AN UNQUIET MIND

AN UNQUIET MIND

sive injection of an antipsychotic medication, but the drug had not yet taken hold. He was delusional, paranoid, largely incoherent, and experiencing both visual and auditory hallucinations. He reminded me of films I had seen of horses trapped in fires with their eyes wild with fear and their bodies paralyzed in terror. I tightened my hand on his shoulder, shook him gently, and said, "It's Dr. Jamison. You've been given some Hal- dol; we're going to take you up to the ward. You're going to be all right." I caught his eye for a moment. Then he screamed again. "You'll be fine. I know you don't believe it now, but you will be well again." I looked over at the three thick volumes of his medical records lying on the table nearby, thought about his countless hospitalizations, and wondered about the truthfulness of my remarks.

That he would get well again, I had no doubt. How long it would last was another question. Lithium worked remarkably well for him, but once his hallucinations and abject terror stopped, he would quit taking it. Neither the resident nor I needed to see the results of the lithium blood level that had been drawn on his admission to the emergency room. There would be no lithium in his blood. The result had been mania. Suicidal depression would inevitably follow, as would the indescribable pain and disruptiveness to his life and to the lives of the members of his family. The severity of his depressions was a black mirror image of the dangerousness of his manias. In short, he had a particularly bad, although not uncommon, form of the illness; lithium worked well, but he wouldn't take it. In many ways, it seemed to me, as I stood there next to him in the emergency room, that all of the time, effort, and emotional energy that I and the others put into treating him were to little or no avail.

Gradually the Haldol began to take effect. The screaming stopped, and the frantic straining against his restraints died down. He was both less frightened and less frightening; after a while he said to me, in a slowed and slurred voice, "Don't leave me, Dr. Jamison. Please, please don't leave me." I assured him I would stay with him until he got to the ward. I knew that I was the one constant throughout all of his hospitalizations, court appearances, family meetings, and black depressions. As his psychotherapist for years, I had been privy to his dreams and fears, hopeful and then ruined relationships, grandiose and then shattered plans for the future. I had seen his remarkable resilience, personal courage, and wit; I liked and respected him enormously. But I also had been increasingly frustrated by his repeated refusals to take medication. I could, from my own experience, understand his concerns about taking lithium, but only up to a point; past that point, I was finding it very difficult to watch him go through such predictable, painful, and unnecessary recurrences of his illness.

No amount of psychotherapy, education, persuasion, or coercion worked; no contracts worked out by the medical and nursing staff worked; family therapy didn't help; no tallying up of the hospitalizations, broken relationships, financial disasters, lost jobs, imprisonments, squanderings of a good, creative, and educated mind worked. Nothing I or anyone else could think of worked. Over the years, I asked several of my colleagues to see him in consultation, but they, like me, could find no way to reach him, no chink in the tightly riveted armor of his resistance. I spent hours talking to my own psychiatrist about him, in part to seek his clinical advice, and in part to make sure that my own history of stopping and starting lithium was not playing some sort of unconscious, unacknowledged role. His attacks of mania and depression became more frequent and severe. No breakthrough ever came; no happy ending ever materialized. There was simply nothing that medicine or psychology could bring to bear that would make him take his medication long enough to stay well. Lithium worked, but he would not take it; our relationship worked, but not well enough. He had a terrible disease and it eventually cost him his life-as it does tens of thousands of people every year. There were limits on what any of us could do for him, and it tore me apart inside.

We all move uneasily within our restraints.

The Charnel House

I reaped a bitter harvest from floridly psychotic mania was followed, inevitably, by a my own refusal to take lithium on a consistent basis. A

long and lacerating, black, suicidal depression; it lasted more than a year and a half. From the time I woke up in the morning until the time I went to bed at night, I

boring, inadequate, thick brained, unlit, unresponsive, was sparkling now was flat. I seemed to myself to be dull, word, movement-was an effort. Everything that once kind of joy or enthusiasm. Everything-every thought, was unbearably miserable and seemingly incapable of any chill skinned, bloodless, and sparrow drab. I doubted, the point of being virtually useless. The wretched, con- though my mind had slowed down and burned out to completely, my ability to do anything well. It seemed as all. What is the point in going on like this? I would ask taunt me with the total, the desperate, hopelessness of it my inadequacies and shortcomings in character, and to only well enough to torment me with a dreary litany of voluted, and pathetically confused mass of gray worked myself. Others would say to me, "It is only temporary, it will pass, you will get over it," but of course they had no idea how I felt, although they were certain that they did. Over and over and over I would say to myself, If I can't feel, if I can't move, if I can't think, and I can't care, then what conceivable point is there in living?

The morbidity of my mind was astonishing: Death and its kin were constant companions. I saw Death everywhere, and I saw winding sheets and toe tags and body bags in my mind's eye. Everything was a reminder that everything ended at the charnel house. My memory always took the black line of the mind's underground system; thoughts would go from one tormented moment of my past to the next. Each stop along the way was worse than the preceding one. And, always, everything was an effort. Washing my hair took hours to do, and it drained me for hours afterward; filling the ice-cube tray was beyond my capacity, and I occasionally slept in the same clothes I had worn during the day because I was too exhausted to undress.

During this time I was seeing my psychiatrist two or three times a week and, finally, again taking lithium on a regular basis. His notes, in addition to keeping track of the medications I was taking-I had briefly taken antidepressants, for example, but they had only made me more dangerously agitated-also recorded the unremitting, day-in and day-out, week-in and week-out, despair, hopelessness, and shame that the depression was causing: "Patient intermittently suicidal. Wishes to jump from the top of hospital stairwell"; "Patient continues to be a significant suicide risk. Hospitalization is totally unaceptable to her and in my view she cannot be held under LPS [the California commitment law]"; "Despairs for the future; fears recurrence and fears having to deal with the fact that she has felt what she has felt. Patient feels very embarrassed about feelings she has and takes attitude that regardless of the course of her depression she won't put up with it. Patient reluctant to be with people when depressed because she feels her depression is such an intolerable burden on others. Afraid to leave my office. Hasn't slept in days. Desperate. At this point there was a brief lull in my depression, only to be followed by its seemingly inevitable, dreadful return: Patient feels as if she has cracked. Hopeless that depressed feelings have returned.

My psychiatrist repeatedly tried to persuade me to go into a psychiatric hospital, but I refused. I was horrified at the thought of being locked up; being away from familiar surroundings; having to attend group therapy meetings; and having to put up with all of the indignities and invasions of privacy that go into being on a psychiatric ward. I was working on a locked ward at the time, and I didn't relish the idea of not having the key. Mostly, however, I was concerned that if it became public knowledge that I had been hospitalized, my clinical work and privileges at best would be suspended; at worst, they would be revoked on a permanent basis. I continued to resist voluntary hospitalization; and, because the California commitment code is designed more for the well-being of lawyers than of patients, it would have been relatively easy for me to talk my way out of an involuntary commitment. Even had I been committed, there was no guarantee at all that I would not have attempted or committed suicide while on the ward; psychiatric hospitals are not uncommon places for suicide. (After this experience, I

drew up a clear arrangement with my psychiatrist and family that if I again become severely depressed they have the authority to approve, against my will if necessary, both electroconvulsive therapy, or ECT, an excellent treatment for certain types of severe depression, and hospitalization.)

At the time, nothing seemed to be working, despite excellent medical care, and I simply wanted to die and be done with it. I resolved to kill myself. I was cold-bloodedly determined not to give any indication of my plans or the state of my mind; I was successful. The only note made by my psychiatrist on the day before I attempted suicide was: Severely depressed. Very quiet.

T. In a rage I pulled the bathroom lamp off the wall and felt the violence go through me but not yet out of me. For Christ's sake, he said, rushing in-and then stopping very quietly. Jesus, I must be crazy, I can see it in his eyes: a dreadful mix of concern, terror, irritation, resignation, and why me, Lord? Are you hurt? he asks. Turning my head with its fast-scanning eyes I see in the mirror blood running down my arms, collecting into the tight ribbing of my beautiful, erotic negligee, only an hour ago used in passion of an altogether different and wonderful kind. I can't help it. I can't help it, I chant to myself, but I can't say it; the words won't come out, and the thoughts are going by far too fast. I bang my head over and over against the door. God make it stop, I can't stand it, I know I'm insane again. He really cares, I think, but within ten minutes he too is screaming, and his eyes have a wild look from contagious madness, from the lightning adrenaline between the two of us. I can't leave you like this, but I say a few truly awful things and then go for his throat in a more literal way, and he does leave me, provoked beyond endurance and unable to see the devastation and despair inside. I can't convey it and he can't see it; there's nothing to be done. I can't think, I can't calm this murderous cauldron, my grand ideas of an hour ago seem absurd and pathetic, my life is in ruins and-worse still- ruinous; my body is uninhabitable. It is raging and weeping and full of destruction and wild energy gone amok. In the mirror I see a creature I don't know but must live and share my mind with.

I understand why Jekyll killed himself before Hyde had taken over completely. I took a massive overdose of lithium with no regrets.

Within psychiatric circles, if you kill yourself, you earn the right to be considered a successful suicide. This is a success one can live without. Suicidal depression, I decided in the midst of my indescribably awful, eighteen-month bout of it, is God's way of keeping manics in their place. It works. Profound melancholia is a day-in, day-out, night-in, night-out, almost arterial level of agony. It is a pitiless, unrelenting pain that affords no window of hope, no alternative to a grim and brackish existence, and no respite from the cold undercurrents of thought and feeling that dominate the horribly restless nights of despair. There is an assumption, in attaching Puritan concepts such as successful and unsuccessful to the awful, final act of suicide, that those who fail at killing themselves not only are weak, but incompetent, incapable even of getting their dying quite right. Suicide, however, is almost always an irrational act and seldom is it accompanied by the kind of rigorous intellect that goes with one's better days. It is also often impulsive and not necessarily undertaken in the way one originally planned.

I, for example, thought I had covered every contingency. I could not stand the pain any longer, could not abide the bone-weary and tiresome person I had become, and felt that I could not continue to be responsible for the turmoil I was inflicting upon my friends and family. In a perverse linking within my mind I thought that, like the pilot whom I had seen kill himself to save the lives of others, I was doing the only fair thing for the people I cared about; it was also the only sensible thing to do for myself. One would put an animal to death for far less suffering.

At one point I bought a gun, but, in a transient wave of rational thought, I told my psychiatrist; reluctantly, I got rid of it. Then for many months I went to the eighth floor of the stairwell of the UCLA hospital and, repeatedly, only just resisted throwing myself off the ledge. Suicidal depression does not tend to be a considerate, outward, or other-considering sort of state, but somehow the thought that my family would have to identify the fallen and fractured me made that ultimately not an acceptable method. So I decided upon a solution that seemed to me to be poetic in its full-circledness. Lithium, although it ultimately saved my life, at that particular time was causing me no end of grief and sorrow. So I decided to take a massive overdose.

In order to keep the lithium from being vomited back up, I had gone to an emergency room and obtained a prescription for an anti-emetic medication. I

then waited for a break in the informal "suicide watch" that my friends and family, in conjunction with my psychiatrist, had put into place. This done, I removed the telephone from my bedroom so I would not inadvertently pick it up-I could not take the phone off its hook entirely as I knew this would alert my keepers --- and, after a terrible row, and in a very agitated and violent state, I took handful after handful of pills. I then curled up in my bed and waited to die. I hadn't planned on the fact that one's drugged brain acts differently from one's alert brain. When the telephone rang I must have instinctively thought to answer it; thus I crawled, semi-comatose, to the telephone in the living room. My slurred voice alerted my brother, who was calling from Paris to see how I was doing. He immediately called my psychiatrist.

It was not a pleasant way not to commit suicide. Lithium is used to teach coyotes to stop killing sheep: often a single experience with a lithium-treated sheep carcass will make a coyote sick enough to keep his teeth to himself. Although I had taken medication to keep me from vomiting up the lithium, I still ended up sicker than a coyote, sicker than a dog, sicker than I could ever wish anyone to be. I also was in and out of a coma for several days, which, given the circumstances, was probably just as well.

For a long time both before and after I tried to kill myself, I was in the close care of a friend of mine, one who redefined for me the notion of friendship. He was a psychiatrist, as well as a warm, whimsical, and witty man who had a mind like a cluttered attic. He was intrigued by a variety of bizarre things, including me, and wrote fascinating articles about such topics as nutmeg psychoses and the personal habits of Sherlock Holmes. He was intensely loyal and spent evening after evening with me, somehow enduring my choleric moods. He was generous with both his time and money, and he stubbornly believed that I would make it through my depression and, ultimately, thrive.

Sometimes, after I had told him that I simply had to be alone, he would call me later, at one or two o'clock in the morning, to see how I was doing. He could tell from my voice what state I was in, and, despite my pleas to be left alone, he would insist on coming over. Often this was in the guise of "I can't sleep. You wouldn't refuse to keep a friend company, would you?" Knowing full well that he was only checking up on me, I would say, "Yes. Trust me. I can refuse. Leave me alone. I'm in a foul mood." He would call back again in a few minutes and say, "Please, please, pretty please. I really need the company. We can go somewhere and get some ice cream." So we would get together at some ungodly hour, I would be secretly and inexpressibly grateful, and he somehow would have finessed it so that I didn't feel like I was too huge a burden to him. It was a rare gift of friendship.

Fortuitously, he also worked as an emergency room physician on weekends. After my suicide attempt, he and my psychiatrist worked out a plan for my medical care and supervision. My friend kept a constant watch on me, drew my blood for lithium and electrolyte levels, and walked me repeatedly to pull me out of my drugged state, as one would move a sick shark around its tank in order to keep the water circulating through its gills. He was the only person I knew who could make me laugh during my truly morbid moments. Like my husband, from whom I was legally separated but still frequently in contact, he had a gentling and calming effect on me when I was vastly irritable, perturbed, or perturbing. He nursed me through the most awful days of my life, and it is to him, only next to my psychiatrist and family, that I most owe my life.

The debt I owe my psychiatrist is beyond description. I remember sitting in his office a hundred times during those grim months and each time thinking, What on earth can he say that will make me feel better or keep me alive? Well, there never was anything he could say, that's the funny thing. It was all the stupid, desperately optimistic, condescending things he didn't say that kept me alive; all the compassion and warmth I felt from him that could not have been said; all the intelligence, competence, and time he put into it; and his granite belief that mine was a life worth living. He was terribly direct, which was terribly important, and he was willing to admit the limits of his understanding and treatments and when he was wrong. Most difficult to put into words, but in many ways the essence of everything: He taught me that the road from suicide to life is cold and colder and colder still, but-with steely effort, the grace of God, and an inevitable break in the weather-that I could make it.

My mother also was wonderful. She cooked meal after meal for me during my long bouts of depression, helped me with my laundry, and helped pay my medical bills. She endured my irritability and boringly bleak moods, drove me to the doctor, took me to pharmacies, and took me shopping. Like a gentle mother cat who picks up a straying kitten by the nape of its neck, she kept her marvelously maternal eyes wide-open, and, if I floundered too far away, she brought me back into a geographic and emotional range of security, food, and protection. Her formidable strength slowly eked its way into my depleted marrowbone. It, coupled with medicine for my brain and superb psychotherapy for my mind, pulled me through day after impossibly hard day. Without her I never could have survived. There were times when I would struggle to put together a lecture, and, having no idea whether it made sense or not, I would deliver it through the din and dreadful confusion that masqueraded as my mind. Often the only thing that would keep me going was the belief, instilled by my mother years before, that will and grit and responsibility are what ultimately make us supremely human in our existence. For each terrible storm that came my way, my mother-her love and her strong sense of values-provided me with powerful, and sustaining, countervailing winds.

The complexities of what we are given in life are vast and beyond comprehension. It was as if my father had given me, by way of temperament, an impossibly wild, dark, and unbroken horse. It was a horse without a name, and a horse with no experience of a bit between its teeth. My mother taught me to gentle it; gave me the discipline and love to break it; and-she understood, and taught me, that the beast was best handled by turning it toward the sun.

Both my manias and depressions had violent sides to them. Violence, especially if you are a woman, is not something spoken about with ease. Being wildly out of control-physically assaultive, screaming insanely at the top of one's lungs, running frenetically with no purpose or limit, or impulsively trying to leap from cars-is frightening to others and unspeakably terrifying to oneself. In blind manic rages I have done all of these things, at one time or another, and some of them repeatedly; I remain acutely and painfully aware of how difficult it is to control or understand such behaviors, much less explain them to others. I have, in my psychotic, seizurelike attacks-my black, agitated manias-destroyed things I cherish, pushed to the utter edge people I love, and survived to think I could never recover from the shame. I have been physically restrained by terrible, brute force; kicked and pushed to the floor; thrown on my stomach with my hands pinned behind my back; and heavily medicated against my will.

I do not know how I have recovered from having done the things that necessitated such actions, any more than I know how and why my relationships with friends and lovers have survived the grinding wear and tear of such dark, fierce, and damaging energy. The aftermath of such violence, like the aftermath of a suicide attempt, is deeply bruising to all concerned. And, as with a suicide attempt, living with the knowledge that one has been violent forces a difficult reconciliation of totally divergent notions of oneself. After my suicide attempt, I had to reconcile my image of myself as a young girl who had been filled with enthusiasm,

I

high hopes, great expectations, enormous energy, and dreams and love of life, with that of a dreary, crabbed, pained woman who desperately wished only for death and took a lethal dose of lithium in order to accomplish it. After each of my violent psychotic episodes, I had to try and reconcile my notion of myself as a reasonably quiet-spoken and highly disciplined person, one at least generally sensitive to the moods and feelings of others, with an enraged, utterly insane, and abusive woman who lost access to all control or reason.

These discrepancies between what one is, what one is brought up to believe is the right way of behaving toward others, and what actually happens during these awful black manias, or mixed states, are absolute and disturbing beyond description-particularly, I think, for a woman brought up in a highly conservative and traditional world. They seem a very long way from my mother's grace and gentleness, and farther still from the quiet seasons of cotillions, taffetas and silks, and elegant gloves that slid up over the elbows and had pearl buttons at the wrist, when one had no worries other than making sure that the seams in one's stockings were straight before going to Sunday-night dinners at the Officers' Club.

For the most important and shaping years of my life I had been brought up in a straitlaced world, taught to be thoughtful of others, circumspect, and restrained in my actions. We went as a family to church every Sunday, and all of my answers to adults ended with a "ma'am" or a "sir." The independence encouraged by my parents had been of an intellectual, not socially disruptive, nature. Then, suddenly, I was unpredictably and uncontrollably irrational and destructive. This was not