The Valorization of Sadness: Alienation and the Melancholic Temperament

Alienation and the Melancholic Temperament At the heart of Listening to Prozac is a thought experiment: Imagine that we have to hand a medication that can move a person from a normal psychological state to another normal psychological state that is more desired or better socially rewarded.[1] What are the moral consequences of that potential, the one I called "cosmetic psychopharmacology"? The question would be overgeneral except that it occurs in the context of a discussion of psychic consequences of technologies. People now experience the self in the light of psychotherapeutic medications as lately they experienced it through psychoanalysis. In the thought experiment, the medication we are to imagine is rather like Prozac, and the less desired state is something like melancholy, when that term refers to a personality style rather than an illness. Melancholics are well described in literature that stretches back for centuries. They are pessimistic, self-doubting, moralistic, and obsessive. They have low energy but use that energy productively. They are creative in the arts. They are prone to depression, especially in response to social disappointments. Listening to Prozac argues that the important action of new medications may be on the melancholic temperament as much as on depression, although the two are presumed to be related. The book's assessment of cosmetic psychopharmacology begins with the observation that for decades, psychotherapy has been the technology applied to melancholy. In this account, psychotherapy includes approaches, such as supportive or strategic therapies, in which self-understanding is not the means or end of cure--where the goal is change in affective state merely. Asking why cosmetic psychopharmacology makes us so uneasy, I did not neglect to consider the targets of treatment--in particular, claims that suffering is an indicator of the human condition; that psychic pain serves an adaptive function; and that melancholy is an element of authentic self. But since the premise of "cosmesis" is movement from normal to normal, the post-treatment state as much as the pretreatment should meet the criteria of Darwinian fitness and human completeness. And those who hope psychotherapy succeeds must be comfortable with the diminution of melancholy. For these reasons, I came to believe that a critical element in a principled objection to cosmetic psychopharmacology must involve the method of change, namely, medication, more than the goals of intervention. To my delight, moral philosophers have taken up this thought experiment, particularly the medical ethicist Carl Elliott, in a series of essays distinguished by their literary appeal. These discussions are a continuation of Listening to Prozac, but they are also a form of backtracking, because the element that interests Elliott is cosmesis's goal. Elliott is worried about the diminution of alienation. I hope here to use Elliott's essays to ask, as rule-keeper for a certain sort of game, whether the concept of alienation successfully identifies grounds on which cosmetic psychopharmacology might be morally suspect. At the same time, I will want to reopen the issue of the legitimate goals of treatment. To preview my conclusion--my impression is that the concern over Prozac, and with imagined medications extrapolated from experience with Prozac, turns almost entirely on an aesthetic valuation of melancholy. Elliott's central claim is that addressing alienation as a psychiatric issue is like treating holy communion as a dietary issue--a category mistake. Included in this claim is the understanding that alienation has a particular moral worth. Neither of these assertions strikes me as obvious. In particular, I want to say that both are thrown into doubt by a premise of our discussion, namely that medication can lessen alienation. The nature of the technology may cause us to reassess the category, and the significance, of the target. …