101 Fascinating Brain Blogs" at Online Education Database. It includes all the well-known ones but also many I wasn't aware of (oh, and it commendably includes Ars Psychiatrica).

2. Art Blog by Bob yesterday featured "The Scream" and several other works of the evidently dysphoric painter Edward Munch (painter of today's illustration here as well). Check it out.

3. For any readers in Kentucky I happened upon a Scientific American article about the United States Narcotic Farm (or Narco) near Lexington. From 1935 until 1975 the huge facility housed many of the nation's criminal addicts, which included some prominent names over the years. It was the setting for a great deal of addictions research involving the prisoners, although toward the end the C.I.A. and others apparently developed concerns that research involving both L.S.D. and less than fully informed consent may have been going on. The article includes a slide show and alludes to a documentary about Narco that would be very interesting.

4. Also in Scientific American is an article on schizophrenia and its relation to language. Schizophrenia is an enormously complex illness and we are far from understanding it, but given the prevalence of auditory hallucinations in the disorder, links to language function have long been a focus. Apparently genes related to language are increasingly suspected in schizophrenia, which may be a casualty of our species' very rapid brain growth over the past million years or so. It is odd to think of such a devastating illness deriving from the same developmental pathway leading to, among many other things, the great poets.

5. The New England Journal of Medicine has an editorial on the current status of physician-assisted suicide in the United States, now legal in both Oregon and Washington state after the latter recently approved it by a decisive 58-42 margin. With 6.7 million people, Washington is twice the size of Oregon and will be an interesting test of the law.

As the article documents, the procedure in Oregon has not drawn the multitudes that were originally feared. From 1998 through 2007 only an average of 34 patients per year carried out the procedure. The law requires two physicians to independently confirm that a patient is both terminally ill and competent to make the decision. As one would expect, the most common diagnosis was terminal cancer. The "physician assistance" usually involves prescription of barbiturates, which the patient apparently must administer himself.

No psychiatrist is required to be involved, although consultation with one is encouraged if there is any suspicion of depression or questionable competence. However, the article notes that no psychiatry consultations were made in 2007, and only 12% of cases involved consultations in the nine previous years.

I have pretty firm opinions on most issues, but this is one I struggle with. We know that suicidal ideation in general is much, much more likely to be related to a mental disorder (most commonly depression, substance abuse, or schizophrenia) than not, and we are familiar with concerns arising from end-of-life suicidality that may stem from inadequate palliative care or fears of being a burden on family members.

A philosophical question in psychiatry is whether suicidal ideation can be anything but a manifestation of disorder. The arguments pro and con are complex and beyond the scope of a blog post (Courtney S. Campbell wrote a heftier review of the issues in The New Atlantis), but I personally believe that it is possible for a terminally ill person, afflicted perhaps with irreversible physical or mental decline, to desire death without being considered clinically depressed.

However, considering the finality of suicide, and the issues of subtle or not-so-subtle suggestion or coercion that can arise, I wonder sometimes if we're making it too easy, too comfortable to make such an existentially stark decision. It may be hard for a psychiatrist to say, but it is a conscious being's inherent right to commit suicide. If someone tells me he's going to, then I will commit him to a hospital or otherwise take steps to prevent him. But if he doesn't tell me or anyone else, then no one is going to stop him.

The question is: why does he think he has a right to get someone else to help him? Some decisions are meant to be excruciatingly difficult and painful; that often means they shouldn't be made at all, or if they are made, certainly not with nonchalance. I think there is some risk to any society of allowing people to go too "gently into that good night." To me this seems the wisest and most conservative approach.

On Psychiatric Overdiagnosis

Consternation and derision greeted the recent Archives of General Psychiatry study that suggested that large numbers of American college students have mental disorders. Every once in a while psychiatrists like to assert that a large proportion of the population needs nothing so urgently as, well, to see a psychiatrist as soon as possible, and it gets everyone in an uproar. Psychoanalysts used to be good at this, but it works just as well for the DSM system. Rather than quibble over numbers, I have a few general comments.

Psychiatrists seem to have the idea that they are the ultimate arbiters of diagnosis. They aren't; the society in which they practice is. Now, psychiatrists do have more expertise than the average person on the street when it comes to mental functioning, but some wisdom is not the same as omniscience. The psychiatric profession--explicitly via the DSM, implicitly via aggregrated clinical habits--submits proposals as to what should constitute mental disorder. However, it is the society at large, contingent upon public attitudes and financial resources, that ultimately decides what the purview of psychiatry will be.

The analogy that comes to mind is the distinction between military tactics and defense policy. As the famous quote goes, war is too important to trust to the generals. In the case of democracy at least, a society decides (by virtue of the government it elects) the general kind of defense policy it will pursue. The military is entrusted with the mission of carrying out those military goals. But the military does not set defense policy--in a democracy at least. To be sure, military personnel have opinions about defense matters that, due to their expertise, should be given particular attention, but they do not have the final say.

To stretch the metaphor to a breaking point, the problem is that the "war on mental illness" (would that be like the "war on drugs" or the "war on terror?") is not a coordinated campaign, but rather comprises endlessly complicated guerrilla tactics carried on in many thousands of consulting rooms. Psychiatrists have their "marching orders," a plan of what is to be accomplished and what is or is not appropriate in carrying out that plan, in the form of, say, FDA recommendations, the DSM, and the nebulous concept of "standard of care," but due to professional privilege it is easy for psychiatrists to become vigilantes. They become so sure of their power and, granted, so honestly aggressive toward "the enemy" (mental disorder, recall, not the patient), that they exceed appropriate bounds. When psychiatrists try to be Batman, things go awry.

When a soldier or even a general becomes insubordinate or even undermines the mission in subtler ways, he can be removed. When individual psychiatrists commit malpractice, of course, they can be removed in a way too. But there is no easy feedback system for influencing the profession as a whole when it has strayed too far. Economics can accomplish this, and did so when society essentially decided that it could not pay for long-term psychoanalysis for anyone who wanted it.

Psychiatry, like the Republican Party, may be venturing farther into the wilderness. Criticism of diagnostic and prescribing trends, along with high-profile pharma cases rocking academic psychiatry, has put the profession out of step with "mainstream America." Psychiatry needs to understand that while people at all ages have varying degrees of mood instability and impulse control, not everyone wants to classify these differences along a diagnostic spectrum. People want to have the freedom to be odd or even imprudent even if it may do them harm; they want the freedom to screw up without having to see a psychiatrist. Lack of "awareness" and "access" can be real issues, but when psychiatrists focus on them excessively they can lose sight of the fact that some people just do not desire their services. Psychiatry seems to think, "If only they knew us better, they would like us--what's not to like?" Hmm.

For the foreseeable future there will be enough truly unambiguous psychopathology to keep the profession plenty busy without having to go stir up diagnoses. None of what I've written is meant to romanticize very real depression, bipolar disorder, schizophrenia, and yes, personality disorder and substance abuse, for which psychiatry is alas, quite necessary. But overall mainstream psychiatry is looking a lot like the party of Delay, Bush, McCain, and Palin. Let's see, whom else can I offend?