In September 1998, Laura wrote to tell me of a brief spate of “that terrible lethargic anxiety.” By mid-October she was starting to sink and she knew it. “I am not yet in a full-blown depression, but am slowing down a little—I mean that I have to focus on each thing I do on more and more levels. I’m not completely depressed at this point, but I have entered a recession.” She began taking Wellbutrin. “I just hate this feeling of distance from everything,” she complained. Soon afterward, she started spending days in bed. The medications were failing her again. She cut herself off from extraneous people and focused on her dogs. “When my regular appetites are diminished by depression—my needs for laughter, sex, food—the dogs provide me with my only really numinous moments.”
In early November she protested, “I only take baths now because the water beating down on me from the shower is too much to deal with in the morning and seems, these days, like a violent way to begin the day. Driving seems like such an effort. So does visiting the ATM, shopping—you name it.” She rented The Wizard of Oz to distract herself, but “the sad parts made me cry.” Her appetite was gone. “I tried some tuna today, but it made me throw up, so I just had a little rice when I made it for the dogs.” She complained that even visits to the doctor made her feel bad. “It’s hard to be honest with him about how I’m feeling because I don’t want to let him down.”
We kept up our daily correspondence; when I asked Laura whether she didn’t find it difficult to keep writing, she said, “Giving attention to others is the simplest way to get attention from others. It is also the simplest way to keep a sense of perspective about yourself. I have a need to share my self-obsession. I am so aware of it in my life right now I wince every time I hit the ‘I’ key. (Ouch. Ouch.) The whole day thus far has been an exercise in FORCING myself to do the tiniest things and trying to evaluate how serious my situation is—Am I really depressed? Am I just lazy? Is this anxiety from too much coffee or from too much antidepressant? The self-assessment process itself made me start to weep. What bothers everyone is that they can’t DO anything to help other than be present. I rely on E-mail to keep me sane! Exclamation points are little lies.”
Later that week: “It is ten o’clock in the morning and I am already overwhelmed by the idea of today. I’m trying, I’m trying. I keep walking around on the verge of tears chanting, ‘It’s okay. It’s okay,’ and taking big breaths. My goal is to stay safely in between self-analysis and self-destruction. I just feel like I’m draining people right now, yourself included. There is only so much I can ask for while giving nothing back. I think if I wear something I like and pull my hair back and take the dogs with me, though, I will feel confident enough to go to the store and buy some orange juice.”
Just before Thanksgiving she wrote, “I looked at old photos today, and they seem like they are snapshots of someone else’s life. What a series of trade-offs medication mandates.” But soon she was at least getting up. “Today I had a few good moments,” she wrote at the end of the month. “More of those, please, from whoever doles them out. I was able to walk in a crowd and not feel self-conscious.” The next day she had a little relapse. “I was feeling better and hoped it was the start of something wonderful, but today I have a lot of anxiety, of the falling-over-backward, drawstring-in-the-sternum variety. But I still have some hope, which helps.” The next day, things were worse. “My mood continues to be grim. Morning terror and abject helplessness by late afternoon.” She described going to the park with her boyfriend. “He bought a pamphlet identifying all the plants. By the description of one tree, it said, ‘ALL PARTS DEADLY POISONOUS.’ I thought maybe I could find the tree, chew on a leaf or two, and curl up under a rock ledge and drift off. I miss the Laura who would have loved to put on her bathing suit and lie in the sun today and look at the blue, blue sky! She has been plucked out of me by an evil witch and replaced by a horrid girl! Depression takes away whatever I really, really like about myself (which is not so much in the first place). Feeling hopeless and full of despair is just a slower way of being dead. I try to work through these large blocks of horror in the meantime. I can see why they call it ‘mean.’ ”
But a week later she was getting distinctly better. Then suddenly, at a 7-Eleven store, she lost her temper when the man behind the counter started ringing up someone else’s purchases ahead of hers. With a rage totally uncharacteristic of her, she yelled, “JESUS CHRIST! Is this a convenience store or a fucking hot dog stand?” and marched out without her soda. “It’s just a jagged climb. I am so tired of talking about it, thinking about it.” When her boyfriend said he loved her, she burst into tears. The next day she was feeling better and ate twice and bought herself a pair of socks. She went to the park and suddenly felt the urge to get on the swings. “While I have spent the last week with the falling-backward sensation looming large, it felt great to swing. You get the opposite feeling: a whooshy, light sensation in the middle of your chest, like when you go just fast enough over a hill in the car. It feels good just to do something so simple; I started to feel a little more myself, and a sense of being light and feeling smart and bright came back. I’m not going to hope for too much more time, but just that feeling of no abstract worries, no inexplicable weight or sadness, felt so rich and real and good that for once, I didn’t feel like crying. I know the other feelings will come back, but I think I got a reprieve tonight, from God and the swingset, a reminder to be hopeful and patient, an augury of good things to come.” In December she had an adverse reaction to lithium; it made her skin intolerably dry. She lowered her dose and went on Neurontin. It seemed to work. “Shifting back to the center, a center, known as ME feels good and real,” she wrote.
The following October, we finally met. She was staying with her mother in Waterford, Virginia, a beautiful old town outside Washington, the place where she had grown up. I had become so fond of her by then that I couldn’t believe we had never met. I took the train and she came to meet me at the station, bringing her friend Walt, whom I was also meeting for the first time. She was svelte, blond, and beautiful. But the time with her family was stirring too many memories and she was not doing well. She was desperately anxious, so anxious that she was having trouble speaking. In a hoarse whisper, she apologized for her condition. Her movements were clearly enormously effortful. She said she had been going down all week. I asked whether I was adding to the strain, and she assured me that I was not. We went out to lunch, and she ordered mussels. She seemed to be unable to eat them; her hands were shaking badly, and by the time she had tried to pry open a few shells, she was spattered with the sauce in which they had arrived. She was not able to talk and cope with the mussels at the same time, so Walt and I chatted. He described Laura’s gradual descent during the week, and she made little sounds of acquiescence. She had given up on the mussels by now and was giving her full attention to a glass of white wine. I was really quite shocked; she had warned me that things were rough, but I was not prepared for her aura of futility.
We dropped Walt off and then I drove Laura’s car since she was much too shaky to drive. When we got back to the house, her mother evinced concern. Laura and I had a conversation that drifted in and out of coherence; she seemed to be speaking from some faraway place. And then as we were looking at some photos, she suddenly got stuck. It was like nothing I’d ever seen or imagined. She was telling me who was who in the photos and she began repeating herself. “That’s Geraldine,” she said, and then she winced and began again, pointing, “That’s Geraldine,” and then again, “That’s Geraldine,” each time taking longer to pronounce the syllables. Her face was frozen and she seemed to be having trouble moving her lips. I called her mother and her brother, Michael. Michael put his hands on Laura’s shoulders and said, “It’s okay, Laura. It’s okay.” We eventually managed to get her upstairs; she was still saying over and over, “That’s Geraldine.” Her mother changed her out of the mussel-spattered clothes and put her in bed and sat and rubbed her hand. The meeting was hardly what I
had anticipated.
As it turned out, some of her medications were having a bad interaction that had caused this seizure; indeed they were the reason for the strange stiffness in the afternoon, for the loss of speech, for the hyperanxiety. By the end of the day, she had come through the worst, but “all the color had drained out of my soul, all the me of me I loved; I was a little doll-shell of what I had been.” She was soon put on a new regimen. Not until Christmas did she began to feel like herself again; and then in March 2000, just as things were looking up, she had the seizures once more. “I am so frightened,” she wrote to me. “And so humiliated. It’s pretty pathetic when the best news you can share is that you’re not convulsing.” Six months later, they hit again. “I can’t keep picking up my life again,” she said to me. “I’m so afraid of the seizures that I get anxiety—today I left the house to go to work and I threw up on myself while I was driving. I had to go home and change my clothes so I could get to the office, and so I was late, and I told them I’d been having seizures but they just gave me a disciplinary notice. My doctor wants me to take Valium, but that makes me pass out. This is my life now. This will always be my life, these terrible plummeting descents into hell. The awful memories. Can I stand to live this way?”
Can I stand to live the way I do? Well, can any of us stand to live with our own difficulties? In the end, most of us do. We march forward. The voices of past time come back like voices of the dead to sympathize about mutability and the passage of the years. When I am sad, I remember too much, too well: always my mother and who I was when we sat in the kitchen and talked, from the time I was five until her death when I was twenty-seven; how my grandmother’s Christmas cactus bloomed every year until she died when I was twenty-five; that time in Paris in the mideighties with my mother’s friend Sandy, who wanted to give her green sun hat to Joan of Arc, Sandy who died two years later; my great-uncle Don and great-aunt Betty and the chocolates in their top drawer; my father’s cousins Helen and Alan, my aunt Dorothy, and all the others who are gone. I hear the voices of the dead all the time. It is at night that these people and my own past selves come to visit me, and when I wake up and realize that they are not in the same world as I, I feel that strange despair, something beyond ordinary sadness and closely akin, for a moment, to the anguish of depression. And yet if I miss them and the past they made for and with me, the way to their absent love lies, I know, in living, in staying on. Is it depression when I think how I would prefer to go where they have gone, and to stop the maniacal struggle of staying alive? Or is it just a part of life, to keep living in all the ways we cannot stand?
I find the fact of the past, the reality of time’s passage, incredibly difficult. My house is full of books I can’t read and records to which I can’t listen and photos at which I can’t look because they are too strongly associated with the past. When I see friends from college, I try not to talk about college too much because I was so happy then—not necessarily happier than I am now, but with a happiness that was particular and specific in its moods and that will never come again. Those days of young splendor eat at me. I hit walls of past pleasure all the time, and for me past pleasure is much harder to process than past pain. To think of a terrible time that has gone: well, I know that post–traumatic stress is an acute affliction, but for me the traumas of the past are mercifully far away. The pleasures of the past, however, are tough. The memory of the good times with people who are no longer alive, or who are no longer the people they were: that is where I find the worst current pain. Don’t make me remember, I say to the detritus of past pleasures. Depression can as easily be the consequence of too much that was joyful as of too much that was horrible. There is such a thing as post–joy stress too. The worst of depression lies in a present moment that cannot escape the past it idealizes or deplores.
CHAPTER III
Treatments
There are two major modalities of treatment for depression: talking therapies, which trade in words, and physical intervention, which includes both pharmacological care and electroshock or electroconvulsive therapy (ECT). Reconciling the psychosocial and the psychopharmacological understandings of depression is difficult but necessary. It is extremely dangerous that so many people see this as a one-or-the-other situation. Medication and therapy should not compete for a limited population of depressives; they should be complementary therapies that can be used together or separately depending on the situation of the patient. The biopsychosocial model of inclusive therapy continues to elude us. The consequences of this can hardly be overstated. It’s fashionable for psychiatrists to tell you first the cause of your depression (lowered serotonin levels or early traumas are the most popular) and second, as if there were a logical link, the cure; but this is poppycock. “I do not believe that if the causes of your problems were psychosocial, they would require a psychosocial treatment; nor that if the causes were biological, they would require a biological treatment,” Ellen Frank of the University of Pittsburgh has said. It is striking that patients who recover from depression by means of psychotherapy show the same biological changes—in, for example, sleep electroencephalogram (EEG)—as those who receive medication.
While traditional psychiatrists see depression as an integral part of the person who suffers from it and attempt to bring about change in that person’s character structure, psychopharmacology in its purest form sees the illness as an externally determined imbalance that can be corrected without reference to the rest of a personality. The anthropologist T. M. Luhrmann has recently written about the dangers posed by this split in modern psychiatry: “Psychiatrists are supposed to understand these approaches as different tools in a common toolbox. Yet they are taught as different tools, based on different models, and used for different purposes.” “Psychiatry,” says William Normand, a practicing psychoanalyst who uses medications when he feels they are useful, “has gone from being brainless to being mindless”—practitioners who once neglected the physiological brain in favor of emotionality now neglect the emotional human mind in favor of brain chemistry. The conflict between psychodynamic therapy and medication is ultimately a conflict on moral grounds; we tend categorically to assume that if the problem is responsive to psychotherapeutic dialogue, it is a problem you should be able to overcome with simple rigor, while a problem responsive to the ingestion of chemicals is not your fault and requires no rigor of you. It is true both that very little depression is entirely the fault of the sufferer, and that almost all depression can be ameliorated with rigor. Antidepressants help those who help themselves. If you push yourself too hard, you will make yourself worse, but you must push hard enough if you really want to get out. Medication and therapy are tools to be used as necessary. Neither blame nor indulge yourself. Melvin McInnis, a psychiatrist at Johns Hopkins Hospital, speaks of “volition, emotion, and cognition” running along in interlocked cycles, almost like biorhythms. Your emotion affects volition and cognition, but it doesn’t take them over.
Talking therapies come out of psychoanalysis, which in turn comes out of the ritual disclosure of dangerous thoughts first formalized in the Church confessional. Psychoanalysis is a form of treatment in which specific techniques are used to unearth the early trauma that has occasioned neurosis. It usually requires a great deal of time—four to five hours a week is standard—and it focuses on bringing the content of the unconscious mind to light. It has become fashionable to bash Freud and the psychodynamic theories that have come down to us from him, but in fact the Freudian model, though flawed, is an excellent one. It contains, in Luhrmann’s words, “a sense of human complexity, of depth, an exigent demand to struggle against one’s own refusals, and a respect for the difficulty of human life.” While people argue with one another about the specifics of Freud’s work and blame him for the prejudices of his time, they overlook the fundamental truth of his writing, his grand humility: that we frequently do not know our own motivations in life and are prisoners to what we cannot understand. We can recognize only a
small fragment of our own, and an even smaller fragment of anyone else’s, impetus. If we take only that from Freud—and we can call this motive force “the unconscious” or “the disregulation of certain brain circuits”—we have some basis for the study of mental illness.
Psychoanalysis is good at explaining things, but it is not an efficient way to change them. The massive power of the psychoanalytic process appears to be misspent if the patient’s goal is an immediate transformation of general mood; when I hear of psychoanalysis being used to ameliorate depression, I think of someone standing on a sandbar and firing a machine gun at the incoming tide. The psychodynamic therapies that have grown out of psychoanalysis, however, do have a crucial role to play. The unexamined life can seldom be repaired without some close examination, and the lesson of psychoanalysis is that such examination is almost always revealing. The schools of talking therapy that have the most currency are the ones in which a client talks to a doctor about his current feelings and experiences. For many years, talking about depression was considered the best cure for it. It is still a cure. “Take notes,” wrote Virginia Woolf in The Years, “and the pain goes away.” That is the underlying process of most psychotherapy. The role of the doctor is to listen closely and attentively while the client gets in touch with his true motivations, so that he can understand why he acts as he does. Most psychodynamic therapies are based on the principle that naming something is a good way to subdue it, and that knowing the source of a problem is useful in solving that problem. Such therapies do not, however, stop with knowledge: they teach strategies for harnessing knowledge to ameliorative use. The doctor may also make nonjudgmental responses that will allow the client sufficient insight to modify his behavior and so improve the quality of his life. Depression is often occasioned by isolation. A good therapist can help a depressed person to connect with the people around him and to set up structures of support that mitigate the severity of depression.
The Noonday Demon Page 14
