If placebos have been squeezed out of medicine to the point where their official place is in clinical trials designed to identify their own confounding effect, the placebo effect nevertheless thrives in psychotherapy. Not only does psychotherapy dispose of placebo effects that are less available to medicine as it becomes increasingly technological and preoccupied with body parts, but factors of the sort inhibiting the use of placebos in medicine have no equivalent in psychology. Medicine today is disturbed by the placebo (...) effect in a way psychotherapy is not. Psychotherapy does not have to grapple with such a disconcerting paradox as successful sham surgery, and unlike those physicians who once pretended to treat the patient’s body while actually attempting to treat the mind, the psychotherapist can treat the mind in all frankness. Perhaps it is because psychotherapy is less burdened by doubts about the placebo effect that it was able to come to its aid when it was orphaned by medicine. It is vain to expect something with so long a history as the placebo effect to disappear from the practices of healing. (shrink)

Narrative medicine is predicated on the importance of narrative to human life. Although that in itself is not controversial, an extension of this principle that has sprung up in narrative psychiatry—namely, that by coming to imagine a different life story one can become a different person—ought to be. One reason one cannot remake one’s life in the image of a story is that life is not to be mistaken for a story in the first place. The seminal study of psychotherapy, (...) Persuasion and Healing, although recommending that the demoralized absorb more uplifting stories about themselves, appears to recognize some limit to the possibility of modeling life on story. The same study likens therapeutic stories to placebos, but as it happens, placebos themselves have their limits, alleviating symptoms but not curing or “healing.” In order for someone to become a different person through the agency of the placebo effect, it would have to be more robust than it is. The argument that life follows narrative is an ironic one for a discipline devoted to narrative to make, given the salience in the tradition of the novel, from Don Quixote forward, of works that explore the fallacies of that presumption. In keeping with its attention to narrative, this article challenges the use of a short story by Chitra Divakaruni as an illustration of the principles of narrative psychiatry. (shrink)

When prostate-specific antigen (PSA) testing was introduced, proponents expected it to cut prostate-cancer mortality and did not expect it to unleash an epidemic of unnecessary treatments. Now that evidence of a mortality benefit remains unclear while evidence of overtreatment in undeniable, there is understandable interest in reducing the human costs of the PSA system. Two related drugs, finasteride and dutasteride, both proven to reduce the incidence of prostate cancer and the ?risk of diagnosis,? are being promoted accordingly. However, if not (...) for the flaws of the PSA system the use of these drugs for purposes of prevention would lose its rationale. Not only are the drugs in this sense dependent on a faulty system, but their own mortality benefits are as speculative as PSA's?in addition to which, they introduce new risks. (shrink)

Over the decades of experimentation on the placebo effect, it has become clear that it is driven largely by expectation, and that strong expectations of efficacy are more likely to give rise to the experience of benefit. No wonder the placebo effect has come to resemble a self-fulfilling prophecy. However, this resemblance is considerably exaggerated. The placebo effect does not work as strongly as it is advertised to do in some efforts to elicit it. Half-truths about the placebo effect are (...) now in circulation, reinforced by a number of other equivocations that it seems to attract. As the deceptive use of placebos has fallen into discredit, the use of half-truths and exaggerations—neither of which is technically a deception—becomes an ever more inviting possibility. However, there are risks and costs associated with the half-truth that the doctor possesses the power to make his or her words come true by the alchemy of the placebo effect. (shrink)

In the late 18th century two medical fashions—Mesmerism in France and the Perkins ‘tractor’ in the USA and England—appealed to the principle that a single universal force acts on all of us and is responsible for health and illness. This principle served both fashions well, as it made it all the easier for those who came within their force fields to experience the sort of sensations that other subscribers to the fashion also seemed to feel. The first research on what (...) is now known as the placebo effect was in connection with these two movements. The propensity to feel what we suppose or imagine that others like us feel remains even now one of the channels of the placebo effect. (shrink)

The publication in January 1972 of what came to be known as the Feighner criteria marked an epoch in the history of American psychiatry. At a time when many psychiatrists were indifferent or even hostile to the niceties of diagnosis, and when conflicting interpretations of similar cases threatened the reputation of the profession itself, the Feighner criteria laid out specific rules for the diagnosis of 16 disorders, from depression to hysteria, from alcoholism to anorexia. Never before had the identifiers of (...) such an array of conditions been codified so precisely. At once detailed and pragmatic, the Feighner specifications furnished a model and precedent for the Research Diagnostic Criteria... (shrink)

In its quest for converts medieval Christendom locked itself into a vicious interpretive circle, pressing unbelievers to join the Christian community and then suspecting them for doing so. Such suspicion drove the Inquisition. An Inquisition whose torture machinery grinds on century after century, as if each execution laid the ground for another, represents a closed system alien to a literary form, the novel, whose English name suggests "the new." As befits a form set in "the present day with all its (...) inconclusiveness," the novel offers a medium in which uncertainty can flourish. In the novel uncertainty is not an intolerable anomaly introduced by converts practicing an ancestral religion in secret, but a condition of human life. (shrink)

Internal blockages and build-ups cause disease: traditionally, this principle seemed intuitive both to professionals and the laity, explained conditions as diverse as melancholy and scurvy, and justified the use of evacuative treatments to get rid of noxious matter. With the collapse of humoral medicine and the establishment of the concept of specific causation, one might have expected time-honoured tropes of obstruction to die off. They did not die off, but moved with the times and adapted to new conditions. Emphasis swung (...) from the noxious character of retained substances to the harms of suppressed urges and emotions—harms including disabling maladjustments as a result of sexual inhibition, and cancer as a result of emotional inhibition. In both cases the causal mechanisms resemble traditional blockages. Theories of noxious inhibitions or psychological blocks, which have a familiar and perhaps even intuitive sound because they have so much history behind them, can easily lead patients into fanciful methods of prevention and treatment. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page W1-W2, December 2011.

'...a new and important reading of Mill that bridges several disciplines. It is essential reading for anybody concerned about the delicate fabric of our republican tradition....The work is scholarly, insightful, and written at a level that makes its important message accessible to student, scholar, and layperson.'-Scott G. McNall, University of Toledo.

It's common knowledge that published medical findings tell only part of the story, the other part consisting of unpublished records of negative trials, sometimes of the same agents. No one, of course, knows precisely how much lies below the waterline, but informed estimates suggest that as many as half of all trials undertaken remain unreported —a percentage sufficient to cast a shadow over the entire corpus of published medical research. The effect is incalculable. That negative findings of trials of cancer (...) chemotherapies would be withheld from publication seems inconceivable, but a paper documented that practice, and its slanting effect on the published literature, some 30 years ago.... (shrink)

While medicine may agree in principle that cancer screening requires informed consent, such consent is not, in fact, common practice. In the case of prostate-cancer screening this means that men in large numbers undergo PSA testing with little understanding of its liabilities – in particular, that it may or may not decrease mortality, often detects cancer of questionable significance, and may lead to unnecessary surgery. Given that prostate cancer is known to be overtreated and that family history is a risk (...) factor, it follows that a man diagnosed with prostate cancer, even if it is of no clinical significance, automatically promotes his son into the high-risk category; and given that those so categorized are subject to heightened medical surveillance and that the more diligently medicine searches for prostate cancer the more likely it is to find it, it follows that the sons of men diagnosed as a result of PSA testing are at risk of being overdiagnosed (and overtreated) precisely because their father was. Twenty years into the PSA revolution, its generational consequences have not been discussed in the medical literature. (shrink)