Blue to Blue

Forwarding Address

nscheurich1@gmail.com (Novalis) — Sun, 13 Jun 2010 01:07:00 +0000

I am in fact shutting down Blue to Blue and have returned to Ars Psychiatrica.

Simplify, Simplify

nscheurich1@gmail.com (Novalis) — Sat, 12 Jun 2010 00:48:00 +0000

I will ponder color and design over the weekend, but here I must recommend a recent David Brooks column stoutly defending the liberal arts in education. Eschewing grand but airy pronouncements (of the kind frequently found on this blog), Brooks argued that the study of history, literature, and other domains creakily termed "the humanities" gives unique insight into "The Big Shaggy," his term for the deeply complex and wayward aspects of human nature that escape systematizing theories, whether biological, political, or otherwise ideological ("The Big Shaggy" isn't the term I would have chosen, but Brooks is writing for the New York Times, while I'm writing here).

His column nicely encapsulated what I've stood for in life and fought for in my years of clinical work, that is, resistance to the dumbing-down of human experience that is often found in diagnostic systems and, well, simple-minded approaches to minds that, rightly considered, are infinitely complicated. And yet I found myself contrasting that truth with a recent Jon Stewart routine in which he showed multiple clips of Barack Obama, with respect to situations like the gulf oil spill, health care, and the economy, pronouncing again and again to reporters, "It's complicated." Stewart followed this up with appalled exasperation: "Well simplify it!"

This usefully reminds me that human beings, while capable of appreciating complexity (to varying degrees) are alike in needing, especially in times of crisis, forceful and dramatic metaphors that are, yes, simple. So when I am tempted to disdain such words as "depression" or, even worse, "chemical imbalance," that seem to obscure a wealth of nuance with a kind of advertising slogan, I need to remember that such terms help to orient people. While a minority of folks--those who seek out psychoanalysts and English doctorates--may revel in boundless complication, most people are not wired that way. That is not to say that they're stupid or simple-minded; they merely crave contrast and direction. Leadership, whether political or clinical, is about providing these things; by breaking things down into basics, it risks dumbing-down, but the alternative risk is endless equivocation.

It seems to me that the art of medicine, like the art of life, is steering a path between over-simplification and over-complication, making use of metaphors without becoming trapped by them. Indeed, isn't language itself a kind of over-simplification inasmuch as it reduces, to paraphrase William James, the blooming, buzzing confusion of experience to a finite number of limited words? We can only grasp reality by making a narrative out of it, a narrative that necessarily distorts the stuff of experience. Just as we charge Barack Obama with constructing a narrative of the gulf oil spill that usefully but modestly apportions responsibility and possible avenues of action, we would charge a psychiatrist with drawing up a diagnostic and therapeutic narrative that is respectful of its own limitations. Whenever one tells oneself, "It's complicated," one should inwardly reply, "Simplify, simplify," and vice versa.

Happy 100?

nscheurich1@gmail.com (Novalis) — Wed, 09 Jun 2010 13:32:00 +0000

I haven't indulged in blogging about blogging for a long time, but I will allow myself this now that Blue to Blue has inched its way to 100 posts over 11 months. However, while I have retained a few core readers (thank you!), overall the readership as reflected in both hits and comments has been smaller than in my first blog Ars Psychiatrica. Reasons?

1. I haven't been as prolific, either in frequency or ambition of posts; it has simply been a more desultory blog overall. For various reasons I haven't devoted the time and energy that I often did last year. However, some Blue to Blue posts have been, I think, every bit as decent as many in the parent blog.

2. While I would hope that most people would visit this sort of blog primarily for textual content, the cool pictures and quotes that often adorned my previous blog have generally been lacking here. All else being equal, people like pictures.

3. Considering style further, I think that the title Ars Psychiatrica, while a bit pedantic, also usefully named the blog's niche in a way that the more inscrutable "Blue to Blue" does not. Also, the midnight blue template, while appealing to me at first, has grown a bit oppressive (or maybe I'm just bored with it).

4. I haven't been as active in reading and commenting on other blogs as I used to be, which affects readership.

5. As Facebook, Twitter, etc. have continued to grow and offer further distractions, maybe fewer people take time for blogs than used to be the case. (?)

6. As compared to its predecessor blog, probably fewer posts here have offered anything like mainstream commentary on psychiatry (again, the niche is less defined).

7. Perhaps the Novalis brand, so to speak, has grown a bit stale. Just as some claim that writers tend to write the same book over and over again, one does tend to revisit the same issues, although hopefully in a spiral more than a circular fashion (theme with variations).

8. In any event, I find myself at another cusp of choosing whether to give up blogging altogether or, on the contrary, to shift gears again and approach things from a different angle. As compared to the past year, I am in a position to devote more attention to writing if desired. I have even considered returning to Ars Psychiatrica (2.0 perhaps), declaring Blue to Blue a finally unsatisfactory detour. Or perhaps I will undertake something else altogether.

On the Perpetuation of Species

nscheurich1@gmail.com (Novalis) — Mon, 07 Jun 2010 22:59:00 +0000

Spanning the gamut of online wisdom, advice columnist Carolyn Hax and philosopher Peter Singer weigh in on the advisability of adding to the sum total of humanity. I've long been curious about the ways in which people choose (when they do have a choice, which they usually do) whether or not to have children.

Hax, responding to a letter-writer who asks if her anxiety disorder may be too severe for her to attempt parenthood, replies, in effect, that wanting to be a parent is no justification for becoming one. She advises the inquirer to consider, in light of her own knowledge of what it is to be a child, whether she would want herself as a parent. How drastically different human history would be if this were a precept that were followed with any consistency! Isn't the presumption of fitness for parenthood pretty much wired into the human organism? Indeed, it may be only the seriously depressed or demoralized, like the letter-writer in this instance, who even consciously consider the matter (which isn't to say that most people who choose not to have children do so for reasons of pathology).

Singer reminds us that creating a child is, of course, a portentous act of either good or ill. He alludes to recent philosophical writing that argues that, well, life often isn't the unqualified good we take it to be (I envision The Onion article: "Philosophers discover that life isn't worth living."). And all joking aside, one does occasionally encounter lives that are so chock full of misery and degradation that, really, not only the moral universe as a whole, but also the possessors of the lives in question, would seem to have been better without them.

Half tongue-in-cheek, Singer wonders whether it would be reprehensible for the species to decide that we will in fact be the final generation. After all, there is no categorical duty to procreate; we do not hold the childless to be guilty of some existential failure or infraction. We cannot be held to have a responsibility for vague beings of the future who may or may not exist; we have duties toward the living, that is all. And yet...one could argue that the presumption of a future for humanity, even if one does not have biological children oneself, is so deeply ingrained in the human organism that the horror of apocalypse far exceeds one's own demise. The future of humanity is not an obligation, but it is a hope, or perhaps a faith.

If one were to genuinely doubt the chance for a worthwhile life of one's offspring, then one would implicitly have to question one's own as well. I am surprised that Singer didn't mention The Children of Men, the movie a few years back that showed the depression and desperation of a world without reproduction. Arguably the final generation, whenever its grim day may come, whether in years or in millenia, will be the saddest one of all.

Maxim

nscheurich1@gmail.com (Novalis) — Mon, 07 Jun 2010 22:14:00 +0000

A nice poem by Carl Dennis (already online at The New Yorker website):

A Maxim

To live each day as if it might be the last
Is an injunction that Marcus Aurelius
Inscribes in his journal to remind himself
That he, too, however privileged, is mortal,
That whatever bounty is destined to reach him
Has reached him already, many times.
But if you take his maxim too literally
And devote your mornings to tinkering with your will,
Your afternoons and evenings to saying farewell
To friends and family, you'll come to regret it.
Soon your lawyer won't fit you into his schedule.
Soon your dear ones will hide in a closet
When they hear your heavy step on the porch.
And then your house will slide into disrepair.
If this is my last day, you'll say to yourself,
Why waste time sealing drafts in the window frames
Or cleaning gutters or patching the driveway?
If you don't want your heirs to curse the day
You first opened Marcus's journals,
Take him simply to mean you should find an hour
Each day to pay a debt or forgive one,
Or write a letter of thanks or apology.
No shame in leaving behind some evidence
You were hoping to live beyond the moment,
No shame in a ticket to a concert seven months off,
Or, better yet, two tickets, as if you were hoping
To meet by then someone who'd love to join you,
Two seats near the front so you catch each note.

Really?

nscheurich1@gmail.com (Novalis) — Sat, 29 May 2010 23:57:00 +0000

"Fortunately analysis is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist."

Karen Horney

Alan Schatzberg, M.D., outgoing president of the APA, has presented a solution for what he sees as a major problem besetting the DSM-5 process, that is, excessive coziness with the common folk and their darned opinions:

"One thing we ought to consider is using more technical language. Our cardiology colleagues don't talk about heart attacks but use the term myocardial infarction. Hematologists are not attacked for including leukemia in their nomenclature, and they wouldn't think of giving it up for "way too many white cells disorder" (WTMWCD)! Why shouldn't we follow their lead? To my view, bulimia would be a better term than binge eating disorder. The latter was attacked by a prominent psychiatric critic as suggesting he could be diagnosed with the disorder after a heavy Thanksgiving dinner. Our language should indicate the severity of the possible impairment. Simiarly, temper dysregulation in children sounds too much like temper tantrums. They are not the same, but the use of the language is problematic. We need to be more serious about our terminology. In the end, we will get it right."

Yes, this is what ails contemporary psychiatry, the lack of abstruse terminology that will mystify and impress the hoi polloi (which wouldn't be a bad term for a mental disorder, come to think of it). Time to haul out the Latin and German dictionaries. American psychiatry's cardinal sin has been false modesty, and an unwillingness to stick its fingers into as many pies as possible. We need to be more aggressive in educating the purblind populace about the grave severity of their mental states, crying out for the local psychiatrist. We need to exaggerate the degree of our actual knowledge, for the good of our patients of course.

What is noteworthy about myocardial infarction, though, and countless other terms from other disciplines, is the useful work that the names do in indicating specific and potentially modifiable pathophysiology (in this case, the death of cardiac muscle cells). Unfortunately it's hard to think of a single psychiatric diagnostic term that has that level of specificity. Are neurologists wringing their hands over the term stroke, which seems to enjoy both wide general use and a meaningful clinical designation?

This sounds like the kind of throat-clearing that might lead a psychiatrist to wear a white coat, which is about as useful on a shrink as it is on an accountant. Not really, of course, as perhaps a white coat would helpfully accentuate the placebo effect, as would the casual use of dumbfounding (if insignificant) expressions like amygdalar aberration, or hippocampal ischemia, or limbic encephalopathy. (Unless the patient starts laughing). Yes, melancholia sounds way cooler than depression, but apart from those of us who enjoy cool words, what would the former accomplish beyond self-importance?

The Unnameable

nscheurich1@gmail.com (Novalis) — Sat, 29 May 2010 00:42:00 +0000

After almost twenty years in my mind, the syllabic cornucopia of psychotropic drug names has made its case for a celebratory post. What has taken so long? And would I want the job of coming up with a moniker for Lilly's next miracle?

I considered a top ten list, but let us consider them by class:

1. Antidepressants: The meat and potatoes of psychiatry, these names are sure to be written with hand-numbing repetition, so it is a good thing that for the most part these drugs are happily named. A linguistic and pharmaceutical titan, Prozac is an arresting amalgam of the soothing, almost soporific Proz- followed by the hard "ack" that provokes comparison with another very popular drug of the 1980's. As the drug itself is meant to do, the name both calms and enlivens.
Zoloft and Paxil, completing the original SSRI trifecta, are also remarkably mellifluous names, although the former's buoyancy wafts dangerously close to corniness. Paxil follows flattery of Latinate pedantry (Latin pax=peace) with the relaxing -il evoking dutiful memories of Elavil, grandaddy of them all.
After these, antidepressant inspiration was spent in both chemistry and name. Celexa, its knock-off Lexapro, and Luvox? Not memorable. Effexor showed a lack of subtlety (Get it, "affects her," the majority of depressed patients being women?), regrettably dubbed "Ineffexor" when failing to work or causing dismaying withdrawal symptoms. Wellbutrin is a name simply rebarbative and without redeeming qualities, and it has been painful to hear a few concretely-minded patients over the years refer to it dismissively as "Badbutrin," which is a crime against both wit and alliteration.

2. Anxiolytics: It is a shame that Librium, lifted whole from a pleasing state of balance, did not prevail as a popular benzodiazepine. Similarly, Valium, connoting valiant equanimity, has largely fallen by the wayside. Instead we have Klonopin, which brings to my mind some kind of blunt instrument; Ativan, which seems to me a very gray sort of word, summoning nothing whatsoever; and the always suspect Xanax, whose pernicious influence may draw somewhat from its palindromic potency. A drug used for panic attacks should not end in -ax. But then again, I have heard that the color red, which tends to make people feel agitated and uncomfortable, sells best in grocery stores. Appropriately an afterthought, Buspar is a drug that eminently deserves its lame designation.

3. Mood-stabilizers: With the exception of lithium, which enjoys the elegant purity of being plucked right from the periodic table, the third lightest element in the universe, this group is composed of referential failures. Depakote. Tegretol. Lamictal. Whatever their pharmacological effects (which may be considerable), these names do not inspire confidence, and can be the insult on top of the injury of a diagnosis of bipolar disorder.

4. Antipsychotics: The hoary first generation of "major tranquilizers" could not be topped in dignity. Thorazine summons a compound of Nordic power with neuropsychiatric precision, a hammer brought down with pinpoint accuracy. Haldol conveys both majesty and trustworthiness, as of a respected elder. Navane is a name both implacable and imperious, sounding as if it should have been given by injection only. The contemporary offspring suffer from a failure of ingenuity. While Seroquel suggests a certain sophistication, Risperdal and Geodon are vaguely boorish in tone, while Abilify is simply an embarrassment. The unfortunate progeny of ability and fortify, it is a name that can't be taken seriously, which is a shame, because it isn't at all a bad drug. "Have you ever taken Abilify?" is a bit like asking, "Have you ever drunk Kool-Aid?" Please.

5. Stimulants: Provigil is sort of cool, evoking the steadily tenacious all-nighter, but maybe a bit too ominously. Compared to Ritalin, which is vaguely reassuring but forgettable, Adderall was a triumph of shameless audacity. The name is a naked directive: add this drug to all the patients you can, period. Why simplify or streamline your life when you can, in fact, add more? Add what? Adderall! You can have it all. At this point we are beyond subtlety, the closest possible thing to the drug name "Takethis."

A note on generics: Chemical drug names, with very few outliers, are infelicitous and afford little pleasure, except to the most self-righteous who refuse to pay their respects to brand names. Fluoxetine, carbamazepine, and thiothixene are flashbacks from Organic Chemistry. The only exceptions would be haloperidol and valproic acid, which are stimulatingly, sinisterly(?) decadent, sounding akin to something like absinthe.

In the world of medication management, we take our gratification where we can. (Note: this spoof concerns names and not the medical value of any of the medications mentioned. Ask your doctor).

Big Deal

nscheurich1@gmail.com (Novalis) — Thu, 27 May 2010 00:13:00 +0000

"If you hate violence and don't believe in politics, the only major remedy remaining is education."

George Orwell, "Charles Dickens"

In last month's Atlantic Monthly, Marc Ambinder usefully reminded us of the complex and multifactorial causes of obesity, and therefore the oversimplicity and unhelpfulness of the traditionally stigmatizing, "willpower" approach to weight loss. After all, when we consider the epidemic of fat in this country (and increasingly in prosperous nations generally) in recent decades, it isn't human nature that has changed, it is context that has changed. Our thinner grandparents didn't stay thin by means of virtuous self-renunciation; they had no other choice.

Ambinder documented now well-known social factors--sedentary residential and work environments coupled with high caloric content of foods (especially those hawked to children, the poor, and minorities)--acting in tandem to foster obesity. And he made the important point that it is more and more the case that "going with the flow," that is, eating what the Joneses eat, and doing what comes "naturally" in our highly artificial environment, will in fact make one fat. For most of our evolutionary history, becoming fat required either heroic effort or terrific good luck. In contemporary society, remaining thin requires either remarkable discipline or genetic good fortune. This brings to mind Nietzsche's point that many are virtuous merely through timidity.

In decrying the still popular tendency to demonize the obese, Ambinder made the point that in the end, stigmatization just doesn't seem to work very well. Would obesity be even more prevalent if there were no stigma whatsoever, or if fatness were actively celebrated? Well, probably, but at least when it comes to eating behaviors, the extraordinary rise of obesity in recent decades despite active stigmatization suggests that the latter stops working at a certain point. One wonders if such a point might be somewhere around the point at which the majority of people are overweight--it is simply hard to stigmatize the majority, it seems to me.

One can push individual responsibility only so far, to the point where the general outlines of mysterious "free will" can be said to lie. Beyond this point, why even speak of some kind of nebulous "free will" that is supposedly going unexercised in some malfeasance of bad faith? If people endure discomfort, ill health, shame, and stigmatization and still do not lose weight, why pretend that they could if they only tried harder?

Ah, this is where it gets tricky. Ambinder acknowledged that in experiments or other settings where people have (voluntarily of course) been put into extraordinary low-calorie and high-exercise environments for extended periods of time, they lose weight of course. Similarly, if one could pay people $1 million per pound lost, the obesity rate would shrink rapidly. Holding a gun to someone's head will help them to make wiser dietary choices. In this sense, obesity is not like cancer, which does not respond to similar incentives.

But unfortunately perhaps for human nature, numerous studies have shown that even most people who do succeed in losing large amounts of weight only rarely keep it off. That is because in our society of abundant calories and minimal necessity of exercise, and in the absence of genetic luck, it requires heroic effort to lose weight and keep it off. That's where human nature comes in; for the most part discipline and consistency are, by definition, average and not heroic.

This brings me back to the Orwell essay, in which he argued that Dickens perpetually urged a revolution in individual moral behavior rather than a reconsideration of social systems and incentives. Orwell suggested that while such urging has a radical aspect (a reimagining of human moral capacity), it also can be a deeply conservative, implicit embrace of the status quo, for when has human nature ever changed from the ground up and in a spontaneous fashion?

But consider Orwell's three-part approach of education, politics, and violence for social change. Inasmuch as childhood obesity is a significant root of the epidemic, then education about nutrition and exercise, a la Michelle Obama's campaign, can play a major role. Politics could reduce the influence of food advertising, influence consumption via taxation, and increase options for safe and convenient exercise in residential and urban locations.

By violence Orwell meant of course social unrest (assassination as the ultimate force for cultural change), but it occurs to me that violence could also refer to, say, bariatric surgery, of which Marc Ambinder openly proclaimed himself a successful beneficiary. If fat is the enemy, then by all means pressure people to fend it off themselves, and create the conditions in which they can best be motivated and educated, but beyond a certain point, stop waiting for mythical humans of superior willpower. Just cut out the fat, figuratively speaking. Kill it, and thereby begin to transform human nature itself. In that sense all technology is violence, altering the material context of human experience.

Happy Birthday Bob

nscheurich1@gmail.com (Novalis) — Mon, 24 May 2010 22:59:00 +0000

I'm told that Dylan is 69 today. If Obama deserved the Peace Prize, how much longer does Bob have to wait for his literature Nobel?

Just Like a Woman

Nobody feels any pain
Tonight as I stand inside the rain
Everybody knows
That Baby's got new clothes
But lately I see her ribbons and her bows
Have fallen from her curls.
She takes just like a woman, yes, she does
She makes love just like a woman, yes, she does
And she aches just like a woman
But she breaks just like a little girl.

Queen Mary, she's my friend
Yes, I believe I'll go see her again
Nobody has to guess
That Baby can't be blessed
Till she sees finally that she's like all the rest
With her fog, her amphetamine and her pearls.
She takes just like a woman, yes, she does
She makes love just like a woman, yes, she does
And she aches just like a woman
But she breaks just like a little girl.

It was raining from the first
And I was dying there of thirst
So I came in here
And your long-time curse hurts
But what's worse
Is this pain in here
I can't stay in here
Ain't it clear that--

I just can't fit
Yes, I believe it's time for us to quit
When we meet again
Introduced as friends
Please don't let on that you knew me when
I was hungry and it was your world.
Ah, you fake just like a woman, yes, you do
You make love just like a woman, yes, you do
Then you ache just like a woman
But you break just like a little girl.

Heart of Darkness

nscheurich1@gmail.com (Novalis) — Fri, 21 May 2010 00:27:00 +0000

"The old doctor felt my pulse, evidently thinking of something else the while. 'Good! Good for there,' he mumbled, and then with a certain eagerness asked me whether I would let him measure my head. Rather surprised, I said Yes, when he produced a thing like callipers and got the dimensions back and front and every way, taking notes carefully. He was an unshaven little man in a thread-bare coat like a gaberdine with his feet in slippers, and I thought him a harmless fool. 'I always ask leave, in the interests of science, to measure the crania of those going out there,' he said. 'And when they come back too?' I asked. 'Oh, I never see them,' he remarked, 'and, moreover the changes take place inside, you know.' He smiled as if at some quiet joke. 'So you are going out there. Famous. Interesting too.' He gave me a searching glance and made another note. 'Ever any madness in your family?' he asked in a matter-of-fact tone. I felt very annoyed. 'Is that question in the interests of science too?' 'It would be,' he said without taking notice of my irritation, 'interesting for science to watch the mental changes of individuals on the spot, but...' 'Are you an alienist?' I interrupted. 'Every doctor should be--a little,' answered that original imperturbably. 'I have a little theory which you Messieurs who go out there must help me to prove. This is my share in the advantages my country shall reap from the possession of such a magnificent dependency. The mere wealth I leave to others. Pardon my questions, but you are the first Englishman coming under my observation...' I hastened to assure him I was not in the least typical. 'If I were,' said I, 'I wouldn't be talking like this with you.' What you say is rather profound and probably erroneous,' he said with a laugh. 'Avoid irritation more than exposure to the sun. Adieu. How do you English say, eh? Good-bye. Adieu. In the tropics one must before everything keep calm.' ...He lifted a warning forefinger...'Du calme, du calme. Adieu.'"

Joseph Conrad

Talk About Cherry-Picking

nscheurich1@gmail.com (Novalis) — Tue, 18 May 2010 10:11:00 +0000

This is it, a double-take headline on NPR that is the unholy spawn of social Internet and medical marketing pressures: speed-dating at the Doc Shop.

I have been mulling over the prospect of a new practice; this is exactly the start-up idea I was looking for.

Let us dispense with the longueurs of the 15-minute visit. Even allowing for the luxury of a 5-minute bathroom break, I can envision 11 accelerated diagnostic evaluations per hour. The Adderall scripts will by flying fast and furious.

(Note to DEA: this is a satirical post).

Auf Wiedersehen to Academia

nscheurich1@gmail.com (Novalis) — Fri, 14 May 2010 14:08:00 +0000

A few days ago a friend and former colleague sent me news that a paper that we had begun at least three years ago (what is that in "blog years?") had finally appeared in the print world. He wrote it, I merely advised and proofread. But while I've been physically removed from the university for two years now, it occurred to me that only now, with the paper trail complete, was the academic experience complete, with closure as the cliche goes. As my first peer-reviewed article appeared in 2000, this nicely rounded the experiment up at a decade.

When I was a senior resident in the late 90's, the department chairman at the time, Allen Frances, M.D. (he of DSM-IV notoriety) rounded a few of us up to discuss our career prospects. At that point I had developed a strong interest in the history and sociology of psychiatry, and told him so. He nodded vaguely, as I recall, and said something about that being a worthwhile "hobby" (his word) to pursue alongside my real career of clinical work and, perhaps, more respectable (and funded) research.

At the time I privately took some offense, for the philosophical dimensions of psychiatry were a primary passion of mine; all of the mainstream trappings of the profession were necessary evils. The clinical experience has always been crucial, but its props (the diagnostic categories, the meds, etc.) I have always taken with some grains of salt. When I entered an academic position at a different institution, it was understood that the "props" (to include inpatient work and ECT) would earn my keep and justify my salary, but the deeper motivation for me was the intense and hard to define strangeness of the psychiatric endeavor itself.

So began a rather parallel career. On a theoretical (not, I hope, a personal) level I fumbled my way toward hysteria as the route to the pervasive but often acknowledged role of narrative and value(s) in clinical work, and I found, in poetry and short fiction, promising windows upon this state of things. In my mainstream work I tried to do good, broadly speaking, for people (ranging from administrators to patients) who want what they contingently want and upon whom thoughtfulness, unfortunately, is all too often wasted. But as I never really felt at home in the psychoanalytic community--it has always seemed a bit hieratic, a bit hothouse to me--a niche wasn't easy to find. I always felt that literature had more to teach psychiatry than vice versa.

Unless one counts a few paid trips to conferences (granted, Emily Dickinson in Hawaii is hard to beat), I was never funded a cent for publications or presentations over those years. My clinical work paid the way, so in that sense Allen Frances was right, my humanistic leanings were a kind of professional hobby in a way. I was an amateur, although hopefully in the best sense of the term. This was probably as it should be; why should taxpayers pay for an academic physician to indulge in esoteric speculations perhaps of no use to anyone (and surely not of measurable use) when he could be doing the "real work" of seeing patients?

I confess I never greatly enjoyed teaching medical students or psychiatric residents, at least not in the classroom setting and not the kind of mainstream stuff (the "descriptions and prescriptions") that they most wanted to know (I don't fault them, as they were responding to a professional and economic system with its own incentives). I mention this somewhat sheepishly, because teaching is one of those things--perhaps like growing your own vegetables or volunteering in soup kitchens--that is considered universally praiseworthy. But I most enjoy those activities that are done for their own sake, and for that reason the best learning takes place outside of a classroom. There were the occasional exceptions, the thoughtful ones; good teachers speak to a group of 30 for the sake of the 5 or so who truly care, or in the hope of increasing that 5 to 10. I'm just not wired that way; an autodidact by nature, I have found my best teachers in libraries, bookstores, and the "book of nature" for the most part.

The reason I finally left academia was the realization that, in medicine at least, tenure means nothing in the absence of separate funding. I was awarded tenure and...nothing changed; I still had to maintain a busy clinical practice to earn a few precious hours per week that I might devote to thinking and writing. But the kind of topics I care about are to medicine what, say, poetry is to the publishing world--it doesn't make any money for anyone. So it occurred to me that I didn't really need the academy; I could do clinical work anywhere to finance my parallel interests in literature and psychiatry. Clinical work--the fact of suffering--is the existential engine, but the narrative mode is the way I prefer to steer.

So the Ars Psychiatrica blog was the unfinished business of my academic career, the things left over that needed saying that I hadn't gotten around to sending to refereed journals. It was nice to publish in three seconds rather than three years, although many, many posts could have benefited from stringent peer review. I have always admired writers who, instead of whining about people not buying their stuff, arrange to have a day job that will earn them a living (T. S. Eliot at the bank, Wallace Stevens at the insurance company). I do get tired of contemporary journalists and writers complaining about the Internet threatening their livelihood. Why don't they do what the rest of us have to do, learn a trade that they can get paid for? I'd love to get paid for keeping a blog, but it isn't going to happen.

Escape Artists

nscheurich1@gmail.com (Novalis) — Sat, 08 May 2010 20:58:00 +0000

"But my mama never warned me about my own destructive appetites."

Jenny Lewis

Let us mark Mother's Day with a nod to one of the least praiseworthy of fictional mothers, Emma Bovary. Forever foisting her daughter--who was an unacceptable intrusion upon her own self-absorption and self-indulgence--upon the maid, Madame Bovary was one upon whom motherhood was truly wasted. Fortunately she had only one offspring to neglect and not several.

Indifferent mother, unloving wife, adulteress twice over, disastrous spendthrift, melodramatic and self-pitying hysteric, and ultimately miserable suicide, Madame would be utterly despicable if it weren't so tempting to identify with her. Her basic problem was an appetite that could not be satisfied by the milieu in which she found herself. The first step toward forgiving her is, of course, the basic feminist recognition that like all women, she was born into a world designed to frustrate female motivations at many turns.

Madame Bovary was a hapless Romantic, an escapist, a fantasist forever pining for some vaguely imagined realm of glamour. She happened to be paired up with the worst possible mate for her, the profoundly unimaginative Charles. Devoted and reliable, he would have proven a serviceable husband for a number of women, but for Emma he was poison.

Charles and Emma ended in calamity and not mere unhappiness because both of them were impractical dreamers. There was no check on the development of parallel marital fictions. Charles achieved his fantasy of domestic bliss through total denial of what was going on in front of his eyes; his only claim of diminished responsibility derives from his low intelligence.

Emma, after all, wants to be able to accept reality as it presents itself to her senses, but she is unable to. She endeavors to love her husband, but the love will not come. She prays for virtue; she fitfully and impulsively tries to summon maternal instincts. The spirit on some level is willing, but the flesh craves more than her straitened bourgeois existence can provide. And that is part of the problem, that she wants it both ways, that is, the respectability and stability of a doctor's wife as well as total freedom and exotic adventure.

One can imagine her as a writer or an actress, pursuits that were open to women even in that pre-feminist era. But she either lacked the courage of her convictions, or she did not understand herself well enough to recognize where she might find what she needed. Perhaps she was a failed artist, or one endowed with an artistic temperament without accompanying discipline or skill. The problem is not really escapism itself, for the pharmacist Homais, who smugly and pedantically revelled in every grubby aspect of "the given," comes off as an odious figure. For it is human nature to be impatient with reality, to be bored, to need perpetual stimulation of one kind of other. Thus religion, thus the arts, thus games and sports (Homo ludens indeed), thus war, drugs, and sexual intrigue. Some are arguably born more bored than others, and inasmuch as relief of boredom is one of the central tasks of life, Madame Bovary made a particular mess of things. Consciousness is restive by nature; the trick is to afford this restlessness its due scope without hurting others or oneself unduly along the way.

It Depends

nscheurich1@gmail.com (Novalis) — Thu, 06 May 2010 00:21:00 +0000

"To generalize is to be an idiot; to particularize is alone distinction of merit."

William Blake

A New York Times article reminds us of the distinction between complicated and complex, and our tendency to mistake the latter for the former. Complicated is a list of 10,000 instructions that must be followed to the letter; complex is a system so intricate that one can only hope to guide and shape its overall outline, not master or control its every detail.

David Barash shows how science neglects individuality in favor of generalizations.

Consciousness and its myriad maladies are instances of complex particularity. Psychiatry is therefore hubristic and diagnosis is stupid, but human beings have a need for these things.

Springs

nscheurich1@gmail.com (Novalis) — Wed, 21 Apr 2010 23:58:00 +0000

Why is April National Poetry Month? Why should spring be more poetical than any other time of year? Here's one take, another by Kay Ryan, "Spring:"

Winter, like a set opinion,
is routed. What gets it out?
The imposition of some external season
or some internal doubt?
I see the yellow maculations spread
across bleak hills of what I said
I'd always think; a stippling of white
upon the grey; a pink the shade
of what I said I'd never say.

Spring, while obviously anticipated intellectually, nonetheless takes the eye and the body by surprise, year after year, teaching us the limits of the imagination and the inexorability of nature, even in its luxuriance. No less than natural disasters, spring is an assault upon the senses, the ultimate exercise of natural power. The mind, too, often surprises. So T. S. Eliot famously wrote:

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.

And Whitman:

When lilacs last in the dooryard bloom'd,
And the great star early droop'd in the western sky in the night,
I mourn'd, and yet shall mourn with ever-returning spring.

Spring's annual ritual is both promise and threat, a display of renewal ironically at odds with a mortal body. Spring best embodies the universe's basic superfluity--why something rather than nothing, indeed?

And yet Stevens warns in "Esthetique du Mal:"

The greatest poverty is not to live
In a physical world, to feel that one's desire
Is too difficult to tell from despair.

And Stevens's remedy?

Beauty is momentary in the mind--
The fitful tracing of a portal;
But in the flesh it is immortal.

Spring should be enough in itself; some of us seem to need poetry to explain why, for restless consciousness, it isn't. Nature has evolved beings who are impatient of nature.

Think Again

nscheurich1@gmail.com (Novalis) — Fri, 16 Apr 2010 13:15:00 +0000

In the throwaway journal Current Psychiatry, editor Henry Nasrallah, M.D. offers what he calls a "psychiatric manifesto," a professional apologia of a kind, which is an interesting if typical example of the perennially insecure status of the discipline.

Here is an alternative "manifesto:"

1. Psychiatry deals with diverse impairments of mood, behavior, motivation, cognition, relatedness, self-understanding, impulse control and personal integration; that is, it deals with disorders of the self. While other areas of medicine deal with generic aspects of biological functioning, psychiatry specifically concerns itself with obstructions to self-determined individuality, in other words, selfhood.

2. Self-determined individuality has an essentially narrative aspect; the self comprises self-fulfilling stories which coincide or clash with the self-fulfilling stories of other persons. That is why third-party corroboration ("collateral information") is so often crucial to psychiatric assessment, and why psychiatry is irreducibly linguistic and why it has so little to say about an unconscious patient.

3. All mental phenomena derive from brain phenomena, so in principle all subjective experience may be influenced by neurophysiological means. However, as noted above, neurology deals with the generic aspects of brain functioning (its infrastructure as it were), whereas psychiatry deals with the idiosyncratic story that the brain, impinged upon by surrounding stories, endeavors to tell about itself. Mental disorders therefore entail an unstable and not precisely definable mixture of voluntariness and involuntariness.

4. While brain phenomena underlie all mental phenomena, the current very limited state of neuroscientific insight is such that practicing psychiatrists are not neuroscientists any more than, say, taxi drivers are auto mechanics. For the routine practice of contemporary psychiatry, the vast majority of neuroscience per se is irrelevant. This may change in the future, but despite freqent promises over the past twenty years that this will change any day now, it hasn't yet.

5. Because it aspires to authority over potentially controversial and debatable aspects of human conduct, such as matters of human behavior, identity, and relatedness, psychiatry has an inherently political and contentious dimension. Psychiatric nosology is an ongoing global process of consensual negotiation in which psychiatrists, while experts of a kind, are also mere participants.

6. Increasing knowledge of brain science and technology will no more solve disputes over psychiatric diagnosis than, say, the Internet has solved political problems. Debates over, say, psychotherapy versus medication arise to some degree from contrasting sensibilities and climates of opinion and are not therefore altogether resolvable by evidence-based analyses.

7. For the above reasons, while the stigma of mental disorders is very often damaging and regrettable, it is naive to think that such ailments will ever be as simple or as straightforward as many medical problems. This is so because any diagnosis constitutes not merely description, but also a moral claim, and in psychiatry's case, an unavoidably equivocal one.

8. While psychiatry as a discipline is probably no more flawed than any other large human institution dealing with complex phenomena, it is unhelpful to view critics of psychiatry as necessarily "ignorant" or "self-interested." The controversy has to do not with any exceptional benightedness of the discipline or its detractors, but rather is inseparable from the nature of the undertaking. Psychiatry attracts critics for the same reason that, on larger scales, the federal government or the Catholic Church do: all relate to powerful and yet deeply ambiguous human needs and vulnerabilities.

National Poetry Month

nscheurich1@gmail.com (Novalis) — Wed, 14 Apr 2010 23:29:00 +0000

I have finally gotten around to reading Kay Ryan:

A Certain Kind of Eden

It seems like you could, but
you can't go back and pull
the roots and runners and replant.
It's all too deep for that.
You've overprized intention,
have mistaken any bent you're given
for control. You thought you chose
the bean and chose the soil.
You even thought you abandoned
one or two gardens. But those things
keep growing where we put them--
if we put them at all.
A certain kind of Eden holds us thrall.
Even the one vine that tendrils out alone
in time turns on its own impulse,
twisting back down its upward course
a strong and then a stronger rope,
the greenest saddest strongest
kind of hope.

This poem spoke to me because of its message of belatedness, contingency, serendipity. We are born into gardens billions of years in the making, yet born also into some bizarre notion that we plant all anew. Yet that is the only way the garden progresses, through the pretense that every moment is pregant with infinite possibilities, not only for generation but for forgetting and "outgrowing." This is a counsel not for fatalism, but surely for circumspection and humility (and self-forgiveness).

Back to the Future

nscheurich1@gmail.com (Novalis) — Mon, 12 Apr 2010 17:18:00 +0000

Practical psychopharmacology is still largely based on mid-20th breakthroughs (chlorpromazine, haloperidol, lithium, benzodiazepines), so it is fitting to see hallucinogens come back around as a possible way out of our SSRI doldrums.

That humanity at large will ever be able to dispense with Artificial Paradises seems very unlikely. Most men and women lead lives at the worst so painful, at the best so monotonous, poor, and limited that the urge to escape, the longing to transcend themselves if only for a few moments, is and has always been one of the principal appetites of the soul. Art and religion, carnivals and saturnalia, dancing and listening to oratory--all these have served, in H. G. Wells's phrase, as Doors in the Wall. And for private, for everyday use there have always been chemical intoxicants. All the vegetable sedatives and narcotics, all the euphorics that grow on trees, the hallucinogens that ripen in berries or can be squeezed from roots--all, without exception, have been known and systematically used by human beings from time immemorial. And to these natural modifiers of consciousness modern science has added its quota of synthetics--chloral, for example, and benzedrine, the bromides and the barbiturates...

Most of these modifiers of consciousness cannot now be taken except under doctor's orders, or else illegally and at considerable risk. For unrestricted use the West has permitted only alcohol and tobacco. All the other chemical Doors in the Wall are labeled Dope, and their unauthorized takers are Fiends...

I am not so foolish as to equate what happens under the influence of mescalin or of any other drug, prepared or in the future preparable, with the realization of the end and ultimate purpose of human life: Enlightenment, the Beatific Vision. All I am suggesting is that the mescalin experience is what Catholic theologians call "a gratuitous grace," not necessary to salvation but potentially helpful and to be accepted thankfully, if made available. To be shaken out of the ruts of ordinary perception, to be shown for a few timeless hours the outer and the inner world, not as they appear to an animal obsessed with survival or to a human being obsessed with words and notions, but as they are apprehended, directly and unconditionally, by Mind at Large--this is an experience of inestimable value to everyone and especially to the intellectual. For the intellectual is by definition the man for whom, in Goethe's phrase, "the word is essentially fruitful." He is the man who feels that "what we perceive by the eye is foreign to us as such and need not impress us deeply." And yet, though himself an intellectual and onen of the supreme masters of language, Goethe did not always agree with his own evaluation of the word. "We talk," he wrote in middle life, "far too much. We should talk less and draw more. I personally should like to renounce speech altogether and, like organic Nature, communicate everything I have to say in sketches."

Aldous Huxley, The Doors of Perception (1954)

Sun

nscheurich1@gmail.com (Novalis) — Sat, 10 Apr 2010 11:22:00 +0000

The Woman in Sunshine

It is only that this warmth and movement are like
The warmth and movement of a woman.

It is not that there is any image in the air
Nor the beginning nor end of a form:

It is empty. But a woman in threadless gold
Burns us with brushings of her dress

And a dissociated abundance of being,
More definite for what she is--

Because she is disembodied,
Bearing the odors of the summer fields,

Confessing the taciturn and yet indifferent,
Invisibly clear, the only love.

Wallace Stevens

Blue

nscheurich1@gmail.com (Novalis) — Tue, 06 Apr 2010 00:06:00 +0000

It troubled me as once I was --
For I was once a Child --
Concluding how an Atom -- fell --
And yet the Heavens -- held --

The Heavens weighed the most -- by far --
Yet Blue -- and solid -- stood --
Without a Bolt -- that I could prove --
Would Giants -- understand?

Life set me larger -- problems --
Some I shall keep -- to solve
Till Algebra is easier --
Or simpler proved -- above --

Then -- too -- be comprehended --
What sorer -- puzzled me --
Why Heaven did not break away --
And tumble -- Blue -- on me --

Dickinson

Push

nscheurich1@gmail.com (Novalis) — Sat, 03 Apr 2010 00:05:00 +0000

In Simon Blackburn's essay (not available online) from The New Republic, on a biography of philosopher R. G. Collingwood, he writes:

...the passage shows Collingwood pouncing on a vitally important point, and the one which gave him perhaps his life's central insight: you cannot tell what someone meant by looking at his artistic, or verbal, productions alone. You must "also know what the question was (a question in his own mind, and presumed by him to be in yours) to which the thing he has said or written was meant as an answer."...You understand someone, according to Collingwood, not in the way you might come to understand a piece of machinery or any other mechanical or causal process, but by "re-enacting" in your own mind the problem they were addressing and the solution they were proposing.

The best way I know to come to grips with puzzling or frustrating behaviors or states of mind, whether in myself or others, is to ask what needs are pressing their demands, with greater or lesser success. For we are propelled by questions insisting on answers and needs calling for satisfaction. As individuals we are not confined in tunnels or locked into tractor beams, but we are beneficiaries--and victims--of a great and persistent push, comprising both general and idiosyncratic factors, through existence.

In this respect perhaps no metaphor is more misleading than "boot-strapping." It is more correct to say that we make use of our ancient species and individual momentum more or less adeptly. We generate no power per se, rather, we perceive our personal trajectories more or less well, and choose to resist or yield to particular biological, social, or intellectual forces. Life is interesting because these forces are fated to collide, and needs are inevitably frustrated. Or perhaps it is desire that is inevitably frustrated. But how to distinguish need from desire? That is wisdom.

Well-Read

nscheurich1@gmail.com (Novalis) — Thu, 01 Apr 2010 16:07:00 +0000

In another in a seemingly endless series of elegies for the culture of reading, Sven Birkerts contrasts the experience of the novel with that of the Internet. He opposes analytical reason, which is the means to an end (usually information), to contemplative reason:

This idea of the novel is gaining on me: that it is not, except superficially, only a thing to be studied in English classes--that it is a field for thinking, a condensed time-world that is parallel (or adjacent) to ours. That its purpose is less to communicate themes or major recognitions and more to engage the mind, the sensibility, in a process that in its full realization bears upon our living as an ignition to inwardness, which has no larger end, which is the end itself. Enhancement. Deepening. Priming the engines of conjecture. In this way, and for this reason, the novel is the vital antidote to the mentality that the Internet promotes.

Perhaps fiction-reading (not unlike aesthetic experience generally) is analogous to meditation: both are modes of both managing and exercising consciousness. But whereas meditation is all about process, even embracing emptiness and eschewing the demand for content, reading revels in content, but in a disciplined and focused way. In meditation consciousness steps back to observe and to accept its own dynamic instability; in art we step back to observe and to accept the world's dynamic instability--and our own part in it.

I have never been able to enjoy the experience of meditation, even though--or perhaps because--a contemplative state of mind comes naturally to me. That does not somehow make me a Zen natural. I find Zen to be a bracing philosophy, just as I enjoy a splash of water on a stifling day, but it is easily taken too far, into a zone of absolute zero. The mind that needs nothing outside of itself, that is affected by nothing outside of itself, is dead. In fiction, by contrast, we may pleasurably luxuriate in the productions of consciousness. In art we realize the hope that our own minds may produce that which we need, and not by denying that need.

Three

nscheurich1@gmail.com (Novalis) — Mon, 29 Mar 2010 21:26:00 +0000

Things that caught my eye:

1. David Elkind in the Times describes the quickly vanishing traditional culture of childhood, although he doesn't mention the major implications for parenting.

2. In an interview physicist (and priest) John Polkinghorne contrasts the impersonal knowledge of science with the deeply personal knowledge of faith, which he attributes to irreducible and untestable individual experience. However, the argument from personal experience, while it has given me empathy with believers, never gets me myself beyond agnosticism. For my personal experience has always been of a transcendently ineffable mystery at the heart of reality, which only folly tries to collapse into the simplistic myths of the Bible or Koran. The devil is in the details, indeed. The religious impulse is profound, but it has no rightly specific implications. Even a disposition such as compassion, supposedly so basic to religiosity, does not necessarily follow from the possibility of a deity.

3. In a review of a biography of philosopher R. G. Collingwood, Simon Blackburn gives this wonderful summary of the function of art:

Collingwood carefully separates art proper from art as craft, where there is a predetermined, independent aim to be achieved; and from art as amusement, where the function is to arouse an emotion so that an audience can indulge it; and from art as magic, where the aim is to facilitate some practice or stance toward the world, by the arousal of an emotion that aids it. Art proper is none of these. It is the expression of the way in which the artist feels and thinks about the subject, and in great art it is the imaginativeness, the truthfulness, and the rarity of those feelings and thoughts that overcome us. Collingwood's description of what is involved in communication, expression, imagination, and truthfulness has never been bettered. Even stripped of its context, his final sentence bears remembrance: "Art is the community's medicine for the worst disease of the mind, corruption of consciousness."

Muddling Through

nscheurich1@gmail.com (Novalis) — Wed, 17 Mar 2010 21:09:00 +0000

A few posts ago a commenter questioned why the perpetual furor over psychiatric diagnosis is so strident and acrimonious. I think the matter, dealing as it does with questions of human nature, identity, and responsibility, hits close to home, and often in a visceral way. Psychiatry presumes to comment upon the selves that we are and the selves we ought to be--as such it is as ambitious and as rightly contentious as politics or religion.

This came to mind yesterday when I read Stanley Fish's typically fine primer on pragmatism as a philosophy of life. Pragmatism is the difficult third option once despotic absolutism and cynical nihilism have been spurned. His piece demands to be read in full, but I particularly liked this:

It is a story, says Margolis (following Kuhn) driven from behind and not by a teleological end awaiting us in the form either of a union with a deity or an ascent to the realm of pure Reason. It is, Margolis tells us, "an extraordinary form of bootstrapping."

Pragmatism, when done well, achieves rigor and clarity without oversimplification and preserves freedom and ambiguity without slack complacency. It is the inherently messy, political, and incremental process by which humanity--comparing and trying out alternatives--somehow muddles through, although often not without appalling errors. I particularly like the idea of the universe as propelled by contingency and not drawn forward by the will-o'-the-wisp of a static perfection.

Psychiatry will never be perfected any more than politics will be perfected. However, we readily recognize some politics as preferable to others--it is not a matter of "anything goes"--and so with psychiatry. There is, in theory, no end to the possible number of DSM editions any more than there could be an absolute end to interpreting the constitution. After all, human nature and culture are moving targets.