Editor's Note: Nancy Costikyan, MSW, LICSW, Director of the Office of Work/Life at Harvard University and Lecturer on Psychiatry at Harvard Medical School, contributed this piece.
“Better sleep with a sober cannibal than a drunken Christian.” ~ Moby Dick
Many of those who enter the field of addiction treatment and research do so with great visions of large-scale change: we hope to eliminate the stigma of addiction; break down the barriers to treatment; or educate an ill-informed public. Whatever personal white whale we seek to vanquish, addiction treatment providers often learn over time to chart a more modest course: to conduct empathic and high quality treatment with our patients; to provide grounding and elucidating teaching to our students; to continue to learn about how to do a better job; and never to forget that there are few better jobs than helping others to forge paths toward recovery.
But with as little as a single publication and a few academic lectures, any one of us might find that we have a much wider audience than we ever intended.
Don’t believe me? Try googling these words: Costikyan+Cannibal.
In 1988, Howard J. Shaffer (also editor-in-chief of the BASIS) and I co-authored an article on cocaine psychosis and the neuropsychiatric manifestations of AIDS. Together we exhorted clinicians who are facing diagnostic dilemmas to use a multidimensional hypotheses-testing model, especially when confronting clinical cases with high potential for countertransference. Our argument was that clinical paradigms can both facilitate and obscure meaningful understandings of our patients’ experiences. The risk is that without such a scrupulous approach to diagnosis and treatment, we might see what we think we should be seeing. We might make the facts fit into our understanding of the world. In our haste to make sense of the nonsensical, we might jump to conclusions.
“There are certain queer times and occasions in this strange mixed affair we call life when a man takes his whole universe for a vast practical joke… and more than suspectsthat the joke is at nobody's expense but his own.” ~ Moby Dick
Indeed, the joke was on us; the paper we wrote so long ago about not jumping to conclusions emerged in a 2012 Miami Examiner report of a tragic and bizarre case involving nakedness and cannibalism in South Beach, Florida. The mystified journalist apparently searched the web with keywords derived from the police department’s speculations about drug involvement and psychosis, along with the journalist’s own observations about South Beach’s “high concentration of gay bars.” Our paper was used to justify an expedient speculation that cocaine use on the part of the perpetrator had produced both the nakedness and the cannibalism. As it turned out, his toxicology screen was negative for all but marijuana. So much for the intersection of scientific and journalistic rigor.
“How wondrous familiar is a fool!” ~ Moby Dick
No matter how modest our aspirations might be as addiction specialists, it is still our obligation to speak out against simplistic explanations when grappling with issues of addiction, lest such facile arguments make fools of us all. Some years ago I explored these concerns in a lecture called “The Dr. Seuss Debates: Clinical Controversies in the Addictions.” I reflected on the surprising frequency with which our field’s conventional wisdom is unsupported or even contradicted by evidence-based science. Our job as clinicians, I asserted, is to examine our own professional epistemologies, to question the dogma that permeates our field, to be impudent enough to ask, “Who says?” I presented this talk in several cities. Audiences liked it. One participant in particular liked it very much. Later in the day, he sought me out and praised the talk. He went on at some length about how refreshing it was, how much it resonated with him, how spot-on I was in my critique of our field and science in general. I was feeling increasingly pleased with myself when I began slowly to comprehend where he was going with his praise. Spoiler alert: the distance between my ideas and the meaning he inferred was wider than the great Atlantic.
It seemed that my talk had publically vindicated his beliefs that evolution is merely an unsubstantiated theory, that our servitude to the scientific method demands the betrayal of Christian beliefs, that I had gotten it so right in the battle-cry of, “Who says?”
“How vain and foolish, then, thought I?” ~ Moby Dick
Religious and scientific perspectives notwithstanding, I felt the fool. It dawned on me that while I had urged others to question everything, I meant question everything except my fundamental premise. Now, with little warning, I was forced to remember that academic argumentation is fair game for deconstruction and re-appropriation. Indeed, without the rough-and-tumble of Kuhnian revolutionary dissent,1 how will firm opinions ever give way to clearer understandings of the world?
The last novel that Herman Melville published, The Confidence-Man: His Masquerade, opens at sunrise on April Fool’s day. Melville despaired then and until his death at what little impact his writing had had on the world. But Melville, like so many of us, could not take the long view and could not know that one day Moby Dick would be considered one of the great American novels.
As works of literature may be discounted and later revered through long iterations of subjective appraisals, scientific beliefs can undergo similar transformations. Our appraisals of phenomena often are constrained by the paradigms to which we are wedded. After all, the world was once flat; all sailors knew it and those who ventured beyond the known world were considered fools. Only over time did our perspective on the horizon change to fit the facts. Lots of time.
If those of us in the field of addiction treatment hope to have an impact on the world with our ideas and our efforts, we must first accept the reality that some ideas get drowned out, some get pirated off to distant lands, and some languish on parched shores until their time has come.
Before we chart a course in search of our own white whales, we should make a frank appraisal of our expectations and our need to be right. And if we insist on charting a course that relies on the even keel of those we encounter in the sea of ideas, we will likely be unprepared for the intellectual storms that lie ahead.
Not to mention the sober cannibals and drunken Christians.
--Nancy Costikyan, MSW, LICSW
1Kuhn, T. S. (1970). The structure of scientific revolutions (Second ed.). Chicago: University of Chicago Press.