"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?
Showing newest posts with label Psychiatry. Show older posts
Showing newest posts with label Psychiatry. Show older posts
Saturday, May 29, 2010
Saturday, May 22, 2010
Recommended Reading
A post at Shrink Rap invites suggestions for recommended reading on psychiatric topics, prompting me to chime in with my top ten. These are not "recommended" per se; these are the books, some read before I became a psychiatrist and some read after, that struck or influenced me most deeply. This sort of list can only relate to the sort of person I was to begin with; other people might read these ten and be disappointedly unfazed, but I can't help believing they are noteworthy in their own ways. In no particular order:
1. "Civilization and its Discontents," encountered in undergrad, was my first experience of Freud, and still the most memorable. He unforgettably explained how the basic human dilemma is not so much intrapsychic as social and interpersonal. As Sartre infamously put it, "Hell is other people," although fortunately it's not so simple.
2. The Birth of Neurosis, by George Frederick Drinka, impressed me with the cultural contingency of hysteria and psychological symptoms in general.
3. The Savage God: A Study of Suicide, by A. Alvarez, used the case study of Sylvia Plath as a springboard to an existential and phenomenological consideration of the suicidal mindset.
4. Listening to Prozac, by Peter Kramer, raised fascinating and vexing questions about the relation of diagnosis to medication.
5. The Myth of Mental Illness, by Thomas Szasz: any serious psychiatrist must know, and come to grips with, the argument that the whole enterprise is fundamentally misguided.
6. Darkness Visible, by William Styron, may be forever the best account of the experience of depression. No sentimentality or silver linings here (although he did recover).
7. "Ward Six," by Anton Chekhov: There but for the grace of God...
8. "Miss Lonelyhearts," by Nathanael West, is a deeply quirky examination of the emotional hazards of the therapy project, broadly considered (in this case, pertaining to an advice columnist).
9. The Perspectives of Psychiatry, by Paul McHugh and Philip Slavney, convincingly argues for the irreducible complexity of psychiatric understanding.
10. With all due respect to Irvin Yalom, I would pick Kafka's brief, gnomic parable "Before the Law" as the ultimate existentialist text: in the end, it's unavoidably up to you.
11. (Honorable Mention): Hamlet, by William Shakespeare: the unfathomably neurotic young psychiatrist as doomed Danish tragic hero.
1. "Civilization and its Discontents," encountered in undergrad, was my first experience of Freud, and still the most memorable. He unforgettably explained how the basic human dilemma is not so much intrapsychic as social and interpersonal. As Sartre infamously put it, "Hell is other people," although fortunately it's not so simple.
2. The Birth of Neurosis, by George Frederick Drinka, impressed me with the cultural contingency of hysteria and psychological symptoms in general.
3. The Savage God: A Study of Suicide, by A. Alvarez, used the case study of Sylvia Plath as a springboard to an existential and phenomenological consideration of the suicidal mindset.
4. Listening to Prozac, by Peter Kramer, raised fascinating and vexing questions about the relation of diagnosis to medication.
5. The Myth of Mental Illness, by Thomas Szasz: any serious psychiatrist must know, and come to grips with, the argument that the whole enterprise is fundamentally misguided.
6. Darkness Visible, by William Styron, may be forever the best account of the experience of depression. No sentimentality or silver linings here (although he did recover).
7. "Ward Six," by Anton Chekhov: There but for the grace of God...
8. "Miss Lonelyhearts," by Nathanael West, is a deeply quirky examination of the emotional hazards of the therapy project, broadly considered (in this case, pertaining to an advice columnist).
9. The Perspectives of Psychiatry, by Paul McHugh and Philip Slavney, convincingly argues for the irreducible complexity of psychiatric understanding.
10. With all due respect to Irvin Yalom, I would pick Kafka's brief, gnomic parable "Before the Law" as the ultimate existentialist text: in the end, it's unavoidably up to you.
11. (Honorable Mention): Hamlet, by William Shakespeare: the unfathomably neurotic young psychiatrist as doomed Danish tragic hero.
Wednesday, March 17, 2010
Muddling Through
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.
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.
Tuesday, March 16, 2010
Why Psychiatry Is Not Neurology
I need to work on briefer posts, so that I can be more consistent here. The blogger as aphorist. Nothing so pithy today, but on Arts & Letters Daily today I found a book review by Sally Satel that pretty much summarizes what psychiatry is about. Read the article yourself--isn't that what makes web links so wonderful, that they obviate the need for dull summaries?
Mental disorders are disorders of agency and intentionality, which is not to say that they are simply chosen or merely willed. That is why psychiatry cannot and should not merge with neurology, which deals primarily with the nervous system as machine. As Satel notes, the crucial difference is the response of mental disorders to contingencies, which gives them a social and semantic distinction from purely physical disease states.
This is not to say that there is a clear and absolute dividing line between mental and non-mental disorders, but the distinction is there nonetheless. Inasmuch as they pertain to ailments of identity and free will, mental disorders are disorders of the self, which may sound grim and slanderous until one remembers that "ailments" range from the blemishes that we all have to, well, the cancers of the soul (which is the brain--how complicated!).
Mental disorders are disorders of agency and intentionality, which is not to say that they are simply chosen or merely willed. That is why psychiatry cannot and should not merge with neurology, which deals primarily with the nervous system as machine. As Satel notes, the crucial difference is the response of mental disorders to contingencies, which gives them a social and semantic distinction from purely physical disease states.
This is not to say that there is a clear and absolute dividing line between mental and non-mental disorders, but the distinction is there nonetheless. Inasmuch as they pertain to ailments of identity and free will, mental disorders are disorders of the self, which may sound grim and slanderous until one remembers that "ailments" range from the blemishes that we all have to, well, the cancers of the soul (which is the brain--how complicated!).
Friday, March 5, 2010
Crooked Timber
What causes schizophrenia? The short answer may be "nothing" or more precisely "no one thing." In most cases, schizophrenia is an end result of a complex interaction between thousands of genes and multiple environmental risk factors--none of which on their own causes schizophrenia. Daniel Weinberger, in his classic paper on brain development and schizophrenia, entertained the "unlikely" possibility that schizophrenia is "not the result of a discrete event or illness process at all, but rather one end of the developmental spectrum that for genetic and/or other reasons 0.5% of the population will fall into." Over 20 years later, this unlikely scenario is looking more realistic. Schizophrenia is increasingly considered a subtle neurodevelopmental disorder of brain connectivity, of how the functional circuits in our brains are wired. Schizophrenia may in fact be the tail end of a distribution of how the estimated 20 billion neurons and their trillions of synaptic connections in our brains are generated, eleminated, and maintained. Schizophrenia may be the uniquely human price we pay as a species for the complexity of our brain; in the end, more or less by genetic and environmental chance, some of us get wired for psychosis.
This eloquent passage by John H. Gilmore, M.D., from a recent editorial in the American Journal of Psychiatry, struck me as emblematic of the field now. In one sense, his statement seems obvious--we nod knowingly, muttering the mantra that the mind is complicated, etc. But in another sense, it seems to dash our hopes. For what if not only schizophrenia, but most or all mental disorders, are no more easily accounted for than are other complex psychological features, such as intelligence, personality, or the nature of consciousness itself?
Even if we never expected to find THE CAUSE of most mental disorders, the smoking guns, nonetheless we have nourished hopes that one or two of the myriad causes might be found to predominate and to offer chances to nip in the bud "the thousand natural shocks that flesh is heir to." This lust for explanation certainly isn't unique to psychiatrists--patients themselves continually cast about for a simple and compelling narrative, whether it be the abusive parent, the head injury at age 12, or whatever.
Potentially the most embarrassing question psychiatrists are asked is "What caused this?" We still cannot legitimately answer beyond vague references to genes, synapes, and life experience, all of which offers little more clarity than the notorious "chemical imbalance." It may be that we are not only in practice (that is, currently with all our technical limitations), but crucially in theory (that is, forever and by nature of the inquiry) no better able to explain why Johnny is depressed than we can explain why his IQ is 112, or why he prefers baseball to football, or why he likes going to church. The contingency goes all the way down.
Gilmore's editorial also implies that mental disorders may not be contingent afflictions, but may be closely bound up with the very nature of the human animal. It is easy to imagine a world without AIDS (oh right, most of history), and even cancer seems no more integral to human identity than smallpox long must have seemed. But a world in which suicide, madness, and addiction don't happen, period, seems no easier to envision than a world wholly without war or poverty. That isn't to say that it can't or won't happen, but it would involve a radical alteration in human experience.
The murkiness of etiology continues to frustrate the project of neatly carving out mental disorders from the (hopefully) broader region known as normality. All we see wherever we look are continua and shades of gray, and the distinction between treatment and enhancement grows fuzzier. If we had a pill that would increase IQ by ten points, then why would an increase from 50 to 60 be "treatment" (of mental retardation) and an increase from 100 to 110 would be "enhancement" if mental retardation is merely part of the natural (normal?) distribution of intelligence? These distinctions threaten to be made primarily based on pragmatic and political bases (e.g. how many IQ-raising pills can we afford to make, how will be distribute them, etc.).
I've always been struck by the example of Alzheimer's disease, the prevalence of which climbs above 50% in individuals over 85. In this case dementia becomes normative, and statistically an example of "normal" aging. Arguably it is no more a "disorder" than death itself is a disorder. So if we had effective treatments for Alzheimer's "disease," then they could be viewed as an example of "enhancement," as an alleviation of potentially normal aging. What we label "disease" is merely what we would choose not to live with.
In philosophy of mind the "hard problem of consciousness" is the vexed question of how a physical brain produces the experience of subjectivity. As a bad pun I can think of a second "hard" problem of consciousness, that is, the existential reality that consciousness is hard to tolerate at times--it can be raw nerve held up to the universe. But there could be a third kind, a sense in which the brain is evolutionarily hard to produce, the most complex object in the universe that we know of. Mistakes were made. To paraphrase Samuel Johnson's infamously misogynistic (and anti-clerical) comparison of women preachers to dogs walking on their hind legs, one marvels not that it isn't always done well, but that it is done at all.
Wednesday, February 24, 2010
The Impossible Profession
In a nice segue to the last post, and with a thanks to Retriever (since the current New Yorker hasn't quite arrived at the house yet), it was a pleasure to read Louis Menand's take on psychiatry's discontents. It is probably the best single overview of the profession's vexing ambiguities that I have seen; it's all there--the diagnostic quibbles, the ideological clashes, the greedy pharmaceutical companies.
Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.
It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).
Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.
There is much more to be said, but this is a lunch hour post.
Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.
It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).
Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.
There is much more to be said, but this is a lunch hour post.
Wednesday, January 6, 2010
Hard Truths
Finally, a position on antidepressants that manages to be both blunt and nuanced. Jonathan Rottenberg, Ph. D. at Psychology Today, discussing recent meta-analyses of antidepressants, conveys the unfortunate news: the primary issue with the treatment of depression is not access, but rather the very limited effectiveness of our treatments.
I've seen many patients who, having been on antidepressants perhaps five or ten years previously, say something like, "But I'm sure newer and better drugs are coming out all the time." At this point I have to resist the temptation to blurt out, "No! They're not!" The menu of options has certain grown bigger as compared to 10 or 15 years ago, but not necessarily better. And then there are those sexual side effects...None of this is a counsel of despair, but in general expectations of antidepressants have been out of control for some time now.
All of this is true as well of medications for anxiety, bipolar disorder, schizophrenia, and substance abuse. Yet the temptation is often to throw the kitchen sink at these disorders when nothing seems to work. Doctors used to be notoriously reluctant to be honest with patients with cancer or some other terminal diagnosis. Even when everything has been tried with a given patient, I think that in psychiatry there may be a similar reluctance to speak what sometimes is the truth: "I don't know that I can help you." The difference is that in psychiatry there is no pathology report or CT scan demonstrating that a patient is in fact beyond help. In psychiatry it is merely...a feeling one gets.
I've seen many patients who, having been on antidepressants perhaps five or ten years previously, say something like, "But I'm sure newer and better drugs are coming out all the time." At this point I have to resist the temptation to blurt out, "No! They're not!" The menu of options has certain grown bigger as compared to 10 or 15 years ago, but not necessarily better. And then there are those sexual side effects...None of this is a counsel of despair, but in general expectations of antidepressants have been out of control for some time now.
All of this is true as well of medications for anxiety, bipolar disorder, schizophrenia, and substance abuse. Yet the temptation is often to throw the kitchen sink at these disorders when nothing seems to work. Doctors used to be notoriously reluctant to be honest with patients with cancer or some other terminal diagnosis. Even when everything has been tried with a given patient, I think that in psychiatry there may be a similar reluctance to speak what sometimes is the truth: "I don't know that I can help you." The difference is that in psychiatry there is no pathology report or CT scan demonstrating that a patient is in fact beyond help. In psychiatry it is merely...a feeling one gets.
Friday, November 20, 2009
Caged Animals
"The fault, dear Brutus, lies not in our stars, but in ourselves, that we are underlings."
Cassius
I've never found it easy to answer the occasional but predictable question, "Why did you become a psychiatrist?" but a succinct, if not simple, response is evoked for me by a Psychology Today blog post by Dr. Mark Goulston. Bluntly entitling his post "Maybe You're Just Wrong," he claims that for some people he works with--especially those with no major Axis I mental disorder--he gives them the option of being labelled ill on the one hand, or in mincing-no-words fashion, "psychologically flawed and emotionally immature" on the other. In the former case, psychotherapy and possible medication may be indicated, whereas in the latter case, some kind of education or training may be called for.
What this speaks to for me is the ever-present question: to what degree must or can we take responsibility for our lives and identities? There is no life without suffering, that's for sure; without being lugubrious about it, it is clear that on the scale of a moment, a day, or a lifetime, existence not infrequently doesn't turn out the way we seem to feel that it should. Why is that? I went into psychiatry not in order to relieve the most suffering in any kind of generic sense; it is impossible to quantify suffering, of course, but maybe I could do more good by working in a soup kitchen or by becoming a hedge fund manager and then donating the majority of my income to charity.
No, I went into psychiatry to try to relieve a particular kind of suffering, that associated with the "mind-forg'd manacles" that prevent us from being as psychologically or emotionally free as we might. There is an odd little Arcade Fire song called "My Body is a Cage." Well, the mind is a cage too, obviously, and this is a troubling notion only if one thinks freedom could possibly be infinite. All are limited by temperament and disposition, although to be sure, some have cages that are far more spacious and pliable--and in far closer proximity to other cages--than others.
The fundamental premise of medicine is that we are not wholly responsible for our own suffering. The sick role is a socially sanctioned kind of forbearance granted to incapacity, stemming from a recognition that it is deeply unjust to pretend that "the cage" isn't there. However, it is equally unjust--in an infantilizing way--to carry on as though another's cage is more restrictive than it has to be.
In his blog post Goulston claims that most of his clients prefer to be considered wrong--and responsible for their own plight--rather than innocent victims. I wish I had his confidence in human nature (personally I think Dostoevsky's Grand Inquisitor was more on the money). Obviously these people aren't paying him with insurance, which would require a listed diagnosis. And I refer to them as clients rather than patients for a reason.
Goulston sets out the free will conundrum in stark terms, which is why the piece struck me, but clearly he constructs a false opposition. For psychiatric care, if it is enlightened, should always endeavor to seek a fair balance between the claims of responsibility and "the natural shocks that flesh is heir to." After all, situations either of absolute responsibility or the absolute lack thereof are very rare. Life is continually lived in a state of partial--and never precisely known--responsibility. And science does not help much with this. Free will is profoundly social and political, relating to what one ultimately must answer for (to hypothetical others). In that sense there is no one Free Will, but a multiplicity of free wills in different social contexts.
So for instance, it is common for a depressed person not to take of himself. He doesn't exercise or eat healthfully, he gains weight, he isolates himself and loses friends, and perhaps even loses his job because he doesn't drag himself to work on time. To what degree is he responsible for his plight, as opposed to being a victim of the medical condition of depression? Arguably science cannot answer this question. To be sure, ever more sophisticated brain scans may show that depressed brains are different in certain ways than non-depressed brains, but inasmuch as psychology stems from neurobiology, such brain scans could theoretically also show differences between, say, lazy and selfish brains as opposed to motivated and selfless brains.
I would argue that responsibility in this case--in all cases--is a pragmatic construct. What helps this person to function better--varying degrees of encouragement, stigma, and penalty (e.g. unemployment) on the one hand, or direct support and perhaps biological intervention on the other? Of course it is likely to be a combination of the two. The depressed person may be given supportive therapy and even medication, but there is also an expectation that he will exercise and socialize more to improve his own lot. Medical and psychiatric care should aim to balance the sick role with social expectation, the latter being mirror image of social responsibility. What does it mean though to "function better?" Ah, the question of how life ought to be lived is beyond the scope of this post--or this lifetime most likely.
I've been curious about the emergence in recent years of "life coaching," "job coaching," etc. Does this stem from a lingering stigma of therapy, or does it derive from a desire for therapy that is more actively interventional? However, if one is primarily "wrong" and not "sick," then a better metaphor may be teaching or even tutoring. A "coach" implies that life is a sporting event to be won or lost, whereas life perhaps is better approached as a skill, like piano-playing or any other. Well no, life surely isn't so straightforward as that--composing may be the better metaphor. Or since this is my post and I have no head for musical composition (as opposed to appreciation), I'll say writing. Yes, life as writing.
Cassius
I've never found it easy to answer the occasional but predictable question, "Why did you become a psychiatrist?" but a succinct, if not simple, response is evoked for me by a Psychology Today blog post by Dr. Mark Goulston. Bluntly entitling his post "Maybe You're Just Wrong," he claims that for some people he works with--especially those with no major Axis I mental disorder--he gives them the option of being labelled ill on the one hand, or in mincing-no-words fashion, "psychologically flawed and emotionally immature" on the other. In the former case, psychotherapy and possible medication may be indicated, whereas in the latter case, some kind of education or training may be called for.
What this speaks to for me is the ever-present question: to what degree must or can we take responsibility for our lives and identities? There is no life without suffering, that's for sure; without being lugubrious about it, it is clear that on the scale of a moment, a day, or a lifetime, existence not infrequently doesn't turn out the way we seem to feel that it should. Why is that? I went into psychiatry not in order to relieve the most suffering in any kind of generic sense; it is impossible to quantify suffering, of course, but maybe I could do more good by working in a soup kitchen or by becoming a hedge fund manager and then donating the majority of my income to charity.
No, I went into psychiatry to try to relieve a particular kind of suffering, that associated with the "mind-forg'd manacles" that prevent us from being as psychologically or emotionally free as we might. There is an odd little Arcade Fire song called "My Body is a Cage." Well, the mind is a cage too, obviously, and this is a troubling notion only if one thinks freedom could possibly be infinite. All are limited by temperament and disposition, although to be sure, some have cages that are far more spacious and pliable--and in far closer proximity to other cages--than others.
The fundamental premise of medicine is that we are not wholly responsible for our own suffering. The sick role is a socially sanctioned kind of forbearance granted to incapacity, stemming from a recognition that it is deeply unjust to pretend that "the cage" isn't there. However, it is equally unjust--in an infantilizing way--to carry on as though another's cage is more restrictive than it has to be.
In his blog post Goulston claims that most of his clients prefer to be considered wrong--and responsible for their own plight--rather than innocent victims. I wish I had his confidence in human nature (personally I think Dostoevsky's Grand Inquisitor was more on the money). Obviously these people aren't paying him with insurance, which would require a listed diagnosis. And I refer to them as clients rather than patients for a reason.
Goulston sets out the free will conundrum in stark terms, which is why the piece struck me, but clearly he constructs a false opposition. For psychiatric care, if it is enlightened, should always endeavor to seek a fair balance between the claims of responsibility and "the natural shocks that flesh is heir to." After all, situations either of absolute responsibility or the absolute lack thereof are very rare. Life is continually lived in a state of partial--and never precisely known--responsibility. And science does not help much with this. Free will is profoundly social and political, relating to what one ultimately must answer for (to hypothetical others). In that sense there is no one Free Will, but a multiplicity of free wills in different social contexts.
So for instance, it is common for a depressed person not to take of himself. He doesn't exercise or eat healthfully, he gains weight, he isolates himself and loses friends, and perhaps even loses his job because he doesn't drag himself to work on time. To what degree is he responsible for his plight, as opposed to being a victim of the medical condition of depression? Arguably science cannot answer this question. To be sure, ever more sophisticated brain scans may show that depressed brains are different in certain ways than non-depressed brains, but inasmuch as psychology stems from neurobiology, such brain scans could theoretically also show differences between, say, lazy and selfish brains as opposed to motivated and selfless brains.
I would argue that responsibility in this case--in all cases--is a pragmatic construct. What helps this person to function better--varying degrees of encouragement, stigma, and penalty (e.g. unemployment) on the one hand, or direct support and perhaps biological intervention on the other? Of course it is likely to be a combination of the two. The depressed person may be given supportive therapy and even medication, but there is also an expectation that he will exercise and socialize more to improve his own lot. Medical and psychiatric care should aim to balance the sick role with social expectation, the latter being mirror image of social responsibility. What does it mean though to "function better?" Ah, the question of how life ought to be lived is beyond the scope of this post--or this lifetime most likely.
I've been curious about the emergence in recent years of "life coaching," "job coaching," etc. Does this stem from a lingering stigma of therapy, or does it derive from a desire for therapy that is more actively interventional? However, if one is primarily "wrong" and not "sick," then a better metaphor may be teaching or even tutoring. A "coach" implies that life is a sporting event to be won or lost, whereas life perhaps is better approached as a skill, like piano-playing or any other. Well no, life surely isn't so straightforward as that--composing may be the better metaphor. Or since this is my post and I have no head for musical composition (as opposed to appreciation), I'll say writing. Yes, life as writing.
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