The goal of “PPT” — still his official name as this goes to press, pre-appeal — is to stifle allegations of inappropriate sexual activity, some of it potentially criminal. PPT asserts that publication of this material by the Guardian and ITN will very likely trigger a suicide attempt in him, thereby causing devastation to his son. “The claimant contends that publication would expose him to a real and immediate risk of serious harm or death,” the judge was told, as if the man were running from the mafia rather than his own demons.

Understandably, most of the interest in this case pertains to the identity of the claimant and the precise nature of the complaints against him, but there are other revealing angles too. To my mind, one of these is the way that PPT pictures the state’s failure to quash a juicy story about him as equivalent to leaving razors lying around a psychiatric ward. A crucial part of his legal argument pertains to pre-existing problems (bipolar, a trauma background, “personality-related vulnerabilities”), a recent suicide attempt, and a current restraint under the Mental Health Act. Given this background, lawyers acting on behalf of PPT argue that the state has responsibility for his welfare, and that curbing press freedom is a way of exercising this duty of care. Nothing other than stopping the media can save him from himself, apparently, not even hospitalization and appropriate psychiatric treatment.

Ultimately, the judge disagreed that PPT’s suicide was inevitable in the circumstances. Ironically, he did so on the grounds that the man was so miserable, he probably couldn’t see straight: “His prediction of his own future conduct is made in the context of depressive illness, hopelessness and catastrophic thinking … it is not a reliable basis for concluding that no future treatment or intervention could alter that risk.” This presents quite the dilemma for any litigants tempted along a similar path. Emphasize your intense mental disarray, and it will follow that you are an unreliable narrator of impending self-destruction. Play that aspect down, and it will no longer appear that the state has any enhanced duty to protect you. 

This catch-22 speaks to a tension lurking within PPT’s arguments, as the judge presumably noticed. The claimant wanted the court to believe he had sufficient mental capacity to anticipate what he was going to do later, should publication go ahead; yet he also seemed to think that suicide was almost certain, as if rationality had nothing to do with it. At times, in the judge’s retelling, PPT appeared to picture his own mind as completely on automatic, with no space for spontaneous reasoning to get a grip. Show the greyhound the moving rabbit, and it will automatically chase it. Show the celebrity the newspaper scandal, and he will automatically end his life.

A more mundane, less tortuous interpretation of what is really going on here beckons, though the judge avoids naming it. In a covert sort of way, isn’t PPT just threatening to kill himself, if publication were to go ahead? Turning to the world of children’s literature for a completely random example, isn’t this just a much more hyperbolic version of the Violet Elizabeth Bott gambit: “I’ll thcream and thcream ’till I’m thick”? I suppose you could interpret Violet as simply describing a dispassionate hunch about what is likely to happen to her body, should she fail to get her way with William, but it seems more apt to say she is making a threat.

When it comes to talking about our own futures, we are rarely just dispassionate forecasters of certain bodily movements, given such-and-such prior causes. We have agency; we plan; we execute. If I announce that I am going to a party, it is an expression of commitment to that project, not an educated guess. If I don’t end up attending, it is not that my prediction failed due to inadequate evidence; I just changed my mind. To think of humans as black boxes, mechanically producing outputs in response to earlier inputs, is an attitude you can only really take to other people (and even then, not for long). As soon as you start to think about what you yourself are going to do, ardent desires, fears, hopes, and so forth start to bear upon the question from the inside.

I assume that part of what lured PPT’s team into ignoring this basic observation is that suicide is so often treated as something that overcomes you, rather than something you actively do. It hasn’t always been this way. For as long as the Christian taboo against suicide was still strong, successive societies could frame the effort to end one’s life both as an intentional choice and a bad piece of personal judgment. To prevent someone doing it was a way of saving his body — and perhaps his soul too. But once we lost the confidence to criticize the act on those traditional grounds, the only remaining option for justifying intervention seemed to be the conclusion that suicide was really no choice at all. These days, we default to the idea that it is a desperate and irrational act, born of mental illness, picturing the urge to do it as an abnormal interloping presence in someone’s mind. Only occasionally will we allow that someone might attempt it for reasons that are not radically disordered — and in that case, there will be those that seamlessly move from trying to stop you, to offering to help finish the job. Assisted death services are a case in point.

This narrative, that a suicide is rarely a genuine choice, makes a lot of grieving relatives feel better, and I can see why; it is hard to accept that a loved one decided to leave you. And in many, perhaps most cases, the person concerned did not decide; suicides took place in extreme states of agitation, paranoia, or psychosis. But it is one thing to consider a particular case sympathetically, and acknowledge that it looks like the ordinary requirements for rational choice were absent there. It is quite another to present the seductive idea that some mental illness or condition generally “causes” suicide, with scant room for individual agency and varying circumstances in the backstory too.

Increasingly, we hear this sort of thing. Large-scale studies correlate autism, or bipolar disorder, or gender dysphoria, or whatever it is, with a significantly increased risk of suicide. On the basis of such studies, authorities who should know better talk as if the particular mental condition in question is highly likely to directly produce the act. Sufferers receive the message that they are unusually prone to self-harm; a thought which can itself produce frightening emotions, and so put the idea more forcefully and apparently inevitably into their heads. This is not supposed to be a complete explanation of any given suicide either, but it is a baleful possible influence too often ignored.

And another problem with glib causal explanations of suicidal tendencies is that they offer cover for manipulative creeps. They allow wrongdoers to pretend to the world, and even perhaps to themselves, that some undeserved psychic pathology is aggressing them, rather than, say, appropriate feelings of shame or guilt. They can tell themselves that, thanks to the mental illness that allegedly puts them in danger, they are owed sympathy and care from others rather than disapproval; perhaps even that they are victims too. Whether any of this applies to PPT remains to be seen. But if the newly incarcerated Russell Brand conveniently brings up his bipolar and ADHD diagnosis in the next few days, I won’t be at all surprised. There are more Jekylls around than you might think.

***

If you are in need of support, you can contact the Samaritans on 116 123, or visit their website. 

The causal power attributed to porn has all the hallmarks of a moral panic. Of course, that isn’t to say that there aren’t lots of good and familiar reasons to dislike pornography. A lot of porn is disgusting, tacky and misogynistic; it certainly harms the people who make it; to be aroused by its more depraved varieties is, in a completely straightforward way, a manifestation of bad taste. Perhaps the young, or those of limited inspiration, even pick up hackneyed or harmful sexual “scripts” from what they watch. Sex-positive progressives who try to suppress this knowledge for ideological reasons are usually guilty of embarrassing levels of self-deceit.

Not content to rely on those considerations, however, the present wave of anti-porn journalists usually also make extravagant empirical claims about the potential population-level effects of porn use. For instance, Louise Perry and others have suggested that the rise in pornography consumption has seen rates of erectile dysfunction “skyrocket”, from single to double digits, in recent years. Such claims may have the ring of truth. But is there any hard evidence behind them? Not really. There is a dearth of gold-standard longitudinal data. Much of what does exist fails to find statistically significant correlations between ordinary levels of pornography consumption and erectile dysfunction. The catastrophizing results have to be cherry-picked: in this case, as the science writer Stuart Ritchie discovered, from unrepresentative self-reported survey data collected from Swiss military conscripts.

Even when pathological, rather than ordinary, use of pornography is brought into focus, journalists steadfastly neglect obvious confounding factors. Extreme pornography use is not independent of other kinds of sexual dysfunction. Men who are predisposed to erectile dysfunction for other reasons may also spend more time seeking solace in porn. Men who are intrinsically bad at relationships will both experience relationship failure and end up as lonely masturbators for want of anything better to do. Innately violent men will both mistreat women and be drawn to depictions of mistreatment in pornography. There is nothing ad hoc about invoking such causes: we have independent reason for believing they are operative. Nobody sensible — and, in particular, no sensible anti-porn feminists — believe on reflection that dysfunctional, violent or aberrant men only came into existence with the advent of high-speed internet. They have always existed. An economical explanatory starting point, then, is that porn does not do all that much to fundamentally reshape men’s sexual dispositions. For the most part it reflects, rather than molds, their natures, ministering to impulses they have already, however depressing that may seem. The contrary view — that porn corrupts healthy minds — is a completely blank-slatist piece of speculative psychological theorizing.

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If anti-porn journalists find it hard to accept that starting point as even a live option, it may be because many of them seem, however unreflectively, to be operating with an unreconstructed “behaviorist” background picture of a kind that few working scientists have accepted for about 70 years. This particular anti-porn school of thought conceives of human (or at least male) sexual psychology as a blank slate written upon by the environment, in particular by the internet. Sexual dispositions are thought of as resulting from a process of stimulus and response under conditions of reinforcement learning. The implicit view is something like this: men watch porn and are psychologically rewarded by the pleasure they feel; the association between porn and reward is reinforced by repetition; the effect is that in their sex lives they seek similar rewards, or never seek sex to begin with, or can’t get an erection, or pursue ever more intense versions of the original reward in the form of more extreme porn, or whatever. In its heyday, behaviorist style associationism was an attractively general account of how all learning might take place, but it was widely abandoned in the mid-20th century in favor of paradigms that posited far more innate mental structure, with all behavioral traits shown to depend significantly on genetic factors. Human beings are not blank slates, either in their lives generally or their sexual lives specifically.

None of this is to downplay the evidence, most notably in the form of recent anecdote and survey data, that men can pick up harmful or sadistic ideas, like strangulation, from porn. People engage in cultural learning and imitation of this kind all the time, to both good effect and ill. Acknowledging it requires nothing like a revisionary psychological account of how internet porn “rewires” the mind. In fact, it is the anti-porn behaviorist journalists who would struggle most to account for such unwelcome cultural developments in an accurate way. For many women, as they accurately insist, are repelled by the gross practices that are now ubiquitous in pornographic culture (women’s brains, somehow, resist being “rewired” by the stimulus). Men on the other hand are helplessly “reprogrammed” by all they watch. The motto seems to be: anti-behaviorist psychological nativism for women, rampant behaviorism for men. But that is just silly: a grab-bag of ill-assorted theories invoked as convenience dictates.

Are our journalists and public commentators really so naïve? Anyone worried that the opposition is presently being straw-manned should read Jo Bartosch and Robert Jessel’s recent, well-received, book, Pornocracy. In among some well-taken points about the iniquities of the porn industry is an utterly bonkers theory of human psychology hastily dressed up in the reassuring language of neuro-jargon. Porn, we learn, is so “addictive as to cause brain damage”. The visual spectacle of humans having sex is, we are rather implausibly told, a “superstimulus we’ve not evolved to process”. Consequently, it does not “serve our sexual tastes; it shapes them”. Porn “rewires the brain to be aroused by what the user sees and only by that”. “The more orgasms you have with porn,” we are warned, “the more sexually and emotionally attached to it you’ll become.” (So far, so behaviorist. But if the pleasure of masturbation really had such a radical conditioning effect, one might wonder why homo sapiens didn’t millennia ago become a short-lived species of emotionally-self-attached solitary tossers.) No allowance is made for the possibility that different men might be innately predisposed to respond differently to the same environmental stimulus. Porn has turned men into “wanking automata”. If only it were true that mere repeat exposure to the same stimulus did in fact “reprogramme” the mind, Bartosh and Jessell could stop repeating themselves so much and consider the reader successfully re-wired.

Duly alarmed by their own findings, the authors wonder gravely whether we may be witnessing the “de-evolution of humanity into an ape whose every thought and action is influenced… by the adult industry and its values – Homo Pornographicus”. Nor are they cautious about offering advice on the basis of this measured and careful analysis. Given the risk that you will wake up one morning next to a “de-evolved” porn-addicted ape, it may “make better sense for women to swear off men than to put up with a partner who uses pornography”.

Now, such bold counsel surely calls for overwhelmingly robust empirical backing. What are Bartosh and Jessel’s grounds for their startling claim that porn “has the power to enslave its users”? Helpfully, the entire second chapter, “How porn changed our brains”, takes up the question, gesturing at an “Everest of evidence” to draw on. “When people use pornography,” we read, “they create new ‘sex rewards’ pathways in their brain.” Every time they masturbate, “men experience a ‘spritz of dopamine’ that further consolidate[s] the connection between pornography and pleasure” — “reinforcing the new ‘pornsex’ brain network at the expense of the ‘real sex’ neural pathways”. The result is “irreparable damage to the brain’s dopamine system”.

Those who feel a twinge of doubt as to whether contemporary neuroscience has indeed uncovered dedicated “porn sex” and “real sex” neural pathways in the architecture of the human brain may turn to the chapter’s references. There they won’t find much. Bartosh and Jessel are unable to cite a single probative randomized controlled trial or longitudinal study to back up any of their alarmist claims about the effects of porn. Instead, they repeatedly cite from an anecdote-driven pop science book by Norman Doidge, a Canadian psychiatrist and psychoanalyst best known for promoting non-standard remedies for congenital and neurodegenerative diseases that make use of the “brain’s healing energies”. Later on, a promising reference to “dozens of studies [that] have identified the addictive capability of pornography” leads to the non-peer-reviewed work of an anti-masturbation campaigner called Gary Wilson. He is best-known for giving a TED talk on porn addiction that accumulated 17.5 million views, and which is now prefaced by a disclaimer notifying viewers that the presentation contains “assertions that are not supported by academically respected studies in medicine and psychology”.

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Polemical overreach often harms a theory more than it helps it. Bartosh and Jessel sidestep obvious responses to their arguments. They misleadingly suggest more evidence is on their side than it is. They ignore evidence that compulsive behaviors have nothing like the pharmacological profile of addictive substances. They risk trivializing the category of addiction by reconceiving all actions positively reinforced by a “spritz of dopamine” as incipient dependencies. And they have their model of porn addiction rely on a strained and somewhat impressionistic analogy between the “extremity” of visual content and stimulant concentration, allowing them to insinuate that men’s initially vanilla erotic tastes escalate insatiably until they all become pornographically-reprogrammed rape fantasists (again, not a phenomenon there is much high-quality evidence to support).

The view that human beings are easily corrupted by imagery is a remarkably seductive cultural trope. Socrates proposed banishing the poets from the ideal city because of their destructive capacity to excite the soul with their fictions. Recent cultural history testifies to our tendency to overestimate the psychological damage done by media of all kinds. The panics of the Nineties and 2000s, over whether video games and R-rated movies disposed their viewers to violence, were remarkably like the porn panic of today. Then too, hysteria far outstripped the arrival of anything close to confirmatory evidence for the theory advanced by panicked columnists and cultural commentators, and such evidence has failed to come to light in the years since. Still, people seem unable to resist the idea that morally depraved media must itself be a kind of poison taken in through the eyes and ears, harming the viewer, despite the striking example provided by the long history of analogous panics whose specific fears now look like relics of parochial concern.

It does no service to the cause of anti-porn commentators that they so often make their arguments depend on shaky psychological presupposition and tendentious empirical conjecturing. But one shouldn’t expect them to stop any time soon. Behaviorist scare tactics provide too versatile a template for cultural critique. And anyway, like the targets of their favorite argument, if there’s one feeling a columnist knows better than most it’s the temptation to set shame and caution aside, slump down in front of the computer, and desperately bash out another one.

Milos Forman’s movie adaptation of Kesey’s novel was released 50 years ago, and a few months later, at the 48th Academy Awards, it came away with the “Big Five” awards — Best Picture, Best Actor, Best Actress, Best Director, and Best (Adapted) Screenplay. The movie was a smash hit with both the public and the critics, and so it’s fair to view it as a mid-Seventies movie-industry event. But in its themes and messages, it is very much an artifact of the early Sixties when it’s set, and when Kesey’s novel was published. These early-Sixties origins are key to the movie’s continuing appeal. They’re also the reason a viewer of Cuckoo’s Nest in 2025 might find it vain and simplistic and a little silly.

The film, which hews closely to Kesey’s novel, portrays the fate of Randall P. McMurphy (Jack Nicholson), a low-level criminal who’s been transferred from a prison work-farm, where he was constantly fighting with prison staff and his fellow inmates, to an unnamed insane asylum. Soon after arriving, he meets the woman who’ll be his antagonist in the film, a stone-faced named Mildred Ratched, Nurse Ratched (Louise Fletcher). McMurphy is assigned to a ward in the asylum in which some patients are totally catatonic and others are normal and functional enough to engage in peaceful card games and board games, and to sit for halting group therapy sessions led by Nurse Ratched. McMurphy immediately identifies Nurse Ratched as someone to oppose, an unjust ruler of the ward’s society, which is much more repressive and repressed than McMurphy thinks it should be. So he sets out both to undermine Nurse Ratched’s authority and to infuse his fellow mental patients with his own rebellious spirit, so that they’ll start to fight their own oppression by the overbearing nurse. Significantly, standing off to the side as this action plays out, usually with the handle of a broom in his grip, is a huge “deaf and dumb Indian” everyone calls “Chief”.

I first saw One Flew Over the Cuckoo’s Nest when I was 13 or 14, and I loved it. My son saw it earlier this year, when he was 14, and he loved it. I suspect that the movie strikes such a chord with teenage boys because, like Kesey’s novel, it celebrates a very boyish sort of righteous mischief. What R.P. McMurphy does is he Resists Authority.

The movie isn’t exactly subtle about this theme, but the novel hits it so hard on the nose it bleeds from both nostrils. In the novel McMurphy’s initial processing into the asylum features a recital of his “file” by Nurse Ratched. “Thirty-five years old,” his file says. “Never married. Distinguished Service Cross in Korea for leading an escape from a Communist prison camp. A dishonorable discharge, afterward, for insubordination.” In other words, when it comes to Resisting Authority, R.P. McMurphy is The Best. Not even Chinese Communists can tell him what to do.

But McMurphy’s heroic defiance has a special fuel, his exemplary sex drive. He’s The Best at rebellion because he’s top-percentile as a horndog. This sexual-political formula is much less profound as social critique than either Ken Kesey or the people who made his novel into a movie believed it to be, which I’ll touch on below. But it does give Jack Nicholson the license and the tools to build McMurphy into an indelible comic character. McMurphy got himself sent to the insane asylum on purpose, because he thought it would be an easier time than the work-camp where he’d been serving a sentence for committing the heroic horndog’s signature felony, statutory rape (“She told me she was 18”). With his lively forehead and those tenting eyebrows, the wide flash of his leering smile, the ambiguous menace in his delivery, Nicholson is beautifully equipped to act like someone who’s acting crazy while also, at a more literal register, Resisting Authority.

His performance is undeniably hammy, but this hamminess is neither distracting nor off-putting. He’s having fun on screen. We’re having fun in the audience. But it’s not just Nicholson who makes Cuckoo’s Nest such a winning film. There’s an intoxicating vitality in pretty much every scene. By this I don’t just mean it’s filled with lively movement, or that it’s briskly edited, but also that its characters are captured with unusual vividness and physical immediacy. One Oscar it didn’t win, but probably deserved, was for Cinematography. (The actual winner, Kubrick’s panoramic Barry Lyndon, was a much more conventional pick for this award.) A testament to the greatness of the film’s photography is how persistently its characters’ faces — smiling, sweaty, bug-eyed, stubbled — live in your visual memory after you’ve seen it.

Of course, the depiction of this ward also highlights one of the film’s more glaring weaknesses: its conveniently wistful treatment of mental illness. This ward of the asylum — McMurphy, his buddies, Nurse Ratched — is presented as a metaphor for society and its repressions. But the ward can do the sentimental and signifying work of metaphor only because the patients in it resemble a gang of likable misfits more than real mental patients. Martini (Danny Devito) is in the nuthouse, it seems, because he squints too much. Cheswick (Sydney Lassick) has a funny voice and can get a little emotional at times. Taber (Christopher Lloyd) is kind of a live wire but seemingly harmless and totally compos mentis. Harding (William Redfield) suffers from some sort of bookish ennui. McMurphy is supposed to at least be acting crazy, but his few moments of overt craziness play as jokes that everyone’s in on. The whole “mental patient” thing is kind of a ruse, in other words. McMurphy’s fellow patients are just compromised enough to be vulnerable to Nurse Ratched’s repressive rule, but otherwise fairly normal and healthy, so that we like them and root for them as we probably wouldn’t root for people afflicted with borderline personality disorder.

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If McMurphy is obviously the central character, the Chief is the audience’s proxy inside the asylum, (and also the novel’s narrator.) But the most thematically central character, at the deepest psychic level the movie is trying to plumb, is stuttering Billy Bibbitt (Brad Dourif). The movie is a portrait of authority, and the operative source of this authority is maternal. Society’s ur-boss is a Mother, and the Mother exercises her authority with an icy, smiling violence aimed right where it hurts, and the movie’s central victim of maternal violence is poor Billy, whose psychic deformities were done to him by his iconic mother, who then delivered him to the asylum ostensibly to be cured of those deformities but actually to be terrorized by a second mother: Nurse Ratched.

In one scene, Billy shows a McMurphyish flash of defiance towards the overbearing nurse-mother, and she unstrings him with a simple reminder that she and his mother are “old friends”. This moment is meant to contain not just drama but diagnostic insight about the real source of Billy’s sickness. In his flush of defiance Billy loses his stutter, but then Nurse Ratched mentions his mother and the stutter comes back with (as it were) a vengeance.

What makes One Flew Over the Cuckoo’s Nest such a heavy symptom of its time is not just this blunt recourse to the then faddish psychological stories and archetypal figures. It’s the specific conflict these characters find themselves fighting. As I said, McMurphy’s exemplary mischief, his irrepressible challenge to the Rules and Rulers, flows from in his brimming libido. The authoritarian mother, Nurse Ratched, thus represents sexual restraint or repression, and her villainy consists in this almost entirely. The antagonism between boyish sexual exuberance and maternal sexual control drives everything in the film. Billy’s unstuttering faceoff with Nurse Ratched, when he briefly lives up to McMurphy’s defiant example, comes after he finally gets laid. By contrast, the ward’s most pliant and least admirable figure is bookish Harding, who not only accepts but understands and justifies the cold motherly rule of Nurse Ratched. Harding’s defining trait is that he’s a dickless cuckold, miserably (and inexplicably) married to an attractive woman who disdains and probably cheats on him. He’s Nurse Ratched’s favorite because he came to her already castrated.

The movie more or less pummels you with these tidy psychosexual politics from 1962, so I’m not claiming bonus points for decoding them, though I do wish it was all as simple as Cuckoo’s Nest suggests. A sexually oppressive mother — or, Society figured as this maternal oppressor of sexual desire — is a satisfying opponent to have in your Romantic struggle for spiritual freedom. If you understand the antagonism in these terms, the bad people being the ones who would keep you from consummating your horniness, then your spiritual protagonist is your own libidinal striving, which — let’s be honest — would have been your protagonist anyway. No wonder making a “revolution” on behalf of this striving was such a winning idea among Western youth soon after Ken Kesey’s novel was published. And no wonder teenage boys like Milos Forman’s movie so much.

Once you question the seriousness of its themes, its critical picture of the world, Cuckoo’s Nest starts to look like a very different sort of film from the one that so impressed critics and Oscar voters in 1975. Back then, admiring viewers might have taken the film to be an heir to the great Freud-inspired works of Buñuel and Bergman, or films of political liberation like The Battle of Algiers. But watching it again, I started to think that its true place in the history of movies lay in a much less exalted film tradition. One Flew Over the Cuckoo’s Nest — critical darling, winner of the Big Five at the Academy Awards, frequent entry on lists of the greatest films of all time — seems like the founding model for certain spirited comedies of the decade that followed, in which gangs of misfits rebel against the repressive rules of stodgy institutions. Animal House (1978), for example, is also set in the early Sixties. It also features a gang of misfits, who oppose Dean Wormer, who is functionally identical to Cuckoo’s Nest’s Nurse Ratched as head oppressor at stodgy Faber College. Animal House also views a man’s rebelliousness as at least partly a function of his carnality, and, like Cuckoo’s Nest, it links willing conformity with institutional rules to certain failures of manly sexual readiness.

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Also in this new Cuckoo’s Nest tradition I’m proposing is Stripes (1981), in which Bill Murray’s John Winger — who rarely wears underwear — musters his own gang of misfits to show the hidebound US Army that there’s a sexier way to be an American soldier. One should probably throw into this likable lineage Caddyshack (1980), in which the repressive, unsexy ways of the suburban country club are finally exposed, and made sexier, by a gang of misfits.

This is not a bad tradition to be the founder of. Those are funny movies. And one advantage of putting One Flew Over the Cuckoo’s Nest at the head of this tradition is that it helps us see the silliness of the ideas the movie expresses.

But using this new category to highlight the silliness of those ideas in their intellectual substance also presents us with darker ironies that attach to those ideas in their practical effects. Along with channeling and packaging the shallow and morally convenient theories about desire and repression that would animate the sexual revolution, Kesey’s novel was a key inspiration for a policy shift that almost rivals the sexual revolution in its importance for everyday experience in America, especially for those of us who live in large cities: the shrinking and shuttering of state mental hospitals across America, leading to the mass release of seriously mentally ill people from custodial care, known as deinstitutionalization.

The reading public was both moved and misled by Kesey’s sentimental portrait of his asylum ward, filled as it is with likable fellows who are not insane but merely oppressed, and by his lurid and inaccurate portrayal of hospital treatments such as electro-convulsive therapy, which he made seem more painful and violent than it actually was, and which he presented as a method of political control. On the other hand, the movie’s famous lobotomy scene reflected a real systemic abuse that, like much else in the asylum system, was a worthy target for aggressive reform — as opposed to the dismantling of that system that actually happened.

Kesey’s novel came out in 1962. In 1963 John F. Kennedy signed the Community Mental Health Act, which set the process of deinstitutionalization on its way. You can’t exactly say the popular book caused the unwise law, but you can’t detach them either. The popularity of Kesey’s novel added real momentum to the ideological forces that would convince Congress and the President to revolutionize the treatment of the seriously mentally ill, to make it so that, instead of being treated inside flawed and overwhelmed but tragically necessary institutions, many of them would not be treated at all.

You might wonder how such a disastrous law came to be made. I don’t have a full explanation, but I figure its badness is probably connected in some way to the fact that its main literary inspiration was also the literary inspiration for such cinematic masterpieces as Animal House, Stripes, Caddyshack, and, if we’re being exhaustive, the several Revenge of the Nerds movies.

The psychiatric profession rapidly embraced the new pills, which more closely resembled the practices of mainstream medicine than the remedies that had previously been used to treat mental illness: insulin comas, shock treatments, lobotomies. Nobody really knew why the drugs worked. We still don’t, entirely. Serious mental illness is a source of profound suffering, and its ravages rapidly spill over to affect patients’ families, their immediate community, and society at large. This creates a desperation to do something — anything — to cope with its symptoms. Yet our understanding of the origins of psychosis remains strikingly primitive and feeble — and so, too, our understanding of its treatment.

Earlier this year, The Times reported that clozapine, a relative of chlorpromazine, is “Britain’s most dangerous prescription drug”. Prescribed in Britain to some 37,000 people suffering from schizophrenia each year, it has been associated, the story noted, with around 7,000 deaths since 1990: the equivalent of around 400 each year. There is a whiff of journalistic hyperbole at work here. A death rate of more than 1% of those taking the drug is certainly cause for concern, but there are far more dangerous drugs in the pharmacopoeia. Nevertheless, it is worth asking how clozapine ended up on the market, and why it continues to be prescribed.

The puzzles psychiatry wrestles with are so difficult to solve that when an intervention appears to work, enthusiasm tends to win out against any cautious restraint. So it was with the arrival of antipsychotics. Within 18 months of the first chlorpromazine pills being approved for the market, they were being prescribed to more than two million patients in the US. The now defunct pharmaceutical company Smith, Kline & French had bought the North American rights to the drug, but others were rushing to create their own copycat versions. In the words of an early advertisement for Thorazine: “Assaultive or destructive behaviour is rapidly controlled… helping to dispel or modify delusions, hallucinations and confusion, while keeping the patient calm and approachable.”

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The drugs did indeed work, to a degree. They didn’t cure psychosis, but for many patients they alleviated some of its most dramatic and disturbing symptoms: the hallucinations and delusions that plagued them. Sadly — and this took years to be acknowledged — these medications had little effect on other devastating symptoms: the intellectual deterioration, the apathy, the failure to connect with others, the loss of spontaneity.

Early on, there were troublesome signs that the drugs imposed a heavy burden on those taking them: side-effects that surfaced and often persisted even after the drugs were withdrawn. Patients became incurably restless. They developed Parkinson’s-like symptoms. Most disturbing of all was a condition labelled tardive dyskinesia. A so-called extrapyramidal disorder, it involves facial tics, grimacing, grunting, rapid jerking and spasmodic movements — all of which are ironically often mistaken by naïve observers as symptoms of mental illness. It afflicts very many patients — estimates range as high as two-thirds of those taking the drugs — and is incurable, continuing even after people stop taking chlorpromazine.

For a decade and more, psychiatrists ignored this on-going iatrogenic disaster. Leading figures in the drugs revolution minimised its presence or significance. Nathan Kline, often called “the father of psychopharmacology” and once a serious candidate for a Nobel Prize in Medicine, insisted that tardive dyskinesia was “of no great clinical significance”. Daniel X. Freedman, the long-time editor of the Archives of Neurology and Psychiatry, claimed that the disorder was only found in a handful of patients, and was an “unavoidable price to be paid” for relief from delusions and hallucinations.

People wanted to believe chlorpromazine was a silver bullet; when you are confronted by the distressing symptoms of mental illness, it is tempting to ignore the drawbacks of anything that might offer relief. The current vogue for poorly researched and dubious interventions for sufferers of depression — deep brain stimulation, psychedelics, ketamine infusions — is only the latest example of this tendency.

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But eventually the medical establishment couldn’t keep ignoring the dangers of chlorpromazine. A 1973 paper by Maryland psychiatrist George Crane, which appeared in the august pages of Science, effectively ended the silence surrounding tardive dyskinesia. By 1980, two other prominent psychiatrists spoke of the profession’s attitude to the issue having moved “from curiosity and mild concern to panic”. But once the period of denial came to an end, the absence of alternative treatments was glaringly obvious. This is where clozapine enters the story.

Clozapine was actually not a new drug at all. First synthesised in 1958 by a small Swiss company later absorbed by Sandoz, it was brought to the European market in the early Seventies, despite concerns about its propensity to provoke seizures and low blood pressure. A significant number of patients developed a serious, often fatal condition called agranulocytosis, where a dramatic loss of white blood cells wrecks a patient’s immune system and leaves them overwhelmingly vulnerable to infections. Before clozapine entered the American market — then, as now, the most lucrative market for pharmaceuticals — it was abruptly withdrawn from sale in Europe. For nearly two decades, it vanished from the scene.

But as concern about chlorpromazine’s side effects mounted, it occurred to Sandoz that clozapine could be brought back to life. With the caveat that patients given the drug would need to have their white cell counts carefully monitored, regulatory approval was soon forthcoming. Now, clozapine is prescribed in cases where other antipsychotics have failed — why it works is a mystery, but the evidence that it often does is solid. Nevertheless, common side effects include agitation, constipation, dizziness and fatigue, seizures and tremors, and serious weight gain. It is an intervention that should be sanctioned only in desperate cases.

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Just as chlorpromazine’s discovery prompted rival drug companies to create a host of copycat drugs, so the re-emergence of clozapine prompted the development of a raft of new potions in the Nineties. Collectively known as second-generation antipsychotics — though their chemical structures often have little in common — these drugs seem less likely to provoke tardive dyskinesia, although a large study funded by the United States’ National Institute of Mental Health, rather than the drug companies, raised some doubts about the strength of the evidence for that claim. But these drugs remain no more effective at relieving hallucinations and delusions than their predecessors, and just as inefficacious at treating other symptoms of schizophrenia: the social withdrawal, the lack of interest in life, the intellectual deterioration and loss of linguistic capacity. A careful 2008 review in Nature found that they were no more than moderately effective in 41% of those treated (versus the 24% who responded positively to placebo), and the response to treatment declined over time. Second-generation antipsychotics are therefore important for those who do respond, but very far from curative; the authors of this particular study concluded that “there is much room for more efficacious compounds”.

Some studies have been more critical. Over time, second-generation antipsychotics provoke massive weight gain (10 or 20kg is not uncommon), and they are associated with heart disease and disorders of the metabolic system. Many of those taking these pills develop diabetes. So it’s unsurprising that one authoritative 2015 review in the Journal of Psychopharmacology concluded that “the [adverse effects] profiles of the newer antipsychotics are as worrying as the older equivalents for the patient’s long-term physical health”.

The danger is that the inappropriate prescription of these drugs will give psychiatry a bad name. That sector of society with little empathy for the psychically troubled — groups like the Scientologists or the followers of the late psychiatrist Thomas Szasz, who proclaimed that mental illness is a myth — will discuss side-effects in order to dismiss psychiatry as toxic or, worse, an “industry of death”. Patients who fail to respond to antipsychotics (and there are many), or who experience only the negative consequences of taking these pills, in many instances echo some of the complaints of these critics. I understand their anger and dismay. As a historian who has researched the foibles and failings of psychiatry, and the manifold ways its interventions have often served to magnify rather than reduce suffering, I’m not blind to the profession’s deficiencies.

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But that very familiarity with the barbarities that often preceded the psychopharmacological revolution prompts me to a somewhat less bleak assessment of the profession’s current state. Before totally denigrating psychiatry, it is necessary to face up to the suffering and disruption that follows in the wake of mental illness. It is vital, I think, not to resort to nihilism. There are substantial numbers of people for whom drugs provide considerable relief. These pills permit many to live some semblance of a normal life.

All medical interventions carry risks, and balancing risks and harms is a problem for medicine as a whole, not just for psychiatry. Caution is especially in order in the psychiatric realm, precisely because the stigma that attaches to mental illness may encourage some to clutch at straws, and because psychiatric conditions cannot usually be cured. But caution and scepticism should not become despair. We’re talking about some of the most profound forms of human suffering. If our treatments are imperfect, we should simply attempt to do better.

Given that Covid tends to affect men more than women, why would long Covid affect women more than men? And given that Covid complications are extremely rare in the young, why would teenage girls be disproportionately affected by long Covid? Finally, given that we can’t accuse a virus of transphobia, why would long Covid affect transgender people most?

The answer lies in the fact that long Covid is not a strictly physical phenomenon. A study of nearly two million people published in Nature found that people who reported three or more symptoms of long Covid included: 4.9% of people confirmed to have had Covid, and 4% of people with no evidence of having had Covid. So, reporting the symptoms of long Covid is only moderately associated with a prior Covid infection. In fact, long Covid correlates about as much with mood disorders as with Covid itself. One study found that people prone to anxiety and depression before Covid infection were 45% more likely to develop long Covid after infection, and the Nature study found that having anxiety and depression before getting Covid almost doubled the chances of reporting long Covid.

This would help explain why women and trans people are disproportionately reporting long Covid: these two demographics have particularly high rates of anxiety and depression.

But why exactly would mood disorders increase the likelihood of long Covid? Some experts have speculated that stress may affect the immune system’s response to Covid and lead to more serious infections. However, a Turkish study found no evidence that anxiety or depression alters the body’s immune response to the virus. A much likelier explanation could be that, since symptoms of mood disorders overlap with those of long Covid, people are mistaking psychological distress for the side-effects of viral infection.

This is part of a broader phenomenon. Young people are reporting despair and distress at an unprecedented rate, and this mental health crisis is a symptom of a malfunctioning society — a society that is making people sick, by teaching them to feel sick. The tendency for people to misdiagnose their despair as a medical disorder can be observed far beyond reports of long Covid. Consider the surge in cases of gender dysphoria. Between 2012 and 2022, the number of adolescents referred to the NHS’s Gender Identity Development Service (GIDS) increased by over 2000%. If the increase were simply due to decreasing stigma around being trans, it wouldn’t be mostly restricted to a single sex and age range, but it has been driven almost exclusively by young people and natal females.

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The group that’s disproportionately reporting gender dysphoria — adolescent girls — appears to be the same demographic as the group deemed in the German study to be disproportionately at risk of long Covid. This is also the group, besides trans people, deemed most at risk of mood disorders. So, again, it seems many young people, particularly girls, are confusing general distress for another illness.

And it’s not just reports of gender dysphoria that have multiplied among young people. Increases have occurred for major depressive disorder, attention-deficit disorder, obsessive-compulsive disorder, social anxiety disorder, generalised anxiety disorder, autism spectrum disorder, and various eating disorders. It seems that young people, and their doctors, are viewing personal issues as medical disorders: we are living through a pathologisation pandemic.

Why are so many people confusing sadness for sickness? It’s human nature to look for single causes to complex problems. The physician’s habit of ascribing all a patient’s symptoms to just one diagnosis led to the formulation of Hickam’s dictum, which states: “A man can have as many diseases as he damn well pleases.” Likewise, it’s tempting to look for a neat and simple reason for people blaming their troubles on a single disorder, but to do this would be to make the same mistake as them. Pathologisation can have as many causes as it damn well pleases.

One may be cyberchondria, the phenomenon whereby people anxiously google symptoms, and, due to confirmation bias, ignore those that don’t apply to them while focusing on those that do, until they become convinced they have the disorder they’re reading about. Another cause may be social contagion, whereby panic spreads through the power of suggestion. According to a UK study, adolescents who reported parents suffering from long Covid were almost twice as likely to report experiencing long Covid symptoms themselves, regardless of whether they’d actually had Covid.

It’s known that social contagions tend to affect girls more than boys, a disparity that could be exacerbated by girls tending to use social media more than boys. But the problem with social contagion as an explanation is that it’s a how, not a why; it offers a means without a motive.

Some have attempted to discern a motive. One is that girls are trying to escape unattainable ideals of femininity. As the arms race of plastic surgery and beauty filters ramps up, natural bodies seem ugly by comparison. This “selfie dysmorphia” may lead to anxiety and depression, as well as symptoms of gender dysphoria, as pubescent girls become desperate to defy the metamorphosis of their bodies into sexual objects. But this explanation doesn’t shed much light on the rise of conditions like long Covid, autism, and obsessive-compulsive disorder. However, a deeper dive into the data does.

When we include politics in the mental health data, it becomes clear that this isn’t simply about gender. A 2020 Pew survey of over 10,000 people found that self-described liberals aged 18-29 were more likely than self-described conservatives of the same age to report suffering psychological problems over the last week. They were also more than twice as likely to say they’d ever been diagnosed with a mental health disorder. Furthermore, those who were “very liberal” were more likely than those who were just “liberal” to report poor mental health. The group most likely to report poor mental health was white liberal females, an alarming 56% of whom reported having received a mental illness diagnosis.

Crucially, controlling for worldview narrowed the gender gap considerably: liberal men were more likely to report poor mental health than conservative women. It would seem, then, that the mental health epidemic among girls and young women is associated with their tendency to have a more Left-liberal mindset than boys and young men — a difference that’s becoming more pronounced over time.

But why would Leftism be associated with poorer mental health? An analysis of data from 86,138 adolescents found, in line with the Pew survey, that between 2005 and 2018 the self-reported mental health of liberals had deteriorated more than conservatives’, and that this deterioration was worst for girls. The researchers blamed this on “alienation within a growing conservative political climate”. However, the New York Times’ Michelle Goldberg debunked this explanation by pointing out that liberals’ mental health woes began while Obama was in power and as the Supreme Court voted to extend gay marriage rights — hardly a conservative political climate.

The real reasons may be deeper. One idea, more than any other, underpins the difference in outlook between liberals and conservatives. Central to Leftism is equality, backed by the idea that people’s fortunes and misfortunes are not their own doing, and therefore undeserved. As such, Leftism de-emphasises the role of human agency in social outcomes, while overemphasising the role of environmental circumstances. As the West has shifted culturally Leftward — due to most writers and artists leaning Left — the depiction of people as hapless puppets has become dominant.

Today’s Left-liberal culture teaches young people that their problems are not their own fault, but rather the product of various systems beyond their control. These systems may be sociological — late capitalism, systemic racism, the patriarchy — but increasingly, they are medical. A common example is “trauma”, a psychiatric term that has become a knee-jerk justification for everything from street crime to silencing opposing views on campus. It’s a word so overused that even clinicians fear it has lost its meaning. Most people, however, are happy to have their personal failings blamed on medical issues, because it absolves them of responsibility. It’s not your fault you violently lashed out, you have trauma. It’s not your fault you lack energy, you have long Covid. It’s not your fault you hate the way you look, you have gender dysphoria.

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Pathologisation is also an effective way to manufacture sympathy. The co-founder of Black Lives Matter, Patrisse Cullors, responded to accusations she’d used donation money to enrich friends and family by claiming that the accusations had given her post-traumatic stress disorder, a diagnosis once reserved for rape survivors and war veterans.

Claims like Cullors’s are instinctively met with sympathy and even awe on the Left, where overeager attempts to destigmatise mental illness can end up glamorising it. On social media, young liberals now engage in “sadfishing”, a kind of digital Munchausen’s Syndrome, where people fabricate ailments for pity and clout; some, such as the TikToker “TicsAndRoses”, fake Tourette’s, while others fake multiple personalities. The power of mental health disorders to attract attention online has turned them into fashion accessories, cute quirks to help kids stand out from the crowd, or “part of my dating appeal”.

Unfortunately, these designer disorders are not just harmless labels; intentional pathologisation by influencers is causing unintentional pathologisation among viewers. Reports tell of adolescent girls suddenly developing “TikTok tics” after viewing videos of alleged Tourette’s sufferers. Others tell of adolescents presenting with multiple personalities after watching videos of people claiming to have dissociative identity disorder. As atomisation makes people more desperate for sympathy, and competition makes them more desperate for attention, it’s likely that sadfishing and its consequences will only worsen.

But as disturbing as all this is, victimhood culture is not the only force behind the pathologisation pandemic. It’s been abetted by a medical industry that has its own incentives for exaggerating the prevalence of mental disorders.

Medicalisation — the tendency for clinicians to recategorise ever more things as medical issues — occurs because clinicians are just as human as their patients, and are therefore just as influenced by culture and their own personal biases. The 1973 Rosenhan experiment showed that psychiatrists who have been told that a healthy person is insane will begin to reinterpret that person’s ordinary behaviours, such as note-taking, as manifestations of their mental disorder. We saw this in the Tavistock scandal, where the staff of the infamous Gids clinic, conditioned by ideologues to look for gender dysphoria, became increasingly hasty to diagnose it.

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The ability of clinicians to see precisely the symptoms they’re looking for is facilitated by concept creep, the tendency for the definitions of disorders to gradually expand to encompass more people. The rise in autism diagnoses, for instance, can be largely attributed to a diagnostic widening of the autism spectrum. Concept creep occurs largely due to the Shirky principle, which states: “Institutions will try to preserve the problems to which they are the solution.” The motive is often financial; the number of pregnancies deemed to require caesarean sections has increased because this method of delivering babies is more profitable. Likewise, if you’re simply sad then medical companies can’t monetise you, but if your distress is reclassified as, say, gender dysphoria, those companies can sell you puberty blockers or surgical procedures. By 2021, GIDS accounted for a quarter of the Tavistock trust’s income. In the States, the sex reassignment surgery market was valued at $1.9 billion and is projected to have a lucrative annual growth rate of 11.23%.

So, we have a medical industry that is both financially and ideologically motivated to overstate the prevalence of illness, and we have a victimhood culture that encourages people to view themselves as oppressed by things they can’t control. In the middle of this we have ordinary people tempted to blame their problems on medical issues for the sake of easy answers.

These three entities together form a mutually reinforcing system. The late philosopher Ian Hacking, in his book Rewriting the Soul, details how in the 20th century, the press, the public, and the medical industry operated in tandem to create new forms of madness out of mere gossip. Prior to 1970, there were almost no cases of multiple personality disorder (now known as dissociative identity disorder), but after one case was well-publicised by the media, people began using the concept of multiple personalities to make sense of their own problems. In so doing, they began to conform, wittingly or otherwise, to the official symptoms of the disorder. When clinicians speculated that people may invent multiple personalities to deal with childhood sexual abuse, people began to do just that. Some even suddenly “remembered” being sexually abused, even though the concept of repressed memories has no basis in fact. Initially, patients reported having two or three personalities. Within a decade, the average number was 17.

Thus, patient reports influenced clinicians’ diagnoses, but clinicians’ diagnoses also influenced patient reports. Diagnostic criteria became prescriptive as well as descriptive; they told patients how they were supposed to feel and act. Hacking called this cycle of mutual reinforcement a “looping effect”, and it proved so powerful that it turned a couple of isolated cases into an epidemic. A similar looping effect, facilitated by a hyperconnected world, seems to be driving the rise in reports of mental illness today.

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This is a problem because imagined sickness can cause real sickness. This occurs in two ways. The first is direct: in rural India, folklore tells that being bitten by a pregnant dog can make one pregnant with the dog’s puppies, and this urban myth has created a new illness: puppy pregnancy syndrome. Victims become so convinced they’re pregnant with puppies that they suffer panic attacks and even manifest symptoms of pregnancy, from persistent nausea to the sensation of puppies crawling in their bellies.

But the second way fake sickness becomes real is far more common and insidious.

Remember how Leftism de-emphasises human agency in the name of equality? Research shows conservatives tend to have an internal locus of control, which means they believe that their decisions, as opposed to external forces, control their destiny. Liberals, meanwhile, tend to have an external locus, which means they believe their lives are determined by forces beyond their control.

The American psychologists Jonathan Haidt and Jean Twenge used national survey data of adolescents to map their locus of control. Their findings were based on the proportion of respondents who agreed with statements such as: “People like me don’t have a chance at a successful life” and “Whenever I try to get ahead, something stops me”. They concluded that, since the Nineties, the locus of control for all teenagers has become more external, but the shift has been greater for liberals, and greatest for liberal girls. Further, when the self-worth of teenagers was mapped, using responses to statements such as “I feel my life is not very useful”, the data showed a universal decline in self-worth since 2012. Again, the decline was stronger for liberals, and strongest for liberal girls.

People with an internal locus of control, believing they control their destiny, tend to be happier and have healthier habits, like good diets and frequent exercise, while people with an external locus of control, believing they’re at the mercy of fate, have higher rates of anxiety and depression and are more likely to abuse drugs and neglect their health. When you believe you have no control, you don’t.

And thus, as society has liberalised, and medicalised, young people have lost both self-belief and resilience. Many have subsequently become trapped in a cycle where they feel distress, and pathologise it, causing more distress, leading to more pathologisation and more distress, which eventually becomes textbook anxiety and depression. The rise in diagnoses is therefore not simply an illusion caused by medicalisation; society is teaching kids to develop real dysfunctions.

This is the greatest danger of the pathologisation pandemic: belief in one’s sickness is self-fulfilling. It’s a disease not of any bodily organ but of hope itself, and it harms its victim by crippling their immunity to everything else.

If there’s a vaccine for the pathologisation pandemic, then the best candidate is Cognitive Behavioural Therapy (CBT). This is a form of talk-based treatment based on the Ancient Greek philosophy of Stoicism. Contrary to modernity, it teaches that our feelings are not always valid, but often deluded and self-destructive. The aim is to reframe harmful thoughts into alternatives that are more accurate, agentic, and soluble. So, instead of “The world sucks”, one could think “I feel like the world sucks right now”. Where pathologisation places problems outside your control, CBT places them within your control. Where pathologisation bundles many small issues into one giant insurmountable problem, CBT breaks down giant problems into small manageable pieces.

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No form of psychotherapy has been as rigorously tested as CBT, and its effectiveness in restoring agency and reigniting hope is documented by decades of research. Some studies suggest CBT is gradually losing effectiveness, but this is mostly because CBT, like everything else in the social sciences, has been corrupted by amateurisation and the desire to be “inclusive” and inoffensive. The newest forms of CBT, such as “Transgender-Affirmative CBT”, are the opposite of classic CBT because they seek not to cultivate strength but to validate feelings.

More than ever, a return is needed to the original, Stoicism-based form of CBT, which has helped everyone from the philosopher-emperor Marcus Aurelius, who governed Rome during a time of war and plague, to Vietnam POW James Stockdale, who used it to withstand torture at the notorious “Hanoi Hilton”. The ultimate cure to rampant pathologisation is to prepare the young to do battle against their greatest foe — their own minds — and to teach them a time-tested truth, bequeathed to us by history’s survivors: you are more than the things that happen to you. And you have as much control over your life as you believe you do.

Many of the misfortunes that befall you will not be your fault, but if you seek explanations for your suffering in things beyond your control, you risk falling prey to a culture and industry that are motivated to keep you feeling ill. Look within for the causes and, most times, you’ll find the cures. Modern society will tell you otherwise, of course, but it’s within your power to defy it, for you are not a helpless leaf in the wind but a mind that holds a world, which, depending on how you think, could be a Hell in Heaven, or a Heaven in Hell.

This was where some women, usually but not always older, rolled their eyes. Did an awkward joke, a bad date, or — as one memorable entry in the infamous Shitty Media Men list alleged — a “weird lunch” really constitute a form of harassment, let alone a cancellable offence? But other women, usually but not always younger, clucked their tongues: it was only because women kept putting up with such behaviour that men kept thinking they could get away with it.

At the time, the younger cohort appeared to the older like a bunch of hypersensitive harpies, retreating to the fainting couch at the slightest whiff of insult. The older, according to the younger, were cosying up to the patriarchy, in a desperate attempt to stave off their own irrelevance.

“We’re tough enough to take it,” said the Olds.

“It’s sad you think you have to,” said the Youths.

This early rift in the movement represented a deeper philosophical disagreement, about the nature and importance of resilience. The narrow question is, when does an annoying man becomes an evil harasser? The broader one is, when does a tolerable nuisance cross the line to become an intolerable transgression?

This question has been on my mind this week, for the most tragic of reasons. On 1st May, a 30-year-old man named Jordan Neely was choked to death on a crowded New York City subway train by a 24-year-old Marine named Daniel Penny. Neely, who was homeless and mentally ill, was reportedly screaming and confronting passengers; he was killed after Penny put him in a chokehold, while two other passengers held him down. Penny, in a statement released through his lawyers, said he did not intend to kill Neely.

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This incident was preventable. Long before his death, Neely was known to New York City authorities as a person who could not manage independent living, and who had been spiralling in recent years, desperately in need of help. For him to die on the dirty floor of a subway car, screaming and defecating on himself while three strangers held him by the arms, legs, and neck, he had to be first failed at every turn by a system that was supposed to shelter and protect him — not just from doing harm, but from being harmed by others when his mental illness manifested in frightening ways.

That Neely slipped through the cracks is not the only sign of institutional failure here. As ridership on the NYC subway has increased in the wake of Covid, so too have instances of violence, including several high-profile incidents in which people have been attacked or killed. New York City mayor Eric Adams was elected in 2021 on a campaign that promised to flood the subway system with uniformed police officers, to combat both crime and the perception that the subway has become wildly more dangerous in recent years.

To what extent this campaign could succeed is not clear. There has always been a baseline level of criminality and antisocial behaviour on the subway; sexual harassment and assault is so ubiquitous that brushing up against it is all but inevitable. I was groped, flashed, or masturbated at probably two dozen times during the seven years I spent living in New York. When a friend moved to NYC last year, I told her that she couldn’t truly call herself a New Yorker until she exited a crowded subway car to discover that someone had ejaculated on her coat. (I was only partly kidding.) It’s not that anyone thinks these things are okay; it’s more that they’re expected, a sad fact of life in a city of 8.5 million people, one of those things you cannot change and hence have to find a way to put up with. You look away, you shrug it off, you don’t let it ruin your day because if you did, it would ruin all of your days.

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Here is where the notion of resilience enters in. New York City residents have perhaps a higher tolerance than most for antisocial behaviour in public places, on the subway in particular. Warm and dry, with a captive audience, it attracts all kinds of colourful personalities: panhandlers and performers, pickpockets and preachers, as well as people like Neely who are in the grips of something darker. Until recently, it was standard practice to meet the arrival of one of these people on a crowded carriage with downcast eyes and silence; there was a tacit agreement that you neither react to nor acknowledge the transgressor. That agreement remained in place as crime rose, and as NYC saw a marked increase in behaviour that, even if it started out as merely weird, could — and did — escalate rapidly to violence. In 2022, for instance, a video did the rounds, of a woman begging for help while a deranged man hauls her around a train car by her hair.

But if it was difficult to know exactly where a tolerance for breaches of decorum became apologia for criminal harassment, it was even harder to identify, after Jordan Neely’s death, where the tacit agreement to tolerate becomes a duty to intervene. How do we know when to stand by, when to step in, when to look away, when to be afraid?

Here, one might have expected that many of the same voices who argued so vehemently against the notion of resilience in the midst of MeToo — the ones who believed that the solution to harassment lay not in teaching women to be assertive, but in teaching men not to abuse — would now demand zero tolerance for male aggression on public transit. If you argue that a woman can be traumatised by bawdy humour in the office or awkward come-ons in a bar, surely you would agree that she’s entitled to be fearful when trapped underground on a metal tube with an erratically-behaving stranger twice her size.

But, no: instead, many of the people who once insisted that men who slid into DMs deserved the complete destruction of their professional reputations became passionate advocates for toughening up when it came to dealing with volatile people on public transit. Coverage and commentary from the Left downplayed the possibility that Neely’s behaviour was frightening; instead, he was “acting erratic“, or “houseless and crying for food“. One viral tweet suggested that tragedy could have been averted with “a dollar and granola bar”. The New York Times guide to navigating similar scenarios on public transit took it a step further, imagining someone like Neely as a wild animal it is everyone else’s duty not to provoke: “Don’t make eye contact — especially prolonged eye contact, which might be perceived as threatening.”

Meanwhile, threads proliferated mocking the notion that New York’s subways might be a dangerous place: “I’ve safely ridden the subway for 23 years and my child has never been menaced by a half naked lunatic, but these imaginary monsters in your head are addressable with therapy,” wrote Elizabeth Spiers, a founding editor of Gawker and journalism professor at NYU. This is a remarkable sentiment, and not just because of its stunning reversal of the MeToo-era catechism that allegations should be believed. Less than a year ago, Spiers was among those advocating for the suspension without pay of journalist Dave Weigel after he retweeted what some perceived as a sexist joke, owing to the way this was allegedly received by his female colleagues (“[Every] woman who works with you thinks you’ve telegraphed publicly that you don’t respect women.”)

To sum up: a man who reposts an off-colour joke is advertising his innate misogyny, to the point where women should feel uncomfortable sharing a workplace with him. But an agitated and clearly unstable man announcing to a crowded subway car — as Neely reportedly did — that he’s been pushed to the brink and is ready to die, or go to prison for life: why in the world would you find that menacing?

This sudden rediscovery of the merits of resilience would have been almost refreshing, if not for the whiplash of its promotion by people who up until very recently were arguing that a tweet made them unsafe. There’s even something to it: the ubiquity of certain kinds of boundary-challenging behaviour in big cities makes it not just impractical but impossible to treat every incident of one-off harassment from a stranger as if it’s the end of the world. And of course, once you’ve survived a run-in with the mystery subway ejaculator, sexist microaggressions are unlikely to faze you: cultivating resilience is how we learn to recognise that a situation can be both genuinely alarming but not materially unsafe, or to make peace with the fact that many things which make us uncomfortable should nevertheless be allowed.

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But this mindset was considered anathema during MeToo. With trauma allegedly lurking just around the corner of every heterosexual encounter, distrust became the default. Not just the default, but celebrated — “men need to feel a cold spike of fear when they begin a sexual encounter,” intoned Vox‘s Ezra Klein, in a proto-MeToo celebration of this new, terrified paradigm for intimacy. The idea, of course, was that women already felt that fear, living as they did at the eternal precipice of victimisation by the patriarchy; in a truly equal society, everyone would be scared.

Of course, today’s 180-degree pivot to brash fearlessness is identitarian horse-trading: MeToo is out, BLM is in. The dynamics of any conflict must be considered along these lines, and the narrative must be massaged accordingly. This was true in 2020 when a white woman called the police on a black man who threatened her in a public park; it is true now, as piety demands that the behaviour of the black, homeless victim of this terrible tragedy must not be scrutinised in any way. On the Left, that is; the Right has spent the past few days waving Neely’s criminal history in the air, singing “He Had It Coming”, in an absolute spectacle of ghoulishness.

In the end, neither the malicious glee from the Right nor the aggressive minimisation from the Left are treating this case with the sensitivity it deserves. The truth is, eyewitnesses did report that Neely was behaving in a threatening way, and other people on the train were calling 911 well before his confrontation with Penny, suggesting that whatever was happening, it was a cut above the ordinary subway madness that New Yorkers are usually so good at ignoring. But it is also true that the tragic conclusion of this incident seems, at least in part, like the result of a cultivated fragility — the kind that results when you encourage people to view every uncomfortable situation as a trauma in the making, every unpleasant interaction as a precursor to a far worse harm, every upset as an offence for which there must be consequences. That mindset, so ubiquitous in the wake of MeToo, so popular among progressives in general, says that no breach of decorum or moment of discomfort is too insignificant to ignore. It must be registered. It must be punished. It’s nothing more or less than a call for constant vigilance. The thing about that: when you demand vigilance, you get vigilantes.

I wasn’t a tomboy. I liked dresses, my long red hair, my collection of Sylvanians who lived soap-opera lives in neat plastic houses carefully arranged by me and my sister. But I knew there was something contemptible about the girlish things I enjoyed from the way the boys at school talked about them. Little by little, I learned to be ashamed of being the kind of person these things belonged to.

Then there were the unmistakable signs that me and my body would not, after all, enjoy our peaceful union forever: the adult women I overheard sociably griping about their own deficiencies (too fat, too big-bummed), the girls my age whose bodies were erupting into curves. The boys leered; the girls yet to start puberty judged. We whispered that the ones wearing bras were stuffing their cups with tissue paper, and said they rustled when they walked. I dreaded becoming one of them, and I feared what it would mean if it didn’t happen to me. One day — I suppose I was 10 — I stood at the corner of the playing field (which was, as usual, taken up by boys playing football) and thought I will not be a girl.

I got no say in the matter, though. My compact, reliable body sprouted embarrassing hair, turned to gooseflesh when boys (not even boys I liked!) looked at me, and exceeded its former bounds so rapidly I was striped with stretch marks all over my hips. We were two things now.

One day, I was dozing in the back of the car as my parents drove the family home and I heard a short story on the radio — I was almost 12 — about a man who wishes to be free of his body, so first cuts off his head, then has his brain removed from his skull. I would like to do that, I thought. To be pure self, no flesh at all. I was in the wrong body. It announced my femaleness, it invited certain ways of being looked at, sometimes touched. It betrayed me. I couldn’t dispose of it, so I hated it instead.

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Porn will destroy you

By Sarah Ditum

The metamorphosis of puberty is hard for almost everyone. For girls, though, there is a specific trauma. You don’t simply become an adult: you become a product on the sexual marketplace, regardless of your own will. This divides you: you learn to see yourself from the outside, as an object, through the imagined eyes of men. You lose your space in the world, and any part of you that goes beyond the strictly minimal can start to feel like grotesque excess.

Did I have dysphoria? There was no one to diagnose me; I only have my own memories to guide me. What I can say is that I don’t know of another word that describes my desire to discipline and punish myself into something safely un-sexed. When I read accounts from other female people describing their own dysphoria, I feel a painful recognition.

Trans man Lewis Hancox’s graphic novel Welcome to St Hell: My Trans Teen Misadventure has a diagram of Hancox’s teenage body, with the breasts marked “fatty lumps that need to be gone” and an arrow pointing to “hips from hell”. These are things I thought about myself. Not so severely as Hancox (I didn’t have an eating disorder), but I thought them.

If I had been offered a way out — a medical “pause button”, as hormone blockers are casually called — would I have taken it? I can’t think, actually, of anything I would have received more gratefully at this time in my life. Nor can I think of a more carelessly poisonous response than adults affirming what I felt about my body. It’s strange, then, that for 31 years, a specialist unit existed within the NHS which effectively took girls like me and told them: “yes, you’re right, your body is wrong, but we can fix that for you.” The unit was the Gender Identity Development Service (GIDS), contained within the Tavistock and Portman Trust in London. What happened there, and how it went so appallingly wrong, is now the subject of a remarkable book by the journalist Hannah Barnes called Time to Think.

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GIDS didn’t only treat girls, but it’s the girls who particularly interest me. That’s partly because, as Barnes outlines, GIDS itself was remarkably uninterested in them. The service was founded by child and adolescent psychiatrist Domenico Di Ceglie in 1989, and initially, the patients had a clear profile: mostly boys, and usually referred in pre-pubescent childhood. Girls with dysphoria weren’t unheard of (the initial case that got Di Ceglie interested in gender identity was female), but they were not typical.

That changed dramatically. In 2011, GIDS saw for the first time an equal number of male and female patients. In 2020-21, 68% of the patients for whom GIDS recorded sex were female. (A repeated theme of the GIDS scandal is poor record keeping: shockingly, no birth sex was recorded for 22% of patients referred in 2021-22.) And these girls were arriving at the clinic older than the boys: pubescent adolescents who, like me, had no previous history of dysphoria.

But while they were strikingly unlike GIDS’s previous patients, these girls were astonishingly similar to each other. Barnes relates the description given by Anna Hutchinson, a senior clinical psychologist formerly employed at GIDS, and one of the many whistleblowers to have gone on the record about the service’s failings:

“Self-diagnosed adolescent trans boys — natal females — started to fill up GIDS’s waiting room with similar stories, haircuts, even names – ‘one after another after another’. They’d talk about their favourite trans YouTubers, many having adopted the same name, and how they aspired to be like them in the future.”

One thing that all GIDS patients had in common, regardless of sex, was that they had far more going on than just gender trouble. A 2012 study found that associated difficulties included “non-suicidal self-harm, suicidal ideation, suicide attempts, autism spectrum conditions (ASCs), attention deficit hyperactivity disorder (ADHD), symptoms of anxiety, psychosis, eating difficulties, bullying and abuse”.

Also, a lot of the girls presenting at GIDS were bisexual or lesbian — over 90%. Or rather, they would have been lesbian, if they’d identified as female. One clinician Barnes speaks to recalls female patients saying things like, “When I hear the word lesbian, I cringe. I want to die”, and “I’m gonna vomit if I hear the word lesbian another time”. Gay and lesbian clinicians who asked whether such internalised homophobia should complicate a dysphoria diagnosis were told that they were “too close” to the subject to be objective. That this dismissal of same-sex attracted people’s experiences and insights was itself a signal instance of homophobia seemed not to occur to GIDS as an institution.

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GIDS, it seems, was no longer interested in asking questions. When the service was founded, one of its principles had been an explorative approach: “Di Ceglie could see that, in some cases, by addressing other difficulties experienced by the child — things like depression, abuse or trauma — it might ‘secondarily affect the gender identity development’. In other words, sometimes the gender identity difficulties might resolve if other difficulties being faced were dealt with as well.” But by the time the majority of GIDS’s caseload had become female adolescents, the culture of the service had decisively changed. In 2009, Polly Carmichael took over from Di Ceglie as head of the clinic. Her tenure saw the clinic adopt a high public profile — participating in a string of documentaries that boosted GIDS’s image and promoted its work — while internally adopting an “us against the world” attitude. Clinicians were encouraged to see themselves as a “family”: disagreement became a personal betrayal. One GIDS staff member recalls that anyone raising criticisms of the service was likely to be told “this has made Polly cry”.

Perhaps as important as the clinic’s leadership, though, were the external pressures: as the concept of “gender identity” took hold more widely, the idea that one’s “subconscious sex” ought to supersede the physical body began to direct treatment. Trans support groups like Mermaids and GIRES promoted an “affirmative model”, which insisted that any child who said they were trans should be treated as trans. This influenced both the expectations of patients and their families, and the practice of GIDS doctors. Hormone treatment became the default. Patients came, not because they wanted to explore their gender issues, but because they wanted puberty blockers. If doctors were unwilling to prescribe them, Barnes reports, patients would simply be referred to a different doctor. There was usually little opportunity for reflection: GIDS staff were expected to manage caseloads of up to 100 patients each, as referrals increased from 97 in 2009-10 to 2,748 in 2019-20 (a 2,800% increase overall, and an even more shocking 4,200% increase in girls). Once patients were on puberty blockers, nearly 100% would go on to take cross-sex hormones.

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A service that had once prided itself on treating its patients as individuals had become something more like an assembly line. Whatever issues a child had, the only answer the clinic had was blockers. What’s terrible about this isn’t just that many children will have been put on a path to transition that could have been avoided; it’s that they were not receiving specialised support for their other, more pressing problems. Barnes tells the story of one boy who, as well as identifying as a girl, had such severe OCD that he couldn’t leave the house. His family got no support for the OCD, but GIDS sent a psychiatrist who offered to make an endocrinology referral.

With its one-size-fits-all plan, GIDS was failing every one of its patients: one of the reasons why, in 2022, an independent review commissioned by the NHS into gender identity services for children and young people made an interim recommendation that GIDS be shut down and replaced with regional specialist centres. (This spring, that advice will be enacted.) But — without diminishing the harm done to boys, which was plentiful — girls were particularly damaged by GIDS, because girls were being put on a pathway that was the definition of male default. GIDS had developed its approach to serve the traditional paediatric sufferer of dysphoria: a pre-pubertal boy. Because the clinic’s culture militated against self-reflection, the treatment stayed the same even though the patients had drastically changed.

It’s not uncommon for women to be badly served by medicine in this way, given that women are neglected as research subjects. Historically, femaleness has been treated as an abnormality, to be ignored if it cannot be remedied. What’s exceptional about the GIDS case, though, is that the underlying philosophy of trans identity effectively made these girls doubly invisible. They were invisible, firstly, to a model that had never taken them into account. But secondly, and more profoundly, they were invisible because gender identity doctrine held that even to think of them as female was to “misgender” them. You couldn’t say how they were different to boys without conceding that they were not, in strict fact, boys.

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The empty promise of pop psychology

By Sarah Ditum

But to hate your body as a teenage girl is one of the most categorically female experiences possible. I didn’t hate my body because I wasn’t a girl; I hated it precisely because I was, and because of everything I feared or knew that being a woman might mean.

Trans activists tend to dismiss stories like mine: if I had truly been dysphoric, they say, I would never have grown up to be the basic bitch I am today. I would have found a way to transition. But if I’d had YouTube, Mermaids and a compliant medical service, the way would have been signposted for me in neon lights. I learned to live with my body, in time, because no one gave me an alternative.

One of the many reasons that the “pause button” claim about blockers is a lie is that going through puberty is one of the ways you become reconciled to puberty. Discovering your sexuality might help you discover that your body exists for your pleasure, not just external judgement. Gradually, the alien flesh can become familiar again. The girls who went through GIDS were denied this. Taking puberty blockers means you never reach adult sexual function. Tentative research suggests that girls who went on blockers actually felt worse about their bodies after several years. Blockers didn’t treat their dysphoria: they exacerbated it.

For some few, transition will have been the right outcome. Others are left forever learning to live with bodies that have been made strange and vulnerable — weakened bones, dropped voices, vaginal atrophy, scarred and breastless chests if they went on to have mastectomies. There is a small, but growing, community of female detransitioners. Barnes quotes one, who has undergone a double mastectomy and a hysterectomy: “I regret all of it… I wish someone would have been there to tell me not to get castrated at 21.”

The things these women did in an effort to become not-girls remind me so keenly of the girl I used to be, with her vague longing for a bodiless life. A perverse sisterhood of doomed escapologists, looking for a get-out from what biology had planned for us. The way I once felt about myself was terrible, but it was also normal: the terribly normal fact of feminine self-loathing. The tragedy of a misogynistic world is that it makes girls believe they need a cure for femaleness. The scandal of GIDS is that it pretended it could supply one.

“So you think I may be delusional, or psychotic, for thinking it’s sex addiction?” She doesn’t seem to be trying to pressure me, she really wants to know. “I don’t think you’re delusional at all,” I reply. “I think you’re trying to understand yourself.”

Abby has good grades, some friends, an ex she still talks to, a few hobbies. She is nervous about her career (should she go to grad school?) and sometimes she feels sad or anxious for no reason. She is also fixated on the idea that she has a severe mental illness, possibly any severe mental illness. Having sat with her for many sessions, I am pretty sure she does not. But I also try, bearing clinical ethics in mind, to take her concerns seriously.

Abby is typical. Many young people I work with try to understand themselves (and often others) through the lens of mental illness. Typically they are focused on one diagnosis, but some, like Abby, are open to having several, many, or any. My co-workers notice it too. One colleague recently brought a question to our clinic’s staff meeting: “Has anyone else noticed a large number of students lately claiming to be on the autism spectrum, despite seeming to be… clearly not autistic based on clinical criteria?” Heads nodded. Why is it that so many young people are concerned that they are sick? And what is a mental health professional to do, in a culture where patients come in having already staked out their symptoms?

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Several of my colleagues, in that meeting, suggested that teens had learned about the diagnosis they had adopted on social media. I was reminded of writer PE Moskowitz’s lamentation, last year, that mental health has become “Buzzfeed-ified”, resulting in a world where being ADHD versus being Bipolar is like being a Hufflepuff versus a Slytherin, or an Aquarius versus a Gemini. I’m not entirely convinced, though. People hear about all kinds of things on social media. To identify with what you hear requires particular conditions: you have to be searching for a convincing story to tell about yourself.

This story is about more than TikTok. The world of diagnosis is experiencing a crisis of confidence. The tools we use are somewhat reliable — we can throw the dart 20 times and hit the same spot, or 20 clinicians can meet the same person and identify that they may be “clinically depressed”. The question now is whether our tools are valid: is the bullseye actually where we think it is? If I’m debating with a college student about whether or not they have Major Depressive Disorder, I have to confront the fact that depression is not just one thing. My university students show me, over and over, that diagnoses of mental illness aren’t like medical diseases, which one either has or one doesn’t. A cluster of depressive symptoms will, in different people, have very different roots — some contextual, some biological, some behavioural. I may agree with other therapists that the patient meets the criteria for a given diagnosis, but we won’t necessarily be able to agree on what it means to have that diagnosis: where has it come from, how long will it last, what shall we do about it?

Part of the challenge lies in this very postmodern acceptance that there is no singular truth. But we do tend to end up using categories, and the ones we have currently are atavistic, more connected to the early pioneers of psychiatry than to up-to-date neuroscience. The still-common diagnosis of Borderline Personality Disorder, for instance, was constructed based on a supposed borderline between the neurotic and psychotic, which is now commonly understood as obsolete. There are myriad categories for psychotic disorders: schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, schizotypal personality disorder — to name just a few. Many date back to the 19th century, some are redundant, several are tough to differentiate. Some have also become politicised: during the US Civil Rights Movement, the label of schizophrenia was used to discredit black men as paranoid and violent (as Jonathan Metzl shows in his searing and meticulous history). This is just one example of how the instability of diagnostic categories stems from something far more complex than mere clinical incompetence; they are a vestige of culture and history, and they blur as times change. Psychologists and psychiatrists are so aware of this problem that it’s common, in academic spaces, to hear Plato’s phrase, “carving nature at its joints”, employed to question just how accurate our diagnostic categories are.

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So why should we trust medicine to diagnose mental illness? Increasingly, we don’t. In the past, we assumed that someone would present with the question “what’s wrong with me, doctor”, and wait for a diagnosis to be handed down to them from a clinical authority. Without getting into the debate between gender critical pundits and trans liberation activists, one way in which transgender discourse has changed how we view mental health is the idea that one can self-diagnose. Part of the so-called trans tipping point is a new way of relating to medical authorities whereby patients, trans or not, come to clinics quite sure of what’s going on with them — and what they need.

This self-election is a particular sticking point in and out of the trans community. Do you have to medically transition to be trans? Do you have to have so-called “gender dysphoria” (a category recently renamed “gender incongruence”)? That these questions are even up for debate indicates a massive shift in our attitudes to diagnosis. And, critically, the centre of the debate is not in hospitals or universities but on message boards and in the writing of patients, particularly young patients, rather than clinicians.

The argument over transgender medical care often comes down to the idea that children, especially trans-identifying children, are somehow being victimised by the illegitimate or unethical authority of either pro-trans adults or gender critical adults. While some claim to be worrying about potential detransitioners, my instinct about many people’s underlying concern is the same as the one plaguing the discourse around mental health generally: who can take care of us? Who has our best interests at heart? Can we trust doctors? Does anyone really understand the boundary between sickness and wellness? The uncertainty about the answer to these questions makes almost all of us uneasy, driving us into polarised positions and moral panic.

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It is tempting, especially for me as a mental health professional, to be anxious about and critical of the diminution of clinical authority. In the clinic, I frequently find myself confronted with the risks of handing the power of diagnosis to adolescents who are struggling with self-concept and inspired by two-minute confessional videos they’ve seen online. Still, when I consider the rustiness of our diagnostic categories and the ways mental healthcare, at least in the US, has been decimated by insurance companies and for-profit care, I am not sure that giving sole authority to clinicians has worked all that well either. In answering the question about who should be in charge of diagnosis, many people have good reasons for staking their positions. Many people have suffered because of inept psychiatry. But people self-diagnosing or rejecting diagnosis altogether may run into problems, too.

A paradigm shift is overdue — and appears to be beginning, though the exact shape of the future’s more democratic, more evidenced-based psychiatry is still nascent. Our ability to come up with new ideas and experiment with them will be critical. Recently the novelist Tao Lin wrote about autism spectrum disorder (ASD) that presents two radical ideas. The first is that he feels he was able to make himself “less autistic” through treatment, including recreationally using the drug MDMA. He does not describe lessening his symptoms, but rather lessening the disorder itself — flying in the face of clinical consensus that ASD is basically an unchanging brain disease.

Second, he raises serious questions about the pluralistic, inclusive, United-Colours-of-Benetton-esque view of neurodivergence, popular among the same teens filling social media with mental illness content from which my clients self-diagnose. The point is to accept and even celebrate disorders as a unique and valuable “part of you”. But Lin makes the case that there are chemical and industrial by-products that could account for the decades-long uptick in ASD, and that by uncritically embracing neurodivergence, we occlude the possibility of asking corporations and regulators to be responsible for what he believes is effectively poisoning people.

While I don’t agree with Lin word-for-word (I tend to think there are both advantages and disadvantages to pluralism, and I can’t speak to the science about the origins of autism), I did learn from his efforts to reframe these issues. His essay is a strong case for centring the voices of people who actually experience illnesses, rather than allowing the voices of clinicians to them drown out. Without listening to the people we diagnose, clinicians have time and again shown themselves to commit errors at best, and atrocities at worst.

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Still, I reluctantly defend my profession’s authority. Despite there being problems within the categories we wield, our knowledge — gained both from abstract research and from simply spending careful, attentive time with hundreds and hundreds of patients — is useful in making sense of the more acutely distressing parts of what we call mental illness. The future of mental health diagnoses will have to be a negotiation between clinicians and the people they seek to treat (as well as the social and cultural context that clinicians and patients co-inhabit, which plays a critical part in how we define and experience psychological variations which then get labelled as disorders).

It won’t be easy to reach a compromise between researchers, clinicians and patients. But possible new paradigms of diagnosis are starting to emerge. There is Nonlinear Dynamical Systems Theory (NDST), for instance, which models psychiatric issues the same way we model incredibly complex ecosystems or financial markets. Within this framework, something like bipolar disorder would have multiple interlocking roots, ranging from better-understood biopsychosocial factors, such as a person’s genetic vulnerabilities, to more postmodern considerations such as the culture of a given psychiatric hospital. The relationship of these factors determines whether the mind holds steady, collapses or glitches under certain kinds of stress; understanding the interplay, in all its complexity, promotes what we might call “dynamic stability”. A skyscraper moving gently in a mild earthquake is a good metaphor for how the mind can weather certain shocks if properly prepared. While NDST is not the sole answer, it is one useful framework for pinning down, or at least functionally describing, what a diagnosis is.

A crisis of authority is not a bad thing, especially if the status quo is dysfunctional. It does, however, create anxiety. A new patient in my office last week asked me if I could capture his distress in a diagnosis. I replied that it sounded like some of his symptoms were anxious, and some were depressive, but that I didn’t have enough information to make a clear categorisation, and that the category itself might leave something to be desired.

We talked about how it felt for him to hear that. He said it was uncomfortable, but he also ventured that, without a category to make meaning for him, he would have to make meaning out of his symptoms himself. That process is what my co-workers and I are trying to enable. The aim is to help young people interpret their experiences with curiosity — even if they come to us longing for the clarity falsely promised by our flawed diagnoses.

Often, such grim descriptions are paired with an upbeat solution: better access to mental health care, including psychiatric drugs. Given the understanding of mental health that has been promoted to the public for the past 40 years, this advice makes sense. We have come to understand that depression and other mental problems are disorders of the brain. Psychiatric treatments fix this brain disorder, or at least induce changes in the brain that are helpful to the suffering person.

However, if the past is prologue to the future, this understanding will continue to make the problem worse. For the past 35 years, we have sought to spread “awareness” of depression and other mental health issues. This has led to a dramatic increase in the prescribing of antidepressants: in 1990, the CDC reported that fewer than 3% of adults had taken an antidepressant during the previous month — a number that rose to 13.2% in 2018 and 23.1% earlier this year. Yet the burden of depression in the United States and other Western countries has only risen during this time.

There is a fundamental reason why. We have organised our thinking, and care, around a narrative of medical progress — of effective drugs that fix chemical imbalances in the brain — that isn’t to be found in the scientific literature. And the chasm between what is told to the public and what is found in the scientific literature has led our societies astray.

Writers, philosophers, and doctors have long observed that melancholy — a time of sadness or grief — visits nearly everyone now and then. As the 17th-century physician Robert Burton advised in The Anatomy of Melancholy, “it is most absurd and ridiculous for any mortal man to look for a perpetual tenure of happiness in this life”. It was only when melancholy became a “habit” that it could be considered a “disease”.

This was the understanding that prevailed until the Eighties. People often suffered bouts of depression, particularly in response to setbacks in life, but such feelings were seen as normal. Depression was only a “disease” in cases where people stayed depressed for no apparent reason, and these were rare. Community surveys conducted in the Thirties and Forties in the United States found that fewer than one in a thousand adults suffered an episode of “clinical depression” each year. Among this group, most did not need to be hospitalised, and only a small minority became chronically ill.

These findings led experts at the National Institute of Mental Health (NIMH) in the Seventies to advise the public that depression was an episodic disorder, which would generally clear up on its own. Most depressive episodes, wrote Dean Schuyler, head of the depression section at the NIMH, “will run their course and terminate with virtually complete recovery without specific intervention”.

However, this understanding of depression was soon to disappear.

During the Seventies, leaders of the American Psychiatric Association (APA) worried that their field was in crisis. Critics argued that psychiatry functioned more as an agency of social control than as a medical discipline, that its diagnoses lacked validity, and that its brand of talk therapy, psychoanalysis, was no more effective than other therapies offered by psychologists and counsellors.

In response, American psychiatry decided to rebrand itself. The public needed to understand that psychiatrists were medical doctors who cared for patients with real diseases. Not only would this rebranding improve psychiatry’s public image, but it would also give psychiatrists a privileged place in the therapeutic marketplace. They had the power to prescribe drugs, while psychologists and counsellors did not.

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The APA, when it published the third edition of its Diagnostic and Statistical Manual in 1980, reconceptualised psychiatric disorders as diseases of the brain. The age-old distinction between ordinary depressive episodes and “clinical depression” was dropped, and both were lumped together as a single “disease”. Nancy Andreasen, future editor of the American Journal of Psychiatry, set forth tenets of this new psychiatry in her 1984 book, The Broken Brain. “The major psychiatric illnesses are diseases,” she wrote. “They should be considered medical illnesses just as diabetes, heart disease and cancer are.” With this understanding in mind, the APA quickly set out to market its new model of depression to the public.

It found an ally in pharmaceutical companies, who were also eager to change the narrative. Erasing the distinction between ordinary depression and clinical depression promised to create a huge market for antidepressants. Pharmaceutical companies gave money to the APA to develop its PR machinery in the early Eighties, and then, in 1988, they provided funds to support a NIMH campaign, called the Depression Awareness, Recognition and Treatment (DART) program, that was designed to sell the disease model to the public.

In anticipation of this campaign, the NIMH had conducted a survey of public attitudes about depression. Only 12% of Americans said they would take a pill — an antidepressant — to treat a depressive episode. And 78% said they “would live with it until it passed, confident that they could handle it with their own”. The purpose of DART was to relieve the public of this “misconception”. According to the NIMH, Americans needed to understand that depression was a “disorder” that regularly went “underdiagnosed and undertreated”. Absent treatment, it could become a “fatal disease”.

The public was also presented with a new — apparently scientific — theory of depression: that it was caused by a lack of serotonin in the brain. Thankfully, scientists had discovered a medicine, selective-serotonin reuptake inhibitors (SSRIs), that fixed this chemical imbalance. Prozac and other SSRIs were heralded in the media as “breakthrough medications” that could not only fix depressed patients but make them feel “better than well”.

Untreated depression was now presented as a pressing public health concern. Most important, people were being trained to monitor their own emotions, and to treat sadness or emotional discomfort as symptoms of a disease requiring medical intervention.

The PR blitz worked. In a 2005 press release, the APA shared the “good news”: 75% of consumers now understood that “mental illnesses are usually caused by a chemical imbalance in the brain”.

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The low-serotonin theory of depression arose in the Sixties from the discovery of how the first generation of antidepressants, tricyclics and monoamine oxidase inhibitors, altered normal brain function. Both hindered the normal removal of serotonin (a monoamine) from the synaptic cleft between neurons.

Once this “mechanism of action” was discovered, researchers hypothesised that perhaps depression was due to too little serotonin. However, when researchers ran experiments to test whether people diagnosed with depression, prior to being medicated, suffered from low serotonin, the results were disappointing. As early as 1984, NIMH investigators concluded that “elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression”.

Investigations into the low-serotonin theory continued, but none provided convincing evidence to support it, and in 1999, the APA, in the third edition of its Textbook of Psychiatry, declared the theory dead, writing that decades of research “has not confirmed the monoamine depletion hypothesis”.

These conclusions were never promoted to the public, and so, this past June, when British investigators published a review of the history of this research and found there was no evidence to support the low-serotonin theory of depression, their conclusions were reported as shocking. In fact, we have known as much for two decades.

The real story, however, is even worse. Antidepressants block the normal reuptake of serotonin from the synaptic cleft. In response, the brain adapts to try to maintain its normal functioning. Since antidepressants raise serotonin, the brain responds by dialing down its own serotonergic machinery. In other words, antidepressants induce the very abnormality — a deficit in serotonergic function — hypothesised to cause depression in the first place.

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Antidepressants, then, do not fix any known disorder. But, their defenders might counter, could they nonetheless help depressed people?

Here, too, the evidence is thin. In the world of “evidence-based” medicine, placebo-controlled, double-blind randomised trials (RCTs) are the gold standard for assessing a drug’s effectiveness. A recent meta-analysis of such studies determined that 15% of depressed patients treated with an antidepressant experience a short-term benefit; the remaining 85% are exposed to the adverse effects of the drugs without any benefit beyond placebo.

Even those short-term results suggest a major problem with widespread use of antidepressants: six of seven patients experience the drugs’ side-effects without any corresponding benefit. The most common side-effect may be sexual dysfunction, which in some cases can last long after patients stop taking the drugs. But some patients can also suffer from a drug-induced worsening of their original symptoms.

There are two notable elements of this drug-induced worsening. First, antidepressants triple the risk that a depressed patient, within 10 months of initial treatment, will turn manic and be diagnosed as bipolar, which is a much more severe disorder than depression. Second, over the long-term, antidepressants increase the risk that a person will remain symptomatic and functionally impaired.

The latter worry showed up in the Seventies, not long after antidepressants were introduced. At that time, clinicians still had a memory of depressive episodes that regularly cleared up without the use of drugs, and several reported that patients treated with antidepressants were now relapsing more frequently than before. Epidemiological studies agreed. The third edition of the APA’s Textbook of Psychiatry, published in 1999, summed up the disappointing findings: Only about 15% of patients treated with antidepressants recover and are still well at the end of one year.

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Studies conducted since then suggest that even that 15% recovery rate may be too high. In the largest antidepressant trial ever conducted, the STAR*D study, only 108 of the 4041 patients who entered the trial remitted and remained well at the end of one year, a stay-well rate of 3%. The vast majority never remitted, remitted and then relapsed, or dropped out of the study. Meanwhile, a 2006 NIMH study of depressed patients who didn’t take antidepressants found that 85% recovered after one year, just like in the pre-antidepressant era.

Naturalistic studies in depressed patients regularly find that, over the long term, medicated patients are more likely to remain symptomatic and to become functionally impaired. These findings led Italian psychiatrist Giovanni Fava to propose, in a series of papers dating back to the Nineties, that antidepressants induce a biological change in the brain that makes patients more vulnerable to depression. As Rif El-Mallakh, an expert in mood disorders at the University of Louisville School of Medicine, put it in a 2011 paper: “A chronic and treatment-resistant depressive state is proposed to occur in individuals who are exposed to potent antagonist of serotonin reuptake pumps (i.e., SSRIs) for prolonged time periods.”

In other words, there is reason to believe that the mass prescription of antidepressants is making us, on the whole, more depressed. Indeed, the “economic burden” of depression — composed of workplace-related costs (absence from work), suicide-related costs, and direct-care costs — has steadily risen since the SSRIs came on the market. In 1990, it was calculated at $116 billion in inflation-adjusted terms. By 2020, it had nearly tripled to $326 billion.

Disability due to mood disorders has also risen. In community surveys conducted in 1991 and again in 2002, 30% of the adult population was found to suffer from an anxiety, mood, or substance disorder, based on DSM diagnostic criteria. However, while the prevalence of these disorders didn’t change, the percentage of people who got treated did, rising from 20% in 1991 to 33% in 2002. Over the same period, the number of American adults receiving a government disability payment due to a mood disorder rose from 292,000 to 940,000.

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Following the publication of DSM III in 1980, the public was told a story of a great advance in medicine. Research had found that depression was due to a chemical imbalance, which antidepressants fixed. We organised our thinking around that narrative: depression was a biological “disease” that required medical treatment. This false narrative is the root cause of our mental health crisis today.

The tragedy is that there is another, more optimistic narrative about depression that exists in the scientific literature. This narrative informs us that human beings are responsive to their environments, and that depressive episodes often arise in response to setbacks in life. Time, and finding ways to change one’s environment, regularly lead to a spontaneous remission of depressive feelings.

A society that wants to promote good “mental health” should strive first to create more nurturing environments — improving access to housing and childcare, and working toward a more equal distribution of financial resources. It should also favour, as a first response, holistic treatments for depression — diet, exercise, walks in nature, social engagements, and so forth — as these complement our natural capacity to recover.

Antidepressants could still serve as a useful tool. Their use would simply need to be informed by research that tells of their limited short-term efficacy and of their potential negative long-term effects. Doctors would also need to inform patients that these drugs do not fix a “chemical imbalance”. True informed consent would dramatically reduce the use of these drugs, and surely diminish prescribing habits that treat them as a go-to response.

Paradigm shifts do happen, and today’s mental health crisis is telling us that one is desperately needed. Forty years of the disease model of depression has left us sicker and unhappier than ever before. There is little reason to believe that more of the same will fix our problems, and plenty of reason to think it will continue to make them worse.

And yet I worry, too. I worry because selling a book, especially for any kind of decent advance, is a tricky business, and the temptation to be prurient and sensationalist must be considerable. I am a committed enemy of romanticising mental illness, which contributes to the impression that the mentally ill are somehow living deeper, more “intense” lives, rather than more painful ones. I want mental health memoirists to understand their profound responsibility to tell the grubby, sad truth about this life.

But mostly, I envy people who write mental illness memoirs. I envy their memories. They can recall the details of their psychiatric histories; I often can’t. Years have passed, faster and faster, since the major incidents in the history of my condition. For important portions of that history, I was brutally depressed, or grindingly manic, or actively psychotic, conditions not conducive to the formation of lasting memories. I have spent 15 years on and off (though mostly off) memory-destroying medications, and have now been on them for five years straight. And for most of that time I was actively in denial, about all of it, to the point of believing at points that it wasn’t real. I did not tell my siblings, those I was always closest to, for more than a decade after my first diagnosis. Sometimes I’d assert that I was finally on the straight and narrow, finally cured — an assertion that always, always preceded the next ruinous crash.

Some things I remember like they were yesterday. Some I don’t remember at all. When I write about my own mental health history, I write in ellipses and at a Dutch angle — for aesthetics, yes, to satisfy my own standards as a writer, but also because to tell it otherwise would make me feel like a liar. I just don’t trust my memory of some details.

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I have spotted a similar instinct in other mental health memoirs. Girl, Interrupted is imagistic and ruminative, much less a recounting of the day-by-day events of Susanna Kaysen’s commitment to McLean Hospital, and much more a series of pleasantly meandering meditations on the concept of sanity and the self. Kaysen also includes original forms and files from her hospital stay; George Scialabba’s brilliant and haunting How to be Depressed consists of little else.

And then there’s Strangers to Ourselves. It’s not a straightforward memoir but rather a collection of brief vignettes, or case studies, about mental illness, written by Rachel Aviv. Her own story opens the volume. She became anorexic as a six-year-old, barely literate, and mostly unable to define what was happening to her. Aviv leaves unsettled the question of whether she was “really” anorexic — her age and stated motives for not eating complicate the question — and instead contrasts her own condition with those of the older patients around her. By reproducing her own experience of mental illness, Aviv brings a little skin to the game in a text that’s mostly about telling other people’s stories for them.

More important, her personal history segues into Aviv setting the boundaries of her project. The book is about people whose “lives unfold in different eras and cultures, but they also share a setting: the psychic hinterlands, the outer edges of human experience, where language tends to fail”. She explains her holistic approach:

“the book draws not only from conversations with them but from their diaries, letters, unpublished memoirs, poems, and prayers… It’s impossible to go back in time and uncover what baseline feelings existed before a story was told — when a person’s angst and loneliness and disorientation had yet to be given a name and a vessel — but I find myself searching for the gap between people’s experiences and the stories that organise their suffering, sometimes defining the course of their lives.”

This is what I needed, from this book, up front: both information about how these individual stories were compiled and an acknowledgment that we all, as patients, construct truths with the raw material of memories that so often refuse to cohere, and therefore use the textual record to confirm and supplement our stories. In the opening section, she quotes her younger self as writing: “I had some thing that was a siknis its cald anexorea.” I was initially sceptical: it sounds like an adult writing the way they think a child would write. But Aviv later explains that she had dug out her childhood diary. I didn’t need her to do so to make her recollection of her illness more real; it just helps to know that the exact wording came from the page and not her memory.

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Sometimes, texts are all there is to go on. Aviv can’t speak to some of her subjects, such as Ray, a depressive who has been dead for years. Instead, she pulls significantly from his unpublished memoir, which follows his decision to sue a psychiatric facility where he was committed. Ray struggled through psychoanalysis at Chestnut Lodge, where he lived in for long months, only to come later to feel that he had been fooled by a broken paradigm that forbade the use of antidepressants. As Aviv tells it, Ray’s psychiatrist seemed to think of such drugs as a shortcut rather than a cure, and therefore avoided their use.

Aviv tells Ray’s story both for its own sake and to consider the fundamental conflict in late 20th-century psychiatry. The Freudian assumption that all psychiatric conditions could be traced to discrete events in childhood, and cured through excavating these memories in psychoanalysis, dominated American psychiatry for decades. It led a lot of patients to endlessly recite early traumas, without much therapeutic gain. That approach was overtaken by an ascendant hope that new drugs could fix chemical imbalances in the brain and turn psychiatry into a medical field like any other. Now, we appear to have swung back the other way: decades of disappointments in psychopharmacology have inspired many to declare that “there’s no such thing as a chemical imbalance”, which has become an inescapable social media bromide.

What frustrates me is that people seem unable to accept that the interaction between the brain and the mind is extremely complex. That the simplistic not-enough-serotonin theory of depression appears to be wrong does not imply that all neurological explanations are off-limits. We don’t have to yaw constantly between “all brain” and “all mind” explanations. Aviv, thankfully, settles on no pat answers to these questions, instead, simply meditating on them via Ray’s strange story.

Likewise, she uses every case study to examine the nuances of some broader social or economic or political issue. There’s Bapu, a Brahmin-class Indian woman whose religious adherence straddles the line between faith and madness; her story considers the conflict between Western medicine and spiritualism. There’s Naomi, a young black mother whose deepening paranoia compels her to attempt to drown herself and her two young children; her story illustrates how entrenched racism complicates psychiatric care for people of colour. There’s Laura, an affluent young woman who starts taking a cocktail of medications at a young age and finds it very hard to stop; her narrative helps explore the thorny questions of how long patients should stay on drugs. It’s never advisable to draw too deeply from individual stories in analysing societal trends, but the connections Aviv draws to such trends give the book teeth, making it more than merely poignant.

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The final section enables us to consider Aviv’s responsibility to her subjects and the difficulties of telling their stories. It focuses on Hava, an anorexic who Aviv encountered at a young age and whose life she sees as something of a road untraveled, given her own early struggles. Hava appeared to be making clear progress in her life, finding a steady boyfriend and planning for her future; sadly, years of making herself sick had damaged her body’s ability to regulate the reflex, and one night she choked on her own vomit in her sleep. She is one the three people profiled who were dead prior to the completion of the book, but Aviv’s deference to their own words makes their stories seem like memoirs all the same.

Perhaps it’s a sign of solipsism that this book often provoked me to wonder what Aviv would make of my story. I crave the simplicity of having my life printed out in black and white text; I also dread the inevitably reductive nature of such an exercise, and I’m scared of what someone else’s eyes might see in my narrative. For me personally, mysteries abound. I couldn’t possibly tell you the name of the doctor who diagnosed me as bipolar. At the time, I was not conscious in a conventional sense and everything that happened seemed to happen somewhere outside of me, people puttering around and talking in strange language I didn’t understand. There was an ER, there was a shot of haloperidol, and there was a stretch in a grey and muted psychiatric facility. Someone must have written my diagnosis down on a chart. Who that was is known only to God and, I imagine, to some mouldering file somewhere that I have absolutely no interest in digging up.

There are a lot of things I don’t understand about my own history. Worse, I can’t remember if the weight of years, mental illness and medication has simply obscured that knowledge, or if I never knew. In general, my time in the mental health system has been marked by constant confusion; I would feel like a liar if I said, “and then this month, in 2011, this happened”.

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Do the subjects in Strangers to Ourselves struggle the same way? What must it feel like, for those who are still living, to read this book? Aviv tends to avoid the overly literal, rescuing the book from questions of simple authenticity and making it, usefully, a record of how foggy our recollections can be. But I can also imagine readers who might be frustrated by the lack of clear lines between certain truth and imperfect memory. All of us long for order in the stories we read. I think that’s why people gravitate towards mental illness narratives, to clarify something that has been obscured by instability. But how do you faithfully translate what is by its nature not translatable?

I honestly don’t think writers tell lies in mental illness memoirs. I wouldn’t even say they bend the truth. I would suggest, perhaps, that they take the fragments of what they know happened, and through them assert a kind of truth, as part of a therapeutic process. That asserted truth might not look exactly like that of a dispassionate observer — say, one of the many doctors who wander into our lives, speak to us condescendingly, make marks on a chart, and shuffle out of our story. But I can’t see much harm done, when patients tell it themselves. The conceit of a memoir is that other people will be entertained by our misfortune; so long as we tell our stories with integrity, those who suffer through the instability and boredom and deprivation of dignity common to serious mental illness are entitled to our own frames. I only hope that both writers and readers know that the attempt to organise the experience is quixotic and we are narrativising the un-narrativisable. I understand the feeling that we must try anyway.

Aviv, like me, is wary of the way that definition can trap and limit us. In our online culture of mental illness, diagnoses are celebrated: young people wield them like talismans for a sense of validation. And I am not entirely a stranger to the seductive power of becoming one’s diagnosis, letting it become the load-bearing element of your personality. But I am also no stranger to the way that, further down the road, that self-definition becomes cramped and uncomfortable, even horrifying, as you start to want to be something else. (To the newly-diagnosed, I urge you, do not become your illness.) For years I resisted writing anything about my mental illness; now I worry constantly that when I do so, I pigeonhole and limit myself.

“People can feel freed by these stories,” Aviv writes, “but they can also get stuck in them… a role that at first seemed freeing, but it began to destroy them.” This is the most recurrent theme in Strangers to Ourselves: the double-edged sword of the stories we tell to make our disorders comprehensible. Aviv’s is the kind of mental illness narrative I trust and value the most: suspicious of narrative itself. It’s perhaps a kind I could even write myself. The bigger kind, the longer kind, the “and then this happened on this date” kind, is both beyond my abilities and against my best interest. As Aviv writes, “there are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which”.

Last year, assisted suicide accounted for 3.3% of all deaths in Canada, a third more than the previous year. At the same time, deaths officially recorded as suicides fell to the lowest rate in two decades. The Medical Assistance in Dying, or MAiD, Act was passed in 2016, requiring that a patient’s condition has to be “grievous and irremediable”, and death “reasonably foreseeable”, for them to qualify for euthanasia. But the law appears to allow loose interpretations of these conditions.

As a child, Alan Nichols had suffered complications from surgery which affected his mobility on one side and left him with hearing loss. Still, he was living independently before his death. Physically, Gary says, his brother had been doing much better: “He was being treated for absolutely nothing, no illness.” But Alan’s mental health was volatile. “He would go through stages where life was good and then he’d hit a stage for a while, for a month or two, where he didn’t feel like living.” He was prone to paranoia and reacted badly to change: if Gary was getting ready to leave, Alan might say: “Are you going to leave me home with all these knives?” And Gary would have to say: “Alan, I trust you. If that’s what you want to do, I can’t guard you 24/7.”

He did guard Alan, as well as he could. After their parents died, Gary and his other brother Wayne took turns in helping Alan to do tasks that overwhelmed him, such as banking. But they both had their own lives, and Alan struggled to accept help from friends. In the months before his death, he had begun to feel increasingly isolated. His local network was coming apart: Wayne had decided to take a trip across Canada; a trusted neighbour was planning to relocate; his favourite shop had closed. His story isn’t unusual: of the 31,664 assisted deaths in Canada, 17% of the patients cited “isolation or loneliness” as a reason for wanting to end their lives.

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The week before Wayne was due to leave, Alan was found by paramedics on the floor of his apartment. The neighbour he trusted had raised the alarm after not seeing him for days. He was malnourished and clearly suffering a major depressive episode. He was taken to Chilliwack General Hospital.

Alan did try to resist being sectioned. Gary was told that his brother “was fighting not to go into the ambulance”. Gary rushed to the hospital to see his brother, who said to him: “If you’re not here to bust me out, you might as well leave.” Gary didn’t bust him out, a decision he now says he regrets. He trusted the hospital to look after Alan. When he called to get updates on Alan’s condition, the staff were optimistic: “The hospital would say, ‘Oh, he’s doing fine. He’s okay. Yeah, he’s eating.’” It made Gary think Alan was “getting back on track.” What the hospital didn’t tell Gary was that his brother had actually signed his own death warrant.

For some Canadians, assisted suicide is a peaceful alternative to an unpleasant death. Patients with terminal illnesses often point out that end-of-life care can be highly undignified, and appreciate the power to choose something else. Don Kent was assisted to die in Ottawa after being diagnosed with terminal cancer. In a blog post written before his death, he declared: “We euthanise our pets humanely, but it is only recently that we have started applying humane dying to our own species. I want medical assistance to ease my way out of this life — nay, I demand it!” His family describe the process as cathartic: “As he requested, Deep Purple’s ‘Child in Time’ was cranked up in the background. His death was completely on his own terms, just as he wished.”

But what happens when there is no terminal diagnosis? What if your family don’t support your wish to die? In the days and weeks following his hospitalisation, Alan refused to take visits from his brothers. Gary tells me that patient confidentiality meant that the doctors didn’t have to inform them about Alan’s application for assisted dying. The people who loved him didn’t find out about it until a couple of days before the procedure was scheduled. Gary sees the hospital as partly responsible for keeping Alan from his family. “The last two weeks, they were treating him for nothing. They were giving him room and board.” He could have gone home. When, later, Gary asked the hospital, “Why did you keep him there?”, they said: “Alan didn’t think he should go home because you guys would try to convince him otherwise.”

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Gary did, indeed, spend the last day of his brother’s life trying to change Alan’s mind. He winces at the memory: “I think we came really, really close to convincing him not to do this.” Aware that his brother felt isolated, Gary told him: “Alan, I’m contemplating retiring this year, and possibly coming back to Chilliwack. To give you a little more support and a little more family close by”: “He just looks at me and says, ‘Geez, I wish I’d known that.’” In Alan’s view, it was already too late to alter his decision.

Now, Gary wonders if his brother would have regretted his attempt to end his life, had it not succeeded. It’s common knowledge in psychiatry that most previously suicidal people do. One Harvard study shows that “nine out of ten people who attempt suicide and survive will not go on to die by suicide at a later date”. Gary says he feels utterly betrayed by the hospital, the Canadian government, the whole system that undid all his family’s hard work to keep Alan alive.

Other countries are taking tentative steps towards a debate on legalised euthanasia. Last year, Spain passed legislation stating that a person can qualify for euthanasia if both incurable illness and “unbearable suffering” are proven. In the UK, both euthanasia and assisted suicide are currently illegal. But in 2021 an Assisted Dying Bill was proposed to the House of Lords and in the same year YouGov polls showed 73% of citizens supported legalising euthanasia for terminal patients. Only 35% of MPs agreed at the time, but since then the violent suicide of a grandfather with debilitating prostate cancer revived the debate, which remains preliminary and cautious.

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Justin Trudeau, meanwhile, is barreling at breakneck speed towards near total liberalisation. The Canadian system is set to become similar to Belgium’s or Switzerland’s. In March 2021, adults with “incurable diseases” but no foreseeable death were made eligible. Now, the “Special Joint Committee on MAiD” is considering whether to expand the law to “mature minors” (no further clarification given) and offering assisted dying to those with solely mental health conditions. Both tweaks to the law could come into effect in Canada as early as 2023.

Evidence suggests that there is demand for these services. Rupa Subramanya recently reported, for Bari Weiss’s Common Sense, on an epileptic woman called Victoria, who was only 21 when she considered applying for MAiD to alleviate her family’s dire financial situation. Subramanya also told the story of 23-year-old Kiano Vafaeian, who is seeking MAiD for depression, and his distraught family. Alan’s MAiD form, which I have seen, only listed “Hearing Loss” as his reason for requesting to die.

The conflicts of interest here are troubling. A 2020 preparatory analysis of MAiD predicted that it could save $66 million in healthcare costs. And facilities that carry out assisted suicides are given government support. In Alan Nichols’s case, the nurse who approved his application was also the “practitioner” giving him the fatal injection. “It’s like you’re writing your own paycheck,” Gary says.

Gary suspects Trudeau will allow the laws to go even further. “Why don’t you just set up a walk-in clinic for it? Because that’s what’s going to happen: once the government opens the door, these physicians and medical teams are just going to open it wider.”

As we say our goodbyes, Gary remembers something:

“In 2008, my mum called me and said: ‘Alan didn’t show up for dinner last night.’ So I said: ‘Okay, I’ll go check on him.’

So, I went over to see him, and his door was locked and wasn’t opening. I called a locksmith who came and opened up the door, and we went in there and he was laying in his bed.

And he says: ‘I knew eventually somebody would come to see me.’”

You can call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

Like so much of Woolf’s diaries, that last description has an echo in her fiction. In Mrs Dalloway, Clarissa, the eponymous wife, thinks about how much she dislikes her own appearance, her “ridiculous little face, beaked like a birds’”.

In her new, annotated edition of Mrs Dalloway, Merve Emre doesn’t footnote the parakeets. But she is frank about Woolf’s less sympathetic side — and the ghastly personal beliefs she subsumed into her fiction:

“The fact is that the working classes are detestable”, Woolf would write in her diary in 1920 — a prejudice she harboured and took great care to ironise in Mrs Dalloway.

Indeed, the point of Mrs Dalloway is to show the thoughtless distance that existed between the comfortable world of the rich and the unquiet world of the poor. Woolf “took great care” to transform the rudeness of her diaries: what appears as shockingly nasty and unprovoked becomes artful and observant — empathetic, even — in her fiction.

Because we do think about other people like that. We can’t control our thoughts. And Mrs Dalloway is concerned with the inner life (“one’s life,” Woolf wrote, “is not confined to one’s body and what one says and does”). Clarissa is so polite, so well mannered, so poised; Woolf drew on her own nastiness to show Clarissa’s interior: frustrated, suppressed, annoyed — about even the smallest things. “For Heaven’s sake, leave your knife alone! she cried to herself in irrepressible irritation.”

To use the language of Twitter, Clarissa Dalloway is trying to control her inner troll — just as Woolf was disguising, ironising and converting hers. In the online age, we are constantly confronted with the dilemma of appropriately expressing our thoughts, of not feeling free to express what ought to be acceptable, of feeling obliged to disguise or edit ourselves, or simply of disliking our own personality. The Annotated Mrs Dalloway is timely.

Woolf wrote in her diary that she detested “egoistical: personal” writing — of the kind that proliferates, now, in autofiction. She worked to be formal, objective. But Emre finds Woolf’s life surfacing everywhere. Woolf’s thoughts, and her self, are irrepressible. Her half-brother used to fondle her in bed, and Emre suggests we can see him “peeping out” from behind Hugh Whitbread, a “sexually abusive” character. Woolf’s early suicide attempt is drawn on. Like Septimus, the soldier suffering from PTSD, Woolf once hallucinated birds talking to her in ancient Greek.

The form of the footnotes mirrors their eclectic contents. They are laid out in thick margins, but sometimes they don’t run in sync with the text, so you have to scout around for the relevant note. There is at least one pile up, where a page of images is put in to allow the notes to catch up with the novel. Emre has created a kaleidoscope of revealing and illuminating images: contemporary photos of London; Duncan Grant’s painting of Regents Park; an etching of Oxford Street by Joseph Purnell; the Tatler cover for May 1922; an X-Ray of a hand. There are also frequent maps showing the characters’ routes through London.

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Just as Woolf’s fragmentary syntax reflects the irrepressible flux of a busy mind, the images and footnotes give a sense of the emergent bustle of London — one of the novel’s essential metaphors — and the disjoined way in which we piece our thoughts together. We are used to this of course — or we should be. Modern culture is chaotic. Social channels and comment threads enable everyone to footnote everything. But still, the annotations show what a marvel it is that Woolf managed to hold together this strange and vivid story — in her head and on the page.

It wasn’t easy. Emre shows how Woolf worked and worked and worked at this book. She was weary with the effort. She resented distractions — she often did. Throughout the letters and diaries, Woolf complains about the demands of other people. “We have seen an endless number of people”. Clarissa’s inventor was, like her, a reluctant hostess. Without people, she relaxed. She wrote to Vita Sackville-West from Sussex in 1928, “I am in soaring health and spirits after one day here and have sat looking at cows for 3 hours instead of chasing round London buying scraps of meat and coming home to find Clive, Miss Jenkins, Sybil, etc.”

Her diary, when she is home, crashes around from notes of where she has been, what she did, who was there, into convoluted psychological, ethical, and philosophical considerations. Just when the discussion becomes intractably deep, she flips into personal admin, grumbles, plans for work, gossip. Woolf seems calmer — nicer — when she is relieved of her anxieties, ambitions, and activities. Unquiet minds, we might speculate, produce unpleasant remarks. They also produce good art. Mrs Dalloway crashes around, too.

Woolf examined her own mind for material, but the novel wasn’t simply a re-working of her diary. Remember: Woolf took great care. She had almost impossibly high standards: she once told E.M. Forster that he wasn’t really a novelist. The poor man had nothing to say other than “Ah!” She criticised him for being unable to marry “satire and sympathy; fantasy and fact.” To meet Woolf’s high standards, then, one must transform the biographical. We must look for the way her rudeness is recreated — not merely expressed — in her art. What we dislike in her private voice, we most likely, unsuspectingly, admire in her public art. If only the same were true of our own vicious internet selves.

It would be easy to cancel Woolf today — parts of her, at least. Emre’s notes introduce critical debates about Woolf’s racism: the diaries are full of unacceptable remarks about Indian people. Mrs Dalloway, however, is not so straightforward. Woolf unflinchingly portrays how the English upper classes saw Indian women as mere objects of desire; as Emre (summarising Supriya Chaudhuri) says: “she represents prejudice from the intimate position of who feels it… Woolf is critiquing what she knows best: her failure to transcend her own racism.” By reading Woolf, we might critique our own rudeness. We might learn, like her, to use our lesser thoughts to encourage ourselves into empathy.

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Because some of the rudeness Woolf buried in her novels has become more, not less, acceptable: Emre shows many lines that were cut from the original draft of Mrs Dalloway, a lot of them about same-sex attraction. Clarissa’s memory of her first kiss with Sally was rewritten so that it described something spiritual and nostalgic, rather than a physical pleasure: “she became instantly soothed and yet stimulated as if myriads of bells chimed.” As with her racism, when writing about concealed desires, Woolf wrote about unacceptable things from the intimate vantage point of one who has experienced them.

Today’s literature looks for the personal everywhere — memoirs proliferate, especially from the unmemorable. But today’s culture is often intolerant of imperfection. We are too close to ourselves, perhaps, to see ourselves clearly, and accept what we find. The distance of fiction can help us see our irrepressible thoughts — to understand we are not obliged to be what we think or say or write.

Reasonably and inevitably enough, Goldwater then sued the heck out of Fact. The American Psychiatric Association then made it a principle of their code of ethics that “it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement”. In the UK, the Royal College of Psychiatrists “strongly supports” the rule.

I’m not a mental health professional. Nonetheless I think it’s a broadly useful principle to live by, especially if — as I do — you write a lot about mental health. Suggesting that some political opponent or other is mentally ill is often easier than wondering why a sane person in command of their faculties might believe something you disagree with.

But there’s an opposite mistake to the one the Goldwater Rule guards against: acting as though mental health issues have no relevance to our political and cultural lives.

Last week, the novelist Chimamanda Ngozi Adichie published a blog post called “It Is Obscene”. It referred to her experiences since she did an interview with Channel 4, in which she said that “trans women are trans women” — that is, she did not say that she thought that trans women are women, without caveats, although she has been a longtime campaigner on LGBT issues. Two young writers who she knew personally, she said, had accused her publicly of transphobia. One had called for people to “pick up machetes” to defend trans people from the “harm” she caused. 

For Adichie, this was a story about the “sanctimony” and “emotional aridity” of the online Left, and the “ideological orthodoxy” which requires people to denounce their friends and toe unwavering political lines in order to remain part of a “chosen puritan class”. I think this is undoubtedly part of the story, but not the whole.

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Adichie did not identify the writers; I will follow her lead, although it was not difficult to identify them from her text. But one of them had publicly declared a few months earlier that they have “dissociative identity disorder”, DID. That is: they have multiple personalities within one body; they refer to themselves as a “system” of personalities rather than a single person.

This is where I bump up somewhat against the Goldwater Rule. DID is a personality disorder which often presents with, or is confused with, another disorder called borderline personality disorder (BPD). About 70% of DID patients are also diagnosed with BPD, and the two conditions are often considered part of the same spectrum. The diagnostic criteria for BPD include “identity disturbance with markedly or persistently unstable self-image or sense of self,” and “severe dissociative symptoms”. Goldwater notwithstanding, I think it’s OK to draw lessons across from one to the other; diagnoses of the various kinds of personality disorder are very fuzzy — often people are in several categories, or don’t fit neatly into any of them. Both BPD and DID are marked by extreme emotional volatility and a lack of a stable sense of self.

This is a marvellous, sympathetic piece on BPD; the metaphor it uses is that people with BPD are cognitively “lighter” than neurotypical people. That is: if you are heavy, it takes a lot to move you. So when something quite nice happens to a neurotypical person, it makes them slightly happier: the wind only moves them a little bit. When something quite unpleasant happens, it makes them slightly sadder.

But if you are cognitively light, then the same events will move you much further. A small victory will make you thrill with joy; a small problem can make you suicidal (and BPD patients have a tragically high suicide risk in their younger years). It also applies to people’s opinions of others: “Either a relationship is perfect and that person is wonderful, or the relationship is doomed and that person is terrible,” as the NHS page on BPD puts it. This is called “splitting”, and again, it’s easy to think of it as someone being light, rather than heavy: being blown on the wind of events.

People with these conditions feel emotions much more strongly. But they also have difficulty forming a strong self-image, and often take on very visible identities, such as being a Goth or a fan of a particular band, dyeing their hair or getting tattoos, in order to give themselves something solid to cling to.

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This piece written by a BPD patient discusses how she would change her entire personality, and with it her wardrobe, with each new relationship or phase in her life: “In my ‘Premier League’ days, it’d be athletic and gym gear; when dating a hipster, I mimicked their use of rings and hats. My wardrobe was like the skin of a chameleon, physically embodying the changes in my personality.” This one talks about “waking up and trying to be a new person every day. Go vegan, go goth, go hipster, go glamour, cut your hair, change your makeup, gain weight, lose weight, and never feel quite there.”

I think this helps make sense of a lot of what was going on with the subject of Adichie’s essay. That person had been a worshipper of Adichie’s: later, they considered Adichie a transphobe and a bigot. A neurotypical person might have been disappointed that their hero was using what they considered insensitive language about trans people, but for someone whose emotions are more easily blown around, it made their opinion swing from 180° from love to hate. The relationship is perfect and the person is wonderful; then, the person is terrible and the relationship is doomed.

The identity aspect makes sense as well. In one Twitter post the author called for people to “pick up machetes to protect us from the harm transphobes like Adichie & Rowling seek to perpetuate”. Those machetes are presumably metaphorical, albeit an astonishingly vivid metaphor, but in other posts they abhor the “violence” of Adichie’s (to me mild-seeming) language towards trans women. This looks like straightforward hypocrisy, but to someone who struggles to form a coherent self-identity, and then finds one with the trans community, any criticism of that identity might well feel like a violent attack on the very core of one’s being.

The Adichie incident is a recent and high-profile one, but I think a disproportionate percentage of the problems with online discourse stem from similar problems. I won’t link to or identify any individuals — they would not benefit from it, and nor would anyone else — but I repeatedly see analogous situations, often from people who in other tweets openly declare their diagnosis.

I want to be very clear about some things I’m not saying. I’m not saying that all online bad behaviour is because of mental health issues or personality disorders: lots of people are just dickheads, and there’s no need to pathologise them. And I’m not saying that all or even most people with BPD or similar disorders end up attacking people online. And — while this example is lifted from the trans activism/gender-critical forever war — I’m certainly not saying that all trans people have personality disorders or that being trans is a mental illness. 

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But one of the cries of our age is to be more sympathetic and understanding of mental health conditions. The trouble is, I find that when people say things like that, they are often thinking of the more acceptable manifestations of mental ill health; people being depressed or anxious, staying home and making cute posts about being introverts.

Sometimes, though, mental health issues cause people to behave badly and cause harm to others, in ways that are not cute or sympathetic or easily understandable. An old friend with a personality disorder once wanted to write about this, on Mental Health Awareness Day: that we’re all keen to be Aware of Mental Health when it means someone being anxious or unhappy. But when it’s about psychotic episodes — or even less sympathetic disorders, such as psychopathy or narcissistic personality disorder — we’re less keen. My friend never wrote the post, but I think it’s true.

For instance: Freddie de Boer, a brilliant and insightful writer on many issues, suffers from bipolar disorder. During a manic period he falsely accused a man of rape and sexual harassment of women, causing enormous harm to himself and the man accused. He holds himself accountable for it and does not blame his illness, but it is nonetheless the case that his mental health issues caused him and others much pain.

Or Johann Hari, a journalist who was fired from the Independent after using fake “sockpuppet” accounts to libel other writers as homophobes and racists and antisemites. He was suffering from depression and addiction at the time. Again, it is not absolving him of responsibility to say that his mental health issues were a factor in the disastrous decisions he took.

I don’t know what my proposed solution is here. But I do think there is a failure — an understandable failure, a failure born of a desire not to offend or stigmatise, but a failure nonetheless — to address the reality of how mental health issues interact with our online discourse. Online, it’s easy to find causes to join, to give you identity; it’s easy to find people who’ll cheer you on, even if whatever they’re cheering you on to do is self-destructive, or damaging to others — calling for people to “pick up machetes” to attack women, for instance, even if it is a metaphor.

In the case of BPD, apparently, the prognosis is generally a good one: we all grow more emotionally stable over the course of our lives (as children, we are very emotionally volatile, and settle down with age) and by middle age, most people with BPD are leading healthy and happy lives. One study followed up patients 27 years after diagnosis and found that 92% of them no longer met the diagnostic criteria.

But we shouldn’t pretend that these issues aren’t a factor in the sometimes toxic online environment. Puritan attitudes, ideological dogma, hypocrisy and cant are all part of it as well, but, Goldwater Rule notwithstanding, we’re missing a part of the story of online discourse if we don’t find a way of addressing, sensitively and without stigma, the role of mental health.

Suffering often means suffering alone and it was this that first inspired the creation of awareness days and, as inflation inevitably happens with these things, weeks. So, although not everybody might be aware of it, this week is Eating Disorders Awareness Week, one of a diverse array of awareness weeks on the awareness week calendar.

There is clearly some value in such events. It is good for people to know that they are not alone and to have easy access to resources that might be of help. Still there are aspects of them — specifically those concerning mental health — which annoy me.

As writers like Jonny Gleadell have argued, modern discourse around “mental health” can pathologise quite normal behaviour. “Many issues have become medicalised,” Gleadell says, “No matter how far the symptoms are from meeting the threshold for diagnosis.” Professor Joël Billieux and colleagues suggest in an entertaining essay on overpathologisation that by the loose standards of some mental health scholars, we could diagnose them with “Research Addiction”. The market for shouty headlines about crises and epidemics ensures that this kind of sensationalism finds a home.

At its worst, this can provide a smokescreen for miserable, fixable material conditions. As students have been confined to their grief holes in British universities, for example, doing seminars online and thinking of the money they will have to spend for the privilege of having been there, we have heard a lot of talk about protecting their “mental health”. But this threatens to conflate a symptom with a disease. One trainee psychiatrist wrote, “I’m struggling to find the mental illness here. There’s no DSM code for being locked in a cupboard. CBT worksheets aren’t going to let students hug their parents again.”

Another problem is how simplistic the messaging can be. There is no doubt that British institutions need a renewed focus on eating disorders as experts warn of a “tsunami” of urgent referrals, and there is no doubt that the loved ones of people who might succumb to anorexia, bulimia et cetera should be aware of warning signs. But the valuable goal of communicating this demands some awareness of their complexities. “Awareness” is not an instant revelatory experience. It takes time and thought.

Some years ago I suffered from bulimia, which developed into anorexia — growing serious enough that I was dangerously underweight and experiencing awful cold, even in June, and obsessive, monomaniacal thought and behaviour. I stubbornly told myself and everybody else that I did not have a problem — accepting that I was sick and had to seek recovery only after working out that I was more emaciated than Christian Bale had been in The Machinist.

I do not believe there was any single cause of this. It would be marvellous, as a writer, to latch onto some unkind remark or anxiety-inducing image that set all of these events in motion — but it would be a lie. I had struggled with my weight for years, but I had struggled with everything: school, university, relationships and, above all, myself. The food I ate, or did not eat, was one thing I could control.

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When I read about eating disorders in the media, though, everything comes back to body image. That one factor is zeroed in on out of a whole spider’s web of causes. A recent well-intentioned BuzzFeed article addressing EDs among men talked about “body insecurity”, “unrealistic body standards”, “ideal paradigms” and “the pressure to have Captain America’s washboard abs and bodies devoid of an ounce of body fat”. Endless think pieces  debate the effects of social media, and fashion models, and the nebulous concept of “diet culture” on people’s sense of self.

As Hadley Freeman wrote in a perceptive article, “Eating disorders are the only mental illness that people still assume is caused by something identifiable and external.” Of course, that does not mean these things are insignificant. Body image plays a role in eating disorders and it is influenced by the people we look up to. Did it help me that one of my favourite albums was the Manic Street Preachers’ Holy Bible and its song “4st 7lbs”? Probably not. But did Richey Edwards take a cheerful and confident young man and make him ill? Absolutely not. The problem is what these articles do not mention. Body image is one factor but it is not alone.

Genetics could be another. According to a 2020 article in Science, “reports showed that 50% to 60% of the risk of developing anorexia was due to genes.” Different reports have claimed that anorexic people often have a specific kind of metabolism that makes them more vulnerable to mental illness. Professor Cynthia M. Bulk, a veteran researcher into eating disorders, suggests, “the processes in the body that normally regulate metabolism, including weight regulation, may be malfunctioning in anorexia nervosa patients.”

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This is all interesting, though not much help to people who have the conditions. But there are other psychological factors at play. Are we witnessing a dangerous rise in young people seeking treatment for eating disorders more because of Captain America and Instagram or because their lives have been upturned by a pandemic which has thrown their education, their social lives and their future into chaos? I suspect that it has more to do with the latter. Food restriction, in such a bewildering and depressing time, is one thing that is in their hands.

I do not want to poeticise illness here. At some point an eating disorder becomes far less of an exercise in self-control than an exercise in addiction. In anorexia, for example, one’s mind and one’s metabolism create a vicious circle in which the more underweight one becomes, the less one is capable of appreciating the need for sustenance. It is as if one is a car in which the emptier one’s petrol tank becomes, the more petrol one sees on the fuel gauge. That is why treatment of the most severe cases focuses on getting people’s weight up. Physiological changes tend to be a precondition for psychological changes. It is a terrible illness.

Still, even if one rejects the idea that someone with an eating disorder controls their illness more than the illness controls the person with an eating disorder, that does not mean one should be so reductionist as to shrink a complex phenomenon down to a single element. That is unhelpful, and more than a little patronising.

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It would be unfair to expect attempts to raise awareness of mental health problems, or any health problems, to reflect their every nuance. After all, these campaigns are not aimed at turning average people into experts, but making them more mindful and empathetic. Yet just as I have the nagging sense that a lot of the discourse around depression is aimed less towards people suffering from its clinical varieties and more towards people suffering from gloom, listlessness and self-doubt, I have the nagging sense that a lot of the discourse around eating disorders serves less to illuminate the lacerating self-abuse of mental illness and more to illuminate sad, common dissatisfaction with oneself. That dissatisfaction is not trivial. But it is not the same.

If you know someone who might be slipping into an eating disorder it is good to be aware of what they eat and what they say about themselves, and their relationship with food. It is also good to be aware of everything else in their life and how it might be contributing to their state of mind. Otherwise, one might miss the forest for the cold, bare winter trees.

If you’re worried about your own or someone else’s health, contact Beat on 0808-801 0677 or beateatingdisorders.org.uk