Manufacturing depression (22 page)

That’s how Kalinowsky explained it to the
New York Times
in
1949. “
As treating physicians,
” he said, “we cannot wait for satisfactory theories…We psychiatrists, like other physicians, will learn to select the right therapeutic techniques for our patients.” Kalinowsky quickly reassured readers that even if doctors didn’t know exactly what they were doing, they would be careful, that shock therapy would be “applied with discrimination.” Talking to his colleagues, on the other hand, he emphasized the importance of discrimination, given the unprettiness of their techniques. After all, something even more important than patient well-being was at stake. “
Indiscriminate use
in neurotics is particularly likely to discredit the method,” said Kalinowsky. You wouldn’t want to kill the goose that laid the golden egg.

Shortly after Joseph Wortis observed Sakel at work in Vienna, and six weeks from when his therapy was scheduled to end, he got a letter from Havelock Ellis:

I am pleased to hear
the Freud analysis has been going well, even though you will be glad to reach the end of it. Not surprising that it has yielded no new revelation of yourself, and you can hardly have expected that it would. But it must certainly yield a revelation of Freud and his technique, and that is what you want.

Wortis was not the only eyewitness to report that Freud was querulous, combative, imposing, and dogmatic. Nonetheless, he did provide one small but important revelation about him. When it came to the insulin cure, and the prospect of a biological psychiatry, Freud, the self-assured pessimist, was surprisingly sanguine and more than a little modest.

Wortis described the insulin therapy to Freud “with great enthusiasm”—and a little bit of taunting:

I said incidentally
that it was now theoretically possible to produce a paranoia in the course of a morning with insulin and stop it in a few minutes with sugar, which seemed to disprove the psychoanalytic explanation of its etiology.

Freud didn’t accept this diagnosis.

Psychoanalysis
[Freud said] never claimed there were no organic factors in paranoia, it simply indicated the psychic mechanisms behind it. A mere organic explanation would explain nothing, any more than you could explain why one drunk became manic and another remained quiet.

The fact that a doctor could induce and curtail a psychological state with a biological intervention was not proof that the doctor had discovered the cause of the psychological state. All he could say with certainty was that he had found the way—or perhaps one of the ways—that the body (and presumably the brain) provided the experience. It was still possible—probable, in Freud’s view—that the psyche needed what the brain was doling out, that the symptom had some meaning.

Freud didn’t dispute the fact that insulin made some people better, but he argued that this didn’t rule out analysis as a cure. “‘
Analysis never claimed a prerogative
over organic forms of treatment, if such a treatment is more successful,’” he told Wortis. And besides, he reminded his young patient, he had always granted that there may be illnesses of the body that manifested themselves as problems of the mind, and “analysis never undertook to cure [them].”

Wortis persisted. “
I said that in New York
one often saw purely organic cases that had been treated in vain for a long time by psychoanalysts, at great expense to their patients.” Here he finally got a rise out of Freud, who was perhaps still smarting from losing the fight over lay analysis. “‘What your American
crooks
’—Freud used
the English word—‘do is certainly not representative or typical of the science of psychoanalysis.’” But his bile soon subsided.

Analysis is not everything. There are other factors…what we call libido, which is the drive behind every neurosis; psychoanalysis cannot influence that because it has an organic background. You very properly say that it is the biochemists’ task to find out what this is, and we can expect that the organic part will be uncovered in the future.

Freud did get in his digs—for instance, when Wortis told him that he’d dreamed that the Sakel method was a failure and Freud responded that “
what [Wortis] really wished
was that Freud would fail in his method.” But he remained firmly, if blandly, ecumenical even as his patient brought the subject up for the third time in three weeks, insisting that there was no reason that psychoanalysis and biological psychiatry couldn’t fashion a peaceable therapeutic kingdom. For that matter, Freud went on, even these two approaches didn’t exhaust the possibilities. “
As Charcot [Freud’s early mentor]
always used to say, ‘We cannot compete with Lourdes’; and many cases were actually sent there.”

The analyst never lay down with the shock doctor (or the priest)—although, as Edward Shorter and David Healy point out, throughout the 1940s and early 1950s, ECT was the “
secret love”
of many analysts, who would quietly send their patients for treatments even while denouncing it in public. Freud may simply have been angling to keep a place for analysis in the temple of a biologized psychiatry. He may have understood immediately what might happen now that doctors had found a reliable biological route to relieving suffering. Perhaps that’s why his first response to the news was to remind Wortis—already the representative of Freud’s antagonists, now going proxy for new challengers—that organic explanations explain nothing, because he knew that the shock doctors were about to claim not only that they could make you better, but that
they had explained what was wrong with you to begin with: that something had gone wrong in your brain, that when it comes to psychological suffering, the psyche is only another side effect.

Joseph Wortis didn’t bring any of this caution back with him when he returned to America from Vienna in 1935. Instead, he brought insulin therapy to Bellevue Hospital, from which it spread to the rest of the country.
He made his own contribution to the method,
perfecting a technique for keeping people in comas for up to twenty-four hours—
the program was terminated
in 1942 after a patient died—and eventually became the editor of the journal
Biological Psychiatry
. Manfred Sakel arrived in the United States shortly after Wortis’s return. He administered insulin treatments to his wealthy clientele in hospitals, hotel rooms, and private homes and acquired a reputation, at least with the
New York Times,
as the “
Pasteur of psychiatry.”
In 1937, a pair of Upper West Side doctors started treating depressed New Yorkers with Metrazol, and in 1940, just as Lothar Kalinowsky set sail for America, an epidemic of ECT spread to asylums in New York, Chicago, Philadelphia, and even Cincinnati. Headlines like “Insanity Treated by Electric Shock” began to appear in the
Times,
and by 1950 the age of biological psychiatry had begun in earnest.

If anyone was worried about the irrationality of all this therapeutic exuberance—other than the analysts whose livings it threatened—they weren’t saying. But then again, the guinea pigs in this experiment were terribly sick, which made it easy to justify desperate measures taken on their behalf. Had the shock doctors’ methods been less extreme and unpretty, had they been, say, gaily colored pills with friendlier names than
electroshock therapy,
remedies that just tweaked consciousness a little bit, that could be taken in the privacy of one’s own home, that had only a few side effects, and that were held out to cure a disease afflicting 20 percent of the population, there might have been a little more worry. In this sense, the depression doctors are in infinite historical debt to the shock doctors. They softened up the market for them, getting people used to
the idea that doctors could mess with their heads even if they didn’t know exactly what they were doing.

They also got people ready for the idea that Freud warned Wortis about and that my clinical trial made a fetish of: that our discontents and their cure are in our brains. The shock doctors, starting with the observation that biological interventions relieved psychic suffering, began to build the case that mental illness is fundamentally a biological problem. They took Kraepelin’s brilliant, build-it-and-they-will-come strategy—claim scientific authority by speaking in scientific language—one giant step farther.

Kraepelin had in effect issued a promissory note: eventually, he promised, an explanation would emerge that would validate his taxonomy; on that assurance, the taxonomy, which
sounded
scientific, should be accepted now. The shock doctors realized that so long as they did something dramatic to a patient’s body, so long as what they did was plausibly biological, and so long as they got results, they could further claim that they had proved what they were still only assuming. They could have the capital without even making the promise. They also identified the market: not schizophrenia, which often remained unaffected by their treatments, and which rendered its victims nearly inhuman, but depression.

My first depression lasted for a couple of years. When drugs made it go away, it was an accident. Not the taking drugs part—that I meant to do—but the depression-lifting, anxiety-erasing, total-revolution-in-my-head part. I’m not sure what I was expecting when I took Ecstasy for the first time—although the name should have been a clue—but what actually happened is the last thing I would have predicted.

When it comes to taking drugs like Ecstasy—whose official name is MDMA, or methylenedioxymethamphetamine—I am an educated and careful consumer. Before my first LSD trip, when I was eighteen, I prepared myself like a Boy Scout. I read about other people’s experiences, learned about what made them good trips or bad trips, sat with friends through theirs. On the appointed day, I made sure I trusted the people I was with, that we were in a safe place, that our nutrition and hydration needs could be met. I did one last walkaround of my own psychic state (as much as one can when one is so young) before I popped that little piece of paper in my mouth. No one told me to do all this; it just seemed prudent, the same way that it is prudent to learn how to drive a car before
you get on the expressway. I guess that when it comes to taking dangerous drugs, I have a self-preservation instinct.

And MDMA can be a dangerous drug. At high doses—not too high, maybe four or five times the normal human dose—it’s neurotoxic.
*
Of course,
so is Prozac,
or for that matter Pepto-Bismol (bismuth causes brain damage), although in both cases you need more like a hundred times the normal dose to cause problems. But that’s not why I hadn’t taken it before 1990. My reluctance wasn’t about the drug itself, but about me. I was concerned that my emotional state was too fragile to risk any disruption. I had, in fact, declared a moratorium on psychedelic drugs when, not long after I first got depressed, I took a dose of psilocybin mushrooms and spent a few hours resisting the urge to dash my brains out on a rock.

Like I said, educated and careful.

On the other hand, my circumstances seemed in some ways perfectly suited to MDMA. Its reputation among psychotherapists, at least of a certain stripe, was stellar. They gave it rave reviews, so to speak, for its ability to foster open, fearless communication—a mainline from the heart to the mouth and the ears, they said. It could, they went on, accomplish in an afternoon what years of therapy could not and was especially effective for couples with relationship issues.

And boy did we have some of those.

Susan had moved across the country to be with me. She’d left behind a marriage to a man whom she had been with for fourteen years, and all the life that went with that—house, friends, money—to move to my little New England village, whose inhabitants’ Yankee reserve registers with anyone from outside as disdain. She arrived to find me in the midst of my first depression, so morose
and sour that I couldn’t even give her a kiss with her Valentine’s Day gift.

We’d agreed not to live together, but that didn’t stop me from feeling responsible for her, a feeling I responded to by keeping her at arm’s length, by being cold, by letting her know in every way that I wasn’t going to take care of her, that I’d had enough of that in my first marriage and in my life and it wasn’t going to happen again—speeches that, had I been able to think clearly about it, I would have realized were unnecessary because that was the last thing in the world she wanted.

Susan was, and is, too humane and proud to pressure me (and maybe too clever; she wasn’t about to fulfill my prophecy), but after a year of my ambivalence, I knew that she was getting impatient. Which I helpfully responded to by being even more standoffish. And more depressed.

My therapist at the time asked, “But in your core, in your heart of hearts, do you love her?” That’s one of the all-time stupidest questions a therapist has ever asked, but I couldn’t blame her. She was tired of my dithering too.

“Love is beside the point,” I told her. “I’m too old for that.” I was thirty-two, but I felt ancient. “I’m just not sure I want to marry her.”

“She’s wants you to marry her?”

“Well, she hasn’t said that. But I’m pretty sure.”

“I wouldn’t be so sure. If someone treated me the way you’ve been treating her, I’m not sure I’d want to marry you.”

Which was one of the all-time smartest things a therapist has ever said. It didn’t do anything for my depression, at least not directly, but I did resolve to figure this out—if for no other reason than to spare further misery to someone whom, in my core, in my heart of hearts, I did love. I gave myself a deadline—six more months and then I’d have to call it quits.

Around that time, a friend of mine sent me some MDMA in the mail. (I should acknowledge that various felonies were committed
here, and unjust as this is, it’s not something I am recommending that you try at home.) Susan and I decided to take it with us when we traveled to a grimy Rust Belt city to see the Grateful Dead. We took the capsules—125 milligrams each of pure, lab-certified MDMA—in our hotel the morning of the show.