Awkward Intimacy

Psychiatry was treating its patients as biological machines. That was George Engel’s fear in the 1970s when he proposed the biopsychosocial model: an insistence that biology, psychological history, and social context are three dimensions of a single illness. In practice, the “bio” colonized the triad. The “psycho” and the “social” became background noise. Modern psychiatry has become a pharmacological and diagnostic science rather than a relational one—organized around the fifteen-minute medication check, the symptom scale, the binary safety question. We have learned to ask whether a patient is a danger to himself or others. We have not learned to ask whether he is loved.

In the decade between my first major mental breakdown and my arrest on felony charges, my illness followed a trajectory I have come to describe in cosmological terms: an event horizon, where the ordinary laws of my life began to bend; a supernova, the spectacular detonation of a manic psychotic break; a black hole, the years of collapse and incarceration; and a nebula, the slow coalescence of new elements into recovery. But within that arc lies a story that psychiatry and the broader mental health system, in their current form, are poorly equipped to tell—one about the role of human connection in driving illness forward or making recovery possible.

Loneliness is not merely a feeling—it is a social wound that disrupts the mechanisms by which the self is regulated and known. When it goes untreated, it does not simply accompany mental illness. Research now suggests it helps cause it. And in a culture that has organized itself around technologies designed to simulate connection without requiring it, the injury compounds while remaining almost entirely invisible.

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For several years, my daily companions were a seventy-pound Rottweiler-Lab mix named Chance and a Jack Russell-Beagle mix named Salvador, a few grams of marijuana, a PS5 controller—specifically for the game Elden Ring, which I played for months with the focused attention I had nowhere else to put—and my phone. That was, with only modest exaggeration, the full inventory of my social world.

I had once been the person who stayed at the party until the hosts began washing dishes—the center of friend groups, the one whose arrival raised the energy in a room, the historian who animated lecture halls. I was gregarious, adept at floating among hierarchies of power, cultivating friends across circles that rarely overlapped. I imagined myself jovial, acerbic, capable—a particular kind of man who could make a room feel seen and leave it wanting more.

The first psychotic break came in 2016, in Chicago, in the middle of what should have been the ascent of my academic career. What followed was four years of misdiagnosis—major depression, one psychiatrist decided, though I had never been depressed a day in my life—and the first of three involuntary commitments before anyone got the name right. After that break, that person disappeared. The extrovert became a ghost who haunted his own apartment. I feared judgment for my failures, told myself relationships were messy, convinced myself the dogs were sufficient company and sealed the door.

My mother, a nurse and bioethicist, watched it happen from a distance I had imposed. She kept a journal of my illness across those years—clinical, dated, exact—while the illness took my friends and then my family’s access to me. My brothers receded. She stayed at the perimeter and refused to leave it.

What I did not understand was that I wasn’t just unhappy. I was making myself sicker. The psychiatric genetics researcher Jehannine Austin has put it plainly: “what separates those of us who do suffer from those of us that don’t is what happens to us during our lives.” Loneliness, sustained and unaddressed, is something that happens to you.

For two years—2020 into the summer of 2022—my father and I lived together. He was a few years into his Parkinson’s diagnosis, the disease advancing with the patient logic of a tide. It had not yet taken his speech or his independence, but it had begun to take his expressiveness—the subtle channels through which a person communicates presence to another, the tone and warmth that tell you the other is genuinely there. What the disease progressively confiscated was not my father’s love but his capacity to transmit it in the registers I could receive.

Every day, we each retreated to our phones. He scrolled sports scores and news; I disappeared into apps and games. I slept on a mattress on the floor, no frame, at thirty-six years old. Some evenings the only sound in the apartment was Chance moving between us, the one resident still fluent in both our languages. My former stepmother Melissa and her daughter Melanie stopped by to clean, aware that my father and I were no longer capable on our own. I remember the sadness on their faces when they saw me—the look people wear when they realize the person in front of them is both present and not. Two people who loved each other, separated by ten or fifteen feet and a silence neither knew how to cross. I was theorizing, in those months, about social media’s effect on intimacy—a manuscript I would eventually abandon—while my father and I were enacting precisely the dynamic I was writing about, too close to see it.

Daniel Siegel, the neuroscientist who developed interpersonal neurobiology, argues that the mind is fundamentally relational—that it emerges not just from within the brain but from the space between brains, from ongoing attunement with other minds. Johann Hari writes that loneliness hangs over our culture “like a thick smog”—present everywhere, noticed by no one because everyone is breathing it. What he means is not that we lack company but that we lack recognition: the experience of being seen by another mind that registers your interior states as significant. My father and I were in the same apartment. We were profoundly alone.

This is the paradox I want to sit with. My father and I had proximity. We had love—real, durable, the kind that had sustained years of difficult history. What we could no longer give each other was attunement: the experience of being genuinely met by another nervous system, of having your interior states registered as significant by another mind. We were present to each other the way strangers on a train are present—in the same physical space, each sealed inside his own world. The psychologist John Cacioppo spent decades documenting what sustained loneliness does to the body: it does not merely sadden us but biologically destabilizes us, heightening the stress response, eroding immune function, fragmenting sleep, and distorting the very social cognition we would need to reverse the damage. Loneliness begets more loneliness, rolling downhill toward a colder and colder place. For older people navigating serious illness, chronic loneliness raises the odds of death in any given year by twenty-six percent. What my father and I were doing—substituting devices for each other—was not neutral. We were feeding the mechanism of our own deterioration.

By the summer of 2022, when his disease had progressed to the point where he needed assisted living , I found myself alone not just in a figurative but in a literal sense. The apartment I had shared with him was no longer available to me. In the wake of my untreated illness and perceived failures, I had cocooned myself from friends and family, wrapped in a shame that felt impenetrable. It seemed easier, somehow, not to try at all—to avoid the friction that produces connection and love, the same friction that chafes against a mind in pain. His departure—slow, incremental, the last of the human tethers loosening—left something that I can only describe as an ecological silence. The social architecture that had given my life its minimum of structure was gone.

In the two years that followed, the dogs became everything. I built my days around them: the morning walk along the chain of lakes that rings Madison, Monona Bay on one side and Lake Monona on the other, the thin spine of the isthmus beneath our feet. Both dogs knew every fisherman who worked that stretch of water—the older men nursing cans of Natural Ice and trading tales of the ones that got away, and their female companions who usually held the rods while the men held court. Chance would approach a fisherman with the gravity of a dog who has decided someone is worth knowing; Salvador would hurtle ahead and double back, the world still astonishing at every turn. The men and women sometimes rewarded them with pieces of catfish or perch. That exchange—man and woman, beast, water, salt, gratitude—was the most uncomplicated social transaction I managed most days.

I told myself this was enough. Dogs love with a totality that humans rarely manage and never sustain. In return for food and attention, they offer unconditional presence—no performance required, no history held against you. “The love of a dog is a pure thing,” Michel Houellebecq has written. “He gives you a trust which is total.” I had betrayed so much that year that the dogs’ fidelity felt like the only reliable data point about who I still was.

But dogs cannot mirror you. They cannot tell you what they see when they look at you. They cannot reflect your interior life back in the form the nervous system requires. What I wanted was to be known. 

Then there was Grindr, and the ruse it enacts.

Gay networking apps arrived with a genuine promise: for gay men in places without urban enclaves, these apps offered a real means of finding each other. That founding logic is not cynical. It names something true about the loneliness of queer life in a heterosexual world.

But what Grindr delivers is something else. I spent real time on it during those cocooning years, and what I was doing was executing a perfect simulation of the connection I was starving for while ensuring I would never actually encounter it. I had worked hard to rebuild my body: the gym was one of the few things I still did outside the apartment, and I put serious effort into recovering the physical form I’d lost in the worst years of depression. It worked. The body returned, and with it came the attention on Grindr that a better body produces. More messages. More interest. The metric moved.

I remember a night in that stretch: the apartment dark, the dogs asleep, the grid glowing in my hand. The inbox was full—a series of images cropped at the neck, the blurrrp of each notification calibrated to arrive with just enough unpredictability to keep me reaching. I answered some. I ignored the rest. Sometime after two in the morning I closed the app, lay back in the dark, and understood that I was lonelier than I had been before I opened it. The metric had moved and nothing else had. 

That was the ruse I had not seen coming: increased attention was not increased connection. More people registering my existence did not mean anyone knew me. The attention was calibrated to an image, a projection curated to attract, and what it attracted was more of the same. The neurobiological machinery that requires recognition registered none of it. The hunger persisted. The scroll continued. What I wanted was love, mutual recognition, the experience of being known by another person over time. What it offered was attention, dopamine, the fleeting relief of being chosen. We pursue what we think we want rather than what we need, and technology is engineered to make the gap between those two things invisible.

This is not a moral argument against gay app culture. It is a neurobiological argument about what these encounters provide and what they withhold. Siegel’s interpersonal neurobiology is unambiguous: the mind stabilizes through attunement—the kind that requires presence, vulnerability, time. A screen can deliver stimulation. It cannot deliver resonance. Jonathan Haidt’s research documents the broader cultural version of this same dynamic: smartphones and social media substitute passive consumption of curated lives for the friction and reciprocity that real relationships require—producing record levels of anxiety and isolation in a population more digitally connected than any in history. What I was doing on Grindr, and with Elden Ring, and on my phone while my father disappeared into his, all belonged to the same category. We were reaching for the sensation of contact without the cost of it. And the cost, it turns out, is the mechanism.

The cost, in my case, also had a date.

The arrest came on an October evening in 2024, mania’s terminus. I had stopped sleeping; a workplace grievance, real in its origins and monstrous in its manic elaboration, had swallowed my judgment, and the emails I sent in those final weeks frightened former colleagues who had done nothing to deserve fear. When the officers came, I was arrested in early autumn air, barefoot and nearly naked, wrapped in a bright blue towel. My first request was that they call my mother—the woman I had told, two days earlier, that I never wanted to speak to her again—to ask whether she would take the dogs. I spent the four months that followed in the Dane County Jail and ten more at Mendota Mental Health Institute, and I want to say something about what the treatment across those fourteen months did and did not address. But Mendota was not the first time the system failed to see that the isolation was part of the illness. . 

The jail offered its own instructive irony. Every inmate was furnished with a personal tablet—a small device you could use to call loved ones (for a fee), order commissary, or take courses on meditation and the solar system. It was, in its way, impressive. It was also a perfect emblem of the same dynamic: the gesture toward connection fully mediated by a screen, the human need for contact routed through a device that could simulate its form while supplying none of its substance. Foucault called jails and prisons the castles of conscience, but this one had WiFi.

From my first involuntary commitment in 2016 through two more in 2017 and 2020, and through hospitalizations for alcohol abuse in 2018 and 2022, social disconnection was never factored into any treatment plan. Clinicians assessed symptoms, adjusted medications, discharged me into the same social void from which I had come. The most consequential failure was in 2020, when I finally received the correct diagnosis—bipolar disorder, after four years of misread symptoms—and was discharged without any effective family support, without love embedded in the plan, and with the anosognosia still fully intact. Anosognosia is the neurological condition in which damage to the brain prevents recognition of one’s own illness, not denial, not stubbornness, but a literal failure of self-perception. Whether or not the psychiatric team in 2020 suspected this, they discharged me without integrating my family, without ensuring I had support that might have compensated for what my own brain could not perceive. I went home and flushed the mood stabilizers and antipsychotics—a regimen that had, in quick order, added close to thirty pounds to my frame and that the manic mind required no further argument to reject—and spent the next four years in the slow-motion catastrophe the diagnosis should have interrupted.

The biological care at Mendota, where the spell of anosognosia broke and I accepted treatment, was real. My lithium was monitored and calibrated. Without it, I would not have been stable enough to engage with anything else.

But the relational ecology the research identifies as central to psychiatric recovery was an afterthought. Treatment team meetings organized around binary safety questions—Do you have thoughts of harming yourself? Do you have thoughts of harming others?—asked at every meeting with the regularity of a procedure, not an inquiry. In those meetings I could feel myself becoming a chart: a set of answers to two questions, recorded and filed. Whatever else I was—son, brother, historian, a patient trying to understand what his mind had done—stayed outside the door. My history of isolation: years in an apartment with dogs and a screen, failed attunement with a dying father, severed relationships with my mother, my brothers, my colleagues, and virtually every friend I had accumulated across four decades—none of this entered the room. 

The unit mandated fifteen minutes per day of peer interaction, but the contact had to take the form of structured activity—a card game, a board game, something countable and reportable. An actual conversation didn’t qualify. Neither did touch: you could give a fist bump, but a hug—the oldest signal of safety one nervous system can send another—was contraband.  

Nor did the content of those peer interactions ever surface in treatment team meetings, where they might have carried weight alongside the crude binary of safety questions. The insights that emerged in sessions with Dr. Laura—the unit’s psychologist who asked about shame and about my mother while the unit psychiatrist asked about medication compliance—were noticeably absent from the monthly, programmatic team meetings. The institution had operationalized the same simulation that Grindr operationalizes: the form of connection, stripped of any acknowledgment that depth and continuity are what make contact therapeutic and meaningful.

What the institution also failed to account for—and what I think of as the deeper structural failure of both jail and the hospital—was continuity. In jail, the sociality on offer was Yellowstone marathons and Spades games, an endless repetition of shallow interaction organized less around real exchange than around the desire to belong to what C. S. Lewis called the Inner Ring—the informal circle of insiders whose inclusion feels like safety. In cell block 607, I was outside that ring immediately: wrong race, wrong sexuality, wrong vocabulary for the passcodes. What I found instead was solitude dressed as company. At Mendota, the problem was different but structurally related: you might connect with a patient on one unit, only to be transferred to another and never placed with him again. Staff rotated. Units changed. The institutional machinery that mandated peer contact gave no thought to the depth or continuity that makes contact therapeutic. You could log your fifteen minutes daily for months without ever being known by anyone.

My mother—who knew my pre-illness self better than any intake assessment could reconstruct—asked to play a substantive role in my treatment. She was told that Mendota did not do family therapy. The person whose presence might have begun to repair the social isolation the research identifies as central to the illness’s persistence was declined.

The exceptions were two people who understood something the institution around them did not.

Colleen, the unit’s recreational therapist, met your eyes. She remembered what you’d said the day before. When I jogged laps around the courtyard, she sometimes fell in beside me for the final stretch—matching my pace, talking the way people talk when they are simply in each other’s company, without agenda. In those laps I was not a patient being observed. I was a person being accompanied.

Dr. Laura wore what I came to think of as her Stevie Nicks blouses—flowing, romantic, with deep V-necks and wide bell sleeves, the wardrobe of someone who had decided the clinical environment would not dictate her self-presentation. She was overextended, her caseload large and her calendar perpetually disrupted, and yet when we met she looked at me—not at my charges, not at my chart, but at me. At the medication checks with the unit’s psychiatrist—whom I’d come to call the Robot—my education, my work history, the languages I spoke, the countries I’d lived in, the people I’d lost: none of it entered the room. Dr. Laura asked about shame. She asked about my mother. She asked about the version of me that existed before the illness had its way with him. It was in that office that I began to distinguish guilt from remorse. “You’re not that version of Patrick,” she told me once. “That was your sickness.”  Together, these two women demonstrated what treating loneliness as a clinical variable—rather than an irrelevant mood—might actually look like.

They were two people. The structural logic surrounding them pointed in the opposite direction.

Healing begins with being held in another person’s mind—the experience of mattering to someone, of being known by a consciousness that holds you as significant and real. Learning to let another person’s seeing reorganize the fractured self that isolation produced is not a warm metaphor. It describes a neurobiological process—the nervous system recalibrating through sustained contact with another nervous system that remains steady, present, and interested.

My mother has been central to that work. We talk every morning, immediately after my workout—calls that run their own natural lengths, sometimes brief and sometimes half an hour of unhurried reflection. She had not stood still during my years of exile. She had educated herself on bipolar disorder, joined NAMI, learned to distinguish the illness from the person she was trying to reach through it. What those morning calls have been doing, I’ve come to understand, is re-establishing something older than language—a rhythm of presence, a daily proof that the connection the illness tried to destroy had survived the destruction. My stepfather Craig has been quietly, steadily supportive. Neither of them required me to be more recovered than I am.

The path back to the rest of the family has been more tentative, and I want to be honest about that, because the tentative nature of it is itself part of the story. My older brother Josh has not been in contact. My brother Cory has been better—genuinely better—but he has not yet sought to understand bipolar disorder in the ways that understanding requires: the reading, the asking, the willingness to let a fixed narrative become unfixed. What we have found, instead, is a side door: his daughter Camryn’s basketball games, her volleyball matches, her piano recitals. I take my place in the bleachers and watch her move across the court with the focused grace of a child who does not yet know how much the world can ask of a body. In the seven months since my release, Cory and I have had a handful of meals together. We are moving in the direction of more. One small step at a time, and each one is healing.

We have built a world that privileges stimulation over presence and convenience over mutuality. There is an American dimension to this worth naming: a culture organized around individual achievement, self-reliance, and the mythology of pulling oneself up by one’s bootstraps is a culture that has systematically undervalued the social infrastructure on which wellbeing actually depends. We celebrate the lone hero and pathologize the person who cannot manage alone—which is to say, the person who is most honestly human. Society replaces people with screens. It should not be surprising when mental illness deepens.

As a matter of public health, loneliness is now classified as a global crisis. The Surgeon General declared it an epidemic in 2023. The WHO established a Commission on Social Connection. The evidence is not obscure or contested. What is absent is a medical system that acts as if the social dimension of mental illness is as urgent as the biological one—that asks not only whether a patient is dangerous but whether she is loved, whether her social world is intact, whether the people who knew her before the illness are still in the room.

The dogs gave me fidelity without recognition. Grindr gave me visibility without recognition. My father and I had each other, and we could not reach each other. Parkinson’s took what he had to give. My illness took what I had to receive. What none of us had was anyone in the room who understood that the silence itself was part of what was wrong. 

Part of why we struggle to treat that silence is something no research report quite names: the genuine difficulty of staying present with a mind you cannot fully trust. One psychiatric resident, speaking to the anthropologist T.M. Luhrmann, explained why he preferred the prescription pad to therapy: he didn’t have to establish “this real close relationship.” He was being honest. Real care requires what Luhrmann called “awkward intimacy”—the willingness to sit with someone whose behavior has frightened you, whose perception of reality has departed from yours, whose illness has made them, at times, cruel or delusional or unreachable. This discomfort is doubled in mental illness specifically, because the stigma of psychic pain is partly the stigma of a mind that has become unreadable. We know how to sympathize with a broken leg. We don’t know how to sit with a broken mind—one that may turn on you, may not recognize itself, may send threatening emails to people it loves and later have no memory of having done so.

It is easier to adjust the medication—lithium, Seroquel, Zyprexa, Invega, the pharmacological menu long and the logic the same. Medication looks like care without requiring the exposure that care actually demands. It is measurable and clean. It does not ask you to stay in the room with someone whose reality you distrust, or to love a person who has made themselves very difficult to love, or to maintain the kind of sustained, embodied, reciprocal presence that interpersonal neurobiology identifies as the mechanism of healing. But every instinct of self-protection pushes against exactly that presence when the person you are trying to reach has frightened you. The screen offers the same escape, just from the other direction. This is not an accident of design. It is the design. 

This is the hidden cost I mean. Not just the loneliness itself, but the cultural and institutional machinery that makes real connection so much harder to offer than a pill—the stigma that makes us flinch from the mentally ill, the individualism that tells us suffering is a private matter, the technology that offers a frictionless substitute, the insurance system that pays for fifteen minutes and a prescription but not for the slow, unglamorous work of being known. 

But what heals is recognition. What sustains it is the willingness to remain in contact when contact is the harder choice. What makes it possible, in the end, is choosing the awkward intimacy over the frictionless escape—and staying in the room.