Auf Wiedersehen to Academia

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.

It Depends

"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.

Think Again

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.