Of all the medical disciplines, psychiatry is the most closely tied to cultural attitudes. So it is hardly surprising that, along with our culture itself, American psychiatric thought and practice should have undergone radical change since the 1960’s and 70’s. What may seem more surprising is that, at least in its later phases, this shift has followed not the surface fancies and leftist ideologies of the age but deeper currents of realism and pragmatism. Just as socialist politics and economies collapsed and were replaced by a newfound admiration for democratic capitalism, so dogmatic Freudianism, with its guilt-assuaging visions of intrapsychic conflict and its view that unconscious Oedipal anxiety explains all mental disorder, came to be replaced by more realistic assumptions and by empirical studies of mental illness and its treatment.
In particular, recent decades have seen two fundamental psychiatric upheavals: one in therapy, the other in the identification and treatment of the two major mental illnesses of manic-depression and schizophrenia. Both upheavals, of which the first is the lesser known, ended up enhancing psychiatric practice and benefiting patients and their families.
By the end of the 1960’s, a number of psychiatrists had already come to acknowledge that, in standard practice, psychotherapy tended to tolerate self-indulgent, aggressive, and impulsive behavior, in most cases explaining it away as a defense against anxiety. But this, it was becoming clear, worked against the recovery of patients, let alone their emotional maturation. What began to emerge in the 1970’s was a more demanding psychotherapy, one in which patients were expected to bring their behavior under control before help could be found for their emotional distress.
The initial outlines of the new psychotherapy were most astutely articulated by the iconoclastic psychoanalyst Otto Kernberg of New York. In his concept of the “borderline” patient, Kernberg identified a large group of individuals showing a pervasive pattern of emotional and behavioral instability. Typically, their interpersonal relationships were characterized by dramatic, often violent alternations between anger and affection. Intense displays of temper, angry separations from relatives and friends, even physical fighting were common, as were unpredictable mood shifts leading to chaotic sexual behavior.
Psychiatrists were well acquainted with patients like these, to whom they gave diagnostic names like pseudoneurotic schizophrenics or intense narcissistic personalities. Generally, they were thought to be inaccessible to therapy. Kernberg, however, focused not on their personalities but on their conduct. Even in the therapeutic setting itself, he observed, such patients would manipulate and polarize, set up false dichotomies (as between presumptive “friends” and “enemies”), and thereby excuse their own often inexcusable behavior. This, said Kernberg, had to be countered. If there were to be any chance of helping these people, they needed to be taken to task and held accountable.
Liberating therapists from their own self-imposed shackles of permissiveness, Kernberg encouraged them to confront aggressive and narcissistic patients who had previously defeated them and force these patients to take responsibility for their feelings and behavior. And indeed, the application of Kernberg’s ideas did bring into therapeutic care many individuals previously excluded from attention, in the process helping them overcome the attitudes that had previously crippled them. Kernberg’s ideas soon spread beyond the specific class of patients he had identified to include other people in other circumstances who suffered from similar tendencies.
In the meantime, and alongside these improvements in the capacities of psychotherapists, an entirely different idea was emerging: namely, that many of the seriously mentally ill—specifically, those suffering from manic-depression and schizophrenia—were not simply expressing deep-seated psychological conflicts, as Freudianism had taught, but had real, medical diseases. Prompting this conceptual breakthrough was the chance discovery in those years of medications like lithium, which both corrected specific conditions and relieved patients of other symptoms that had proved resistant to psychiatric treatment.
Over the ensuing decades, much has been written about this second development, including by patients or ex-patients who in describing their own ordeals have placed the advances of psychiatry in the light of personal experience. One such patient is the writer Andrew Solomon, whose book, The Noonday Demon: An Atlas of Depression,1 caused a considerable stir when it was published earlier this year and has recently been nominated for a National Book Award. The Noonday Demon joins such other accounts of depression as Darkness Visible (1990) by the novelist William Styron and An Unquiet Mind (1995) by Kay Redfield Jamison, a well-known academic psychologist, but it is much more ambitious in scope. Inadvertently, it also reveals how many of the temperaments and attitudes challenged by Otto Kernberg continue to linger—and to be indulged.
As his subtitle implies, Solomon means to do more than describe for us his own life and his encounter with depressive illness—though he certainly does that in very great detail. He also set out to characterize the entire state of current professional thinking about depression, the vast array of therapies applied to it around the world, and the history and politics of its study. All of this is undoubtedly of interest, if marred by Solomon’s fundamentally uncritical attitude toward the information he has assembled and his tendency to see benefit in every treatment he encounters.
Over the course of this book we certainly learn much about Andrew Solomon. He is independently wealthy—his father directs a profitable pharmaceutical company that produces, mirabile dictu, an anti-depressant. He is well educated, with an MA from an English university, has written for the New Yorker, and conducts an active social life. Also, he is sexually adventurous, choosing both female and male partners. And he has tried a wide variety of addictive drugs, although he claims that he never became dependent on any of them because he lacks, as he puts it, “an addictive personality.”
As for his depression, the first attacks, Solomon says, seemed to come out of the blue, and at a time when he thought he had “solved most of [his] problems.” As the depression worsened, all his emotions turned downward, he found it progressively harder to find joy in anything, and ultimately he withdrew to his bed, stopped eating, and fell into a stuporous, self-neglectful condition from which he was rescued, essentially, by his father.
There followed many different kinds and forms of treatment, including but hardly limited to both orthodox psychoanalysis and pharmacological medication. With the help of the latter, Solomon recovered from his initial spell of depression, but in the next few years he fell into two more, almost as severe, both of which were precipitated by physical illness and the cessation of medication. In each case he was beset by self-loathing, became preoccupied with thoughts of death, and engaged in the crudest forms of sexual behavior in order to expose himself to HIV and thus gain a real excuse for suicide. Nothing he could do or think about would relieve his symptoms. In the end, only the working-out of an efficacious regimen of pills has helped him and kept him well.
We learn all about Solomon’s many treatments in this book, and also about the problems each type entailed. As he became more and more persuaded of the biomedical nature of his condition, he studied the theories behind anti-depressant medications and the way they act on different patients, and this research, too, he shares in detail with his readers. He also visited many different psychiatric centers and healing places, from the conventional to the outre, inquiring in each case into patients who experienced states of mind similar to his own and the way therapists and physicians responded to these patients and what advances they anticipated in knowledge and methods of practice. The record of all these experiences—along with interviews of leaders of the psychiatric profession and a broad review of the contemporary periodical literature—fills out the book.
Aside from the many things we learn about the adventures of Andrew Solomon, however, what exactly do we learn about depression? To answer that question it is useful to compare The Noonday Demon with the memoirs by William Styron and Kay Redfield Jamison. They, too, describe from a personal viewpoint the mental changes wrought by depression and mania, and offer detailed accounts of treatment, particularly by means of drugs and electric shock. Both authors are exceptionally good at portraying the loss of control felt during attacks of depression, especially the irrational but all-encompassing despair that accompanies it. Thus, Styron at one point compares his depressed mind with “one of those outmoded small-town telephone exchanges, being gradually inundated by flood-waters,” while, for Jamison, the engulfing sense of personal worth-lessness and hopelessness made her regard even her body as “uninhabitable . . . raging and weeping and full of destruction.”
The precision with which these writers strive to capture the stages of their condition, from onset to eventual recovery, marks something of a contrast with Solomon’s often blurry reportage and omniumgatherum approach to medical information. More importantly, both of them bring into focus, as he does not, the particular form of depression that all three suffered from. For, as a mental symptom, depression can have many different causes and can also manifest itself in an entire range of feelings, from discouragement and demoralization to something much more elemental. The depression that these books are describing—here again Solomon’s approach tends to muddle necessary distinctions—is of the latter variety.
To be still more precise, this form of depression is a symptom or, better, an expression of what is called affective disorder. This is an affliction in which an otherwise ordinary mental faculty—namely, the link between the mind’s affective domain (moods, emotions, and drives) and the mind’s cognitive domain (thoughts and perceptions)—has been disrupted. As a consequence, affects run autonomously and ungoverned, shifting with any given attack of the disorder either toward the misery and withdrawal of depression or toward the energy and over-confidence of mania. That is why most psychiatrists prefer to use more exact terms like manic-depression or bipolar disorder to refer to this class of affective illnesses, although for ease of understanding I shall continue to refer to it by the somewhat misleading catch-all of depression.
Many people, including many patients, still believe that at the heart of this particular disorder lies some great personal and moral flaw, one that can be corrected if only they would not let their emotions run amok. The great virtue of the Styron and Jamison books, especially if read in conjunction with more specialized studies like Francis M. Mondi-more’s Depression: The Mood Disease (1990), is that they help dispel this mistaken notion. Rather, they demonstrate, this form of depression shares more attributes with a disease like epilepsy than it does with a character trait like self-pity—and, like epilepsy, it can respond to medical treatment. Kay Jamison, in particular, has inspired many victims of depression to realize that if they can overcome this mental ordeal as she did, they might at last put it behind them and move on into life.
Andrew Solomon’s book is much more equivocal in its message. Although thorough to a fault as a description of personal experience, and no less exhaustive in its account of treatments and the theoretical conceptions behind them, it is, at its heart, a book about him, and correspondingly less than useful either as a true “atlas” of depression or as a guide for fellow-sufferers.
The problem comes to light right at the start, with Solomon’s portentous first sentence: “Depression is the flaw in love.” Similar aphoristic statements turn up again and again: “Depression like sex retains an unquenchable aura of mystery. It is new every time.” “Strength of will is the best bulwark against depression.” Not only are these assertions melodramatic, they are quite simply—and revealingly—wrong.
To repeat, the particular disorder at issue here is a disease, an affliction that disrupts a natural function of emotional control. This disease, like other diseases both physical and mental, renders the afflicted person impaired in ways that are essentially the same from case to case. The injury is no more related to “love” than it is to any other emotion: all affective functions are disrupted. And far from being “new every time,” it is so similar from occasion to occasion that a veteran patient—or an experienced relative—can detect its recurrence from the first subtle effects on emotional tone, attitude, facial expression, even posture. Finally, strength of will has no more to do with this disorder and its course than strength of will controls the progress of Alzheimer’s disease.
The awful but crucial thing about disease, mental or physical, is that it stands apart from who you are as a person. You can be discouraged, demoralized, and down-hearted about events in your life that have blocked your hopes and plans. If you happen to be selfish, willful, and irresponsible, you might drive others away and thus bring on symptoms of loneliness and despair. If you take up attitudes and assumptions that promote anorexia nervosa, alcoholism, or drug addiction, you might suffer the miseries these behaviors carry with them. These states of mind are often and confusingly labeled depression, but none of them is the depression I am talking about, which is not a you but an it, a thing unto itself and not just the dark side of human emotion.
You cannot choose for or against this disease. It chooses you, just as does epilepsy, cancer, or heart disease. It turns you into a stereotyped copy of every other person afflicted with it. You are not in charge of it, you are not to blame for it, and you can do little about it except to seek the help that may enable you to escape its clutches.
Styron and Jamison understand this. By contrast, Solomon seems in thrall to an earlier, quite romantic, and quite literary notion of mental illness. Although he stipulates that his first attack seems to have come out of nowhere, he also clearly regards it as emerging from deep within his psyche, as reflecting some intimate flaw that he has yet to work through. He is enamored of himself for having this flaw, and he is enamored of himself in the end for having worked through it. Along the way, he is even a little enamored of his behavior in the course of suffering it.
In one scene of this book, Solomon describes, and excuses, a vicious assault on one of his homosexual partners in which he broke the man’s nose and jaw and sent him to the hospital in need of blood transfusions. Some of the physical sensations he felt as he delivered his bone-crushing blows were, he freely admits, pleasurable. More: even today, “part of me does not rue what happened, because I sincerely believe that [without it] I would have gone irretrievably crazy.” And a bit later he adds: “Engaging in violent acts is not a good way to treat depression. It is, however, effective. To deny the inbred curative power of violence would be a terrible mistake.”
At least one admiring reviewer of The Noonday Demon paused to point out that these statements might appear to justify acts that were, well, criminal. They certainly do that, not to mention that they conjure up images of brownshirt thuggery. But they also happen to flow naturally from Solomon’s conception of depression less as an illness than as a stage on which to enact a heroic drama of the self.
So, too, does another picturesque scene in The Noonday Demon in which our hero undergoes an African ceremony called “ndeup”: an “animist ritual that probably antedates voodoo” and that amounts to a kind of exorcism. On the recommendation of “the mother of a friend of the girlfriend of a friend,” Solomon traveled to Senegal to undergo this treatment. There he was taken in hand by a mysterious priestess who supervised the ceremony. While he danced to drums being beaten by members of the local community, Solomon was smeared “on every inch” of his body with blood from a cockerel and a ram. The blood, caking like a scab, attracted thousands of flies. Five women dressed in loose-fitting robes and wearing belts filled with prayers and iconic objects danced about him as he chanted to his bewitching spirits, “Leave me be; give me peace; and let me do the work of my life. I will never forget you.” The ceremony ended with a great barbecue of the ram.
Solomon does not say whether the treatment actually helped him, though he does allow that it “jolted the system, which could certainly throw one’s brain chemistry into overdrive—a kind of unplugged ECT [electro-convulsive therapy].” It would be hard to argue with that.
Please do not misunderstand me. In depression, just as in any illness, including cardiac disease and cancer, “you” and “it” do exist together. You do not cause or control the disease, but you may make the expression of it stronger or weaker, the treatment of it easier or harder. This is a very important point, and one that cannot be emphasized enough. But what The Noonday Demon gives us is a different and in many ways opposite scenario: a lonely existential fight against darkness and despair in which a star is born, whose name is Andrew. Romanticizing the “it,” Solomon is obtuse about the “you,” to the point of embracing acts of criminal violence as conducive to “sanity.”
And this brings me back to Otto Kernberg, and to the other revolution in the understanding of mental illness with which I began. Although Andrew Solomon managed not to encounter one, a growing number of psychotherapists these days are less willing to sit by as patients make up their own rules for living or disregard consequences and moral meanings. To the contrary, they tend to insist that patients take note of their own selfish attitudes and behaviors and recognize their role in generating the distress for which they seek treatment. In fact, one of the most difficult clinical problems today is figuring out how to differentiate disorders tied to a “you,” where therapeutic guidance and strengthening are essential, from the several “its” that damage mental faculties, are to be apprehended as diseases, and need to be cured and prevented.
The disciplines that surround psychiatry—neuroscience, psychology, pharmacology, and epidemiology—have brightened the prospects of dealing successfully with the particular affective disorder I have been calling depression. At the same time, the “judgmental” turn taken by psychotherapy has helped many a patient escape the trap of narcissism and emotional instability. To anyone who has followed or participated in the frequently destructive wars of the psychiatric profession, it cannot but be heartening that the recent turn to the pragmatic in therapy should be accompanied, and strengthened, by an essentially moral vision of human responsibility. The model celebrated by Andrew Solomon is, one earnestly prays, a throwback.
1 Scribner, 571 pp., $28.00.