The kinder and more generous of our friends want to call it a decision, to respect her autonomy, and trust the dignity of her desire for peace. But, in the words of Edna St. Vincent Millay, “I know. But I do not approve. And I am not resigned.”
Leijia and I were best friends for over a decade. She could cut to the quick of any problem, make your stomach hurt from laughing when you started off sobbing over some heartbreak or another, and elegantly destroy anyone with words, with the kind of careful grace that hurt to even witness.
This piece, written a few years before she died, tries to answer a question that haunted her: What is it to be mad?
There exists a tidy concept of “mental illness” determined by a complex casual network of biological, traumatic, social, and structural conditions. Experts wield studied analyses to create convenient diagnoses, each with a dotted line leading to its formulaic chemical solution, which fit hand-in-glove with certain notions of “care” or “support.” This narrative — one of dependency and learned helplessness — frightens me.
Leijia moves quickly through diverse reference points, pitting the National Institute of Health against Foucault and Fanon, tracking Ketamine from parties to clinics, imagining a world that demands Prozac and a world that merely includes it. Of course drugs work, of course this world is maddening, of course we have deviant bodies and minds. And yet, something is missing: what she calls autonomy and meaning, which have their seat not in the subject doted on by the reactive solutions of science and care, but in the potency of a divine subjectivity that never fully passes over into these.
Her thinking is brilliant and erudite, as it’s always been, and yet, beyond remaining unfinished, it stops short of answering the question directly, if it’s even possible to answer. What does it mean to be — or become — a person with this kind of subjectivity?
Leijia knew that in the end, neither god, nor communism, nor “each other” was sufficient. Having a horizon to aim at, cultivating relationships of reciprocity and interdependency, these things can be a salve. But the capacity to act is completely of one’s self, of one’s own body, born in one’s own mind. The locus of control moves from an external to an internal position. The writers she and I loved demanded that we ruthlessly cut away everything imaginary in our feelings, that we follow our own furrows and not copy another, and come for the wreck and not the story of the wreck — the thing itself and not the myth.
Of course, there’s always another mirage. Potent or terrifying, it’s the only option.
—Banu, November 2022
I am in a work-mandated Mental Health First Aid training, presented by NYC Gouverneur Hospital. I’m here, it would seem, to learn about psychological disorders in the third person — as though psychosis were wholly in the domain of the other — and also in order to get a laminated completion certificate to bring to my supervisor. When the facilitator begins to lecture us on the ubiquitous availability of mental health care and resources, I check out entirely. I wonder nonchalantly how redundant this is; how many people in the room have ever tried to kill themselves. I had to reschedule therapy for this.
The endless employment of statistics in discussions of mental health is kind of pathetic. Some reports estimate that 18.5% of American adults suffer from one mental health issue or another; other studies suggest that roughly 20% of the country’s adult population is already on some form of psychiatric medication. The continuum between a casual dose of Prozac and a three-part anti-psychotic cocktail garnished with a designer club drug seems irrelevant. We’re all crazy and most of us don’t know it. Or that seems to be the popular consensus, anyway, periodically reinforced or refuted by the folk contention that, in fact, the only crazy person is Adam Smith; that the concurrence of record suicide rates (a 30% increase between 1999 and 2016: 13.4 people out of 100,000) and the accelerating pace of late capitalism is no coincidence. There is push back against the idea that despair is chemical. There is only flimsy originating evidence, all too eagerly seized upon by a monumentally lucrative and influential pharmaceutical industry and generations of greedy psychiatrists.
Michel Foucault, of course, wrote extensively on the devastating power dynamic between physicians and those labeled as mad, arguing that there is no shared language between the man and the madman. The true historical basis of psychiatry as an industry was the fear of undesirables. Regardless of one’s position towards the anti-psychiatry that Foucault’s work has helped to inspire, this absence of language rings true, as is easily confirmed by anyone who struggles to explain what psychosis feels like to a medical professional, only to be crushingly frustrated with the results echoed back to them. But beyond the futility of another trip to the doctor’s appointment, at a more general level, from lite think-pieces to casual conversations, this failure of understanding — or, more often, this refusal to understand, with all its obvious structural motivations — often ends up coded as merely “stigma around mental health.”
Mental health diagnoses are a needless swamp that in fact obscures the reality of madness. They elevate societal standards of normalcy far above individual subjectivity, and do so in a manner that runs contrary to mountains of scientific evidence that, although less publicized, is every bit as compelling as the pharmaceutical party line.1 In general, madness is a construction exacerbated by attempts to remedy it, a willful misunderstanding of what are simply different ways of apprehending the world. Another friend reminded me last winter of Frantz Fanon’s assertion that in an insane world, only the sane person is truly out of their mind, while everybody else just fundamentally gets it. The flip side of this sentiment follows the same logical vein, and has been rightly echoed by many, most recently (to me) by my mother: “This society makes people sick.” You can’t fix a brain that is shattered daily by wage labor, patriarchy, and demons that resemble Richard Spencer. In communism, though, is everybody happy?
I can only report what I’ve lived: that the web of mental health diagnosis is at least as absurd as everyone says it is, if not more so; that these diagnoses are endlessly capitalized upon by vultures of every variety; that the narrow field into which standard-issue psychiatry attempts to cram experiences of the mind is an ahistorical joke; yet, nonetheless, that certain digressions from functionality and happiness are likely not just the world being crazy (as it is) and the industry trying to profit (as it does) — that these experiences can be truly terrible and incongruous with any attempt to be alive, and that any resolution, regardless of whose dirty hands it may play into, carries the value of its outcome. This is a strange sort of middling position, but navigating mental health as a patient or even simply as a subject necessarily implies a lot of balancing, so it’s an appropriate theme.
Designer club drugs make their entrance. The first investigations into the mental health benefits of Ketamine took place at Yale University in 2000. After years of clinical use as a sedative and off-label use as an anesthetic, it began to be studied for its treatment potential in depressed patients whose disorders are “treatment-resistant,” that is, whose circumstances do not improve, or at least not substantially, with traditional drugs and therapy. Ketamine for depression is not yet approved by the FDA, but this has hardly curbed its commercial success. The drug circumvents traditional medications, which work upon neurotransmitters, by instead reshaping how synapses communicate. As the anesthesiologist I saw put it to me, it’s a hardware fix rather than a software fix. It is the case for many people who experience even mild trauma in their early lives, he said, that the synapses don’t form properly by the end of neurological development in the late teen years.
When I was in high school, kids snorted Ketamine at parties for $20 a hit. A clinical dose is only a fraction of a street dose, but an IV will put you out $425 per treatment, of which it is recommended that patients try six to start. Insurance doesn’t cover this, although those lucky enough to enjoy out-of-network coverage can file some paperwork and hope for partial reimbursement. Patients who respond well are recommended to continue infusions every four to six weeks after the initial set, returning whenever they feel their mood crashing — many can stop entirely after a year and a half. It’s as close to a “cure” as there is. The commonly cited success rate is roughly 70%, although there are reports of both higher and lower numbers, from both clinical trials and the outpatient clinics that offer the off-label treatment.
Ketamine is not reported to have any long-term side effects, yet its use is still sufficiently new that it’s too early to tell. In the immediate, the infusion itself comes on like a mild version of what happens to your consciousness on Ketamine in higher doses. Dissociation is common, but anecdotally noted as an indicator of effectiveness in the patient. The traditional K-hole experience is rare in these settings. There is often nausea, against which Zofran and/or Reglan is added to the IV as a precaution.
I tried Ketamine at the recommendation of my psychoanalyst. Conventional psychotherapeutic medication often helped, but not quite enough, making me an ideal candidate for the therapy. After a brief conversation with the anesthesiologist running the clinic, I sat in a reclining chair in a room painted a pleasant pastel yellow, had my blood pressure taken, and was hooked up to an IV drip. I asked about listening to music, and was advised to select something upbeat and distracting, due to others’ negative experiences listening to anything too dark or contemplative. My dad sat with me. For the next hour, I tripped mildly, listening to my own voice as if spoken from somewhere else, trying to isolate the outlines of the objects in the room without quite managing to do it, losing my train of thought often.
I did this six times over the course of a week and a half. My mood ascended and crashed rapidly; I called the office frequently to be reassured that everything seemed normal. I made extra appointments with my therapist. On good days, I read in the park, sitting in the sunshine. There were bad days: I only went to work once, and left after a few hours, having sunk at breakneck speed into a sullen ditch.
In the end, my response was “atypical,” per assessments by the director of the clinic and my psychoanalyst. The ups and downs continued after the treatments ended; I would alternate between feeling capable of a different way of being in the world, and capable only of a deeply clinical type of despair. It was unclear if the Ketamine had been completely ineffective, or merely more tenuously effective than in the glittering success stories I’d excitedly pored over in weeks prior.
Ultimately, the potential benefits of Ketamine infusions are exciting but inaccessible to most — there are an extremely limited number of clinics that offer the treatment and only in select cities, and the price is daunting.
Back at work, it is explained to us that Mental Health First Aid is just like any other first aid: there are first responders present for damage control and to act as a conduit to trained professionals, and as a stop-gap until the latter are available. We are given a long list of physical and mental afflictions and told to rank them from least to most debilitating in terms of their impact on one’s ability to live, laugh, learn, and love — “the Four Ls” that form the building blocks of a good life. We must recite them periodically. We are taught what to say to someone who is depressed, what to say to a paranoid schizophrenic, we draw pictures of a person having a panic attack, we get handouts with hotline numbers on them. The facilitator scolds us repeatedly for never thinking about mental health, for not taking the problem seriously. I take frequent cigarette breaks.
When I began this piece, I wrote, “peak accelerationism is either designer Ketamine or suicide” — assuming that the vanishing point of a subjective lifetime might be joy or death. With the invention of the pharmaceutical industry came the invention of one or the other. The long term is a tricky thing to think about: it feels like a truer way of posing the question in general would be to speak of treatment windows, sick days, the seizure of whatever is fleetingly visceral. When a more distant future creeps in, it is aided by wondering — whimsically, even — what communism looks like for the sick who are told that they’re not sick, the sick who are at once patients and liars, the sick whose sickness works from the outside in as much as the inside out. I wonder about care for sickness which, by some accounts, everyone has but nobody can see, sickness which we have been told is really just awareness, really the only health possible.
At base, I don’t have an answer because I don’t know what the question is. In a back-and-forth with an editor, it was suggested that I try to zero in on whether or not communism will make us happy — or maybe, if communism doesn’t make us happy exactly, whether or not we will simply be happy in communism, freed from the stressors of a mode of production whose preeminent effects on the psyche are monotony and despair. Will there still be Prozac? Will we need it? Will we miss it? If all the exorbitantly wealthy anesthesiologists are lined up and shot on revolutionary principle, how will we mainline Ketamine?
It might be a special kind of cynicism that makes me believe that autonomy from the flows of capital doesn’t necessarily imply autonomy from glitches in brain chemistry; or, if brain chemistry is truly a non-starter of an explanation, from sadness as a way of life, as a pervasive lens of understanding. I don’t believe that communism is an absolute horizon of everlasting, unequivocal joy. But I do think that the beauty of a revolutionary ideal must lie in its capacity to apprehend despair as a psychological phenomenon as much as a political one, viewing these terrains in symbiosis with neither total conflation nor false separation. Communism is unlikely to save us from ourselves, but I would welcome a post-capitalist way of being in the world that allows for us to save each other.
It isn’t too prefigurative, I think, to encourage a more comprehensive approach to mental health. If drugs make someone feel better, maybe it’s properly “working” or maybe it’s a placebo effect, but placebo effects are underrated — an effect is an effect, and I’m relatively unconcerned with the specifics. This is just to say that even those unconvinced by the validity of contemporary psychiatry would have a difficult time arguing that drugs never make any difference, and as such, whatever the mechanics of that difference, they have the potential to be a decent option regardless of the smoke, mirrors, and prescription deductibles. Whether the imperative is to take psychopharmacological drugs or to avoid them, moralizing is a poor course of action. Perhaps psychology is the last frontier of the individual; when all else has been communalized, we are still left with sadness not lived by everyone, anxiety without an object, but with prayers of their dissipation when the factories finally burn.2
I have often felt resentment toward the Icarus Project. The rhetoric of “flying too close to the sun” and “dangerous gifts” annoys me on some level, as though I’m meant to be grateful for the gift of sadness, as though it’s something divine and full of potential. Not everything in life, I would posit, is a blessing in disguise. Some things are just a drag. But I’ve begun to think that if embracing this paradigm feels healthy — that is, if it has a positive net impact on the resilience of one’s being — there is little to be gained by dismissing it out of hand, rather than accepting it as one perspective or set of psychological potentialities among many.
A crucial aspect of any project to reimagine grappling with mental health is an interrogation of the idea of care. The feminized quality of care as we understand it is a death trap, aligned with the gendered division of labor writ large, which preempts any possibility of collective engagement. Every meeting about care work to which men don’t show up only doubles down on the same message: some of us needn’t bother with care. Mental health distinguishes itself from broken bones precisely to the extent that treatment necessitates not just technique but also empathy. The biggest shithead in the world can still read an X-ray provided he has two eyes and a medical degree, but the capacity to adequately tend to grief requires more than a mechanical investment. Men exempt themselves from this investment through the cop-out of improper socialization, those fragments of conventional masculinity which we take as real. I don’t mean to invoke a dialogue here about “unlearning” — nobody ever “unlearns” anything, we merely synthesize experience into truism and try to do something different next time. I simply wish to posit that communist projects must not merely accept these divisions as an inconvenient fact, neither in general, nor when it comes to the work of caring for one another. Calls on the internet to Venmo your friends for their emotional labor might comically transactionalize human relationships, but the very notion would become obsolete if the potential recipients of your $5 weren’t so limited. If we accept that care, empathy, and compassion are uniquely the domain of those who occupy a position apart from maleness, we sacrifice not only mental health, but all possibility of meaningful modes of engagement with each other, and all revolutionary potential that might stem therefrom. We’re not going to radically transform the world by caring for one another, but we might be better equipped to do so, or at least to get through the day — which, given that communism is thus far eternally a vision of tomorrow, is arguably step one.
I remain unconvinced by most things: antipsychiatry, Ketamine, and most revolutionary promise. I’m given to skepticism more often than not. But I’m fairly certain that whatever “treatment” means, it requires an approach that operates on as many terrains of experience as those on which despair emerges: chemical, social, structural, and otherwise. The fundamental critical question must be one addressed not to the subject, but rather to subjectivity itself — that is, it is not concerned with individual actions and reactions but what it means to be a person with the capacity for action and reaction, and how we adapt that experience to a world that seeks to crush it. On the level of psychological autonomy, there are no wrong answers except the allegation of a wrong answer. As an interrogation of neurotransmitters, SSRIs do not preclude communism as an interrogation of the forces of unhappiness. And ultimately, as accurate as an analysis of a desperate society may regularly prove to be, if the latter interrogation presumes to resolve those forces in their entirety, it is precisely that lack of nuance or reflection which will likely fuck everybody over as soon as we are tasked with facing the world after the barricades.
Months before I was ever compelled to learn about Mental Health First Aid, I recall telling someone that brains are just brains, that I don’t believe that mine either works properly or not per se, that individual chemical reactions are totally idiosyncratic, and that this kind of neurological function doesn’t really exist as an absolute. My psychiatrist had told me I needed to stop drinking and my Medicaid insurance was refusing to cover an antipsychotic I’d been taking. Lost for an adequate substitute, I chain smoked instead. It may very well be that there is nothing “wrong” with anyone’s mind, but rather, that we desire something different — for our synapses as well as our capacity for autonomy and momentum in the world. This is as good a reason as any to seek it out.
Images: Ana Mendieta