Everyone is on drugs. I don’t mean the old-fashioned, illegal kind, but the kind made by pharmaceutical companies that come in the form of pills. As a psychoanalyst, I’ve listened to people through the screen of their daily doses; and I’ve listened to them without it. Their natural rhythms certainly change, sometimes very dramatically—I guess that’s the point, isn’t it? I have a great many questions about what happens when a mind—a mind that uniquely structures emotion, interest, excitement, defense, association, memory, and rest—is undercut by medication. In this Faustian bargain, what are we gaining? And what are we sacrificing?
There is new resistance to the easy solution of medicating away psychological problems, because of revelations about addiction and abuse, a better understanding of placebo effects, or, for example, the startling realization that antidepressants, far from saving some teenagers from committing suicide, can sometimes push them to do it, which means that these pills should not be a first line of defense. Perhaps the time is right to return to the conundrum of mind and medicine.
The story of psychopharmacology stretches from the advent of barbiturates at the turn of the century to the discovery in the early 1950s of the first antipsychotic, based on a powerful sedative used for surgical purposes that was described as a “non-permanent pharmacological lobotomy.” This drug, Chlorpromazine, led to the development of most of the drugs used today for psychiatric management. The proliferation of psychiatric medications, ones with supposedly less overt dangers, began in the late 1980s—at the same time, a watershed lawsuit was filed in the UK against the makers of benzodiazepines, a class of drugs used for treating anxiety and other disorders, for knowingly downplaying knowledge of their potential for causing harm. Today, psychopharmacology is a multibillion-dollar industry and an estimated one in six adults in America is on some form of psychiatric medication (a statistic that doesn’t even include the use of sleeping pills, or pain pills, or the off-label use of other medications for psychological purposes).
Until I started researching the history of psychopharmacology, I didn’t know that it was an antipsychotic that had spurred the developments of most of the medications we know so well today, such as Prozac and Xanax. But it was the issue of antipsychotics that first made me think about what we were trading as individuals, and as a society, in relying so widely on psychiatric meds. When I went to work in a psychiatric hospital during my training, nothing seemed more self-evident than the need to sedate a psychotic person. They were the most clearly “out of their mind” and the medications worked quickly to reduce psychotic symptoms, especially the auditory hallucinations that menaced these patients. How could this be wrong? (...)
I am indeed a Freudian psychoanalyst, that strange anachronism maligned by psychiatry for not being as scientific as medication supposedly is, by virtue of the control studies that can be done with drug treatments. Modern psychopharmacology goes hand in hand with a psychiatric diagnostic system that has, over time, been redefined to rely on medicating symptoms away rather than looking at the structure of the mind and its complex permutations in order to work with a patient in a deeply engaged way over the long haul. Modern psychiatry is hailed as a scientific success story, and drug companies have profited from the fact that talking therapies are often thought to take too long, their results frequently dismissed as unverifiable. I question, though, whether we should demand verified results when it comes to our mental life: Do you believe someone who promises you happiness in a pill?
Psychoanalysis still has the power to intrigue people, it seems—so embedded is it in American popular culture. Psychoanalytic language has entered the vernacular and psychoanalytic concepts permeate the way we all understand human relationships, especially sexuality. I have the sense that we need it more than ever to help us with our discontents because there is enduring value in the Freudian understanding of, on the one hand, the unceasing conflictual relationship between civilization and neurosis, and, on the other, what talking, simply talking, can do.
Freud himself was anything but hostile to psychopharmacology. Indeed, he was a notorious experimenter with drugs, especially cocaine, whose anesthetic properties and psychological effects he was one of the first to discover and champion (until, that is, a host of his friends and family to whom he administered the drug became addicted, contributing even to the death of one friend whose morphine abuse escalated after using cocaine in tandem, until he eventually overdosed). Freud himself underwent a course of experimental hormonal therapy with the first neuro-endocrinologist to see if it would improve his mood. Such research became the foundation for sex-change therapies today, along with a number of other medical discoveries that earned that doctor seven nominations for the Nobel Prize.
Freud’s beliefs about the human psyche thus did not exclude his own quite liberal experiments with medication and medical procedures. Importantly, at the end of his life, Freud chose to forgo any pain medication after almost thirty surgeries for oral cancer, so that he could think clearly with patients and continue to write—though he never ceased smoking the cigars he loved that had almost certainly caused his disease. The lesson I take from Freud is that you can choose your poison, which is the reason I wanted to turn to the topic of drugs, using what I’ve learned as a psychoanalyst over the last two decades.
We do have a choice about whether to medicate and how we do so. I think we have forgotten this because of how easy it is to obtain pills, along with the pervasive idea that our problems are simply chemical or genetic. So I want to begin by recalling what the drug panacea is treating at the most basic psychological level: pain, attention, sadness, libido, anxiety, sleep. Freud was surprisingly insightful about these crucial aspects of the psyche, even from his earliest writings before the turn of the century. By elucidating some basic psychoanalytic notions concerning the most common “troubles” of the mind, and by focusing on the different categories of medications prevalently used, I hope to disrupt our blind passion for prescriptions.
Painkillers
I’d like to begin with painkillers since they have been filling our headlines and because pain is often not thought of as having a psychological component (whereas I believe it does). Given that we have a crisis that has seen opioid-related deaths increase by 600 percent over the last four years, exceeding gun deaths and traffic fatalities in America, with 72,000 dead from overdose in 2017 alone, there is a problem with the way we medicate pain.
Pain is much more enigmatic than is commonly recognized. Why some people have a much higher threshold for tolerating physical pain than others is not fully understood. Nor do we know enough about the relationship between physical and emotional pain.
Freud recognized that pain was an important part of evolution, built into our being as a primary means of apprehending reality and adapting our behavior to avoid the threat of harm. Yet he also called pain a “failure” and a stark limit to the efficiency of the psychic system because it was, on the one hand, too easy always to “fly from pain” (in other words, to obscure it) and, on the other, too difficult to master pain since it creates indelible memory traces that do not lose their intensity even, in some cases, with the passage of time. The memory of pain is often as bad, if not worse, than the pain that was experienced. Consider post-traumatic stress disorder.
“Pain,” writes Freud, is a pure “imperative” that produces a state of “mental helplessness.” And in his view, physical pain and emotional pain are made of the same stuff—what Freud called a breach of the stimulus barrier that protects us from the outside world, where, analogous to our skin, there is a protective layer that is meant to remain intact and unperturbed. When it comes to pain, a shock to the barrier sets off a multitude of nerves that then fire too rapidly to prevent a reaction. This built-in alarm system makes a demand on a person and those around one, forcing everyone to address whatever painful circumstance has arisen.
Even what we call pleasure, or the reward-system of the mind, does not always have a positive outcome, but can involve a lowering of our sensitivity to pain, allaying the alarm system. The opioid receptors of the brain do just this—something Freud called, when speaking about cocaine, the happiness of “the silence of the inner organs.” Lulling can be dulling. Freud also notes that pain and the sounds associated with it, such as screams or groans, coallesce as a first memory trace, bringing together the sensory realms of internal feeling with an acoustic correlative. Our mind creates a solid bond between pain and the sounds we associate with it, which have the power, through empathy, to immediately produce pain in others. This is what makes the cries of an infant so intolerable. So our experience of pain involves not just our own pain, but also our relation to the pain of others.
With the abuse of pain medication, then, we are not only treating our own pain, which is always somewhere between the physical and emotional, but we are also dulling the immense pain around us. Modernity has increasingly allowed a breaking through of the stimulus barrier, from the impossible demands and the chaotic pressures of contemporary life, to a sense of mounting helplessness in the face of environmental disaster, poverty, loneliness, injustice, annihilation. One could say that “all this pain” is nothing new, but the constant forced attention to the theater of it has come with easy access to a powerful antidote: the ability to medicate the pain away, not just our own, but all of it.
Fascinatingly, Freud notes in his later work “On Narcissism” that the pain arising from organic causes often increases our narcissism, making us give up our interest in the outside world—so “concentrated is his soul… in his molar’s narrow hole,” Freud quotes Wilhelm Busch on the poet who is suffering from a toothache. This is a state that, Freud says, resembles sleep, or what he called “the narcissistic withdrawal of… the libido onto the subject’s own self,” a turning-away from the world. So pain and narcissism are bedfellows—and what else is the abuse of pain medication but a synthetic version of this couplet, fulfilling the wish to keep sleeping, to keep dreaming, to turn away from the world. Overdose appears immanent in this schema, as the risk of slipping into permanent sleep, falling down the narrow hole that seems to promise the cessation of all pain.
There is an ethical twist to this understanding of narcissism’s relationship with pain. The opioid crisis enacts the paradox of a society that seeks to annihilate pain as quickly as possible, even as it refuses to care for or attend to it and its underlying causes.
Annihilating pain, or “flying” from it, will never permit us to master pain, but only increases the need for its continued obliteration. This mastery of pain Freud explained as the formation of a mental response network, which strengthens our tools for dealing with pain beyond “toxic agents or the influence of mental distraction.” Freud always advocated “work,” which was how he characterized what happens in psychoanalysis; he also said that drive or libido could be thought of as the demand that a body can make upon the mind for work—like the emotional pain that can come from others’ requiring us to revisit it again and again to try to make more sense of it.
So what are painkillers, finally? They are drive-killers, which is why their effect on sexual function and even digestion is about the ceasing of work. This suggests the acute danger of these pills, insufficiently regulated, with drug companies profiting from this simple desire: no body, no drive, no pain, no helplessness, nothing. Stretched to the logical extreme, they are about permanent sleep. Death. (...)
Antidepressants
Moving from induced mania to depression, it’s been twenty-four years since Prozac Nation was published; I never read it but practically everyone I know has been on a modern antidepressant Selective Serotonin Reuptake Inhibitor (SSRI) like Prozac at one point or another. Do antidepressants help with depression? It’s a touchy subject; they have clearly helped many through periods of depression, saving the lives of some who have struggled with suicidal feelings. One thing I will say is that I prefer my patients not to be on them if possible, or eventually to get off them. True, the lows aren’t as low, but neither are the highs high, and pleasure is limited to some medial zone. To borrow Sylvia Plath’s metaphor of the bell-jar, the whole system feels caught between two glass walls.
Psychoanalytic work depends on following the natural emotional rhythms of the mind, stretched between anxiety, sadness, and excitement, allowing a certain amount of tension to build at the points of blockage. This is what creates breakthroughs. With the SSRIs, it’s as though the machine becomes frictionless and idling, and the complaints—which don’t go away—spin in neutral, never gaining purchase or momentum. That said, who can afford to have lows in today’s world that demands that we always be on and productive? I understand this. I do think the demands that we make use of ourselves are excessive—and nearly a depressant in itself.
by Jamieson Webster, NYRB |
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Image:Wayne Miller/Magnum Photos
With moose heads intact in his Athens, Ohio, lab, Witmer dissected the noses for a closer look, finding enough compelling information to write a paper published in the Journal of Zoology.
With moose heads intact in his Athens, Ohio, lab, Witmer dissected the noses for a closer look, finding enough compelling information to write a paper published in the Journal of Zoology.
