Narrative Psychiatry

Albert Ellis and the Serenity Prayer

     A throwaway article in a "throwaway" journal (Psychiatric Times) sums up the worldview of the famed cognitive therapist Albert Ellis as follows: if you're unhappy about your situation, change it; if it is beyond your ability to change, accept it because it is reality.  Why is this so hard to do?  If the Serenity Prayer were ever conclusively answered, people like me would be out of work.

     Life is hard because none of us ever really attains the wisdom of the Serenity Prayer (i.e. to know the difference between what is in our power to change and what isn't).  Sure, we know we're never individually going to modify the constellations or even affect climate change in a major way, but when it comes to a host of more modest life situations, we grow frustrated because we feel that there must be a way to effect change if only we achieve sufficient persistence or ingenuity.  Most of us err on the side of passivity or of futility--to get it right would be to live on a tightrope.  To what extent do we actually exert control over our lives?  Time will tell.

Autonomous Reason

Anthony Gottlieb persuasively argues the basic irrelevance of evolutionary psychology to the practical understanding of human culture.  Once we became conscious beings blessed (cursed?) with the ability to deliberate about possible courses of action, we were thrown into the realm of the moral, the political, and the aesthetic; that is, we had to take ownership of the cultural script instead of passively acting out a biological one.  This is of course a pragmatic and not a metaphysical sort of freedom, and merely a rephrasing of Sartre's "Existence precedes essence." 

I think that an understanding of our evolutionary origins may have most impact on spiritual life, for evolution offers a perfectly plausible alternative to the creationist narrative.  And the notion that we developed contingently, not necessarily, out of inert matter over billions of years not only supports a sense of kinship with non-human life but also fosters a form of transcendence quite different from that of the human, all-too-human gods that have ever haunted humanity.

Politics and Change

As if on cue, vis a vis the last post, a post at Shrink Rap considers the ethics of physicians enjoining their patients to lose weight (when, after all, lasting weight loss is uncommonly successful and the health effects of less-than-morbid obesity remain debatable).  There is a fine line always between encouragement and scolding, and this is clearly a case in which moral disapproval is an attempt to motivate.  The problem is that when the hoped for motivation does not happen, and yet the disapproval persists, shaming is the likely result.  The widespread phenomenon of obesity perfectly illustrates our excessive faith in simplistic free will; physicians nagging patients to lose weight is a moral "treatment" that has a low (but non-zero) success rate, and that can cause significant emotional side effects.    

 

A couple of posts ago I alluded to Orwell's comment that change can only occur through education, politics, or violence--but I didn't comment on politics.  Politics is essentially moral debate in which contending parties posit or repudiate, as the case may be, particular visions of value and the good life (if education is about cognitive and conceptual means, then politics is about ends, and religion is a metaphysical form of politics).  Psychotherapy is largely about education ("know thyself"), but inasmuch as questions of value are intrinsic to the endeavor, interpersonal politics play a role--a psychotherapist doing meaningful work must stand for particular views of what the good life ought to be, above and beyond mere symptom reduction.    

The purpose of moral judgement, whether of others or oneself, is the modification of behavior in the name of a desired ideal. Indignation becomes pathological when it persists far beyond its realistic ability to shape events, rather than acting in creative tension with radical acceptance of things as they are.

Found

Robert Hughes on the Surrealists (from The Shock of the New): "They would rather have been seen as bad priests than as good engineers." 

A Human Science

     The disputes about psychiatric diagnosis and medication are not scientific disagreements, per se, but rather are debates about personal responsibility and meaning.  To what degree is the sick role empowering or infantilizing?  Does a medication enhance or corrupt the vision of the good life?  These are at once theoretical and pragmatic matters, not to be settled by brain scans or biochemistry.  To be sure, there must be a biological basis to psychiatry, but only a basis, just as landscape architecture must entail knowledge of horticulture and ecosystems.

     The psychiatrist is not an artist, but rather functions as biographical editor and critic; as such, her first duty is respectful attention.  The office visit is a secular ritual meant to acknowledge and contain suffering that is more properly of the person than of the body.  Neither psychotherapy nor medication treats a disease; instead, their goal is to remove impediments to a person's achievement of the good life.  The hard part, in balancing the willing spirit and weak flesh--change versus acceptance--is realistically optimizing the scope and shape of narrative freedom.

Narrative in Psychiatry

 

Even if one had a full knowledge of human nature and its evolutionary history, and a radically intimate and complete acquaintance with one's own neurobiology and unconscious dispositions, one would still have to decide--contingently in the devising of a life--what to do next.  So free will is a social and narrative necessity, not a physical truism, and biography, culture and politics are the unfolding of practical freedom and value over time.  This for me is why the narrative and the existential are one and the same.  What to do?  How to live?

     I recall reading once in some George Orwell essay that change can only happen in three ways, through violence, education, or politics.  Arguably all somatic medical treatment, whether major surgery or an antidepressant, is a kind of violence done to the body, violence that may be necessary for helpful change.  Psychotherapy is a kind of education inasmuch as it illuminates and broadens possibilities.

     Today I finished Jim Holt's marvelous Why Does the World Exist? and I note two notable quotes:

 

"And if reality has no special feature, then my own presence in it cannot be explained by the hypothesis that I somehow enhance that feature, add something to it.  Thus there can be no cosmic point to my existence--or rather, the only point to my existence is that I exist.  Sartre was on to something like this when he said, "Existence precedes essence."  And the purpose of my life?  As eponymous antihero of Ivan Goncharov's great novel Oblomov is wisely told by his friend Stolz, "The purpose is to live."  That is a tautology worth remembering."

 

And in considering whether death represents a loss even in the case of severe suffering, Holt quotes the philosopher Richard Wollheim in what seems the most compelling rational case against suicide that I have encountered:

 

"It is not that death deprives us of some particular pleasure, or even of pleasure.  What it deprives us of is something more fundamental than pleasure: it deprives us of that thing which we gain access to when, as persisting creatures, we enter into our present mental states...It deprives us of phenomenology, and, having once tasted phenomenology, we develop a longing for it which we cannot give up: not even when the desire for cessation of pain, for extinction, grows stronger."