Having Half the Fun

Once, the mad were exhibited at Bedlam for the fascination of Sunday tourists; ooh’ed and ahh’ed at as examples of how the human mind can distort the civilised and rational behaviour which was supposed to be its very particular accomplishment. Lately, they are more freely available between the covers of books, described and philosophised over by neurologists, psychiatrists and therapists who, besides seeking to cure them, wish to illuminate the meaning of their mad patients for the general – as in normal – public. We are offered the chance to marvel at the way minds warp, and to feel that there is some telling connection between the warped mind and its supposed original state of sanity. There is anxiety, too, mixed with a little excitement, at the indistinct boundaries between madness and sanity, and perhaps a degree of envy, with the suspicion that the mad, agonised though they may be, are having a more interesting, or at least more significant, time of it.

It’s not hard to imagine a near-future when the neurobiologists will have identified the physiological bases for all the major mental disorders, but I doubt that, even then, we will think of them in the same way we think of physical illness. Afflictions like multiple sclerosis or osteo-arthritis do not carry the same weight of apparent meaning as manic depression and schizophrenia, for all that discrepant genes may turn out to be equally implicated in all of them. People don’t read case-studies of diabetes in the hope of gaining some insight into the nature of man’s relationship with the world, even though extreme physical illness and pain may be quite as tumultuous and alienating to the individual as mental disturbance.

Madness has always been modish: Shakespeare dramatised it; the Romantics romanticised it; the Surrealists painted it; the Existentialists philosophised with it. It is, as Lévi-Strauss said of totemic animals, good to think with – unless you are mad, of course. Then you are thought about, and so far as treatment goes, at the mercy of whatever school of belief or current trend you happen to fall in with. In the past, you might have been hosed down with icy water, had parts of your brain excised or been cut loose and sent off to the margins of society. Now, you might be given drugs, electro-convulsive therapy, paint, drama, group conversation, a strict one-on-one analysis – or be cut loose and sent off to the margins of society. You might also, if Kay Redfield Jamison and Lauren Slater’s books are any indication of present trends, choose either to become a creative artist or, if the muse doesn’t speak, train as a clinical psychologist. Nowadays, it seems, you can be a success or a failure as a mad person. As if mental disarray wasn’t enough to cope with, there are career decisions to think about.

Neither Jamison nor Slater is writing about mild neuroses: their books concern major debilitating, life-destroying mental afflictions – manic depression in Jamison’s case, schizophrenia and severe personality disorders in Slater’s. And both write about their specialties in the context of their own experience of mental illness. Jamison’s is the most overtly autobiographical, being a straightforward description of her manic depression and its management throughout her student and working life. She is a professor of psychiatry at Johns Hopkins School of Medicine and clinical director for the Dana Consortium on the Genetic Basis of Manic-Depressive Illness. She subscribes to the current view of bipolar illness: that there is almost certainly a genetic predisposition, and that it must be managed throughout the course of the patient’s life with drugs, preferably lithium.

Mood swings are something everyone is familiar with. Most people wake up on some mornings filled with an unreasonable optimism and confidence, on others with their unreasonable opposites. Unaccountable feelings of well-being are bright spots in most of our lives, gratefully received. For Marie, one of Slater’s patients, they were all that kept her from committing suicide. Marie would probably be diagnosed as manic depressive on Jamison’s criteria, though Slater sees her as a chronic depressive with sporadic remissions. She was depressed almost all the time: there were episodes often lasting only days, but sometimes longer, when she was energetic and filled with the light of the world. This is the kind of mild mania that makes unipolars mutter grimly that bipolars have all the fun. And from the outside, at least for a while, it is a most beguiling state to witness. As Jamison describes it, ‘my manias, at least in their early and mild forms, were absolutely intoxicating states that gave rise to great personal pleasure, an incomparable flow of thoughts, and ceaseless energy.’ When you see it in someone else it is hard not to want to join the party. For Marie, the mania never really gets out of control before depression intervenes. For Jamison the mania ran riot, sliding from a sense of well-being into catastrophe. Manic depression forms a continuum from surprising intermittent pleasure to cyclical disaster: where you stand on it depends on whether you have the chemistry to stop feeling good before it’s too late. Watching someone you know to have severe manic-depressive illness reach a condition of vitality and euphoria after months, or even years, of feeling low and utterly flattened by their chemistry, you are both delighted and filled with alarm. Responsibly, you must say to them, as they display real pleasure: ‘You are getting ill.’

Jamison’s delicious highs turned into classic manias, running out of control, keeping her on a 24-hour schedule, emptying her bank account on wild spending sprees, allowing her uncontrolled thoughts to spill out into the world in the form of abuse to friends and lovers, eventually wrecking her system, bringing terrifying hallucinations and a suicide attempt. She was given lithium along with supportive therapy, and the mood swings stopped, but here is the catch that all manic depressives know about and the nub of her book: the effect of lithium is to colour the world grey. It can impair memory, concentration and attention span, and make reading almost impossible. It flattens the emotions, causes you to feel physically heavy and lethargic and often makes people seem mere shadows of themselves. Jamison, like many others, found it intolerable, stopped taking it once she started to feel better – and had another manic episode.

Her experience gives her the authority to take a tough line with her patients: if you have manic depression you have it for life and there is no alternative but to take lithium. Although it is possible for some people to manage on a low enough dose for the effects to be less debilitating, the consequence is an increase in the degree of mood swing. Jamison herself opted for this solution, deciding to live with a certain amount of cyclical emotional upheaval. But it doesn’t work for everyone. Some people simply have to live with the disability that seems to be an unavoidable part of the cure. Most people are not so fortunate as Jamison in having the kind of professional and family support that enabled her, remarkably, to maintain her career as both an academic and a clinician. Her colleagues, her lovers and her professional superiors all, by her account, accept her condition, and do everything they can to enable her to continue her career and social life. Very few people with her severity of illness can have been so lucky. Those I know with the condition find their lives repeatedly in tatters, long periods in hospital and the debilitating effect of lithium making an uninterrupted career no more than a passing dream, their friends and family often alienated, frightened and simply exhausted.

It is not just the unpleasant physical effects of lithium that incline people not to comply with treatment. ‘People say, when I complain of being less lively, less energetic, less high-spirited: “Well, now you’re just like the rest of us” ... But I compare myself with my former self, not with others. I am far removed from when I have been my liveliest, most productive, most intense, most outgoing and effervescent.’ To be in the early stages of mania is intoxicating: to be ‘just like the rest of us’ is to be reduced and domesticated. Even someone like Slater’s patient, Marie, concussed by depression most of her life, subsists on the memory and hope of the brief highs when she feels ‘unbelievably alive’. Jamison, knowing how hard it is to give up the chance of euphoria, is all the more adamant that bipolar illness is a strictly physical disease which must be treated pharmacologically. She rails against ‘clinicians who somehow draw a distinction between the suffering and treatability of “medical illness” such as Hodgkin’s disease or breast cancer, and psychiatric illness such as depression, manic depression, or schizophrenia. I believe, without doubt that manic depression is a medical illness; I also believe that, with rare exception, it is malpractice to treat it without medication.’ It’s a good practical argument, and there is masses of corroborating evidence for her insistence that manic depression is a neurophysiological disease, but it is a medical illness that makes people feel at times that they are the inheritors of the universe, and the pain of knowing and having to lose that sensation is very great, while the side effects of lithium make it a desperate (if necessary) remedy.

An earlier book, Touched with Fire, written by Jamison a couple of years before An Unquiet Mind, sits uneasily though not incomprehensibly with her rigorous medical approach to manic depression. It is a study of the relationship between manic depression and what she is pleased to call the artistic temperament. She is not the first to locate the wellsprings of poetry in a diseased mind, and though she insists that talent, as well as manic depression, is necessary for great art, she nonetheless equates the ‘possession’ poets speak of with manic states. Byron, Blake, Coleridge, the Jameses, Melville, Van Gogh and, of course, Virginia Woolf are all tested, by their works and their known heredities, for bipolar illness and the findings are positive. While Jamison acknowledges that ‘there are many artists, writers and composers who are perfectly normal from a psychiatric point of view’, she focuses on those in whom she divines mental illness because ‘the fact that there is only a partial correlation does not mean there is no correlation at all.’ So I suppose you could turn the whole thing on its head, and using the partial correlation of mental health with writers, artists and composers, write a study showing sanity to be a remarkable trait in creative types.

While on sabbatical in England, Jamison conducted a survey of 47 modern British writers (using the receipt of literary prizes as the criterion, and the self-selection of those who responded to her questionnaire) and found that 38 per cent had been treated for a mood disorder, of whom three-quarters had been given anti-depressants or lithium, or been hospitalised. Further historical research shows many of the writers Jamison deems to be manic depressive to have relatives also suffering from mental illness. A genetic theory emerges which suggests that the downside of the mutation in other family members is offset by the benefits conferred on society by the positive achievements of those suffering relatives who are driven towards creativity. ‘Such a compensatory advantage ... would be roughly analogous to the resistance to malaria found among unaffected carriers of the gene for sickle-cell anaemia.’ It would be nice to think that nature regarded great art as an essential benefit in species survival, but Jamison, accepting that a genetic push for poetry is a little unlikely, explains that manic depression must also be the spur for many industrial and scientific innovators.

Even so, underlying her thesis is the irritable question that is asked of all writers and artists: where do you get your ideas from? For Freud it was unresolved, sublimated neurosis; for Jamison it is the over-excited, speedy state of mania. ‘Hypomania and mania often generate ideas and associations, propel contact with life and other people, induce frenzied energies and enthusiasms, and cast an ecstatic, rather cosmic hue over life.’ So much for where ideas come from. The other ubiquitous question is: ‘How do you discipline yourself to work?’ That’s where the depression side of the equation comes in. ‘Depression prunes and sculpts: it also ruminates and ponders and, ultimately, subdues and focuses thought. It allows structuring, at a detailed level, of the more expansive patterns woven during hypomania.’ First you soar into the realm of ideas, then you come down for the editing process.

This is not, Jamison insists, a reductive view of the artist, but an enhancement of our understanding. She is not she says, merely reiterating the stereotypical tormented artist with statstical and diagnostic knobs. ‘Seeing Blake as someone who suffered from an occasionally problematic illness ... may not explain all or even most of who he was. But, surely, it does explain some.’ This supposes that who Blake was needs to be explained. The diagnosis is of no use to Blake, because he is dead. Is it of some help to his readers? Only if, like Jamison, you feel that a diagnosed Blake gives us more than the texts he left. You can carry the diagnosis to the text, but whether that enhances our understanding of it is moot. Of course, if Blake were not dead, he could be treated with lithium, which would doubtless make it less likely that we should find him sitting naked up a tree in his garden. Would Blake on lithium have been Blake? This doesn’t strike me as an urgent question. I would sooner know in what way we think we benefit from pathologising the extraordinary. Is it because, like Jamison’s friends, we like the idea that properly medicated, the extraordinary become ‘just like the rest of us’; and that medicalised and unmedicated they are simply sick? I do wonder what dismal effect books like Touched with Fire have on those sufferers of manic depression who do not find themselves compensated with artistic greatness, but only scuppered by a dreadfully debilitating illness.

Lauren Slater has a more flowery approach to her patients. ‘My patients – borderline personalities, sociopaths, bulimics, schizophrenics of every type – are foreign, tropical, green roses and striped plants that are hard to understand. I seek their scents and sounds, to enter deeply into their cupped, closed worlds because that is the struggle lying at the core of me.’ Beneath the barrage of very distressing prose, Slater’s ‘me’ lies at the core of all these essays purporting to describe her work with the mentally unwell. Each individual, no matter how catatonic and remote from the world, is eventually understood via an insight about Slater herself. Her own emotional experiences and psychiatric history shed comprehension on all mental disturbance. Peter’s violent leather-clad misogynist is interpreted in terms of her own bout of adolescent anorexia. ‘I made my body a whitened bone, a pale blade. Like any real man, for years I lived with my fist and not my flesh. I was so hungry, but I could not risk the softness of surrender.’ They are, it seems, one and the same. So things look up for her relationship with Peter when he is shaken by the desertion of his masochistic woman. ‘And I, well, I grew to love him and love the strength of his slow surrender.’

Marie, the depressive with momentary flashes of happiness, provokes an ecstatic emotional decline in Slater: ‘I closed my eyes and dropped down. At the bottom of the hole, past the push of scalpels, lies that unalterable stone of suffering. I could see the stone now, in half-sleep – deep blue, raw coral.’ In the meantime, having tried every anti-depressant in the book, including Prozac, Marie is still trying to cope with two children and deep depression. Looking out of the consulting-room window, Slater still wonders ‘if I was taking on some of Marie’s heightened moments, some of her occasional spasms of joy. I wondered if, in travelling with me into the wound, she had, inadvertently, shown me a place of clear colour and exceptional angles.’

Joseph, a middle-aged schizophrenic, once an academic, suffers from writing mania, penning his every cluttered thought. Eventually, Slater takes his writings and edits them into what she considers to be their proper order. She creates a community of ‘me and him together ... He put his hand on my mouth as a lover or a mother might, and I let myself breathe into him.’ She is aware that she is making her sense of Joseph’s hypergraphia but ‘perhaps narratives are the one realm that cannot ever ... be confidently claimed by any individual.’ Still, Joseph is pleased to have his words typed up. ‘My words’, he weeps, stroking the ‘streamlined sentences’.

None of the patients described here seems to benefit over the long term from this rampant counter-transference. Marie, told that after all she must just learn to live with her depression, is justifiably pissed off. Peter is deemed to be on the road to recovery when he finds himself a fat woman, and Slater has seen enough of him ‘to imagine how his body would be within a fat woman’s arms ... I could not help but see her spread legs on a bed, and he, a little cowed by the sight of so much, trying to touch her, first with his fingers, then with penis, allowing himself entry into the many layers of her life.’ Watching Joseph weeping over her typescript, Slater concludes: ‘there is only so much you can do for a patient, only so much hurt you can heal. This is what is hard about my work, knowing when to exit, knowing there are times you must take a soft touch, fingers formed into a strainer, and bring them back to your own body.’ Everything is brought back to Slater, and her patients fade from the page, managing as best they may.

Her actual task at the clinic where Joseph was one of the patients was to help them master ‘low-level self-care skills’. To get them washing, eating, able to go to the shops, budget, make a meal. To give them a modicum of practical self-sufficiency. She detected, however, a passionate desire for intimacy within their psychotic terrors that she considers more interesting than the provision of day-to-day independence: ‘I sometimes catch glimpses of continuous themes, diced-up apples of desire, green leaves of love. I want to go there, tread through those gardens.’ And this is a pretty accurate description of what she is; a tourist in the gardens of the mad where the hard graft of actual gardening is somebody else’s task.