From Abracadabra to Zombies
by Kay Redfield Jamison
(New York: Vintage Books, 1997)
first published by Knopf in 1995
"Manic depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live."
It must have come as quite a shock to her patients to be told by their therapist that she had been suffering from manic depression herself for over thirty years. Perhaps an even greater shock was felt by many of her colleagues, since Dr. Jamison is one of the leading scholars and authorities on manic depression. The general public, being generally ignorant of mental illness and kept that way by mass media emphasis on sex and violence, probably won't read the book, but if they did there would be the danger that it would feed the stereotype of the therapist as loon. As it is, the book will probably be read mostly by those in the mental health professions, mentally ill patients and their loved ones. If a film is ever made which is true to Jamison's life, it would be one of those rare films which does not depict a mentally ill person as a troubled artist, mass murderer, brilliant criminal, amusing rebel, blathering idiot, drug addict or alcoholic. Even so, such a film would still be misleading, as is Jamison's book and her emphasis on the relationship of madness and creative genius. This is a favorite topic of hers. (See her Touched With Fire: Manic Depressive Illness and the Artistic Temperament.)
The book begins brilliantly with a metaphor for her illness taken from an actual experience: a child witness to an Air Force plane leaving its defiant flight against the gravity of earth and diving from the beautiful sky past a schoolyard full of playful innocents into the woods, leaving behind nothing but vapors in the sky and ashes on the ground. The book then moves rapidly, somewhat clinically if poetically and literately, through the stages of the author's life, her lifelong battle with her illness and her emergence as a mentally ill person with a Ph.D. in psychology, co-author of a standard text book on manic depression, recognized scholar in the academic world, and tenured professor at Johns Hopkins University. Jamison emerges from her struggles with manic depression as a woman with a love of the arts and poetry, with more than a fair share of romantic liaisons, and a marriage now going into its second decade. In short, the book should give hope to those who suffer from a similar neurochemical dysfunction; for, she has shown that it is possible to live a good life despite being mentally ill. She makes it clear that this is possible only because she takes her medicine (lithium) and goes to therapy. Unfortunately and disappointingly, she does not describe what kind of therapy she has undergone. Perhaps she will write another popular book whose focus is on the various therapies which have been scientifically examined and which have been proven effective, along with pharmacological treatment, for various forms of mental illness.
Manic depression is a horrible disease. The horrors of years spent wishing you were dead, incapable of getting out of bed or reading a newspaper, of withdrawal from friends and family, of fear of meeting anyone, and of trying to kill yourself, are documented, as are the years of euphoric sexual energy, creativity, productivity, wild spending sprees, of friends and family withdrawing from you, of inexpressible joy at feeling high and mighty, consumed by incomprehensible thoughts and doomed to absurd behavior. The disease controls your thoughts and actions: you are not a person who is free to think and do as you wish and in accord with your talents. But with medication and therapy, a good deal of control over your life is possible. Yet, one of the great fears of many manic-depressives is that drugs will control them (or others will use drugs to control them) and therapy will brainwash them (forcing them to fit some mold of the "normal" person). With treatment from the right kind of physician and therapist, these fears are unwarranted. Good medicine and good therapy can give a person control over his or her life, not take it away. Of all Jamison's messages, I think this is the most important one.
The internal horror of mental illness experienced by the ill person cannot be equaled by the external horror experienced by family, friends, lovers and any unfortunate strangers who happen to be in the wrong place at the wrong time. Still, the harm done to those close to the mentally ill is measurable and is very large. Jamison describes the suicide watches put on her. Several lives must have been consumed by the fear that she would kill herself. She mentions their love and concern with affection, but I wonder if she can know the Hell she put them through any more than they could know her kind of Hell.
With mania there are other problems, such as feelings of persecution, indiscreet sexual behavior, spending sprees and risky investments, racing thoughts and rapid speech, sleeplessness but still maintaining boundless energy, inflated and unrealistic feelings of power or capacity for achievement, feelings of special communications from God or the dead, and, in some cases, psychotic symptoms such as hallucinations and delusions. (Delusion is defined by mental health people as being a false belief which cant be changed by argument or evidence.) Jamison describes in general terms the euphoria she feels while manic, a euphoria comparable to a cocaine high and apparently just as addictive. She describes in general terms that her behavior caused others a great deal of trouble, but she does not begin to give the reader a sense of what it must be like to love as a sister, friend or lover someone who is very bright but has lost any semblance of good sense or judgment. Jamison's spending sprees did not make her homeless. She has a brother who mopped up after her manic episodes, loaned her money and enabled her to maintain her wealth. A manic spending spree by a less educated and poorer manic-depressive can wipe out a lifetime of accumulated wealth in a few weeks. The mental health system seems to be designed to make sure nobody interferes with the patient's right to go bankrupt and become homeless.
Because of the tireless work of the American Civil Liberties Union and individual messiahs such as Thomas Szaz, the legal system in California (where Jamison had her first major breakdown) makes sure that the patient is protected from meddlesome and greedy family members, friends and loved ones. The mental health system seems to have been designed by lawyers for lawyers. The social context of mental illness is ignored in favor of protecting individual rights. The patient determines whether she wants treatment, even though she may be incapable of making a good judgment about mundane matters. The patient determines whether the doctor can talk to any family member or friend about the patient, even though she may be incapable of telling the truth to the doctor as to what exactly has been going on in her life. A family member who gets a call from a merchant saying he is going to the district attorney with felony charges against a relative for passing a $10,000 bad check during a spending spree cannot even talk to the patient's doctor about it, unless the patient gives permission. Often, the paranoid delusions that accompany extreme mania preclude the patient from trusting her most trustworthy friends and family members. The patient determines whether she talks to anyone. The patient decides whether anyone is notified about her condition or when she will be discharged from the hospital. If you want to know about a loved one who is being treated for mental illness, you will have to read about it in the papers. As one psychiatrist I know put it: the patient has the right to die with her rights on. The patient's right to be protected from evil relatives has been the paradigm for creating mental health law. The one right which has been ignored by the lawmakers and defenders of patient rights is the right to proper treatment. Proper treatment requires knowledge of the patient's past behavior and good judgment on the part of mental health professionals regarding how much to involve family and friends in getting information helpful in making the diagnosis. Confidentiality laws, however well-intentioned, are often a major hindrance to proper treatment.
Jamison touches on these issues but she does not give the reader the sense that she fully appreciates the Hell she has put others through. Intellectually, she clearly understands how she has harmed others, and she expresses concern for them, but it is apparent that she is her own main concern. Her egocentrism and vanity may be survival defense mechanisms or they may be manifestations of her illness. In any case, these traits are not very charming or endearing, but they do not interfere with her ability to describe manic depression from the inside and give hope for a good life to those who suffer the same rotten luck, as one of her paramours put it..
Jamison does not pretend that manic depression can be cured or that the manic-depressive can become relieved of all symptoms once and for all by some sort of magic cocktail of drugs and therapy. There is no magic to be worked here. It is all hard work, constant struggle, battling the demons within and the ignorant and unsympathetic without. Feelings of guilt for thinking and acting as you do, even though your thoughts and actions are mainly determined by your brain chemistry, are hard to overcome. Dealing with the blame others put on you for the thoughts and actions you cannot control is very hard. When a friend and colleague, a psychiatrist, tells you that he is "deeply disappointed" in you for having attempted to kill yourself, you realize how deep the ignorance runs in our society. It is not just those whose highest cultural endeavor is listening to talk radio or TV who are without knowledge; it is often the professionals themselves who demonstrate the most ignorance, the ones who are supposed to know and understand better than the rest of us just what mental illness is and how to treat persons with brain diseases. Books such as Jamison's are essential to overcoming this almost total ignorance regarding mental illness. Only those who have been to Hell know what Hell is like. If you needed a road map to escape from Hell, who would you buy it from? From one who lives there or from one who has read about it in his study in north Paradise?
Manic depression is a disease which is biological in its origins. There is also strong evidence that there is a genetic basis for the illness. There is also evidence that lithium, the most common drug used in treatment for the disease, can cause birth defects. Think of the complications this means for a woman who wants to have children. If I go off the drug and get pregnant, what will happen if I have a manic episode during the pregnancy? If I stay on the drug while pregnant, what will happen if my fetus is adversely affected? If I have a child, will the child be manic depressive? What kind of mother can I be if I am ill? Eventually, perhaps another question will be askable: if a genetic test indicates my fetus has the gene for manic depression, should I abort? Add to these dilemmas, the comment of a psychiatrist who tells you that you should not even think about having children and you have a blueprint for a condo in Hell.
Hell is fueled not only by the fire in the brain. Jamison herself was the child of a mentally ill father, one who functioned quite well for many years before becoming hopelessly mad. Not only would Jamison not exist if her father had taken the advice of this psychiatrist, but the world would be a much duller place, less creative and diverse, certainly the worse for it if the mentally ill did not reproduce. The desire for a "pure" race of balanced brains is a vision of Lilliputian proportions, worthy of a small mind living in small, tidy, dull world. It does not take long to whip up a list of great artists, poets, writers, athletes, etc. who have suffered from neurochemical dysfunction. It is obvious that the species and human culture have benefited from the mentally ill and their progeny. To suggest that anyone with a neurochemical dysfunction should not even think of having children is an idea so preposterous as to deserve laughter rather than the rage it is likely to evoke from a mentally ill woman of Jamison's character and disposition. Who knows what great achievements would not have been conceived much less attempted but for mania? And who knows what foolish endeavors have been avoided because of the depression of world leaders? What would our libraries and museums look like if we removed everything created by a mentally ill person or the descendent of a mentally ill person? But while laughing at the suggestion that we should practice eugenics with the mentally ill, we should not get so carried away as to think that somehow having a neurochemical problem is a ticket to creativity or genius. Even if it were, the pain and suffering that accompany the diseases of the brain would not justify a policy of breeding creative geniuses.
The reason it is easy to come up with a list of great insane people is probably not because the genes which are major causal factors in neurochemical problems are also the genes which are the major causal factors in creativity or intelligence. The reason is much more mundane. There are lots of famous people and there are lots of people with neurochemical problems; that the two lists should overlap a great number of times is to be expected. The vast majority of the mentally ill are probably of ordinary intelligence and creativity. We never hear of them because they are not eloquent, do not create great works of art, etc. We only hear about mental illness from eloquent people: either the highly educated professionals who care for them or the highly articulate and creative ones among them, or, as in Dr. Jamison's case, both. Studies which claim there are a disproportionate number of poets, artists, composers, etc., who suffered from depression or manic depression may be accurate, though it is difficult to establish just what percentage of any population is "mentally ill." Also, I don't know how many poets would appreciate being told that their affinity for alliterative allusions may be due to a neurotransmitter malfunction.
Many of the "ordinary" mentally ill persons roam our streets and sleep in ditches. They scavenge the trash bins in our cities and towns. Some of them have children and it is monstrous to suggest that none of these people should have been born or given birth. The shame on humanity is not from its mentally ill, but from the rest of us because of the way we treat them...or rather because of the way we mistreat or fail to treat the less fortunate among us. But the lack of proper treatment for a large percentage of the mentally ill is a social problem and is not Jamison's area of specialization. Clinical problems, however, are her specialty.
The main clinical problem with manic depression is not that it can't be treated effectively with drugs and therapy, but that many patients don't take their medications and many others don't seek treatment. The latter is due to ignorance, "poor medical advice, stigma, or fear of personal and professional reprisals." The former is due to a combination of several factors. Often there is knowledge that drugs are used to make people docile and easy to handle in institutions. Drugs have sometimes aggravated mental illness and done irreparable damage. There is knowledge that drugs might take an edge off one's intelligence and memory, as well as diminish physical coordination. Medicine often has painful and annoying physical side effects. When medicine works and one is feeling good, one often quits the medicine because one comes to believe medicine is no longer necessary. Medicine prevents the euphoria and burst of creative energy of manic episodes, which are extremely pleasant and addictive. There is a cultural taboo against using drugs, as well as a cultural stereotyping of people as weak and lacking character if they cannot solve their own problems by determination and guts. Anyone should be able to control their thoughts and actions by an act of will. In short, there are numerous personal, social and cultural hindrances to proper treatment of manic depression. These hindrances often outweigh the knowledge that there is hope for the manic depressive through proper medication and therapy. Jamison should know. Even though she is an expert in the field, it took a near death experience (not the mystical kind, but the kind caused by intentionally taking an overdose of lithium), to awaken her to the fact that though she hated taking lithium, the alternative was worse.
Jamison is a survivor, literally. If we are to believe her, she is much more. She had several love affairs of romantic novel proportions and all of them with brilliant psychiatrists. She has a Ph.D. in psychology yet is a "professor of psychiatry." She is not medically trained, but she has been so extraordinary that she has been put in charge of medical facilities. And when she has been wronged, it was never trivial but monumental. She loves poetry and is fond of sprinkling literary quotes throughout her book. She obviously likes to drop names and present herself as a very important person. There isn't a murmur of humility which comes through as one reads her unquiet memoir. In short, her account comes across as a very honest description of a manic depressive.
In conclusion, the reader might wonder why I have not used the American Psychiatric Association's preferred moniker of "bipolar disorder." Dr. Jamison's book is not a memoir of moods and bipolar disorder. Jamison prefers the term "madness" to bipolar and I don't blame her. 'Bipolar' is very clean and impersonal. It is useful mainly for diagnostic classification. (Jamison describes herself in DSMV-IV terms as having bipolar I disorder; recurrent, severe with psychotic features, full interepisode recovery. DSMV-IV is the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual.) Imagine your physician telling you that you have "oncology disorder B-6" rather than breast cancer. I don't like 'madness' or 'manic depression' very much either. I prefer 'neurochemical dysfunction', 'neurochemical imbalance' or 'neurophysical damage', or even 'brain disorder'. Such terms are not very descriptive and they are very vague, but they do not imply that there is a single cause which gives rise to all forms of the disease. 'Manic depression' or 'melancholia' call attention to the behavior of the ill person and may encourage the belief that the ill person is not ill but needs a good laugh, a good kick in the butt or some serious jail time. Such responses to the mentally ill are too typical and indicate a profound and pathological type of ignorance. Being ignorant is a condition a person can remedy by an act of will to study the issue. Being controlled by a dysfunctioning brain is not.