Everyone is on drugs. I don’t mean the old-fashioned, illegal kind, but the kind made by pharmaceutical companies that come in the form of pills. As a psychoanalyst, I’ve listened to people through the screen of their daily doses; and I’ve listened to them without it. Their natural rhythms certainly change, sometimes very dramatically—I guess that’s the point, isn’t it? I have a great many questions about what happens when a mind—a mind that uniquely structures emotion, interest, excitement, defense, association, memory, and rest—is undercut by medication. In this Faustian bargain, what are we gaining? And what are we sacrificing?

There is new resistance to the easy solution of medicating away psychological problems, because of revelations about addiction and abuse, a better understanding of placebo effects, or, for example, the startling realization that antidepressants, far from saving some teenagers from committing suicide, can sometimes push them to do it, which means that these pills should not be a first line of defense. Perhaps the time is right to return to the conundrum of mind and medicine.

The story of psychopharmacology stretches from the advent of barbiturates at the turn of the century to the discovery in the early 1950s of the first antipsychotic, based on a powerful sedative used for surgical purposes that was described as a “non-permanent pharmacological lobotomy.” This drug, Chlorpromazine, led to the development of most of the drugs used today for psychiatric management. The proliferation of psychiatric medications, ones with supposedly less overt dangers, began in the late 1980s—at the same time, a watershed lawsuit was filed in the UK against the makers of benzodiazepines, a class of drugs used for treating anxiety and other disorders, for knowingly downplaying knowledge of their potential for causing harm. Today, psychopharmacology is a multibillion-dollar industry and an estimated one in six adults in America is on some form of psychiatric medication (a statistic that doesn’t even include the use of sleeping pills, or pain pills, or the off-label use of other medications for psychological purposes).

Until I started researching the history of psychopharmacology, I didn’t know that it was an antipsychotic that had spurred the developments of most of the medications we know so well today, such as Prozac and Xanax. But it was the issue of antipsychotics that first made me think about what we were trading as individuals, and as a society, in relying so widely on psychiatric meds. When I went to work in a psychiatric hospital during my training, nothing seemed more self-evident than the need to sedate a psychotic person. They were the most clearly “out of their mind” and the medications worked quickly to reduce psychotic symptoms, especially the auditory hallucinations that menaced these patients. How could this be wrong?

I see that question very differently today. For one thing, these antipsychotic medications still come, three generations after their arrival, with severe, life-threatening and life-shortening side-effects, from tardive dyskinesia (TD), or involuntary movement disorder, which can become permanent, to type II diabetes, obesity, dementia, cardiac arrhythmia, and even sudden cardiac death. This is to say nothing of a whole host of less severe side-effects, especially the overall blunting of the personality. Working in an inpatient unit, onecomes to know well what we called the “psychotic shuffle,” a characteristic way of walking among patients suffering from the bodily tremors caused by TD and the sedative effects of these medications.

What did we do before these substances? We hospitalized people, long-term, and tried various alternative treatments, which is expensive, especially compared to medications. But a major problem with the drugs is that people with severe psychotic symptoms—like schizophrenia, for example—commonly abandon them because the medications make them feel terrible. So these patients end up becoming acutely psychotic over and over, and have to be hospitalized and rehospitalized. Many of them now end up in nursing homes, which have come to be used as psychiatric holding pens in the absence of long-term psychiatric hospitals—many of which closed in the US as psychopharmacology took hold and became the dominant mode of treatment. Such nursing homes are facilities with little to no therapeutic program, intended to house the elderly and the severely disabled. How much money are we now saving by this system? Are we cutting short the lives of these patients by medicating them for life?

There are alternatives to this system. As Sigmund Freud posited decades ago, a psychotic person who is helped to pass through the most acute phase of their symptoms by being kept safe, and who then receives a continuous form of talk treatment, as well as some means of education or ability to work, can potentially stabilize without excessive medication. A fascinating, rare collective of psychoanalysts in Quebec known as “the 388” have created a clinic that provides psychoanalytic treatment and 24/7 emergency care to individuals suffering from psychotic problems. A study of eighty-two patients treated in their facility for three years or more demonstrated that the program was able to reduce incidences of hospitalization by 78 percent, while 82 percent were living autonomously and 56 percent were able to provide for themselves financially. Proving that such a course of treatment costs far less in the end than the conventional one, the 388 group has recently been asked by the Canadian government to open more facilities and expand its approach.

But that’s Canada. This is practically unimaginable in America. The scarcity of resources and the legal hassle a doctor could face would likely be enough of a deterrent to taking on the risk of treating those with severe mental illness, especially given that most medics graduate with too much loan debt to consider such a precarious experiment. And if one such facility did begin to gain traction, drug company lobbyists would surely work to quash it.

This is the extreme end of the story because schizophrenia has always been the most serious of the mental disorders and a litmus test for how our society views mental illness, how we treat it, revealing what our ethical position is toward those who are suffering psychologically. By that measure, it doesn’t look good: from what I have learned, we are trading more humane treatments for a solution that superficially seems effective, but on closer examination is not helping patients in any long-term way and may actually be killing them.

I am indeed a Freudian psychoanalyst, that strange anachronism maligned by psychiatry for not being as scientific as medication supposedly is, by virtue of the control studies that can be done with drug treatments. Modern psychopharmacology goes hand in hand with a psychiatric diagnostic system that has, over time, been redefined to rely on medicating symptoms away rather than looking at the structure of the mind and its complex permutations in order to work with a patient in a deeply engaged way over the long haul. Modern psychiatry is hailed as a scientific success story, and drug companies have profited from the fact that talking therapies are often thought to take too long, their results frequently dismissed as unverifiable. I question, though, whether we should demand verified results when it comes to our mental life: Do you believe someone who promises you happiness in a pill?

Psychoanalysis still has the power to intrigue people, it seems—so embedded is it in American popular culture. Psychoanalytic language has entered the vernacular and psychoanalytic concepts permeate the way we all understand human relationships, especially sexuality. I have the sense that we need it more than ever to help us with our discontents because there is enduring value in the Freudian understanding of, on the one hand, the unceasing conflictual relationship between civilization and neurosis, and, on the other, what talking, simply talking, can do.

Freud himself was anything but hostile to psychopharmacology. Indeed, he was a notorious experimenter with drugs, especially cocaine, whose anesthetic properties and psychological effects he was one of the first to discover and champion (until, that is, a host of his friends and family to whom he administered the drug became addicted, contributing even to the death of one friend whose morphine abuse escalated after using cocaine in tandem, until he eventually overdosed). Freud himself underwent a course of experimental hormonal therapy with the first neuro-endocrinologist to see if it would improve his mood. Such research became the foundation for sex-change therapies today, along with a number of other medical discoveries that earned that doctor seven nominations for the Nobel Prize.

Freud’s beliefs about the human psyche thus did not exclude his own quite liberal experiments with medication and medical procedures. Importantly, at the end of his life, Freud chose to forgo any pain medication after almost thirty surgeries for oral cancer, so that he could think clearly with patients and continue to write—though he never ceased smoking the cigars he loved that had almost certainly caused his disease. The lesson I take from Freud is that you can choose your poison, which is the reason I wanted to turn to the topic of drugs, using what I’ve learned as a psychoanalyst over the last two decades.

We do have a choice about whether to medicate and how we do so. I think we have forgotten this because of how easy it is to obtain pills, along with the pervasive idea that our problems are simply chemical or genetic. So I want to begin by recalling what the drug panacea is treating at the most basic psychological level: pain, attention, sadness, libido, anxiety, sleep. Freud was surprisingly insightful about these crucial aspects of the psyche, even from his earliest writings before the turn of the century. By elucidating some basic psychoanalytic notions concerning the most common “troubles” of the mind, and by focusing on the different categories of medications prevalently used, I hope to disrupt our blind passion for prescriptions.

Painkillers

I’d like to begin with painkillers since they have been filling our headlines and because pain is often not thought of as having a psychological component (whereas I believe it does). Given that we have a crisis that has seen opioid-related deaths increase by 600 percent over the last four years, exceeding gun deaths and traffic fatalities in America, with 72,000 dead from overdose in 2017 alone, there is a problem with the way we medicate pain.

Pain is much more enigmatic than is commonly recognized. Why some people have a much higher threshold for tolerating physical pain than others is not fully understood. Nor do we know enough about the relationship between physical and emotional pain.

Freud recognized that pain was an important part of evolution, built into our being as a primary means of apprehending reality and adapting our behavior to avoid the threat of harm. Yet he also called pain a “failure” and a stark limit to the efficiency of the psychic system because it was, on the one hand, too easy always to “fly from pain” (in other words, to obscure it) and, on the other, too difficult to master pain since it creates indelible memory traces that do not lose their intensity even, in some cases, with the passage of time. The memory of pain is often as bad, if not worse, than the pain that was experienced. Consider post-traumatic stress disorder.

“Pain,” writes Freud, is a pure “imperative” that produces a state of “mental helplessness.” And in his view, physical pain and emotional pain are made of the same stuff—what Freud called a breach of the stimulus barrier that protects us from the outside world, where, analogous to our skin, there is a protective layer that is meant to remain intact and unperturbed. When it comes to pain, a shock to the barrier sets off a multitude of nerves that then fire too rapidly to prevent a reaction. This built-in alarm system makes a demand on a person and those around one, forcing everyone to address whatever painful circumstance has arisen.

Even what we call pleasure, or the reward-system of the mind, does not always have a positive outcome, but can involve a lowering of our sensitivity to pain, allaying the alarm system. The opioid receptors of the brain do just this—something Freud called, when speaking about cocaine, the happiness of “the silence of the inner organs.” Lulling can be dulling. Freud also notes that pain and the sounds associated with it, such as screams or groans, coallesce as a first memory trace, bringing together the sensory realms of internal feeling with an acoustic correlative. Our mind creates a solid bond between pain and the sounds we associate with it, which have the power, through empathy, to immediately produce pain in others. This is what makes the cries of an infant so intolerable. So our experience of pain involves not just our own pain, but also our relation to the pain of others.

With the abuse of pain medication, then, we are not only treating our own pain, which is always somewhere between the physical and emotional, but we are also dulling the immense pain around us. Modernity has increasingly allowed a breaking through of the stimulus barrier, from the impossible demands and the chaotic pressures of contemporary life, to a sense of mounting helplessness in the face of environmental disaster, poverty, loneliness, injustice, annihilation. One could say that “all this pain” is nothing new, but the constant forced attention to the theater of it has come with easy access to a powerful antidote: the ability to medicate the pain away, not just our own, but all of it.

Fascinatingly, Freud notes in his later work “On Narcissism” that the pain arising from organic causes often increases our narcissism, making us give up our interest in the outside world—so “concentrated is his soul… in his molar’s narrow hole,” Freud quotes Wilhelm Busch on the poet who is suffering from a toothache. This is a state that, Freud says, resembles sleep, or what he called “the narcissistic withdrawal of… the libido onto the subject’s own self,” a turning-away from the world. So pain and narcissism are bedfellows—and what else is the abuse of pain medication but a synthetic version of this couplet, fulfilling the wish to keep sleeping, to keep dreaming, to turn away from the world. Overdose appears immanent in this schema, as the risk of slipping into permanent sleep, falling down the narrow hole that seems to promise the cessation of all pain.

There is an ethical twist to this understanding of narcissism’s relationship with pain. The opioid crisis enacts the paradox of a society that seeks to annihilate pain as quickly as possible, even as it refuses to care for or attend to it and its underlying causes.

Annihilating pain, or “flying” from it, will never permit us to master pain, but only increases the need for its continued obliteration. This mastery of pain Freud explained as the formation of a mental response network, which strengthens our tools for dealing with pain beyond “toxic agents or the influence of mental distraction.” Freud always advocated “work,” which was how he characterized what happens in psychoanalysis; he also said that drive or libido could be thought of as the demand that a body can make upon the mind for work—like the emotional pain that can come from others’ requiring us to revisit it again and again to try to make more sense of it.

So what are painkillers, finally? They are drive-killers, which is why their effect on sexual function and even digestion is about the ceasing of work. This suggests the acute danger of these pills, insufficiently regulated, with drug companies profiting from this simple desire: no body, no drive, no pain, no helplessness, nothing. Stretched to the logical extreme, they are about permanent sleep. Death.

Adderall

Let’s move from a world asleep to a world on stimulants. Whole college campuses and schoolrooms of children obeying the commands to: Wake up! Sit still! Pay attention! I hate to see a child put on Ritalin even as their parents compulsively check their emails or their Twitter feed, waiting for any conversational lull that licenses them to look at their phones. This hypocrisy reaches into the very core of our beings when we realize that we can exert the most concentrated attention on certain tasks—spending hours on video games, or shopping on Etsy, or online vacation-planning—but not on what we don’t like or what is most pressing.

Work is hard. When the painful demands of concentration on work or life are overwhelming, when success or failure seem to hang in the balance, the temptation to check social media accounts and procrastinate is powerful. So we are really in a jam: no one wants to pay attention, no one can easily be still; and no one really knows whether the drugs help or not with achieving better grades or being more productive, aside from our feeling better on them, the megalomaniacal high we get from stimulants.

We psychoanalysts like to call this the medicating away of “castration anxiety,” which is what speed, like cocaine, does. What we mean by this is that it is a way of trying to slip past both the pangs of conscience (for, say, a missed deadline on a piece of work) and the fear of failure (because the work was late and also judged inadequate) that run through our heads like an executioner’s song. Or to put it in other terms, ADD medication creates a false ego-boost, a momentary halo of self-esteem. Freud said in his 1926 paper “Inhibitions, Symptoms, and Anxiety” that most patients sought help for inhibitions that, he said, affect the ego in the realms of either sexual function, eating, locomotion, or vocation. (Problems of locomotion might seem the oddest category in this list, but we recognize well the difficulties with work, eating disorders, and sexual function— on which more follows.)

We are still very inhibited. So many patients cannot easily perform sexually, enjoy the pleasures of the appetite, or succeed at work. But here is what Freud writes specifically about vocation:

Inhibition in the field of occupation, which so often becomes a matter for treatment as an isolated symptom, is evidenced in diminished pleasure in work, or its poor execution, or such reactive manifestations as fatigue (vertigo, vomiting) if the subject forces himself to go on working. Hysteria compels the suspension of work by producing paralysis of organs and functions, the existence of which is incompatible with the carrying on of work. The compulsion neurosis interferes with work by a continuous distraction of the attention and by loss of time in the form of procrastination and repetition.

Sound familiar? Are we, as a society, moving closer and closer to what Freud calls compulsion neurosis?

Freud is here distinguishing between that condition (which is close to Obsessive-Compulsive Disorder) and hysteria. The hysteric—who has a whole host of bodily symptoms, from pain to paralysis to nausea, that prevent him or her from working—is structured differently from the compulsion neurotic who can’t work because of distraction and procrastination. Freud actually finds the hysteric easier to treat because, more often than not, the hysterical patient is avoiding something in the external world—usually sexuality—whereas the compulsion neurotic is rigorously avoiding something in their internal mental life. It is not easy to turn someone’s attention toward what they want to stay away from, especially when it is something on the inside. This force of resistance has to be overcome. But the hysteric is easily led to the source of his or her suffering, trauma, and conflict, and the bodily symptoms, and failure to attend to life, vanish. Those with ADD on the side of compulsion are much more adept at avoiding the source.

All in all, Freud is no fan of attention for its own sake. He felt that it is always easily disrupted. He writes in The Psychopathology of Everyday Life, his early work from 1901 that is essentially about mistakes and lapses of attention, that an “unconscious readiness to look for something is much more likely to lead to success than consciously directed attention.” Freud was fascinated by the phenomena in which an intentional attempt to direct attention to something forgotten could be easily opposed, whereas priming oneself for wanting to know, and then letting go of one’s attention to it, often caused the information to shoot back into one’s mind. We perform best not when we try to direct the whole of our attention to a task, but when we are able to use a split in our attention and act automatically, without thinking, when “scarcely any conscious attention” is paid.

We can also see this, for example, when we read aloud. Often, we read perfectly and yet have let our thoughts wander while doing so to the extent that we have no idea what it is exactly that we’ve read. What Freud says about this is that it isn’t “a lessening of attention,” as many psychologists would have it, but “a disturbance of attention by an alien thought which claims consideration.” It was for this reason that Freud wrote the book on mistakes as lapses in attention that had some underlying motivation. Freud being Freud, he wanted to see if he could analyze the reason for calling your significant other your mother, or for leaving your umbrella in your psychoanalyst’s waiting room.

In a sense, Freud trusts unconscious mental life more than the vicissitudes of consciousness or the functions of the ego. In his model of the mind, one has to let the mind be claimed by this alien force, let some processes go on automatically, let others drift. One has to play into this flux. This, in fact, became the very model for how the psychoanalyst works: their split, hovering attention, which allows them to attend to what is evoked unconsciously by what a patient comes to say, while still listening to what is said, tuning in and tuning out, catching the thoughts that distract us, returning to a task. Rigid, unblinking attention is overrated.

So if one is alienated from what is already alien (unconscious thoughts), which can easily make claims on one’s attention, well, then you are in very deep water, psychoanalytically speaking. This is the problem with ADD, or compulsion neurosis: it is the purest form of alienation from internal life, which is why everything is turned into some external problem of avoidance, distraction, and procrastination. Work draws on one’s unconscious, on one’s emotional life, and on the reserves of self-esteem that help with one’s inevitable anxieties.

For those with ADD, you will easily see that the unconscious is what cannot be tolerated—not the Excel spreadsheet, but you yourself. Stimulants help you jump the hurdle, but the drugs cannot completely erase your internal life, which will always be there waiting for you on the other side of the come-down, at some point when you find yourself in a speed-free moment of stillness. Don’t you want to know what’s in there before you chemically dampen it?

To conclude on a rather depressing note—one that follows on the heels of the uncanny fact that these very same ADD stimulants were used by the Third Reich to aid soldiers in performing acts of extermination—the sociologist Theodor Adorno in his article “Freudian Theory and Fascist Propaganda” noted the irony of the Nazi slogan, “Germany Awake!”—when what Germany was engaging in was mass hypnotism by a fascist leader. What the Nazis meant, he said, was the exact opposite—“Germany Asleep!” Might the same hold true here with our mass medicating of collective distraction?

Antidepressants

Moving from induced mania to depression, it’s been twenty-four years since Prozac Nation was published; I never read it but practically everyone I know has been on a modern antidepressant Selective Serotonin Reuptake Inhibitor (SSRI) like Prozac at one point or another. Do antidepressants help with depression? It’s a touchy subject; they have clearly helped many through periods of depression, saving the lives of some who have struggled with suicidal feelings. One thing I will say is that I prefer my patients not to be on them if possible, or eventually to get off them. True, the lows aren’t as low, but neither are the highs high, and pleasure is limited to some medial zone. To borrow Sylvia Plath’s metaphor of the bell-jar, the whole system feels caught between two glass walls.

Psychoanalytic work depends on following the natural emotional rhythms of the mind, stretched between anxiety, sadness, and excitement, allowing a certain amount of tension to build at the points of blockage. This is what creates breakthroughs. With the SSRIs, it’s as though the machine becomes frictionless and idling, and the complaints—which don’t go away—spin in neutral, never gaining purchase or momentum. That said, who can afford to have lows in today’s world that demands that we always be on and productive? I understand this. I do think the demands that we make use of ourselves are excessive—and nearly a depressant in itself.

Further, the work of psychoanalysis is tough—both analyst and patient must push past (or work through, as Freud put it) pockets of melancholia, which are real and painful, and affect us not just psychically, but on a biological level, sometimes leading to lethargy, insomnia, and even psychotic delusions of persecution. Freud wrestled with the problem of melancholia all his life, and at various points he wasn’t sure it was treatable by psychoanalysis, especially its most extreme form—cyclical depression or what we now call bipolar disorder. More often than not, in these cases, even antidepressants don’t really help and psychiatrists often turn to more extreme treatments. When I worked in the hospital, we often used Electro-Convulsive Therapy, or ECT, which induces a seizure in order to jump-start your mental system, wiping out swaths of memory in the process.

At other moments, Freud saw depression as a tendency within any neuroses, an affective change in which the dissatisfaction that characterizes neurotic sickness mounts to the pitch of a depression. He also saw this kind of depression as a nodal point where the conundrums of loss touch us deeply. In some sense, melancholia is what we have inherited from our ancestors—what hasn’t been worked through or metabolized. It is an expression of trauma passed down and repeated over generations. In 1937, Freud wrote to Princess Marie Bonaparte a now infamous letter about his thoughts on depression:

The moment a man questions the meaning and value of life, he is sick, since objectively neither has any existence; by asking this question one is merely admitting to a store of unsatisfied libido to which something else must have happened, a kind of fermentation leading to sadness and depression. I am afraid these explanations of mine are not very wonderful. Perhaps because I am too pessimistic. I have an advertisement floating about in my head which I consider the boldest and most successful piece of American publicity: “Why live, if you can be buried for ten dollars?”

Freud is always comical whenever he mentions America—here finding the perfect illustration for the fermentation process of depression that makes a certain kind of calculation regarding the value of life possible. Life—unsatisfying, painful, without objective meaning—may for some add up to the idea that death would be better; better, that is, if death were less terrifying and could be had cheaply.

We are all familiar with the soliloquy on suicide of that great melancholic, Hamlet: “To die, to sleep—no more—and by a sleep to say we end the heartache, and the thousand natural shocks that flesh is heir to.” It’s true that depressives can loath having bodies which registers the shocks of life; the inevitable disappointment with loved others feels like salt rubbed in already gaping wounds. Hamlet nevertheless choses a life he finds miserable and unjust because it’s the life he knows, rather than the uncertainty of death. For Freud, the problem is that Hamlet thought life was to have more meaning than it did, implicit in his desire for justice, happiness, and love. But then as Freud says, my answers aren’t wonderful, and I may be too pessimistic.

So why do some enter into this process of depressive fermentation? Early in his career, Freud pointed to the relationship between a history of anesthesia, or loss of feeling—especially pleasure—and melancholia. There are varying degrees of this libidinal depletion. In cyclic depression, there is both a draining and a flooding of the libido that creates the severe vegetative and manic symptoms of the illness. In their moving from a loss of all feeling and purpose to an excess of them, manic people suddenly have a million things they need to do with the utmost urgency and excitement—like buying and sending forty Volkswagens to Yemen to compensate for the children who died in an American-supported airstrike.

Freud modeled what was called depressive neurasthenia—a state of languor, malaise, and boredom—on excessive masturbation, or too much manual discharge of the libido, which weakens the overall system. This negative view of masturbation was endemic to the Victorian era, but minus this moralism dressed up as medicalism, Freud was pointing to the problems of indulgence that induce anesthesia; or melancholia as followed by an excess. He includes in this all the problems of addiction, including sex addiction, or simply hedonism more generally.

Finally, he says there are those for whom bodily feelings are trapped at the border, unable to transform into thoughts, ideas, or feelings, and end up appearing as diffuse anxiety. When this anxiety begins to deplete the libido, we have what Freud called anxiety melancholia. Under this rubric, he would include alexithymia (lack of emotional awareness), anhedonia (inability to feel pleasure), asexuality (loss of sexual desire), anorexia (loss of appetite), and many of the vicissitudes of disappointment that can reach the pitch of a mild melancholia. It is this latter category that the antidepressant campaigns are targeting in those strange television ads in which cartoons ask if you feel lonely, sad, or just not yourself.

Freud concedes that anesthesia is possible without melancholia, but melancholia is never possible without anesthesia of some kind. And this is vital, because while this numbing is part of depression, it is also what depression is trying to escape by increasing the feelings of agony and pain. Unfortunately, antidepressant drugs stop the agony and keep the anesthesia. It wraps your depression in bubble wrap.

Is it any wonder, then, that what is most obviously sacrificed in taking antidepressant medication, though it is never fully acknowledged, is orgasmic pleasure itself? Antidepressants can, and most often do, cause a severe attenuation of both sexual desire and the capacity to reach orgasm. It’s not easy to live with sexuality, with a body, with all its unpredictable pleasures and pains—the thousand natural shocks that flesh is heir to. Sexual desire, that constant engine that demands we start over and over, is what is shed through depressive numbing. Instead, you don’t want anything—always to be followed by the rage that takes its place, and certainly not from you.

This is perhaps why in Freud’s 1917 article “Mourning and Melancholia,” he gave the problem of melancholia more substance, saying that it was more than just a libidinal process gone haywire, it was also an inability to sustain desire because of a morbid, unconscious attachment to a lost loved one. Somewhere, the melancholic was sentimentally attached to someone or something that was crushing them from the inside. They simply couldn’t let go, let something new in, desire something else, let the engine turn off and turn on again, as it will. So, while depressives declare life devoid of meaning, there is a secret attachment to some part of life that they are guarding. The depressive rage against the machine was a way to continue loving someone or something that has been lost, and the pain is the mind’s attempt to finally break free of this, to acknowledge not the meaninglessness of life, but the end of a certain way that life had taken on meaning.

Sexual desire takes the biggest hit in depression as that longing transforms into hopelessness, or, as Freud poetically put it, “the shadow of the object falls on the ego.” Are antidepressants a substance that aids and abets in this holding on and coasting at neutral to negative by refusing to work through painful experiences of loss? No sex, no desire, no loss, no gain—just me and you and this dull pain. Or, as a Pink Floyd lyric once put it, “The child is grown. The dream is gone. I have become comfortably numb.”

Viagra

Sexual dysfunction—and our drug panaceas to treat it—are logically next on the list, not least because antidepressants are one of the major factors in both erectile dysfunction in men and sexual interest/arousal disorder in women. The incidence of sexual interest/arousal disorder for women aged twenty to sixty is estimated to be 30 percent, though many acknowledge that women are less likely to speak about the problem, whereas, since Viagra was released in 1998, men have become much more comfortable talking about it. Half of all men between the ages of forty and eighty report some problems with erectile dysfunction (ED), and the global drug market to treat ED is worth over $3 billion.

A 2017 meta-analytic study found that depression increases the risk of erectile dysfunction and erectile dysfunction increases the risk of depression, especially if one is living in a developed country. This puts us in a tight, almost claustrophobic bind—something Freud pointed to as early as 1908 in “‘Civilized’ Sexual Morality and Modern Nervous Illness.” In this article for the medical journal Sexual Problems, Freud is one of the first to say that sexuality by itself does not generate conflicts or dysfunction; rather, it is in sexuality’s interaction with culture and morality that something goes askew.

Freud worries that damage to an individual’s sexuality will eventually threaten society as a whole. He ends the article saying that the restrictions imposed on sexuality that are causing new forms of neurotic illness are also making people more anxious about life. That creates an excessive fear of death that interferes not only with a person’s capacity for enjoyment, but diminishes the inclination to have children and thus participate in the future of civilization. It’s not just about not being able to do it, nor even just about not really wanting to, Freud is saying; it is that we are in a deep crisis about the meaning of intimate relationships and life generally.

Freud is quite the sexual revolutionary in this article: criticizing the restrictions of monogamy and the double standard that allows men infidelities, recasting what were often considered sexual perversions as a normal part of sexuality, and showing how the aim of sexual drives is pleasure, not reproduction. But he was far from being a fan of hedonistic sexual indulgence. He thought such indulgence, especially excessive masturbation, weakened one’s psychological constitution. He was also skeptical about romantic love, which he found fickle, since it was not easily combined with, or sustained by, sexual desire, and was often part of neurotic illusions or religious-moral idealism.

Later, Freud pointed to the difficult truth that the misogynistic debasement of a sexual partner helped men greatly with their potency. In fact, of the majority of men seeking treatment for what Freud named “psychical impotence,” it was always easy to discover that they were impotent only with some women and not with others. The women they demonstrated sexual prowess with were generally those whom they didn’t respect or have affectionate feelings toward—in short, women of a lower class, or prostitutes. This thesis about male sexuality and debasement, I want to note, was formulated well before the age of Internet pornography, which has finally caught up to Freud. Freud named this problem, in one of my favorite titles for an essay, “The Universal Tendency to Debasement in the Sphere of Love.”

Developing this theme, Freud said the Madonna-whore complex is caused by incestuous fantasies—meaning that once a woman is remotely reminiscent of a man’s mother (by virtue of her becoming a mother, or because of his being intimidated by her, or simply feeling dependent on her), erectile function goes out the window. Women, he said, have their own version: they like secret relationships, and once something is sanctioned, it loses its exciting, transgressive edge; into that scenario enters frigidity. Despite skepticism regarding Freud on women (and much else), these ideas continue to be of help to feminists, showing how misogyny is structured, as well as women’s symptomatic abandoning of desire in response to conventional forms of sexuality.

Both women and men, Freud said, have to surmount their feelings of “respect” that act as a curb on their sexual desire. Furthermore, they have to face up to their incestuous fantasies: we all have them—hence the universal in the essay’s title. Actually, it seems many of us are trying to face up to our incest fantasies since some variety of Mom porn came number three, four, five, and six among Pornhub’s “most searched” categories in 2017. And since 2016, we have had a president with an apparent penchant for debasing women, even as he expresses frank admiration for his daughters’ bodies. At the same time, we are still a society saturated with sexual morality, or sex panic, as some like to call it. I include in this not simply ideas or ideals about sex or sexuality, but also notions of love, marriage, and family.

The idea of the family has never been stronger despite divorce rates hovering at around 45 percent and birth rates dropping to their lowest since 1987. Despite the patent fiction of shows like The Bachelor or The Bachelorette, in which no one really can believe that the Reality TV contestants are finding true love that will lead to marriage and a family, we nevertheless want to believe. In fact, nothing seems to sell better than when it is associated with a family, like The Kardashians, Duck Dynasty, or the Trumps. Perhaps, now, the family sells better than sex does since, in the past few years, many researchers are reporting large drops in sexual activity across the globe, with a 15 percent fall in the United States, and the most extreme statistic coming from Japan, where a reported 46 percent of women and 25 percent of men say they “despise” sexual contact.

The researchers blame porn, they blame increased working hours and stress, they blame depression and the insecurity of modern life. But Freud, surveying his patients in 1908, says that the problems with sexual desire often arise not simply from an external situation, but when someone can’t acknowledge or speak a truth about their love relationships. Often, they repress the truth in order to live up to a societal ideal regarding family life or what they imagine it means to be in an intimate relationship, and then fall into illness. But illness causes just as much lack of satisfaction and situation of worry as would have been caused by acknowledging the truth. In a comment whose sardonic tone cannot be ignored, Freud says: “This example is completely typical of what a neurosis achieves.”

So what Freud is saying is that we have a problem concerning sex and sexual desire and we have a problem with truth. This is an enormous double challenge for the practice of psychoanalysis that deals with speaking about one’s desires and sexual difficulties as honestly as possible. It takes a long time; even with all the restrictions loosened, people still have great difficulty speaking about what they want. It seems that many people would prefer to turn away from uncomfortable sexuality, which seems to invade them from the inside. So, without hard therapeutic work, we are going to need a lot of medication.

Naturally, Big Pharma is furiously working to come up with a Viagra for women. The latest pill in testing has been named Lybrido—note how they put the phonetic equivalent of “breed” in the name given our penchant for sexual dysfunction-inducing moralism. Interestingly, in a long article about the trials for this medication in The New York Times in 2013, the women interviewed were strikingly ambivalent: they wanted the medication desperately, sometimes insistently, but at the same time seemed not to follow instructions, claimed that they were in the placebo group, forgot to attempt the prescribed application of medication followed by sexual intercourse, even reported having orgasms but without leading to any overall change in desire. Nor did these women seek out any alternate solutions, such as therapy, to try get to the bottom of the matter; they chose instead to wait for the day that the real pill comes along. Funny, because I’m not sure they really want it. But there’s the rub.

Benzodiazepines

Now, to everyone’s favorite: anxiety meds. Anyone can appreciate a Xanax or Klonopin on one of those days when we’re frayed at the edges and the after-work “happy hour” tequila doesn’t really help. The problem with these pills, as every doctor will attest, is that these substances are highly addictive: their half-life is short, tolerance to the medication mounts quickly, and, with respect to the anxiety that they’re treating, they do nothing but medicate it away, very temporarily, and the physical strain when trying to wean oneself off the medication is severe and dangerous.

The second day off from even a minor “housewife’s helper” habit is a horror; you feel the pressure mounting as the medication wears off and that buzzing starts to creep back in, like the insistent pinging of alerts on your iPhone in the other room. What if I put it in a drawer, or maybe even in the basement? Take another pill. Take two more… So I worry very much when my patients start developing a taste for Xanax, a condition that usually starts with the recommendation that you carry it in your purse or wallet, prescribed “as needed.” We are telling people to carry a powerful sedative around in their pockets, just in case?

Most of my patients come with a mixture of anxiety and depression, and antidepressants don’t help all that much with anxiety symptoms. Even Wellbutrin (“the skinny antidepressant,” as it has come to be called because it doesn’t cause the weight gain that the others often do), which is said to help with this mixed picture, can’t really touch anxiety in the way a benzodiazepine-type drug can. In fact, it can sometimes make things worse since it has more pick-me-up than the other antidepressants, and entering more fully into life often means experiencing more anxiety. But what is anxiety? Doesn’t everyone have it to some extent?

For some, anxiety is coextensive with existence: to live is to have anxiety. This is what Kierkegaard and some of the other mid-nineteenth-century Existentialists pointed to and even celebrated. For psychoanalysts and psychiatrists, anxiety was fear without an object—dread would be a good word for it. Even if it is an intrinsic tendency within the psychological system, for some it could become a powerful disposition. They used to call it “nervousness” by virtue of the anxious person’s overly sensitive nervous system, reacting without any substantial instigating cause. Anxiety responds to anything and everything, which is the problem. It has no end or outside, which must somehow be constructed.

In fact, when anxiety does develop into a phobia or panic attack proper, it is more easily treated. At least then there is an object of fear or a climax to an anxiety, which otherwise tends to feel diffuse and infinite. Logically, the extreme poles of anxiety are agoraphobia, on the one hand, and claustrophobia, on the other, meaning one isn’t happy where one is, inside or outside, alone or with others, since one cannot get out of the steel jaws of the trap that is anxiety. Horror movies play on this feeling to the hilt.

Freud was always very worried about anxiety and its costs on one’s mental life. He refined his theory of anxiety from the beginning to the end of his work, and even changed his theory drastically late in the day, deciding that anxiety wasn’t the result of psychological defenses, but actually of their failure or absence. We would be less at the mercy of anxiety if we had better defenses and symptoms—such as repression, which makes us forget what is unpleasant, or phobias, which concentrate our anxiety in something symbolic, like spiders or public speaking. No spider, no anxiety. There is a reversal here, as Freud is making symptoms a kind of achievement. Symptoms, for Freud, are always creative psychic solutions, adaptations we can make use of in our artistic or scientific or other vocational endeavors. He actually called a certain kind of symptom formation without anxiety a “beautiful indifference.” This is what the anxious person can’t achieve.

We are also living in times that many have characterized as deeply anxious and insecure. Some psychoanalysts have pointed to what they call the breakdown of collective fantasies that helped shore up our defenses against anxiety—such as belief in God, or the American Dream, or the Enlightenment, or Prince Charming, and so on. In fact, what I see in my patients is that talk about anxiety and its many immediate palliative solutions function as a new religion. Anxiety and its solutions bring with them a whole host of new rituals—from the taking of supplements (more pills), to checking social media, to Facebook stalking even. Freud called these kinds of solutions to anxiety “crooked cures.”

In Freud’s very first attempt at discovering the cause of anxiety, he decided it was a result of what he called “coitus interruptus.” By this term, he meant to imply any stoppage of orgasm. It’s one of those moments in Freud, as when he thought that men menstruated out of their noses, when you think, Okay, he’s young, or maybe he was on a lot of cocaine. But Freud was linking two ideas for the first time: one was an understanding of our individual psyches and how they are structured, and the other was how this structure affects our relationships with others, especially in our intimate sexual relationships, and vice versa. First, Freud contrasts anxiety and orgasm: orgasm is the externalization of the drive in the outside world, what he called the ejection into the outside of the libido, while anxiety is the libido trapped on the inside, unable either to enter into thought or mental work, and take some form in the world, or to return to the body. Next, Freud says this internal failure of sexuality is mirrored in the outside world in a failure to achieve orgasm with our partners, to not surrender to sexual enjoyment. We were spoiling sex; we were leaving ourselves, and our partners, half-satisfied, and this mirrored an internal condition of bodily energy never really developing—into pleasure or into any definable mental content. This is the very stuff of anxiety.

Freud then takes this one step further (and this is what is ingenious): both of these failures, internal and external, essentially amount to a recognition of our separateness, our aloneness in our bodies, and our inability to achieve a unity or communal satisfaction with others. Anxiety is the truth of the infinite difficulty of sexuality and sexual relationships. This was the interpretation Freud was making of coitus interruptus: in this failed sexual encounter, a moment when our expectations are high, especially for some kind of experience of union, we realize how separate we really are. Anxiety!

It wasn’t until much later in his career that Freud really puts all of this together regarding anxiety, when he says that anxiety is always what it was when it first appeared in childhood: namely, separation anxiety. Children, Freud says, are not afraid of the dark, or even of strangers; what they are, in these moments, is longing for the primary care-taker who satisfies all their needs. The build-up of longing for the other—who takes care of me, makes me feel safe, provides me with pleasure—can tip into anxiety that must then be mastered, since we must, at least at some point, begin to take care of ourselves.

Dealing with anxiety, then, is part of developing our autonomy. What we see Freud doing here again is showing that this mastery must take place both internally and externally: not giving in to anxiety, but transforming the feeling of loss and aloneness into the ability to work (or if not that, then at least turning it into a definable symptom). This also means coming to tolerate the momentary absence of others, and perhaps even their eventual loss. As they say about relationships: either it ends badly because we break up, or it ends badly because one of us dies.

What separateness means for psychoanalysis is that even if it is a simple fact—we are irrevocably separate from one another and even from ourselves—separateness is still a major achievement, one we have to continually refine. We can do this work by ourselves or, to be less pessimistic for once, we can also work at it with others. We can do this so long as the parties involved understand the value, as well as the difficulty, of separation. Otherwise, we usually end up playing into the other’s fantasy and providing a crutch (co-dependence, anyone?).

It would seem that despite our hyper-individualistic, incest pornography-saturated world, or maybe in reaction to it, we are all having a lot of trouble with separation. Anxiety is a family affair. We miss our parents; and we miss whatever illusions they swathed us in; we miss feeling as though we did not have any real needs, and were gratified whenever we wanted something. We prefer this ideal fantasy and we see adult life and all its responsibilities as terrible and boring at best, and anxiety-ridden at worst: the injustice! Also, we are angry that sex doesn’t work out the way we thought it would.

But the problem here, or maybe even the solution, is that we anxious people do know the truth: we are all going to die alone, others do what they like, something in sexuality inevitably fails, who even knows what anyone is thinking, I don’t know what I want, I don’t know how to give you what you want, and I certainly don’t know what is going to happen, between us, or at all. Anxiety is always the signal of a truth that is calling you. Which is why the psychoanalysts, in some sense, are celebrating the breakdown of our collective fantasies, hoping that we all make it through to the other side of this wall of anxiety, to what they like to call—a little cynically, maybe with some cruelty—reality.

Ambien

Sleeping pills are a good place to end, especially since the one truth in psychoanalysis that I think should be retained at all costs is the staggering value of dream life. This is something I think of as entirely democratic, since it is available to all, for free, and not just to those who happen to have stock in Pfizer. Sleeping pills kill dream life, both because they affect REM sleep (which is when you dream), and because one is often too groggy upon awakening to retain the memory of a dream. They also knock out the importance of preparing to sleep: the cessation of thought, the drawing inward, the letting-go of the day, in an act through which we create an intermittency in life.

Yes, sleep resembles death, and that is scary, but perhaps that is the point: it is about coming to terms with the fact that we can’t be awake forever, can’t keep thinking, acting, planning, wishing. We have to let our bodies rest. We need to close down our receptivity to perceptions or other sensations. We must allow the control exerted by consciousness to slacken. Sleep, we might say, is separation—from ourselves and from others.

“Dreams,” Freud famously said, “are the guardians of sleep.” Which often makes many ask about the dreams, or rather nightmares, that wake a person up. In a sense, nightmares for Freud are failed dreams insofar as the mechanism of distortion in a dream that disguises any distressing thoughts and feelings—what makes dreams nonsensical on the surface—has failed, allowing too much anxiety and fright. A dream is supposed to keep us asleep, preserve the state of paralysis in the body, absorb any external perceptions or sensations, and produce an imagistic narrative that is the equivalent of a hallucinated wish.

Every dream for Freud is a wish fulfillment, even when it is a nightmare—usually, the nightmare is a dream that is following the wish to master some terrifying experience or set of feelings. This is why there is much to be learned from one’s dreams. But this essay is not about the meaning of dreams; rather, we are concerned with the psychopharmacology that targets sleep. So why does someone become sleepless, or have difficulty falling asleep?

In a 1915 essay titled “A Metapsychological Supplement to the Theory of Dreams,” Freud speaks about how the relaxation of the ego throws us back onto the unconscious, which is what is expressed in dream life: “The stronger the Unconscious instinctual cathexes are, the more unstable is sleep. We are acquainted, too, with the extreme case where the ego gives up the wish to sleep, because it feels unable to inhibit the repressed impulses set free during sleep—in other words, where it renounces sleep because of its fear of its dreams.” By which he means, the more we haven’t made friends with our unconscious, the more dangerous it’s going to feel, and the more sleep will be affected.

At the extreme end, we can develop a phobia of sleep. And the most dire psychogenic disturbance of sleep is seen in the zombie-like conditions of depressives who never really sleep while sleeping all the time. The drawing-in of the libido necessary for falling asleep cannot take place because the mind, Freud says, is hemorrhaging. He called it the pain of a container with no bottom.

Enter the sleeping pill. But beware: as with laxatives and peristalsis, you will lose the feeling quickly for how to work in that place between the voluntary and involuntary.

There is something strange here. Freud describes sleep itself as a blissful state equivalent to narcissism. He describes this narcissism and its relation to dreams as the pure imagistic and auditory projection of an internal process, a veritable psychosis (in the contradictory logic of dreams and their madness), a series of hallucinated wish fulfillments (where all our dreams come true), and a relaxation of morality and rationality. Who wouldn’t want this? Why don’t we just sleep all the time? (In one article I’ve read, a psychoanalyst described the most severe addiction he ever treated as one of a patient who took sleeping pills during the day.)

In this case, if sleep and dreaming are so desirable, why have we become sleepless and restless, avoiding the moment when we can turn away from world, especially in a psychopharmacology of everyday life that seems to be looking for just this? I don’t know that I have a very good answer, but I suspect that if dreams are the royal road to the unconscious, then this must be worse than turning away from what is painful in the world. Facing the anxiety of meeting with our unconscious, we must prefer instead rules and rationality and dissatisfaction and oppressive authorities and wishlessness and imagelessness and memorylessness… I could go on.

Freud always said that the greatest resistance would be to the unconscious, maybe even to a greater extent than to death itself. This is why, in an apocryphal story of when he and Jung are on a boat for his one trip to the United States, to speak at Clark University in 1909, he turns to Jung and says, “Do they know that we are bringing them the plague?” In a 1917 article, Freud puts this another way, writing that he regards himself as one of those who, as the German poet Hebbel says, “disturbs the sleep of the world.”

It might sound as though Freud is a complete megalomaniac (and that I’m making a powerful pitch for myself on that score), but if it is true that we spend a third of our lifetimes asleep, wouldn’t it be better to think that it had some usefulness to the other two thirds of our lives, especially one that brings us closer to the truth, rather than just adopt some physiological explanation that leaves us, our minds, our lives, our histories, out of it? Wouldn’t it be better to think of this unmediated access to ourselves from inside as a gift—one that can even be material, to the extent that many psychoanalysts have noted how dreams can often show knowledge of an organic illness in the body before even our conscious selves or a doctor can?

Perhaps our penchant for pills, our restlessness, our desire for less pain, better sexual functioning, less emotional turmoil, is also a deep desire to get better acquainted with our unconscious life? And perhaps not. Last night, I dreamed of a one-eyed guinea pig—and I still haven’t figured out why, even though I’ve been doing this for twenty years now. And the night before, my partner and I had the same dream, after discussing wanting to have the same dream, which, in one sense, is uncanny, and, in another sense, is an unconscious joke—the unconscious likes to joke, and it’s oh-so-funny—except for the fact that what we both dreamed about was death in the form of the ashes of the other that we were forced to eat. Love and mourning as cannibalism. My unconscious added another joke to this joke: the ashes I was to eat were in the form of toast, which is itself an idiom for death. Ash toast: hilarious. But I had also just found out that my aunt, who lives in Ashville, was diagnosed with colon cancer. Sleep of death, indeed.

Even if I love my partner so much I have to dream of eating him, and also dream of him dead, since that would be easier than continuing to love him, when I wake up, and he’s still there, and I don’t eat him—but perhaps indulge in too much kissing, or eating, or other oral gratification—I am more aware of the gap between us. It is in this gap that the drive works, organizing my wishful fantasies into a dream that teaches me about the depths and cruelty and narcissism of my desires. Also, about tenderness. It’s funny to think of the illusion of dreams dispelling illusions—but that was Freud’s ingenious discovery, and also how he thought of the psychoanalytic cure.

The narcissism of sleep can cure actual narcissism since we can better reach out toward the world after experiencing and working through our worst narcissistic fears in dreams, especially injuries at the hands of others. Often, when a nightmare can return to a proper dream, to a dream full of wishes, with feelings other than fright, anxiety has been mitigated. Through a relaxation of our moral strictures and of our ferocious rationality, we will, in real life, be less severe with ourselves and others, and also more creative. Through the flawless projection of internal bodily processes (this is what a dream is), these processes return to themselves, able to work on their own, in their own time, in their own space: an organic movement from body to psyche and back. Psychoanalysis harnesses these effects.

This “getting to know your unconscious” is not a quick fix. The pills will be easier, for a time, and I understand that—I’ve taken plenty of them, too. But there is so much more to be gained in psychoanalytic work, which I’ve witnessed, in myself, and in my patients.

Perusing Freud for this piece, I stumbled upon yet another of his scathing remarks about America—this time in relation to sleeping pills, in his work The Future of an Illusion, in which he engages with an imaginary interlocutor on the question of religion:

It is certainly senseless to begin by trying to do away with religion by force and at a single blow. Above all, because it would be hopeless. The believer will not let his belief be torn from him, either by arguments or by prohibitions. And even if this did succeed with some it would be cruelty. A man who has been taking sleeping draughts for tens of years is naturally unable to sleep if his sleeping draught is taken away from him. That the effect of religious consolations may be likened to that of a narcotic is well illustrated by what is happening in America. There they are now trying—obviously under the influence of petticoat government—to deprive people of all stimulants, intoxicants, and other pleasure-producing substances, and instead, by way of compensation, are surfeiting them with piety. This is another experiment as to whose outcome we need not feel curious.

It is a nice reminder that psychoanalysis has little desire to take on your medications with any sense of piety. Rather, we hope for better, sturdier pleasures—earthly ones, in this lifetime. Freud said he wanted us to take this step, and, quoting the German writer and poet Heinrich Heine, to leave heaven “to the angels and the sparrows.”