“Literalism is idolatry, taking shadows for reality…letting the metaphors go dead, and then, when dead, bowing down before them.” - Norman Brown, Love’s Body
Introduction
The argument that follows below — that our prevailing and stubbornly indomitable paradigm of medical psychiatry stands on the wrong side of a fault line that would not be too much to call civilizational — proceeds as a series of numbered statements. This is not out of a pretentious gesture to fashion some Tractatus Psycho-Pharmacologicus or any kind of airtight logical system. Instead, its modular construction both condenses an otherwise sprawling web of thoughts into a package compact enough for people to maybe actually read, and more importantly, was easy to begin working with after my entire brain had been burned to ash by a bad reaction to an SSRI.
Those who know me know firstly that my whole perspective of the world jumps off from the collision between a cluster of perverse neo-illnesses gathered after a decade-and-a-half psychiatric treatment and the practitioners who have seen in those illnesses only further evidence of an inner pathology. It’s tempting to try to give a full, lurid account of that contest, but doing so would weigh this down with the unbearable stuff of cloying trauma memoirs. But I’m forced to give one so illustrative it almost seems fictional, from a stay at a Philadelphia inpatient ward overseen by a Ratched-spirited charge nurse. Just like Nurse Ratched, she ran the ward like a capo and relished in doling out punishment, and overall found ways both subtle and obvious to make sure you knew she fucking hated you. On my first night there, I asked for a sedative to relax and was given the first-generation antipsychotic Haldol, whose side effects can include dystonia, a form of muscle contraction that results in the kind of terrifying contortions canonized in psych ward iconography, turning patients into survival horror NPCs. Every time I managed to bend my neck to its proper position, it would snap back as if held fast by a rubber band, and after this went on for about an hour, I went to this Nurse Ratched with my neck twisted at an inhuman angle, screaming and crying and telling her that something had gone wrong, begging for her to do something, to which she simply said, “Stop acting up, no one presents like this."
As this project suggests, this type of transaction — in which a drug is introduced, the drug produces an undesirable effect, and the effect is attributed to the patient themself — flavors an unrecognized portion of mainstream psychiatric intervention, usually in more pernicious, less theatrical forms. So why exactly I would again stand in line at a CVS for orange bottles after a decade of abstention in the hopes of a better outcome is a testament both to how mad one can become when you brew lost love with an atomized social fabric, and how few alternatives are at hand for those experiencing madness at all. The argument below asserts that this lack of alternatives, and its destructive results, follow from the flattening of experience into mere behavior, the aliteral into the literal, contingency into fixed essence. In weighty Heideggerian terms, our dominant paradigm is what happens when everything becomes technological, when a demand for the end of mystery coerces the elusive into becoming explicit. This paradigm’s ability to evade accountability for its own dismal results while continuing to run on schedule, disseminating powerful psychopharmacological regimens to millions upon millions of people, has left us with medical and cultural ramifications that are, because of their very evasiveness, genuinely incalculable.
Portions of the second part of this argument draw from archived reporting I conducted ten years ago for an article that was never published. That project’s demise is a story in its own right, but it also demonstrates (at least in a slightly self-charitable interpretation) how impregnable this topic was throughout the 2010s, when supposedly courageous editors turned skittish upon a writer’s attempts to revive the spirit of psychiatric critique that prevailed in the 1960s. While medical psychiatry as practiced remains virtually indistinguishable from 10 years ago, there are at least cracks forming in our collective perception of it. As the philosophy professor Justin Garson (whose work I draw upon below) writes in a forthcoming paper, “It seems to me that society is not only waking up to the fact that our language and conceptualization of mental health is mired in an entrenched dysfunction-centered framing, but we are also waking up to how harmful these framings can be and to the extent of alternatives to them.”
The aspiration of this argument is not only to chip in one more perspective to this awakening, but to further shore up the various propositions of Components over the past five years, which recurrently gravitate towards a single declaration:
and we are all unwitting conscripts in the holy war between them.I. The land of "just as it is"
1. In April 2024, a Harvard professor of psychiatry published an op-ed encouraging the FDA to topple the last remaining barrier to antidepressant access by making the drugs available over-the-counter. But the mixture of support and opprobrium the writer encountered overlooks the reality that making Lexapro available without a prescription would effectively function as a minor formality. At this point, the form of psychiatry enshrined in the DSM, its pharmacological and therapeutic interventions, and its clinical language have become, to borrow the term, hypernormalized, so enmeshed in our self-understanding as to nearly go unnoticed. Between 2016 and 2022, antidepressant prescription rates for American teens and young adults increased by 66%. Today, one in ten people in the United Kingdom is on an antidepressant. Direct-to-consumer subscription companies like Hims now sell antidepressants with the aesthetic of a Rag & Bone ad.
2. In the past few decades, a once-pervasive discourse that leveraged penetrating critiques of psychiatry into commentary of the world at large has receded so far into our intellectual background that it is for all functional purposes scarcely remembered at all. But ironically, the total ebb of this strand of cultural criticism coincides with an often obnoxiously dominant referentiality to two of its most towering figures, Foucault and Deleuze. We have somehow arrived at a place where talk of rhizomes, panopticons, grids of intelligibility, diffuse power structures, and the very deconstructionist tendencies that underpin our raging culture wars seem to go on ad nauseum,
3. How and why the plot got lost is beyond the present scope. Instead, it’s worth reciting what Foucault actually argued about psychiatry in Madness and Civilization. As the basic argument goes, modern psychiatrists ultimately assumed authority by cloaking their discipline in medical scrubs and situating the physician in relation to the patient as the father to the child, or the judge to the condemned. In reducing the interpretation of madness to "mental illness", psychic aberrations became mere physical perturbations emerging ex nihilo from the patient themself, and accordingly, became the patient's responsibility to tame. As Foucault argued, our present understanding of madness is not the result of ever increasingly precise scientific understanding, but the result of historical contingencies that abstracted a form of dominion into something diffuse enough to no longer be identified as dominion at all.
4. We’ll come back to the contingency aspect, and there are good reasons to refute the historical argument as excessively cynical. But beside all this, Foucault makes another equally consequential assertion: that the ascent of medical psychiatry resulted in the conclusion that, as he writes, “madness, after all, was only madness."
5. What is meant by this only-ness, or mereness? The merely melancholic is so not out of some relation to God or the world, but simply because they are melancholic. The hysteric or paranoiac offers no reflective surface from which we can glean their context, their personal history, or the narrative of mankind; there is simply something wrong with them. Justin Garson neatly summarizes this perspective in Madness: A Philosophical Exploration: “Madness begins its remarkable journey from an expression of divine punishment, a revelation or betrayal of individual sin, to a biomedical phenomenon, and ultimately, to an empirical fact among other empirical facts: it is 85 degrees Fahrenheit out; the Pacific Ocean reaches a depth of over 10,000 meters in places; Jayani is a paranoid schizophrenic; Roby has melancholy…If the madman is melancholic and raves that he has sinned against the Holy Spirit and awaits his condemnation, it is because that is the kind of thing the melancholic says.” (Emphasis in original.)
6. Another way to say this is that Foucault identified the evolution of madness into what we might call an unembedded entity, a perhaps needlessly fancy term, but one that I think provides an intuitive way to understand what’s happening.
7. To better understand what this means, let’s first consider what it means to be an embedded entity. In Wittgeinstein’s philosophy of language, a word’s meaning is not determined through its description in a dictionary or any other form of self-reference, but through its use with other words. In this way, the word’s meaning and use are indistinguishable: The meaning of “tree” is dependent upon our use of “wood” and “book” and “swing”, just as the meaning of “swing” is reciprocally dependent upon our use of “tree”, and so on.
8. One of the ways this understanding of language has translated into computation is a technique in natural language processing called word embeddings. A word embedding is a vector that represents where a word exists in abstract space based on how it’s used in relation to other words. To oversimplify what this looks like, let’s say we have a dataset where only three words ever appear: “tree,” “book,” and “swing.” Each of these words has an axis, just like on an x-y coordinate system. The more commonly one of these words is used with “swing,” the higher its value will be on the “swing” axis, and the more commonly it appears with “book,” the higher its value on the book axis.
9. A typical word embedding does this with many more words across many more axes, depending on how many words appear in the corpus. To identify a word’s so-called meaning from a word embedding, then, is to view its entire set of relationships to all the other words in that corpus. The word itself is these very relationships.
10. Similarly, the way we hear a given note in a piece of music is dependent on the notes preceding and succeeding it. We don’t simply hear the C# in isolation; we hear, through that note, the entire song. What the C# “means” is entirely dependent not only on personal perception, but whether it functions as a cadence, whether it’s in the middle of a measure, and so on. The C# has no independent aesthetic qualities outside of its context.
11. So if an embedded entity is discernible only through its relationship with other entities, an unembedded entity exists no matter what. It’s static, just there. The tautology of “madness…was only madness” follows from an unembedded entity only fathomed through endlessly recursive self-reference. As a consequence of becoming unembedded, an entity becomes literal and univariate. Stripped of its embedding, the C# can go up and down on the volume axis, you can change its timbre, but it is just a different kind of C#. The C# cannot mean anything other than what necessarily inheres to it, and that meaning (to the extent the word can even be used) can therefore only be sought through the details of its waveform, spectral analysis, and so on. In robbing the note of its relationship to other notes, the C# becomes merely a C#, a floating signifier that can only be described and explained through different forms of self-reference, increasing the resolution with which you describe these immutable characteristics.
12. But let’s take a detour away from psychiatry for a moment. Where does this literalism and unembeddedness appear elsewhere in our culture? Well, everywhere. Baudrillard considered it to be a defining trait of America, which he described as partaking in "joy in the collapse of metaphor, which here in Europe we merely grieve over. The exhilaration of obscenity, the obscenity of obviousness...This is the only country which gives you the opportunity to be so brutally naive: things, faces, skies, and deserts are expected to be simply what they are. This is the land of the 'just as it is'." The meaning of a smile can never shift just as the meaning of a C# can never shift; the smile, and the C#, have no dynamic contexts that engender their very existence, and therefore no metaphorical possibilities.
13. In this way, literal entities being “simply what they are” means that, obviously, they can never be what they seem not to be. What is seen is all there is, and what is must be seen.
14. For example, consider the literalism of our predominant sexual culture, gleaned most clearly through a form of pornography that unavoidably gravitates to imagery that is virtually anatomical, and that at its greatest extremes becomes genuinely endoscopic. The univariate, literalist nature of pornographic sexuality leads to the cinematic decision that the more explicit the image is, the more sexual it is, leading to absurd results and clashing with any suggestion that sexuality might paradoxically emerge from diminished exposure.
15. Eroticism, on the other hand, is embedded and aliteral. The psychoanalytic understanding of eroticism sees adult sexual desire as the end product of a set of reverberations from a childhood play spirit that was only organized into its genital focal points over time. Eroticism is sexuality that does not exist “just as it is,” but is inseparable from all our desires stretching back to infancy. Unlike the pornographic, which satiates sexual desire with its literal fulfillment, the erotic summons these childhood tendencies towards flirtation, innuendo, and most importantly, play.
16. By severing the erotic connectivity between sexual desire and not explicitly sexual acts, the literalist also denies the fulfillment offered by sublimating the libido into other outlets. While the aliteralist achieves satiety of the libido by channeling it into the playful and creative – making art, watching a movie, having an engaging conversation, playing with a dog – the literalist demands a straightforward, univariate satiety of the sex drive, which can be satisfied only by securing more sexual partners, resulting in Don Juanism. In our own culture, this has recently been refactored into an artless form of polyamory.
17. Or consider the literalism endemic to Silicon Valley. Operationally, literalism underpins the spirit of fake work and productivity app proliferation that has defined the management of the Valley’s firms since the early 2010s. Under this ethos, tech companies have operated under the premise that if something appears as productive, it is productive. As I wrote in Fast Company, “The perfectly ordered Google calendar does not facilitate other goals — it is the goal.” The organizational spawn of this principle, assembled from so many shards of productivity software and optimization strategies, are companies equally unproductive and unprofitable. (This strategy has since led to the bloody culling of these firms since the 2022 interest rate increases, when it became too expensive to subsidize this performance.)
18. But nowhere is the literalism of Silicon Valley more visible than in the limited self-expression it offers the denizens of its product worlds. In the virtual environments forged by Meta and Apple, self-expression becomes synonymous with replication. The avatars offered by both are merely alterations of one’s physically existing self, rather than an expansion of the possibilities yielded from abandoning the pursuit of literal representations. In neither company’s proposed model of virtuality can one temporarily don the identity of anything dredged from the creative unconscious or play with the very instability that underlies our ultimately centerless, contingent selves.
19. In other words, a world of literal representations and a world of fun are incompatible with one another. The paradigm of medical psychiatry, residing in the former, is pitted against the latter. But before we wind our way back to psychiatry, we’ll pass through one more exploration of literalism in America.
20. “New textualism,” the framework of statutory interpretation championed by Justice Antonin Scalia and since taken up by the rest of the Supreme Court to varying degrees, is expressly literalist by design. New textualist arguments depend on exacting readings of a law’s plain language rather than any reference to legislative history or intent, instead opting for meticulous parsing of “verbs and infinitives and gerunds and other grammatical constructions,” as one legal scholar described. A 2022 Harvard Law Review article posited that Scalia inherited this literalism from his literary critic father, a practitioner of the New Criticism popular in the 1950s that rejected any and all external factors outside the plain text itself in interpreting a work of literature, which Scalia transformed into a method of jurisprudence.
21. Three scholars in the Columbia Law Review summed up the transformation accordingly: “For generations before the current dominance of the new textualism, judges typically followed a pragmatic approach that sought to determine the statutory meaning (1) understood by legislators, (2) passing a statute that advances public purposes, (3) as reasonably applied to current circumstances. [We refer] to this approach as ‘traditional pragmatism.’ In contrast, Scalia’s new textualism offered a seemingly straightforward alternative methodology that determined the meaning (1) understood by the ordinary person, (2) applying standard rules of semantics, definitions, and grammar, (3) at the time the statute was enacted. This methodology seemingly could be boiled down to ten words: the text, the whole text, and nothing but the text.”
22. At the risk of reducing a complex debate of legal theory into talking points, it is not too far off the mark to say that Scalia’s new textualism has acted as the framework for roughly 40 years of right-wing jurisprudence, granting corporations the right to speech and frustrating even the smallest efforts against gun regulation.
23. But what is this “traditional pragmatism” the authors mention? This was the form of jurisprudence most strongly advocated by Oliver Wendell Holmes Jr., who in the early part of the 20th Century was a leading progressive voice on the bench. In Holmes’s view, the meaning of a law was to be measured by its effect, not by semantic inference. As he summed up in one of his most famous quotes, “The life of the law has not been logic: it has been experience.” Where new textualists devolve into meticulous linguistic debate,
24. The legal pragmatism of Holmes was the practical application of philosophical pragmatism, whose most important figure was John Dewey, the patron saint of this website. To Dewey, a human being is just like any other organism – they are first and foremost an experiencer of their environment, engaging in an uninterrupted transaction between their senses and their surroundings. This very transaction between them forms the basis of what they understand reality to be. From this perspective, the tree that falls in the forest with no one else to hear it doesn’t make a sound (though it may have other effects), because the sound exists only in this transaction itself, just like the embedded word only exists in the relationship with other words. And also like that embedded word, the person hearing the sound of the tree is not hearing an objective phenomenon, but a relationship between themself and the tree. The late neo-pragmatist philosopher Richard Rorty summed up this core pragmatist tenet by describing it as the belief that “everything is what it is by virtue of its relations to everything else. You can't and shouldn't try to capture X in its purity because there isn't anything to X except those relationships.”
25. In our terminology, then, this Deweyan idea of uninterrupted, processive undergoing is one in which everything is an embedded entity – our bodies, understandings of self, knowledge of the world, and so on are coordinates in a web of relationships from which any given entity is inextricable from the other. This renders the idea of some immutable, certain reality moot, just as it does the notion that a person can ever be unembedded from their environment.
26. To flatten this environmental embeddedness to what is commonly known as “environmental factors” of someone’s psyche is to miss the point. As Garson summarizes the thinking of the Deweyan psychoanalyst Harry Stack Sullivan, “The self is a kind of ‘social construct’ — if that term has not been entirely evacuated of meaning by now.” To Dewey, Sullivan, and the others of this camp, the self is not just a set of booby traps triggered by the environment; the self, like the word or the tree sound, is the embedding.
27. But if we don’t see people as experiencers, as embedded, what then do we see? R.D. Laing, a Scottish contemporary of Foucault and a Deweyan in practice, argued that the medical paradigm fixates on mere behavior. “We can see other people's behavior, but not their experience,” he wrote in The Politics of Experience. “This has led some people to insist that psychology has nothing to do with the other person's experience, but only with his behavior.”
28. How does this help us think of madness? Here’s one example: In January, I took a trip to San Francisco. As with every trip there, I witnessed an outsized number of people experiencing what outwardly appears as a form of aggressive, dysphoric mania that is more prominently displayed in that city than anywhere else I have been in the world. Madness in San Francisco is less inert than elsewhere, charged with a volatile energy that feels particular to it, and if you’ve spent enough time there, you know exactly what I mean.
29. Let’s consider how our two respective paradigms view this person. Seen as a non-experiencing subject, their behavior is merely their behavior, and if they scream incoherencies in SoMa on a Friday night amid reveling product managers, they do so because, to rephrase Garson, that is simply the kind of thing the manic San Franciscan does. The description of that person and their behavior’s origins becomes trapped in the same loops of self-reference as the unembedded C# – but instead of waveforms and spectral analysis, we can describe malfunctioning pathways of the brain’s HPA axis, overactive calcium channels, the expression of a specific genotype, and so on, beginning with the patient’s pathological category (e.g., bipolar disorder, schizophrenia, etc.) and describing it in ever more granular, cellular detail. Just like Roby and his melancholy, the San Franciscan’s mania becomes a plain fact and an immutable, necessary characteristic of their persona.
30. But to Dewey, Laing, Sullivan, and the rest, this approach severs the subject from the very embedding of relationships required to fathom their experience. As Laing wrote, “The relation of experience to behavior is not that of inner to outer. My experience is not inside my head. My experience of this room is out there in the room.” So we have to describe the room the San Franciscan finds themself in, and in that room we discover VCs attending onesie parties, management consultants with polyurethane skin, and equity-rich young adults who render the city into a ghost town during Christmas. The room is a Panglossian community whose expansion has driven its non-members to ever deeper levels of abjection over the past 20 years, rapidly corroding the social bonds Dewey knew were required to exist. “Individuals who are not bound together in associations, whether domestic, economic, religious, political, artistic or educational, are monstrosities,” he wrote. If we are only our embeddings, if our experience is out there in the room, then the monstrosity of the mad person is the monstrosity of this room, of the city itself.
31. Here’s the final point: The dichotomies between unembeddedness and embeddedness, literalism and aliterism, pragmatism and logic, cluster on a schism synonymous with what Rorty deemed the dividing line among philosophers in the West. Rorty put Western philosophers into two buckets: systematic and edifying. Plato, Kant, and Decartes are systematic philosophers – they believe that, as Rorty said, “truth is out there”, behind the light that casts shadows in the cave, in the noumena, in our minds, wherever. We can find it or not, but it exists independently of us; the tree that falls alone does make a sound. Systematic philosophers are preoccupied with drilling into reality’s essence, of building ever more accurate systems of representation.
32. The edifying philosophers, while not descending from a single lineage, coalesce around a “distrust of the notion that man’s essence is to be a knower of essences…They have kept alive the historicist sense that this century's 'superstition' was the last century's triumph of reason.” For the edifiers, our notion of truth (whether of the world or ourselves) is contingent, produced by historical accidents, family histories, stochastic encounters, shifting around in a suspension fluid. The container of edifying philosophers includes the later Wittgenstein, the later Heidegger, Kierkegaard, Nietzsche, Foucault, and, of course, Dewey. (Rorty more or less counts a number of non-philosophers in this spirit, such as Freud, Kundera, and Goethe.) The role of the edifiers is to disrupt our notion that we’ve arrived at some final understanding of reality, to frustrate the project of philosophy itself – “to keep the conversation going rather than to find objective truth." It is, as Rorty says, to revive the spirit of metaphor that defined our understanding of the world before it was reduced to literalism, to point to the embeddings in which our understanding of the world resides.
33. To Rorty, it is only when we abandon this project to discover and depict fixed essences of the world that we can begin to pursue Dewey’s conception of a truly flourishing society: "In [Dewey's] ideal society, culture is no longer dominated by the ideal of objective cognition but by that of aesthetic enhancement,” Rorty writes in Philosophy and the Mirror of Nature, a book he hoped would essentially end the profession of philosophy entirely. “In that culture, as he said, the arts and the sciences would be the 'unforced flowers of life.'" Rorty’s post-philosophical world is one with “more novels and fewer theories,” less of the “theoretical spirit” and more of “the spirit of humor.”
34. In other words, it is the Kraeplins, the Platos, the Scalias, the Zuckerbergs, and the behaviorists who, in their elevation of essences and literal representation as a primary objective over “aesthetic enhancement,” keep us from having any fun. And it is through the infectious agents of their systematic world – spiritually dead avatars, textualism, hyper-expository porn, and seeing madness as only madness – that we deepen our roots in a joyless terrain.
II. The washout process
35. Ultimately, though, as Holmes implied in his maxim, what matters for pragmatists isn’t reaching some notion of Truth, but arriving at an understanding of the world that works. Embeddings, literalism, VR avatars, and all other abstractions aside, does our medical model at least provide enough relief from psychic pain that people can cultivate Dewey’s “unforced flowers of life”? Does the medical model accomplish its own goals of remediating psychiatric symptoms?
36. As Laing wrote, “An inhuman theory will inevitably lead to inhuman consequences.” Our collective experience reveals that this literalist model has not achieved what it even nominally sets out to. Given the track record of what happens when we productize this model, this shouldn’t be surprising; the univariate, more-is-more, just-as-it-is approach that defines projects guided by this model is fatal to each of their putative objectives. Spotify, in removing every last barrier of exposure to music, has accordingly devalued music so much that it can’t turn a profit; SaaS productivity startups that promised to facilitate workflows by increasing the software integration load of companies have all gone bust since they didn’t actually improve anything; the obscenely expensive Lockheed Martin F-35 that leads our Air Force can’t shoot straight, operating as just one more piece of novelty-obsessed, malfunctioning miltech that has led the United States to become a full-time loser of conflicts post-Cold War; and the greater autonomy promised by ever larger domestic vehicles has resulted in absolutely no psychological respite from the prison of American roads.
37. Medical psychiatry is no different. So how can we measure this failure? One place to start is with the often unrecognized blowback from the industry’s crusade to remove the “stigma” of mental illness by linking madness to brain-based disorders. Research demonstrating as much dates back to at least the 1963, when researchers found that job interviewees were evaluated more favorably if they attributed their prior psychiatric hospitalizations to interpersonal problems than to illness.
38. In 1997, researchers from Auburn University and the University of Connecticut conducted a study in which students were paired with partners they were told belonged to one of three groups: a “normal” group with no psychiatric history, a “psychosocial” group whose psychiatric history was attributed to family and relationships, and a “medical” group whose psychiatric history was attributed to having “a disease like any other”.
39. Following up on these results in 2003, researchers from the University of Leipzig surveyed respondents in four regions – East Germany, West Germany, Russia, and Mongolia – to measure how respondents perceive people suffering from schizophrenia or depression based on the etiology of the condition. When people associated the conditions with biological causes, they also expressed more desire for social distance from the afflicted individuals. "Attributing the causes to socialization results in a reduction of the social distance desired," they wrote. Turkish researchers discovered the same aversion to people whose distress is medicalized the following year.
40. But the blowback against the campaign to destigmatize through medicalization pales in comparison to the consequences yielded by the treatment that medicalization necessitates. To my knowledge, the most comprehensive account of this phenomenon remains Robert Whitaker’s 2010 book Anatomy of an Epidemic, which will evoke anything between warm recognition and violent animus from those familiar with the title. In 2015, I interviewed Whitaker in his office in Cambridge, MA., where he told me about his trajectory from working as a journalist for the Boston Globe to becoming the Director of Publications for Harvard Medical School to gradually blackpilling himself in the Harvard library by poring over piles of studies on the pathology-inducing effects of psychopharmacology.
41. Anatomy is an attempt to reconcile a paradox: Why, amid the explosion of supposedly life-saving psychopharmacology, have disability rolls for mental illness in the United States skyrocketed, going from 1 in 184 Americans in 1987 to 1 in 76 in 2007? Why did those rolls increase for children thirty-five fold while they declined for every other cause? Amid this renaissance of treatment, why have people seemed to get sicker and sicker?
42. Whitaker’s argument is that the drugs are not simply correlative, but causal: that psychopharmacology as practiced in the United States renders episodic illnesses into chronic ones, that psychiatric treatment instantiates a disease process whose ramifications are attributed to the patient’s own psychopathology – that the perverse irony of identifying madness as a medical illness is that it induces actual medical illness. It reduces a libidinal, defiant McMurphy into his post-electroconvulsive self – but, in Foucauldian fashion, it often does so in a way that is nearly impossible to identify, subtly pathologizing the patient more and more via pharmacology and assigning responsibility for the deleterious outcomes to the patient themself.
43. Anatomy includes studies on the long-term pathologies wrought by pharmacological treatment for nearly every class of psychiatric drug, from antidepressants to anxiolytics – the iatrogenic development of rapid-cycling bipolar disorder, treatment-resistant depression, supersensitivity psychosis, post-benzo syndrome, and so on. But one study in particular best condenses the book’s thesis into a single set of data and reflects medical psychiatry’s inability to grapple with the ramifications of its methods.
44. In 2007, Martin Harrow, a professor of psychiatry at the University of Illinois Chicago, published a 15-year study on the divergent outcomes of people admitted to hospitals in Chicago for schizophrenia or other forms of psychosis. In the fifteen-year period, Harrow’s team checked in with the patients five times and assessed their long-term outcomes on a number of metrics, including their relapse into psychosis or other symptoms, their ability to support themself, exist among their community and family, work, avoid hospitalization, and so on.
45. On every measure, the unmedicated group performed better than the medicated one. The group that remained off the meds was rehospitalized at a lower rate, had better “global functioning,” more favorable prognosis, and experienced psychosis significantly less frequently.
46. However, Harrow’s interpretation of the data deflected against attributing the divergent outcomes to medication, instead attributing them to the patients’ own predispositions. As he wrote, the non-medicated group’s “more favorable outcome is associated with internal characteristics of the patients, including better premorbid developmental achievements, favorable personality and attitudinal approaches, less vulnerability, greater resilience, and favorable prognostic factors.” In other words, medications didn’t cause worse long term outcomes, it was simply that more resilient patients were able to avoid medications in the first place.
47. Critics of Whitaker seized on his decontextualized use of the study in his thesis. The most common and focused critique of Anatomy in medical journals was that Whitaker misinterpreted the data in a way at odds with Harrow’s own conclusion, which they portrayed as a jumble of correlation and causation that infected the entire argument. One reviewer said Whitaker’s use of the study to support his thesis involved “tortured logic.”
48. Whitaker attended the 2008 American Psychiatric Association annual meeting in Washington DC to ask Harrow about his conclusion. After Harrow gave a talk about his findings at the conference, Whitaker was granted a brief press interview. Harrow again explained the divergent outcomes in patients’ predispositions to recovery, telling Whitaker “it was those who did better [initially] who then went off the medications.” “When I pressed on with a question about whether his findings supported a different interpretation,” Whitaker wrote in Anatomy, “which was that the drugs worsened long-term outcomes, he grew a bit testy. ‘That’s a possibility, but I’m not advocating it,’ he said.”
49. In August of 2015, I called Harrow,
50. I asked Harrow why he framed the results of the data as causally unrelated to the drugs. “Medically to get it accepted, we made excuses for it, because it’s not a popular view in the field,” he said. “We didn’t want to frighten the editor.”
51. Let’s assume that Harrow meant what he said in this interview, and that Whitaker didn’t misinterpret the results of a longitudinal study showing that long-term exposure to psychiatric medication yields worse long-term outcomes in people’s lives, inducing a chronicity in their condition and leading to worse scores on a host of psychosocial metrics. If that’s true, then the criticism most strongly wielded to undercut Whitaker’s argument – that the evidentiary piece de resistance was misapplied – is mostly defused. Therefore, the proliferation of these medications –- often at high dosages, in combination with other drugs, and for treatment periods that are more or less indefinite – has wreaked a population-level effect on our society.
52. The inevitable question is, What does that effect look like on an individual level? From the vantage of the behavioralist practitioner, the effect of drug treatment looks identical to mental illness itself. The very absence of objective, physiological diagnostic criteria for mental illness allows prescribers to escape accountability for the virtually untestable adverse effects of their treatments. Because the behaviors (observable and therefore putatively objective) of adverse drug events and what might simply be referred to as “normal psychopathology” can closely mimic one another, the latter is not merely mistaken for the former. Rather, the behavioralist perspective allows for no distinction to begin with, as outward displays or patient reports of distress are flattened into merely distressing behavior, warranting still further treatment. In other words, the suppression of experience in favor of behavior as the primary material under examination allows the nature of these undesirable outcomes to evade full examination.
53. But as former and current patients can attest, these experiences are not the same. The anhedonia and sexual dysfunction induced by SSRIs and their sometimes protracted withdrawal is not synonymous with their chiral forms in depression.
54. Perhaps unsurprisingly, this dynamic is almost universally overlooked in television, film, literature, and most any other media in favor of what we might call the reversion-to-the-original narrative. In this narrative, a patient on psychiatric medication ceases treatment and shortly thereafter reverts to their prior, pre-medicated self, unblemished by their pharmacological exposure. If they were sick before, their sickness returns in its original form. If they were well before, they regain their original wellness.
55. A collection of archaic references from the aughts and 2010s comes to mind. In the now nearly forgotten HBO series Six Feet Under, the manic depressive Billy throws out his lithium and immediately succumbs to a wild spending spree followed by debilitating depression. A similar arc plays out in Homeland after the CIA agent Carrie stops taking her mood stabilizers. In Garden State – arguably still the most iconic reversion-to-the-original narrative produced – Zach Braff, swept away by a whimsical Natalie Portman, quits his cocktail of psych meds cold turkey and immediately rediscovers his capacity for grief, aliveness, etc., culminating in the movie’s climactic primary existential scream in the rain.
56. In the real world, a sudden withdrawal from polypharmacy would certainly leave Zach Braff screaming, but hardly with the same vital catharsis. But if withdrawal syndromes, chronicity, and all the other bad long-term outcomes are starkly manifest in data, what complicates our ability to depict them aesthetically? There is a concrete discrepancy between our empirical and our cultural perception. And it is arguably this very discrepancy that has perpetuated the epidemic in question.
57. What we need more than further studies, then, are more individuations of this disease process that produces bad long-term outcomes. So long as these outcomes remain quantitative abstractions unrooted from our day-to-day experience of the world, these studies may as well not exist at all. How can we link what we know happens with what we see? How can we reinflate the flattened distinction between madness and emergent pathologies induced by the treatments themselves?
58. The story of David Foster Wallace canonized in D.T. Max’s biography, Every Love Story is a Ghost Story, and in Rolling Stone writer David Lipsky’s reporting, is a reversion-to-the-original narrative. This narrative, in its broadest strokes, goes as follows: Wallace begins to experience a crippling depression while a sophomore at Amherst College in the early 1980s. He and everyone around him frame this depression in its unembedded, just-as-it-is form — as Max writes, “Wallace was beginning to understand things that had either never been told to him before or that he was only now ready to hear: that he had a biological condition that was with him for the rest of his life.” While an MFA student in Arizona, Wallace experiences another episode of depression following a breakup and begins treatment with the early generation antidepressant Nardil.
59. This reversion-to-the-original interpretation remains plausible if the examination stops at this rough outline; it becomes implausible once we parse its more banal details. And it is the process of parsing those details that we encounter the very reason why aesthetic depiction of the epidemic feels nearly impossible to capture.
60. Wallace’s depression as an Amherst student was initially treated with the drug Tofranil.
61. During an early attempt at recovery in the late 1980s, as part of an enterprise towards sobriety and away from all chemicals, Wallace got off the Nardil for the first time. He sunk lower, became haggard and withdrawn, tried to kill himself, and eventually attempted to get back on the drug, but to no avail. As Max writes, “The same psychiatrist who had prescribed Nardil for him the first time put him back on the drug, but it did not have the same effect…The Nardil didn’t stabilize Wallace and his psychiatrists recommended electro-convulsive therapy.”
62. Wallace underwent six courses of ECT, followed by a period of stability. He published The Girl with Curious Hair and enrolled as a philosophy graduate student at Havard. He came to immediately regret his decision to enroll, continued drinking and using drugs, and within a year, told the student health services at Harvard that he wanted to kill himself. He was sent to the storied McLean Hospital, where they urged him in to become sober, and he did, becoming the recovering addict
63. During his early recovery, Wallace begins a relationship with the writer Mary Karr, breaks up with her, and descends again into depression. He checks into another psychiatric hospital, where they increase his dose of Nardil and, as Max writes, “begins to improve."
64. In the ensuing years, Wallace published Infinite Jest, married the artist Karen Green, and became one of the biggest celebrities in the literary world. Throughout, he remained on a high dose of Nardil for two decades. After his hypertensive reaction, he decided to go off the drug. And he experienced a psychopathology whose account marks it as a wholly distinct syndrome from what came before.
65. During the withdrawal, Wallace wrote to his friend that that he was experiencing “disabling nausea/fatigue,” adding, “I’ve been blowing stuff off and then having it slip my mind…This is the hashest phase of the ‘washout process’ so far; it’s a bit like I imagine a course of chemo would be.” He stopped shaving, lost weight, hollowed out. He was hospitalized and placed on a carousel of drugs that didn’t work. Eventually he tried to get back on the Nardil. But as Lipsky writes, “The Nardil wasn’t working. It can happen with an antidepressant; a patient goes off, returns, and the medication has lost its efficacy.”
66. “It can happen” implies that there’s an element of dumb luck in whether returning to a drug will work or not. But over decades of use, the brain undergoes conformational changes that induce a dependence not easily broken, and certainly not after the kind of rapid withdrawal Wallace is described as having undergone. As any savvy prescriber and any former psych patient can pinpoint, Wallace’s cold-turkey from Nardil broke every rule in the book about psychiatric drug titration and the glacial pace with which it must take place in order to avoid the most catastrophic results. As Adele Framer notes in her paper, once these botched withdrawals become protracted, reinstatement of the original drug may no longer be an option.
67. And so we have a depression once episodic, reactive, inflamed by drugs and alcohol and break-ups and ameliorated by sobriety and relationships and literary success, morph into a disease of unprecedented virulence, untreatable, idiopathic in origin, and completely unremitting. In other words, we have the exact contours of Whitaker’s epidemic. And we have no way of conveying this with the same brevity carried by that of a writer simply so depressed that he couldn’t endure the world. We instead have diagrams, exhibits, mind-numbingly meticulous comparisons of drug regimens and symptom comparisons — an argument made of insoluble fiber.
68. Nine years ago, when I raised this possibility to Max, he dismissed it outright, telling me he saw no reason to believe that Wallace’s treatment bore any responsibility for the end of his life. (Whitaker was more straightforward, telling me simply, “Of course that’s what happened.”) Perhaps this is because Max believes so strongly in the medical model he can’t fathom another possibility. But perhaps he is also expressing a general aversion to the idea of something so exogenous impinging on a coherent biography, as if being killed by Nardil were as meaningless and absurd as Wallace being killed by eating dinner. As the biography stands, Wallace is the victim of his own headstrong desire for literary purity, undone by his unwillingness to accept his biological limitations and aching for an unfettered artistic mind, ultimately destroying himself in the process. This biography allows Wallace to be a tragic figure, with a tragic flaw — it allows his life to be a work of art that being a pharmacological casualty would deny.
69. So we are left with a work of art pitted against an insoluble pile of evidence; we still have only data and no prose, unless we can rearrange that evidence into something new.
70. My attempt to do so is to suggest that Wallace’s pharmacologically-induced suicide was not an aberration incurring on his life — it was its very consummation. As he wrote in Infinite Jest, “[A] little-mentioned paradox of Substance addiction is: that once you are sufficiently enslaved by a Substance to need to quit the Substance in order to save your life, the enslaving Substance has become so deeply important to you that you will all but lose your mind when it is taken away from you.” Wallace could perceive to a certain extent that alcohol and television shared a common addictive DNA that defined American life. But that perception was too limited for him, or his biographer, to grasp that DNA’s full malignance, to understand that the fictionalization of the enslaving substances was Wallace unwittingly outlining his own cause of death.
71. But having arrived where we have, it’s more important to consider why the grip of Wallace’s work seemed to slacken within a decade after his death — why the shelf-life of one of the biggest celebrities in American literary history seemed to expire barely a decade after he did.
72. One of Wallace’s first stories, published while a student at Amherst, was titled “The Planet Trillaphon as It Stands in Relation to The Bad Thing.” The Bad Thing is the semi-autobiographical college student narrator’s word for what the doctor diagnoses as “severe clinical depression.” The narrator describes the sensations of The Bad Thing, the aching sickness he feels, and so on. To the narrator, this Bad Thing has no origin. It just is. And as the narrator comes to realize, the fact that the Bad Thing simply is parallels the way that he himself simply is. “[Y]ou say to yourself, ‘Boy oh boy, how the heck is the Bad Thing able to do this?’ You think about it — really hard, since it’s in your best interests to do so — and then all of a sudden it sort of dawns on you . . . that the Bad Thing is able to do this to you because you’re the Bad Thing yourself! The Bad Thing is you. Nothing else: no bacteriological infection or having gotten conked on the head with a board or a mallet when you were a little kid, or any other excuse; you are the sickness yourself. It is what ‘defines’ you, especially after a little while has gone by…[Your] very essence is characterized by nothing other than the feature of sickness; you and the sickness are, as they say, ‘one.’”
73. And so The Bad Thing becomes, as Garson put it, another “empirical fact among other empirical facts,” madness as only madness. Wallace falls on the same side as the behaviorists and the systematic philosophers, where madness is unembedded, just as it is, a fixed essence — something that, as the title of his story makes explicit, one stands in relation to. Wallace did not apprehend what Dewey and Rorty and Laing and all the edifiers could — that you don’t stand in relation to the Bad Thing; the Bad Thing, just like Every Thing, is the relation itself.
74. We don’t remember the works of art that argue otherwise. We no longer think about Six Feet Under because ultimately it doesn’t matter, just like we no longer think about the books of David Foster Wallace or a random empirical fact among other empirical facts. We remember songs, not C#’s. Madness that is only madness doesn’t take root in us because it doesn’t illuminate our embeddedness — and since we are these embeddings, it doesn’t speak to us, about us. But no one strains to recall Raskolnikov’s psychosomatic attacks in Crime and Punishment from the guilt of his murder; of King Lear screaming into the storm after his children’s treachery; of A.J. Soprano tying a cinderblock to his leg and throwing himself into the pool, buckling under the weight of the mad world around him.
-Andrew Thompson
Thanks as always to the other members of Components, Kyle Paoletta and Jules Becker, for their continued contributions to this project and this site. This project would almost certainly not have been completed without the meticulous stewardship and existentially critical support of Chris Good, nor would this topic have been exhumed after years of dormancy without the very early encouragement of Lois Biggs. Thank you to Steve Teare for the epigraph (and for introducing me to Norman Brown two years ago), to Jameson Orvis for his always thoughtful feedback, and to Robert Whitaker for spending so many hours with me years ago on the earlier form of this research. Thank you to everyone in January and March who made sure I actually made it to a place where writing essays was possible: Claire Peters, Maya Heiland, RJ Gilligan, Amy and Josh Lachewitz, Stephen Metzger, Carina Giamerese, Patricia Bass, and Porter Burdett.
Lastly, thanks to these guys for research assistance:
