Medicine is a family affair in Chuuk. I’ve spent the first days in the general practice clinic of the only state hospital working side by side with local doctors and our staff. Dr. Tavo is the physician we typically work with. (Tavo is her first name, as all the Chuuk physicians introduce themselves as “doctor” followed by their first names.) A pleasant native Chuukese woman with curly hair and smiley eyes, she has been practicing for about ten years since trying to study a few other fields to escape the family business. Her parents encouraged her to try a non-medical profession, but she found her way back to medicine after seeing her enjoyment matched the needs of the community.

Dr. Tavo typically sees 30+ patients in a typical day. She’s less encumbered by electronic medical records than we tend to be—the doctors in Chuuk just note a working diagnosis and the treatment prescribed in the chart. Still, the patient load is high, especially whenever the doctors are on call for the emergency department or inpatient ward. Dr. Tavo feels bad about turning anyone away since patients often travel to Weno island by boat from other islands.

Some patients also heard the American doctors were also in town and came specifically to be seen. We’ve been instructed to work directly alongside local doctors to build up partner capabilities, so we consult on cases together. We tend to be helpful for antibiotic recommendations, diabetes care, and teaching point of care ultrasound to identify things like hernias, abscesses, and different knee injuries. Dr. Tavo shows us how to treat the parasitic worm infections common in the area and to identify signs of malnutrition.

After lunch one day, we return to clinic to see an older doctor with similar long curly hair, just more grey and with a pensive facial expression. She introduces herself as Dr. Siana, the OBGYN who Dr. Tavo said would be covering while she had an afternoon meeting. Dr. Siana asks how we like working with Dr. Tavo so far, which we answer positively. “She’s my daughter!” she exclaims with pride. When we mention to Dr. Tavo that we met her mother, the younger doctor displays some teenager-like embarrassment.

Dr. Siana is one of two OBGYNs in the state and is having trouble finding a successor, and call shifts can be bad. Some of the doctors mention that their children have gone on to practice medicine, law, or engineering, but have not returned home from abroad. Brain drain is evidently a problem, and lack of private and state funds play a part.

Subscribe now

Not-so-rare rare diseases

Another area hit by low funding is the mobile leprosy outreach clinic, but the clinic coordinators are creative. The World Health Organization declared leprosy eradicated based on its low worldwide prevalence, which is the percentage of people in a population who continue to have a disease. Based on leprosy’s WHO designation as eradicated, barely any funding is now available for tracking and treating the disease. Yet, leprosy remains prevalent in many Pacific islands. In Weno island, the doctors report a prevalence of 5 cases per 1,000 people. That high figure grows to 19 per 1,000 when considering Chuuk as a whole, including islands that the team can’t reach as frequently. The leprosy outreach team makes do by combining leprosy work with their tuberculosis work, which is better funded. Their work on both diseases gives them high visibility in the communities.

Leprosy, or Hansen disease, is caused by either of two Mycobacterium species, M. leprae and M. lepromatosis. They’re slow-growing bacteria, even slower than Mycobacterium tuberculosis, which means they’re also slow to get rid of. Transmission is thought to be by respiratory droplets over prolonged periods of time, so not through casual contact. Only 3-5% of people without immune problems are susceptible to developing the disease, and it takes 3-5 years for the bacteria to incubate in a colonized host before causing symptoms. For those who develop the disease, disfiguring skin changes occur on the face and throughout the body, along with nerve swelling that weakens the facial and hand muscles. Thankfully, if caught within a few years, the effects can be completely reversed.

The most reliable and practical way to evaluate someone for leprosy is physical exam. The outreach clinic tracks whoever has the disease and their close contacts, especially family members. The outreach teams then visit common areas like churches and schools so these contacts and anyone interested can be evaluated for Hansen disease. The teams go to sites around Weno and take boats to the surrounding islands.

The evaluation includes a skin exam, paying particular attention to the areas behind the ears, on the arms, and on the lower legs where marks first tend to appear. After examining the skin, we test facial, finger, and toe strength and sensation to ensure no nerve injury. People with household exposures are given rifampin, an antibiotic, to prevent developing Hansen disease. The coverage lasts 3-5 years.

Many of the early skin lesions would seem fungal were it not for loss of sensation over the areas and the way they’re distributed. They first start off lacy and elliptical before causing thickening and knobbly changes to the skin. There are also skin changes that occur with times of increased immune system reaction against the bacteria. We saw this with one of the patients in the hospital.

The acute skin reactions are treatable with oral steroids like prednisone. For the bacteria, patients receive from 6 to 24 months of a triple combination of antibiotics. Some patients stop antibiotics after noticing improved skin after a few months, causing the disease to return with complications. Therefore, the clinic sends public health employees to observe patients taking their medications directly. Patients are even advised to return from travel to receive treatment in Micronesia if they run out of pills, as most doctors in the U.S. aren’t experienced with treating Hansen disease. It’s rare for an American doctor to see it in his lifetime!

One of the two doctors at the leprosy outreach, Dr. Bále, shows us how quickly he distinguishes leprosy lesions from other skin markings. The Chuuk locals have many scars and infected patches on their legs from activities in the forest and rocky beaches. Dr. Bále points out everyday injuries at a glance, sometimes giving topical antibiotics. When I ask him about a blackened area on some of the locals’ ankles, he explains these are calluses from sitting cross-legged on hard ground. This doctor is a charming curmudgeon. When we greet him at 0900 (early for island time), he is eating his breakfast of saimin noodles in the unlit meeting room. “Doctor, why are you eating in the dark? Turn on the lights!” one of the nurses urges. Dr. Bále barely glances up, grunting briefly about how he likes his dark room.

A few days later, Dr. Tavo invites us to dinner in the town. “Did you meet the doctor at the leprosy outreach? He is my father!” I’m only a little surprised this time and joke about her family running a medical mafia on the island. The health of much of the state truly does depend on their work. With local talent emigration, poverty and health literacy issues among the population, and processed foods replacing traditional food culture, they have their work cut out for them.

At dinner, the team exchange gifts with Dr. Tavo and Dr. Siana, including some shell necklaces Dr. Tavo has given us in appreciation of our work alongside her. She also brings her young toddler son, who is wide eyed and friendly.

“Do you think he’ll carry on the family business and be a doctor?”

Dr. Tavo laughs. “We think he will join the military.”

Subscribe now

Every few years, the U.S. Navy returns to this site of victory as part of a global health and development mission called Pacific Partnership. The mission carries medical, environmental health, and engineering personnel to develop infrastructure and share clinical information with partners around various Pacific countries. I’m joining the crew to spend a couple weeks with local clinics and health outreaches.

Last month, my medical residency program invited me to join the mission, and a couple of my resident colleagues will take my place at the next stops. After 36hrs of travel with layovers in Japan and Guam, I arrived at our ship docked in Weno port. Sleep in the triple bunks isn’t the best rest, but after some refreshing snorkeling over the shipwreck coral reefs, we hit the ground running.

I’ve already spent a few days in clinic with local physicians at the Chuuk state hospital, the main clinical site for the state’s population of 50,000 people. So far we’ve been showing them ultrasound techniques and ways to identify and drain abscesses. We also compared treatments for non-communicable diseases like asthma and diabetes.

In turn, they’ve taught us about de-worming, leprosy, and tuberculosis. We rarely see leprosy if ever in the United States, so this trip has multiple once-in-a-lifetime possibilities all together!

The landscape is a contrast between the small islands and the vast ocean and night sky. This is the sort of mission that the public affairs crew encourages us to post about, so I hope to make a couple reflections on my time here soon. Thankfully, I’ve been having some interesting spiritual experiences starting before the trip that will help me receive the experience for all it offers. More on those later. In the meantime, reading and writing help me stay awake in the setting of sleep-inducing tropical heat, so please write to me any comments or news from your settings. Thank you for reading and for your prayers.

Share

Meanwhile, in primary care land, much is business as usual. We’ve been underfunded and overworked for a long time, so if that’s you now, welcome to the club! Primary care gets 50% of outpatient visits but less than 5% of funding, an order of magnitude less than the public expects (abysmal stats here). So, most primary care doctors, especially the more independent-minded, have zero skin in the game for preserving the current research system. This situation gives us some perspective for reimagining what democratic, patient-centered research could look like.

Even once I finish family med training, I’ll keep low-budget research lessons in mind as I go on to pursue clinical trials and further training in addiction med. These lessons for a no-name budget researcher could apply to any scientists or policy makers stewarding community partners’ and taxpayers’ money. Here are three, each drawing from a barely-funded article I authored or co-first authored with friends the past couple years.

1. Local and citizen science are underrated resources.

We need more locally-run research. Local clinicians and community members become invested in study results when they get the chance to contribute data. With public health topics like food security, mental illness, viruses and other disease modeling, and more, empowering members of the community to collect data can build trust in public health efforts. This benefit is in line with the principle of subsidiarity.

Remember those nature walks and visits to the science museums as a kid, when the docents talked about citizen science? That’s actually a thing researchers can use. In our study in North Philly, we partnered with churches, interpreters, and health professions students to collect data on food insecurity, or not having enough available food. The study was run through a local federally qualified health center (Esperanza) that could use the results with patients and other local organizations. The study provided a view of food insecurity prevalence (37% food insecure!) and risk factors in the North Philly area where Esperanza was located. This area had high opioid use and other social factors contributing to a different food insecurity profile than is the case nationally.

Much of the gap between public health researchers and the public could be bridged if the local community and clinicians on the ground contributed to public health messaging. Public health will in turn get more accurate, locally actionable data.

2. Get iterative feedback from patients and end users.

Feedback gives a better idea of whether something works at a small scale before you invest at a larger scale. In design, the end user gives feedback at all stages: statement of the problem, ideation, prototyping, and refining. In traditional research, there are also opportunities for the study population to give feedback: at study design, pilot study, randomized clinical trial, and multisite randomized clinical trial (and their counterparts in basic sciences).

In design and research, lack of feedback creates problems with demand and buy-in for the finished result. In various missions and public health trips, I’ve observed development workers from orgs like USAID (RIP) and Gates Foundation et al complaining that local leaders weren’t putting effort into the orgs’ development goals (read: regime change and/or cultural imperialism). During an internship in Kenya, foreign workers decided to build contraception clinics. They got frustrated that local leaders, who hadn’t been involved in the decision, were letting the facilities deteriorate instead of doing maintenance. Zero feedback and zero buy-in meant that the social programmers were not only too obvious but also incompetent. In contrast, iterative feedback incorporates the social principle of solidarity.

Unresponsiveness to market and public desire also characterizes much research today. Some important topics may be over normal people’s heads. But, there also are many topics of great importance to the public that aren’t funded because they’re uninteresting to pharmaceutical companies and the food industry: some include restorative reproductive medicine, regenerative agriculture, and phone and porn addiction. Meanwhile, I can almost guarantee there was zero public request for the puppy-parasite study (NIH grant R21AI130485) or the even more gruesome study growing human fetal scalps on mice (NIH/NIAID R21AI135412).

For the below project, we partnered with architects and community representatives to design South Philly’s first immigrant and refugee clinic. Community feedback introduced new ideas into the project including consultation rooms and the multipurpose gallery. It was a great joy seeing the project start and finally seeing the first patients in the space.

3. Crowdsource ideas and funding whenever possible.

Crowdsourcing has had big impacts in business and nonprofits, but it hasn’t yet been tried at scale for research. It would be a great way to democratize the research process and get the public involved in studies they actually want done. Practically speaking, we also need alternative funding sources if cuts persist. Democratizing research could also happen through state funded rather than federally funded projects, allowing a kind of federalist vision of science (an idea from other physicians). More grassroots or state-level funding of projects could encourage competition and innovation while supporting the social principle of participation.

For this project, we worked with another federally qualified health center to make a clinical decision tool to treat opioid addiction. This clinical algorithm is the first to include injectable buprenorphine, a drug that blocks opioids for a month and reduces cravings. Patients and community members provided ideas when developing the algorithm, since a big part of its effectiveness depends on whether patients will actually be willing to take the medication. The diverse input the project received made me think of crowdsourcing as a solution for continued scientific funding and innovation.

Subscribe now

This post was spur of the moment since I heard the Winged Ox Forum in Philly is having a discussion on research agendas tonight! Since I can’t be there in person, I imagined this as my contribution to the discussion. I also wanted to recap some of the research I’d done the past couple years, so this was a good chance to do it. Thanks to the friends who worked on these projects, including Eric Fung, my go-to biostatistician for two of these papers! Please congratulate Eric on his recent acceptance (again) to Harvard, this time for his PhD, and consider him for any epidemiology work.

Anyone interested in the ongoing discussions in Philly, please email jperezbenzo@collegiuminstitute.org and ask about Winged Ox.

How to use: One item from each category will suffice to inform cultural engagement (besides Bible—read the whole thing!). Beyond that, read whatever you like for a fuller picture. I picked the books assuming the reader has a bandwidth of about 3-5 books per year. I still recommend asking an ethicist, consecrated lay worker, priest, or other thoughtful practitioner for guidance to see how to apply the texts or how they fit together.

Modern fiction for boosting creativity

• A Wrinkle in Time and its sequel A Wind in the Door

  Madeleine L’Engle

  This is sci-fi that celebrates home and family. Winner of the Newbery Medal and great for all ages, the series mixes science, angels, biblical references, and coming-of-age.

• Dune

  Frank Herbert

  Herbert envisioned regenerative agriculture before it was cool, and on a planetary level too. The protagonist faces a choice between creating Space Islam or Space Liberation Theology.

• Infinite Jest

  David Foster Wallace

  The redemptive epic of American consumer culture. Along with mentors and life experience, this book helped inspire my entry into addiction medicine.

• Boxers and Saints

  Gene Yuen Lang

  There’s promise and peril when cultures collide. The author, a DC and Avatar the Last Airbender illustrator and a Catholic, provides a masterclass for enculturating the Gospel. Brilliant idea to make a comic book on the Boxer Rebellion, a messy time in Chinese history and Christian missions.

  

Recommended journals and Substacks

• No-BS cultural analysis that remains gracious. Renn loves American Christianity enough to appraise our cultural weaknesses honestly while proposing solutions. The old newsletter and new long form articles are especially high-yield. Male-coded in a good way.

  Aaron Renn

  Compelling insights on society, Christianity, family, cities, politics and economics.

  By Aaron M. Renn

• Institute for Family Studies

  Rigorous and up-to-date info on the current state of marriage, intersexual dynamics, and family formation in the United States.

• Plough

  Accounts of Christian and communitarian ethics that people are actually trying to live out.

Bible

• Any Gospel for which you find personal affinity

• Genesis

• Nehemiah

• Amos

• Acts of the Apostles

  Subscribe now

Bonus: Medical-industrial complex

• Slow Medicine

  Victoria Sweet

  Physician and historian Victoria Sweet critiques the bureaucratic takeover of medicine and envisions a new way of caring for patients inspired by the medieval saint and mystic Hildegard von Bingen.

• This is Your Brain on Birth Control

  Sarah Hill

  Pairs well with the fascinating account of the animal and human experiments by feminist and eugenicist Margaret Sanger and colleagues that led to development of the Pill.

• Deaths of Despair and the Future of Capitalism

  Anne Case and Angus Deaton

  An exposé of how our current biomedical industry and economic systems sacrifice specific groups of our countrymen, namely working class folks. Great to contrast with the opposite goal of human flourishing empirically described by Vanderweele and colleagues.

• Interview and book: The Rise of the Biomedical Security State

  Aaron Kheriaty

  The First Things interview is a good overview for the working professional, and the book offers a deep dive. Great applications of Foucault and analyses of past totalitarian regimes to our technological zeitgeist.

  Human Flourishing

  Welcome to my writings on civil liberties, bioethics, public health policy, and society. I regularly post updates here on my legal efforts to oppose government censorship, advocate for transparency from public agencies, and protect medical freedom.

  By Aaron Kheriaty, MD

• Good Energy

  Casey Means and Calley Means

  I aim to read and critique this when I get the chance. If you would like to read it along with me, please let me know!

Full combined PDF of parts 1 and 2 here:

Booklist Cultural Renewal

1.12MB ∙ PDF file

Download

Download

I notice most reading lists for a non-academic audience tend to take an academic-lite approach. By academic-lite, I mean that these lists take what one might get from a liberal arts education and make an accessible, greatest hits version of that huge body of knowledge. Popular media sources like Father Mike Schmitz’s reading recs, Bishop Barron’s Word on Fire, or Ted Gioia’s excellent list do great work popularizing the great books.

The end-goal or ideal reader of these lists seems to be someone who learns how to enjoy our millennia-long cultural conversation and engage it in a way modeled by professional academics, just more casually. This is a great goal. I’m all for a liberal arts education just as I encourage fine art or music appreciation, and it’s essential for some lines of work. Yet, the life of contemplation isn’t the right move for everybody at all times, and traditionalists and renewers of culture lack reading lists geared towards informing action.

I’m personally more curious about how professionals can contribute to a cultural conversation by speaking from their strengths. Many workers and creatives want to be part of cultural renewal. But, focusing on being amateur academics can make people worse versions of ivory tower types, at least when it comes to cultural impact. What we also need are doers. A book list for doers gives just a little guidance on how to direct that “doing” alongside some ways of communicating what we’re doing.

There are special insights a culture can receive from lives spent in engineering, construction, materials science, regenerative farming, and other solid fields. As in the great lists I mentioned, books help us develop a common language of shared cultural and literary references. My hope is that these books also help us communicate to academia and the larger culture the fruits of a life of action and experience. If the list helps you articulate what you do or inspires you to build new structures, please let me know! It’s a continuing work in progress, so I’d love your feedback.

Leave a comment

How to use: One item from each category will suffice to inform cultural engagement. (Besides the Bible—read the whole thing!) Beyond that, read whatever you like for a fuller picture. I picked the sources assuming the reader has a bandwidth of about 3-5 books per year. I still recommend asking an ethicist, consecrated lay worker, priest, or other thoughtful practitioner for guidance to see how to apply the texts or how they fit together. Part 2 linked here.

Theology

• Jesus of Nazareth series

  Benedict XVI

  These first books listed provide all the background in biblical studies needed for most people. Benedict XVI represents the full flowering of Vatican II theology, combining the best of biblical criticism, diverse biblical traditions and typologies, and a deep love for the subject matter (the person of Jesus).

• Streams of Living Water: Celebrating the Great Traditions of Christian Faith

  Richard Foster

  Foster details different renewal movements in Christianity in this modern and ecumenical “lives of the saints.” Different spiritualities flow naturally into corresponding ways of fulfilling the works of mercy.

Christian and secular ethics

• The Peaceable Kingdom

  Stanley Hauerwas

  The enduring classic on Christian communitarian ethics.

• The Foundations of Bioethics, second edition

  H. Tristram Engelhardt

  Explore the foundations of different ethical theories and test them as applied to bioethics: Is a secular consensus feasible? If it’s possible for a bioethicist to be radicalizing, Engelhardt does it.

Cultural engagement strategies

• Christ and Culture

  H. Richard Niebuhr

  A typology of different ways Christians interact with broader culture, and applicable to different cultural minorities. What type do you tend towards?

• Antifragile

  Nassim Nicholas Taleb

  Brilliant reframing for conditions of instability. Personally, this book along with some Chinese philosophy helped me learn to enjoy change.

  

Subscribe now

Social structures and institutions

• You Are What You Love

  James K.A. Smith

  Our everyday rituals and purchases form us more than a typical Sunday service. Thankfully, we can design the liturgies with which we surround ourselves. The author’s own adaptation of his excellent Cultural Liturgies trilogy.

• Habits of the Heart

  Robert Bellah and colleagues

  Sociology incorporates philosophy and history to examine individualism’s effects on American institutions. The authors coined the now widespread term “expressive individualism.”

• The Young Adult Playbook

  Anna Moreland and Thomas Smith

  In a world of previously stable social norms upended by Boomers, the authors guide us through new social scripts for work, leisure, and love. I read this book and got it for my sister as a way to imagine alternatives to the dreaded rat race.

The Family

• Love and Responsibility

  John Paul II

  A clear exposition of John Paul II’s theology of the body and the family.

• Address to the U.S. National Prayer Breakfast, “Whatever You Did Unto One of the Least, You Did Unto Me”

  Mother Teresa of Calcutta

  Guts and clear teaching all in one speech.

Education

• The Religious Sense

  Luigi Giussani

  Encounter the Truth and test it by being open to experience.

• The Great Learning (大學)

  Zengzi

  This is a short classic of Chinese philosophy by Confucius’s disciple on honing the basics and learning from experience. I recommend the translation and commentary in A Source Book in Chinese Philosophy, the same anthology read by Bruce Lee.

Psychology

• 12 Rules for Life

  Jordan B. Peterson

  The gateway drug to going to church. As attested by friends, pastors, and countless articles.

• The Optimal Work Podcast

  Kevin Majeres and colleagues

  Cognitive behavioral psychology meets virtue theory. Your work becomes a way to know and improve yourself.

Philosophical history

• Strange New World: How Thinkers and Activists Redefined Identity and Sparked the Sexual Revolution

  Carl Trueman

  A more concise version of his excellent Rise and Triumph of the Modern Self. Traces the development of expressive individualism as the prevailing Western ethos.

• Why Beauty Matters documentary

  Roger Scruton

  If we built beautiful environments in the past, why are many cities and buildings ugly today? A curmudgeonly yet delightful encouragement to rebuild beautifully.

Part 2 below:

You want to change the world.

That’s a great outlook for having agency. Far better to change the world than be at its mercy. But it gets unclear whose world we’re talking about and where we should start. There are many ways of parsing the world into the worlds of people, animals, machines, conservation, medicine, economics, and so on. These are different networks and different tracks within which we can progress. We can even combine or make our own tracks for success.

Without a sense of the scope of the world and its parts, we’ll get paralyzed by these limitless options. Thankfully, our own development has given us a world to start off in. This is the world of our fundamental relationships.

We first get our view of the world from our immediate family.

This isn’t just our beliefs about the world like politics and religion. Literally, our sense perception and processing of the world stems from our family, our stable relationships growing up. We perceive the world as a place we inhabit that’s also outside of us. Developmental psychology shows us that our relationships pattern our cognitive abilities. From the womb onwards, the experiences of observing our parents and having our needs met generate mental tools like object permanence (seeing things as really existing in the world, even when we’re not looking at them), theory of mind (considering others’ thoughts and perspectives), and attachment (our sense of connectedness to the world and our relationships).

When these relationships are out of whack, like when parents split up or there’s violence in our neighborhood, we see prefrontal cortex changes and less emotional stability. Sometimes we get the problems with mapping and planning out the world related to that brain area. Major adverse childhood experiences and early substance use are likewise linked to impaired development of our neurocognitive reasoning, planning, and self-control abilities.

What’s striking is our lifestyles in the West now mimic that familial disruption all the time. It’s normal for those in our managerial, service, and elite classes to pack up every few years and move to a new place without local connections. Our interactions with others are brief, bouncing from one advancement to the next yet not committing to journey alongside any particular person, while the friends we have slip in and out of our lives.

The philosopher Charles Taylor calls this kind of life “atomized.” Imagine how it might feel to be a gas particle bouncing around, like in your high school chemistry class. We’re each the center of our lives without intermediate structures like family or community to mediate what we believe or how we make our way in the world. This kind of life is filled with dizzying numbers of interactions, yet many of us somehow feel less free and more lonely and forlorn.

Subscribe now

That feeling is a signal

pointing us towards solutions in more humane forms of living. We need to commit to at least a few people and networks that will remain with us as we journey through the world. But these connections are much more than social support. They’re the relationships that will be most impacted by the changes we make in the world. It’s for their sake we work and innovate.

Our success or failure means different economic and living circumstances for them. Maybe we’ll do well and bring recognition to a locale or a family. Even more directly, our close connections can inspire or be the recipients of our innovations. The inventors of surgical gloves and Band-aids devised their creations for loved ones suffering the painful nicks and cuts of manual labor. The modern wheelchair was an engineer’s design for his disabled friend. India’s “PadMan” changed the lives of millions of women through his quest to develop a clean, affordable menstrual hygiene product for his wife.

Continued growth, then, can come from keeping up the relationships that helped us grow in the first place. If we lacked those relationships growing up, we can build them through new commitments. Doing things for the sake of these relationships will help us stay grounded and integrated rather than adrift in the world. Paradoxically, iterating at this “smaller” scale of relationships maximizes our scope. We can first see our impact on our immediate, closest social relationships and get their accurate feedback as those who have skin in the game. Real people keep us honest and out of the ivory tower. We also don’t need to jettison the more abstract ideals of helping humanity or advancing knowledge, but rather see the concrete relationships we have as the real opportunities to enact those ideals (the opposite of this example in Dostoevsky).

Working and innovating for the sake of close relationships thus fills our lives with meaning, avoiding alienation and the atomized life. So, thank you for reading this and for how you’ve played a role in my development!

We can find solutions to atomization in the very origins of therapy, which would have us realize and affirm the family’s authority.

Thanks to everyone who sent me feedback on my last therapy post on individual dosing. Now, we can explore the accumulated social effects of the new therapeutic authority. Just as an overly therapeutic mindset can hamper an individual, this mindset accumulated over many people destabilizes a society. So, this post will discuss the right place for therapy to benefit the family and the community by looking at psychotherapy’s roots.

Therapy has a high level of authority over our interpersonal behavior in the West. We see it works when we have assertiveness training and a partner or boss takes our requests more seriously, or when we learn to manage social anxiety and get to go out more often through exposure and cognitive behavior therapy. 

But nowadays, we evaluate more and more of our personal lives through the therapeutic, the default interpretive lens for anything affecting our emotional states. Labeling behaviors and people “toxic,” or cutting off family members for lack of affirmation and various traumas appeal to popular (if inaccurate) imports of therapeutic ideas. Sometimes these actions are warranted. And every competent therapist would refrain from directly endorsing them or engaging in labeling. Yet, these behaviors have become widespread in the West by appealing to therapeutic concepts. 

The therapy-state alliance

A more direct exercise of therapeutic authority comes through the state’s ability to mandate types of individual or family therapy. Previously, abusive family dynamics fell under the censure of traditional authorities in the community. Interventions came from religious or extended and older family members, albeit imperfectly. What changed is the state’s selection of psychology as the authority that informs judgment and mediates punishment.

While psychology continues to develop as a science, it would be naive to assume the state uses psychological power more objectively than traditional authorities used their powers. We tend to think that through scientific reasoning, we can avoid human error and messiness, but we really just shift authority to another set of biased actors. Thus, motivated actors may designate culturally diverse ways of raising children or relating to spouses as pathological. These behaviors and relationships are therefore to be eliminated (e.g., APA’s guidelines on men and boys or the Duluth Model). To engage in some behaviors is to incur punishment by the state once the therapist diagnoses the vicious party.

Through the therapist’s alliance with the state, therapy gains the ability to dissolve the family under some circumstances. Therapy can influence the division of assets and children among different parties. This authority to dissolve becomes authority over the family in our personal and cultural understanding. Hence the appeal to therapeutic ideas like trauma and attachment that we use to guide our increasingly anxious family interactions. The family becomes fragilized before the threat of therapeutic correction.

Subscribe now

The transfer of authority from the family to psychology occurred gradually through changing social norms but also was cheered by influential social theorists, who supported an alliance between clinical psychology and the state. The critical theorist Herbert Marcuse, drawing on psychoanalytic theory, rejoiced in the prediction that psychotherapy would overthrow the tyranny of the family, symbolized by the despotic father. More ambivalently, Michel Foucault railed against the authority of both family and psychiatry and noted the repressive power of one would give way to the state’s surveillance through the other.1

For many, this transfer of authority from the family and traditional community to the state, via the medium of psychology, has led to more loneliness: our connections are overseen by vast impersonal structures instead of authorities we personally know. However, we can find solutions to this atomization in the very origins of therapy, which would have us realize and affirm the family’s authority.

Family inspires psychotherapy

Therapeutic techniques have their roots in the normative behaviors of the family. A fundamental aspect of therapy is unconditional regard for the patient, a belief in the patient’s basic goodness and ability to make positive change. Carl Rogers, a formative figure for psychotherapy, was a sometime seminarian before coming to renown as a psychologist. His description of unconditional positive regard stems from two sources: the influence of Christian (particularly mainline Protestant) understandings of love and stable family upbringing.

This regard stems from the givenness of the relationship. Nothing I can do will change the fact I was born from my mom. Naturally, the behavior of my parents towards me takes the form of unconditional love, or rather, love conditioned on an irrevocable fact. The therapist’s regard for the patient is modeled off this other type of relationship.

Likewise, Freud based the concept of transference on the relationship one has with one’s parents, especially one’s father. Transference is the client’s attribution of attachment relationship qualities to the clinician. This means the client relates to the therapist as to a father or mother figure and invests trust in the therapist. In return, the client receives a safe relationship in which to explore experiences and develop emotional regulation. The quality of this transference happens to be the decisive factor for any therapy’s effectiveness.2

Therefore, we can see that the family is normative for models of therapy and not the converse. The authority of families comes before psychology in terms of what we should trust by default. Developmental psychology and neuroscience also show that in the family we develop our sense of self (Kopp), empathy for others (Kohlberg), and our relation to objects in the world, i.e. how we go about exploring and gaining knowledge. When these relationships are broken, therapy can come into play like a prosthetic version of these foundational developmental relationships. A prosthetic leg isn’t the best model for a leg, but it’s helpful when the original is missing. The prosthesis can help the patient rehabilitate to regular life. A goal of therapy then is to “graduate” the client from therapy and help him or her form stable attachments with new chosen family members and friends.

Share

If family and friendship are the source of most of our long-term stability, how can we renew these natural institutions in a therapy-supervised society? We should remember the basics. On a personal level, we can maintain the integrity of sibling and parent-child relationships. Biblical and Chinese wisdom traditions advise honoring the benevolent authority of parents throughout life, even if some friendship-like aspects also develop with age. 

We can avoid bringing clinical language into our everyday relationships. Likewise, we can refuse to normalize pathology or treat families as regularly pathological: while each family has its challenges, we shouldn’t use popular terms like “family trauma” casually as though pathology were a normal part of family life.

Finally, psychology can become a useful repository for what makes relationships run smoothly. In an increasingly atomized world, community wisdom is harder to find. Like breastfeeding and child-rearing, getting along with family is a natural but difficult skill that experienced elders used to pass down, hands-on, in multi-generational families and communities. These settings are rarer, but some of their wisdom has been preserved in scientific disciplines. As we look to renewing communities, we can retrieve that refined knowledge as a tool to build up, not threaten, our families and friendships from which that knowledge comes.

New developments:

• The Hippocratic Society is a new organization devoted to renewing medicine and helping physicians pursue virtue. I’m involved with the group and am excited for the vision! We recently started several new chapters in different cities and universities. Check out the newly launched website.

• Thanks to friends and readers who’ve started sending me research articles to comment on. I always enjoy chatting about new studies offline and plan to write some commentary soon.

Subscribe now

“America! America!

God shed His grace on thee

And crown thy good with brotherhood

From sea to shining sea!”

Happy Independence! What common ideals will move our country forward? Our national ethos is up for grabs: May we direct it to the goals of our founding and realize our freedom in our common destiny.

Along with the above from “America the Beautiful,” here’s a quote from Fr. Luigi Giussani for reflection. Besides founding the movement of Communion and Liberation, Fr. Giussani was a keen scholar of American theology:

“Complete self-fulfillment, this is freedom. Freedom, for the human being, is the possibility, the capacity, the responsibility to be fulfilled, that is to say to reach and face one’s destiny: it is the total aspiration for destiny. Thus freedom is the experience of the truth of ourselves.” The Religious Sense, Chapter 8.

I hope your day is a joyful one for celebrating these United States and our freedom!

Subscribe now

Continuing my article commentaries, this post discusses how corporate skills are essential for serving others, using an example from health design. Don’t worry, I’m not going to beat the drum about how to build your personal brand, but it’s really about how people skills bring out what’s most human in working among the poor and vulnerable.

When I was growing up, I found the idea of networking distasteful. In response to my studies of missions, Dad would suggest, “Why not be a missionary businessman?” which I never interpreted seriously. My corporate parents urged me to read classic books like How to Win Friends and Influence People, but of course I was immediately repelled by the title, rejecting all targeted social skills improvement as fake and Machiavellian. As a young introvert who often preferred books to people, there was probably a little self-justification for social awkwardness going on. Only once I started med school did I realize presentation and networking skills could be enjoyable, even essential for serving others at scale. 

My med school, Thomas Jefferson University, had a curricular option for learning design thinking to solve health problems. I entered the program through a partnership between my undergrad and the med school, and with a few other Princetonians benefited from mentorship with Bon Ku, an avid surfer and professor of emergency medicine and design. When Dr. Ku wasn’t chasing waves, he taught us design thinking methods and threw us into community- and corporate-facing projects. 

Design thinking is a valuable skill in itself (you can learn about it in the linked article), but it also cultivates another versatile skill of navigating corporate and funding environments. By applying design principles, we can elicit the goals and underlying beliefs of different parties. These differ and inevitably conflict, so the benefit of design is harmonizing them in a product that satisfies everyone. Fundamental beliefs were something I was theoretically interested in as a religion scholar, so it was even more interesting to bring those out of people and apply them to community work. 

Gathering feedback and presenting solutions in a compelling way was intimidating to a wee med student, especially in front of corporate execs, architects, and community representatives who are just meeting each other. Dr. Ku was generous enough to trust me and a couple other students to run meetings during some design projects. The meetings ended up being the best practical education. Our major project was the design process for a South Philly refugee and immigrant clinic with a top-tier architecture firm. This clinic is the first of its kind in the area and serves primarily Southeast Asian patients (Laos, Malaysia, and Vietnam) along with some Latino and Chinese immigrants. We wrote up the process here.

As the article notes, the design thinking process refers to the end user’s experience and goals at every stage of design, from generating ideas to prototyping and testing. These priorities can only be realized through communication with funders and corporate decision makers, who also have a creative vision. Effective business communication humanizes the corporate decision makers to the end users, while showing that the end user’s goals can creatively benefit the organization’s goals. We all want to feel good about our work helping others: that feeling signifies actual cooperation when parties are honest and motivated to work with each other’s goals thanks to effective communication. 

When goals are imposed from corporate or NGO top-down, without input from the end user, the user’s investment is low and the product can’t be maintained. For instance, I spent a summer doing public health research in the Kenyan savannah, living at a research center with people doing different biology and development projects. Many development workers lamented, “Why don’t the villagers maintain their clinics or classrooms? Don’t they know what’s good for them?” Yet, these buildings had been built with minimal local consultation and included social engineering projects meant to subvert traditional local values (cough cough, Gates Foundation). 

In contrast, keeping the end users at the forefront of each step respects them as a source of design solutions. In our case, using insights from religious studies and anthropology, we envisioned what it might be like for patients and their multigenerational families to move through a clinic visit. Patients would treat the clinic much more as a ritual or hospitality setting, like they did with traditional healers in their countries of origin. We tested this insight through prototypes ranging from drawings (low-fidelity) to virtual reality (high-fidelity). The center has now been open since 2021 and includes the clinic, social services like immigration support, a gallery, and training for clinicians.

Subscribe now

In poorly resourced settings, design and good communication are even more important for working amid rapid changes. Displacement of people groups or the influx of drugs make issues as basic as visiting a clinic or getting food look much different on the ground compared to national studies, as in the last post. Organizational leaders want to contribute to solutions but need to know what’s happening to act responsibly. Yet, many of us working in nonprofit settings struggle with motivation to learn corporate communication. Reframing that communication as a way to understand everyone’s fundamental goals and values helps us feel more connected when co-designing solutions (there’s a theological correlate of “co-creating” somewhere in there).

I’m grateful to all who have taught me communication skills and encouraged me to learn more about business mindsets, even when I was a stubborn idealist (Dad, you were right). I am still an idealist, but hopefully less stubborn, so if you share with me any business ideas or communication tips via comments or messages I’ll be most appreciative.

• Speaking of communication skills, I’ve used these principles in teaching settings like the Winged Ox Forum, the theology and medicine seminar with the Collegium Institute. I’m continuing to work in different teaching and speaking settings and value your support. If you’ve attended any presentations or seminars I’ve facilitated, I would be grateful if you could leave a review here for others to learn about (last post I forgot to include the link here)!

• Stay tuned for some examples of experienced communicators among peers and inspirational figures.

  Leave a comment

A plug for service-minded practitioners and theologians: many Christian clinics continue to be shining examples of consistent practical ethics and social teaching. Theologians and cultural commentators mainly tend to discuss schools as the organizations representing a community’s ethics in service to the broader society. This is the case when looking at outlets like First Things and Public Discourse, culture warriors like Doug Wilson, and often mainstream media in conflicts such as funding for parochial schools and test results in Hasidic Jewish schools. Yet, clinics like primary care centers, pregnancy centers, and community mental health are often quieter examples of excellent engagement with the broader culture.

While schools are presented as positive and negative examples of cultural engagement, medicine has been overwhelmingly portrayed as a negative cultural influence in recent memory, especially among traditionalists and conservatives. We hear of medical horrors related to physician-assisted suicide, abortion, IVF, and human-animal chimerism (trigger warning) to name a few of the hot-button cultural issues today. Locally, however, Christian clinics are examples of consistently Christian social ethics in practice. Along with faith-based schools, they are some of the few organizations still presenting a cohesive, faith-informed vision to people of all backgrounds. Other faith-based institutions such as religious media, voluntary associations, and, of course, churches tend rightly to focus on the faithful.

These clinics tend to stay out of the limelight. Still, their advantage is in directing the local community’s resources to issues through the lens of faith with reason. Their local approach can be more high-resolution and can attend to those often overlooked by secular elite priorities. For example, this study I helped carry out with Esperanza Health Center when I lived in Philly looked at food insecurity (frequently being unable to get or afford enough food) in the areas they serve, which have high levels of homelessness and opioid use.

We found a much higher percentage (37%) of people were food insecure in their area compared to national levels. Many of these people differed from the typical picture of food insecurity in America. They were often of lower weight rather than obese, and they tended to be younger. We hoped an accurate picture of food insecurity would help this Federally Qualified Health Center better serve and understand their patient population. 

Subscribe now

Christian clinics are sites of creative problem-solving thanks to the staff’s common vision. These places model integrated, holistic health for their surrounding communities through church youth exercise programs, gyms, and nutrition programs. Some even have urban farms for teaching how to eat and grow nutritious food, like this initiative by another center, Lawndale Christian Health Center, in Chicago. They model primary care’s full potential by their broad scopes of practice and coordinating dental and mental health care. Walking through North Philly’s streets for Esperanza’s door-to-door health screenings and community health fairs, I got to witness their warm relations with their neighbors and their close partnership with local organizations for their common mission.

Not only do these centers embody consistent beliefs, but they also have the organizational ability to carry out the resulting vision. Therefore, they’re a hugely underrated opportunity for partnering to do research and invest funding. Theologians looking to understand ideas empirically or reflect on faithful practice should also look to these centers. I highly recommend trainees rotate in these settings to get a sense of what faith integrated with work could be like.

*See: Inguito, K., Joa, B., Gardner, J. et al. Differentials and predictors of food insecurity among Federally Qualified Health Center target populations in Philadelphia: a cross-sectional study. BMC Public Health 23, 1323 (2023). https://doi.org/10.1186/s12889-023-16208-3

• Esperanza hosts the Summer Medical Institute, a Christian medical outreach which is currently happening. You can pray for and support the participants here. I’m not currently affiliated with them but find them a great example of what I write about.

• I’m continuing to develop my speaking and teaching skills now that I’m in San Diego. If you’ve participated in any of my lectures or seminars and found them helpful, please consider leaving a review to help others learn about the experience!

For Joe, the best storyteller I know among our peers.

1. Bodies and normal time. Human bodies keep track of natural time and sacred time through our biological rhythms. But there are also addictive time and addictive rhythms that hijack biology.

Classically, humans have thought of time in two ways, as the ancient Greeks described well. It was usually only possible to experience time as chronos, as a linear measured progression, or as kairos, as events that give meaning to one’s life story in a community. Because time is interdependence between natural bodies, time governs us externally as physical contingency and as commitments. Time also governs us internally, as natural compulsions. 

The 21st century has brought forth different qualities of time. Only recently have humans and technology become able to hijack internal compulsions on a large scale and alter the quality of time itself. We’ve become able to experience time as non-natural and as non-event on an unprecedented level. I call this type of time anti-kairos. 

What characterizes the other two types of time, chronos and kairos, is connected interdependence. The old ties in chronos and kairos connect our internal clocks with either sequential events (chronos) or notable events (kairos) in the world. Internal clocks and good, normal compulsions, i.e. obligations that we feel in our bodies, correspond to real movements. Chronos and kairos tie the functions of the body to social and sacred activities in the world. We all share similar biological and cultural responses to universal chronological events, like the rising and setting of the sun or to the sensation of hunger. 

2. Conditions creating anti-kairos. Classic drugs of addiction (e.g. heroin) that produce distinct highs bring about anti-kairos. So do addictions of behavior for things like gambling, pornography, food, and some types of gaming. Finally, some mental disorders like sleep-wake disorders, schizophrenia, and forms of stroke can produce moments of anti-kairos for those suffering them. These conditions are included to highlight our need for building shared time and to understand the different individualizing effects of modern life, not to shame anyone struggling with such issues. 

Instead of shared biological and cultural responses, these conditions create individualized feedback loops. Such loops turn a person ever inward. Addictions create cycles of desire and reward that a person only shares with his craving, not even with his self. Normal desires like eating and relationships are put on hold, leading to problems with personal integration. 

Other disorders like schizophrenia create internal frames of reference that shrink perception of the world. Some people with schizophrenia experience hyper-consciousness and feel forced to over-consider everything: “levels of consciousness multiply” and create mental paralysis such that automatic actions like moving one’s leg become difficult, as psychiatrist and philosopher Iain McGilchrist notes (The Master and His Emissary, 394). If all moments are equally high-stakes, we have no narrative, no shared experience; moments need variation to be part of a narrative. A plot needs big and small points and highs and lows for comparison.

Subscribe now

3. Internal reference. For anti-kairos, the internal clock has no external reference, only an internalized technological reference. Therefore, anti-kairos is a severing of connection. Today, anti-kairos is much more common because we can manufacture new types of unnatural rhythm while removing natural rhythms. 

All medications and drugs take a certain amount of time to be processed in the body. They act for a time and then leave the body. We typically measure the time it takes for the latter as a drug’s half-life. Sometimes drugs have withdrawal effects. This timing is a property of the drug and of the person ingesting it, and with addictive drugs and behaviors, a person’s life starts to organize around that property. Time gets measured based on the last hit, the amount of time the high lasts, and how long it will be before cravings come back.

Since these unnatural rhythms are not shared, they take us out of social time. Yet, anti-kairos has an intrinsic and not just social quality of being meaning-emptying. This is because anti-kairos by nature engrosses the attention towards the moment in time as a truncated narrative, as all-there-is. The all-engrossing quality of anti-kairos, coupled with its nature as non-event, means that it stands apart from the life narrative—it feels larger than life when we’re inside of it, but it is really a negation of direction in life. In contrast, during chronos and kairos, one is aware of the context of life around and flowing into that time; the event is something the time has led up to and will move away from. Once the specific time is over, we can put it into perspective as an event that has some effect on our life story. 

With anti-kairos, once that seemingly all-encompassing event is over, it fades away, not to be recorded in our meaningful memory. So, the first few times using a drug are kairos—they have a huge role in a person’s life narrative, even if for ill. It is repeated use that begets anti-kairos. Then, using a drug becomes like every other similar moment, every hit of the same drug before it. 

4. Internal fulfillment. Like kairos, anti-kairos gives the feeling of being transported out of chronos. Yet, anti-kairotic times have no narrative aspect at all but rather destabilize narrative. Rather than becoming part of a larger life arc, each moment of anti-kairos is its own fulfillment, yet, it is non-fulfillment since the desires are not for real things. This narrative is therefore one of (non-)fulfillment of unreal desires. The fact that this is a narrative is apparent in the neurology accompanying such moments like addictive compulsion: a complete activation of the brain’s dopamine circuits that deal with wanting, seeking, and getting. Through the brain, we experience this whole arc all at once, with no loose ends to tie, except somehow overall unsatisfying. This completeness is one reason why the experience has no place to fit into the rest of our life stories, which are comprised of otherwise incomplete experiences (like chapters with teasers at the end).

5. Narrative challenges. Expect more anti-kairos to be produced before we can minimize it. Factors contributing to anti-kairos are growing. Addictive tendencies arise with increasing fragmentation, fueled by our medicalized and hyper-regulated ways of living. A fragmented, mechanical view of the world is growing. It’s also no wonder schizophrenia is associated with our modern organization of cities. A sense of time controlled by AI will further mechanize our views of the world and ourselves, breaking up our sense of meaning in time. In the world ahead of us, we’ll need the best of storytellers to show the meaning in such flat material.

Reads and mental connections for your enjoyment:

• With Ming Wilson and some other friends, I’m doing research on Chinese philosophy and music for a crazy semi-secret project. One interesting find: Chinese worship and speculation of a Supreme Being and source of divinity predate Plato and the West by hundreds of years, explained by the legendary Cantonese scholar Jao Tsung-I.

• I gave a bioethics presentation this week on the topic of unexpected death and was reminded of the father of modern medical ethics and medical humanities, Edmund Pellegrino. Maybe someone will take up his canonization cause someday if suitable. Pellegrino was one source of inspiration for the Winged Ox Forum, the Collegium Institute’s theology and medicine seminar group, which I directed in Philly and hope to visit soon!

• If you’re interested in an accessible philosophy group, check out this free hybrid seminar on Thomas Aquinas. It’ll be run by my friend Ammar, an accomplished philosopher and young executive from Dallas. I got to witness Ammar’s enthusiasm for philosophy as a social activity when we were Collegium colleagues.

Thanks for reading and staying in touch. If you enjoyed this or think someone you know would be interested in reading, please leave a comment or share this newsletter!

I’m writing this during a week of ICU night shifts. Consider this a kind of experiment to see how philosophy helps process thoughts and emotions, since night shifts leave a person in a mental fog. If it makes zero sense, please send critiquing memes! Despite being a night owl for writing, I somehow feel groggier at 10PM on night shift than at the same time after an active full day on a normal schedule. But, the feeling helps me consider the function of our internal clocks, which somehow connect our moods to movements of giant rocks and gas in space. Properly connected, the moods rise with the sun. When our clocks are misaligned, then anyone in caffeine withdrawal can tell you the effects.

Why do these connections exist? Objectively, time is a quality of connectedness. It’s the greatest networking tool since the beginning of, well, time. But subjectively, we feel time as a scarce and limiting thing, as contingence. Our measure of time is a measure of dependence on underlying reality and of interdependence with other people and nature. Time affects meaning in our lives depending on how we experience its ties.

The ancient Greeks recognized two of the ways we experience time. The first is chronos, sequential time or the time of duration. This is the time we’re inclined to measure in seconds, hours, days, etc. We experience this time as forward motion. It’s the sense of time associated with death, fate, and the unstoppable process of aging. 

The second is kairos, the time of occasions and opportunity, or what the ancients and biblical language describe as the “appointed time.” Kairos ties our actions to meaningful events that form a large part of our life narratives. 

Finally, there’s a type of time that’s become easier to recognize these days, which I call anti-kairos. Anti-kairos is time that takes you out of networks of meaning and into cycles of disorientation, and it’s associated with addictions and mood disorders. This will be a subject for another, shorter post. While we can measure chronos, we can’t make it, but we do have a part in creating kairos and anti-kairos. A meaningful life benefits from sharing chronos, creating and recognizing more moments of kairos, and minimizing anti-kairos.

2. Limits are creative substrates, like a canvas or page. Without the limit of the canvas, there’s nothing concrete for an event or narrative to hold onto, nowhere for a paint to stick. So, the limit of time creates the condition for our lives to be stories. The thread of time, woven into a canvas, is a measure of dependence and interdependence in the vertical and horizontal directions. The vertical is where we are relative to the earth and matter as well as to transcendence, like universal truths or our experience of God. The horizontal is relations with other people. 

Chronos and kairos are canvas-like substrates for sacred and social moments to emerge. They enable synchronicity: meeting others in time. Time is the condition for care because it eventually leads towards death. Chronos conditions our care for ourselves and for those with whom we share it because it is always towards death, so our limited time with others gains the quality of scarcity. Our being in chronos thus makes us “being towards death,” as Heidegger calls us (Being and Time).

3. Chronos and kairos are morally neutral. But, they determine the magnitude and effect of moral choices. Kairos presents an opportunity, but the combination of your decisions and others’ is what gives the opportunity a moral dimension. Whatever happens in that kairos is still bound to be meaningful to your life narrative. It just won’t necessarily be beneficial! Caesar’s assassination on the Ides of March was certainly an event that had a defining effect on his life narrative. Likewise, saying yes or no to a marriage proposal is your choice, but it will still be a defining event.

4. Bodies naturally track time, both chronos and kairos. Being attentive to the rhythms of the body helps us be aware of kairos emerging from our lives. Time is one reason life, especially human life, is considered in many cultures a reflection of the divine. Naturally alive bodies don’t just move within time. They carry in themselves markers during chronos that become, at periodic intervals, kairos. Therefore, a body can become a site wherein sacred events transform natural processes.

For example, the circadian rhythm is one of the body’s fundamental time measures. (Because it’s preserved at the cellular level and across many species, biology would call a sense of time “well-conserved,” something that’s a commonly expressed trait across time). All cells in our bodies and those of almost every other organism are regulated by a 24-hour cycle. Exposure to specific wavelengths of light from the sun keeps the cycle on track every day, or the internal clock will drift to around 24 and a half hours per cycle. Being just a little out of sync can add up every day, leading to serious problems.

This rhythm gives us one of the most basic natural rituals: greeting the light every day. This is a patterned behavioral response that the patterned structure of the world invites, hence a ritual: “There was evening and there was morning, the first day” (Gen. 1:5).  Keeping that ritual is natural. The ritual regulates our moods, makes our sleep efficient, allows us to metabolize food, and is an essential part of our physiologic and social processes. Breaking the ritual by frequently switching sleep-wake times or avoiding light makes us irritable and stressed, leading to poor use of nutrients and fat gain. We further reinforce the natural ritual by designating it as part of sacred time, e.g., through morning and evening prayers that open and close the day with mini-moments of kairos.

Similarly, the seven-day cycle reflects a natural division of time that gives opportunity for kairos. Numerous organ functions and some animal activities appear to follow circaseptan (seven-day) patterns, so that division into seven days is not arbitrary. A natural division of chronos allows us to recognize kairos when we consistently designate a day or days as reflecting certain meanings. Ancient Babylonian and Jewish cultures show the first notable discoveries of the seven-day cycle as a tie between natural and divinely sourced rhythm, most notably with the Sabbath. So, the work week benefits from a motivating structure and moves towards days of rest, family time, or worship. The natural and sacred structures precede the social structure surrounding these days but are also reinforced by the social.

Subscribe now

5. Social ties. This social reinforcement brings us to how time ties us to each other, in addition to the cosmos and our sense of the divine. Experiencing natural chronos alongside other people can make the everyday rhythm of life more enjoyable and leads to familiarity with others. Everyday events with another person in time become shared history. Sometimes these natural rhythms become kairos through the presence of others, like dinner with future in-laws or closing a business deal with lunch.

Eating together is a sharing of needs. Synchronizing our internal clocks creates intersubjectivity and togetherness. We all get hungry. Yet, three meals a day aren’t just a suitable convention for nutrition. Meal times enable a unity of our physiologic needs with others’ in time. This time ties groups of people like families together. Like metabolism, shared time extends the effects of the oneish-hour meal throughout social space and the rest of greater time, i.e. the 24-hour day. Hence why the symbolism of missing a meal for work or gaming or trivial pursuits is so damaging to home life and is anti-kairotic.

In those cultures that lack sacred time, tardiness is the worst. Relative to no sacred time, time only has value in terms of intersubjectivity. So, the social dimension of time becomes relatively most important. My time is the most valuable to me, and it gains the impression of greater value by compounding with another’s time. Older cultures with other values around time care less or differently. According to some of my friends, we’re not “late” but rather operating on “minority time!”

6. Social-sacred time. An added social element complicates sacred time. A moment of sacred kairos for a person, like in individual prayer, becomes a larger way of structuring social and even cosmic reality when shared with others. Jewish culture recognizes that sacred activities, shared in time, reverberate the effects of sacred time throughout space and chronos time:

“For in the seventh year there shall be a Sabbath of solemn rest for the land, a Sabbath to the LORD. The land will yield its fruit, and you will eat your fill and dwell in it securely. I will command my blessing on you in the sixth year, so that it will produce a crop sufficient for three years. When you sow in the eighth year, you will be eating some of the old crop; you shall eat the old until the ninth year, when its crop arrives.” (Lev. 25:4,19, 21, 22, regarding Sabbath and Jubilee years.)

Christian culture likewise recognizes this extension of social sacred time through space and ordinary time. Note the words of the Mass: “you never cease to gather a people to yourself, so that from the rising of the sun to its setting a pure sacrifice may be offered to your name (Eucharistic prayer 3),” and, “It is truly right and just, our duty and our salvation, always and everywhere (semper et ubique) to give you thanks.” 

The compounded social-sacred effect is a reason why calendars arise as sacred tools in cultures that discover or invent them. Calendars mark common events for the people to celebrate together. Even the French revolutionaries’ calendar was implemented as an (anti-)sacred device. Its twelve months of thirty days each, split into hideous ten-day weeks, facilitated planning holidays such as their Festival of Reason and Festival of the Supreme Being.

Share

7. Closeness and context. With kairos and especially sacred kairos, we gain a sense of cohesion to our lives because these times give us a feeling of context, of being tied to other formative times. The Canadian philosopher Charles Taylor describes kairotic events that reference other events as “closer” in time than chronological time (A Secular Age, 55). For example, your birthday this year refers to the day of your birth. It’s closer to that day all those years ago than it is to any preceding day this year. Similarly, for Catholic and Orthodox Christians, any celebration of the Eucharist is now the closest time to Christ’s Passion two thousand years ago. 

These references develop complexity as part of an unfolding narrative, but they aren’t flatly circular, like a repetition of history. Rather, in a good life, the references layer on one another, hopefully in an upwardly spiraling fashion. Note wedding anniversaries.

8. More meaningful time. To maximize meaning in time, respect the body’s rhythms and be mindful of the ways it keeps track of different types of time. Find ways of sharing time, especially biological time. Sharing chronos, including shared measurements of chronos in our bodies, gives a feeling of familiarity with time, surroundings, and others. Literally, familiarity is what leads women to share a time clock when they “sync up.” (Maybe the individualizing effects of the Pill aren’t just socio-psychological or between men and women but also biological and between women and women.) Pubertal rites of passage for young men in most cultures familiarize groups and form identities in a shorter period of time, like a narrative pressure cooker. For our anti-traditional culture, we must either renew or reinvent traditions recognizing defining moments in the body’s time. Traditions recognizing bodily and sacred kairos will help us feel tied together rather than fragmented as bodies, social beings, and story-less characters all running on different timelines.

Life becomes more meaningful the more interconnected and developed one’s threads of time become. Events in which biological, social, and sacred time tie together bring the greatest sense of meaning. When these events connect to similarly layered events later in life, one has a meaningful life. Tying together events happens through references shared between the events themselves and through the events’ effects reverberating in our life narratives.

Share

For the sons of this world are more shrewd in dealing with their own generation than the sons of light. And I tell you, make friends for yourselves by means of unrighteous wealth, so that when it fails they may receive you into the eternal dwellings. If then you have not been faithful with the unrighteous wealth, who will entrust to you the true riches?

Luke 16:8-9,11, ESV Catholic ed.

When I was leading theology and medicine seminars in Philadelphia, one question we struggled with as medical trainees was how our finances and settings of practice and had moral significance. ’s work appeared in most semesters of our two-year curriculum to bridge the gap between moral-theological foundations and on-the-ground practice. So, it’s fitting that my new foray into writing mention his newly released book, Life in the Negative World. Christians and moral conservatives will benefit from its insights, which warn against mission drift and advise adopting the strategies of a moral or cultural minority.

Renn’s book builds on a model featured in several of his essays such as his 2022 First Things article. The model describes different phases of relationships between Christianity and the surrounding culture during Christianity’s decline in the West, from the 1960s to today.

Initially, identifying and acting as Christian garnered status in elite settings. This situation gave way to neutral and now negative perceptions towards Christianity, such that holding and practicing Christian ideals now damages one’s social standing. Each of these eras saw its own cultural engagement strategies emerge. The era of positive perception featured strategies such as “culture war,” whereas prominent Evangelical figures in the neutral era preferred a “faithful presence” approach. 

The latter approach, typified by pastors like Tim Keller and practitioners like Francis Collins, aimed to place Evangelicals in semi-elite positions as a Christian presence. Such Christians minimized conflict with secular culture and emphasized Christianity’s fulfillment of or agreement with that culture. While successful at gaining some converts, “faithful presence” has attracted criticism for frequent moral compromise and for accelerating policies hostile to Christian ideals. These approaches are largely ineffective now that the culture is explicitly post-Christian, but no new approaches have emerged for this current era. 

As one studying religion and its social effects, I’ve observed these trends in cultural strategies with interest and am thankful for Renn’s analysis. After all, Evangelicalism has been the dominant expression of American religion the past few decades. Any changes in the movement will affect the cultural environment and even the health of all Americans. More personally, as a Catholic former Baptist with many Evangelical friends, part of me will likely stay Evangelical at heart, and our moral communities continue to have much to learn from each other.

Feeding the mouth that bites you

I’d venture that more than in any other profession, Christians in medicine exemplify the neutral world elite strategy and furthermore share the Evangelical discomfort towards “the very idea of elite-ness” (77). We seek elite positions but refuse to identify as elites with elite responsibility (noblesse oblige). Medicine predictably draws a large number of Christians and other altruists high in the conscientiousness personality trait. Conscientious but typically low- or medium-openness professionals like physicians, engineers, and sometimes even professors like to focus on the nitty-gritty. They leave questions of vision to their executives and administrators whose numbers have mushroomed.

Many of us believe that by adhering to a strong work ethic and a prescribed career course, we’ll achieve financial security while living meaningfully and helping others. We work hard and keep our heads down. Supposing that it doesn’t matter under what practice structure we operate, we choose the most convenient options. Hence the majority of professionals choose to be employees in cosmopolitan settings rather than exercise local leadership. 

In so doing, we offer crucial labor to hospital conglomerates, academic centers, and multinational corporations run by people hostile to Christian morality. Such organizations stifle competition, promote procedures destructive to bodily and psychological integrity, and lobby for abortion and other issues opposed to our moral communities. Contributing to these institutions undermines our own interests and the common good. As Renn argues, Christians should consider revoking their institutional investment and redirect their energies to strengthening their own communities’ integrity.

Subscribe now

Minority strategies

Renn offers a number of practical strategies to promote integrity at the familial, community, and institutional levels while mitigating the “negative consequences of living in a lower-trust society” (161). Essentially, these are strategies for becoming uncancellable. Those unworried about losing sources of income from being fired or sued will be much more likely to live out biblical marriage, educate their children as they wish, or advocate historical Christian positions on controversial issues. Example strategies include FIRE (financial independence, retire early), pursuing ownership of real estate and means of production, and high-trust business networks based on familiarity and local excellence as opposed to faceless global meritocracy: 

Ownership of assets—institutions like schools, our economic life, social and cultural space, and even real estate—will be increasingly important for evangelicals in a world where the mainstream institutions of society are both degrading in their competence and increasingly hostile toward evangelical values (Life in the Negative World, 142).

Many of these approaches were previously unknown to many Evangelicals. Therefore, some of these strategies could have been better fleshed out in the main text, although there’s great value in the notes section. Renn leaves much more controversial information, such as data on intersexual dynamics and singleness in churches, in these references. Since he already included many Bible references, I do wish he’d ventured into some theological analysis to give the book more lasting appeal. He briefly mentions H. Richard Niebuhr’s Christ and Culture, which I re-read alongside the book and found helpful for demonstrating the theological “end game” of each cultural strategy. 

Renn borrows from other traditions (Catholics, Jews, Orthodox) to develop Evangelical strategies. He likewise could’ve offered constructive criticism for how social conservatives from those or other traditions could learn from Evangelical strengths. He pulls punches when mentioning other groups’ political strategies, such as the Catholic avoidance of grassroots work in favor of top-down rulings, which resulted in poor outcomes for the pro-life movement (see 46). 

This diplomatic tone of writing has been consistent over the past few years and is still commendable, and many may prefer how the book’s overall style reads as an extension of his newsletter. Many of his recommendations apply to moral and cultural minorities in general and will be useful to a diverse audience, provided readers understand the book’s Evangelical coding.

Some strategies like FIRE and creating employment opportunities are out of reach for most people. Yet, that means Christians with stable professions or higher socioeconomic status have a special role to play: rather than downplay Church teaching to preserve their status, they must (1) be willing to sacrifice, and (2) create the conditions and resource networks that will make sacrifice more attainable and fruitful for their brethren and for themselves. This book makes sense of longstanding, unarticulated cultural undercurrents, and the practical and theological consequences of sacrifice in a post-Christian era will need more unpacking. I hope this book will become one early example among many for reframing this era’s challenges, which are opportunities for honing new leaders and getting Christians of different backgrounds to collaborate for mission.

Aaron Renn, Life in the Negative World: Confronting Challenges in an Anti-Christian Culture. Zondervan, 2024.

Every treatment has a therapeutic dose and a toxic dose. The dose makes the poison, goes the adage attributed to Paracelsus, the legendary Renaissance physician. For that reason, nearly every health intervention has an established therapeutic dose range. One notable exception today is therapy. I’ll discuss why we need individual limits to therapy today and leave the societal effects of too much therapy for another part.

Limiting interventions is prudent for both individuals and society. Usually, when establishing a drug’s safety profile, researchers first examine its toxic and therapeutic effects on the individual level. Individual adverse effects are often analogous to larger effects.

For instance, antibiotics can alter individual gut microbiomes, killing beneficial gut bacteria while leading to overgrowth of antibiotic-resistant inflammatory bacteria.1 Similarly, overuse of antibiotics among a population leads to emergence of dangerous antibiotic-resistant “superbugs.” Yet, antibiotics save millions of lives and were a main driver of the Golden Age of Medicine, demonstrating how our most valuable interventions need stewardship if they are to remain beneficial and not harmful to us. They are extraordinarily useful so long as we take them in extraordinary circumstances.

For mental health interventions, popular culture takes the opposite approach. Sleek ads abound for on-demand therapy. Young people share and compare therapists like gossip. Some even see not going to therapy as a dating or friendship red flag, though this pressure has rightly received pushback.

Removing stigma to improve access to mental health services is important but shouldn’t remove critical thinking about risks and benefits. It’s not a given psychological interventions will be helpful for all individuals. Even vitamin supplements have individualized tradeoffs, so we make informed decisions to take them.

Too much of a good thing

Where did this assumption of limitless therapy being a good thing come from? I’m not sure, though I have some ideas. Perhaps commercial interests profit from pathologizing normal parts of life, especially now that online therapy platforms are popular. Maybe the sociocultural trend of atomization has made reliance on friends and family taboo and outsourced their everyday support to therapy. Or, once-widespread effects of religion—community, moral frameworks, organizing life path narratives, etc.—are gone, leaving a void replaced with therapeutic coping mechanisms.2

Regardless of how this therapeutic expansion happened, its effects on individuals show the consequences of too much of a good thing. Unbounded use of therapy leads to stasis and complacency. People would rather talk than take action to change: having therapy always available means always an opportunity to talk, removing the impetus for timely change. 

Therapy can also lead to emotional fragility. Reliance on the presence of a therapist to deal with events and emotional reactions to events can become an ingrained habit. Some reliance (transference) is a necessary part of the therapeutic relationship.3 It’s like training wheels for emotional regulation, so that one can learn a regulated response within the relationship before learning to self-regulate. Real personal crises can certainly require brief reliance on that relationship to get back to equilibrium. However, treating that relationship as the main automatic response to stress keeps a person emotionally dysregulated towards everyday events. If I learn to cope using the therapy itself and not the skills I learn in therapy, I lose the ability to see events in perspective and evaluate them as things to which I can control my response. Losing that response control will mean more and smaller things can set me off.4 When something truly big comes along, I’ll have lost the ability to cope with it.

Furthermore, there’s a risk of the therapization of life. This risk will become more important regarding social effects (stay tuned for part 2), but it’s still a problem for individuals. Psychology is just one way to look at the world, not the way. Seeing the world in exclusively psychological terms is a path to cynicism and an impoverished view of the world. There are transcendent parts of the human experience, and whatever is beautiful, good, and true extends far beyond psychology’s bounds. Turning therapy or psychological thinking into one’s personality is unhealthy.

Subscribe now

How to dose

One could argue that these effects only result from bad therapy. Yet, good therapy is necessarily dosed. Effective therapy, as with any treatment, has doses and delivery methods corresponding to specific goals and diagnoses. Cognitive behavior therapy (CBT), for instance, started off with dosing. Aaron Beck and colleagues, who developed CBT, saw disadvantages to the more meandering, unstructured approach of analysis. A dose of 8-12 sessions moves progress and allows checkpoints for assessing the therapy’s effectiveness.5 CBT currently has the most robust evidence base and has long-lasting benefits. Its average time to resolving a depressive episode is 3-6 months.

Contrast that with traditional psychoanalysis, which lasted on average 5-7 years.6 That’s at least five times longer than the average depressive episode takes to resolve without treatment, which is 6-12 months.7 It would seem then that unlimited dosing might even prolong depression!

Interestingly, the current-day inheritor of the analytic approach, psychodynamic therapy, is quite effective, with outcomes at least as good as CBT depending on the condition; it, too, often has a prescribed dose of 12 sessions.

Not to say doses have to be rigid. Good treatment adapts to individual variations and situations. Patients and clients should also feel free to re-dose and seek help as needed if significant mental health problems emerge. But one should know that re-dosing is for a specific condition one is having evaluated. 

Several months ago, I was asked to summarize a review article of an online therapy topic for another journal. One of the studies included in the review noted an increased risk of adverse effects with online therapy. The study was small and very uncertain, and I initially didn’t think of mentioning it. At the time, adverse effects from therapy sounded ridiculous! After doing some more thinking and reading, however, I can now imagine various ways problems might develop. Online therapy is both the most available and the least embodied form of psychotherapy so far. While improving access is good, using therapy judiciously becomes more difficult if I have it at my fingertips. And, by making everything a potential indication for therapy, we make therapy less effective, or even an anti-therapy that makes us less resilient. 

To help therapy work for us, we need to bound it and give it a circumscribed place in our lives. It’s one occasional intervention among our normal, everyday support networks of friends, family, and community that make up much of human flourishing.8 Therapy shouldn’t supplant them but should encourage us to venture into deeper involvement with the people given to us. Using therapy this way, we’ll have a better chance at the mental clarity we seek.

Update: See part 2 here.

If you liked this post, please share it and help grow my newsletter!

Subscribe now

Welcome to my newsletter!

If you’re reading this, you’ve either read one of my previous newsletters, attended a lecture or seminar I’ve led, or supported my journey in theology and medicine. So, thank you!

After encouragement from friends and loved ones to put my thoughts on a writing platform, I figured this time of year after my licensing exam was as good a time as any to oblige. May this newsletter provide at the very least entertainment amid the winter doldrums. Hopefully it will also give you material for action, reflection, and exchanging ideas.

As to the contents of these thoughts, they’ll mostly cover three areas: (1) Re-enchantment and meaning-making as solutions to addictive behaviors, from the perspectives of medical and psychological sciences, philosophy, and theology, (2) practical ethics, and, (3) commentary on my and others’ recent medical and psychological research, especially in addiction. The last area was a suggestion from people who were interested in my research topics but found my and other scientific writing too dry and overwritten. The writing styles journals encourage are clunky and also discourage drawing deeper moral or theological implications. I’m still learning to optimize my writing in those settings.

In the meantime, I’m indebted to those who told me to rewrite the way I would’ve wanted. I’m excited to include the style and philosophical commentary that should accompany some of these articles. Basically this newsletter lets me make a “Taylor’s version,” or Brandon’s version, of any academic articles (instead of music albums).

While I’ll do my best to stay focused on those listed topics, my distractible family med brain sometimes redirects me to other topics up to and including actual theology. Thankfully, this medium encourages practice and feedback, so please let me know what I might improve on and what you’d like to see more discussed. I’m aiming to put out a few essays first and then a new piece every 1-2 months along with links to other work. As pieces come out, please share this with anyone you’d think would be interested. (And of course, I wouldn’t be offended if this isn’t your thing and you’d rather opt out/unsub early.) I’d love to hear from all of you. With that, may discovery and meaning-making commence!