Friday, August 25, 2006


It has been a busy week for me professionally--one of those weeks, in fact, that occasionally make me wonder why I ever went into psychiatry to begin with. Usually when that thought pops into my head (and it does with some regularity) it is my red flag indicating I need a vacation or something, because I'm feeling a little burned out.

Many people have the mistaken impression that psychiatry is an "easy" medical specialty; and I suppose it is if you don't really care very much about the people you are seeing. Or, if you can't be bothered to really listen and take in what they are trying to tell you.

And that's the hard part. To do it right often means letting go to some degree of the internal boundaries we each set up that protect us and separate us from other people; opening yourself to another's pain in a way that makes you feel it yourself. And then sharing whatever strength you have to offer to help them deal with it.

The art of therapy is to become the other person, but not to lose yourself in the process; to immerse yourself in someone else's pain, but hold onto the objectivity and knowledge that can bring you both out of the wilderness whole.

I find the process extremely exhausting at times.

It would be very seductive to think of this profession as a simple matter of correcting altered or abnormal brain chemistry, because to some extent that is just what it is. And, as a biochemist, I have no problem with appreciating the physiological basis of behavior. But there is no question in my own mind that something more is going on; and that this added layer of complexity is completely compatible with the biochemistry, but at the same time is orthogonal to it.

One of my biochemistry professors in college passed on to me a powerful metaphor related to this that I have appreciated almost daily in my professional life. He and I were discussing my interest in how the brain works and the concept of consciousness; and whether it would be better for me to go to medical school or to apply to study graduate biochemistry.

Think of the brain as a beautiful, elegant, and melodious grand piano, he told me. Now imagine that someone had taken an axe to that lovely piano, chopping it into millions of tiny little pieces. Biochemisty, he said, is picking up one of those millions of pieces and attempting to appreciate the sound of the music that could be played on the piano. Imagine Beethoven's 9th Symphony or a Rachmaninoff piano concerto being predicted--or understood and appreciated--merely from the study of dopamine and norepinephrine pathways!

His point, I think, was that biochemistry, while it is one path to understanding, cannot begin to describe the vastly complex and intricate music of the human brain; and that it seems inconceivable that anyone could imagine all that the human mind is capable of from just a study of the interaction the small molecules within. At some point, the level of complexity reaches a certain threshold that makes it surpass the mere sum of its microscopic parts.

Music lover that I was, I decided to go to apply to medical school and eventually wound up in psychiatry (with a detour to get a graduate degree in biochemistry along the way as it happens).

About a year ago there was an article in the NY Times that said psychiatrists are beginning to believe in the reality of evil. Somehow, I was reminded of that professor's anecdote.

For a long time now, behavioral scientists have been somewhat overly giddy with the many practical successes in medicine and psychiatry directly attributable to understanding a few of the pieces of the chopped up piano. But however much they know and understand, they are no closer to really understanding either the human capacity to create beauty or its capacity to do evil.

Outside the ivory tower, though--here in the real world--we are able to feel awe listening to the chords of a symphony composed by a fellow human being; and likewise, we are also able to feel a parallel revulsion at the all too frequent evidence of human evil.

Psychiatry is the branch of medicine dealing with the diagnosis and treatment of mental disorders. We are the piano repairmen of the medical world. We willingly use the science of the biochemists who create the drugs; but we should never forget that we are dealing with more than a conglomeration of chemicals and electrical circuits.

Good and evil exist within all humans--the capacity to create life and the capacity to desstroy it. I don't think that antidepressants would have helped Hitler appreciate the Jews; nor would placing Saddam on antipsychotics have helped the Iraqi people. And, even if medications might have helped, neither of the two psychopaths-- nor thousands like them through history-- would have agreed to treatment.

There are some things that medication cannot fix. Some pianos that cannot be tuned--maybe because there is a crack in the baseboard; or the materials used in construction were warped; or even that those same materials were irreversibly changed by exposure to malignant environmental factors.

Any piano repairman will also tell you that some pianos start out as lemons (just as some cars) and cannot produce the same sounds as their peers. Some are so broken that even after repair they are not much more than junk.

It is possible we will never adequately be able to explain fully every aspect of human brain function--expecially what leads to good or evil--by resorting only to an appreciation of the chemicals and the electrical circuits. But maybe we don't have to in order to enjoy and appreciate the music.

Maybe it is just good enough to nurture the good and fight the evil, whenever we observe either in ourselves or in others.

[Note parts of this post were published earlier]

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