{"id":39143,"date":"2013-08-12T17:30:49","date_gmt":"2013-08-12T21:30:49","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=39143"},"modified":"2013-08-12T18:06:42","modified_gmt":"2013-08-12T22:06:42","slug":"an-obligation-to-explore","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/08\/12\/an-obligation-to-explore\/","title":{"rendered":"a cybernetic sermon: the obligation to explore…<\/sup>"},"content":{"rendered":"\n

In my youth, I read a lot of science and a lot of science fiction as well. There are some great science fiction writers, authors who use the genre to weave a solid story with a thoughtful message in the background. And there are many others who just hack out pulp fiction, moved from the old west or the bounding main into an imagined future. A lot of science fiction authors play on the impersonality of technological advances – human essence lost in the wake of a mechanized future ruled by technocracy. And many actual science writers have the same worries, ie Informatics [Scot Silverstein MD] on Healthcare Renewal<\/a> who writes about the dangers of Electronic Medical Records [EMR]. Science has caught up with science fiction. Now, with our iPhones, GPS devices, Internet connected PCs, automated telephone systems, ubiquitous databases, etc, we’ve arrived in a world where science and science fiction have run into each other. Bots travel the Internet messing with my comments section and lord only knows what the unseen activities of the NSA and its genuinely unseen counterparts are up to. Even our police dramas rely on CCTV cameras and DNA tests to find the bad guys:<\/p>\n

Back in 1950, Alan Turing developed a test<\/a> that carries his name to determine if a given machine has intelligence<\/em>: <\/div>\n
\n
In the original illustrative example, a human judge engages in natural language conversations with a human and a machine designed to generate performance indistinguishable from that of a human being. All participants are separated from one another. If the judge cannot reliably tell the machine from the human, the machine is said to have passed the test.<\/div>\n<\/blockquote>\n
When I read it as a college student. I thought it was far fetched. And when I played with ELIZA<\/a>, the electronic therapist, I wasn’t very impressed. I don’t have a lot of trouble telling the difference with the maddening answering machines, and frequently scream "I want a person" into the receiver. But I expect that we’re not far from the day when they’ll pass the Turing Test with flying colors.<\/div>\n

I obviously balk in general at the introduction of metrics or machines into psychiatry, and it’s not because of an aversion to computers and technology. I’m as big a techno·computer·geek as you’ll ever find among the ranks of the touchy·feely<\/em> – a term brought to us by our APA President Jeffrey Lieberman [over a cliff…<\/a>]. My objections have to do with something else – my basic understanding of mental illness. I grew up in the world of Darwin, Freud, Bowlby, Sullivan, Winnicott, etc. and I buy that humans are indeed animals, herd animals at that. And I believe that much of what matters about human psychology and mental illness is interpersonal in nature. Even before I’d even heard of those authors, I realized that a lot of what I learned about patients on the medical wards came from how they interacted with me. It’s why I started reading those books in the first place, and never stopped. And I think of empathy as a real thing and an important source of information.<\/p>\n

I’m aware of the criticisms of psychoanalysis and other interpersonal theories and agree with more of those criticisms than you might imagine, but nothing has ever shaken my conviction about the things I said in the last paragraph. Even in situations where I agree with a biological causation like Schizophrenia, or Melancholy, or Mania, I still see the internal experience of the interviewer as an important diagnostic tool. And my balk extends to treating patients with medications based solely on symptom listings just as I would balk at treating medical patients in that way. I was taught and believe that treating symptoms prior to an investigation of cause is verboten, and have never found a reason to change my mind about that. <\/p>\n

I’m saying it this way because I accuse myself of being indirect in my last two posts. If someone shows up depressed, I feel an obligation to explore<\/font><\/strong> why. There are certainly situations where you can’t answer the why question, but most of the time, you can get in the ballpark. And it’s a pretty important ballpark to play in. Long ago, Bibring suggested that depression is a biological signal of helplessness<\/font><\/strong><\/em>, and that has certainly played out to be true in my time in grade. If someone shows up signalling helplessness, I feel that it’s important to figure out the underpinnings of that feeling if I can. Even the absence of a reason<\/em> is important information. Maybe I can help. Maybe all I can do is provide a place where the patient can say what’s gotten to them. Maybe we might decide to try some medication. Maybe not. But the maybes<\/em> follow and are informed by the exploration<\/em>.<\/p>\n

I think a psychometrist might say that a waiting room screening instrument is aimed in that very direction – to alert me to do the exploration. Two objections: First, I see many patients who have been put on medications because of the screening without any exploration. But second, I think it’s pretty important to a depressed person for another human being to receive their communication directly rather than read it from a computer screen. So here I go with that touchy·feely <\/em>stuff again. The process of reaching a diagnosis is an important meeting of two people – whether it’s a medical or a psychiatric problem that’s at issue. People who come to a doctor for help have put a lot of thought into coming. It’s important to honor the visit by taking the complaint seriously and being thorough. <\/p>\n

So I don’t think people who act like machines<\/font><\/em><\/strong> or machines that act like people<\/font><\/strong><\/em> will ever replace diagnostic interviews by actual human beings. Psychometry is a ‘confirmatory or refining tool’ [or even sometimes a hindrance]. We use it in clinical trials only because it can be controlled, not because it’s an otherwise good idea. The Science Fiction writers pretty uniformly agree with me…<\/div>\n","protected":false},"excerpt":{"rendered":"

In my youth, I read a lot of science and a lot of science fiction as well. There are some great science fiction writers, authors who use the genre to weave a solid story with a thoughtful message in the background. And there are many others who just hack out pulp fiction, moved from the […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-39143","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39143","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=39143"}],"version-history":[{"count":30,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39143\/revisions"}],"predecessor-version":[{"id":39173,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/39143\/revisions\/39173"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=39143"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=39143"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=39143"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}