Foreword to The Withdrawal
What happens when the psych drugs disappear.
Dear Jules,
I’ve attached a draft of the foreword, although I must confess that I found it rather more difficult to write than I anticipated.
I have taken the liberty of being quite critical of certain aspects of the book, particularly where I think you have sacrificed scientific plausibility or ordinary human dignity to the demands of your narrative. I hope you won’t mind. You have written a profoundly disturbing novel, and I think it deserves a serious response rather than a merely complimentary introduction.
I am also conscious that the foreword has become rather more personal than I intended. And that it is an obvious work of two irreconcilable parts. The fact is that the book has unsettled me considerably, and I am not entirely sure that I have finished thinking about it. I think, though, that in this state the foreword will have to do.
Your offer of editorial freedom was very generous and I hope that it still stands. Please feel free to make any amendments where I have misrepresented the text either in whole or in part. Other than that I would prefer to have my opinions stand or fall on their own merits, especially where they differ from yours.
With my warmest regards,
Annie x
PS: I have been so bold as to suggest a counterfactual of my own towards the end, and that there may be a further book in it. To show my bona fides I will put money down for an advance copy☺
THE WITHDRAWAL
By P. Julian
Foreword by Dr Anne Barrett
I have spent most of my professional life attending to people who are suffering from some disturbance of the mind.
I have prescribed courses of psychiatric medication — both short term and long term — to many thousands of patients: sometimes with extraordinary success, probably more with results that I would prefer not to recall. I have seen lives restored by these medications. I have seen families reunited, people brought back from states of misery and chaos that would once have condemned them to permanent institutional care.
I have also seen people badly damaged by the very psychiatric medications that were intended to help them. Some of these injuries may have been unavoidable, some were definitely the consequence of honest mistakes, but there were many others that arose from medications whose directly antitherapeutic effects I now regard as unacceptable.
I mention these things because I am a psychiatrist, and because the book you are about to read is concerned with a calamity involving psychiatric medication, with consequences so far-reaching — even in what we naively call the real world — that a person like me was perhaps the only suitable person to introduce it.
The premise is simple enough. At a certain moment, without warning or explanation, every psychiatric medication in the world disappears. Not merely from pharmacies, hospitals and warehouses, but from the bodies of the people who have been taking them. Tablets vanish from blister packs and bottles, injectable preparations disappear from their syringes, and the active compounds already circulating in the blood and tissues of patients cease to exist. Even the manufacturing equipment, raw materials and industrial infrastructure required to produce them are destroyed or rendered permanently useless.
There is no explanation. The event is sudden, instantaneous and apparently irreversible. No evidence of divine intervention or extraterrestrial agency emerges, and although the early chapters are crowded with theories, no satisfactory account is ever established. The author does not trouble himself with the physical impossibility of what has happened, nor does he offer the reader the consolation of an explanation.
One moment the world possesses a vast pharmacological apparatus for treating mental illness, and the next it does not.
The consequences of this event are explored in extraordinary detail. Patients taking antidepressants, antipsychotics, mood stabilisers, sedatives and other centrally acting psychiatric medications find themselves abruptly deprived of drugs on which they may have depended for years or decades. Those who are vulnerable to discontinuation syndromes begin to experience them, some within hours and others over the following days. People whose illnesses have been held in remission begin to deteriorate, although their relapses follow different courses and cannot always be distinguished from the physiological effects of withdrawal. Some suffer greatly and recover. Others deteriorate beyond anything they have previously experienced. A substantial number seem scarcely affected at all.
Withdrawal is not the same thing as relapse. Nor is dependence synonymous with addiction, or symptom suppression necessarily evidence that an underlying illness remains unchanged. The effects of discontinuing psychiatric medications vary enormously according to the drug, dose, duration of treatment and characteristics of the individual patient. Abrupt cessation can be extremely dangerous in certain circumstances, while other medications can be discontinued without serious difficulty.
Nevertheless, the novel’s imaginative accomplishment lies not in its pharmacology but in the consequences it draws from the simultaneous withdrawal of treatment from many millions of people, against a background of mounting social panic and institutional collapse.
The book moves between episodes on a human level and descriptions of events on an almost inhuman scale. There is a beautiful and terrible passage describing an elderly man in Kyoto who has been taking medication for severe recurrent depression since the death of his wife. He discovers that his tablets have vanished and spends the afternoon telephoning pharmacies, hospitals and former colleagues, becoming increasingly agitated as he learns that the disappearance is universal. Eventually he sits down at the kitchen table and writes a letter to his dead wife, asking whether she knows what has happened.
The author describes one terrible morning in a city whose identity is deliberately withheld:
They fell down from the towers in the light of the sooty dawn. Falling both piecemeal and in flurries, as though the wind had shaken them loose. Amidst the terrible sound of falling bodies rainlike through the narrow streets, thudding against pavements and the roofs of cars and plastic rubbish bins put out so long before, tearing through the awnings of cafes and boutiques whose owners would not arrive to open them. With the people learning not to negotiate those streets but rather to flee from the city and the body fall that marked every street equally and the same.
This is appalling writing in the best literary sense. The imagery is accomplished, but I found myself recoiling from the aesthetic pleasure the author makes of it. Those bodies belong to people, and people do not become less worthy of dignity because they are numerous or because their deaths produce an arresting image.
There is a particularly effective chapter describing a large hospital whose psychiatric patients have been moved into an improvised ward in a basement car park. The staff have constructed partitions from bollards, bedding and whatever materials they can find. A young registrar, who has been awake for almost three days, is attempting to organise a roster when she discovers that the hospital’s chief executive has been admitted as a patient.
He has been receiving treatment for bipolar disorder for many years. He recognises the registrar immediately and begins instructing her on the management of the emergency.
His instructions are sensible, even brilliant, until they are not.
The registrar cannot determine whether she is witnessing the return of an exceptionally capable administrator or the emergence of an illness that is gradually compromising his judgment. The tragedy is that for some hours the distinction makes no practical difference. He is more useful to the hospital than anyone else in the building.
In city after city, individuals emerge claiming to understand the meaning of the disappearance. Some are people with established psychiatric disorders whose symptoms have returned. Others have no psychiatric history. Religious movements form spontaneously, sometimes under the direction of charismatic figures who appear to have undergone extraordinary spiritual transformations. Here is one description of a procession through the streets of what feels like a major South American city:
Every street corner seemed to have grown some wild-eyed prophet, and unto every such prophet his little company of penitents. Barefoot and wailing and dragging their sack-clothed frames through the narrow streets and gutters calling upon the very buildings to repent of their sins. Some carried children pot-bellied in their arms and old women were borne upon the shoulders of those still hale enough to bear them. Wherever they passed the crowds milled around them crying out in hope and fear such that it was no longer apposite to distinguish the mad from the holy even if due criteria could be uncovered. To tell prophet from pretender or to know who had simply lost his mind from fear.
Religious belief, even when extravagant, is not itself evidence of mental illness. Nor should we assume that a person who reports an unusual spiritual experience is necessarily suffering from a disorder. Psychiatry has historically been too willing to make such assumptions, particularly when a patient’s experiences offend the cultural or metaphysical convictions of the treating clinician. However, the point the book makes is wider than this: that under many conditions it can be completely impossible to tell whether a person is in some kind of religious ecstasy or merely experiencing an episode of mental illness.
I was raised by nuns who possessed an almost supernatural ability to make the ordinary business of childhood unpleasant. They also succeeded in extinguishing every part of my sympathy for organised religion. I spent the first half of my professional life dismissing spiritual experiences that I did not understand, and the second half trying to moderate that same tendency. Until I find myself at an age when one becomes much less impressed by the certainty of one’s own convictions, and where the pressing reality of death prompts a irrational person towards some consideration of what might come after.
The author is making a larger point here. When the pharmacological means of treating certain forms of psychological distress disappear, the world does not simply revert to some earlier and more natural condition. It generates new structures of meaning, authority and consolation. Some of these are humane and beneficial. Others are grotesquely exploitative.
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Time and time again I was reminded of Yeats’s The Second Coming, particularly the lines:
Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned…
And also the following lines, which express the malaise of our current society so very well: “The best lack all conviction, while the worst / Are full of passionate intensity.” A lack of passionate intensity is certainly something that this novel could never be accused of exhibiting.
There are biblical echoes too, most obviously rooted in the apocalyptic passages of the Gospels and Revelation. At one point the author invokes the terrible promise in Isaiah that the foundations of the earth will be shaken. Elsewhere the novel seems to enact the prophecy of Micah that a man’s enemies will be the members of his own household.
Children abandon parents who have become frightening or impossible to care for. Parents abandon children while fleeing imagined persecutors or attempting to secure food and shelter. Marriages collapse under the pressure of sleeplessness, relapse, poverty and fear and random outbursts of erotomania. Old resentments emerge with extraordinary violence.
One passage describes a mother travelling through the outskirts of a ruined city, searching for the daughter she believes has been taken from her:
The children had abandoned their parents and many parent had been cused to run from their children too. The streets were swollen with tiny people crying out for mothers rendered insensate who would never return, and the elderly calling the names of children who were not current children but only their own young selves in their childhood abandonment long ago. And plea passed unanswered to stack up against the rest, so that the whole city broke into a lost maze of abandoned relationships to which no person belonged but only longed for that connection that would never be restored to them.
The novel is at its best when it recognises these moral difficulties without resolving them. There is another chapter in which a teenage boy returns to his mother’s house after she has been taken away by an emergency psychiatric team. He discovers that she has prepared his school lunch and laid out his clothes for the following morning. She has also written a series of increasingly incoherent letters warning him that the neighbours intend to kill them both.
The boy eats the lunch, folds the clothes and places the letters in a drawer. Then he goes to bed.
Nothing more happens.
I thought this one of the finest episodes in the book.
It is important to know that this book is not anti-psychiatry, as challenging as the premise would seem. Some of the most plaintive episodes in this section concern people who are desperate to have their medication restored. Psychiatrists reading the text might find themselves moved by how desperately people wish to return to their former doctors and the treatments that had helped them.
One woman, who has experienced severe recurrent episodes of psychotic depression, travels several hundred kilometres in search of a hospital rumoured to possess a surviving supply of medication. When she discovers that the rumour is false, she sits on the steps of the building and weeps for what has been lost.
About halfway through the book the narrative begins to lose any conventional kind of structure. Characters introduced with great care disappear without explanation. Events recur in altered forms. Geographical distinctions become unreliable, and the author increasingly abandons individual stories in favour of enormous descriptive passages depicting the convulsions of cities, nations and entire populations.
At first I found this exasperating. I wanted to know what happened to the registrar in the hospital basement, to the teenage boy whose mother had been taken away, and to the woman who had travelled so far in search of medication. I wanted some account of the international response, of the efforts to develop substitutes, and of the eventual fate of the institutions that had survived the first weeks of the emergency.
The author offers almost none of these satisfactions.
Instead the narrative accelerates into scenes of escalating disorder. Vast migrations begin as populations abandon cities that can no longer sustain them. Religious movements collide with political authorities. Entire communities reorganise themselves around new forms of care, discipline or collective belief. Some appear to flourish briefly before collapsing into violence or exhaustion. As these things happen the language of the novel becomes increasingly elevated and declamatory, as though the writer himself has been precluded from access to the psychiatric medications that keep him sane.
In one of the fragmented final chapters the author describes a great procession moving through the ruins of an unnamed capital:
They came ferrying their bedrolls and their memories of their dead and they carried their infants and the tools of their trade and what little burnished charms and fetishes that had survived the foundering of the world. They came lamenting the loss of their minds or with their passions returning, their old afflictions flowered and new afflictions multiplied within them. Calling out querulous and hopeless to the emptied lands around them: who is it that has done this to us? For what purpose was it done? Who would render us naked, ashamed? Who would tear away the bolsters of our minds?
There are passages of considerable beauty in this final section, but also passages that seem almost wilfully excessive. The author appears determined to overwhelm the reader with images of destruction, suffering and religious frenzy, until the distinction between individual catastrophe and collective collapse becomes difficult to sustain.
The foregoing was written immediately after I had read The Withdrawal, and as I read it back now I see that too much of it comes from the standpoint of an insulted professional who has had her life’s work brought into question by a writer who could not even conceive of the burden that the role carries.
But there is enough of the scientist left in me to recognise that the plot of this book is really best seen as some kind of counterfactual intended to illuminate a question about psychiatry that most psychiatrists never consider.
It uses the mechanism of narrative imagination in order to ask the question: what damaging or pathological social conditions are being covered over by the fact that we now have such efficacious medication for the treatment of mental illness? Even if these medications do not completely cure the condition, they can provide significant symptomatic relief for people who are suffering.
The book dares to ask whether our treatment of mental illness is propping up or prolonging conditions of life that are hostile to human happiness and human flourishing. To what extent is mental illness not so much an illness as the direct result of an almost complete derangement in the conditions of society? And what could be done about it?
The question is a pressing one. If severe mental illness were suffered by a small and confined proportion of the population, then there would seem to be few societal consequences for treating and relieving the symptoms of that illness.
If, however, mental illness is suffered by a very large proportion of the population — and there can be no denying that this is now the case — should we not be looking harder at the root causes of the illness? Sheeting it home to a sick society rather than continuing to batter individual people with some theory that they have a broken brain?
These questions are regularly put by the social sciences without seeming to have much impact on our profession. They concern the pathologisation of distress by psychiatry and the damage caused by psychiatric medication, including whether that damage is disproportionately borne by women because of patriarchy and other power structures that routinely demean and patronise them.
This raises an even more troubling possibility. My long experience in the field has shown me that a huge range of what are in effect psychiatric conditions are not treated as mental illness at all. Rather they are misidentified as hormonal conditions that are treated by the widespread prescription of the birth control pill. If you include this population within the population of women who are suffering genuinely psychiatric symptoms it is not difficult to identify a catastrophic epidemic of mental dysfunction amongst women in the world.
Let me put it as plainly as I can. The book raises the (untestable) possibility that we live in a society so sick and so divorced from the needs of the human soul that we have had a catastrophic decline in our mental health. That comes with the allegation — again practically untestable — that psychiatry may be working the most appalling set of cruelties and deprivations that has ever been worked on human beings.
Again, we are limited to that as an imaginative supposition. But taking it seriously for one moment: is it possible that we would really see bodies falling from windows in our cities if the suppressive effects of psychiatric and birth control medication were removed? And if this is even a remote possibility: how do we go about moderating the practice of psychiatry in order to remove this social dampening effect so we can see just how bad things have become?
The tragic part of it is that these questions are unanswerable. We do not have the data and there is no way we ever will. All we have are imagined counterfactuals no matter how convincing they might be. But it may now be incumbent upon everybody who practises medicine — who has any impact upon people’s mental well-being — to consider the possibilities seriously, and begin at least to talk about our role in concealing how hostile society has become to the human spirit.
The book does make reference to at least one reason that psychiatrists may not be sensitive to these issues: the undeniable fact that they make enormous amounts of money and can lead lives of astonishing wealth and privilege. The psychiatrists I know occupy big homes in leafy suburbs, they travel the world in luxury and I have seen them luxuriate in the astonishing power they wield over their patients. The very people who should notice the deteriorating conditions of our society are completely cushioned against it.
What if their privilege could somehow be torn away and they could genuinely feel what it is like to be homeless, to be struggling with serious mental illness, to experience violence and exclusion and fear, what it feels like to sleep rough on the streets, not for just one night in those charity spectacles designed to make them feel virtuous? What if psychiatrists were forced to take Acuphase or be put into seclusion, if they were forced to take intramuscular antipsychotics and feel the deadening effects on their soul?
A book is just a book, no matter how impactful, and there is no way to teach those who luxuriate in wealth and privilege what it feels like to have that snatched away. The only way is to snatch it away. Perhaps if the world becomes a little bit more depraved and a little bit more disorganised and a little more horrifying, perhaps that will in fact reach even to the comfortable and the wealthy.
Perhaps. Perhaps. By the time that happens, though, the conditions of society will have become so degenerated that no good would come of the lesson. It would come far too late in the day to make any humane difference at all.
Dr Anne Barrett FRACCRU
Consultant Psychiatrist
Adjunct Professor of Psychiatry, Tintagel College
