by Oliver Sacks
“Seduction” is the crucial word here (it is also the key word in the title of Edward Podvoll’s marvelous book The Seduction of Madness, on the nature and treatment of mental illness). Why should psychosis, and mania in particular, be seductive? Freud spoke of all psychoses as narcissistic disorders: one becomes the most important person in the world, chosen for a unique role, whether it is to be a messiah, a redeemer of souls, or (as happens in depressive or paranoid psychoses) to be the focus of universal persecution and accusation or derision and degradation.
But even short of such messianic feelings, mania can fill one with a sense of enormous pleasure, even ecstasy—and the sheer intensity of this may make it difficult to “give up.” It is what prompts Custance, despite his knowledge of how dangerous such a course is, to avoid medication and hospitalization in one attack of mania and, instead, embrace it, undertaking a risky and rather James Bond–like adventure in East Berlin. Perhaps a similar intensity of feeling is sought by drug addicts, especially those addicted to stimulants like cocaine or amphetamines; and here, too, a high is likely to be followed by a crash, just as a mania is usually followed by a depression—both, perhaps, due to the exhaustion caused by neurotransmitters like dopamine in the overstimulated reward systems in the brain.
Mania, though, is by no means all pleasure, as Greenberg continually observes. He speaks of Sally’s “pitiless ball of fire,” her “terrified grandiosity,” of how anxious and fragile she is inside the “hollow exuberance” of her mania. When one ascends to the exorbitant heights of mania, one becomes very isolated from ordinary human relationships, human scale—even though this isolation may be covered over by a defensive imperiousness or grandiosity. This is why Lensing sees Sally’s returning desire to make genuine contact with others, to understand and be understood, as a propitious sign of her returning to health, her coming back to earth.
Psychosis, as Lensing says, is not an identity, but a temporary aberration or departure from identity. And yet having a chronic or recurring mind-altering condition like manic-depressive illness is bound to influence one’s identity, to become part of one’s attitudes and ways of thinking. As Jamison writes,
It is, after all, not just an illness, but something that affects every aspect of my life: my moods, my temperament, my work, and my reactions to almost everything that comes my way.
Nor is it just a piece of biological bad luck. Although Jamison agrees that there is nothing good to be said for depression, she does feel that her manias and hypomanias, when not too out of control, have played a crucial and sometimes positive part in her life. Indeed, in her book Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, she has provided much evidence to suggest a possible relationship between mania and creativity, citing the many great artists—Schumann, Coleridge, Byron, and Van Gogh among them—who seem to have lived with manic-depressive illness.
When Sally is hospitalized, her father asks the psychiatric resident about her diagnosis. “Sally’s condition,” the resident says, “has probably been building for a while, gathering strength until it just overwhelmed her.” Greenberg asks what her “condition” is. He is told, “What we call [it] is not what’s important right now. Certainly many of the criteria for bipolar 1 are here. But fifteen is relatively early for fulminating mania to present itself.”
In the last couple of decades, the term “bipolar disorder” has come into use, in part, Jamison suggests, because it is felt to be less stigmatizing than “manic-depressive illness.” “But,” she cautions,
splitting mood disorders into bipolar and unipolar categories presupposes a distinction between depression and manic-depressive illness…that is not always clear, nor supported by science. Likewise, it perpetuates the notion that depression exists rather tidily segregated on its own pole, while mania clusters off neatly and discreetly on another. This polarization…flies in the face of everything that we know about the cauldronous, fluctuating nature of manic-depressive illness.
Moreover, “bipolarity” is characteristic of many disorders of control—like catatonia and parkinsonism—where patients lose the middle ground of normality and alternate between hyperkinetic and akinetic states. Even in a metabolic disease such as diabetes, there may be dramatic alternations between (for instance) very high blood sugar and very low blood sugar, as the complex homeostatic mechanisms are compromised.
There is another reason why the notion of manic-depressive illness as a bipolar illness, swinging from one pole to the other, can be misleading. This was brought out by Kraepelin more than a century ago, when he wrote of “mixed states,” states in which there are elements of both mania and depression, inseparably intertwined. He wrote of “the deep inward relationship of such apparently contradictory states.”
We speak of “poles apart,” but the poles of mania and depression are so close to each other that one wonders if depression may be a form of mania, or vice versa. (Such a dynamic notion of mania and depression—their “clinical unity,” as Kraepelin put it—is underlined by the fact that lithium, for those patients in whom it works, works equally well on both states.) This paradoxical situation is described by Greenberg with often astonishing oxymorons, as when he speaks of the “abysmal elation” Sally sometimes feels “in the throes of [her] dystopic mania.”
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SALLY’S FINAL RETURN from the mad heights of her mania is almost as sudden as her taking off into it seven weeks earlier, as Greenberg recounts:
Sally and I are standing in the kitchen. I have spent the day at home with her, working on my script for Jean-Paul.
“Would you like a cup of tea?” I ask. “That would be nice. Yes. Thank you.” “With milk?” “Please. And honey.”
“Two spoonfuls?” “Right. I’ll put the honey in. I like watching it drip off the spoon.” Something about her tone has caught my attention: the modulation of her voice, its unpressured directness—measured, and with a warmth I have not heard in her in months. Her eyes have softened. I caution myself not to be fooled. Yet the change in her is unmistakable….It’s as if a miracle has occurred. The miracle of normalcy, of ordinary existence….
It feels as if we have been living all summer inside a fable. A beautiful girl is turned into a comatose stone or a demon. She is separated from her loved ones, from language, from everything that had been hers to master. Then the spell is broken and she is awake again.
After her summer of madness, Sally is able to return to school—anxious, but determined to reclaim her life. At first, she keeps her illness to herself and enjoys the company of three close friends from her class. “Often,” her father writes, “I listen to her on the phone with them, intimate, biting, gossipy—the buoyant sound of health.” A few weeks into the school year, after much discussion with her parents, Sally tells her friends about her psychosis:
They readily accept the news. Being an alumna of the psych ward confers social status on Sally. It’s a kind of credential. She has been where they have not been. It becomes their secret.
Sally’s madness resolves, and this, one might hope, would be the end of the story. But the very defining feature of manic-depressive illness is its cyclical nature, and in a postscript to his book, Greenberg indicates that Sally did have two further attacks: four years later, when she was in college, and six years after that (when her medication was discontinued). There is no “cure” for manic-depressive illness, but living with manic-depressive illness may be greatly helped by medication, by insight and understanding (in particular, by minimizing stressors like sleep loss and being alert to the earliest signs of mania or depression), and, not least, by counseling and psychotherapy.
In its detail, depth, richness, and sheer intelligence, Hurry Down Sunshine will be recognized as a classic of its kind, along with the memoirs of Kay Redfield Jamison and John Custance. But what makes it unique is the fact that so much here is seen through the eyes of an extrao
rdinarily open and sensitive parent—a father who, while never descending into sentimentality, has remarkable insight into his daughter’s thoughts and feelings, and a rare power to find images and metaphors for almost unimaginable states of mind.
The question of “telling,” of publishing detailed accounts of patients’ lives, their vulnerabilities, their illness, is a matter of great moral delicacy, fraught with pitfalls and perils of every sort. Is Sally’s struggle with psychosis not a private and personal matter, no one’s business but her own (and that of her family and physicians)? Why would her father consider exposing his daughter’s travails, and his family’s pain, to the world? And how would Sally feel about a public disclosure of her teenage torments and exaltations?
This was not a quick or easy decision for either Sally or her father. Greenberg did not grab a pen and start writing during his daughter’s psychosis in 1996—he waited, he pondered, he let the experience sink deep into him. He had long, searching discussions with Sally, and only more than a decade later did he feel that he might have the balance, the perspective, the tone that Hurry Down Sunshine would need. Sally, too, had come to feel this, and urged him not only to write her story but to use her real name, without camouflage. It was a courageous decision, given the stigma and misunderstanding that still surround mental illness of any kind.
It is a stigma that affects many, for manic-depressive illness occurs in all cultures, and affects at least one person in a hundred—there are, at any time, millions of people, some even younger than Sally, who may have to face what she did. Lucid, realistic, compassionate, illuminating, Hurry Down Sunshine may provide a sort of guide for those who have to negotiate the dark regions of the soul—a guide, too, for their families and friends, for all those who want to understand what their loved ones are going through.
Perhaps, too, it will remind us of what a narrow ridge of normality we all inhabit, with the abysses of mania and depression yawning to either side.
The Lost Virtues of the Asylum
We tend to think of mental hospitals as snake pits, hells of chaos and misery, squalor and brutality. Most of them, now, are shuttered and abandoned—and we think with a shiver of the terror of those who once found themselves confined in such places. So it is salutary to hear the voice of an inmate, one Anna Agnew, judged insane in 1878 (such decisions, in those days, were made by a judge, not a physician) and “put away” in the Indiana Hospital for the Insane. Anna was admitted to the hospital after she made increasingly distraught attempts to kill herself and tried to kill one of her children with laudanum. She felt profound relief when the institution closed protectively around her, and especially from having her madness recognized. As she later wrote:
Before I had been an inmate of the asylum a week, I felt a greater degree of contentment than I had felt for a year previous. Not that I was reconciled to life, but because my unhappy condition of mind was understood, and I was treated accordingly. Besides, I was surrounded by others in like bewildered, discontented mental states in whose miseries…I found myself becoming interested, my sympathies becoming aroused….And at the same time, I too, was treated as an insane woman, a kindness not hitherto shown to me.
Dr. Hester being the first person kind enough to say to me in answer to my question, “Am I insane?” “Yes, madam, and very insane too!”…“But,” he continued, “we intend to benefit you all we can and our particular hope for you is the restraint of this place.”…I heard him [say] once, in reprimanding a negligent attendant: “I stand pledged to the State of Indiana to protect these unfortunates. I am the father, son, brother and husband of over three hundred women…and I’ll see that they are well taken care of!”
Anna also spoke (as Lucy King recounts in her book From Under the Cloud at Seven Steeples) of how crucial it was, for the disordered and disturbed, to have the order and predictability of the asylum:
This place reminds me of a great clock, so perfectly regular and smooth are its workings. The system is perfect, our bill of fare is excellent, and varied, as in any well-regulated family….We retire at the ringing of the telephone at eight o’clock, and an hour later, there’s darkness and silence…all over this vast building.
The old term for a mental hospital was “lunatic asylum,” and “asylum,” in its original usage, meant refuge, protection, sanctuary—in the words of the Oxford English Dictionary, “a benevolent institution according shelter and support to some class of the afflicted, the unfortunate, or destitute.” From at least the fourth century A.D., monasteries, nunneries, and churches were places of asylum. And to these were added secular asylums, which (so Michel Foucault suggests) emerged with the virtual annihilation of Europe’s lepers by the Black Death and the use of the now-vacant leprosaria to house the poor, the ill, the insane, and the criminal. Erving Goffman, in his famous book Asylums, ranks all of these together as “total institutions”—places where there is an unbridgeable gulf between staff and inmates, where rigid rules and roles preclude any sense of fellowship or sympathy, and where inmates are deprived of all autonomy or freedom or dignity or self, reduced to nameless ciphers in the system.
By the 1950s, when Goffman was doing his research at St. Elizabeths Hospital in Washington, D.C., this was indeed the case, at least in many mental hospitals. But creating such a system was hardly the intent of the high-minded citizens and philanthropists who had been moved to found many of America’s lunatic asylums in the early and middle years of the nineteenth century. In the absence of specific medications for mental illness at this time, “moral treatment”—a treatment directed towards whole individuals and their potential for physical and mental health, not just a malfunctioning part of their brain—was considered the only humane alternative.
These first state hospitals were often palatial buildings, with high ceilings, lofty windows, and spacious grounds, providing abundant light, space, and fresh air, along with exercise and a varied diet. Most asylums were largely self-supporting and grew or raised most of their own food. Patients would work in the fields and dairies, work being considered a central form of therapy for them, as well as supporting the hospital. Community and companionship, too, were central—indeed, vital—for patients who would otherwise be isolated in their own mental worlds, driven by their obsessions or hallucinations. Also crucial was the recognition and acceptance of their insanity (this, for Anna Agnew, was a great “kindness”) by the staff and other inmates around them.
Finally, coming back to the original meaning of “asylum,” these hospitals provided control and protection for patients, both from their own (perhaps suicidal or homicidal) impulses and from the ridicule, isolation, aggression, or abuse so often visited upon them in the outside world. Asylums offered a life with its own special protections and limitations, a simplified and narrowed life perhaps, but within this protective structure the freedom to be as mad as one liked and, for some patients at least, to live through their psychoses and emerge from their depths as saner and stabler people.
In general, though, patients remained in asylums for long terms. There was little preparation for a return to life outside, and perhaps after years cloistered in an asylum, residents became “institutionalized” to some extent: they no longer desired or could no longer face the outside world. Patients often lived in state hospitals for decades, and died in them—every asylum had its own graveyard. (Such lives have been reconstructed with great sensitivity by Darby Penney and Peter Stastny in their book The Lives They Left Behind.)
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IT WAS INEVITABLE, under these circumstances, that the asylum population should grow—and individual asylums, often immense to begin with, came to resemble small towns. Pilgrim State Hospital, on Long Island, housed nearly fourteen thousand patients at one time. Inevitable, too, that with these huge numbers of inmates, and inadequate funding, state hospitals fell short of their original ideals. By the latter years of the nineteenth century, they had a
lready become known for squalor and negligence, and were often run by inept, corrupt, or sadistic bureaucrats—a situation that persisted through the first half of the twentieth century.
There was a similar evolution, or devolution, at Creedmoor State Hospital in Queens, New York, which had been established in 1912, very modestly, as the Farm Colony of Brooklyn State Hospital, holding to the nineteenth-century ideals of providing space, fresh air, and farming for its patients. But Creedmoor’s population soared—it reached seven thousand by 1959—and, as Susan Sheehan showed in her 1982 book, Is There No Place on Earth for Me?, it became, in many ways, as wretched, overcrowded, and understaffed as any other state hospital. Yet the original gardens and livestock were maintained, providing a crucial resource for some patients, who could care for animals and plants, even though they might be too disturbed or too ambivalent to maintain relationships with other human beings.
At Creedmoor there were gymnasiums, a swimming pool, and recreation rooms with Ping-Pong and billiards tables; there was a theater and a television studio, where patients could produce, direct, and act in their own plays—plays that, like de Sade’s theater in the eighteenth century, could allow creative expression of the patients’ own concerns and predicaments. Music was important—there was a small patients’ orchestra—and so, too, was visual art. (Even today, with the bulk of the hospital closed down and falling into decay, the remarkable Living Museum at Creedmoor provides patients with the materials and space to work on painting and sculpture. One of the Living Museum’s founders, Janos Marton, calls it a “protected space” for the artists.)
