Culture lag and schizophrenia

October 14, 2018

R. D. Laing opens Sanity, Madness and the Family with some sobering statistics about interrater reliability in the diagnosis of schizophrenia, and a thoroughgoing indictment of the biomedical community’s reliance on data collected in the inpatient environment, in the absence of contextual information about the origin of the substance of the patient’s conversation, to interpret when he or she speaks “schizophrenese”.

Situating his clinical vignettes squarely in the life histories of his patients, taken through in-depth interviews with parents, siblings, and the patients themselves – often after years of inpatient neglect – Laing proceeds to deal with the content of his patients’ delusions analytically, without resort to any Freudian tropes more arcane than the act of offering “the listening cure”. His books, read back to back, are a somewhat repetitive catalogue of middle class family dysfunction and “catatonic withdrawal” coping mechanisms, which has led some of his critics to accuse him of blaming run-of-the-mill, if sometimes obtuse, parenting styles for clinical outcomes in schizophrenia.

But the stories he tells are more compelling than blame games – they elucidate meaning where none was anticipated, achieve sense-making where “nonsense talk” was officially diagnosed, and re-humanize the most thoroughly stripped-down specimens of the human condition medicine in his day had to offer. This, I think, is an admirable achievement.

These books have been relegated to a past now referred to as “the anti-psychiatry movement,” because Laing refused to tranquilize most of his patients, and categorically rejected the then-popular electroconvulsive therapy that had been used to reduce vaguely agitated patients to a mostly vegetative state before they were brought into his more humane care.

Is that fair? To understand Laing in his own context, one must look at his life story and humanize the author of these compelling, activist critiques of unreflective psychiatry. And the recent David Tennant film Mad to be Normal does exactly that, zeroing in on perhaps the most controversial of Laing’s career accomplishments, his “Kingsley Hall experiment” of running a group home for unmedicated schizophrenics.

mad-to-be-normal

Laing drank heavily – even his patients drank, more than likely to self-medicate. Sometimes they experimented with acid. Although there were no murders, there were some close calls. And although his patients’ symptoms did not remit without medication, many of them responded positively to the acceptance and safety he offered them instead.

Was the “experiment” a success? Or was it simply an intervention? In the film, Kingsley Hall comes across as a collective hideout for doctors and patients appalled and bewildered by the scientific community’s insistence on shock therapy and its promulgation of mutism and catatonia as a supposedly “improved” condition. Eventually, Kingsley Hall was shut down.

Why didn’t Laing trust Haldol, the first of the successful antipsychotics? Perhaps because psychopharmacology had gone out on a limb and acted on the dopamine pathway in the brain without first theorizing as to how this might be therapeutic – commenting only that their patients seemed “disinterested” in their surroundings, less agitated, in short, tranquilized. All they had to offer was the peace of a dull stupor, in Laing’s day.

Today’s more sophisticated dopamine agonists modulate brain chemistry less catastrophically, and have less profound tranquilizing effects, although they still instill a “dysphoria” by dampening the brain’s perception of “motivational salience”. But this way of looking at dopamine is new to psychiatry, and marks an important departure from the search for “atypical sedatives”.

The modern antipsychotic, such as geodon/ziprasidone, is genuinely anti-“psychotic” in a way that is more noticeable since the patient is not rendered vegetative by these new drugs. “Salience dysregulation” is the mistaken perception that everything going on in your immediate environment, from background noise (neighbors moving out, birds singing next door) to the gaze of strangers (are they looking at me? are they talking about me?), has to do with you personally, in effect, that the world literally revolves around you and that everyone is trying to get your attention at once – a hostile and distressing environment indeed.

Figure 1 (reproduced below) in Kapur et al.’s foray into explaining psychosis and schizophrenia in terms of the dopamine pathway also maps out the natural history of schizophrenia, with an on-again-off-again attitude toward medication being a normal human reaction to “feeling normal” on the medication, and thus questioning its usefulness.

antipsychotics

This model goes a long way toward explaining how schizophrenia can run in families, by firmly locating the psychotic experience to a biochemical predisposition in the brain. In Laing’s vignettes, intergenerational incomprehension – the culture lag in medical literacy, compounded by the medical community’s lack of explanations and persuasive treatments for schizophrenia at the time – looms large as an exacerbating factor in patients’ vulnerability to being institutionalized with no end in sight.

What sort of culture lag was this, at the time of Kingsley Hall? His patients were adults in 1965, so their parents grew up in a world new to biomedicine, were probably uneasy with Freud and were avowedly uncomfortable with the Beatles. The age of penicillin would have seduced them into trusting injections uncritically, so only grotesque failure to effect a cure could have sent them comparison shopping among doctors until they found their way to Laing’s door. Failure was, indeed, typical of psychiatric intervention at the time. Only a decade earlier one Canadian proponent of electroconvulsive therapy had attempted to cure a woman’s menopausal symptoms in this way, and totally failed to understand why she did not respond better to “therapy”.

One vignette ends on a remarkable note that brings home the importance of culture lag here.

“RUTH: Over this matter I am a bit in the air. Not over all the things in the world, not over everything – not everything – however this I am a bit sort of dubious, because most people sort of look down on beatniks and things like that don’t they? I know my girl-friend wouldn’t tolerate going out with them.
INTERVIEWER: Well, it’s a different point of view, isn’t it?
RUTH: Yes, it’s just a different point of view.
INTERVIEWER: But do you feel you have to agree with what most of the people round you believe?
RUTH: Well if I don’t I usually land up in hospital.”

For this patient and all the others, Laing does a remarkably persuasive job of discrediting the writing behaviors of the clinicians and case workers who have made contributions to her file, simply by delving directly into the family’s account of when and under what circumstances she was first diagnosed, later rehospitalized, etc. These compelling accounts of the shortcomings of clinical psychiatry in its routine manifestations are seductive and powerful.

But any schizophrenic who has been through “intake” and has seen his or her own clinical notes will recognize these writing behaviors as par for the course. It is truly a mystery how medicine happened upon a cure for such a muddle under the circumstances.


Grey geese

October 13, 2018

Grey geese draw the chariots of dream-weavers,
North by the second solstice, deerhound-like, played out
but hurtling ahead with meteor abandon.

Morning shadows pale, disgorge green canyons,
blue fjords and ice plateaus no sun has ever
forgotten to embrace by day, give way
to nesting grounds left undefended
on the tundra’s plains.

What arctic fox, what lynx, what snowy owl
do these grey messengers lie down before
in this, their home, so patiently?

On most days unmolested, but sometimes robbed
of what all creatures, strange and common, hold to
heart, they count their nurslings and tuck down their wings.
Young. These, too, they will return, laden with dreams.

Grey geese reply to no grey dawn, those silver
trumpet bursts of cloud slip through their wings
like so much muted fog, and dreams descend.

To watch their shadow V’s deflect the season’s
bitter frailties is to imagine dreams resend
the memories of lives unknown to dreamlight
and unfearing and twice-blessed, unburdensome.

geese


Euthyphro and “lex talionis”

October 13, 2018

Impiety in the name of bare fairness, a public prosecutor with a conflict of interest invoking the punitive state for the safeguarding of the helpless – a snakes’ nest of problems is at stake in Plato’s Euthyphro. Martha Nussbaum bring’s this gem up in an introductory remark to her chapter on the criminal justice system in Anger and Forgiveness, asking what we are to make of a son’s suit against his father for the murder of a serf – is this true justice? Is it needful? Is it helpful? Her answer, it seems, is that much depends on the structure and disposition of the court that hears the case.

justice

The enigma of Euthyphro’s case cannot be answered so simply as Socrates hopes when he draws the plaintiff into word games over the question “what is piety?”, exclaiming on Euthyphro’s singular self-assurance in flouting the conventional wisdom that this suit is impious because it involves a son marring the reputation of his father. Euthyphro answers common-sensically that piety amounts to upholding what is dear to the gods, to which Socrates argues that the gods, too, have their reasons, and that we should inquire after those.

His route to this stickier question is circuitous indeed. “But that which is dear to the gods is dear to them because it is loved by them, not loved by them because it is dear to them,” he points out. In the fuzzy logics of conventional expression, even this linear distinction is not self-evident – feedback loops circulate between “that which is precious” or was not obtained “at a small price” and the ongoing action of loving “one’s own”. Word play is the only device here that engages our attention, for the fundamentals escape notice in the footnotes of abstract philosophy.

Taking a step backward in the argument, consider the claim that a thing is not “led because it is in the state of being led… neither does it suffer because it is in a state of suffering.” Cannot a “born follower” be in a state of “following along” without being led in any particulars on purpose? And is that not the meaning of being led “because it is in the state of being led”?

And does not the mind get stuck in a stable equilibrium of self-perpetuating misery when its chemical and reflexive routines have settled into a pattern of depression? To shift that equilibrium out of its base state and into a happier, healthier condition is the purpose of medical intervention for mental illness. Homeostatic processes must be overcome by brute force and careful machinations to achieve this, and until they are overcome, one suffers precisely “because one is in a state of suffering”.

But let us return to Nussbaum’s book. In her discourse on everyday justice and the role of the courts in a just society, Martha Nussbaum reverses direction on a theme of the first half of her book, Anger and Forgiveness. Having carefully explained how counterproductive and unhealthy a victim’s demand for a thoroughgoing apology can be, how status-obsessed and backward-looking the insistence on an admission of guilt can be, she now says that the courts, unlike the defendants in the courts, are in fact obligated to acknowledge that wrongdoing has occurred, and to acknowledge this publicly, for the record. By assuming the role of confessing that injustice has occurred, the court absolves the defendant of the humiliating mouthing of what the victim wants to hear, without depriving the victim of a sense of restored human dignity for a wrongful injury.

Doing so, importantly, is a separate issue from meting out punishment or rehabilitating the defendant. Quoting another philosopher who makes a similar point about the court’s role in “calling to account” wrongdoers, she explains that for the law to mean what it says, “it is committed to censuring those who engage in such conduct.” In her own words, “To remain silent would be to go back on its commitment to its own values.” Here she interjects that this is part of the state’s give-and-take in the trust games that make the social contract viable.

What is punishment, then? A confrontation between the court and the convict, in which the convict is compelled to attend to the court’s decision that wrong has been done, and that it must not be repeated? Nussbaum raises these possibilities and challenges them with the prospect of producing a hardened offender, whose childhood predisposed him to a life of cynicism and alienation from the goods of the social contract, and whose expulsion from these goods through the criminal justice system may in turn consign him to a life of preoccupation with further opportunities to reoffend, rather than reforming him at all.

Here, Nussbaum refers back to her work on the “capabilities approach” to welfare economics, valuing a distributional system of justice not in terms of what goods and services it provides to the needy but by what capabilities it fosters in them. She names many different kinds of capabilities as holding non-interchangeable intrinsic worth to all individuals and as constituting entitlements that they should not be denied.

These capabilities constitute the positive attributes of her alternative to “unaccommodated man,” Lear’s “bare, forked animal” roaming nakedly in a storm. One of these is the right to cultivate self-respect, that is, freedom from humiliation, and the opportunity to realize and retain one’s personal dignity. This right, she argues, is inalienable and should be protected even within prisons – she describes the far less shaming and degrading conditions of European prisons as a better alternative to the way mass incarceration has played out in the United States.

In weighing retributive justice norms against the ideals of crime prevention, reintegration and mercy, Nussbaum is quick to acknowledge that mercy is a virtue born of strength and invulnerability. Whether one is blithe and unimaginative like the “merciful” Portia in A Merchant of Venice, who could care less about Shylock’s reasons for insisting upon his bond, patient only in the sense of being unperturbed, like the creditor Nietzsche puts forward who “always becomes more humane to the extent that he has grown richer”, or one adheres to the virtues of Seneca’s Stoic judges whose mercy is forward-looking and perhaps even practical, one needs a position of relative strength and power to feel the sting of status injury in wrongdoing so little that mercy towards the wrongdoer makes sense.

portia

But as societies, she warns us, mercy in the courts is our due to criminals, repeal of mandatory sentencing for “victimless” crimes is imperative, and more fundamentally, the welfare of future criminals should be safeguarded and improved through radical overhaul of our institutions to prevent substandard living conditions from producing so much crime in the first place. And mercy, she argues, is both different from and better than apology-extracting forgiveness, being less backward-looking and less humiliating to the offender.

Here, she is not recommending the imperious “mercy” doled out in A Merchant of Venice, but rather a Greco-Roman virtue common to Greek Stoics and Romans like Seneca, one more at home with the institutions of democracy than the intransigencies of monarchy, and one more akin to her own Aristotlean roots in philosophy.

So, was it Euthyphro’s place to extend mercy to his father, or should he have brought the suit and laid his father’s fate at the feet of the court, in the name of the serf’s rights, in the absence of an institution like our modern public prosecutor? Nussbaum never comments on this question, having only alluded to the case in passing. But she does suggest that, for the law protecting individuals’ rights to flourish to mean anything, wrongdoing needs to be addressed with some modicum of consistency, impartiality and rigor. It is her next chapter that deals with the grievances of activists who, like Euthyphro, feel the need to step up in the absence of institutional protections for the vulnerable or oppressed, even when this means going against the grain of convention and violating the “social graces” of the status quo.


That “awful” elation / on a knife’s edge

September 25, 2018

To bear up under oppression, to feed one’s anger on grief and emptiness, to cry justice and hold up a knife’s edge – these are timeless states of mind peculiar to the human condition, known to any number of minorities in any number of epochs.

undertheknife.jpg

Shakespeare’s Shylock grips the knife with ruthless determination, and on this insistence loses everything. Is this where violence will lead us all?

In the UN’s seminal Pathways for Peace report, describing more than 50 years of research on conflict prevention and putting forward evidence-based best practices for peace building, we learn that violent contestation loses more arguments than it wins, in the perennial struggle within and among nations for minority rights. Nonviolent action is more successful, on average.

And what of government-sanctioned abuses? Governments guilty of human rights abuses experience a greater number of violent conflicts and a greater intensity of violence, according to the same numbers.

respect for human rights

In this figure, “respect” is for human rights, and is measured in inverse frequency of extrajudicial killings, torture, etc. Source.

Why, then, is violence any temptation to us? How does it compel so much senseless repetition, what is the impetus behind the vicious cycles that perpetuate repression and violent agitation at times like these?

In her short essay Prisons we Choose to Live Inside, Nobel prize winner Doris Lessing tells us something about the hold the “drums of war” have over our bodies and minds, as human beings, and as social animals:

“People who have lived through a war know that as it approaches, an at first secret, unacknowledged, elation begins, as if an almost inaudible drum is beating .. an awful, illicit, violent excitement is abroad. Then the elation becomes too strong to be ignored or overlooked: then everyone is possessed by it.”

She goes on to share a history lesson out of her experience as a socialist dissident in colonial Africa and as a lifelong observer of the inconsistencies of socialist rhetoric and reality over time:

“Before the First World War, the Socialist movements of all Europe and America met to agree that capitalism was fomenting war, and that the working classes of all those countries should have nothing to do with it. But the moment war was actually there, and the poisonous, fascinating elation had begun, all those decent, rational, honorable resolution about keeping out of the war were forgotten.

I have heard young people discussing this, uncomprehending. This is because they do not understand how it can have happened. It is because they have not experienced, and have not been told about that dreadful public elation that is so strong – strong because it comes from an older part of the human brain, of the human experience, than the decent, humane, rational part, which passes resolutions condemning war.”

Further on her essay, Lessing describes how craftily the hawkish Margaret Thatcher primed her viewing public’s animal brains in the way her election campaign was stage-managed, making the most of the manipulative powers of the media at her disposal. She does this not to demonize the Thatcher government, but to bring up an interesting point:

“Meanwhile, it is interesting that those people who like to regard themselves as the armies of the good, the well-intentioned, disdain such means. I am not saying they should use them, but they will often refuse even to study them, thus leaving themselves open to being manipulated by them.”

I think Lessing would be gratified to see how far the pacifists at Greenpeace, Amnesty and the ACLU have come, along with all the rest of us, in growing more self-aware and media-savvy about the human brain. I write about her frustrations, dated 1987, to remind my readers how new this information is to us as a polity, how uncomfortable it is to contemplate, and how essential it is to understand.