No, really, I’m fine
June 16th, 2016
I don’t know why, maybe it’s one of those anniversary things, you know, the kind where the sun is at a particular angle or the air smells just this way or the insects’ chirring reaches a certain pitch, and you find yourself inexplicably in mind of past events or people you once knew, and the next thing you know you’re leafing through old photos or picking up the phone or or listening to a song you haven’t played for awhile. Or sending an email, and asking that person you’ve been reminded of how he is doing, and why he, not known for taciturnity, has been silent, and wondering if he is okay.
Or maybe not. Maybe it’s just coincidence. Or just that there’s some circadianish rhythm to these things, that at regular intervals a writer writes, and when he doesn’t the absence is noted. And people ask. Whatever the case, relative to my inbox traffic, I’ve been getting a huge number of inquiries into my wellbeing, along with gentle encouragement to pick up the quill.
Which is both surprising and strangely gratifying. I mean, I’ve never been too sure just why I write. It’s never been a huge crackling fire in me, the kind that some writers experience and sometimes complain about, that leads them to live in whatever they’re working on while the bills pile up and the spouse and kids go unloved and their armpits stink. My urge is more like a little sparker, the kind that drags a flint across a rasp to ignite a torch. It happens pretty much every day, usually in the morning, and sometimes it sets off a little flame, but it’s also really easy to ignore. There is so much else to do. So when I hear that people are wondering what has become of me, and even wishing that I would write something else–missing my voice, I suppose–I am momentarily confused. “Oh yeah,” I say to myself. “I write stuff.” And sometimes, evidently, it moves people. That’s the surprise, and the gratification.
I haven’t been entirely not-writing. I had a nice little essay about The Confidence-Man, Herman Melville’s last novel (if you don’t count Billy Budd as a novel, which is one of those debates not worth having) in The Believer, and which I like to think predicted the rise of Donald Trump, although it never mentioned him or presidential politics. But it was all about how precious confidence is, and how eagerly we will hand over autonomy, common sense, money, and integrity to the person who promises it. Another essay came out in Harper’s, about religious conversion, Islamic and otherwise, and there’s one in the queue there about chickens, the weather, and the war on terror. (All of which are what are known in the magazine biz as evergreen topics, meaning they are always relevant, meaning there is no particular hurry to publish articles on them.) A piece in the Times’ Couch feature about why therapists should not write about their patients; more than one friend counseled me not to read the comments section, so I did not, but I gather I upset some people. Plus I helped my sister with her book, Rogue Justice, which is about the rise of the national security state, and worth reading so you can get depressed and buy another copy of Manufacturing Depression. And I kept adding to my little memoir, Scotland, which started life as a kindle single (and a #1 bestseller at that), got expanded into a paperback and, after a week of fevered writing in the highlands of Chiapas, is up to 40,000 words. It’s also, so I am told by both my agent and my editor, unpublishable, but I’m thinking about making it available somehow anyway, because I am fond of it.
I suppose that sounds like a lot, but that’s pretty much my entire output over the last two years. And really there’s nothing on the burner, front or back. At least nothing book-like. Or, for the most part, magazine-like. Or, to judge from my silence here, even blog-like. I haven’t retired exactly, and it’s not quite right to say I’ve lost interest, at least not in the enterprise of putting words on paper and showing them to people. But something in me has gone quiet. Like a few months ago, when I was talking to an editor at a major magazine about a story that would probably have been a good one, and in which they were quite interested, but he asked me a series of questions, all of which were totally reasonable (and mostly answerable), and I just found it impossible to spend the shoe leather on answering them. I looked for my ambition, and discovered, as Gertrude Stein did in Oakland, that there was no there there.
Speaking of theres that aren’t, that story would have been about the mental health industry, which may have been part of the problem. I think I’ve said what I have to say on that subject. I’m glad I said it, but it does not bear repeating, and there really isn’t much more to say, at least not without becoming an annoying little lapdog yapping around psychiatry’s cankles. Peter Kramer just came out with a new book. I didn’t know it was coming out until I read Jen Senior’s review of it in the Times. (And by the way, Jen Senior is the best book reviewer the Times has right now, and maybe ever. She’s funny and smart and irreverent, and I have a huge writer crush on her. If I ever write another book, it may only be in hopes she will review it.) Evidently, my ear is not to the ground. The book is a full-throated defense of antidepressants, which is sort of like mounting a full-throated defense of ketchup. I had a few vague thoughts about the book, and about what it means that Kramer is flogging Prozac again, and a moment of pity for him that he’s got to go out on the hustings and field the usual stupid questions, that he is chained forever to this topic. But mostly I was like, meh. And grateful that no one asked me to review the book (and that I didn’t know about it in time to pitch a review), because I might have been tempted and that would just be soulless work.
So maybe I just haven’t found anything else to write about. Or maybe I just like doing other things more than I like writing. I’ve been spending a lot of time building an apartment above our garage so our son can move out of our house. I’m much worse at building than I am at writing. I can’t visualize in three dimensions, I have shitty eye-hand coordination, I’m not particularly muscular. I’d fire me if I were my contractor, especially if I watched myself and saw how many 2x4s I waste, how much time I spend redoing things that came out wrong the first time. I’ve also been playing in a Grateful Dead cover band. I’m probably a worse musician than builder, and God knows the world does not need another bunch of guys wanking on China Cat Sunflower, but I play with really good musicians and it’s really fun, plus when you can see the connection between your fingers on the keys and the pelvises of the dancing girls, well, that’s as close as a happily married guy is going to get to the joys of adultery.
All of which is to say that I appreciate the concern and I am deeply flattered that anyone would want to read another word of mine, but that while I can’t fully explain my not writing, and while this has been a very challenging year for all sorts of non-writing-related reasons, I’m basically okay. And while I am swearing off writing about psychiatry, I’m not swearing off the whole word-jockeying thing. So I will probably write something else sometime. Meantime, I’ll get those recent pieces put up on the website and figure out a way to make the whole Scotland megillah available.
And thanks for asking.
Paging Doctor Obama
December 7th, 2015
Well, I swore off writing about psychiatry. (How many times can you point out the obvious?) Then I swore off writing about David Brooks. (I really truly began to feel sorry for the big lug–not for having to suffer my yapping around his ankles, but for having to be David Brooks.) Then my town decided not to lynch me. Some people seem to have forgiven me for introducing sex offenders into their midst. And I them. Wendy, the avenging mom who led the charge, is now a member of the zoning commission. She’s not quite my new BFF, but I just appointed her to lead an important subcommittee. And I personally invited Pete the Farrier to come to a hearing and deliver his stump speech about the Constitution and the evils of regulation and high taxes and people just trying to survive, all to help us decide whether or not to limit backyard pigkeepers to five or fewer pigs. Which he did, eloquently as usual, and then we shared a cigarette out by his pickup, not exactly postcoital, but a cigarette nonetheless.
So all that swearing off and kumbaya left me with nothing to write about. Which is fine. I did write a pretty blistering letter to the head of the state technical school system, explaining why we were withdrawing my son from their school. She had one of her assistant wardens call me a couple weeks later to assure me that my letter “had not fallen on deaf ears,” but I think he was kidding. Or protesting too much. The withdrawal has been mostly a good thing. Turns out the fundamentalist Christians among us have contributed more to our society than the occasional Planned Parenthood shooting. In their zeal to protect their children from knowledge, they’ve created a homeschooling infrastructure, one that includes easy online access, reasonable fees, and a bona fide, fully accredited high school diploma. It also turns out that the curriculum is not entirely dedicated to teaching ignorance. The science section (earth science) did not insist that the earth was created in 4004 BC and that dinosaurs romped with Pebbles and Bam-Bam, and in English he’s reading Midsummer Night’s Dream. He’s been plugging away at it (at other people’s homes, thank the Christian God), and I think he will be a high school graduate in a few weeks, thus sparing him more than a year of spending his days doing what he’s not good at and fighting with us about it. We’ll send him to welding school, get him a commercial driver’s license, maybe buy him a little more machinist training, and then it’s off into the world with him. Meantime, he’s putting a Ford V-8 into a Chevy S-10. Last night he painted the transmission. He’s around home a little too much for his misanthrope father, but we do sometimes happily gearhead out together, and removing the stress of school has really improved our home life. I will never forgive the public school system for the damage and suffering it inflicted upon us, nearly all of it unnecessary.
But that’s a topic for a different day. Today, I’m afraid I’m back to psychiatry, but only temporarily. Another thing I did this year was help someone out with a book on terrorism. And I just finished up an essay for Harper’s about religious conversion, especially of the Islamist type. Plus which I read the paper (when I can find one to buy–they’re disappearing as fast as buggy whips did). So the subject was already on my mind when Richard Friedman, the psychiatrist who writes an occasional column in the New York Times, checked in with his suggestion that in response to the Recent Unpleasantness, Barack Obama should become “our therapist-in-chief and give us all a dose of cognitive-behavioral therapy for the country.”
Now, before I get started on this, let me just say that I think Richard Friedman sounds like a really nice man, warm and humane and compassionate. He also seems unusually honest. He’s written about how the choice of which antidepressant to prescribe amounts to a flip of the coin, or when he acknowledged that the effectiveness of SSRIs does not mean depression is caused by serotonin deficiencies. I’m guessing he’s a good clinician, as many psychiatrists are. I think he understands that his profession has a limited scientific infrastructure and that he has to make the best of it. If he doesn’t go the next step and talk about how psychiatry’s power ought to be commensurate with that infrastructure–i.e., less than what it is–you can’t fault him too much for that. And he’s humble enough that he’s probably helping more people than he’s hurting, which is all that any of us in the mental health racket can hope to do. And a final caveat: Friedman is writing in an excruciatingly circumscribed forum–a <1000-word column in a daily paper. So his opportunity to get nuanced is limited, as is his time for reflection.
But even so, one wishes his critiques did not seem so inadvertent, or to put it another way, that his critical faculties were more engaged. His suggestion that Obama identify, challenge, and correct “the mistaken and distorted thoughts that generate distress” reminds me of something Freud once said: that medical school is exactly the wrong education for a psychotherapist. “It burdens [a doctor] with too much of which he can never make use,” he wrote, “and there is a danger of its diverting his interest and his whole mode of thought from the understanding of psychical phenomena.” Among the topics from which the would-be doctor is diverted is “the history of civilization,” and in its place is offered “anatomy, biology, and the study of evolution.” The same can be said of psychologist education, the doctoral programs that increasingly are dominated by the cognitive-behavioral school and thus offer the study of evolution and of the mind as a computer made out of meat. And what both educations also have in common is their almost criminal historical naivete, their failure to convey to students (who then to on to become teachers as well as clinicians) the history of their fields, the philosophical and cultural and economic events that gave rise to the understanding of human behavior which underlie their efforts to relieve our suffering.
Because what else besides naivete can explain Friedman’s suggestion that President Obama relieve our terror by putting these attacks in perspective? Perhaps he should remind us that religious terrorists, Christian and Muslim, have managed to kill fewer than 100 people in the last fifteen years, that 9/11 killed less than one-tenth of the number of people killed in car wrecks in 2001, that lightning strikes more often than terrorists, and so on. There’s always a chance that your coworker will turn out to be a religious zealot armed with a legally purchased AR-15, the kind of guy who makes sure his kid is looked after before he and his wife and slay a roomful of fellow bureaucrats, but once our attitudes are properly adjusted, we will be able to “find a way to live with this uncertainty and put it in perspective.” Chillax, dude, the therapist-in-chief should say, it’s probably not going to happen to you, so turn that frown upside down and get out there and buy some Christmas presents already. Maybe an AR-15 for the wife and Glocks for the kids.
I wish I was exaggerating, but I’m really not. (OK, I am, but deal with it.) The education Freud favored was of more than intellectual interest. It could remind clinicians of the contingency of our theories and otherwise keep us humble, fully in the grips of our negative capability, which is, I believe, the talent we should cultivate the most. A historically informed understanding of cognitive-behavioral therapy would acknowledge that it is a peculiarly American way of understanding what’s wrong with us and how it can be made right. Specifically, it can be read as an ideology of optimism. According to CBT, we are meant to be resilient, forward-looking, stable, and hopeful, and when we are not, when we are anxious and/or depressed instead, it is because of those mistaken and distorted thoughts which Friedman wants Dr. Obama to disabuse us of. CBT, in other words, hinges on is the idea that rationality should prevail, and when it does, then we will see the world as it is–a place of uncertainty, to be sure, but nothing that should put our hair on fire and really, on balance, quite a fine place to spend our three score and ten. (Unless you are depressed or anxious, in which case, hie thee to a CBT practitioner and learn how to manage that shit.)
I have all sorts of objections to this ideology, not the least of which is that it pretends not to be an ideology (and I am duty bound to point out that the presidential candidate most interested in mobilizing optimism is Donald Trump), but the one that Friedman’s column reminded me of is the one about how weak and unreliable (and, as a way to guide life, historically contingent) rationality really is. Freud knew this, of course, and it was this aspect of psychoanalysis that Aaron Beck, the founder of CBT, meant to challenge when he developed his theory–not coincidentally, in the early 1960s, in the middle of the American Century, at a time when it sort of made sense for people to believe that pessimism was a pathology. After all, full employment, a young handsome president, rockets headed to the moon, what could possibly go wrong?
But much as I am a fan of rationality and all that it has brought with it–science, capitalism, democracy, universal human rights, the nation-state, etc.–the idea that it ought to guide our lives is a relatively new one. It’s not our genetic destiny, and it has its flaws. They’ve been noted by religious people forever, and not just Popes and Jihadis, but by sober thinkers like Robert Bellah (and, dare I say it, DAvid Brooks, who has been sober since his teen years), who remind us that rationality is what killed God and left us bereft of the agreed-upon meanings that can hold a world, not to mention an individual life, together. You want to be free to figure things out for yourself? Fine, but in return you have to accept that you’re on your own, and that little rational mind of yours, which is all you have to figure out the Big Picture, what life is supposed to be and why–it doesn’t know shit. And the corollary: you are totally dependent on other people agreeing with you that science, capitalism, democracy, universal human rights and the nation-state represent progress, that rational is how we are meant to be. They have to share your faith, in other words. And if they don’t, well, then all bets are off. Can you say nasty, brutish, and short?
This is why people of such disparate politics, like Samuel Huntington and Christopher Hitchens, can agree that we’re in the midst of a clash of civilizations, and that we really have to win this war. (Which is an attractive idea, I have to admit, although it’s hard to know exactly whom to engage and on which battlefield.) What they have in common is their belief that the Enlightenment was a Good Thing. It’s a view to which I am sympathetic, but not enough not to see and note its pathologies: climate change, materialism, individualism, nuclear weapons, amazon–none of which are going to be CBT’d away anytime soon; indeed to the extent that they have been glossed over in favor of feeling better, it’s been to our detriment. And surely not sympathetic enough to believe that doubling down on the Enlightenment virtues, whether through war or CBT, is really going to save the day.
Because the rot is within us. The reason a married couple with weapons and a dream can dominate our conscious minds is not only that we can all imagine ourselves in that room, or its equivalent, helplessly facing their blazing hatred. It’s that they seem to have found the weak spot in Western civilization. Or at least they stand for all the ways that irrationality can pierce the veil, all the ways that horror lurks just beyond our view. The last five hundred or so years of human history have bequeathed us much that is wonderful. But it has also given us a very unrealistic idea of how much safety we can expect. (Indeed, it seems that the generation now coming of age has come to believe it is entitled to safety in the form of shelter from anything that might disturb their psyches.) The real answer is: very little. You’re much more likely to get done in by an exploding artery in your brain than by an exploding Muslim; in fact you’re living on top of a time bomb, or, to mix metaphors shamelessly, there’s a bullet out there with your name on it, and it’s only a matter of time before it finds you, and you are fully cognizant of what that means: that your little life will soon be over. To be capable of knowing this may give rise to all sorts of fruitful endeavor, but it absolutely does not make sense. It is not rational. And whatever distress you feel about it is not the result of distorted and mistaken thoughts. To the contrary, whatever shelter you find from it is built out of them.
But I digress. Here’s what I want to say about religious terrorism. It’s terrifying in the same way that it would be terrifying if suddenly people randomly stopped driving on the right side of the road (or in the COmmonwealth, the left). It makes us realize just how dependent we are on people agreeing on basic things like the value of life, on that most fragile of human arrangements: the promise. It makes us see that when it comes to those basic things, it’s history all the way down. The guiding signs did not come from Heaven. People put them there, and not one at a time, or in full understanding of what they were doing, which means there is no one to blame, and no originary moment to be revisited and undone. You can’t edit history. We’re stuck with it, the epiphanies and the pathologies both, the terrorists and the saints.
Not every problem has a solution. But every civilization falls.
Daddy, Can I Eat at the Grownup Table?
January 9th, 2015
You’ll want to read this first, if you can stand it.
God knows I’ve tried, Daddy. Every day I wake up and I say to myself, “Today is the day I will stop putting my thumb in the eye of authority. Today is the day I will state my objections with good manners and consideration.” I put sticky notes on my mirror that say “Civility” “Respect” and “Politeness.” And I mean it. I want to eat at the adults’ table, to partake of their wine and conversation, their wealth and taste, and their establishment organs instead of the tripe and Coca-Cola they serve to us cackling kids.
But gosh darn it, Daddy. Sometimes it’s just so flipping hard. I mean, some days the excrement just hits the fan so hard. (And please note the restraint, resisting blasphemy, an f-bomb and bathroom allusion in three consecutive sentences, a regular hat trick of civility.) Like today. I went to bed last night, I’ll admit it, with immature and unkind thoughts in my head about religion, thoughts that failed to distinguish adequately between fundamentalists and the truly religious, you know, the ones capable of multiple viewpoints, who can, for instance, have a son in the Israeli military and yet remain dispassionate about the Palestinian situation. I was thinking about all the stupidity that religious belief gives birth to–and not just religion but godless faith as well. I was thinking about Charlie Hebdo of course, but I was also thinking about the Christian kid I met with yesterday who discovered that his pastor had been sleeping with a parishioner for many years, even fathered a kid or two with her, about how crestfallen the poor kid was, and how unaccountable the pastor. I was dwelling on piety, in other words, on the way that people armed with the right combination of certainty and weaponry can wreak holy havoc, and even as I drifted to sleep I was filled with the wish to grind my thumb into the eyeball of the nearest zealot–or, more accurately, to make some hostile jokes about the pious, because everyone knows that what satirists and provocateurs and other outlandish figures share, in addition to their puerility, is their cowardice. They don’t have the courage of good manners, which is why society, in its unerring judgment, rightly denies them complete respectability or an invitation to the grownup table. .
So I woke up today resolved to be brave. I kissed my wife good morning–a peck on the cheek, no tongue. I did not grope or leer at her or sneak up on her in the closet when I knew she would be naked like some kind of adolescent. I made coffee in my tasteful stainless steel coffeepot and drank it black, none of that kiddie cream-and-sugar stuff. I listened to NPR and not The Daily Show while I washed my breakfast dishes. I did not mock its droning; I did not allow myself to be offended by its inoffensiveness. I switched on the New York Times, and did not engage in the usual hermeneutics of being fit to print. I let the paper horrify me with details about Paris, and then, on the op-ed page, reassure me that Islam was not to blame. I was heartened by Ezekiel Emanuel’s recommendation that I skip my yearly physical, relieved not to have to endure the prostate exam one more time, and I did not indulge the thought that maybe I shouldn’t take medical advice from a guy who wants to check out when he’s seventy-five. I nodded along as Paul Krugman once again tilted at the right wing windmills, did not entertain my fantasy in which some Eurocrat says, “You know what, Paul? You’re absolutely right. We’re a bunch of paranoid, ignorant, power-hungry sycophants. No wonder you won the Nobel. We’re changing our ways now–not because you are right, but because we realize this is the only way to make you stop.” I did not groan or gnash my teeth or bore my wife with my outrage. I just sat at the table and read and nodded. I even pretended I was reading the Times on actual newsprint, that I was licking my thumb and adjusting my reading glasses and, between sips of my perfectly brewed coffee, quietly turning the pages.
I was, in short, the picture of the man with a complicated view of reality and a forgiving view of others. But then I clicked to David Brooks. Oh, how I tried, Daddy! How I tried! I got past the “I am Not Charlie Hebdo” headline without thinking too much about Lloyd Bentsen. When he compared the slaughter in Paris to “campus micro-aggressions,” I did not bellow in outrage but rather recalled my days on a college faculty and how professors could be like beavers who had run out of trees and had to gnaw on each other. I accepted his offer to turn this into a teachable moment, reminded myself that Brooks teaches at Yale, so why not be taught by the best? You can’t get more complicated and forgiving than that, can you?
Honest, I think I would have made it. I think I would have gone all the way with Brooks. I would have cruised past his condescension and his arrogance and his self-puffery. I would have read his “Satirists and ridiculers expose our weakness and vanity when we are feeling proud,” his “most of us” and his “rest of us” and his “we” who “maintain standards of civility” without saying back, “Who’s this ‘we,’ white man?” maybe even without wanting to say it. I’d have bypassed his making an equivalence between Ann Coulter, who, let’s face it, is mean and creepy and idiotic, and Bill Maher, who is actually funny and very smart even if sometimes abrasive, chalked it up to Brooks’s compulsion to show how both sides are always wrong, which of course leaves him as the one-man Isle of Right, but which nonetheless seems involuntary, the pundit version of Tourette’s syndrome. I’d have let go the whole thing about manners and standards and respect, and nodded in vigorous, well-mannered agreement with his conclusion that we shouldn’t outlaw offensive voices, even as we ostracize those to whom they belong, as if this sin-not-the-sinner argument weren’t bathetic beyond belief, as if college campuses were legislative bodies, and as if “social discrimination,” at least when practiced by the mighty, wasn’t more powerful than any legislation could be. And then I’d have licked my thumb, turned the page, and waited for my evite to the adults’ table.
But Daddy, how could I? How could I look past that crack about “their unguided missile manners?” Could a man so smart, a man who makes his living with words, be so unaware of language, of the fact that he’s saying that in the end those poor bastards at Charlie Hebdo deserved what they got? Who’s firing the missiles here? I wanted to say. (And did, out loud, even though my wife had already left.) Who’s got their hands on the trigger? It’s the people who have the guns. The fanatics, of course–who were not, for fuck’s sake (sorry, Daddy!), firing back at unguided non-metaphoric missiles, but firing first, and shooting real bullets into unarmed people–but also the calm and civilized and sedate grownups, the ones who do their level best, day in and day out, to quiet and pacify and reassure and, when that doesn’t work, to suppress and discredit the dissenters, to damn the “holy fools” with faint praise, to level their AirSoft Uzis at them, to paint them with the tar of extremism, to do whatever it takes–equate Coulter to Maher, dismiss them and their kind as puerile and irresponsible, even grudgingly accept them (while claiming this as a virtuous act)–to keep the guns in their own hands.
So I guess I can’t join you with the crystal and the china and the sterling and the foie gras and the fine burgundy and your glittering conversation and your good manners. I’m sorry, Daddy. I really am. But maybe when you stop acting so outrageously, I’ll finally be able to grow up.
Scotland: The Paperback, Second Edition
January 9th, 2015
Available now: the updated version, complete with amazon kindle bestseller status emblazoned on the cover, and the epilogue. Thirteen more pages, same low price.
Top Doc: I Just Flip a Coin
January 9th, 2015
I swore off writing about psychiatry, but today’s Times features–in addition to what we all have to hope will be the Most Inane David Brooks Column Ever–Weill-Cornell psychiatrist Richard Friedman once again letting the cat out of the bag, so I can’t resist.
Writing about the latest neurodoggle, in which Helen Mayberg claims to have found a biomarker that can predict whether a depressed person will respond to drugs or CBT (really, this stuff sounds more like phrenology or palmistry every day), Friedman says this:
In fact, I used to delight in tormenting the drug company representatives when they asked me how I picked an antidepressant. I would take a quarter out of my pocket, flip the coin and say I’d let chance decide because their drug was no better or worse than their competitors’.
Now I gotta tell you–this one puts a hair across my ass. If I had a dime for every psychiatrist from Stamford to Seattle to Sydney who has accused me of inducing patients to stop taking their drugs and throw themselves under the nearest bus simply by telling them that prescribing antidepressants is a guessing game, I’d be able to make a lot of phone calls, if there were still payphones and they still cost a dime. And yet here it is, confirmed by a prominent psychiatrist on the pages of the newspaper of record in a way that I would never dream of saying: “Yeah, we just flip a coin.”
Not that I mind being yelled at, at least not too much. I mean, if you poke a polecat, you’re gonna get sprayed. But really, who’s the one who seems uncaring about the patients? The guy who raises doubts about the science behind the treatment and suggests that people do their homework before they embark on a course of drugs that work by changing their brains (maybe forever), or the guy who compares it to figuring out who kicks off in the Super Bowl?
You also have to wonder how Jeffrey Lieberman, head of psychiatry at Weill-Cornell’s uptown rival Columbia, is going to take this news. In his forthcoming book, Lieberman, in the course of assuring us that psychiatry has “matured from a psychoanalytic cult of shrinks to a scientific medicine of the brain,” claims that psychiatrists are now “empathic prescribers of medication targeted to specific diseases,” and that the drugs fit the illnesses “in a lock-and-key relationship.” Seems to me you shouldn’t have to flip a coin if that’s so.
Oh, and one more thing. Friedman uses his column to take a swipe at the National INstitute of Mental Health, which has recently (and famously) decided to double down on the bet that we can decode the brain and figure out its role in mental illness. I personally think this is a doomed undertaking–or, more precisely, that it can only succeed at the cost of redefining the human, which is more than even the most ambitious and self-assured psychiatrist would consciously take on–but it at least has intellectual integrity. If mental illnesses are medical illnesses, they are saying, then by gum we should look for them directly in biology, which is better than just punting the issue as psychiatry has done for 150 years. Sadly for many psychiatrists, however, the NIMH initiative (known as RDoC) points to something sort of embarrassing, which is that we still don’t know what mental illness is, or which ones exist. RDoC is focused on symptoms rather than diseases, and the preliminary findings are challenging the boundaries of long accepted diagnostic categories like schizophrenia and bipolar disorder, mental illnesses that are many psychiatrists’ bread and butter.
So many psychiatrists are sore at NIMH, especially because it decided to go fully public with RDoC right on the eve of the release of the DSM-5, and to use that unveiling to announce that it is moving away from the DSM style of diagnosis. Lieberman spanks NIMH director Tom Insel for his timing (and for his ideas) in his book, and Friedman joins the chorus in his column. Following up on the conclusion that some patients are more suited to talk therapy than drugs and vice versa, he wonders if we can specify which therapy is right for which patient. But, Friedman laments,
right now we don’t have a clue, in part because of the current research funding priorities from the National Institutes of Mental Health, which strongly favor brain science over psychosocial treatments. But these are important questions, and we owe it to our patients to try to answer them.
Friedman overlooks not only that RDoC, at least on paper, is committed to psychosocial research, but also that researchers have tried for nearly eighty years to answer that question, and keep coming up with the same one: that all therapies are equally effective (or ineffective). This finding even has a name: the Dodo Bird Verdict (check your Alice in Wonderland for the reference.) The only consistent effect that can be found is that success in therapy is not a function of technique but of relationship, but mostly it seem it is nearly impossible to answer the outcome question without assuming your conclusions as your premises. In other words, the research almost always shows that the researchers’ methods are the best. this may indicate that therapy is not penetrable by the scientific gaze, but Friedman decides to overlook the knotty epistemological issues here and take the easy way out. He just blames the government. And blaming NIMH for the Dodo Bird Verdict is like blaming hte National Weather Service for the weather.
And not only that, but guess who paid for Mayberg’s research? That’s right: the National Institutes of Health.