The diagnosis and clinical management of various mental disorders are aided by knowing the predisposing, precipitating, and perpetuating factors in a given case. Both the themed album and the full-length movie of Pink Floyd’s, The Wall, depict these factors in the course of the main character’s—”Pink’s”— mental health deterioration through music and film. In this episode, we draw from selected songs on the album and from selected scenes in the movie connecting the three factors with particular behaviors Pink manifests. In the process, we show how they are used in medical education and training in real time.

Joining us is Dr. Anthony Tobia, who is the campus chair in the Department of Psychiatry at the Rutgers School of Medicine and is also the Service Chief of Psychiatry at Robert Wood Johnson Barnabas Health in New Brunswick, NJ. Dr. Tobia is certified by the American Board of Psychiatry and Neurology and is certified in internal medicine and psychosomatic medicine. He also holds a secondary appointment in the Division of General Internal Medicine at Rutgers. Dr. Tobia is the Director of Graduate and Interprofessional Education at Rutgers University Behavioral Health and has received the Outstanding Clinical Faculty Member Excellence Award in 2018 and 2019. He is an active contributor to the medical literature with publications, reviews, and abstracts. Dr. Tobia’s educational interests include the merging of popular culture and the field of behavioral medicine, which is evident from this episode and from his previous appearance on the podcast episode featuring The Who’s Tommy. Along with Dr. Tobia for this episode is Kevin Frederiks, who at the time of recording, was a fourth-year medical student at Rutgers.

Citations
For the recorded album: Pink Floyd. The Wall. Columbia Records, 1979.
For the movie: Parker, Alan, director. Pink Floyd The Wall. MGM, 1982.

Link
Please send us comments, recommendations, and questions here, or email to: ru***************@***il.com.

Thanks to Dr. Anthony Tobia and (by now) Dr. Kevin Fredriks for their interesting and insightful contributions to this episode. 

Thanks for listening, and please subscribe to The Clinic & The Person wherever you get your podcasts.

Web image by Russel Teagarden

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Why did you write this book?

I’m encountering more and more people over the last few years, particularly post-COVID, who have the perception that the categories we use in psychiatry have a kind of fixed, objective, and quite rigid reality. Twenty years ago, when I started as a GP, I might have seen somebody who said, “I feel anxious all the time,” whereas now I’m more likely to meet somebody who’ll say, “Well, I have generalized anxiety disorder.” That’s a shift in the way that society talks about mental illness. At the same time, a lot of people are questioning these categories’ usefulness, so there’s a paradox—a sort of polarization.

I wanted to write a book which explains, from my perspective, A, how the way we think about mental illness has always been shifting and evolving. How we think about mental illness changes with culture, time, and geography. And B, if we can adopt a more flexible and humble approach to our current understanding, that actually offers more hope to patients. Because believing “I have generalized anxiety disorder,” rather than “I feel anxious,” can sometimes be helpful, but it can also box you in and become self-fulfilled. I’m seeing that same shift across the whole spectrum of mental illness and suffering, and the book is a call to question that and reassess where we’re at in the mid-2020s—and a plea for a little bit more kindness and flexibility.

What would that look like in practice?

For example, if somebody comes to me saying, “Well, I have generalized anxiety disorder, so I can’t do this stuff,” part of my work is to help that patient adopt a more hopeful perspective: that there are strategies that they can learn, that there are medications that can help, and that our mind is shaped by many different influences. There may be explanations for their anxiety that have to do with the brain and neurotransmitters and so on. But in most people, there are also more influential factors that have to do with their early childhood experiences and their current social setup, the precarity of their relationships or their economic situation, the quality of their sleep, or the substandard nature of their housing. There are all sorts of other factors that are having a bearing on their anxiety that I would seek to help them explore, rather than them just blanketly saying, “I have generalized anxiety disorder—can you give me the pill for that?” I’m trying to encourage my patient to say, “Yeah, there are pills that can help. But there are all these other factors that we need to think about. And do I really find that label helpful?” For some people, once you start to dig into it, they don’t.

We can extend that way of thinking to people who’ve had a psychotic episode. Between 10% and 20% of people who have a psychotic episode will never have another. For substantial numbers of people, their psychotic episode is actually a product of all sorts of stressors that are on them at that time. If you can find a way to modify their stressors, put them in a more supported state, and understand what place that episode has in the story of their life, you can then make a story that makes sense of that episode as the product of a uniquely difficult moment in their life. That can help people get over that episode and also, I hope, make it more likely that they don’t have subsequent episodes. Or, if they do, then they’re able to return fully to their normal functioning in between.

You write, “For the last forty years much Western psychiatry has behaved… as if our thinking is a simple matter of chemical levels in the brain. The truth is far more complicated.” For example, a 2023 study you cite challenged the serotonin theory of depression. [1] Why do you think that the chemical imbalance narrative has persisted?

There’s a number of reasons. That hypothesis came through at a time when our lab technology was starting to be able to measure neurotransmitters, and it offered a good story. If you become depressed, you feel as if you’re lacking something—as if you’re lacking some kind of fuel or energy. That lack translates very easily, in our metaphor-making minds, to the idea that there must be some kind of lack between our brain cells.

At the same time that this technology was becoming widespread, there was the promotion of a drug which seemed to help: Prozac. There’s no doubt that SSRIs do make a difference. Again and again, they’re shown to be better than placebo. The effect is probably a lot smaller than a lot of the drug companies would tend to promote in their materials, but they do help, and I continue to prescribe them. But what that study you’re referring to was saying was that, even if these drugs help, they don’t help by boosting serotonin levels. We can’t find evidence that substantiates that theory.

The first half of the 20th century was governed by Freudian ideas. Psychiatry in much of the West was dominated by those kinds of psychoanalytic ideas. Then, during the ’50s and ’60s, as we started to develop tricyclic antidepressants and experiment with other kinds of antidepressants—the first were anti-tuberculosis drugs—the idea grew that there might be a chemical solution, which fit very well into our technologically and pharmaceutically focused medical culture. Then, from the late ’90s, there was a huge explosion of the idea that, actually, a lot of it was genetic.

Now, even the idea that neurotransmitters are strictly excitatory or inhibitory is starting to be questioned. Essentially, the whole picture is vastly more complicated than the neurotransmitter hypothesis from the ’90s suggested. I don’t take that as a great failure of the hypothesis; it was an attempt to make sense of something very complicated, and the drugs that spoke to that metaphor are useful and are still among some of the most widely prescribed in the world. But the fact that we no longer think that low mood is purely because of low serotonin is a really positive step forward. It encourages us to embrace more fully the biopsychosocial approach to mental illness. The field of psychology and psychiatry is not known for consensus, but one thing everybody agrees on is that it’s not just biology, it’s not just psychology, and it’s not just sociology—it’s all these influences that have an effect on our mental health.

Are there other common assumptions about mental illness that you think deserve closer scrutiny?

Every age uses the metaphor of its highest technology to make sense of the mind. In the 19th century, the mind was famously described as an enchanted loom; the mind was thought to be weaving our experience, moment by moment. We’ve now got these very pervasive metaphors of wiring, which I find quite unhelpful because the brain is nothing like a circuit board. It would be like a circuit board made of jelly that can fix itself. So I think the wiring metaphor, although it has its uses, has gone too far because it’s too deterministic. It’s not organic enough.

Half a century ago, Stanford psychologist David Rosenhan wrote, “A psychiatric label has a life and an influence of its own.” To what extent can psychiatric labels help, and to what extent can they hinder?

There’s a lot of controversy about the Rosenhan experiment. [2] He’s been accused of being a charlatan and fabricating quite a lot of his data. But I think the value of his reflections still stands. I’ve definitely seen in my clinical practice that people will be treated differently because of a label that has been put in their notes, even though that label might have changed several times. I’ve had patients who’ve had four or five different labels in the course of their career, while they’ve had actually pretty much the same kinds of experiences and distress throughout all of those.

What I find really helpful in my conversations with patients is the fact that we don’t always have to give a label. If someone is really keen for one, then I’m happy to explore that with them and tell them, “These are the psychiatric categories that are on offer in the current edition of the DSM. Some people find them really useful, but with every new edition of the manual, they change, so they’re not describing something discrete, fixed, or in the natural order of things. They’re a way of describing and approaching distress, so let’s talk about how much they would be helpful for you.”

Now, in the U.S., I understand that labels can be essential because of insurance-based medical payments. In a U.K. context, a label may not be as useful because our psychiatric services are organized differently. I gently explore with each patient how much for them it’s going to be transformative. If it’s going to help ease their suffering and get them the treatments that they want, then I embrace it and help them get the one that fits best. But if it’s not going to be transformative in terms of how they can access care, then I tend to try to avoid giving a label because that can allow a level of optimism and dynamism about their state of mind. It more genuinely reflects the possibility of change and adaptation, rather than risking somebody changing the way they think of themselves.

As human beings, we’ve got such a huge tendency to put shame on one another. What labels seem to do in our current moment is absolve people of that shame in a really helpful way. I’ve had patients say to me, for example, that until they got their diagnosis of ADHD, they felt so ashamed of not being able to focus properly at work, and what that label did was offer a kind of absolution from that shame because it said, “There is this category of being that is separate from you and which seems to be affecting you, but it’s not your fault.” That can be wonderfully liberating. In those kinds of situations, I’m often keen to embrace the label if it’s going to help the patient cast off their shame. But I’m also questioning: Why have we got that shame? Isn’t it a pity that people often feel that they need to embrace a medical diagnostic label in order to rid themselves of that shame?

What strengths do primary care physicians bring to mental healthcare compared to someone more specialized?

One great advantage of somebody in my kind of role is that I’m embedded in the community. I often know the whole family, and I’m seeing people for all kinds of other problems which have a bearing on their mental health. I’ve become more aware of the connections between families and individuals; a specialist only sees the one individual with a particularly distressing problem—for longer appointments, granted, but removed from that context.

There’s a wonderful GP writer in the U.K. called Iona Heath, who has written a lot about the fact that it’s in the primary care consulting room where suffering is either given a label and understood within a medical model, or not. Some people see primary care physicians as essentially holding a line, or acting as some kind of gatekeeper, between the huge mass of human experiences that are out there and which ones become medicalized. A lot of people will come and see me about something fairly banal—almost to try me out, to try and figure out whether I’m going to be kind, compassionate, friendly, or approachable. Once they’ve tried me with a symptom that they’re not too fussed about, then they’ll risk sharing the one that they’re really worried about.

As a primary care physician, I feel I have a very privileged role: You’re not part of the family, but you’re not part of the establishment—you’re somewhere between the two. I’m often the first port of call for people hoping to make sense of their experience.

One line from your book that struck me: You write that today’s DSM categories will one day “seem as overconfident as the old phrenology charts.” How literal or hyperbolic do you mean that comparison to be?

Phrenology was debunked about 130 years ago. By the late 19th century, it was already starting to lose its traction because good thinkers were realizing it was a load of rubbish. If I could fast forward to 2176 and ask the doctors of that time what they’ll make of the DSM-5, I don’t think they would see it as phrenology, but they would certainly see it as utterly obsolete and unhelpful to them because it’s a cultural document of the West in the early 2000s. We can’t imagine what Western culture is going to look like in 2176. I’d argue that it’s quite likely that it will be very different from our current culture, that our neuroscience and genetics will have progressed in huge leaps and bounds, and that the organization of our society—while it may not have progressed—will have changed utterly. The DSM-5 will be of purely historical interest. When I was born in the ’70s, they were using the DSM-II, which is now considered very much a historical document—and that’s within my lifetime. I’m hopeful that the DSM-6, if and when it ever appears, is going to be an improvement on the DSM-5.

What inspired the book’s title?

From my chair in the clinic, I don’t see people’s minds as brittle and fragile. I see people as immensely resourceful, resilient, adaptive, and dynamic. People are incredible; they always amaze me with their ability to get over even the most extraordinary difficulties, suffering, and traumas. In my seat, I see the mind as far more unfragile than a lot of the rhetoric in our culture suggests.

The Unfragile Mind: Making Sense of Mental Health
Gavin Francis
Publisher: The Experiment, New York. 2026. 256 pages.

[1] Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2023). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry, 28, 3243–3256. 
https://doi.org/10.1038/s41380-022-01661-0

[2] In the 1970s, Rosenhan and eight pseudo-patients feigned auditory hallucinations to gain admission to a dozen psychiatric hospitals across the U.S. Once inside, Francis writes, they “declared themselves free of the hallucinated noises, but found it very difficult to be believed, and be discharged” (p. 47).

Web image created from book cover by Medhum.

Conditions change once Sweet Home’s owner dies of a stroke and his widow brings in her brother-in-law and his young nephews to help run Sweet Home; the small liberties granted to the enslaved people are revoked by the new leadership, and cruelties ensue. The enslaved people, including Halle and a man named Paul D, plot to escape north; however, Sethe and her children are the only ones who succeed in doing so, only after she is violated by the nephews and brutally whipped by the brother-in-law for informing him of the assault. These events and Sethe’s flight are complicated by her near-full-term pregnancy. Approaching death from exhaustion and exposure, she is saved by a white girl who helps Sethe give birth. Her daughter is named Denver after the contextually benevolent white girl.  

Carrying her newborn, Sethe arrives at 124, greeted by her other three children, into the care of Baby Suggs. The bittersweet happiness of her arrival without Halle is marred one month later by the arrival of a team intending to reclaim Sethe and her kids for Sweet Home. Rather than allow herself and her children to be forced back into slavery, Sethe intends to commit infanticide and suicide, succeeding in the murder of her older daughter. This action effectively prevents them from being taken, and Sethe is exonerated of her charges. Despite this, her act of desperation crushes her family, eventually leading to Baby Suggs’ death and to the flight of her sons from the household. Eighteen years later, Paul D arrives at 124. He begins a relationship with Sethe and manages to evict the poltergeist.  

Soon thereafter, a strange woman arrives by the name of Beloved, the word Sethe had engraved on her child’s tombstone. Sethe is initially unaware of the stranger’s origins, and Paul D is effectively forced out by the new arrival. Once Beloved’s identity as the deceased child is understood, she, Sethe, and Denver become wrapped up in each other, blurring the lines of their identity. Sethe loses her job, but Denver manages to extricate herself to find work. Hearing of the family’s plight at the hands of the “unholy” Beloved, thirty black women of the area band together to purge 124 of her presence. Beloved leaves without a trace. Paul D eventually returns to 124, and memories of Beloved slowly fade into oblivion. 

Beloved is a pure work of art. Toni Morrison crafted a brilliant piece fueled by the lived experiences of enslaved people’s descendants in America and informed by the temporal proximity of the ratification of thirteenth amendment. The summary outlined above fails to capture the impact of the work’s nonlinear form, both in time and perspective. Flashbacks seamlessly interweave with the driving plot. Not only are the past and present difficult to distinguish, but this intermingling also elevates the past in status compared to the present, allowing the past to rival––and often exceed––the present in narrative importance. Time becomes a unique character, one whose primary achievement is the marring of other characters’ physical beings. Through this lens, the recapitulation of Sethe’s tree scars mirrors the historical impact of slavery on the modern-day United States. This context is further validated by the work’s inspiration, the life of Margaret Garner, an African- American enslaved woman who escaped, was recaptured, and who murdered her daughter while being returned to the South. 

Toni Morrison’s mastery of figurative language builds upon the nonlinearity of the piece. Her writing is powerfully displayed through allegories, the most notable of which is found on pages 248-252. Through Beloved’s perspective, Morrison blends hell and slave ships into one entity. This same section of the novel further unifies the perspectives of Beloved, Sethe, and Denver through a mélange of emotion and perception.  

The relevance of this piece to contemporary American politics and social issues is profound and disturbing. American history continues to discredit the experiences of people of color, particularly those of who identify as Black or African-American. This novel demands that we confront the United States’ history of racial oppression. Its magical realism provides new dimension to a historical narrative, allowing for greater imaginative accessibility to the meaning behind its story. As a last powerful image, I refer to the biblically paralleled coming of the four horsemen to “reclaim” Sethe: the sheriff assumes responsibility of reinforcing the dehumanization of Sethe and “addressing” her perceived cultural, psychological, and racialized aberrancy through punishment sans reformation.  

Miscellaneous 

Beloved
Toni Morrison

Awards
National Book Award Finalist for Fiction (1987); Pulitzer Prize for Fiction (1988); American Book Award (1988); Anisfield-Wolf Book Award (1988); Frederic G. Melcher Book Award (1988)  

Publisher Vintage 
Place Published United States 
Edition 2004 
Page Count 324 

Originally published on September 16, 1987 by Alfred A. Knopf Inc. 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database . 
Web image by Alex Conti

Many modern physicians minimize, or are unaware of, a second source of historical medical success: the power of language and ritual to facilitate physical and psychological healing. Assisted by his priests, Aesculapius, the Greek god of medicine, healed the sick through poetry, narrative, and ritual. Even Hippocrates, the father of naturalistic Western medicine, paid tribute to Aesculapius in his famous Oath, and emphasized in many of his case histories the importance of interpersonal and contextual factors in patient care. While the healing power of language and context was rarely explicit in the subsequent history of Western medicine, it finally emerged into consciousness during the last two hundred years, when it was given the name placebo effect. Initially considered a minor aberration in suggestible people, more recently this component of healing has been recognized as an almost universal human facility (or reaction) of varying and sometimes amazing power.  

In this essay I present a case study of a traditional healing ceremony in which the therapy consists entirely of language, especially poetry, and the ritual context in which the language is spoken and chanted. I argue that this is a very powerful example of contextual healing. I then examine our contemporary understanding of the placebo effect, which is also a form of contextual healing, albeit ordinarily much less striking and more “dilute” than the Navajo example. Finally, I comment briefly on some features of healing miracles in the Catholic Church, arguing that these, too, are powerful instances of contextual healing that suggest at their upper limit, so to speak, such mechanisms may actually be able to reverse disease processes, like cancer or neurological impairment. Of course, this outcome is rare, unpredictable, and not at all understood.  

Sarah Mailcarrier and the Night Way 

Dark cloud is at the door. 
The trail out of it is dark cloud. 
The zigzag lightning stands high upon it. 
An offering I make. 
Restore my feet for me. 
Restore my legs for me. 
Restore my body for me. 
Restore my mind for me. 
Restore my voice for me. 
This very day take out your spell for me.  

Happily, I recover. 
Happily my interior becomes cool. 
Happily I go forth. 
My interior feeling cool, may I walk. 
No longer sore, may I walk. 
Impervious to pain, may I walk. 
With lively feelings may I walk. 
As it used to be long ago, may I walk.¹ 

These lines constitute a small segment from one of the poems chanted during the Night Way, a nine-day Navajo healing ceremony. In the early 1970s, Sarah Mailcarrier was the matriarch of an extended family whose camp was at Cornfields in Beautiful Valley near Klagetoh Mesa. A healthy woman well into her 60s, she developed severe lower abdominal pain, vaginal bleeding, poor appetite, and swelling of her legs over a period of two to three months. Her family took her to Fort Defiance Indian Hospital, some 50 miles from home, where she was discovered to be suffering from cancer of the cervix, which had spread widely, blocking lymphatic ducts in her legs and partially obstructing her kidneys. The recommended treatment was palliative radiation at Gallup Indian Medical Center, a larger hospital in Gallup, New Mexico, another 30 miles distant from Cornfields. Sarah and her family declined this option and, instead, consulted a hand trembler, who diagnosed her problem and recommended a Night Way Sing or healing ceremony. The family hired a ha’a’tali or traditional healer who, along with his assistants, conducted the ceremony over nine days and nights at her camp in Cornfields.² 

According to Navajo diagnostic taxonomy, Sarah had fallen out of harmony with the cosmic narrative that defines the proper relationships among the Earth Surface People, the Holy People, and the natural world. This likely was the result of certain traumatic exposures and events in her life. Healing would require restoration of harmony through the chants, rituals, images, and stories that the Holy People had given to the Navajo for just this purpose. The ceremony was successful. Sarah’s symptoms were relieved, her energy restored, her anxiety disappeared, and she continued to function in her role as matriarch for several months until she drifted into a long sleep and died. 

To explore the nature of Sarah’s healing, I have to explain a little more about Navajo medical beliefs. In traditional Navajo thought, all illness represents disharmony, in essence a snag or gap in the interconnectedness that characterizes the dineh (people), the harmonious Navajo Way. While there are many causes of disharmony (e.g. witchcraft, demon possession, soul loss, taboo violation, and traumatic exposure, as with Sarah Mailcarrier), the goal of treatment is always the same—to restore proper harmony at all levels, from within the patient’s own heart, to his or her relationship to the cosmos.  

The ceremonies, which can last up to nine days, require the patient and family to hire an ha’a’tali and his assistants, and to invite friends and clan members to set aside their other responsibilities and participate in songs, dances, prayers, and other rituals appropriate to the ceremony. Sung by the ha’a’tali these are magnificent narrative poems that tell of the creation of the Navajo people, and how all things were originally placed into their proper order. Likewise, in ceremonial dances, men impersonate Yei Be Chai, intermediaries between the Holy People (whom we might call “gods”) and the Earth Surface People (us), and channel their healing power.  

However, the dineh have never rejected Western medicine. Instead, they have integrated Western physicians, clinics, and hospitals into their overall worldview, considering them synergistic with, rather than antagonistic to, traditional ceremonies. The dineh believe that Western health care has simply added a different set of stories and a different network of ceremonies (e.g. clinic visits, x-rays, penicillin shots, arthritis pills) onto their already existing—and far more important—traditional healing practices. The Navajo were quick to observe that bilighani treatments were effective in alleviating outward manifestations, or what we would call symptoms, of disharmony, but they also maintained that such treatments had no influence on the underlying existential disorder. In other words, penicillin shots and arthritis pills are only symptomatic treatments. While bilighani methods could make the fever or rash or cough disappear, at least for a time, the fundamental issue of disharmony would remain. Why me? What does this illness mean in my life? How does this illness reflect my relationship to the cosmos? These questions could only be answered with reference, for example, to the story of Spider Woman, or the Hero Twins, or other narratives of Navajo cosmogony.  

Returning to Sarah Mailcarrier, it appears that by undergoing a Night Way Sing, she experienced a dramatic improvement in her quality of life. From a Western perspective, why might this be the case? First, the lengthy ceremony provided extensive and intense social support, represented by the participation of her extended family and friends, their contributions of time and money³, and overall solidarity. An extensive body of research indicates that high level of social support and prosocial behavior are associated with longer life, less morbidity, less disability, and greater satisfaction. Second, Sings are integral components of religious practice. For a person like Sarah Mailcarrier, religious belief (in the Western sense of the term) and cultural practices were inextricable. Once again, considerable research indicates that frequency and intensity of religious practice is associated with the same positive outcomes. Third, the ritual chants, vivid poetic images, storytelling, sandpainting, and dancing of the Night Way embody a belief system that generates positive expectations—and restores coherence to the patient’s life.⁴  

These components—social support, core beliefs, and positive expectations—all rely on language and communication. Empathy, the human ability to “intuit” what another person is thinking or feeling⁵, is a more basic neurological property than language, but without language humans could not have created the rich symbolic world in which we live. In the 1980s the psychiatrist Donald Sandler distinguished between Navajo symbolic healing, based on an integrated cultural narrative, including symbol and ritual; and scientific healing, which he believed could be clearly distinguished from the latter and which relies solely on specific instrumental effects of drugs, surgery, and so forth.⁶ Like Sandler, today’s physicians are quite willing to make allowances for the beliefs of patients from other cultures, but at the same time they cling to the belief that scientific medicine transcends culture and our effectiveness as healers is solely, or almost solely, explained by the instrumental effects of drugs and procedures. Thus, there is a widespread belief that scientific medicine is, as a system of curing disease, intrinsically culture-free. Antibiotics kill bacteria whether the patient is a middle-class American or an Amazonian Indian. Culture may enter into the picture for the Indian, e.g. because of his mistaken beliefs about illness, but has no effect on the American, whose beliefs (whatever they are) are medically invisible.  

From Placebo Effect to Contextual Healing 

For over 200 years Western physicians have been explicitly aware of the so-called placebo effect, but for most of that time have considered it a minor and somewhat disreputable factor on the medical scene. The first person to recognize and demonstrate the placebo effect was English physician John Haygarth in 1799, who was curious about the purported benefit a popular medical treatment of his time called “Perkins tractors,” metal pointers supposedly able to ‘draw out’ disease from the patient’s body. They were sold at the extremely high price of five guineas, and Haygarth set out to show that the high cost was unnecessary. He did this by comparing the beneficial results obtained by using dummy wooden tractors with those obtained with a set of allegedly active metal tractors. There was no difference. He published his findings in a book called On the Imagination as a Cause & as a Cure of Disorders of the Body.⁷ Subsequently, the term placebo (“I will please”) was coined to mean, as in this 1811 definition, “an epithet given to any medicine adopted more to please than to benefit the patient.” 

The modern understanding of the power of placebo intervention probably originated with Henry K. Beecher‘s 1955 classic paper, “The Powerful Placebo,” in which he described his experience as a medic during World War II⁸ After running out of pain-killing morphine, in desperation he replaced it with a simple saline solution, while continuing to tell the wounded soldiers that the injection was morphine. He often found that saline appeared to be almost as effective as morphine in relieving his patients’ pain and anxiety. Despite this dramatic demonstration, the orthodoxy surrounding placebo effects for the next several decades came to include three major components:  

• A focus on the specific intervention as its cause, i.e. the pill or the procedure itself “carried” or “transmitted” the placebo effect. 

• Importance of patient vulnerability, i.e. only suggestible persons were placebo-responders. 

• Miscommunication, i.e. the patient must deceived, directly or indirectly, into believing that he or she was receiving an “active” treatment.  

However, research in the last 30 years has completely exploded this orthodoxy and replaced it with a much more complex understanding that sheds light, for example, on the power of traditional medical systems, like the Navajo, that rely on poetry, narrative, and ritual to heal. To quote Franklin Miller and Ted Kaptchuk, two of today’s most prominent investigators in the field: “To promote a more accurate understanding of the elusive and confusing phenomenon known as the placebo effect, we suggest that it should be reconceptualized as contextual healing… Factors that may play a role in contextual healing include the environment of the clinical setting, cognitive and affective communication of clinicians, and the ritual of administering treatment.”⁹ Elsewhere, Kaptchuk added, “Research also suggests that (narrative and) ritual healing not only represents changes in affect, self-awareness, and self-appraisal of behavioral capacities, but involves modulations of symptoms through neurobiological mechanisms.”¹⁰  

Contextual healing, as the term implies, occurs in the context of expectations that arise from a network of beliefs. Moerman and Jonas, highlighting the fact that context can communicate therapeutic meaning to the patient, prefer using the term “meaning response.”¹¹ In some cases these beliefs may be based on past experience, but isolated from, or not intimately connected to, deeply meaningful worldviews (e.g. that penicillin cures a sore throat). In other cases they may closely connected to robust belief systems about the nature and origin of illness and healing (e.g. the Navajo Night Way). The latter are obviously more important than the former. The net valence of one’s beliefs determines the meaning of any medical interaction or treatment and, therefore, one’s expectations of its effect. Language, communication, empathy, narrative, and ritual determine the healing context. The universality of contextual effects on symptom relief has been demonstrated convincingly in neurobiological studies, especially those dealing with pain reduction. For example, on fMRI “placebo” treatment reduces activation of pain-related areas of the brain, e.g. the dorsolateral pre-frontal cortex.^{12, 13}  

Contemporary research on contextual healing has also revealed a number of unexpected features that are inconsistent with the earlier orthodoxy regarding placebo effects. For example, 

• Placebo effectiveness does not require deception; patients may report relief of symptoms even when told they are receiving placebo treatment.¹⁴ 

• There may be a link between genetic variants in the dopamine, opioid, serotonin, and endocannabinoid pathways in the brain and placebo responsiveness.¹⁵ 

• Placebo effects (as well as nocebo, or harmful effects) can exist in routine clinical practice, even if no “intervention” is given.^{16, 17} 

• Placebo response is greater when observed in clinical practice than when measured in randomized clinical trials.^{8, 19}  

This last feature requires some clarification. This is precisely the opposite of specific medication effects, which are almost always more prominent in clinical trials than in routine practice because the populations in trials are highly homogenized (e.g. limited age range, selected to exclude co-morbidities), adhere to highly structured protocols (e.g. frequent follow-up, expert clinicians. methods to insure, or at least measure, compliance) and include only highly motivated subjects. These conditions are ideal for demonstrating the drug’s maximal specific benefit (efficacy), while at the same time somewhat less ideal for showing contextual healing power, since individual variation and personal narrative are minimized. The specify potency of a drug tends to be less in ordinary clinical practice (effectiveness) where there are a mixture of patients with different ages, backgrounds, comorbidities, and levels of compliance. However, the latter less-than-standardized conditions are likely to enhance the power of contextual healing. For example, “It seems likely that the effectiveness of placebo for pain relief in osteoarthritis can be considerably larger than its efficacy. The artificial conditions of a clinical trial constrain the extent to which context effects…” can be manifested.²⁰ 

Can Language Spoken in Context Cure Disease? 

Given that contextual or narrative healing may be a powerful force in relieving symptoms and improving quality of life, can it ever cure chronic or progressive disease? It is unlikely that Sarah Mailcarrier’s Night Way ceremony damaged her cancer cells or had any influence on their progress. However, it seems clear that narrative healing may in many cases “cure” at least some cases of major depression, generalized anxiety, post-traumatic stress syndrome, substance abuse, and perhaps even schizophrenia. Since these disorders are all characterized by abnormal concentrations or function of neurotransmitters, it is safe to say that contextual healing influences brain chemistry. Likewise, fMRI studies have shown that placebo treatments alter brain function. For example, placebo treatment in Parkinson’s disease may result in demonstrable changes in imaging, primarily resulting from increased dopamine release in certain areas of the basal ganglia.²¹ These changes may be associated with improvements in patient function. Likewise, placebo has also been shown to modulate physiological processes, like lowering blood sugar in diabetics and treatment enhancing immune responses, which may be related to neurophysiology in complex ways. ^{22, 23} 

There is a long history of rare, unexplained, but yet well-documented, cures in medicine. As medical knowledge has increased, the number of such inexplicable or “miracle” cures has diminished. Nonetheless, instances of the disappearance of widely metastatic cancer, or the resolution of aggressive autoimmune disease, do occur. Religious persons attribute these unexplained cures to supernatural intervention. Jacalyn Duffin’s 2009 book Medical Miracles: Doctors, Saints and Healing in the Modern World describes her investigation in the Vatican archives of 1400 cases of miracle cures that were cited as evidence in canonization proceedings between 1588 and 1999.²⁴ Of these, 503 cases occurred in the 20^th century and 220 of them between 1975 and 1999, the final year of her study. Most in the 1975-1999 group were extremely well-documented. 20^th century cures included 41 cases of cancer or leukemia, 109 neurological diseases (e.g. multiple sclerosis, myasthenia gravis, Parkinson’s disease), and 89 obvious orthopedic conditions. The unifying factor was that every “miracle” was associated with narrative and ritual. Prayer to Jesus, Mary, or another person, i.e. the candidate for sainthood, took place in various contexts, solitary or communal narrative associated with Masses, novenas, relics, monuments, tombs, etc. These features are all analogous to Navajo healing ceremonies. The same sort of analysis has been applied to “miracle” cures at Lourdes, a pilgrimage site in France, with similar results: a relatively small number of thoroughly documented and inexplicable cures among many thousands of claims.²⁵ 

A Note on Nocebo 

Traditional cultures also recognize the power of language to harm, as well as heal. This includes spells, hexes, curses, and similar verbal insults that produce harmful effects on the person to whom they are directed. Since the phenomenon of “Voodoo death” was described by Cannon in 1942²⁶, various other syndromes of illness and death based on witchcraft and curses were re-evaluated or newly described have been reported; for example, “bone-pointing” (kurdaitcha) in Australia and “breaking tapu” in New Zealand. Among Aboriginal people an individual targeted by bone pointing may die within 24 hours or may decline inexorably over a period of days. ²⁷ Such a curse can only be reversed by the intervention of an appropriate sorcerer. Among the Navajo, many serious illnesses are caused by curses that lead to “soul loss” or “possession.”  

Likewise, in Western medicine the words of physicians or other health care professionals, and the context in which they are spoken, may actually increase a patient’s symptoms, anxiety, and suffering. The eminent internist Eric Cassell, paraphrasing an old childhood chant, taught “Sticks and stones may break your bones, but a word can kill you.” (Personal communication) There is no room here to discuss nocebo-inducing language in medical practice, which is analyzed in detail in chapter 13 of Coulehan and Block.^{28, 29} 

Conclusion 

In this essay I make the claim that contextual healing (aka the placebo effect) plays a major role in medical practice and that language, either spoken verbally, or used internally to represent beliefs and personal meanings, is the carrier or operative agent of contextual healing. In most circumstances contextual healing has a limited, but clinically significant, range of effects. The clinician by employing “skillful means” (to use a Buddhist expression) can promote and enhance contextual healing in the clinical setting.^{20, 31} Navajo medicine is an example of a traditional medical system built almost entirely on exploiting the vast resources available to contextual healing. To a greater or lesser extent, Curanderismo, Vodun, homeopathy, Christian Science, and many other approaches to the treatment of illness are based on contextual healing. The upper limit of this healing power is normally modest, but under certain circumstances for certain people it may be quite spectacular, as in presumptive miracle cures.  

Notes 

1. Navajo Night Way Song, https://www.lindavallejo.com/wp-content/uploads/2018/12/Chants-Prayers-Poems-2011-2.pdf, accessed on 3 December 2025. 
2. Coulehan J. May I Walk in Beauty. Humane Medicine, 1992; 8: 65-69. 
3. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B. 2011; 366: 1849-1858 
4. By “intuit” I mean the development of a theory of mind (i.e. others have minds just like me). Primates and perhaps some other mammals have an analogous ability, but presumably without a symbolic language. 
5. A Sing is expensive. The patient’s family must hire an ha’a’tali and his assistants and also provide food and drink for a large number of participants and attendees. Some participants must also take time off from their jobs or other pursuits for several days. 
6. Haygarth J MD. On the Imagination as a Cause & as a Cure of Disorders of the Body, Bath; R. Cruttwell, 1801. 
7. Sandler D. Navaho Symbols of Healing. New York, Harcourt Brace Jovanovich, 1979, pp. 265-273.  
8. Beecher HK. The powerful placebo. JAMA. 1955;159(17):1602-1606 
9. Miller FG, Kaptchuk TJ. The power of context: reconceptualizing the placebo effect. JRSM. 2008; 101: 222-225, p. 223. 
10. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B Biol Sci. 2011; 366: 1849-1858, p. 1849. 
11. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002; 471-476. 
12. Brody H, Miller FG. Lessons from recent research about the placebo effect—from art to science. JAMA 2011; 306 (23): 2612-2613 
13. Colagiuri B, Schenk LA, Kessler MD, Dorsey SG, Colloca L. The placebo effect: From concepts to genes. Neuroscience. 2015; 307: 171-190 
14. Pecina M, Zubieta JK. Molecular mechanisms of placebo responses in humans. Mol Psychiatry. 2015; 20: 416-423 
15. Miller FG, Coilloca L, Kaptchuk TJ. The placebo effect: illness and interpersonal healing. Perspect Biol Med. 2009; 52: 518 
16. Stub T, Foss N, Liodden I. “Placebo effect is probably what we refer to as patient healing power”: a qualitative pilot study examining how Norwegian complementary therapists reflect on their practice, BMC Complementary and Alternative Med. 2017; 17:262 
17. Benedetti F, Pollo A, Lopiana L, Lanotte M, Vighetti S, Rainero I. Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses. J Neurosci. 2003; 23: 4315-4323 
18. Dieppe P, Goldingay S, Greville-Harris M. The power and value of placebo and nocebo in painful osteoarthritis. Osteoarthritis and Cartilage. 2016; 24:1850-1857 
19. Haake M, Muller HH, Schade-Brittinger C et al. German acupuncture trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007; 167: 1892-1898 
20. Dieppe et al, p. 1852. 
21. Fuente-Fernandez R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ, Expectation and Dopamine Release: Mechanism of the Placebo Effect in Parkinson’s Disease. Science. 2001; 293: 1164-1166. 
22. Skvortsova A, Veldhuijzen DS, van Dillen LF, Zech H, Derkson SM, Sars RH, Meijer OC, Pijl H, Evers AWM. Influencing the Insulin System by Placebo Effects in Patients With Diabetes Type 2 and Healthy Controls: A Randomized Controlled Trial. Psychosomatic Medicine. 2023; 85: 551-560 
23. Smits RM et al. The role of placebo effects in immune-related conditions: mechanisms and clinical considerations. Expert Rev Clin Immunol. 2018; 14(9): 761-770. 
24. Duffin J. Medical Miracles. Doctors, Saints, and Healing in the Modern World. New York, Oxford University Press, 2009. 
25. François B, Sternberg EM, Fee E. The Lourdes medical cures revisited. J Hist Med Allied Sci. 2014 Jan;69(1):135-62.  
26. Cannon WB. “Voodoo” death. American Anthropologist, 1942; 44: 169-181. Reprinted in Am J Public Health. 2002; 92 (10): 1593-1596. 
27. Spencer, Baldwin; Gillen, F.J. Native Tribes of Central Australia. Cambridge University Press, 2010 [1899], pp. 476–477. 
28. Coulehan J, Block M. The Medical Interview. Mastering Skills for Clinical Practice. Philadelphia, F.A. Davis Company, 5^th edition, 2006, pp. 21-44 and 249-278.  
29. Hansen E, Zech N. Nocebo effects and negative suggestions in daily clinical practice – forms, impact and approaches to avoid them. Front Pharmacol. 2019 Feb 13; 10:77. 
30. Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389. 
31. Blasini M, Peiris N, Wright T, Colloca L The role of patient-practitioner relationships in placebo and nocebo phenomena. Int Rev Neurobiol. 2018; 139:211-231.  

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Literature mirrors the general culture. There has been a recent explosion of books in which AI is the central plot device moving the narrative forward to endings that range from a utopian fulfillment of human destiny to the catastrophic collapse of civilization and the annihilation of humankind. But AI infiltrated the literary space several decades ago. Philip Dick imagined a world in Do Androids Dream of Electric Sheep? where cyborgs were being hunted down because of fear that they might take over the world. In 2001: A Space Odyssey by Arthur C. Clarke, a robot named Hal murders nearly all the crew of a spaceship on a planetary mission because of a programming error. 

Speak by Louisa Hall is more recent addition to the AI library. But it was published several years before large language models became a routine tool to plan a vacation or write a letter of recommendation. Is it still worth reading in 2025? 

The novel is a composite narrative centered around five interwoven stories spanning the time period from 1663 to 2040. In the first narrative, a young Puritan girl who finds herself in an unwanted marriage, records her thoughts in a diary that she is writing on a treacherous ocean voyage to America. Fast forward to the 20^th century and we meet Alan Turing who is writing letters to the mother of young man to whom he was emotionally attached and who died prematurely. He is troubled by his inability at times to communicate with people. A decade later we meet Karl and Ruth Dettman, a couple whose families escaped Nazi Germany but under vastly different circumstances. The husband, Karl, is a computer scientist who has developed a program named MARY to enable computers to interact with humans. Ruth, his wife, is a historian who has built a career centered on the publication of old diaries like the one written by the young woman traveling to America. She is trying to convince Karl to expand the memory of his computer program and enrich it with more human material, but Karl stubbornly refuses because he is concerned about the power of his program to overwhelm its users if its database is expanded. Finally, we jump ahead to 2040, and we read the transcripts of the trial of Stephen Chinn, a man who is being prosecuted for the production of robots that are too life-like. Chinn is being accused of causing physical and psychological harm to the people who have used his robots and of weakening normal relationships between people. A young adolescent named Gaby, who was given a doll powered by a version of MARY, is one of his alleged victims. His own personal recollections are folded into the trial proceedings, as he tries to describe his intentions, justify his actions, and make amends for where they may have gone awry. 

Taking stock of our world today, there is clear evidence that AI can improve the day-to-day lot of people, make life more convenient and efficient, and promote better health outcomes. However, much of the current angst that permeates discussions of AI is focused on the potential economic and sociopolitical consequences. There is fear that systematic adoption of AI will lead to widespread loss of jobs and financial distress for people left behind. The generation of false data and uncontrolled dissemination of unfiltered information may, it is feared, foster social unrest and destabilize democratic institutions.  

All of these predictions, for good or for bad, center on the word “intelligence.” If it is defined as the creative use of information towards a specific goal– my definition, to be sure — then it exists along a gradient and there is not an opposing term. In that case, the mixed picture about the future of AI seems accurate. Humans can process information to both noble and destructive ends. If machines are provided information by humans, then it is likely that there will be worthy and flawed outcomes. It is not a reflection of the logical structures or neural networks that are built into us as humans or artificially placed into machines. It simply is the nature of intelligence. Information is agnostic and it can be processed in a limitless number of ways; there is no guarantee of what will happen when it is processed. 

On the other hand, if we center our predictions on the word “artificial,” there is an opposing term, namely “genuine.” Speak looks beyond AI as intelligence and forces us to think about its impact on interpersonal communication and interactions. The design of the robots that are being created in fiction and in our world of 2025 is steadily improving. The voices become more lifelike, the reactions more emotionally appropriate, the reactions more convincing. They display keen intelligence and manifest seeming empathy with their handlers. Like the artificial friend in Klara and the Sun by Kazuo Ishigura, the robots may even appear to have more feelings and awareness of the ever-changing psychological state of their owners than family members and friends. But it will always remain artificial. Speak forces us to ponder whether interactions between human beings have an element that cannot be programmed, that is not simply manipulation of information. It is that piece that accounts for the genuine nature of relationships between people and it is that component that is vital for human growth and maturation. The interconnected stories in Speak raise the concern that reliance on AI, in whatever embodied form it takes, to provide support and companionship may inevitably fail and leave damaged humans in its mechanical wake. The intelligence of AI may not be sufficient for humans to thrive. It remains difficult to put into words exactly what to call this additional component of human interaction. Thankfully, there is literature, and creative novels like Speak, to help us grapple with what it might be and to help us steer a course where AI is developed thoughtfully with full awareness of its limitations and potential for good and harm. 

SPEAK  
Louisa Hall 
EccoPress, New York 2016, 356 pp 
Web image by Medhum.org

Let’s start back to front. First, role-playing. This likely brings to mind Dungeons and Dragons from 1974, a tabletop game that is, indeed, still wildly popular (and even used clinically in the psychotherapy space). While the games are similar, the term refers to something slightly different in video games. In both, you assume the role of a character and enact the narrative of that character; yet, in video games, you are most often playing a pre-set character with a relatively established narrative path using scripts provided for you instead of creating the scripts yourself. In Forspoken, you play as Alfre “Frey” Holland, a young adult woman who grew up in New York City. Her role, as we will discuss, involves being transported to an alternate medieval-esque world of magic and monsters, Athia, and discovering her connection to said world and its people. The role-playing element occurs as you vicariously live through Frey’s experiences in Athia.  

Next, and probably most self-evident yet confusing, is the term “action.” You may be thinking, “Aren’t all video games action?” After all, are you not taking actions in Pac-man as you consume fruits and ghosts, or in Space Invaders when you move the cannon on the bottom of the screen and shoot the aliens? You’re absolutely right, but there are plenty of games that involve slow, careful deliberation. I won’t get into this too much, but I find the easiest way of thinking about this is the difference between soccer and chess. Forspoken is much more in the camp of soccer; you make in-the-moment decisions as you play as Frey. In this case, these actions are restricted to moving around the screen and fighting the aforementioned monsters. Paradoxically, other than progressing the game, these actions have no direct bearing on the narrative of Forspoken, merely on the elements surrounding the narrative. For example, a quest (i.e., a portion of the overall plot) could ask you to save the father of one of Frey’s new friends in the new world of Athia. You must then travel to the specified destination, locate her father, and fight monsters on the way using magic. While the contents of the quest (i.e., saving the father) are core elements of the overall plot, how you carry it out (e.g., what path you take, what monsters you fight) usually does not matter more than being a conduit for the action elements of the game. Essentially, action games are a test of hand-eye coordination, dexterity, and processing speed.  

Finally, the term “open-world.” Games under this moniker allow players to take their character wherever they want in the game world. Traditionally, games followed a relatively constrained pattern––you could go only where the narrative was actively occurring. The open-world concept expanded this to allow players to explore areas other than those pertinent to the primary narrative. In the truest form, this allows players to access the entirety of the game’s area from the start. Most games, however, follow a variation of the traditional linear approach wherein new areas are locked by the progression of the main story but previous areas are accessible after they have first been explored. Forspoken follows this latter pattern. As you––Frey––complete the main story quests, you unlock new areas of the map. Subsequently, you unlock more powers that you can then use to more deeply explore the areas you’ve already been by accessing areas you could not get to without the new powers (e.g., the ability to cast water magic and glide on the surface of water). This game highlights a core element of video games, particularly in relation to other genres: the narrative is only one piece of the puzzle; some people mainly play for the story, others primarily enjoy the exploration and action, and the majority come for a combination of them all. 

Forspoken combines these three elements––role playing, action, and open world––to immerse the player in a fast-paced journey through Athia and Frey’s place within it. After being transported to Athia from New York City, Frey gains the ability to use nature magic and discovers the last bastion of human civilization in Athia. Her original goal is to find a way back to New York, leading her to help locate key individuals who may help her do so. As she learns more about the land’s history and politics––particularly the landscape as influenced by a magical and biological blight she calls the Break––Frey becomes the target of the former, all-powerful leaders of the world, the Tantas. These four women were once the saviors of the land, protecting its people from all threats. Yet you learn that they seemingly lost their minds around the time the Break started to devour the people and landscape; the Tantas turned against their people, their benevolence morphing into tyranny. They remain in their respective domains while the Break consumes more and more of the landscape, invading the people’s last city at the center of the landmass. Frey appears to be the only one unaffected by the Break. As such, she assumes the begrudging role of exploring beyond the limits of the city to confront the “evil” Tantas. Without getting too caught up in the finer details of the story, you learn the cause of the Tantas’ madness as you defeat them one by one. Eventually, Frey must also confront the instigator of their insanity while questioning her own place in her original life and the new life thrust upon her.  

First, our main character. Frey’s life experience falls under the “prototypical” model of chronic, complex trauma. She is a woman of color who grew up in the New York City foster care system after being found by the Holland Tunnel as an infant. The story starts in a courthouse where Frey is undergoing a hearing for petty theft, apparently a repeat offense. We learn that she has been doing small-time criminal jobs to get by after aging out of the foster system. Just when she has amassed enough money to leave the city, the derelict apartment she’s squatting in gets set on fire by former criminal associates with a grudge. She escapes, but the fire engulfs her cash savings. With nowhere left to go, she wanders to the Holland Tunnel to sit with her sorrow. As her hopelessness seems to peak, she sees a golden armband in an abandoned shop window, and upon touching the armband, she is whisked to Athia against her will.  

Frey has not had stability her entire life. Passed from family to family, she did not have a caregiver she could trust. She learned to take care of herself without relying on others, shunning––and, at times, backstabbing––all those who tried to get close to her. The feeling of abandonment from her family of origin colored all her interactions. She even believes that her world of origin abandoned her, stripping her of her future plans and allowing her to be shipped to a new world without any apparent means of returning. The people Frey meets in Athia initially serve only as a means of getting back to her world of origin. While she could be their protector, she vehemently resists this, at first covertly to delude those around her and then overtly as they expected more from her. Had Frey not been individually targeted by the Tantas, she would not have engaged in the plight of Athia’s people. She appeared selfish in her self-preservation, preventing these strangers from having the opportunity to hurt her. The narrative of the game is, in part, a restorative arc in which Frey learns to form stable, secure attachments, albeit through significant suffering. For example, Frey comes to trust the Athian governors, who initially jailed her and sought to kill her, after they gradually revealed their own trust in Frey’s ability to combat the Break. In a sense, Frey’s healing is the core of her hero’s journey. She saves the world, but only by confronting the recurrent scars left by the chronic trauma of her upbringing.   

The surviving people of Athia experience a different form of trauma, more classically related to post-traumatic stress disorder (PTSD). In less than one generation, their entire world fell apart and their leaders turned against them. They had to fend for themselves to survive. They banded together as refugees against the onslaught of the Break––nearly the entire population lost their homes, families, and livelihoods. The Break spread from the coasts inward, pushing the surviving population to their last, central city. As the Break slowly encroached on society’s last home, they faced the potential for death with every passing day. Their fight-or-flight system could never shut off. The chronic, inescapable trauma wore on their minds, manifesting as complex PTSD for most––if not all––of the population. It re-shaped their worldview, affecting their relationships with themselves, with each other, and with their world. Despite Frey’s deus-ex-machina-esque appearance and resolution of the world’s conflict, the people must confront the terrors from their pasts to restore Athia. In this way, the populace of Forspoken embody chronic societal trauma.  

Finally, the Tantas. Over the course of the game, you learn that these rulers had made a major sacrifice––they had to contain the power of an evil entity, a demon summoned by an enemy nation to destroy Athia. The Tantas defeated the demon and contained it, but the process of doing this split their attention, and, more importantly, the incessant voice of the entity in their heads poisoned their minds. The entity’s whispers forced the Tantas’ magic to run wild and uncontrolled, ultimately causing the Break. The Tantas’ trauma is thus twofold: the constant attacks on their consciousness by the entity, and the constant moral injury engendered by their actions. They sought to protect their people from the imminent threat of the entity but, in so doing, caused irreparable harm as this burden drove them to break from reality. Through these repeated traumas, the Tantas developed psychosis. This did not occur immediately. Rather, it took years of psychological trauma to culminate in their psychotic breaks, which was the ultimate goal of the entity. Just like the previous two examples, the Tantas could not escape. Only through their defeat by Frey could they find redemption and release.  

As I hope these examples have demonstrated, trauma permeates Forspoken. This is not an uncommon motif in role-playing games; however, most games focus on singular traumatic events, more in the realm of classic PTSD. Forspoken shifts focus to the chronicity of trauma, highlighting the multi-faceted ways that trauma can occur. To the player, the trauma is understandable––if delivered in a stilted narrative at times––and allows for exploration of this concept in the safety of a magical world. Unlike the characters in the game, the player is empowered with the means of fighting against it, thus highlighting a critical element of trauma that leads to morbidity: the feeling of powerlessness.  

To the astute player, Forspoken is as much a psychological case study as it is an enjoyable way to pass the time. You zoom around the map with fantastical power and control, all the while healing a trauma-scarred world and people. Forspoken comments on the richness of the human experience and is, without a doubt, a prime example of video games’ place as a health humanity.  

That is just the start of it. 

The plot has numerous twists and turns. The perspective and writing style shift from character to character with each passing chapter.  There is movement backward and forward in time. The backdrop changes with the suddenness of the movement of scenery between acts in a play. The lives of the characters branch out in many directions, venturing into uncharted territory and intersecting unexpectedly at key moments. The prose and the imagery are textured to match each character. However, all the elements cohere, creating the experience of reading in a lived world. 

The trajectory of each parent evolves darkly over time. Dickie is blackballed because of an identity he has kept secret all his life. Imelda becomes increasingly desperate, and her actions become more and more unhinged. The two children can only turn to one another to fill the gap left by their wayward parents. As disaster draws closer and closer to Dickie, he partners with a  laconic neighbor to build an underground bunker in the woods to survive the coming Armageddon. Don’t say I didn’t warn you. 

This 643- page book is extraordinary.  When I started it on the strong recommendation of my dependable oldest daughter, I was unsure if I would have the patience to persevere to the end. But this is an all-encompassing novel. Paul Murray has created a world, hauls you into it, and hurtles you forward into the turbulent stream of the characters’ lives. The artistry is astonishing. The setting, the interior monologues, the conversations, the actions are aptly described. 

The story has an air of inevitability to it, which brings me to an aspect of this book that made it truly special: do things happen in the world at random or is everything linked in a deterministic web of causation? The classic expression of the determinist view is — if one single monarch butterfly flaps its black and orange wings in New York, then the subtle change in air flow in the Big Apple is passed along across the Atlantic, through Europe, across Asia in countless incremental steps and culminates in a monsoon in Bangladesh. The bee sting that furnishes the title for Murray’s novel is a seemingly innocuous event on the day of Imelda and Dickie’s wedding. But in the world of the book, it unleashes  a sequence of events for each member of the Barnes family that defines their destiny. It seems as if they are trapped in a dense web  and cannot escape the forces driving them forward to their ultimate doom. Yet, each character confronts moments of crisis, episodes of personal vulnerability and they make choices. They fail to answer the phone call, they opt to go to the party, they invite relatives to visit. Who or what is controlling their fate?

Philosophers have traditionally debated and continue to argue whether free will is a reflection of reality or whether it is a convenient delusion. We may never fully know or comprehend why things play out the way they do in each of our lives. It may always appear as if we are being moved around by relentless forces that are bigger than and invisible to each of us. At the same time, we feel that we have agency. That is the mystery of life. In a novel, there is an inscrutable controlling power, the author who is the puppeteer manipulating all the movements of his characters and the story. She can make events play out in whatever way she thinks best matches her vision of the paginated world. But good authors know that they must create human characters and not marionettes. They have to walk the philosophical tightrope between determinism and free will. Within a tightly constructed literary universe, authors must create a world in which the narrative captures the larger forces buffeting  the characters drawn on the page, be it climate change, immigration to a new county, or the outbreak of war. But there must be space for the characters to behave as recognizable people subject to the consequences of their own choices or those of others. When authors succeed, the readers of their books realize that have been offered a precious insight about what it means to be fully human. No one has done this better than Paul Murray in this monumental book.

THE BEE STING
Paul Murray
Farrar, Strauss, and Giroux
New York, 2023 pp 643

Photo credit: Boris Smokrovic

Born in Berlin to a Jewish father and a Christian mother, Harry Benjamin (1885-1986) became a physician in 1912 at a time when German physiology and medicine had much to celebrate. He ended his days in New York City more than a century later, a much lauded, if controversial founder of the entirely new field of transgender medicine. The path was not easy as his own transitions were often painfully turbulent: bullied as a schoolboy for being neither Jew nor Christian, shunned in wartime America for being German, accused of quackery for being an advocate of glandular therapy. And he transited the Atlantic many times always both at home and alien on two continents. Nevertheless, he kept his faith in the miraculous effects of hormones and held fast to an undiminished will to help people live happier lives. 

Using intimate diaries, letters, and interviews in both German and English, Alison Li has written a sensitive, insightful biography that not only traces this remarkable life, but also tracks the birth of endocrinology and the advent of an unprecedented discursive consciousness that challenged social norms. Her earlier biography of J.B. Collip, biochemist of insulin fame, provided her with extensive knowledge of emerging hormones; she handles the technicalities with deft, accessible prose.  

From witnessing the “resurrection” of a moribund patient with dried thyroid medication, Benjamin was captivated by the potential of hormones to bring even the sickest of people to perfect health. Initially intent on the rejuvenating possibilities, he thought of his work as “gerontotherapy” –treatment of the elderly – not so much to live longer but to live better. He became a devoté of Eugen Steinach and his procedure – which aimed to enhance hormone production of the gonads by suppression (through X-irradiation) of their competing elaboration of eggs or sperm. As the female and male hormones became commercially available as pills, they were added to the protocol. Inevitable slippage led to equating (or reducing) these goals to enhancing sexual prowess and attractiveness. 

Along the way, Benjamin encountered many prominent figures, and we read their impressions of each other. Havelock Ellis, Alfred Kinsey, Robert Masters, and Robert A. Wilson make appearances. The semi-autobiographical novel Black Oxen (1923) of his ever-loyal Californian patient, Gertrude Atherton, proclaimed the power of glandular therapy to a wide public and cemented Benjamin’s reputation for dealing with problems of sexuality. From listening carefully to each patient, he realized that the socially pervasive male/female binary failed to reflect individual identifications and orientations; gender was not a duality but a spectrum. Language had to evolve too and that is another theme of the book.  

Married to a much younger woman, Benjamin consulted Sigmund Freud when his desire for her waned; however, thinking of himself as a courtly ladies’ man, he was offended by Freud’s suggestion that he could be a latent homosexual. The experience conditioned his mistrust of psychoanalysis. Choosing physiology over psychology, both men, we learn, underwent Steinach’s treatment.  

With an office in New York City and later a satellite in San Francisco, Benjamin moved in a heady circle of artists, writers, politicians, and intellectuals—striving to find comfort in their own identities. He viewed the source of what became gender dysphoria as something biological.  Instead of fixing the mind, he sought to repair bodies to match minds. For some, peace came from simply living as one of the opposite sex, for others it was hormones, and eventually, for some, it was surgery. Benjamin befriended Christine Jorgensen and collaborated with a few surgeons willing –even eager–to develop operative interventions that resulted in physical sex change. After their transition, he continued to follow his patients to understand if and how the procedures had helped their quality of life. 

Always in private practice, never associated with academe except through research organizations of his own creation, Benjamin was dismayed by how his work was shunned by the medical establishment. From 1929 to 1935, he waged a lengthy lawsuit against Morris Fishbein the crusty leader of the American Medical Association for having disparaged him and his work. Benjamin wanted a retraction and an opportunity to explain in the pages of JAMA how his treatments were based in scientific research. He never got it. 

Nevertheless, at the end of his long career Benjamin witnessed the establishment of gender identity clinics at universities beginning with John Hopkins University and extending to some twenty sites by the late 1970s. He also witnessed their numerous closures in the 1980s as a struggle was waged between those who saw gender dysphoria as a mental illness– not deserving of physical intervention, and those who followed Benjamin’s pragmatic, biological approach.   

With curiosity and tolerance, Li probes the convoluted path of Benjamin’s career. She recreates the atmospheric ambience of exotic pre-war Berlin and the heady optimism of post-war America. She privileges the stories and perspectives of well-known trans people –Renée Richards, Reid Erickson, Jan Morris and many others. Without defensiveness, she presents the current criticisms of Benjamin and his so-called “standards” that had been generated to guide the medical approach to people with gender dysphoria. She treats the critics with the same attentive balance and consideration that Benjamin gave to his patients.  

As a physician, Benjamin could scarcely formulate solutions to the distress of those who sought his help in any way other than through a disease model. His efforts brought their plight out of the shadows of deviance and crime to the attention of well-intentioned minds who applied pills and procedures to serve their complex needs, empowering them to live openly, and enabling them to eventually reject the disease model entirely. Trans is diversity—one of many to populate the postmodern world. This is a very good book. 

Wondrous Transformations: A Maverick Physician, the Science of Hormones and the Birth of the Transgender Revolution   
Alison Li
Chapel Hill NC: University of North Carolina Press, 2023 

https://uncpress.org/book/9781469674858/wondrous-transformations
https://alisonli.com