Archive for the ‘psychology’ Category
A great article in the NYTimes illustrates a major problem in contemporary psychiatric practice–its mind/body dualism. The author Daniel Carlat, who has a book coming out on the subject next month, describes how psychiatric practice has moved over the last fifty years from an exclusive focus on the mind to an exclusive focus on the brain:
Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ” The brainless period was a reference to psychiatry’s early infatuation with psychoanalysis; the mindless period, to our current love affair with pills.
More specifically, writes Carlan, “psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them.”
This is due to a number of factors including the fact that insurance companies “pay nearly the same amount for a 20-minute medication visit as for 50 minutes of therapy” as well as the fact that patients in today’s busy culture are unlikely to want to commit valuable time to weekly therapy. But a big reason for the move to meds over therapy is that the drugs seem to work. But appearances can be deceiving. Carlat writes,
But over the past few years, research studies have shown that therapy is just as effective as medications for many conditions, and that medications themselves often work through the power of placebo. In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect.
Nobody knows exactly how the mysterious placebo effect works, but it is clear that it has impacts on the brain that can be seen as clearly as medication effects. In one study conducted by pain researchers at the University of Michigan, subjects were given an ache-inducing injection of saline into their jaws and were placed in a PET scanner. They were then told that they would be given an intravenous pain treatment, but the “treatment” was merely more saline solution, acting as a placebo. The PET scan showed that the endogenous endorphin system in the brains of the subjects was activated. The patients believed so strongly that they were receiving effective treatment that their brains followed suit. Presumably, a corresponding brain change occurs when depressed patients are given placebo pills.
Therapy, you may be surprised to discover, also leads to empirical changes in the brain.
n an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment.
What this article points out is that the dualistic distinction between mind and matter does not correspond to reality. The “mind” is not some metaphysical entity distinct from and trapped inside the material trappings of the brain. Rather, the mind is matter, or perhaps more specifically, the mind is consubstantial with matter. As scientists like Steven Pinker and Antonio Damasio have illustrated, the legacy of Descartes that there is some sort of “ghost in the machine” is false. The metaphysical “mind,” complete with values, personality, and character, exists substantially in the material components of synapses, axons, and cortex.
We might consider this a development from a more Platonic to a more Aristotelian psychology and biology. Ethically, it challenges us to see how care for the soul cannot be separated from care for the body. We are not spiritual beings who can somehow transcend the trappings of the body with all of its inconveniences, but nor are we purely material beings, as transparent and obedient to the laws of nature as a stone. What is metaphysical in our nature influences and is influenced by what is material.
This new understanding of the nature of the human person, what we might call a philosophical anthropology, needs to influence the way we think of medicine. As Carlat writes,
Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered “nonbiological” treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real.
For him practically, this has meant a shift to what he calls “supportive therapy” which involves not only prescribing drugs, but also listening to patients, helping them solve basic problems, and offering emotional support. The implications, however, extend beyond just psychiatry to all of medicine. Carlat concludes that good doctoring “involves perfecting all the skills relevant to healing and deploying them when needed.”
This will be a challenge in upcoming years as our health care system becomes more systematized, more reliant on complex care networks dependent largely on electronic patient records rather than a simpler primary care provider/patient relationship. In an of itself, this is not a bad thing and a more efficient system will allow more patients to receive and benefit from healthcare. But doctors need not forget the value of that standard question “how are you feeling?” and most importantly, cultivating a disposition to listen to the response. They may find themselves prescribing fewer meds and getting healthier and happier patients as a result.
Today’s NYTimes front page features an article on the new Diagnostic and Statistical Manual of Mental Disorders (DSM V), due out in 2013. The DSM is the psychiatric field’s encyclopedia of mental disorders which allows practitioners to determine who is mentally “normal” and who is not.
This is no small deal:
“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth. “And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”
One concern is that the revisions for the new DSM have “been the subject of intense lobbying by advocacy groups.” Considering the fact that many of the new diagnoses will also come with prescription drug remedies, many worry that the pharmaceutical industry is playing a big role in expanding the diagnostic criteria in order to increase profits from psychiatric drugs. Many of the comments on the NYTimes page note that it seems the new DSM is a matter of politics rather than medicine, or another move by “big pharma” making money by drugging people.
From the EverydayThomist perspective, the problem with the new DSM is that it assumes too much normativity in human behavior. Human behavior is not only incredibly complex, it also varies a lot from person to person. Some children are born with more of a natural tendency toward moderation in food and drink; others are prone to excess. Some children are very shy; others are prone to excessive anger and aggression. Human beings are too diverse to be able to neatly label as “ordered” or “disordered” to the extent that the new DSM attempts to do.
It reminds me of the manuals of moral theology, especially those written at the end of the 19th and beginning of the 20th century which strived to precisely label and categorize every possible sin. This is, however, impossible, as Josef Pieper notes in his most excellent book The Four Cardinal Virtues:
How are we to react to a proposition such as this one, found in one of the most popular handbooks of moral theology: “To look at the private parts of animals out of curiosity, but without voluptuousness . . . is a venial sin”? Not to mention other distortions, it seems that here the limit beyond which casuistry becomes meaningless has been considerably exceeded. Propositions so constructed seem entirely to miss the true purpose and scope of casuistry, which is to provide a tentative approach and an auxiliary means for the practice of discernment. Is it not to be feared that a discernment schooled by such methods will be misguided toward an unrealistic rigidity and a prematurely fixed judgment, instead of toward a sober evaluation of the realities of life; and that this in turn may lead to a total incomprehension of the reality of man as a being who responds to the richly orchestrated world with every power of his soul, and thus reaches his choice?
The pre-conciliar moral manuals were striving toward certainty in their evaluation of human behavior, in much the same way that DSM V seems to be doing. Whereas the moral manuals wanted to define precisely in every possible case what could be considered “sin,” the DSM uses the more contemporary scientifically minded language of “pathology” and “disorder,” but the intent is the same–the desire for rigid and precise criteria to judge human behavior.
A virtue ethics perspective rejects the need for such certainty, recognizing that two people may do the same things, and yet act (in light of circumstances and intentions) in very different ways. As Josef Pieper writes,
It is temperantia, the virtue that realizes the inner order of man in himself, which St. Thomas has in mind when–in contrast to justice, in whose province that which is ‘properly and in itself right’ can and must be determined–speaking of ‘the other moral virtues which refer to the passions and in which right or wrong cannot be determined in the same fashion, because men vary in their attitudes toward the passions,’ he says, ‘therefore it is necessary that what is right and reasonable in the passions should be determined with reference to ourselves, who are moved by the passions.’ But especially in the province of temeprantia ‘we ourselves’ have the choice of innumerable possibilities: for example, to desire halfheartedly or wholeheartedly, to tolerate, to let things take their course, to give in to pressure or to be carried away. ‘Who could determine,’ writes the perceptive Thomist H.D. Noble, ‘who could determine when lack of control ends and where temperance begins?’ St. Thomas says that the realization of temperantia varies too much according to individuals and periods to allow the establishment of hard and fast, universally valid commandments.
Aquinas recognized in the 13th century that there was no such thing as “normal” human behavior. Which is why he referred to the virtues as powers within a person to help her realize for herself within a specific community with specific practices which behaviors would be conducive to happiness. But the problem for a lot of people with virtue ethics is that it leaves too much room for ambiguity, too much room for diversity in behavior which makes human beings, even the most open-minded contemporary human beings, very uncomfortable. So we’ve done away with sin manuals, but have we simply replaced them with an ever-expanding encyclopedia of mental disorders?
In the last post, I said that I was going to do a series of posts on some of the thoughts I have been having related to the “theodicy” issue, or the problem of evil and suffering in light of the belief that God is all-good and all-powerful. In this post, I am going to use as my starting point a quote from Harold Kushner, who I mentioned in the last post wrote a very famous book on theodicy called When Bad Things Happen to Good People. In his effort to explain God’s involvement in the suffering humans experience on this earth, Kushner writes,
We can recognize our anger at life’s unfairness, our instinctive compassion at seeing people suffer, as coming from God who teaches us to be angry at injustice and to feel compassion for the afflicted. Instead of feeling that we are opposed to God, we can feel that our indignation is God’s anger at unfairness working through us, that when we cry out, we are still on God’s side and God is still on ours (45).
In this post, I am going to expound on Kushner’s provocative idea about anger from a Thomistic framework in order to determine the moral and theological significance of anger, and whether Kushner is right is saying that suffering should prompt anger.
We tend to think of anger as vicious or harmful. Somebody may say, “I didn’t mean to do X, but I was blinded by anger,” or “anger is wrong; I want to be a more peaceful person.” Aquinas is aware that anger connotes sinfulness. There is good reason for this. In Matthew 5:22, for example, Jesus claims that one who is angry with his brother is liable to judgment. In his discussion of anger, Aquinas asks whether all anger is contrary to virtue, to which he answers a resounding no. Anger, which is a passion, can be aroused according to reason, which makes anger in some situations virtuous.
So how do we determine if anger is virtuous (according to the standards of reason) or not? Aquinas looks at the object of anger, or that to which the anger is directed. He identifies two objects to anger: one is the injury that the person suffers, and the other is vindication (vindicatio) that the person seeks. The vindicatio is the justice that one seeks to exact against an perceived injustice. It is the way of making an injustice right. The vindicatio is an evil under the aspect of good. Denying a person his freedom for a number of years in punishment for theft, for example, could be a vindicatio because it is an evil (imprisonment) that seeks to rectify an injustice (the theft), thus rendering the vindicatio itself a good.
If a person seeks a vindicatio against a person who does not deserve it, for example, the anger would be sinful. If a person seeks too great a vindicatio, such as when a person repays an injustice with a much greater injustice (beating a child for spilling milk), such anger would be sinful. So anger is virtuous if a truly unjust offense occurs and the response is proportionate to the injustice.
What about Matthew 5:22 that says that anyone who is angry against their brother is liable to judgment? In light of scripture, how can Aquinas still say that anger can be virtuous? One way which Matthew 5:22 has been explained is using the person/sin distinction. That is, it is wrong to be angry against a person, but okay to be angry against a sin. Because Jesus is referring to the former in his condemnation of anger, it does not contradict the thesis that anger can be virtuous. This is the explanation Augustine used, claiming that one is properly angered at the sin of one’s brother, not one’s brother himself. Thomas disagrees with this, claiming that if a person is unjust, it is fitting and proper to be angry towards that person, granted that one’s anger is proportionate and the vindicatio sought is just.
The reason is that anger is that, according to Aquinas, has a two-fold object—the injustice, and the rectification of that injustice. An injustice is when a person is not given their due. The order of the universe which is in natural things and in the human will reveals that there is justice in God. God orders things and orders that they be in right relationship, and this is what is meant by God’s justice. Kushner is right in identifying that when we recognize that things or people are not in right relationship, we are participating in God’s justice.
Anger, then, because it is concerned with justice, is properly determined by relationships. In order to determine if anger is appropriate, one must be in some relationship of justice, that is, a relationship that is ordered according to God’s standards. This requires a little explanation. I cannot be angry against an inanimate object, for example, because the inanimate object cannot do me an injustice. I may stub my toe on my desk, but my anger cannot rightfully be oriented towards the desk. Nor can I be angry at a hurricane or a virus for the same reason. I may be hurt by these things, but they cannot be the object of my anger because they did not commit an injustice against me. Anger, for Aquinas, is really properly directed at people.
Additionally, if anger is to be justified, the right rectification must be sought. A child who commits a grievous fault–perhaps he hits one of his siblings–has committed an injustice which the parents, due to their relationship of justice with the child, have a responsibility to rectify. Perhaps they will ground the child, or require some sort of positive compensation to the assaulted sibling. However, the sibling who has been harmed is not in a relationship that allows him to seek the necessary vindicatio. It would be inappropriate for the sibling to ground his own sibling or to hit his sibling back. It would also not be appropriate for a stranger to punish the pugilistic sibling. Nor would it be appropriate if a child was the victim of an injustice committed by a parent to seek vindicatio. If a child is hit by a parent, the appropriate response is to appeal to a higher authority, like the police. In short, in order to seek a vindicatio, one has to be in the right position of seeking justice.
This is why we frown on vigilantes, or civilians who go out to seek vindicatios against injustices that are going unpunished. Because such civilians are not in the proper relationship of justice to the people whom they are punishing, they are actually committing an injustice in their actions in seeking a vindicatio that is not theirs to seek. Their anger is not virtuous, because the vindicatio sought is not virtuous.
Reasonable anger (and hence, virtuous anger) according to Aquinas is (1) prompted by an occasion of injustice, (2) directed at the perpetrator of injustice, and (3) seeks a just vindicatio to restore the injustice. If anger meets these three requirements, Aquinas would say it is virtuous.
So how does this play out regarding the theodicy question as Kushner sees it? First of all, the object of anger must be an actual injustice, not just something that makes us unhappy. Aquinas would not say it is virtuous to be angry if you, for example, get diagnosed with a terminal illness. This is not an injustice that should rightfully prompt anger. Moreover, there is no committer of an injustice towards which one can direct their anger. A more proper response would be sorrow at the fact that one is experiencing an evil, but not an injustice. But it would be proper to experience anger at a news story relating how somebody has been raped or murdered, or to be angered when you hear about the violence in the Middle East or Zimbabwe. Here, we do have an injustice, and perpetrator, which can be the object of our anger.
Second, the anger must be directed at the right person. If I read about what is going on in Zimbabwe and get angry at Robert Mugabe, my anger may be justified. If I read about Zimbabwe and get angry at black people, my anger is definitely not. Similarly, if I get angry at God when I hear about Mugabe’s egregious offenses against his people, my anger is not targeted at the right person. Such anger, according to Aquinas would not be justified.
Lastly, the vindicatio sought must in itself be just. If I decide that I am going to go assassinate Mugabe to stop his injustices, the unjust vindicatio thus renders my anger unjust. A more just vindicatio might be writing to the UN or raising awareness in this country by writing letters to the newspaper or marching in DC, or praying to God for the Zimbabweans who are suffering.
Kushner is right that we should feel compassion and sorrow for those who suffer. But I am not quite sure that an appropriate response to suffering is anger. Anger connotes that an injustice is being done that one can do something about. Sickness, death, and natural disasters are indeed evils, but they are not injustices. Such tragedies may be handled in an unjust way. Hurricane Katrina, for example, was not itself an injustice, but the subsequent way it was dealt with in many ways was.
This is not to say that Aquinas thinks we should remain Stoic in the face of suffering. He acknowledges that the passion of sorrow, which is the apprehension of some pain or evil, is a appropriate. When one is faced with a pain or evil, it may be appropriate to weep, to seek to remove or alleviate the harm, or even, as is the case with Job, demand answers from God. But for Aquinas, and I think he is right, it is not an injustice to experience pain, nor does God owe us any answers. The proper response to suffering, I would argue against Kushner, is not anger, but rather sorrow. The situations that concern Kushner, the death of a child for example, do not arouse God’s anger because no injustice is being done. God’s universe is still in order, even if we suffer.
But this is not the final word for Aquinas against Kushner, which will be the subject of another post on the issue. Aquinas, as a Christian, has not only a God that gets angry at injustice, as Kushner does, but also, a God who through the incarnation, is capable of suffering with, or feeling compassion and sorrow with his creation. And through the resurrection, Aquinas has a God who not only suffers with his creation, but has also ultimately defeated suffering in the grand eschatological scheme. Thus, for Aquinas, suffering should prompt not only anger if an injustice is done, or sorrow if no injustice is done, but should also prompt us to reflect on the God who loved us so much, that he suffers with us, and is himself ultimately the remedy to our sorrow.