This podcast and transcript was first published on Mad in America on November 6th 2024
Rose Cartwright is a screenwriter and the author of Pure, a hugely successful memoir which was then turned into a series for Channel Four. She is also a writer and producer on Netflix’s 3 Body Problem. Pure portrayed Rose’s autobiographical account of finding that she had OCD, a “mental illness”, and the breakthrough that this medical framework provided her. This was short-lived. In her new book The Maps We Carry, she writes about the dawning realization that the “illness” story she had believed in and publicly advocated for, was wretchedly incomplete and often dangerous.
In this interview, Cartwright charts her journey of painful and lonely disillusionment with the “mental illness” framework. She talks about understanding the place of her own childhood trauma and also the limitations of simplistic trauma narratives. She speaks about the place of psychedelics and meditation in helping her uncover her disconnection, eventually to realize the importance of trusting relationships and communities. In this brutally honest book and interview, Cartwright reflects on the importance of holding all our understandings around mental health and suffering, lightly.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: You wrote ‘Pure’ about your experience with intrusive thoughts and the diagnosis of OCD. It was then turned into TV show. At that point you were a huge advocate of the medical model of understanding human suffering. But things shifted — you write that you were confronted with information and experiences that challenged this understanding. First, could you tell us briefly about your struggle with intrusive thoughts?
Rose Cartwright: Around 15, I started experiencing vivid and graphic intrusive thoughts of a sexual, violent, and harm-related nature. These images started coming into my mind almost nonstop, hundreds of times a day, and they were profoundly terrifying and shameful. Their content was deeply disturbing and I didn’t tell anybody because I was ashamed. This continued into my 20s.
There were other problems that went alongside the intrusive thoughts; there was self-harm, bulimia, lots of control behaviors, a great deal of anxiety, and suicidal ideation. I was in a really difficult place. I was searching for answers. I didn’t understand my experiences and I was lost. I started to Google intrusive thoughts to find if there were people experiencing the same thing as me. I found that intrusive thoughts are a common symptom reported by people with OCD. I started reading about obsessive compulsive disorder, and it seemed to fit so, so well. I learned what I was doing was compulsive behavior.
It all seemed to make a great deal of sense. Alongside these revelations came a medical framing of the whole experience. So, not only did I now have language — ‘obsessions’ and ‘compulsions’, but also a psychiatric diagnosis and a whole set of assumptions as well — OCD is something that is experienced by hundreds of thousands of people around the world, which it certainly is, but also that this is a brain-based problem, that it can be explained by theories of neurocircuitry and serotonin imbalance, and that targeted medications and therapies can help with those symptoms. The whole framework was illness.
I bought into it and in Pure, I wrote about the experience of intrusive thoughts and internal compulsions, and that resonated with people. But what I was also promoting was this medical way of seeing my problems, that my OCD had arisen spontaneously when I was a teenager – completely decontextualized, like the symptoms of a cold. It’s a story that didn’t serve me for very long.
Dhar: That makes sense. We are provided with a meaningful framework that gives us language, a causal explanation for why this is happening, and also some hope for alleviation of suffering. You say that you used this medical framing but eventually began to rethink this understanding of human distress. What happened that made you go – “Wait, this is not serving me. Maybe I don’t buy into it anymore”?
Cartwright: There was a series of catalysts. It was an intellectual and an emotional shift. The most blatant thing was realizing that I wasn’t getting better. The diagnostic model had provided relief but it had been temporary. Discovering other people with OCD had felt like a life raft but in the long run my problems kept returning. How I characterized it at the time is I kept on relapsing, this illness kept on coming back. There was a sense that “I’m not sure that the model that I’ve bought into is getting to the heart of what’s wrong for me”. But I repressed a lot of those doubts. There wasn’t anybody in my circle who was questioning this.
Another catalyst was an intellectual one. I went to Trinity College Dublin to interview a neuroscientist called Dr. Claire Gillan, a brilliant professor. She explained to me that OCD isn’t a biological reality. That was a very difficult thing to hear because my identity was built around the idea that OCD is a biological phenomenon where the brain is distinct from people who’ve got depression or anorexia.
She’s not saying that OCD isn’t happening at the level of the brain, of course it is. When my OCD was at its worst, if you looked at my brain, you would have seen neural correlates. What she was saying is that there aren’t biomarkers that distinguish DSM diagnoses — that was news to me! I thought the DSM was based on biological data. I realized that I was mistaken about a lot of my assumptions about what we know about mental health. We know much less about the brain than a lot of people in the mental health advocacy space realize.
Dhar: Yes, people have this idea that if it’s not biological, the pain can’t be serious or real. Tell me about this experience of disillusionment, from diagnosis being a huge part of your identity, and it happens to many that they become attached to it and molded by it, and then to have the scales fall off your eyes.
Cartwright: It was a lonely one because I spent several years becoming very bedded in as an OCD advocate, and that community is founded on assumptions with a very biomedical worldview. There wasn’t much space for another way of seeing the problem of obsessions and compulsions.
Dhar: Eventually you found the trauma model that talked about extreme childhood stress events, and it explained a lot of your suffering. Tell us about what you found helpful about this view that your OCD was partly caused by early childhood stress.
Cartwright: When I started doing high dose psychedelics, what emerged from those experiences was a crystal-clear realization that had always been lurking in my peripheral vision — that my severe mental health problems were influenced by the fact that my mom was severely depressed throughout my childhood, had been given a diagnosis of bipolar disorder, and was repeatedly being admitted into psychiatric hospitals. At home there was a constant level of ambient chaos. I saw a lot of distressing things when I was very young and into my 20s. It makes sense that that a young psyche would go to extreme lengths to manage the stress.
Dhar: You also write that there are certain problems if we adhere to the trauma model too rigidly, which is a focus on this singular lens of trauma. Sometimes looking only at trauma can be a barrier in seeing the role systemic factors to play in our distress. Could you talk about the issues with using the trauma model rigidly?
Cartwright: Sometimes the trauma model can be too focused on single issues. It can hold a magnifying glass over childhood relationships, as important and influential as they are, without looking at the broader context in which those relationships are nested. My mom’s distress was impacted by everything going on around her. My dad was out of work; I was raised on benefits and there was a huge amount of financial stress. The school system was very poor, my brother had a lot of behavioral and learning difficulties, and he was not being supported.
In one sense you could say that my distress was caused by having a difficult relationship with mom as a result of her illness, but in another sense, you could say that my distress is actually reactive to a much broader set of social, national, even international stressors. The trauma model can be slightly limiting if it turns our parents or our caregivers into pawns, in simplistic psychological stories, in simplistic ideas of cause and effect, because it’s never simple.
Dhar: Your first experience with an altered state of consciousness was spontaneous and not psychedelic induced. Let’s get into that story.
Cartwright: Around the same time as this shift was happening in how I saw mental health, I got into Vipassana meditation. I was desperately looking for answers. My OCD had relapsed. I couldn’t believe I was back at square one after a book and a TV show that told my redemption story. It was unbearable. I wanted to explore meditation. I dived in at the deep end and went on a 10-day silent meditation retreat in California.
The retreat hosted by Josh Goldstein. The first three days were hell on earth. When you’ve got intrusive thoughts hundreds of times a day, sitting with those thoughts is a very challenging thing to do. On day three, something very interesting happened. I started to have an experience of altered state. I had never taken psychedelics, but I had a two-hour long experience of a non-duality, white lights, feeling like the boundaries of my body were eroding and blending with the cosmos, a sense of overwhelming love, a sort of an impersonal love that extended to all beings. My mind was absolutely blown by this!
It was the first time in 15 years that I had been liberated from intrusive thoughts.
It also didn’t fit with my understanding of mental health problems at the time, that I had a disease. In the wake of this experience, I thought (A) what the hell was that? I hadn’t taken any drugs. I didn’t know that those kinds of states were possible. (B) if I’ve got a disease how can the symptoms just spontaneously subside for a couple of hours and then return?
Dhar: That’s where psychedelics enter right? What has been your experience with psychedelics? What have they offered you?
Cartwright: I started reading and there is a lot of overlap between the brains of experienced meditators and the brains of people who are post high dose psychedelics. I started speaking to psychedelic healers, neuroscientists, and psychedelic researchers about what was going on during the psychedelic experience. Why is it so strange, mystical?
I’d kind of glimpsed behind the curtain at a version of existence that was possible beyond the misery that I’d been locked in for 15 years. I wondered if there might be other routes into that place. I decided to take the plunge and do a high dose of psilocybin (magic mushrooms) in Amsterdam with guides. It was that trip which blew the doors off the medical model. In that trip, I watched my mom, the essence of my mother, get sucked into a giant black hole in the sky. I was just sobbing and begging her not to leave me, not to leave me here alone with this pain. I came away realizing that that was pain that had been lurking under the surface of my experience since I was a little kid.
Dhar: That sounds terrifying and painful. I have had a similarly educative but terrifying experience.
Rose: Educations are like that. It was a profoundly terrifying but valuable experience.
Dhar: I want to talk about people’s expectations. You write about how people go into therapeutic psychedelic experiences with expectations that “I will find my trauma”. Afterwards they might cling too tightly to a story and it becomes this rigid fixed identity, just like a mental disorder diagnosis. You write this is also problematic. What’s a good state of mind for someone to enter a therapeutic psychedelic experience with?
Cartwright: Often the framing of psychedelic experiences is that you’re going in to explore your trauma, feel all the pain that you repressed when you were a little kid, release that pain, and come out feeling better. It can be simplistic. Psychedelic experiences tend to surprise you. It’s a good idea to let go of any assumptions of what you’re going to find, and really surrender to the unknown and to uncertainty.
I wrote about the Zen Buddhist concept of Shoshin, a beginner’s mind, trying to let go of any preconceptions and expectations of an end results. It’s important both in terms of going into an experience and in terms of integrating experiences afterwards. If you go in with the expectation that everything that comes up is to be interpreted literally, you can run into problems because some of these experiences are extremely esoteric, often very metaphorical. You might have something that feels like a memory but perhaps isn’t. It’s very difficult to navigate if you’re trying to arrive at an objective truth about what’s happened to you.
Hold conclusions with love but lightly. Use any conclusions that you come to about your psychedelic experience until they are helpful, but don’t let them calcify and become part of your identity. You don’t want to walk around like a traumatized person. You want to be reborn in each moment. That’s the whole Buddhist philosophy.
Dhar: That was my favorite part, the gentleness. You write that you worry about how psychedelics are getting co-opted by pharmaceutical industries. Tell us more.
Cartwright: I do an exercise in my book where I speculate that if psychedelic therapy been available to my mother when she was at her worst, would it have been helpful? She was spending months at a time in bed, sobbing at the dinner table, crying at night — catatonic, unable to experience her life, let alone enjoy it. It could have been helpful to a certain extent. But after the trip she would still have come back to the stress of trying to feed a family of six on low income and benefits. She would still have been isolated. My dad would still have been out of work.
My concern with the medicalization and industrialization of psychedelics, and these very profound experiences being turned into protocols and interventions, is that they don’t actually address the social determinants of distress that lead to a huge amount of trauma in the first place.
Dhar: One of the final realizations in your book seemed to be that psychedelics were important, but it was eventually about community, people, relationality. Something about community helped as you had your main psychedelic experience with others, right? What did you find about the place of others in this whole process of healing?
Cartwright: One way to conceptualize how those experiences were healing to me is the way they changed my brain. Another way is I was able to re-experience and let go of repressed emotion related to my traumatic past.
Another way to think about it is that I went into those experiences, and was able to, because I worked with guides and in a group. I was able to fully let down my defenses in front of other human beings for the first time. Afterwards I was able to sit and be extremely vulnerable with people who cared, could be relied upon, and who would be there for me in the following weeks.
Where the healing comes from, that’s a really complex question, but I think that last part is as important as the rest.
Any psychiatric or psychological intervention counts for nothing unless we’re held in trusting, loving relationships. What beats under every mental health problem is that we want to feel safe and loved. Unfortunately, the way that we live gets in the way of that core need.
One of the things that came up in these psychedelic experiences was loneliness — there’s no one coming, and there’s no one that I can reach out to. I think that was a hearkening back to real desolation I felt as a kid. My mental health is dramatically better right now and I put it largely down to psychedelics but in another way, psychedelics opened up another wound in that the loneliness. It’s appropriate to be lonely in the world that we live in right now, and psychedelics don’t solve any of the conditions of modern life that contribute to our loneliness — the fact that we live in a consumer society, are atomized from those we love, from other generations, the fact that we don’t live in community.
The next layer is dealing with that existential loneliness and treating it with tenderness, and not expecting it to go away. I don’t consider it a mental health problem to feel lonely when I live in London.
Psychiatrist Bruce Perry talks about relational poverty — a lot of people in the West, we have a huge amount of privilege and political stability compared to a lot of the world but we paid a really high price for our financial stability. Where we used to have strong communities, we now have strong markets, and I think most of us have just normalized isolation. Psychedelics can lead one to become disillusioned with modern life, and that can be difficult.
Dhar: Thank you. Let’s change gears. More than a year ago, Joanna Moncrieff and her colleagues published a huge umbrella review that dealt a final blow to the serotonin theory of depression. Many psychiatric experts scoffed saying “well, of course, we’ve known about this for decades”. You write that there is a huge gap between this expert reaction to the article and that of the actual public. Please speak about that.
Cartwright: I encountered dismissiveness along the lines of “of course, no one believes in the serotonin theory of depression anymore. Why are you even talking about this stuff? You’re just knocking down a straw man.” I sat there thinking, hang on a second, you guys in your ivory towers might have figured out the nuances, but these simple stories were disseminated by the psychiatric industry for decades because they were profitable. The vast majority of the public still buy into them and into the products of that industry.
The psychiatric community claims to have moved on to a biopsychosocial approach, but the story that is out there among most people on the street, is that depression is caused by a spontaneous malfunction in their brain. How can the psych professionals can be so dismissive of ideas that people who went before them put out into the world. I think it’s their responsibility to provide the corrective.
We know very little about the brain, but we do know that the brain reacts to the environment, and that people’s emotional health reacts to environmental conditions. I think there’s a duty of care that is not being done.
Dhar: I reported on an international psychiatric conference in India which took a public health approach. For three days, we talked about structural determinants of mental health (poverty, discrimination, violence etc.); it was amazing. But there was no conversation about treatments or interventions. When I asked about it, they went back to “antidepressants have shown promise”. I wanted to pull my hair out. So, let’s shove a pill down this farmer’s throat whose distress is caused by climate change, exploitative money lenders, pro-corporation policies, where he can’t feed himself and his family. This trending conversation around structural determinants doesn’t translate to practice when it comes to interventions.
Cartwright: I think you’re absolutely right. Part of the problem is that medicine has a very important but quite small role to play for the most seriously mentally unwell. The structural and policy changes we’re talking about, it’s not a doctor’s job. Well, there’s social prescribing — the doctor basically gives you a directive to join a social club or a sports team. But you don’t need a medical degree to do that. We’ve always known how to live in community.
Dhar: My last question is a comment. This is the pattern I found in the book — you wrote about the biomedical model, the trauma model, use of psychedelic therapy, and relationality, and at every point you also talked about the limitations. For example, everything reduced to personal trauma might limit a person’s ability to see larger systems, or the way psychedelics can be co-opted. There is a very thoughtful and nuanced take around these topics. How did you reach this careful, tentative, and complex understanding?
Cartwright: My meditation practice has been very instrumental. Meditating is not just about feeling better. It’s also about learning how to think and realizing how we get attached to our thoughts and ideas, and then they become part of our identity. One thing my Buddhist teachers do is they tread very softly with ideas. They encourage you to think critically about your own assumptions; if something feels really true and solid, just stay with that and see if it changes.
One thing that characterizes the harmful practices in psychiatry and psychology is an imposition of a simple story rather than a facilitation of self-inquiry. You go to the doctor and you’re offered a simple solution. I didn’t want to contribute to that.
I see the same thing in trauma narratives — everything that you feel is about your relationship with your dad or mom, and none of this is sufficient. What is helpful to me is to foster a cognitive flexibility — cultivate uncertainty because I’m guilty of being dogmatic in the past. I don’t want to make the same mistakes again.
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