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.
Scotland: The Paperback
December 21st, 2014
My buddy Glenn Cheney has a little publishing company called New London Librarium. There he publishes a lot of his work, which is very good. Glenn is testimony to the way that talent itself is not what gets rewarded when it comes to the writing biz. (Or the music biz, or anything else that happens where art meets commerce.) He put together the pages and designed a cover and presto! a book. Which you can order right there on the website, or, I believe from amazon. Although, really, does amazon need your business?
Speaking of the devil, many have asked about my experience with amazon. Everyone I worked with there was smart, courteous, prompt, and competent. Everything happened exactly the way they said it would. Scotland topped the Kindle singles charts for the better part of a week. They voted it into the top ten of the year. That has all translated to selling about 2500 units, total royalties $3000. Which, depending on how you look at it, is either pitiful or better than a sharp stick in the eye.
I don’t know whether amazon’s point is to turn writers into sweatshop workers, but our relationship to amazon is chillingly like the relationship of iphone assemblers in China to Apple. In the interests of bringing consumers what they want for low price, amazon will turn us all into content serfs. Too bad.
That’s the only reason I regret my involvement with them. But it’s a pretty big reason.
To be fair, one thing I think amazon is trying to do by having this tier of not-quite-self-published work is to restore the curatorial function of the publisher–which, of course, they have done everything they can to destroy. I mean, they must recognize that most of what gets self-published is pretty bad, writing-wise, and that as profitable as it is for them to kill the gatekeepers (for what is the necessity of gatekeeping when the gate is only a portal to bits and bytes? You just open the gates, collect a dime from everyone who passes through, and after that who cares?) there is still some reason, some responsibility even, to exercise judgment and to help the public figure out what to read. They don’t recognize it enough to pay an advance or a guarantee, but still at least they’re trying. I don’t exactly hope they will succeed, but if this is what is going to happen, if the tastemaking function of the traditional publishers is going to be obliterated, then I suppose I don’t want them to fail either. It’s just too bad that the emerging model will make it so that the only people who can afford to write (aside from the Gladwells and the Cornwells out there) will be the independently wealthy, the impoverished, and the otherwise engaged.
Of course, Sony Pictures, a traditional gatekeeper, sure did a poor job of tending its gates recently. And plenty of crap has gotten in, and plenty of really excellent material (like Glenn Cheney’s) has been largely excluded by the old regime, so I’m not sure the good old days were really so good. Things are never as good as they used to be, and they never were.