A recent WIRED essay, "The Painful Truth About Long Covid," argues that research into the illness has been captured by patient advocates who insist it is purely biological, and that this insistence has made it impossible to study mind-body treatments with an open mind. The piece will anger nearly everyone who has staked a position in this debate. So, I expect, will this one. That two writers can provoke the same people from opposite directions is worth pausing over before we ask who is right.
Here is what I have come to believe after years of treating these patients: the data both camps need is already in front of them, and it is not the data that divides them. Both sides can read the same trials, the same failures, the same absence of a single approved treatment or confirmatory test. What separates them is not evidence but narrative — the story each side tells itself about what this illness means. The advocates carry a story about trauma and betrayal, earned across decades. The recovery communities carry a story about wellness and the power of the mind to heal. The essayist carries his own, an evident preference for reading fatigue as something to be talked out of. Each story generates certainty the evidence does not support, and certainty is what makes the fight so bitter. So if I am going to answer, I will not answer with a wall of citations that neither camp lacks. I will answer with stories, because that is how human beings actually understand a thing. I have four.
The Baby and the Sword
The oldest of them comes from the Book of Kings. Two women come before Solomon, each claiming to be the mother of the same infant. There is no test, no witness, no way to adjudicate the claim. So Solomon calls for a sword and orders the child cut in two, half to each woman. One woman agrees: if I cannot have him, neither shall she. The other cries out — give her the baby, do not kill him — and by her willingness to lose the child, Solomon knows she is the mother. The lesson is usually remembered as clever judging. Its actual lesson is about who is willing to surrender a claim in order to keep the child alive.
Long COVID is the baby, and the sword is already raised. One camp will have the illness be wholly biological; the other will have a way forward through the mind. Both, if you watch closely, would sooner see the patient divided down the middle — the body assigned to one court, the psyche to the other — than concede the claim. The essay does this. It diagnoses a discourse deformed by confident people who do not grasp what they are discussing, and then presses the science in its preferred direction with the force of anecdote and the heat of grievance. An argument that we must study these treatments dispassionately, written so that no one possibly could, cuts the child. And the advocates, when they answer such a piece by demanding the author's silence and attacking the man rather than the claim, cut it from the other side — and in doing so confirm the very caricature of a closed and frightened community that the essay drew of them. I do not think either party is cruel. I think each would rather win than relinquish, and the winning is what does the harm.
The physician's task, if the parable means anything, is to be the mother who lets go. I have given up the vindication my training would let me claim — the insistence that a dual board in neurology and psychiatry entitles me to be believed about the mind's role in this illness. I have given it up because insisting on it would cost me the patient. In the story, that surrender is not weakness. It is the only evidence of love that counts.
The Vaccine
A vaccine works by a small deception. You take a fragment of a threat — a fraction of a virus, too little to cause the disease — and you show it to the body. The immune system, primed by the preview, builds a defense, so that when the real thing arrives it is met and defeated. It is one of the most elegant ideas in medicine: resistance, deliberately cultivated by a dose too small to do the work of the illness itself.
The patient community has been vaccinated against psychological thinking. For decades, people with this family of illnesses were told they were lazy, or hysterical, or cursing themselves with false beliefs about their own bodies. A large and famous trial once concluded that talk therapy and exercise were the answer, and a generation of patients experienced its recommendations as harm; some were investigated as if their own illness were a fabrication or a danger to their children. That history was the antigen. The community developed resistance to it, and the resistance was rational — it was earned, and for a long time it protected people from real mistreatment.
The trouble is that immunity can be cross-reactive. The body sometimes learns to attack not only the pathogen but anything that resembles it closely enough — a healthy tissue, say, that happens to share a surface feature with a virus. The patient community's defense now works this way. It cannot always tell the pathogen from the cure. It attacks effective and useless interventions alike, because they share surface features — the words nervous system, retraining, fight or flight, psychology — with the rhetoric that once did damage. When I meet a patient who cannot hear the word "psychiatry" without flinching, I am not meeting ignorance. I am meeting a defense that was correct for years and has begun to injure the one it protects.
And here the story stops being only a story. The most coherent current picture of Long COVID is one of immune dysequilibrium — a system that will not return to rest after the infection has gone. The immune system also happens to be one of the places where the old wall between mind and body plainly does not stand: psychological states measurably alter immune function, and immune signals measurably alter mood, cognition, and fatigue. The traffic runs both ways, and it is not mystical; it is chemistry that can be sampled. Which means the barrier both camps are defending — biology on this side, psychology on that — does not exist in the biology itself.
They are fighting over a border that the body does not recognize. The immune system is precisely where "physical" and "psychological" turn out to be two descriptions of one process — which is why a treatment aimed at the mind can move a measurably physical symptom, and why that fact should surprise no one.
If that is so, then a piece like the WIRED essay does something worse than annoy. Every provocation is another exposure. It does not open the community to careful treatment; it raises the resistance. It is a dose too small to accomplish anything and just large enough to inflame — which brings me to the next story, because a dose too small is not a harmless dose.
One Tablet of Ten
Imagine an infection that will yield only to a full course of an antibiotic — ten tablets, no fewer. Give all ten and the patient is cured. Give none and you treat the wound another way and hope. But give one, and you have done the worst available thing: not enough to cure, and enough to teach the surviving organisms to withstand the drug. The next course, even a complete one, works less well. A partial dose of the right medicine is how you manufacture resistance to it.
I believe some of my patients could be helped by treatments the community has been inoculated against. Neuromodulation — vagus nerve stimulation, transcranial direct current stimulation — carries the best evidence among them, though it is still early. Psychotherapy has real promise in the right hands, at the right intensity, begun at the right moment. But intensity and timing are not details; they are nearly the whole of it. And here I have to say the thing that will be quoted against me: I often do not offer these treatments, even when I believe they could work. Not because I doubt them — because I practice in a system that would let me begin a course I cannot finish. A handful of insurance-permitted visits. Few local therapists I have vetted to treat this illness rather than to mishandle it. An effective therapy delivered at an ineffective dose does not simply fail. It teaches the patient that the therapy failed, and it strengthens the very resistance I would have to overcome to try again.
So I keep that tablet in my pocket. I clean the wound with what I have, bind it, advise frequent dressing changes, and I do not administer one dose of a ten-dose cure. I am not proud of this. I think, given the constraints I actually work within, it is correct.
Jesus Drank
The last story I was told as a child. A devout woman was holding forth on the moral evils of drink. A man reminded her that Jesus himself had turned water into wine at Cana. "I know," she said, "and I'd like Him a good deal better if He hadn't."
I think of her often. Most of my patients know I trained in psychiatry, and I am fairly sure that many of them, like the woman with her wine, would like me a good deal better if I had not. They have their reasons, and their reasons are not foolish. I have made my peace with it. I would rather be the physician they mistrust a little and return to than the one who was proven right about them and lost them for it.
I do not think I can fix this debate. The two camps are unlikely to be moved; the provider already settled in one of them will probably stay. Those are not the readers I am writing for. I am writing for the patient in the dark room, and for the provider still close enough to the edge of a camp to be nudged out of it. To them I would say only this: the child on the table does not need to be divided, and the wall being fought over is not there. What is required of us is the willingness to lose an argument in order to keep a person. I have not managed to end the war. I have only decided which mother I intend to be.