The return of reefer madness

The U.S. drug czar's office is running ads implying that smoking marijuana can lead to insanity. But pushing dubious science is no way to persuade teenagers not to do drugs.

By Maia Szalavitz

Topics:Mental Illness

Parents who read the New York Times or Newsweek this past summer could be forgiven for freaking out when they came across a full-page ad warning them about the effects of marijuana on their teenagers. If the kids were off somewhere sparking up a joint, the federally funded message seemed to say, they were at risk for severe mental illness. Were those parents hallucinating, or was Reefer Madness, long since debunked, suddenly a real problem to be reckoned with?

The latest salvo in the never-ending war on drugs, the ads, which also ran in magazines like the Nation and the National Review, bore a stark warning. Under the headline “Marijuana and Your Teen’s Mental Health,” the bold-faced subhead announced: “Depression. Suicidal Thoughts. Schizophrenia.”

“If you have outdated perceptions about marijuana, you might be putting your teen at risk,” the text went on. It warned that “young people who use marijuana weekly have double the risk of depression later in life” and that “marijuana use in some teens has been linked to increased risk for schizophrenia.” It followed with the sneering question, “Still think marijuana’s no big deal?”

The rhetoric is alarming. But the research data used to support the ad campaign is hazy at best. Though carefully worded, the campaign blurs the key scientific distinction between correlation and causation. The ad uses some correlations between marijuana use and mental illness to imply that the drug can cause madness and depression. Yet these conclusions are unproven by current research. And several leading researchers are highly skeptical of them.

Scare tactics in the war on drugs have been around at least as long as Harry J. Anslinger, the federal drug warrior of the 1930s famed for his ludicrous pronouncements about the dangers of marijuana. But they’re widely regarded as ineffective in deterring teen drug use. In fact, some research suggests they may actually increase experimentation. If anything, experts say, the latest ad campaign’s overblown claims could damage credibility with teens, undermining warnings about other, more dangerous illicit substances. With medical marijuana a matter of renewed national debate, and with evidence emerging that there may be no connection between marijuana and lung cancer — a key strike against the drug’s use in the past — the government’s new campaign smacks more of desperation than science.

Spearheaded by the Office of National Drug Control Policy, better known as the “drug czar’s” office, the ad campaign ran in print during May and June; it continues today on the federal government’s Web site, Parents: The Anti-drug. There are plans to roll out more print, television and radio ads, according to an ONDCP spokesperson, if Congress approves the agency’s current $150 million appropriations request this month.

At the press conference launching the mental illness campaign in May, the Bush administration’s drug czar, John Walters, emphasized, “New research being conducted here and abroad illustrates that marijuana use, particularly during the teen years, can lead to depression, thoughts of suicide, and schizophrenia.”

While the launch was attended by a former director of the National Institute on Drug Abuse, the current occupant of the office, Dr. Nora Volkow, did not attend or speak, nor did her deputies. This is unusual: The National Institute on Drug Abuse is the federal agency responsible for scientific research on the medical effects of drugs, so a campaign about marijuana’s health effects would ordinarily feature at least one top representative discussing the science. The agency’s name does not appear on the list of organizations endorsing the ad.

David Murray, special assistant in the drug czar’s office, says that the National Institute on Drug Abuse was “involved in every aspect” of the planning of the campaign and “cleared and vetted” the statements in the ad and on the Web site. He says the drug czar’s office didn’t want to include more than one federal agency in the endorsements, adding that Volkow was out of the country at the time of the launch.

“Our research provides most of the evidence undergirding the campaign and we certainly support its goals,” says Dr. Wilson Compton, director of the Division of Epidemiology, Services and Prevention Research at the National Institute on Drug Abuse. But Compton concedes that the findings cited in the ad are “not completely established” and that experts consider them “controversial” and worth further investigation.

According to Murray, the latest available data shows that the consumption of cannabis is a key risk factor for the development of serious mental illness. With regard to schizophrenia, the campaign cites one study of nearly 50,000 Swedish soldiers between the ages of 18 and 20, published in the British Medical Journal in 2002, which found that those who had smoked pot more than 50 times had a rate of schizophrenia nearly seven times as high as those who did not use marijuana at all.

The American Psychiatric Association is one of the major groups backing the campaign; a spokesperson referred to part of the group’s policy statement as the reason for its endorsement: “The American Psychiatric Association is concerned and opposed to the use of drugs and alcohol in children.”

Yet leading experts in psychiatric epidemiology (whom the APA recommended contacting, but who do not officially speak for the organization) are far from convinced about causal connections between marijuana and serious mental illness. One key problem, they say, is that it’s very difficult to determine whether pot smoking predisposes people to schizophrenia or whether early symptoms of schizophrenia predispose people to smoking pot — or whether some third factor causes some people to be more vulnerable to both.

In the Swedish study, for example, when factors already known to increase risk for schizophrenia were removed, such as a childhood history of disturbed behavior, the connection between marijuana use and risk for the disease was substantially reduced. Just one or two additional unknown influences could potentially wipe out the apparent marijuana-schizophrenia link, according to Dr. William Carpenter, a professor of psychiatry and pharmacology at the University of Maryland. Carpenter noted in a letter published in the British Journal of Psychiatry in October 2004 that the same genes that predispose someone to schizophrenia might also predispose them to substance abuse, but that drug use might start earlier simply because many people start using drugs in their teen years, while schizophrenia most commonly begins in the early 20s.

Perhaps the strongest piece of evidence to cast doubt on a causal connection between marijuana and schizophrenia is a long flat-line trend in the disease. While marijuana use rose from virtually nil in the 1940s and ’50s to a peak period of use in 1979 — when some 60 percent of high school seniors had tried it — schizophrenia rates remained virtually constant over those decades. The same remains true today: One percent or fewer people have schizophrenia, a rate consistent among populations around the world. This is in stark contrast to studies linking tobacco smoking with lung cancer, where rises in tobacco use were accompanied by rising rates of lung cancer.

“If anything, the studies seem to show a possible decline in schizophrenia from the ’40s and the ’50s,” says Dr. Alan Brown, a professor of psychiatry and epidemiology at Columbia University. “If marijuana does have a causal role in schizophrenia, and that’s still questionable, it may only play a role in a small percent of cases.”

For the tiny proportion of people who are at high risk for schizophrenia (those with a family history of the illness, for example), experts are united in thinking that marijuana could pose serious danger. For those susceptible, smoking marijuana could determine when their first psychotic episode occurs, and how bad it gets. A study published in 2004 in the American Journal of Psychiatry of 122 patients admitted to a Dutch hospital for schizophrenia for the first time found that, at least in men, marijuana users had their first psychotic episode nearly seven years earlier than those who did not use the drug. Because the neurotransmitters affected by marijuana are in brain regions known to be important to schizophrenia, there is a plausible biological mechanism by which marijuana could harm people prone to the disorder. Both Brown and Carpenter say that people with schizophrenia who smoke pot tend to have longer and more frequent psychotic episodes, and find it very difficult to quit using the drug.

Of course, the U.S. government’s current ad campaign targets a much broader population than those highly vulnerable to schizophrenia, fanning fears based on a statistically rare scenario.

The campaign also declares that today’s pot is more potent than the pot smoked by previous generations, implying heightened risk. Fine sinsemilla may seem more prevalent than ditchweed nowadays, but there is debate over whether today’s average smoker is puffing on stronger stuff than the average stoner of the 1970s, as Daniel Forbes detailed in Slate. And, as Forbes showed, the drug czar’s office has grossly exaggerated the numbers on this issue in the past.

Meanwhile, UCLA public policy expert Mark Kleiman has pointed out that federally funded research by the University of Michigan shows that since the 1970s the level of high reported by high school seniors who smoked marijuana has remained “flat as a pancake.” In other words, even if today’s kids are smoking more potent stuff, they don’t get higher than their folks did — like drinking a few whiskey shots rather than multiple mugs of beer, they use less of the good stuff to achieve the same effect.

With regard to depression, evidence of a causal role for marijuana is even murkier. In general, depression rates in the population did rise sharply during the time period in which marijuana use also skyrocketed. But there were so many other relevant sociological factors that marked the last half of the 20th century — rising divorce rates, the changing roles of women, economic shifts, and better diagnoses of psychiatric conditions, to name a few — that scientists have rarely focused on marijuana as a potential cause for the increase in depression.

Murray maintains that scientists have simply overlooked marijuana in their search for explanations. One study published in the Archives of General Psychiatry in 2002, by New York University psychiatry professor Judith Brook and several colleagues, found that early marijuana use increased the risk of major depression by 19 percent. But that’s not a substantial amount, according to Brook. And though the association remained after other factors were controlled for, such as living in poverty, it weakened further. “I wouldn’t say that it’s causal,” Brook says. “It’s an association. It appears to contribute.”

The campaign selectively uses another piece of data, citing an Australian study published in the British Medical Journal in 2002 to assert that for teens, weekly marijuana use doubles the risk of depression. What that study found was that the risk doubled for teens who smoke marijuana weekly or more frequently. And it found that depression rates increased substantially in girls but not in boys. It also noted that “questions remain about the level of association between cannabis use and depression and anxiety and about the mechanism underpinning the link.”

Moreover, a June 2005 study by researchers at University of Southern California, using the Center for Epidemiologic Studies’ Depression Scale, found that marijuana use was in fact associated with lower levels of depression. Because the research was conducted using an Internet survey, it’s possible that the most severely depressed people did not participate; nonetheless the study of more than 4,400 people found that both heavy pot smokers and moderate users reported less depression than did nonusers.

Dr. Myrna Weissman, a psychiatrist and leading epidemiologist of depression at Columbia University, sums up the current research and her view of marijuana’s role in depression rates this way: “I can’t imagine that it’s a major factor.”

The distortion of science under the Bush administration is, of course, nothing new.

“This is just more red-state culture-war politics,” says UCLA’s Kleiman, of the latest anti-marijuana campaign. He notes that since the government measures success in the war on drugs by a reduction in the number of drug users — rather than by declines in drug-related harm or addiction — marijuana is the obvious drug to go after. According to the most recent National Survey on Drug Use and Health from 2003, approximately 25 million Americans reported using marijuana over the previous year; compared with approximately 6 million users of cocaine and 1 million users of methamphetamine — both far more addictive substances — marijuana is a big, soft target.

Yet, for a public desensitized to fear-mongering antidrug messages, a campaign touting selected statistics from tenuous studies seems especially tone deaf, if not irresponsible.

“If I tell my 15-year-old that he’s going to have a psychotic episode if he smokes pot, but he knows that his older brother already smokes pot and is fine, is he going to believe me when I tell him that methamphetamine damages the brain?” asks Mitch Earleywine, an associate professor of psychology at the State University of New York at Albany, who coauthored the USC study. Amphetamine psychosis is an established effect of taking large doses of that class of drugs; warnings about it appear on the labeling of prescription amphetamines. “What’s going to happen,” says Earleywine, “is we’re going to lose all credibility with our teens.”

The drug czar’s office may soon face a full-blown credibility problem of its own regarding its fight against marijuana. Drug warriors have always had at least one powerful argument to fall back on when other attacks against marijuana seem to go up in smoke — but in the face of a new study, that may no longer be the case.

Previous research has pointed to the notion that smoking marijuana could cause cancer, the same way tobacco smoking has been incontrovertibly linked with cancer and death. The Institute of Medicine, charged by Congress with settling scientific debates, said in its last major report on the subject in 1999 that the fact that most users smoke marijuana is a primary reason to oppose its use as medicine.

But that reasoning was called into question in late June, when Dr. Donald Tashkin of the UCLA School of Medicine presented a large, case-control study — of the kind that have linked tobacco use with increases in lung cancer — at an annual scientific meeting of the International Cannabinoid Research Society in Clearwater, Fla. Tashkin is no hippie-dippy marijuana advocate: His earlier work has been cited by the drug czar’s office itself, because his research showed that marijuana can cause lung damage. The new study, however, found no connection between pot smoking — even by heavy users — and lung cancer. In fact, among the more than 1,200 people studied, those who had smoked marijuana, but not cigarettes, appeared to have a lower risk for lung cancer than even those who had smoked neither.

The new research has not yet been peer reviewed, but it appears congruent with earlier studies that found no link between marijuana and increased cancer risk. If the data holds up to further scrutiny and testing, one can only speculate what new ad campaign the drug czar’s office might cook up. Marijuana may not make most people crazy, but this latest discovery could really drive the old drug warriors bonkers.

: Maia Szalavitz is the author of the forthcoming book "Tough Love America: How the 'Troubled Teen' Industry Cons Parents and Hurts Kids" (Riverhead, 2005). She has also written for the New York Times, Elle, Redbook and other publications. More Maia Szalavitz

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My friend is losing his mind

I wish I could help, but he's moved away and won't communicate

By Cary Tennis

(Credit: Zach Trenholm/Salon)

Topics:Since You Asked, Mental Illness

Cary,

A close friend is losing his mind. We’ve known each other since early childhood and might as well be family by now.

He is an artist, and lives up to many of the stereotypes. He is unrealistic and impractical. He is immensely gifted in a small number of areas and deficient in many more. He is self-absorbed.

These things have always been true, and more than tolerable, because he used to be a joy to be around.

Now he is depressed, paranoid and disturbingly misogynistic.

Two years ago he lost his job in the video game industry. The circumstances, as he relayed them, were cloudy. Given his great talents, he was surprised to find himself jobless.

He never really recovered. He became depressed, and his natural inclination toward isolation worsened considerably.

Although we were lucky enough to find ourselves in the same city after years of separation, by the time I moved there, he had retreated to his apartment. I could only find him there or at a particular coffee shop.

His dependence on weed and alcohol grew.

Along with all of this, he has become an ardent misogynist. That would bother me anyway, but I am gay and many of my closest friends are women.

It’s hard to say exactly where the misogyny comes from. It’s also hard to say what relation, if any, it has to his loss of employment. But his depression, paranoia and misogyny have all worsened at about the same rate, and become especially noticeable after his termination.

I’ve tried to be a good friend to him. I’ve been patient with hateful emails excoriating myself and other friends for mostly imagined crimes, as well as many links to anti-woman garbage he’s found on the Internet. I try to calmly brush that stuff aside while still providing some kind of interaction. He’s closed his Facebook account and will not answer phone calls, so we primarily communicate through email.

He has also moved back home, leaving the city we both love.

So there is a lot going on.

At times I’ve been worried he might harm himself. When his emails grew particularly grim and vile, I called his mother and expressed my concerns. She assures me he is doing “much better” and further that he is seeing a therapist on a regular basis.

And yet, he has declined to see me or anyone else over the holidays. He has not answered phone calls, emails or texts. And based on our most recent exchanges, I would say he is not better at all.

I no longer know what to do. He is at home under the care of his parents. He is (I think) seeing a therapist. It is out of my hands but I feel strongly that he is not better and may pose a risk to himself, a risk that his parents do not see.

I am at a loss.

Yours,

A Friend

Dear Friend,

You would like to do something but do not know what. There are a few simple facts that it helps to keep in mind. One of them is that you have no power to fix this person’s mind. It is wise to remain vigilant and to keep in touch, so that if he makes a suicide attempt or begins to make threats to others, you can take action. But right now, you are in the unenviable position of standing by and watching.

As an advocate, you can watch and if he leaves therapy you can urge him to continue. If he is on medication you can urge him to continue the medication. You can advocate for stability and long-term commitment to treatment. You can be a voice for sticking with it and weathering the storms. You can advocate politically for more mental health services. You can donate to places the provide such services. And you can get support for yourself through groups that help family members and friends of the mentally ill.

I am convinced that some of our tragedies, in a statistical way, would be averted if public policy favored more public mental health services. It wouldn’t stop all the terrible things that people in violent, unbalanced mental states commit, but every now and then, if more mental health services were available in more towns and neighborhoods and if more individuals found it easy to say, you know, it looks like you’re having some mental health issues and here is a good place to go for help, every now and then some awful and unnecessary tragedy would be averted. Every now and then, some prison cell would not be filled; some car would not turn over; some judge and some lawyer and some public defender and some families would not have to go through the tedious and grinding administration of justice that follows an act of violent madness. Every now and then the money we spend on greater availability of mental health services would pay off.

And likely nobody would notice because nothing would have happened. Life would go on as it had been, and now one would look up and say, gee, nobody’s shot up the Carl’s Jr. here in, like, 10 years. Isn’t that nice? Nobody would say, gee, there are fewer depressed people and fewer living on the edge and fewer threats being made to the mayor. Nobody would notice except researchers who keep records of such things and correlate them with public health policy.

So that is one side of it. My opinion is that as a society we are very lucky to have the mental health services we have, but we could have more, and we could be more open about mental health and mental illness, and we could treat it more like other illnesses of the body. For instance, there are certain acts that are just out of bounds and if you perform one of these acts the state will act precipitously. For instance, if you steal something. Acts against property or against a person’s body get the attention. But in this other realm, the realm of the mind or the spirit, acts against our own spirit or the spirits of others do not get the same attention. And in certain ways that is a good thing. I am a bit of an absolutist about free speech and creative speech. At the same time, there is a kind of violence to the spirit that does not get the attention of the courts until it manifests in a shooting or a stabbing, and that is sad and unfortunate.

So how do we as individuals respond when we see someone slipping into madness? What can we do? Most of us, as individuals, aren’t equipped to heal mental illness. And even if we are mental health professionals, we can’t just randomly shoot people with sanity guns. We can’t force them to pursue the courageous and difficult path of therapy, lifestyle change, deep personal reflection, meditation and/or drugs that may lead to a better life. We can’t reach out and cure people.

We can’t inoculate them. Although in a way we can. I mean, for certain people who are already not doing well, a precipitating event such as job loss might be met, in an enlightened, generous and wealthy society, by elaborate and vigorous mental health intervention. It might. And we might thereby be spared a certain amount of social madness and its sometimes tragic results. Maybe.

So there is a lot you can do, but there is also a limit to what you can do.

In the end, there is just you, seeking peace and serenity in a turbulent world, wishing and perhaps praying that your friend gets better, keeping vigilant watch, advocating for consistent care, and marveling at the beauty that remains.

Cary Tennis is Salon's advice columnist. His latest book is "Citizens of the Dream: Advice on Writing, Painting, Playing, Acting and Being." He leads writing workshops and creative getaways, and occasionally tweets and bellows as @carytennis on Twitter.

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Therapists revolt against psychiatry’s bible

Mental health professionals say new diagnoses will lead to overmedication

By Rob Waters

Your mental illness defined here

Topics:Mental Illness, Psychology, DSM-5

Anyone who’s ever tried to get reimbursed by a health insurance company after seeing a psychiatrist or psychotherapist, or taking a child or teenager to one, has no doubt noticed the incomprehensible numbers that appear on the clinician’s statement, perhaps preceding some slightly less imponderable phrase.

Maybe you are a 296.22 (major depressive disorder, single episode, mild) or a 300.00 (anxiety disorder NOS–not otherwise specified). Hopefully, you are not a 301.83 (borderline personality disorder). Your kid might be a 313.81 (oppositional defiant disorder) or, more likely, a 314.01 (attention deficit hyperactivity disorder, predominantly hyperactive-impulsive type).

Since 1952, a tome called the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM, has been reducing to a few digits the psychological malady said to afflict a patient. This bible of mental health treatment, published by the American Psychiatric Association (APA), provides a list and description of every mental health condition known to—or invented by—psychiatry, from histrionic personality disorder (301.50) to transvestic fetishism (302.3).

Over the decades, the manual, adapted from a guide for mental diseases developed by Army and Navy psychiatrists, has ballooned. The number of listed disorders tripled to nearly 300. A few have been discredited and dumped along the way. Most famous were battles over the inclusion of homosexuality. Successive iterations of the manual listed homosexuality as a “sociopathic personality disturbance,” then modified that to describe a more limited “sexual orientation disturbance” among people who were “in conflict with” their attraction to people of the same sex. That was later replaced by a disorder called “ego-dystonic homosexuality,” applied to those whose homosexual arousal was a source of distress. That item was dropped in the DSM-III-R, published in 1987.

The great book’s coming edition, the DSM-5, is slated for publication in May 2013. As the task force producing it has posted drafts on its website, an undercurrent of dissatisfaction has exploded into a full-scale revolt by members of U.S. and British psychological and counseling organizations. The chief complaint is that the newest version will lower the criteria needed to diagnose some conditions, creating “subthreshold” disorders, and generally making it easier for healthcare professionals to label a person with a psychiatric disorder and medicate him or her.

The latest rebellion against the DSM-5 began with a salvo from across the Atlantic. In June, a special committee of the British Psychological Society complained in a letter to the APA that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences.” The committee criticized the proposed creation of an “attenuated psychosis syndrome”—a sort of poor-man’s psychosis with less severe symptoms—“as an opportunity to stigmatize eccentric people.” They also objected to a proposed reduction in the number of symptoms needed to diagnose adolescents with attention deficit disorder (ADD) because it might increase diagnoses and the use of meds.

Then David Elkins, professor emeritus at Pepperdine University and president of the Society for Humanistic Psychology, a division of the American Psychological Association, formed a committee to discuss similar objections and draft a petition enumerating them. In October, he posted the petition online. “I figured we’d get a couple hundred signatures,’’ Elkins said.

The response stunned him and his colleagues. The petition attracted more than 6,000 signatures in three weeks; as of mid-December it had topped 9,300 signatories and garnered the endorsement of 35 organizations. On Nov. 8, American Counseling Association president Don Locke jumped in with a letter to the APA objecting to the “incomplete or insufficient empirical evidence” underlying the proposed revisions and expressing “uncertainty about the quality and credibility” of the DSM-5.

“This has become a grassroots movement among mental health professionals, who are saying we already have a national problem with overmedication of children and the elderly, and we don’t want to exacerbate that,” says Elkins.

For many critics, Exhibit A is childhood ADD. As the disorder describing fidgety, easily distracted kids morphed from “hyperkinetic reaction of childhood” to the current “attention deficit hyperactivity disorder,” the number of children given the diagnosis exploded, fueling, by one account, a 700 percent increase in the use of Ritalin and other stimulants in the 1990s. Diagnosis requires checking six of nine boxes from a list of symptoms that include “often does not seem to listen when spoken to directly” and “often fidgets with hands or feet or squirms in seat.” Sound familiar, parents?

Two other newly proposed disorders singled out as problematic in the petition are “mild neurocognitive disorder” in the elderly and “disruptive mood dysregulation disorder” in children and adolescents. Both lack a solid basis in research and may fuel the use of powerful antipsychotic medications, which cause weight gain, diabetes and a host of other metabolic problems, the petition says.

“We are gravely concerned that if this is published as is in 2013, it will create false epidemics where hundreds of thousands of children and the elderly who really are normal will be diagnosed with a mental disorder and given powerful psychiatric medications that have dangerous side effects,” Elkins says. “That is not tolerable.”

David Kupfer, the University of Pittsburgh psychiatrist who chairs the task force overseeing the manual’s preparation, says he expects the final number of disorders included in the DSM-5 to be about the same as in the current book. He says he welcomes the criticism and that nothing is final. The task force has been testing proposed new diagnoses in 2,300 patients at seven adult treatment centers and four adolescent centers that are acting as field-test sites, he says.

“There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made,” he says. “Just because [things have] been proposed doesn’t necessarily mean they’ll end up in the DSM-5. If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward.”

The most surprising critic of the DSM is a one-time pillar of the psychiatric establishment. Allen Frances, professor emeritus at Duke University, chaired the task force that created the DSM-4. Now he’s railing against both the process and proposed content of the new DSM in blogs on the website for Psychology Today that blast the new revision as “untested” and “unscientific.”

Psychiatric diagnoses are loose enough already, Frances told me, and that laxity has led to “epidemics of over-diagnosis in child psychiatry” causing huge numbers of children to be unnecessarily labeled with attention deficit disorder and bipolar disorder and treated with medications.

“DSM has to be a safe, reliable and credible guide to current clinical practice,” he says. “It can’t be an untested program for future research.’’

The user revolt against the DSM-5 has emerged as a major challenge to the document, Frances says, and its future is looking unclear. He and Elkins are proposing that an independent committee of experts review the proposed draft and make recommendations.

The fight over the DSM-5 pits some of the greatest minds and biggest egos in the world of psychiatry, but it’s more than a battle among 301.81s (narcissistic personality disorder). For people seeking help for life’s problems who don’t want to be labeled mentally ill or have their treatment limited to medication, and for clinicians who want to help people without reducing them to a category, the stakes are high.

: Rob Waters writes about health, mental health and science from his home in Berkeley, California. His investigative feature in Mother Jones, “Medicating Aliah,” examined pharmaceutical industry influence over prescribing guidelines and won the Casey Award in 2006. His articles have appeared in Bloomberg Businessweek, Mother Jones, Health, Reader’s Digest and other publications. More Rob Waters

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How PTSD took over America

The diagnosis is now being applied to everything from muggings to childbirth. An expert explains why it's bad news

By Alice Karekezi

(Credit: David Royal Hanson nando viciano via Shutterstock)

Topics:Health, Neuroscience, Mental Illness

In the past 30 years, post-traumatic stress disorder has gone from exotic rarity to omnipresent. Once chiefly applied to wartime veterans returning from combat, it is now a much more common diagnosis, still linked to traumatic events but now including those occurring outside the battle zone: the death of a loved one on a hospital bed, a car crash on the highway, an assault in the neighborhood park. Many would argue that this is a good thing: greater recognition of psychologically distressing events will lead to more people seeking treatment and a decrease in the preponderance of PTSD – a win-win.

Stephen Joseph disagrees. In his new book, “What Doesn’t Kill Us,” the professor of psychology, health and social care at the University of Nottingham (in the U.K.) warns that our culture’s acceptance of PTSD has become excessive and has led to an over-medicalization of experiences that should be considered part of ordinary, normal, human experience. This has kept us from proactively working through our grief and anxiety: We’ve become too quick to go to the shrink expecting him to fix us, rather than allowing ourselves the opportunity to grow and find new meaning in our lives as a result of painful, but common, events. Joseph advocates for a push toward post-traumatic growth as therapy to treat the stress of trauma, which he distinguishes as being different from the hokey, blue skies and rainbows, pop psychology that he claims has exploded in our culture in the past decade.

Joseph spoke to Salon over the phone to discuss our misunderstanding of the disorders, the meaning and usefulness of suffering, and if some cultures are more prone to PTSD than others.

How would you define a traumatic event? Is it subjective or are there some basic requirements that must be met?

I see trauma as a psychological rupturing. It’s when something happens to us that ruptures our psychological skin. Or, something which shatters our assumptions about ourselves in the world. That’s what I think of as traumatic, and in a way that can be many things. So, that can include a wider range of experience, and I can understand trauma in that broader way. There are lots of different experiences, such as being in a road traffic collision, or experiencing an illness – those sorts of things can be traumatic to people. It can be experienced as psychologically traumatic. But whether it’s necessary to create a psychiatric diagnostic category to capture those experiences is perhaps not necessary.

Do you believe that PTSD is over-diagnosed?

Well, that’s a really, really tricky question to answer because in a way it’s diagnosed pretty much exactly as it’s described in the Diagnostic and Statistical Manual (DSM). So whether the definition of PTSD is too broad is a different question, if you see what I mean. When PTSD was first introduced in 1980, it was defined much more tightly. The gatekeeper criterion to the diagnosis was: Have you experienced a traumatic event? In 1980, it was defined in such a way that only people who had experienced an event that was really outside the range of usual human experience, [like] Vietnam or the Holocaust, had experienced the sorts of experiences that were thought to elicit PTSD. So if you experienced something like a car accident or a traumatic birth, then you couldn’t get a diagnosis of PTSD, because, by definition, you hadn’t experienced a traumatic event.

In 1994, the definition changed in such a way as to include other, broader experiences. Equally persistent was the person’s subjective experiences of what they thought was traumatic. When that happened, people who had experienced car accidents, traumatic births, what we would have otherwise thought of as more ordinary life events, insofar as they are not statistically unusual, could then be diagnosed as a having PTSD. So now we are in a position where lots of people are able to receive the diagnosis of PTSD. So it’s not that it’s being over-diagnosed in that sense. The difficulty or problem, if there is one, is whether, generally speaking – PTSD would be part of this – the DSM over-medicalizes human experience. Things which are relatively common, relatively normal, are turned into psychiatric disorders.

Can you describe some of the typical symptoms of PTSD?

When people experience trauma, when their assumptions about themselves and the world come crashing down, there’s often a period of avoidance. People just try to block out what happened. Switch off. Turn their attention to other things. That’s quite understandable. Then, over time, that gives rise to memories and emotions that come flooding in as the person sort of begins to try to make sense of what happened, and that can become so powerful and distressing that they have to push that away again and go back into a period of avoidance. So sometimes people go through that, periods of avoidance and intrusion. That seems to me as a healthy and adaptive way of working through something painful, emotionally painful, that has happened to us. So those are the experiences. PTSD is when those experiences become so overwhelming that the person can’t function anymore – at work, or school, or in their social life. It takes over so much. But otherwise the symptoms of PTSD are fairly normal, natural ways of dealing with adaptation.

It’s important to see those experiences as quite normal and natural. They are not symptoms of a disorder by themselves. They’re just the way that people deal with an upsetting event in order to be able to make sense of things and to move on. It’s only when they become so overwhelmingly intense that they might be considered a disorder. I think that’s where we get into the problem with what PTSD is: when people are going through that normal experience, but they see it as having a disorder rather than a normal process of adaptation.

That will diminish over time?

Exactly.

Is the emotional pain overblown in such cases?

The suffering is very real. We’re not saying that people don’t have difficult emotional experiences and aren’t suffering. What we’re saying is this is not necessarily a disorder that people are experiencing, and if people think like that, it can be very disempowering to them.

What is the detrimental effect of over-medicalizing these more common human experiences of grief and pain?

When we think of ourselves as suffering from a disorder in a medical sense, well we go to the doctor and we expect the doctor to prescribe whatever the medical treatment is. We’re not in the driver’s seat. We go along – we tell them [our] symptoms, they listen to us, they diagnose what the problem is, and then they work out what the appropriate treatment is. That’s the mind-set when we’re working within a medical framework and we think of ourselves as suffering from a disorder. We sit down in front of the therapist and we expect the therapist to be like a doctor – to be looking out for what the symptoms are so that they can make the correct diagnosis and prescribe us the right treatment. The language of PTSD invokes those ideas, and I think it’s those ideas that can be quite unhelpful at times. For what we’re talking about here, if it’s a normal, natural process, what’s really important is for the person to be in the driver’s seat for themselves – to make their own choices, their own decisions, because we’re dealing not with a disorder, but a battle within the person to find new meanings and new ways of understanding the world. That’s what they have to do. Nobody else can do that for them.

What is “post-traumatic growth”?

Post-traumatic growth is when people come out of trauma having learned new things about themselves and about the world and about their relationship with the world. People develop new philosophies of life. They develop new priorities in life. People learn an awful lot about themselves: their strengths; what they’re good at; having new respect for themselves. They sort of see their lives as divided into two halves: before the event happened and after the event happened. There is a clear demarcation. And they recognize that something happened to them that sliced their world in half in that way, and things for them are now completely different. How they lead their lives has been transformed – their priorities about life, their relationships.

I think one of the things that captures that the most [starts with] the idea that, sometimes, people lead their lives in a way that is dictated by external forces of status and wealth, which are very much big drivers in our capitalist society. We often, in our everyday lives, forget about the small things that are quite important – our relationships: remembering to nurture them, to look after the people around us, to be giving, to be compassionate. When traumatic events happen, people are often shaken back to reality, and remember what really matters to them. Often it is those other things – remembering somebody’s birthday; nurturing our friendships; looking after our parents, the people around us; really embracing our relationships; and letting go of a more materialistic outlook. People often describe it as getting back to who they really are, or feeling more true to themselves, or being more genuine or more authentic. Somehow the idea of the false self that people create around them is shattered, like Humpty Dumpty falling off a wall. The essence of who they are emerges.

Yes, becoming truer to oneself captures the idea very well. Realizing that life is short and sometimes there isn’t as much time left as we thought to put up facades.

This kind of makes trauma sound like a blessing (you even mention people describing it as a “gift”). Is finding meaning the same thing as condoning the traumatic event? And doesn’t this talk of growth all sound very “kumbaya-ish” and unrealistic?

One of the reasons, sometimes, that post-traumatic growth can be seen unfavorably is that it seems like saying that trauma can lead to greater happiness; that for people who have been through trauma, it’s a good for them – they’re happier. That’s just so not the message. It’s not saying that trauma leads to happiness, in terms of smiling and feeling good and laughing and joy – not that type of happiness. What we’re talking about is how trauma can lead to a deeper, more existentially meaningful and fulfilling life, and that in turn may lead to greater happiness further down the road. But, post-traumatic growth is not about happiness in the sort of yellow, smiley face sense.

In essence, post-traumatic growth is a very simple idea, but it has been overshadowed by this mass of psychiatric literature over the past 30 or 40 years about the overwhelming destructive side of trauma, and about how these lead to medical problems. It’s a very simple idea, but [post-traumatic growth] sits, on the one hand, very uncomfortably within mainstream culture of the world of psychology and psychiatry, and on the other hand it seems to sit very comfortably with some other parts of Western culture, such as positive thinking, but it also clashes with some of that literature which is quite superficial, and not grounded in scientific research, and makes unsupported claims.

So, no, post-traumatic growth] doesn’t mean that [people] value or cherish the bad thing that has happened to them. They just accept that it has happened to them. People will often say they wish it hadn’t happened, or they wish they could go back, but there is a realism that they know they can’t. So it’s accepting that they can’t go back; they can’t change things. The only way forward is to go forward. It’s when people can’t accept that something has happened, and they [try] to go back to how they were before, is when they struggle. Acceptance is just being realistic – not seeing it as a good thing.

And someone not experiencing growth — or experiencing PTSD — is that person always trying to go back?

I think that often that’s what gets people stuck – trying to go back, trying to rebuild their lives exactly as it was before. That can lead people to get very stuck because it just isn’t possible when traumatic events happen and we’re presented with new information about the world, or with losses. It just isn’t possible to go back and make things as they were. We have to somehow accept what has happened to us and move on.

Is post-traumatic growth something completely in opposition to PTSD or post-traumatic stress? Either you have one or the other?

They can sit together. The way I see it, post-traumatic growth mostly arises out of post-traumatic stress. So it’s how people deal with the post-traumatic stress; how they manage to deal with the intrusive thoughts that are plaguing them; and the new sense they make of their experiences. So it’s through the post-traumatic stress, through the struggle of post-traumatic stress that post-traumatic growth arises. So often there’s a period of time in which people will begin to talk about post-traumatic growth but they will still be suffering from post-traumatic stress. They’re not in opposition. In a way, they are opposite sides of a coin.

You make a claim that true happiness is something that in and of itself cannot be pursued, and one is doomed to fail if one tries. How is that?

Well, that’s an idea that some philosophers have put forward. Some of the research seems to suggest that what’s really important to finding happiness is meaning and purpose in life. If we think our road to happiness is through seeking hedonistic pleasures night after night, then that’s not likely to lead to a deep, fulfilling level of happiness. But, if we find ways of finding meaning and purpose, wherever that might be, then we’re not setting out directly aiming for happiness but that’s what we’re going to get. We’re going to find a more fulfilling life. Happiness is a byproduct, but in a sense it’s more guaranteed.

When we think of psychological therapies, and the helping professions in general, they often have been about helping people feel better. [For] people with various problems of depression, anxiety or post-traumatic stress, therapy is about getting the person to have a more positive emotional state. That’s been, really, what the therapy world has been about for 50 years, and yet that’s only half the picture. The other half is about the meaning we put on things, our purpose in life, our sense of ourselves, our sense of autonomy, our relationships. Psychology can also be about those things. I’m not saying that therapists have ignored them altogether; for sure, they haven’t, but those more existential ideas have been overshadowed by trying to feel good. This is the idea between what psychologists call subjective well-being, which is about feeling good, and psychological well-being, which is what you could call “meaning-good,” and it’s just about getting the balance between those two things right.

Are there some cultures that are more prone to post-traumatic growth?

That’s a really good question. I don’t think the research has really documented that yet as to whether it may be more common. What the research has shown, however, is that post-traumatic growth is something observed in pretty much all cultures that have been investigated, though differently defined in slight ways. “Post-traumatic growth” sounds like a very Western idea, but [it’s one that] gets back into history and into all sorts of cultures. It’s an idea that’s very resonant with Buddhist and some Chinese philosophy ideas, as well as ideas in Western religion.

: More Alice Karekezi

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NPR celebrates crazy forum troll’s decision to practice unlicensed medicine in Libya

A young man with a history of paranoid writings and no combat or medical experience gets an uncritical interview

By Alex Pareene

Kevin Dawes (Credit: YouTube/Kevin Daws)

Topics:NPR, Media Criticism, Libya, Mental Illness

NPR’s “Morning Edition” profiles Kevin Dawes, a brave young American who went to Libya as a medical aid worker last summer, but who ended up taking up arms against pro-Gadhafi forces. It’s an inspiring tale of one man’s courage, and also one man’s possible mental illness. Because as numerous NPR commenters have pointed out, Dawes isn’t a “medical aid worker,” he’s an unbalanced Internet forum troll who taught himself rudimentary medicine on YouTube.

: Alex Pareene writes about politics for Salon. Email him at apareene@salon.com and follow him on Twitter @pareene More Alex Pareene

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Keira Knightley talks about Freud, Jung, Cronenberg and spanking

The one-time "Pirates" wench explains her new role as Carl Jung's patient -- and kinky S/M sex partner

By Andrew O'Hehir

Keira Knightley (Credit: AP/Joel Ryan)

Topics:Interviews, Mental Illness, Psychology

If it seems ludicrous to talk about Keira Knightley moving into a new phase of her career at the ripe old age of 26, it’s nonetheless true. Knightley was thrust into international stardom as an actress, model, cover girl and celebrated beauty at an extraordinarily young age; she was 13 when she played the Decoy Queen to Natalie Portman’s Queen Amidala in “Star Wars: Episode I — The Phantom Menace,” and 17 when she starred in both “Bend It Like Beckham” and the first “Pirates of the Caribbean” movie. Ever since then, Knightley has been a polarizing pop-culture figure, with millions of fans and seemingly just as many detractors. She has been promoted by lad-mags like Maxim or FHM as an object of fantasy and attacked by some feminists and Fleet Street tabloids, for essentially the same reasons: She is skinny and striking, she emanates poshness and upper-class privilege, she became very famous very young for reasons that had little to do with her acting.

But whether or not you believe Knightley was a competent actress at the beginning of her career, she is most definitely one now. Don’t take my word for it; put aside your preconceptions and consider her films since she walked away from the “Pirates” franchise — and, for all practical purposes, from big-budget Hollywood movies — in 2007: “Atonement,” “Silk,” “The Edge of Love,” “The Duchess,” “Last Night” and her heartbreaking performance in last year’s “Never Let Me Go,” which probably deserved an Oscar nomination it didn’t receive. (Her lone nomination came for “Pride & Prejudice” in 2006, and let’s table that debate for another time.) That’s a highly uneven list of movies, and I won’t claim that Knightley has an unerring instinct for picking winners. But she’s trying to carve out a new path in more idiosyncratic fare, and she displays more dramatic reach in each of those roles than in her entire career up to that point.

If you haven’t seen all those films (and not many people have), just go see Knightley as Sabina Spielrein, the mysterious woman who comes between Carl Jung (Michael Fassbender) and Sigmund Freud (Viggo Mortensen) in the “intellectual ménage à trois” of director David Cronenberg’s “A Dangerous Method.” (That movie has its United States premiere this week at the New York Film Festival, and opens in theaters next month.) Working with the meticulous and demanding Canadian filmmaker and two of the most acclaimed male actors of our time was surely its own kind of validation. But Knightley more than holds her own playing the Russian Jewish émigré who was Jung’s first analytic patient, then his mistress and collaborator. She later became a therapist in her own right, and helped shape Freud’s notion of the relationship between Eros, the sexual urge, and Thanatos, the death wish.

Spielrein was also the first prominent masochist in the psychoanalytic literature, and perhaps the first woman in history to articulate a desire to be spanked or beaten as an extension of “normal” sexuality. (One should be cautious about such proclamations; the Marquis de Sade predates her by more than a century.) Knightley’s performance is both ferocious and desperate; Spielrein comes to Jung’s clinic outside Zurich in a state of near-psychotic delirium, convinced that she was possessed by a demonic spirit. But eventually the power dynamic between them begins to shift, and she seduces him into a sadomasochistic sexual relationship, along the way becoming his and Freud’s intellectual peer. Yes, you will indeed see Knightley both spanked and whipped by Michael Fassbender in this film, but Cronenberg presents their encounters more in terms of clinical compulsion than steamy spectacle.

I’ve interviewed Knightley twice, and have found her extremely sharp, in all senses of the word. This conversation occurred in an anonymous hotel meeting room in Toronto, the day after the festival premiere of “A Dangerous Method.” (She admitted to being both hung over and jetlagged.) She’s an intense and focused talker, cordial enough but not especially funny. (I maintain she was miscast in the “Pirates” movies for exactly that reason.) Once she understood that I wasn’t going to ask her questions about her weight — she is undeniably thin but looked healthy to me — or her sex life, she warmed up considerably, and talked fluently about the history of psychoanalysis, Wagner’s Ring Cycle, masturbation and the ethics of filming a spanking scene.

You know, Keira, an hour after I saw the film, it occurred to me that Sabina Spielrein was a legitimate feminist hero. In terms of her intellect, in terms of her sexuality, in terms of what she represented, in every way. She should be on a postage stamp! Did you think about it that way?

Only latterly, actually. I didn’t really think of it from the feminist point of view when I was doing it. I should have. I don’t know why I sort of missed that. I was so busy trying to figure out what the fuck was going on in her head that I didn’t really see it from the outside point of view. But you’re absolutely right. I mean, what she achieved was absolutely extraordinary. And then there’s the fact that she was lost. She was working in a world where, you know — Freud gave her a footnote in one of his papers, but Jung absolutely didn’t.

No mention whatsoever.

Nothing at all. And the papers she wrote were absolutely extraordinary. I think she was the first woman to write a dissertation on schizophrenia. She was an extraordinary feminist hero, as you say. Or she should be. I don’t know whether she would have seen herself in those terms either, to be honest.

Probably not. There’s also the factor that she basically disappeared into the Soviet Union later in life.

She was in the Soviet Union, and then she was killed by the Nazis. So a lot of her work was lost. I’m telling you this now, and I’m probably going to get it wrong, but she opened up these really progressive child psychoanalytic centers — the white nurseries, or something like that — but at a certain point Stalin banned all psychoanalysis and it all stopped anyway. She was living in Rostov and kept on doing it in an underground way, but it had been banned. So a lot of her stuff disappeared because of the Communist period, but then, of course, because she was killed.

Did the Nazis kill her because they knew who she was?

I don’t think so. Again, I’m not completely sure about that, but she was rounded up with a lot of Jews who were living in Rostov and then shot. So I don’t know that it had anything to do with being a psychoanalyst. It’s an absolutely extraordinary story. I mean, a completely tragic one, but also one that I found incredibly inspiring. She was so troubled, so ill. They had totally lost hope, and I think she had lost hope. Before she got to the Bürgholzli institute [Jung's clinic], she’d been thrown out of asylums, because they said, “There’s no way, there’s nothing we can do.” So the idea that you’ve got somebody from that stage, who literally believed that she’d been possessed by a devil, and that through analysis you can pull out that intellectual side of her and stimulate it to the extent that she came up with ideas that influenced Freud and Jung, whether they gave her credit for it or not — it’s an extraordinary thing.

And she ends up getting totally scrubbed out of the picture.

Yeah, absolutely. It’s very much a story of its time. I don’t think women were allowed in higher education in Russia at that time, which was why a lot of them ended up in Germany or Switzerland, because they were being quite progressive about women’s education. So she was given the opportunity to do that, but within that society it was still very rare for women to be taken seriously intellectually. So it’s a fascinating period — and you’re right about that: It is once again the men keeping the women down!

From the first second we see her in the film, it’s pretty intense. She’s carried from a carriage having some kind of seizure, being restrained by two men, howling and grunting. Was all that in the script?

I mean, yes and no. In the script, it said: “Has hysterical fit and is ravaged by tics.” And you kind of go, OK, but what does that mean? So I read an awful lot trying to find descriptions of tics or why they happened. Even in Jung’s case notes for her, he didn’t describe what it was. He said her face was ravaged by them, but didn’t describe what they were. So I spoke to a couple of analysts, trying to figure out what it would be, and they basically said it could have been anything, tics come in all kinds of ways. So I watched a documentary on Tourette’s, to try to get some ideas from that. I asked David, “OK, do you want it in the body so you can shoot around it if it gets too much?” And he said, “No, I definitely want it in the face.”

So then I found an excerpt from her diaries in which she describes herself as a dog or a demon, and I thought, that’s such a fucking horrendous description, you know, to see yourself like that. That’s not in the script, and I thought that was incredibly important, to show that physically in some way. She was going through a shocking internal struggle, so I wanted it to be shocking on the outside too.

That’s what you’re doing with your jaw! That’s exactly it — she’s acting like a dog.

Well, I spoke to a psychoanalyst about what tics were, what they meant. Because she was masturbating a lot, and I wanted to know what the reason for that was, or the kind of compulsive sexuality, what the reason for that was. And this analyst said, “Well, it’s about trying to release energy, trying to get it out in some way.” So I thought that was interesting physically. I sat in front of my mirror for a couple of hours pulling faces at myself. Then I got on Skype with David and said, “OK, I’ve got a couple of options, which one do you like?” Right away he went, “That jaw thing, that’s great!”

I honestly wondered whether you had dislocated your jaw. It looks painful.

It looks like that, doesn’t it? It’s just trying to get at that demonic, animalistic thing. And to look as shocking as possible.

It works! Was that a state you could just get into on the set, or did you have to remain in character like that?

I’d sort of been working on it, on the text or the background reading, for about four months beforehand. We didn’t rehearse any of it, just me doing my own stuff. So I’d planned it. You’re playing mad, whatever that means, and the outside world may see it as illogical and totally crazy, but there was complete logic — as much as it’s a terrifying illness on the inside — to the way she behaved. So it was about trying to find that logic, going through the script and finding the trigger words, finding the exact moment when the tics would be triggered. That was quite interesting. So, um, yeah. [Laughter.] What was the question? Have I answered it?

Not yet. What did you do on set to get in character?

Because it was so prepared — there is an amazing thing about David’s sets. They’re so focused. It’s very quiet, it’s very collaborative, it’s incredibly supportive, but it is absolutely focused on the work. We only did one or two takes for absolutely everything, and he’s pretty much edited it in his head, so he didn’t even run the scenes all the way through. He’d go, “I know I’m only going to use the close-up for that bit, so we’re only going to run that bit.” It is an incredibly focused environment, though, so, no, I wasn’t in character the whole time, twitching! But I used music an awful lot, I was constantly listening to music and reading the stuff I’d found that was helpful. Stravinsky was used a lot, and Wagner.

I love the conversations about Wagner in the film! And that’s probably the only time I’m going to say that about a movie this year.

There’s actually very little about that in the film, but she was absolutely obsessed by [the redemptive warrior hero] Siegfried and the Ring Cycle, and it is fascinating reading. She had lots of dreams about it. She saw Jung as Siegfried, or thought Siegfried was going to be the son she would give him. She was really obsessed with it. I did listen to the whole Ring Cycle, that was really interesting, and I went to see some of it in Cologne.

To me, the Wagner stuff is like an aspect of her brilliance and an aspect of her madness, at the same time.

Absolutely, and that’s what I found so interesting about her. It’s so interlinked, the madness and the brilliance, as I think they so often are. Trying to figure out exactly when it turns into something more obsessive, something crazy — I don’t like the word but I don’t have another one — that was really interesting.

So let’s talk about the sex scenes in this movie, if we may. That’s certainly going to get a lot of attention, because you and Michael Fassbender are playing one of the first famous S/M relationships. It’s restrained and not all that salacious, but there’s no denying some people may find it arousing …

Yeah. I don’t know if they will, though. I mean, it’s certainly not shot like that, and that was one of the reasons why I thought I was all right doing that. I didn’t want it to be sexy, in that kind of voyeuristic way. David was very clear about that, it has to be a reflection of that brutality, that side of her. It has to be part of the character, and he wanted it to be clinical. Particularly in the age of the Internet and everything, you have to ask a lot of questions about whether it’s relevant, what the downsides and upsides are of doing something like that. I nearly turned it down because of that, and it wasn’t until I’d spoken to David to ask, “OK, what is this, and how are we doing it?” that I actually went, all right, I can do that as long as it’s not a sexy spanking scene.

At the same time, she was a sexual revolutionary, wasn’t she? To be able to “come out” about such a forbidden desire. It wasn’t something people talked about at all, except in a pornographic context. Certainly not in the context of being a legitimate sexual expression.

No. And part of the reason for hysteria among women — it was declining at that point, I guess — but it was only amongst women, and the thing with her was that nobody had explained the facts of life to her. She was an adult, but nobody quite knows when she was actually told about sex. It could have been after a lot of the analysis with Jung had already happened. She came from a family where any physical feeling among the girls was seen as being a sin, and being the devil taking you over. It’s an insane thing to think about! So yes, absolutely, it was completely revolutionary in that way.

She was very clearly a masochist, but speaking to psychoanalysts, they tell you that sadomasochism is always a circle, so the masochist is always looking for a sadist and will force people into that role, and even become the sadist themselves in order to form that circle. So I thought that was really interesting, the manipulation is strangely powerful. At the same time as she plays the victim, she’s creating these situations and manipulating them. There are these complex things, these opposites at work, which made an interesting dynamic.

Right. Well, there’s a psychological truism in the world of S/M that holds that the person who’s being spanked or tied up or whatever is actually the person in control of the situation. It strikes me that that’s how you guys played it.

Yeah, that’s the decision we took with it, and to me that’s more interesting than the other way around.

It’s never clear whether or not Jung is actually into it, or if she’s kind of dragging him along.

Yeah, it is ambiguous and we thought that was quite important. It was her thing, and not necessarily his. In all the research that I did, I’ve never seen that he was especially into that, although he was a very strong and controlling person, so it could have taken that path.

It seems to me, at least from the film, that he was in love with her but felt ashamed about many aspects of the relationship: the adultery, the S/M stuff, and not least of all the way he betrayed her.

I think there was definitely shame over the way he handled the whole situation and the fact that he denied it. He never mentions her, and beyond that 1913 point, she isn’t anywhere. Let alone any of her work being recognized, he doesn’t mention her at all, which is quite strange in itself, given that she was such a huge part of that period of his life.

Someone asked me an interesting question after we watched the film. On the first day, when she’s howling and seemingly inarticulate, Jung sits down behind her in a chair and starts to ask her questions, and she responds right away. Did that really happen? And how could it have worked so quickly?

I don’t think anybody had ever asked the questions before. That’s literally what happened, it’s all written down. Jung chose her very specifically. They knew she was frighteningly bright and was already interested in medicine and science. He picked her out. But I think you’re right, nobody had ever spoken to her about these things, it was completely revolutionary. So the idea of being asked about these things and not simply being told that you were a lunatic, you were sick, was probably something that would make you go [exhalation of breath]. You speak to people who have been analyzed, and in the same way that interviews can very easily become that kind of confessional thing, it’s a very weird experience when somebody actually asks you your opinion. Very strange things can happen.

It’s like he saw her as a potential intellectual partner — and maybe also as a potential lover — right away.

You know, Freud said that analysis wouldn’t work with stupid people, with people who hadn’t had an education. I don’t think that’s still what people think. But it’s what he said.

“A Dangerous Method” premieres this week at the New York Film Festival and opens Nov. 23 in major cities.