Re: “Penicillin of the Mind” by Vivian Rakoff (April 2008), the best cures are out of fashion. If you’ve humiliated a defenceless friend, try a dose of guilt-easing self-flagellation; if jealous because your lover has cheated on you, send him to the guillotine. Since I doubt that guilt and jealousy are diseases, it is moot whether these are cures. The same goes for our psychiatric patients: since I doubt that anxiety, despondency and extreme oddity are diseases, it is moot whether shocks, drugs and psychotherapy are cures. That is why psychiatrists do neither physical examinations nor diagnostic tests. Through conversation, we assess our patients’ social practices, then diagnose them as normal or pathological—evaluative euphemisms that stand in for approval or disapproval. Like literary critics, we are social adjudicators: the former appraise artistic performance; we appraise behavioural performance.
We have given up on whips, guillotines and blood-letting—and (mostly) on electric shock treatment: it is out of fashion. It is not that ECT does harm; running a marathon and a good pummelling at the hands of a favourite dominatrix may well wipe out more neurons than a modern ECT machine. Harmless or not, physical treatments are no longer our style. I expect that the hopes of Edward Shorter and David Healey for a resurgence of shock therapy will be dashed; since psychiatric treatments are social practices, deeply rooted in tradition, we will use ECT only in cases so extreme that dramatic measures are called on.
Pharmaceutical cures are more refined, but it’s well known that, if effective at all, antidepressants are barely better than sugar pills. Until therapeutic fashions change, doctors will prescribe and patients will ask for antidepressants. Then another pill, herb or diet will take over. Like meeting with a talking doctor, swallowing things is one of our permanent infatuations. Vivian Rakoff is right that prescribing medications is, and always will be, popular, although, like for those given ECT, there is no medical sign of anything that drugs could cure. Except for those pesky testimonials, the ones gleefully collected by quacks and charlatans—and fools.
Finding the right talking doctor is as tricky as finding the right pill. My bias is to tell you to pick someone who has thought seriously about Freud, The Brothers Karamazov and cultural anthropology, but lots of those who love Mick Jagger, read The Da Vinci Code and attend to the musings of Oprah Winfrey are perfectly good talking doctors. My ex-wife once said that marriage is luck. Well, finding a good talking doctor is luck, too.
Gordon Warme
Toronto, Ontario
