Map of life expectancy at birth from Global Education Project.

Tuesday, June 06, 2006

Dichotomous Dualistic Dilemmas

A guy I knew in college* said that the way to get an A on a paper was to begin with an irrelevant quote from Alice in Wonderland, and use the word "dichotomy" in the first paragraph. So here goes.

`Get up!' said the Queen, in a shrill, loud voice, and the three gardeners instantly jumped up, and began bowing to the King, the Queen, the royal children, and everybody else.

`Leave off that!' screamed the Queen. `You make me giddy.' And then, turning to the rose-tree, she went on, `What have you been doing here?'

`May it please your Majesty,' said Two, in a very humble tone, going down on one knee as he spoke, `we were trying--'

`I see!' said the Queen, who had meanwhile been examining the roses. `Off with their heads!' and the procession moved on, three of the soldiers remaining behind to execute the unfortunate gardeners, who ran to Alice for protection.

`You shan't be beheaded!' said Alice, and she put them into a large flower-pot that stood near. The three soldiers wandered about for a minute or two, looking for them, and then quietly marched off after the others.

`Are their heads off?' shouted the Queen.

`Their heads are gone, if it please your Majesty!' the soldiers shouted in reply.

Okay. Please don't get me wrong. I'm not anti-psychiatry. Some of my best friends are psychiatrists. Really. In fact, now that I think about it, most of my best friends are psychiatrists, or psychologists. A signficant chunk of my professional responsibility is the evaluation of mental health treatment programs. I'm in this thing up to my hippocampus. What I am doing here is trying to highlight some of the dichotomies that psychiatry wrestles with. Yesterday, it was the dichotomy between an agency of healing, and an agency of social control.

But perhaps this is a false dichotomy. Maybe they're really on a continuum. As our typically incisive commentators indicated, you can't necessarily do one without a little bit of the other.

Then there is the dichotomy between repudiating a dichotomy -- mind/body dualism -- and celebrating it, which I highlighted previously. On the one hand, Cartesian dualism is seen as archaic and unscientific. On the other hand, the concept of mind as a distinct entity is the very foundation of psychiatry. Without it, psychiatry would disappear into neurology, as indeed some of its former territory has already. But perhaps this is a false dichotomy as well, and this is really about levels of analysis -- holism and reductionism.

Then there is the dichotomy between rationality and morality, manifested as disease vs. evil. We have glanced at this problem in the cases of Michael Ross, who haunted my second hometown in Windham County; Ted Kaczynski, who was proclaimed insane not because of his antisocial behavior, but because of his radical beliefs; and Wayne S. Chapman, the rapist of little girls upon whom I was called to sit in judgment as a juror, who condemned himself to imprisonment by refusing to undergo penile plesythmography. Once again, however, perhaps this is not a dichotomy but a complex phenomenon. Just as healing may sometimes involve coercion, force or fraud, disease may consist in part of subjective distress, and in part of social disability or deviance. After all, we are social beings; our status in society is a part of what we are. But whose job is it to define deviance, to ordain that it be corrected, and to carry out corrective action? Where does the authority come from?

And so a final dichotomy, between medical and social problems. Is there something wrong with this patient, or is there something wrong with the world in which this patient lives? If our diagnosis is the latter, what should we, as soul healers, do about it, if anything? It is in the context of these -- perhaps not dichotomies, but tensions, or dilemmas, or creative principles, yin and yang -- that the era of psychopharmacology developed and continues.

*I ran into him a year or so after graduation at my cousin's house in New Haven. He was in the foyer playing the piano, which he did very well, along with being fluent in classical Greek and able to solve differential equations in his head. He said to me, "Guess what Cervantes? I'm not an asshole any more! I used to be an insufferable jerk, but I've changed. I'm a nice guy now." And you know what? It was true, every word.

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