Thursday, May 27, 2010

 

Casa da Palavra

A Terceira margem do Rio

(Guimarães Rosa )

Nosso pai era homem cumpridor, ordeiro, positivo; e sido assim desde mocinho e menino, pelo que testemunharam as diversas sensatas pessoas, quando indaguei a informação. Do que eu mesmo me alembro, ele não figurava mais estúrdio nem mais triste do que os outros, conhecidos nossos. Só quieto. Nossa mãe era quem regia, e que ralhava no diário com a gente — minha irmã, meu irmão e eu. Mas se deu que, certo dia, nosso pai mandou fazer para si uma canoa.Era a sério. Encomendou a canoa especial, de pau de vinhático, pequena, mal com a tabuinha da popa, como para caber justo o remador. Mas teve de ser toda fabricada, escolhida forte e arqueada em rijo, própria para dever durar na água por uns vinte ou trinta anos. Nossa mãe jurou muito contra a idéia. Seria que, ele, que nessas artes não vadiava, se ia propor agora para pescarias e caçadas? Nosso pai nada não dizia. Nossa casa, no tempo, ainda era mais próxima do rio, obra de nem quarto de légua: o rio por aí se estendendo grande, fundo, calado que sempre. Largo, de não se poder ver a forma da outra beira. E esquecer não posso, do dia em que a canoa ficou pronta.Sem alegria nem cuidado, nosso pai encalcou o chapéu e decidiu um adeus para a gente. Nem falou outras palavras, não pegou matula e trouxa, não fez a alguma recomendação. Nossa mãe, a gente achou que ela ia esbravejar, mas persistiu somente alva de pálida, mascou o beiço e bramou: — "Cê vai, ocê fique, você nunca volte!" Nosso pai suspendeu a resposta. Espiou manso para mim, me acenando de vir também, por uns passos. Temi a ira de nossa mãe, mas obedeci, de vez de jeito. O rumo daquilo me animava, chega que um propósito perguntei: — "Pai, o senhor me leva junto, nessa sua canoa?" Ele só retornou o olhar em mim, e me botou a bênção, com gesto me mandando para trás. Fiz que vim, mas ainda virei, na grota do mato, para saber. Nosso pai entrou na canoa e desamarrou, pelo remar. E a canoa saiu se indo — a sombra dela por igual, feito um jacaré, comprida longa.Nosso pai não voltou. Ele não tinha ido a nenhuma parte. Só executava a invenção de se permanecer naqueles espaços do rio, de meio a meio, sempre dentro da canoa, para dela não saltar, nunca mais. A estranheza dessa verdade deu para. estarrecer de todo a gente. Aquilo que não havia, acontecia. Os parentes, vizinhos e conhecidos nossos, se reuniram, tomaram juntamente conselho.Nossa mãe, vergonhosa, se portou com muita cordura; por isso, todos pensaram de nosso pai a razão em que não queriam falar: doideira. Só uns achavam o entanto de poder também ser pagamento de promessa; ou que, nosso pai, quem sabe, por escrúpulo de estar com alguma feia doença, que seja, a lepra, se desertava para outra sina de existir, perto e longe de sua família dele. As vozes das notícias se dando pelas certas pessoas — passadores, moradores das beiras, até do afastado da outra banda — descrevendo que nosso pai nunca se surgia a tomar terra, em ponto nem canto, de dia nem de noite, da forma como cursava no rio, solto solitariamente. Então, pois, nossa mãe e os aparentados nossos, assentaram: que o mantimento que tivesse, ocultado na canoa, se gastava; e, ele, ou desembarcava e viajava s'embora, para jamais, o que ao menos se condizia mais correto, ou se arrependia, por uma vez, para casa.No que num engano. Eu mesmo cumpria de trazer para ele, cada dia, um tanto de comida furtada: a idéia que senti, logo na primeira noite, quando o pessoal nosso experimentou de acender fogueiras em beirada do rio, enquanto que, no alumiado delas, se rezava e se chamava. Depois, no seguinte, apareci, com rapadura, broa de pão, cacho de bananas. Enxerguei nosso pai, no enfim de uma hora, tão custosa para sobrevir: só assim, ele no ao-longe, sentado no fundo da canoa, suspendida no liso do rio. Me viu, não remou para cá, não fez sinal. Mostrei o de comer, depositei num oco de pedra do barranco, a salvo de bicho mexer e a seco de chuva e orvalho. Isso, que fiz, e refiz, sempre, tempos a fora. Surpresa que mais tarde tive: que nossa mãe sabia desse meu encargo, só se encobrindo de não saber; ela mesma deixava, facilitado, sobra de coisas, para o meu conseguir. Nossa mãe muito não se demonstrava.Mandou vir o tio nosso, irmão dela, para auxiliar na fazenda e nos negócios. Mandou vir o mestre, para nós, os meninos. Incumbiu ao padre que um dia se revestisse, em praia de margem, para esconjurar e clamar a nosso pai o 'dever de desistir da tristonha teima. De outra, por arranjo dela, para medo, vieram os dois soldados. Tudo o que não valeu de nada. Nosso pai passava ao largo, avistado ou diluso, cruzando na canoa, sem deixar ninguém se chegar à pega ou à fala. Mesmo quando foi, não faz muito, dos homens do jornal, que trouxeram a lancha e tencionavam tirar retrato dele, não venceram: nosso pai se desaparecia para a outra banda, aproava a canoa no brejão, de léguas, que há, por entre juncos e mato, e só ele conhecesse, a palmos, a escuridão, daquele.A gente teve de se acostumar com aquilo. Às penas, que, com aquilo, a gente mesmo nunca se acostumou, em si, na verdade. Tiro por mim, que, no que queria, e no que não queria, só com nosso pai me achava: assunto que jogava para trás meus pensamentos. O severo que era, de não se entender, de maneira nenhuma, como ele agüentava. De dia e de noite, com sol ou aguaceiros, calor, sereno, e nas friagens terríveis de meio-do-ano, sem arrumo, só com o chapéu velho na cabeça, por todas as semanas, e meses, e os anos — sem fazer conta do se-ir do viver. Não pojava em nenhuma das duas beiras, nem nas ilhas e croas do rio, não pisou mais em chão nem capim. Por certo, ao menos, que, para dormir seu tanto, ele fizesse amarração da canoa, em alguma ponta-de-ilha, no esconso. Mas não armava um foguinho em praia, nem dispunha de sua luz feita, nunca mais riscou um fósforo. O que consumia de comer, era só um quase; mesmo do que a gente depositava, no entre as raízes da gameleira, ou na lapinha de pedra do barranco, ele recolhia pouco, nem o bastável. Não adoecia? E a constante força dos braços, para ter tento na canoa, resistido, mesmo na demasia das enchentes, no subimento, aí quando no lanço da correnteza enorme do rio tudo rola o perigoso, aqueles corpos de bichos mortos e paus-de-árvore descendo — de espanto de esbarro. E nunca falou mais palavra, com pessoa alguma. Nós, também, não falávamos mais nele. Só se pensava. Não, de nosso pai não se podia ter esquecimento; e, se, por um pouco, a gente fazia que esquecia, era só para se despertar de novo, de repente, com a memória, no passo de outros sobressaltos.Minha irmã se casou; nossa mãe não quis festa. A gente imaginava nele, quando se comia uma comida mais gostosa; assim como, no gasalhado da noite, no desamparo dessas noites de muita chuva, fria, forte, nosso pai só com a mão e uma cabaça para ir esvaziando a canoa da água do temporal. Às vezes, algum conhecido nosso achava que eu ia ficando mais parecido com nosso pai. Mas eu sabia que ele agora virara cabeludo, barbudo, de unhas grandes, mal e magro, ficado preto de sol e dos pêlos, com o aspecto de bicho, conforme quase nu, mesmo dispondo das peças de roupas que a gente de tempos em tempos fornecia.Nem queria saber de nós; não tinha afeto? Mas, por afeto mesmo, de respeito, sempre que às vezes me louvavam, por causa de algum meu bom procedimento, eu falava: — "Foi pai que um dia me ensinou a fazer assim..."; o que não era o certo, exato; mas, que era mentira por verdade. Sendo que, se ele não se lembrava mais, nem queria saber da gente, por que, então, não subia ou descia o rio, para outras paragens, longe, no não-encontrável? Só ele soubesse. Mas minha irmã teve menino, ela mesma entestou que queria mostrar para ele o neto. Viemos, todos, no barranco, foi num dia bonito, minha irmã de vestido branco, que tinha sido o do casamento, ela erguia nos braços a criancinha, o marido dela segurou, para defender os dois, o guarda-sol. A gente chamou, esperou. Nosso pai não apareceu. Minha irmã chorou, nós todos aí choramos, abraçados.Minha irmã se mudou, com o marido, para longe daqui. Meu irmão resolveu e se foi, para uma cidade. Os tempos mudavam, no devagar depressa dos tempos. Nossa mãe terminou indo também, de uma vez, residir com minha irmã, ela estava envelhecida. Eu fiquei aqui, de resto. Eu nunca podia querer me casar. Eu permaneci, com as bagagens da vida. Nosso pai carecia de mim, eu sei — na vagação, no rio no ermo — sem dar razão de seu feito. Seja que, quando eu quis mesmo saber, e firme indaguei, me diz-que-disseram: que constava que nosso pai, alguma vez, tivesse revelado a explicação, ao homem que para ele aprontara a canoa. Mas, agora, esse homem já tinha morrido, ninguém soubesse, fizesse recordação, de nada mais. Só as falsas conversas, sem senso, como por ocasião, no começo, na vinda das primeiras cheias do rio, com chuvas que não estiavam, todos temeram o fim-do-mundo, diziam: que nosso pai fosse o avisado que nem Noé, que, por tanto, a canoa ele tinha antecipado; pois agora me entrelembro. Meu pai, eu não podia malsinar. E apontavam já em mim uns primeiros cabelos brancos.Sou homem de tristes palavras. De que era que eu tinha tanta, tanta culpa? Se o meu pai, sempre fazendo ausência: e o rio-rio-rio, o rio — pondo perpétuo. Eu sofria já o começo de velhice — esta vida era só o demoramento. Eu mesmo tinha achaques, ânsias, cá de baixo, cansaços, perrenguice de reumatismo. E ele? Por quê? Devia de padecer demais. De tão idoso, não ia, mais dia menos dia, fraquejar do vigor, deixar que a canoa emborcasse, ou que bubuiasse sem pulso, na levada do rio, para se despenhar horas abaixo, em tororoma e no tombo da cachoeira, brava, com o fervimento e morte. Apertava o coração. Ele estava lá, sem a minha tranqüilidade. Sou o culpado do que nem sei, de dor em aberto, no meu foro. Soubesse — se as coisas fossem outras. E fui tomando idéia.Sem fazer véspera. Sou doido? Não. Na nossa casa, a palavra doido não se falava, nunca mais se falou, os anos todos, não se condenava ninguém de doido. Ninguém é doido. Ou, então, todos. Só fiz, que fui lá. Com um lenço, para o aceno ser mais. Eu estava muito no meu sentido. Esperei. Ao por fim, ele apareceu, aí e lá, o vulto. Estava ali, sentado à popa. Estava ali, de grito. Chamei, umas quantas vezes. E falei, o que me urgia, jurado e declarado, tive que reforçar a voz: — "Pai, o senhor está velho, já fez o seu tanto... Agora, o senhor vem, não carece mais... O senhor vem, e eu, agora mesmo, quando que seja, a ambas vontades, eu tomo o seu lugar, do senhor, na canoa!..." E, assim dizendo, meu coração bateu no compasso do mais certo.Ele me escutou. Ficou em pé. Manejou remo n'água, proava para cá, concordado. E eu tremi, profundo, de repente: porque, antes, ele tinha levantado o braço e feito um saudar de gesto — o primeiro, depois de tamanhos anos decorridos! E eu não podia... Por pavor, arrepiados os cabelos, corri, fugi, me tirei de lá, num procedimento desatinado. Porquanto que ele me pareceu vir: da parte de além. E estou pedindo, pedindo, pedindo um perdão.Sofri o grave frio dos medos, adoeci. Sei que ninguém soube mais dele. Sou homem, depois desse falimento? Sou o que não foi, o que vai ficar calado. Sei que agora é tarde, e temo abreviar com a vida, nos rasos do mundo. Mas, então, ao menos, que, no artigo da morte, peguem em mim, e me depositem também numa canoinha de nada, nessa água que não pára, de longas beiras: e, eu, rio abaixo, rio a fora, rio a dentro — o rio.

 

Salon

Enemy Combatants


Glenn Greenwald writes at Salon.com:

The most recent liberty-abridging, Terrorism-justified controversies have focused on diluting the legal rights of American citizens (in part because the rights of non-citizens are largely gone already and there are none left to attack). A bipartisan group from Congress sponsors legislation to strip Americans of their citizenship based on Terrorism accusations. Barack Obama claims the right to assassinate Americans far from any battlefield and with no due process of any kind. The Obama administration begins covertly abandoning long-standing Miranda protections for American suspects by vastly expanding what had long been a very narrow "public safety" exception, and now Eric Holder explicitly advocates legislation to codify that erosion. John McCain and Joe Lieberman introduce legislation to bar all Terrorism suspects, including Americans arrested on U.S. soil, from being tried in civilian courts, and former Bush officials Bill Burck and Dana Perino -- while noting (correctly) that Holder's Miranda proposal constitutes a concession to the right-wing claim that Miranda is too restrictive -- today demand that U.S. citizens accused of Terrorism and arrested on U.S. soil be treated as enemy combatants and thus denied even the most basic legal protections (including the right to be charged and have access to a lawyer).
This shift in focus from non-citizens to citizens is as glaring as it is dangerous. As Digby put it last week:
The frighting reality is that not even Dick Cheney thought of stripping Americans of their citizenship so that you could torture and imprison them forever --- even right after 9/11 when the whole country was petrified and he could have gotten away with anything. You'll recall even John Walker Lindh, who was literally captured on the battlefield fighting with the Taliban, was tried in civilian court. They even read him his rights.
I think this says something fairly alarming about the current state of our politics.
There is, of course, no moral difference between subjecting citizens and non-citizens to abusive or tyrannical treatment. But as a practical matter, the dangers intensify when the denial of rights is aimed at a government's own population. The ultimate check on any government is its own citizenry; vesting political leaders with oppressive domestic authority uniquely empowers them to avoid accountability and deter dissent. It's one thing for a government to spy on other countries (as virtually every nation does); it's another thing entirely for them to direct its surveillance apparatus inward and spy on its own citizens. Alarming assaults on basic rights become all the more alarming when the focus shifts to the domestic arena.

Tuesday, May 04, 2010

 

Mind over Meds

April 19, 2010

Mind Over Meds

By DANIEL CARLAT

One day several years ago, I was reaching the end of my first visit with a patient, J.J., who had come to see me for anxiety and insomnia. He was a salesman for a struggling telecommunications company, and he was having trouble managing the strain on his finances and his family. He was sleeping poorly, and as soon as he opened his eyes in the early morning, the worries began. “I wake up with a list of things to worry about,” he said. “I just go through the list, and it seems to get longer every day.”
A psychiatric interview has a certain rhythm to it. You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others. As I listened to J.J. (a nickname that he agreed I could use to protect his privacy), it was clear to me that he had one of the anxiety disorders, but which one? In order to systematically rule in or rule out the disorders, I asked J.J. dozens of questions. “Do you have panic attacks?” “Do you get fearful in crowded situations?” “Have you ever experienced a traumatic event that later caused flashbacks or nightmares?”
Each of J.J.’s answers provided me with a clue, closing off one possibility while opening up others. At its best, when you are working with an intelligent, insightful patient, the process is fun, involving a series of logical calculations, much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt confident that I had arrived at J.J.’s diagnosis. “I think you have what we call ‘generalized anxiety disorder,’ ” I told him. It may start with a defined series of causes, as was true for J.J., but then it spirals outward, blanketing the world with potential threat. J.J. worried about what the future would bring and experienced a predictable series of physical symptoms: insomnia, muscle tension, irritability and poor concentration.
“I’m going to write you a prescription for a medication called Zoloft,” I said, picking up my prescription pad. He asked what was causing his anxiety, and I began one of the stock neurochemical explanations that psychiatrists typically offer patients about low serotonin levels in the brain. The treatment involved “filling up the tank” by prescribing a medication like Zoloft, Celexa or Paxil.
“So Dr. Freud, the causes are all in the brain? Isn’t there some explanation in my childhood?” It was a good-natured tease.
“I specialize in prescribing medications,” I said with a smile. I was a psychopharmacologist and specialized in medication rather than psychotherapy. “I can refer you to a good therapist in the area if you’d like.”
After J.J. left my office, I realized, uncomfortably, that somehow, over the course of the decade following my residency, my way of thinking about patients had veered away from psychological curiosity. Instead, I had come to focus on symptoms, as if they were objective medical findings, much the way internists view blood-pressure readings or potassium levels. Psychiatry, for me and many of my colleagues, had become a process of corralling patients’ symptoms into labels and finding a drug to match.
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. J.J., I saw, had inadvertently highlighted a glaring deficiency in much of modern psychiatry. Ultimately, his question would change the way I thought about my field, and how I practiced.
I originally became interested in psychiatry primarily because of my father: he is a psychiatrist practicing in San Francisco. But there was a darker side to my career choice. My mother suffered severe mental illness, with debilitating depressions and paranoid thoughts. One autumn day during my junior year in college, she committed suicide. Psychiatry then became personal, a way for me to come to terms with her illness.
I majored in psychology at U.C. Berkeley, and at U.C. San Francisco I labored through medical school’s rites of passage in order to qualify for a psychiatric residency. Eventually, on a steamy July day in 1992, I stood on a Boston street, far from home, gazing at Massachusetts General Hospital (known as M.G.H.), where I was about to start my training.
This was a momentous time at M.G.H. Prozac was introduced four years earlier and became the best-selling psychiatric medication of all time. Zoloft and Paxil, two similar medications, were in the pipeline, and many of the key clinical trials for these antidepressants were conducted by psychiatrists at M.G.H. who were to become my mentors. M.G.H. and other top programs were enthralled with neurobiology, the new medications and the millions of dollars in industry grants that accompanied them. It was hard not to get caught up in the excitement of the drug approach to treatment. Psychopharmacology was infinitely easier to master than therapy, because it involved a teachable, systematic method. First, we memorized the DSM criteria for the major disorders, then we learned how to ask the patient the right questions, then we pieced together a diagnosis and finally we matched a medication with the symptoms.
But learning the formal techniques of therapy was like navigating without a compass. While I learned how to form an alliance with my patients and begin a good dialogue, becoming a skillful therapist requires much more practice than busy psychiatry residencies allow.
When my father did his residency at U.C.S.F. in the 1950s, he learned therapy well, because, with few medications available, it was the main treatment psychiatrists could offer their patients. Psychiatric residencies focused on therapy, and many residents extended their training further by enrolling in postgraduate psychoanalytic institutes. When modern medications came on the scene, my father adapted by incorporating them into his therapy practice, as did many of his colleagues. I call this the “golden” generation of psychiatrists, those currently approaching retirement age, who were skilled at offering the full package of effective psychiatric treatments to patients.
The newer generation of psychiatrists, who graduated in the 1980s and afterward, trained in programs that were increasingly skeptical of therapy and that emphasized a focus on medications. M.G.H. was by far the most influential of these modern programs. Graduates of the M.G.H. program and its sister program at nearby McLean Hospital have fanned out throughout the country, becoming chairmen of departments and leaders of the National Institute of Mental Health.
A result is that 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 trend was most recently documented by Ramin Mojtabai and Mark Olfson, two psychiatric epidemiologists who found that the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent.
While it is tempting to blame only the biologically oriented psychiatrists for this shift, that would be simplistic. Other forces are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?
In fact, during my 15-to-20-minute medication visits with patients, I was often gratified by the effectiveness of the medications I prescribed. For perhaps a quarter of them, medications worked so well as to be nearly miraculous. But over time I realized that the majority of patients need more. One young woman I saw was referred to me by a nurse practitioner for treatment of depression that had not responded to several past antidepressants. She was struggling to raise two young children and was worried that she was doing a poor job of it. Her husband worked full time and was rarely available to help. She cried throughout our initial interview. I started her on Effexor and referred her to a social-worker colleague. She improved initially, but over the years since, her symptoms have waxed and waned. When she reports a worsening of her anxiety or depression, my first instinct is to do one of three things — switch medications, increase her dosage or add another. Over the course of 15 or 20 minutes, this is about all I can offer.
My treatment of this young woman follows the “split treatment” model, but a less charitable description is “fragmented care.” Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.
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.
Like placebo, psychotherapy has typically been considered a “nonbiological” treatment, but it has become clear that therapy, like placebo, also leads to measurable changes in the brain. In 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.
In depression treatment, too, pills and therapy each lead to brain changes, but in this case they appear to be intriguingly distinct. In studies by Helen Mayberg, a professor of psychiatric neurology at Emory University, depressed patients given cognitive behavior therapy showed decreased activity in the frontal lobe, the brain center that might be responsible for the overmagnification of life’s problems that leads to depression in some patients. And they showed increased brain activity in parts of the limbic system, a brain region associated with strong emotion. But Mayberg found that when patients were given medication, their brain activities changed in the opposite direction, stimulating the frontal lobe and damping down the limbic system. “Our imaging results suggest that you can correct the depression network along a variety of pathways,” she said.
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.
After I saw J.J., I decided that I wanted to try to change my approach to treatment. I gradually began to carve out room in my schedule for longer visits with my patients. I endeavored to do what’s called “supportive” therapy, a technique favored by many therapists and involving basic problem solving and emotional support. It is a bit like what a friend would do for another friend offering advice in times of trouble, but more elaborate and with an accompanying raft of studies endorsing its effectiveness in psychiatry.
When I started to probe my patients, I realized I barely knew most of them. I had exuberantly documented their moods, sleep habits, energy levels and whether they had suicidal thoughts, but I didn’t know what made them tick as people. For example, I had treated Jane (her middle name), a health care administrator in her 40s, for depression and bulimia for many years, focusing on a complicated combination of medications like Effexor, Provigil and Xanax. Then she had a depressive relapse. This time, rather than simply adjusting her medication, I asked her what was going on in her life. I found out that her boss had recently given her an impossible assignment to complete and had berated her when the results were not to his liking. It seemed clear to me that her depression was partly triggered by the fact that she blamed herself for her boss’s poor communication skills and managerial lapses. I encouraged her to question that assumption each time it popped into her mind. Over the next few visits, she improved — relating better to her boss, able to take his criticism with a grain of salt and feeling more confident.
But while my simple therapeutic suggestions were helpful, as Jane and I continued to explore her work issues in detail, she said that she often lacked focus on the job. Knowing that poor concentration can be a symptom of depression, I asked if she associated her distractibility with periods of sadness. But she said there was no such correlation with her moods.
I wondered if she might have an adult version of attention deficit disorder. Indeed, carefully reviewing her years in school, I saw she was always easily distracted but overcame this problem by working extra hard, and managed to achieve good grades. Even now, her job performance was consistently rated as excellent, but the extra work this entailed sapped her energy.
I decided to prescribe her a version of Ritalin, the standard treatment for A.D.D. The next month, she said she felt that this medication had turned her life around. Not only did she feel more focused and productive at work, but she was more apt to get things done at home, which in turn enhanced her mood, indirectly improving her depression.
Is Jane’s story an argument for psychiatrists providing both medication and some sort of psychotherapy? I think it is. This does not mean that dedicated psychotherapists are not crucial — they are, because they can provide the in-depth therapy that psychopharmacologists will never have time to deliver. When our patients need more from us than just medication, however, we should be prepared to provide it. Oddly, managed-care companies discourage us from doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-minute medication visits every three months and to hire a lower paid non-M.D. for more frequent therapy visits. But the few studies that have analyzed the economics of these arrangements have found that integrated treatment actually saves money. Mantosh Dewan, the chairman of psychiatry at SUNY Upstate Medical University in Syracuse, found that when psychiatrists do both medication and psychotherapy, the overall amount of money paid out by insurance companies is actually less than when the treatment is split between psychiatrists and psychotherapists. When patients see only one provider, they require fewer visits overall.
It may be time to consider whether the term “psychopharmacologist” is actually doing damage to the field of psychiatry. The American Society of Clinical Psychopharmacology defines “psychopharmacology” on its Web site as “the study of the use of medications in treating mental disorders.” But in a recent article, three Harvard psychiatrists (interestingly, two of them from Mass General) have pointed out that no other medical specialty has carved out a separate “pharmacology”subspecialty. Good doctoring, they remind us, involves perfecting all the skills relevant to healing and deploying them when needed.
During my mother’s last months, she isolated herself from her family, so I don’t know what kind of treatment she was receiving before her death. But I do know what kind of treatment I would have hoped for her. She needed medication to combat her paranoia and the emotional pain of her depression. She needed someone who could expertly probe her thought process, in order to understand the fateful logic that led her to conclude that the only solution was to end her own life. She needed treatment that was intensive and exquisitely coordinated.
Such care is not always capable of saving damaged lives. But it is the best that we can do. It’s what we owe our patients — and ourselves.
Daniel Carlat is an associate clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report. His book, “Unhinged: the Trouble With Psychiatry,” will be published in May.

Monday, May 03, 2010

 

More Api - Arguments Convince Nobody - Borges

“Merely a Man of Letters”
Jorge Luis Borges: an interview
Philosophy and Literature 1 (1977): 337-41.
www.denisdutton.com
On April 14, 1976, Denis Dutton and Michael Palencia-Roth, both editors of Philosophy and Literature, along with their colleague, Lawrence I. Berkove of the University of Michigan – Dearborn, interviewed Jorge Luis Borges at Michigan State University, where he was visiting professor for the winter term. The transcript below contains the central and substantive portions of that conversation, which was conducted in English. It has recently been re-edited for greater detail and accuracy from a newly digitized version of the 1976 recording. This Philosophy and Literature interview is made available online here for the first time.

You may listen to an MP3 file of the original conversation HERE. Listening time is just over fifteen minutes.

Denis Dutton: Why don’t you tell us about some of the philosophers who have influenced your work, in whom you’ve been the most interested?
Jorge Luis Borges: Well, I think that’s an easy one. I think you might talk in terms of two: those would be Berkeley and Schopenhauer. But I suppose Hume might be worked in also, because, after all, of course Hume refutes Berkeley. But really, he comes from Berkeley — even if Berkeley comes from Locke. You might think of Locke, of Berkeley, and of Hume as being three links in an argument. But when somebody refutes somebody else in philosophy, he’s carrying on the argument.
Michael Palencia-Roth: Where would Schopenhauer come in?
Borges: Schopenhauer is very different from Hume. Of course, Schopenhauer had his idea of the Will. That is not to be found in Hume. But of course in the case of Berkeley it is different. I suppose he thought of God as being aware of all things all the time, I mean if I don’t get him wrong. If we go away, does this room disappear? No, it doesn’t, of course, because God is thinking about it.
Jorge Luis Borges, mid-1970s
Now, in the case of Schopenhauer, I was rereading Die Welt als Wille und Vorstellung, The World as Will and Idea, and I was rather taken aback, or rather baffled I should say, or puzzled by something that keeps on recurring in Schopenhauer. Of course it may have been a slip of the pen, but as he goes back to it, and as he was a very careful writer, I wonder if it is a slip of the pen. Well, for example, Schopenhauer begins by saying that all this, the universe, the stars, the spaces in between, the planets, this planet, those things have no existence, except in the mind which perceives them — no?
MP-R: Yes.
Borges: But then, to my surprise — and I suppose you can explain this to me, since you are philosophers and I am not — what Schopenhauer says is that all those things have no existence except in the brain. And that the universe — I remember these words, I don’t think I’m inventing them now — “ist ein Gehirnphänomen,” that the world is a cerebral phenomenon. Now, when I read that I was baffled. Because, of course, if you think of the universe, I suppose the brain is as much a part of the external world as the stars or the moon. Because the brain after all is a system of — I don’t know — of visual, of tactile, perceptions. But he keeps on insisting on the brain.
MP-R: Yes.
Borges: But I don’t think, for example, that Bishop Berkeley insists on the brain, or Hume, who would have insisted on the mind, consciousness….
DD: People sometimes say that they see Berkeley in stories like “Orbis Tertius.”
Borges: Yes, I suppose they do. Well, of course. But in that story I was led by literary means also.
DD: How do you distinguish the literary from the philosophical means in that story? Could you explain that?
Borges: Oh, well, yes, I’ll explain very easily…. Encyclopedias have been, I’d say, my life’s chief reading. I have always been interested in encyclopedias. Well, I used to go to the Biblioteca Nacional in Buenos Aires — and since I was so shy, I felt I could not cope with asking for a book, or a librarian, so I looked on the shelves for the Encyclopædia Britannica. Of course, afterwards, I had that book at home, by my hand. And then I would pick up any chance volume and I would read it. And then one night I was richly rewarded, because I read all about the Druses, Dryden, and the Druids — a treasure trove, no? — all in the same volume, of course, “Dr–.”
Then I came to the idea of how fine it would be to think of an encyclopedia of an actual world, and then of an encyclopedia, a very rigorous one of course, of an imaginary world, where everything should be linked. Where, for example, you would have, let’s say, a language and then a literature that went with the language, and then a history with it, and so on. Then I thought, well, I’d write a story of the fancy encyclopedia. Then of course that would need many different people to write it, to get together and to discuss many things — the mathematicians, philosophers, men of letters, architects, engineers, then also novelists or historians. Then, as I needed a quite different world from ours — it wasn’t enough to invent fancy names — I said, why not a world based on, let’s say, Berkeleyan ideas?
DD: A world in which Berkeley is common sense instead of Descartes?
Borges: Yes, that’s it. Then I wrote that story, “Tlön, Uqbar, Orbis Tertius” that day, which has attracted many readers. And of course, the whole thing was based on the theory of idealism, the idea of there being no things but only happenings, of there being no nouns but only verbs, of there being no things but only perceptions.…
Lawrence I. Berkove: “Tlön” is a good example of one of your stories where, however the story ends, the reader is encouraged to continue applying your ideas.
Borges: Well, I hope so. But I wonder if they are my ideas. Because really I am not a thinker. I have used the philosophers’ ideas for my own private literary purposes, but I don’t think that I’m a thinker. I suppose that my thinking has been done for me by Berkeley, by Hume, by Schopenhauer, by Mauthner perhaps.
MP-R: You say you’re not a thinker…
Borges: No, what I mean to say is that I have no personal system of philosophy. I never attempt to do that. I am merely a man of letters. In the same way, for example that — well, of course, I shouldn’t perhaps choose this as an example — in the same way that Dante used theology for the purpose of poetry, or Milton used theology for the purposes of his poetry, why shouldn’t I use philosophy, especially idealistic philosophy — philosophy to which I was attracted — for the purposes of writing a tale, of writing a story? I suppose that is allowable, no?
DD: You share one thing certainly with philosophers, and that is a fascination with perplexity, with paradox.
Borges: Oh yes, of course — well I suppose philosophy springs from our perplexity. If you’ve read what I may be allowed to call “my works” — if you’ve read my sketches, whatever they are — you’d find that there is a very obvious symbol of perplexity to be found all the time, and that is the maze. I find that a very obvious symbol of perplexity. A maze and amazement go together, no? A symbol of amazement would be the maze.
DD: But philosophers seem not content ever to merely be confronted with perplexity, they want answers, systems.
Borges: Well, they’re right.
DD: They’re right?
Borges: Well, perhaps no systems are attainable, but the search for a system is very interesting.
MP-R: Would you call your work a search for a system?
Borges: No, I wouldn’t be as ambitious as all that. I would call it, well, not science fiction, but rather the fiction of philosophy, or the fiction of dreams. And also, I’m greatly interested in solipsism, which is only an extreme form of idealism. It is strange, though, that all the people who write on solipsism write about it in order to refute it. I haven’t seen a single book in favor of solipsism. I know what you would want to say: since there is only one dreamer, why do you write a book? But if there is only one dreamer, why could you not dream about writing a book?
DD: Bertrand Russell once suggested that all the solipsists ought to get together and form a solipsist association.
Borges: Yes, he wrote very cleverly about solipsism. And so did Bradley in his Appearance and Reality. And then I read a book called Il Solipsismo by an Italian writer, where he says that the whole system is a proof of the egoism, of the selfishness of this period. That’s idiotic. I’ve never thought of solipsism in that way.
MP-R: How do you think of solipsism?
Borges: Well, I suppose that solipsism is unavoidable.
MP-R: Avoidable or unavoidable?
Borges : I should say, it’s unavoidable in a logical way, since nobody can believe in it. It is a bit like what Hume says of Berkeley: “His arguments admit of no refutation and produce no conviction.” Solipsism admits of no refutation and produces no conviction….
DD: Do you think that it is possible then for a story to represent a philosophical position more effectively than a philosopher can argue for it?
Borges: I have never thought of that, but I suppose you’re right, Sir. I suppose you — yes, yes, I think you’re right. Because as — I don’t know who said that, was it Bernard Shaw? — he said, arguments convince nobody. No, Emerson. He said, arguments convince nobody. And I suppose he was right, even if you think of proofs for the existence of God, for example — no? In that case, if arguments convince nobody, a man may be convinced by parables or fables or what? Or fictions. Those are far more convincing than the syllogism — and they are, I suppose. Well, of course, when I think of something in terms of Jesus Christ. As far as I remember, he never used arguments; he used style, he used certain metaphors. It’s very strange — yes, and he always used very striking sentences. He would not say, I don’t come to bring peace but war — “I do not come to bring peace but a sword.” The Christ, he thought in parables. Well, according to — I think that it was Blake who said that a man should be — I mean, if he is a Christian — should be not only just but he should be intelligent ... he should also be an artist, since Christ had been teaching art through his own way of preaching, because every one of the sentences of Christ, if not every single utterance of Christ, has a literary value, and may be thought of as a metaphor or as a parable.
DD: What do you think ultimately, then, separates the philosophical from the literary temperament, if they share these things in common?
Borges: I suppose a philosopher goes in for a rigorous way of thinking, and I suppose a writer is also interested in narratives, he’s telling tales, with metaphors.
MP-R: Can a narrative, especially a short narrative, be rigorous in a philosophical sense?
Borges: I suppose it could be. Of course, in that case it would be a parable. I remember when I read a biography of Oscar Wilde by Hesketh Pearson. Then there was a long discussion going on about predestination and free will. And he asked Wilde what he made of free will. Then he answered in a story. The story seemed somewhat irrelevant, but it wasn’t. He said — yes, yes, yes, some nails, pins, and needles lived in the neighborhood of a magnet, and one of them said, “I think we should pay a visit to the magnet.” And the other said, “I think it is our duty to visit the magnet.” The other said, “This must be done right now. No delay can be allowed.” Then when they were saying those things, without being aware of it, they were all rushing towards the magnet, who smiled because he knew that they were coming to visit him. You can imagine a magnet smiling. You see, there Wilde gave his opinion, and his opinion was that we think we are free agents, but of course we’re not….
But I would like to make it clear that if any ideas are to be found in what I write, those ideas came after the writing. I mean, I began by the writing, I began by the story, I began with the dream, if you want to call it that. And then afterwards, perhaps, some idea came of it. But I didn’t begin, as I say, by the moral and then writing a fable to prove it.
****
This ends the recorded portion of the conversation with Borges, though that conversation began earlier and also continued for several minutes more in the room, as well as later over lunch.


Copyright 1977 © The Johns Hopkins University Press. All rights reserved.

 

Untimely Death - NYT Obit

April 26, 2010

Alice Miller, Psychoanalyst, Dies at 87; Laid Human Problems to Parental Acts

By WILLIAM GRIMES
Alice Miller, a psychoanalyst who repositioned the family as a locus of dysfunction with her theory that parental power and punishment lay at the root of nearly all human problems, died at her home in Provence on April 14. She was 87.
Her death was announced Friday by her German publisher, Suhrkamp Verlag.
Dr. Miller caused a sensation with the English publication in 1981 of her first book, “The Drama of the Gifted Child.” Originally titled “Prisoners of Childhood,” it set forth, in three essays, a simple but harrowing proposition. All children, she wrote, suffer trauma and permanent psychic scarring at the hands of parents, who enforce codes of conduct through psychological pressure or corporal punishment: slaps, spankings or, in extreme cases, sustained physical abuse and even torture.
Unable to admit the rage they feel toward their tormenters, Dr. Miller contended, these damaged children limp along through life, weighed down by depression and insecurity, and pass the abuse along to the next generation, in an unending cycle. Some, in a pathetic effort to please their parents and serve their needs, distinguish themselves in the arts or professions. The Stalins and the Hitlers, Dr. Miller later wrote, inflict their childhood traumas on millions.
“The Drama of the Gifted Child” struck a chord with mental health professionals. “Clinically, she is almost as influential as R.D. Laing,” the British psychologist Oliver James told The Observer of London in 2005. “Alice Miller changed the way people thought.”
The book also stirred the general public, selling more than a million copies. Its central argument was easy to grasp and, for many readers, offered a tempting explanation for their sorrows and failures.
Dr. Miller is often credited with turning the attention of therapists to child abuse, both physical and sexual, but also with encouraging millions of adults to regard themselves as victims.
Daphne Merkin, assessing Dr. Miller’s book “The Truth Shall Set You Free” in The New York Times Book Review in 2002, wrote that Dr. Miller “could be said to be the missing link between Freud and Oprah, bringing news of the inner life, and especially the subtle hazards of emotional development, out of the cloistered offices of therapists and into a wider, user-friendly context.”
Dr. Miller further developed her ideas in two books published immediately after “The Drama of the Gifted Child’: “For Your Own Good: Hidden Cruelty in Child-Rearing and the Roots of Violence” (1983) and “Thou Shalt Not Be Aware: Society’s Betrayal of the Child” (1984). She applied her theory of childhood development to explain the passivity of the German people in the face of Nazi tyranny and took aim at Freud, whose theories, she believed, cast parents as innocents and children as depraved.
Often she used prominent artists as her case studies. In “The Untouched Key” (1990), she held up Friedrich Nietzsche, Pablo Picasso, Kathe Kollwitz and Buster Keaton as illustrations of her theories. In “The Body Never Lies: The Lingering Effects of Cruel Parenting” (2005), she put Dostoyevsky, Proust and Joyce under the microscope.
Alice Miller was famously reclusive, and deliberately kept details of her early life sketchy. She was born in Lwow, Poland (now Lviv, Ukraine), on Jan. 12, 1923. She studied philosophy and literature at the University of Warsaw, which operated underground during the war.
After the war, a Swiss charity arranged for her to continue her studies at the University of Basel, where she wrote her dissertation on the neo-Kantian philosopher Heinrich Rickert and received a doctorate in 1953.
After undergoing Freudian psychiatric training in Zurich, she went into practice as an analyst. In the 1960s a wave of revisionism swept over the profession, as psychoanalysts adapted the ideas of Freud and Jung to social criticism.
Strongly influenced by the education writer Katharina Rutschky’s notion of “black pedagogy,” a term for the authoritarian style of German parenting, Dr. Miller came to view all forms of parental coercion, and even mild physical discipline or emotional coldness, as fatal to healthy psychic development. In her English books, the term is rendered as “poisonous pedagogy.”
“Humiliations, spankings and beatings, slaps in the face, betrayal, sexual exploitation, derision, neglect, etc. are all forms of mistreatment, because they injure the integrity and dignity of a child, even if their consequences are not visible right away,” she writes in an explanatory essay on childhood mistreatment and abuse on her Web site, alice-miller.com. “Beaten children very early on assimilate the violence they endured, which they may glorify and apply later as parents, in believing that they deserved the punishment and were beaten out of love.”
By the time she wrote her first book, published in German in 1979, Dr. Miller had stopped practicing psychiatry. The relationship of analyst to patient, she came to believe, replicated the insidious power relationship of parent to child. Her initial critique of Freud led to a full-scale break described in “Banished Knowledge: Facing Childhood Injuries” (1990), a semi-autobiographical work that revealed her own abuse as a child, which she discovered through paintings she created spontaneously.
“Not once did she apologize to me or express any kind of regret,” she later wrote of her mother in “The Body Never Lies.” “She was always ‘in the right.’ It was this attitude that made my childhood feel like a totalitarian regime.”
Having broken with Freud, Dr. Miller resigned from the International Psychoanalytic Association in 1988 and embraced a number of alternative therapies. She became a disciple of J. Konrad Stettbacher, an advocate of regression therapy, and expressed enthusiasm for Arthur Janov’s primal-scream approach, but soon rejected both. Over the years she became increasingly reclusive.
She is survived by a son and a daughter.
Uncompromising and often strident, Dr. Miller preached her message with an often messianic fervor and a polemical style of argument that cost her support from early admirers. The underlying precepts remained unchanged in later works like “Breaking Down the Wall of Silence” (1991) and “Free From Lies: Discovering Your True Needs” (2009).

 

Slovenia Uber Argies...

A logical paradox

Zizek writes at Lacan.com:

How is this circle of changing the past possible without recourse to travel back in time? The solution was already proposed by Henri Bergson: of course one cannot change the past reality/actuality, but what one can change is the virtual dimension of the past – when something radically New emerges, this New retroactively creates its own possibility, its own causes/conditions. [2] A potentiality can be inserted into (or withdrawn from) past reality. Falling in love changes the past: it is as if I always-already loved you, our love was destined, “answer of the real.” My present love causes the past which gave birth to it. The same goes for legal power: here also, synchrony precedes diachrony. In the same way that, once I contingently fall in love, this love was my necessary Fate, once a legal order is here, its contingent origins are erased. Once it IS here, it was always-already here, every story of its origins is a myth, like the Swift story of the origin of language in Gulliver’s Travels: the result is already presupposed.
In Vertigo, it is the opposite that occurs: the past is changed so that it loses objet a. What Scottie first experiences in Vertigo is the loss of Madeleine, his fatal love; when he recreates Madeleine in Judy and then discovers that the Madeleine he knew already was Judy pretending to be Madeleine, what he discovers is not simply that Judy is a fake (he knew that she is not the true Madeleine, since he recreated a copy of Madeleine out of her), but that, because she is NOT a fake – she IS Madeleine -, Madeleine herself was already a fake – objet a disintegrates, the very loss is lost, we get a “negation of negation.” His discovery changes the past, deprives the lost object of objet a.

Are, then, today’s ethico-legal neoconservatives not a little bit like Scottie in Hitchcock’s Vertigo: in wanting to recreate the lost order, to make a new distinguished Madeleine out of today’s promiscuous and vulgar Judy, they will be sooner or later forced to admit not that it is impossible to restore to life Madeleine (the old traditional mores), but that Madeleine WAS already Judy: the corruption they are fighting in modern permissive, secular, egotist, etc. society was there from the beginning. It is like with Zen Buddhism: those who criticize the Westernized New Age image and practice of Zen, its reduction to a “relaxation technique,” as the betrayal of the authentic Japanese Zen, obliterate the fact that the features they deplore in the Westernized Zen were already there in Japanese “true” Zen: after WWII, Japanese Zen Buddhists immediately started to organize Zen courses for business managers, during the WWII their majority supported Japanese militarism, etc.

In true love, after discovering the truth, Scottie would have accepted Judy as “more Madeleine than Madeleine herself” (he DOES that just before the rise of the mother superior…): here Dupuy should be corrected. Dupuy’s formula is that Scottie should left Madeleine to her past – true, but what should he have done upon discovering that Judy IS Madeleine? Past Madeleine was an imaginary lure, pretending to be what she was not (Judy played Madeleine). What Judy is doing now in playing Madeleine is TRUE LOVE. In Vertigo, Scottie does NOT love Madeleine – the proof is that he tries to recreate her in Judy, changing Judy’s properties to make her resemble Madeleine. This is why the idea to clone a child to parents who lost him (or her) is an abomination: if the parents are satisfied, their love was not true love – love is not love for the properties of the object, but for the abyssal X, the je ne sais quoi, in the object.

 

French Thought - Vallejo

From excellent new site Concept and Form: The Cahiers pour l'Analyse and Contemporary French Thought:

In an early draft from 1897, Freud had already begun to speculate on the specific 'structure' and 'construction' of early childhood fantasies: 'Fantasies arise from an unconscious combination, in accordance with certain trends, of things experienced and heard […] Fantasies are constructed by a process of amalgamation and distortion analogous to the decomposition of a chemical body which is compounded with another one' (SE 1: 252). During the process of construction, the original memories on which they are based disappear, leaving only the libidinal structure. The idea that fantasies were constructed step-by-step gave Freud a means of reconstructing or analysing in reverse the structure of fantasies as they presented themselves in patients. Freud returns to the idea of the 'construction' of the fantasy in his key paper on the subject 'A Child is being Beaten' (1919). He develops the idea that the fantasy may be approached from different angles, according to whether one is a subject in it, or outside it. Thus fantasy figures may express desires that are not straightforwardly those of the person having the fantasy. The dreamer may themselves be in the fantasy, or may not. If he is in it, he may be playing an active or passive role.

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