An Unquiet Mind

Many thanks to Sarah for recommending this book!

Kay Redfield Jamison, the author of An Unquiet Mind, is a Professor of Psychiatry at Johns Hopkins, and is a pre-eminent contemporary psychiatrist. Although I am not familiar with her, she is an accomplished psychiatrist - and a sufferer of manic depression - or bipolar disorder. Actually, she herself writes about preferring the term 'manic-depressive illness' to the newer label 'bipolar disorder', but I won't get into detail about that. At least in this marginal commentary, however, I will generally follow Dr Jamison's preference.

An Unquiet Mind may be called Dr Jamison's 'biography of mental illness', for in it she describes coping - for a long time unsuccessfully - with manic depression. In having such a focus, it is a lot more like C. S. Lewis's Surprised by Joy than it is like the other biographies I've commented upon on The Marginal Virtues, namely; Hitman by Bret Hart, The Apprentice by Jacques Pepin, and The Glass Castle by Jeannette Walls.

There is something to be said about the use of the term 'bipolar disorder', and that is the word 'disorder' - manic depression is the 'disordered' form of modes of experience and feeling that everyone experiences. I would go so far as to say, although with the caveat that I am no professional, that all of us have 'manic' and 'depressive' moments, but they are neither so severe nor prolonged, in most cases, to be in any way noticeable.

My focus, then, will be on a handful of passages in which Dr Jamison describes her illness, and what, if anything, I think it also describes of common human experience. The edition from which I cite passages was the re-published version (with a new preface by the author) of 2011 by Vintage Books.


One of the things Dr Jamison found most difficult was adjusting to life on medication:

People go mad in idiosyncratic ways. Perhaps it was not surprising that, as a meteorologist's daughter, I found myself, in that glorious illusion of high summer days, gliding, flying, now and again lurching through cloud banks and ethers, past stars and across fields of ice crystals. Even now, I can see in my mind's rather peculiar eye an extraordinary shattering and shifting of light; inconstant but ravishing colors laid out across miles of circling rings; and the almost imperceptible, somehow surprisingly pallid, moons of this Catherine wheel of a planet. I remember singing "Fly Me to the Moons" as I swept past those of Saturn, and thinking myself terribly funny. I saw and experienced that which had been only dreams, or fitful fragments of aspiration.
Was it real? Well, of course not, not in any meaningful sense of the word "real." But did it stay with me? Absolutely. Long after my psychosis cleared, and the medications took hold, it became part of what one remembers forever, surrounded by an almost Proustian melancholy. Long since that extended voyage of my mind and soul, Saturn and its icy rings took on an elegiac beauty, and I don't see Saturn's image now without feeling an acute sadness at its being so far away from me, so unobtainable in many ways. The intensity, glory, and absolute assuredness of my mind's flight made it very difficult for me to believe, once I was better, that the illness was one I should willingly give up. Even though I was a clinician and a scientist, and even though I could read the research literature and see the inevitable, bleak consequences of not taking lithium, I for many years after my initial diagnosis was reluctant to take my medications as prescribed. Why was I so unwilling? Why did it take having to go through more episodes of mania, followed by long suicidal depressions, before I would take lithium in a medically sensible way?
Some of my reluctance, no doubt, stemmed from a fundamental denial that what I had was a real disease. This is a common reaction that follows, rather counter-intuitively, in the wake of early episodes of manic-depressive illness. Moods are such an essential part of the substance of life, of one's notion of oneself, that even psychotic extremes in mood and behavior somehow can be seen as temporary, even understandable, reactions to what life has dealt. In my case, I had a horrible sense of loss for who I had been and where I had been. It was difficult to give up the high flights of mind and mood, even though the depressions that inevitably followed nearly cost me my life.
My family and friends expected that I would welcome being "normal," be appreciative of lithium, and take in stride having normal energy and sleep. But if you have had stars at your feet and the rings of planets through your hands, are used to sleeping only four or five hours a night and now sleep eight, are used to staying up for days and weeks in a row and now cannot, it is a very real adjustment to blend into a three-piece-suit schedule, which, while comfortable to many, is new, restrictive, seemingly less productive, and maddeningly less intoxicating. People say, when I complain of being less lively, less energetic, less high-spirited, "Well, now you're just like the rest of us," meaning, among other things, to be reassuring. But I compare myself with my former self, not with others. Not only that, I tend to compare my current self with the best I have been, which is when I have been mildly manic. When I am my present "normal" self, I am far removed from when I have been my liveliest, most productive, most intense, most outgoing and effervescent. In short, for myself, I am a hard act to follow.
And I miss Saturn very much. [pp. 89-91]

Commentary: 'I miss Saturn very much' tells us everything we need to know why Dr Jamison resisted giving up the highs of mania for so long, why, for so long, she resisted staying on lithium. Given the description of what is very nearly a visionary experience - 'the intensity, glory, and absolute assuredness of my mind's flight' makes one think of St Paul's vision of being taken up into the third heaven. The 'ravishing colours', the 'miles of circling rings', the 'stars at [her] feet and the rings of planets through [her] hands', the heartbreakingly beautiful vision which her mania provided: little wonder she had so much difficulty giving up all that, let alone the 'most productive, most intense, most outgoing and effervescent' state which she experienced while within milder states of mania. Here is a picture of Saturn: imagine being in a waking state and being able to 'see' Saturn, up close, as if you were flying by it as did the Voyager probes.
'Milder' mania may be clinically described as hypomania; according to that source 'mania' refers strictly to the severest of manic episodes, while 'hypomania' may be used to describe the alluring state whose loss Jamison mourns.
One work I read about procrastination described as 'hypomania' the 'rush' one gets when one is starting that paper for that class the night before it is due, knowing that one will be up all night - I have been there and known that feeling, and I am not alone. Dr Miller, the link to whose letter I included first in the above paragraph, writes that this state needs to persist for several days before it can be clinically diagnosed as hypomania. In any case, that state is electrifying, and replacing it with a sober and steady approach to any task, whether writing papers or doing housework, is difficult. We don't want to give up our romantic notions of creativity or of accomplishing tasks (excellently and briefly punctured by sociologist Eviatar Zerubavel in The Clockwork Muse): either cleaning the house is to be an Herculean labour, like the cleaning of the Augean stables, or it is not to be done at all. (Incidentally, Hercules was set to his Twelve Labours for killing his wife and child in what could be described as a fit of mania inspired by the goddess Hera.)
A less noxious, and more helpful, state of mind and mood that I wonder isn't akin to hypomania is described as 'flow'. As defined by social theorist Mihaly Czikszentmihaly (who has become more and more prominent over time), 'flow' is the state of being in which we are intensely focussed on what we are doing, and one which rewards us with a deep-seated sense of being 'at one' with the task.
One of the reasons, then, that hypomania (clinically defined) is so 'seductive' is because it is not, after all, so much different than either the less noxious, although still unhelpful, state one enters when one is rushing to complete a task after procrastinating ('acting out', to borrow a turn of phrase from the behaviours of addicts), or the positive notion of 'flow'. In all of these states we are, to a certain extent, ecstatic. Finally, however, this mania (the word derives from a Greek word meaning 'to be mad') leads to a psychotic break from reality. One wonders whether the ultimately noxious states of hypomania and mania are not, after all, excessive kinds of the more stable and positive state of being which Cziksentmihaly defined as 'flow'; just as recklessness and cowardice are extremes of the virtue of courage, and not wholly distinct from it, mania is an extreme of a state or mood that all of us are capable of having and which is, in itself, good to feel.
Jamison gives three reasons why she found it so difficult to stick to her prescription, and I suspect that these hold for many people who have been prescribed medication for, well, any illness, let alone mental illness, and yet do not follow through. I won't treat them in any particular order.
Grief for what she must lose if she stays on her meds is prominent in this section (later in this chapter Jamison describes several unpleasant side effects of lithium). She describes a 'horrible sense of loss for who I had been and where I had been.' Grieving the loss of something is even more difficult when it is so easy to get it back, if you want it. At any time Dr Jamison could have her old self back; all she has to do is stop taking her medication. In this sense it is easier than grieving the loss of something, or someone, now beyond our reach. It is hard enough to grieve, when you cannot get back what you've lost; if you can, why then suffer the pain of grief? But Jamison had to suffer the pain of grief at the loss of a part of herself in order not to relapse into madness.
The second reason she gives is denial. '... [M]y reluctance... stemmed from a fundamental denial that what I had was a real disease.' It was possible to deny she was ill, because her illness was an illness of mood, a fundamental experience of human existence. We all have moods, and they vary in intensity, in duration, in kind; it was possible for her to convince herself that what she was experiencing was somehow 'normal'. This also provides additional support for the notion of mental illness as the disorder of normal, regulative states of mood, thought, and perception. We can deny being unwell because sickness and wellness are not absolutely distinctive, but relative positions along a spectrum from healthy to unhealthy functioning. Like the proverbial frog in the pot, it is possible to ignore or be unaware of changes in our health that indicate that things are approaching boiling point.
Finally, there is the admission on Jamison's part that she didn't care for being 'normal' - the three-piece-suit way of life. When you have lived in exceptional circumstances, however noxious, how hard it must be to adjust to the ordinary, the quotidian! It is not reassuring, superficially, to be 'normal' when you are accustomed to 'highs' of the kind Jamison describes so vividly, even many years after the event. It would be quite something to perceive a 'Catherine wheel of a planet'. It may be said that it is our duty to be extraordinary, but clearly some forms of extraordinariness are worse than others. It is not only the mentally ill who chafe at the restrictions of ordinariness, the 'cross' of everyday life which we grudge to carry.
Perhaps most notably is Dr Jamison's admission that, despite being an expert on the subject, she 'for many years after [her] initial diagnosis was reluctant to take [her] medications as prescribed,' even though, as she explains, '[e]ven though [she] was a clinician and a scientist, and even though [she] could read the research literature and see the inevitable, bleak consequences of not taking lithium'. Expertise is neither foolproof, nor infallible. Expertise, the patient cultivation of habit and discipline in the professional and academic aspect of life, does not guarantee that we will be any better equipped to make the right decisions for ourselves, or for others. This is ironically so, for the same habits and disciplines that enable us to become experts are, when applied to the field of moral choice, precisely what enables us to choose wisely; yet so many people who are experts are as incapable of wisdom as those who are uneducated - one reason why I vehemently dislike the despite of the learned for the unlearned.
Speaking of lithium, there is a Royal Canadian Air Farce skit called 'The Outsider's Report' which pokes fun at Canadian entrepreneur Dave Nichol,  who single-handedly turned the fortunes of the Loblaws grocery store chain around in the seventies and eighties (or so it may be said). In this particular skit (Air Farce had several radio and TV spots parodying Nichol's 'Insider's Report'), 'Dave' introduces his grocery store's new line of generic drug products, featuring 'for that special manic-depressive in your life, it's I Can't Believe it's Not Lithium!' Meanwhile, the song to which Jamison refers, 'Fly Me to the Moons' would have been her 'cover', so to speak, of 'Fly Me to the Moon'. What other changes to the lyrics she would have made during that state I don't know, but I'm sure they would have been very interesting. The song itself disappointingly refers to interplanetary travel only in the first stanza (or verse, depending on how you reckon poetry), and then only as a thin metaphor for the experience of what it is like to hold the beloved's hand or kiss her (in, say, Sinatra's case) lips.

An Unquiet Mind is packed with notable passages about which I could expatiate for ages, but it shall suffice to quote three more. The first is Dr Jamison's vivid account of her psychotic break:

The rites of passage in the academic world are arcane and, in their own way, highly romantic, and the tensions and unpleasantries of dissertations and final oral examinations are quickly forgotten in the wonderful moments of the sherry afterward, admission into a very old club, parties of celebration, doctoral gowns, academic rituals, and hearing for the first time "Dr.," rather than "Miss," Jamison. I was hired as an assistant professor in the UCLA Department of Psychiatry, got good parking for the first time in my life, joined the faculty club posthaste, and began to work my way up the academic food chain. I had a glorious—as it turns out, too glorious—summer, and, within three months of becoming a professor, I was ravingly psychotic.
...
I kept on with my life at a frightening pace. I worked ridiculously long hours and slept next to not at all. When I went home at night it was to a place of increasing chaos: Books, many of them newly purchased, were strewn everywhere. Clothes were piled up in mounds in every room, and there were unwrapped packages and unemptied shopping bags as far as the eye could see. My apartment looked like it had been inhabited and then abandoned by a colony of moles. There were hundreds of scraps of paper as well; they cluttered the top of my desk and kitchen counters, forming their own little mounds on the floor. One scrap contained an incoherent and rambling poem; I found it weeks later in my refrigerator, apparently triggered by my spice collection, which, needless to say, had grown by leaps and bounds during my mania. I had titled it, for reasons that I am sure made sense at the time, "God is a Herbivore." There were many such poems and fragments, and they were everywhere. Weeks after I finally cleaned up my apartment, I still was coming across bits and pieces of paper—filled to the edges with writing—in unimaginably unlikely places.
My awareness and experience of sounds in general and music in particular were intense. Individual notes from a horn, an oboe, or a cello became exquisitely poignant. I heard each note alone, all notes together, and then each and all with piercing beauty and clarity. I felt as though I were standing in the orchestra pit; soon, the intensity and sadness of classical music became unbearable to me. I became impatient with the pace, as well as overwhelmed by the emotion. I switched abruptly to rock music, pulled out my Rolling Stones albums, and played them as loud as possible. I went from cut to cut, album to album, matching mood to music, music to mood. Soon my rooms were further strewn with records, tapes, and album jackets as I went on my way in search of the perfect sound. The chaos in my mind began to mirror the chaos of my rooms; I could no longer process what I was hearing; I became confused, scared, and disoriented. I could not listen for more than a few minutes to any particular piece of music; my behavior was frenetic, and my mind more so.
Slowly the darkness began to weave its way into my mind, and before long I was hopelessly out of control. I could not follow the path of my own thoughts. Sentences flew around in my head and fragmented first into phrases and then words; finally, only sounds remained. One evening I stood in the middle of my living room and looked out at a blood-red sunset spreading out over the horizon of the Pacific. Suddenly I felt a strange sense of light at the back of my eyes and almost immediately saw a huge black centrifuge inside my head. I saw a tall figure in a floor-length evening gown approach the centrifuge with a vase-sized glass tube of blood in her hand. As the figure turned around I saw to my horror that it was me and that there was blood all over my dress, cape, and long white gloves. I watched as the figure carefully put the tube of blood into one of the holes in the rack of the centrifuge, closed the lid, and pushed a button on the front of the machine. The centrifuge began to whirl.
Then, horrifyingly, the image that previously had been inside my head now was completely outside of it. I was paralyzed by fright. The spinning of the centrifuge and the clanking of the glass tube against the metal became louder and louder, and then the machine splintered into a thousand pieces. Blood was everywhere. It spattered against the windowpanes, against the walls and paintings, and soaked down into the carpets. I looked out toward the ocean and saw that the blood on the window had merged into the sunset; I couldn't tell where one ended and the other began. I screamed at the top of my lungs. I couldn't get away from the sight of the blood and the echoes of the machine's clanking as it whirled faster and faster. Not only had my thoughts spun wild, they had turned into an awful phantasmagoria, an apt but terrifying vision of an entire life and mind out of control. I screamed again and again. Slowly the hallucination receded. I telephoned a colleague for help, poured myself a large scotch, and waited for his arrival.
Fortunately, before my mania could become very public, this colleague—a man whom I had been dating during my separation from my husband, and someone who knew and understood me very well—was willing to take on my manic wrath and delusions. He confronted me with the need to take lithium, which was not a pleasant task for him—I was wildly agitated, paranoid, and physically violent—but it was one he carried out with skill, grace, and understanding. He was very gentle but insistent when he told me that he though I had manic-depressive illness, and he persuaded me to make an appointment to see a psychiatrist. ...
I felt infinitely worse, more dangerously depressed, during this first manic episode than when in the midst of my worst depressions. In fact, the most dreadful I had ever felt in my entire life—one characterized by chaotic ups and downs—was the first time I was psychotically manic. ...
Although I had been building up to it for weeks, and certainly knew something was seriously wrong, there was a definite point when I knew I was insane. My thoughts were so fast that I couldn't remember the beginning of a sentence halfway through. Fragments of ideas, images, sentences, raced around and around in my mind like the tigers in a children's story. Finally, like those tigers, they became meaningless melted pools. Nothing once familiar to me was familiar. I wanted desperately to slow down but could not. Nothing helped—not running around a parking lot for hours on end or swimming for miles. My energy level was untouched by anything I did. Sex became too intense for pleasure, and during it I would feel my mind encased by black lines of light that were terrifying to me. My delusions centered on the slow painful deaths of all the green plants in the world—vine by vine, stem by stem, leaf by leaf they died, and I could do nothing to save them. Their screams were cacophonous. Increasingly, all of my images were black and decaying.
At one point I was determined that if my mind... did not stop racing and begin working normally again, I would kill myself by jumping from a nearby twelve-story building. I gave it twenty-four hours. But, of course, I had no notion of time, and a million other thoughts—magnificent and morbid—wove in and raced by. Endless and terrifying days of endlessly terrifying drugs... finally took effect. I could feel my mind being reined in, slowed down, and put on hold. [pp. 62-3, 78-83]

Commentary: If I had emphasised how much Jamison's experience had in common with our every day lives in the previous segment, it was so that after quoting this one I (and others) did not fall into the trap of thinking that her psychotic episode - horrifying and unreal as it was - was wholly alien from our experience. Indeed, although it is a rough estimate, and difficult to quantify, it has been claimed that one in five Canadians will experience mental illness, with about the same percentage of Americans also noted. Most such experiences wouldn't feature a psychotic breakdown so vivid as Dr Jamison's, of course.
Where Jamison's psychotic episode coincides with everyday experience is her procrastination about doing something about it. She 'certainly knew something was seriously wrong, [and that] there was a definite point when I knew I was insane.' She had been, she writes, 'building up to it for weeks.' Did she go and seek professional help? No; instead she contemplated suicide, and ran or swam pointlessly for hours on end. To a degree this is no different than someone letting some important task slide and then crashing and burning in a vain attempt to do it at the last minute, like frantically starting a paper due the next day but not having it done on time (which, ironically, would be a better wake-up call than finishing the paper after a 'heroic' all-nighter). She could tell that the worst was coming, but, it seems, was unwilling to allow an impartial observer to confirm her impression - just like someone who knows he has bad breath but won't ask anyone else if that's the case.
I think it is incredibly brave of Dr Jamison to paint herself in such a light. Most of us would look at such an accomplished and successful woman (who by then had earned her doctorate and was a member of the teaching faculty at the UCLA) and think that she would not be prone to such behaviour. Of course a mood disorder as crippling as manic-depressive illness is undoubtedly going to affect adversely one's capacity for rational thinking and behaviour; but I think there's a belief that those who are successful or accomplished are 'above and beyond' such things - that they are immune to procrastination, blocking, and denial, somehow. Realistically we should know better; although anyone with any success must be able to overcome bad habits in order to succeed - Dr Jamison would not be a doctor of anything today but for her work ethic and ability to keep from procrastinating in her academic life - the fact is that such habits are pervasive.
Interestingly, the hallucination Jamison experienced was, as she wrote, 'an apt but terrifying vision of an entire life and mind out of control.' While there's no reason to think that the vision was anything but the product of madness, it is nevertheless striking that it is capable of rational interpretation: a waking nightmare, it spoke a certain truth that she was not willing (or able) to acknowledge consciously. Bonus points to Dr Jamison for using 'phantasmagoria', although given that it is defined as any of: a) 'a constantly shifting complex succession of things seen or imagined;' b) 'a scene that constantly changes;' or, c) 'a bizarre or fantastic combination, collection, or assemblage', using the word with respect to this specific psychotic delusion alone (the centrifuge of blood) is imprecise; however, 'phantasmagoria' accurately describes the collection of images to which she refers throughout the passage.
For some reason I was oddly amused by the fact that Dr Jamison 'poured [herself] a large scotch' after her psychotic break while she waited for her friend to arrive. I can't quite put my finger on what was amusing to me about it; perhaps it is because it seems to me curiously uncharacteristic of an educated professional: a double scotch sounds like something one English gentleman would 'prescribe' to another after the same sort of thing. But, as a depressant, alcohol might have helped her get a bit of a grip (although she remained, as she put it, 'wildly agitated, paranoid, and physically violent') in the immediate aftermath of her psychosis.
To get a good idea of just what it is Jamison was imagining, this is what a centrifuge for separating elements in a specimen tube looks like (as opposed to those used to generate G-forces on people training to be astronauts). There are several sizes of them, and while, for obvious reasons, Dr Jamison probably could not describe exactly what model of centrifuge her evening gown-wearing double placed the tube of blood into (and even if she could, it would, let's face it, frankly ruin the story to include such information; imagine if she'd written her psychotic episode in the style of Tom Clancy: 'I saw a tall figure in a floor-length evening gown, of an Italian style from the nineteen-seventies by the famous New York designers Kallistos & Scherzi... the huge black centrifuge looked like an oversized tabletop model, the XC-7V150 by BioData Inc.'), I like to think it was an oversized version of one of the littlest kinds. The primary purpose of this kind of centrifuge is, as I said, to separate elements: here is a demonstration (one of the best I could find) of what that looks like, and while the centrifuge itself in this demonstration, is a different kind altogether, the principle of separation is the same.
As for the description of Dr Jamison's apartment, this is probably the part of the passage with which everyone has some understanding. While Jamison's description of her messy apartment is pregnant with menace - I've never found untidiness so threatening before - you might say that it is all the more remarkable for conveying such menace when you consider that the dorms of most undergraduate students probably either rival or beat her apartment for messiness. Rather like her psychotic delusion, her apartment was, as it were, a symbol of her loss of control. The more I think of it, the more I appreciate what a gift it is, for yourself and for others, to have a tidy and clean home. Sure, it's a drudge to keep clean, but then you can always have company over; you can always feel good about having got something useful done that day; and menial chores are a great thing to do to keep your body occupied while your mind does its thing. I find going for walks helps in much the same way - although the downside there is that if you are lost in thought when walking about you miss a lot of opportunities to connect with people or to enjoy what is going on around you.

The second is Dr Jamison's bout - a prolonged bout - with suicidal depression, which followed upon the psychotic break recounted above:

I reaped a bitter harvest from my own refusal to take lithium on a consistent basis. A floridly psychotic mania was followed, inevitably, by 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 was unbearably miserable and seemingly incapable of any kind of joy or enthusiasm. Everything—every thought, word, movement—was an effort. Everything that once was sparkling now was flat. I seemed to myself to be dull, boring, inadequate, thick brained, unlit, unresponsive, chill skinned, bloodless, and sparrow drab. I doubted, completely, my ability to do anything well. It seemed as though my mind had slowed down and burned out to the point of being virtually useless. The wretched, convoluted and pathetically confused mass of grey worked only well enough to torment me with a dreary litany of my inadequacies and shortcomings in character, and to taunt me with the total, the desperate, hopelessness of it all. What is the point of going on like this? I would ask 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 unrelenting, 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 unacceptable 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. ...
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.

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 horrible 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 of even 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 for 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 topics such 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 is time and money, and he stubbornly believed that I would make it through my depression, and, ultimately, thrive.
...
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. ... 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. [pp. 110-8]

Commentary: An editorial note: all italics in the passage, as well as the editorial comment in Dr Jamison's record of her psychiatrist's notes (having to do with LPS) are original. 'LPS' refers to the Lanterman-Petris-Short Act, which concerns itself with ensuring due process when it comes to the involuntary commitment of people into psychiatric care in California. According to the California Hospital Association, the LPS Act is in need of reform.
Perhaps the most noticeable thing for me is the contrast between how tension-building the build-up to Dr Jamison's attempted suicide (and the dramatic nature of the event itself), and the gentle, quiet nature of the aftermath and her subsequent recovery. I have omitted much of the latter (including an entire section on the help offered her by her mother), when, perhaps, I should have focussed less on the drama of her attempted suicide and more on the care she received on her long road to recovery.
Another striking aspect of the passage is Jamison's largely successful effort to keep her suicidal intention and plans a secret. Although, as she records, her family, friends, and psychiatrist were keeping a 'suicide watch', the latter did not notice anything unusual on the day of her attempt, although that may just have been because all she had in mind at the time was that she was intent on killing herself (and had the plan for a lithium overdose), and she did not have a specific time in mind - which makes sense, given her own insistence on the irrationality of suicide.
Although Dr Jamison's depression was both severe and chronic - eighteen months of 'pitiless, unrelenting pain' as she describes it - her experience with depression is probably the aspect of her illness with which more people than not may feel sympathy, in that they, too, have suffered from depression to a greater or lesser extent.
Canadian statistics show that a sizeable minority of the population suffer from symptoms of depression; a list of common symptoms includes: 'feelings of sadness and loss;' 'feelings of guilt and worthlessness;' 'feelings of extreme impatience, irritability, or a short temper;' 'loss of interest or pleasure in usually-enjoyed activities;' 'changes in weight or appetite;' 'changes in sleeping patterns like insomnia;' 'reduced ability to think clearly or make decisions;' 'difficulties in concentrating or with short term memory loss;' 'constantly feeling tired;' 'noticeable lack of motivation;' 'anxiety and restlessness, sometimes leading to panic attacks;' 'muscle and joint pain;' 'constipation or other intestinal problems;' 'frequent headaches;' 'lack of interest in sex;' 'recurring thoughts of suicide or self-harm;' and, 'withdrawal from friends and family.' The Public Health Agency of Canada encourages those who have experienced at least five of these symptoms for more than two or three weeks to contact a health professional; and likewise alerts people to seek medical help if they or anyone they know has recurring thoughts of suicide.
I've definitely experienced a number of those symptoms myself, although not to the degree that I could be diagnosed with clinical depression. Put another way, everyone has felt depressed at one time or another; more often than not the depression lifts, but sometimes it is not a merely circumstantial experience (i.e., triggered by particular events), but a chronic illness - an enduring experience.
In 2009 in Canada, the primary factor in nearly two-thirds of cases of suicide was depression, and nine out of ten Canadians who committed suicide in 2009 suffered from mental illness. (As the overview explains, of course, no single factor adequately determines whether or not someone will attempt suicide.) In the US, there is a similar extent of correlation between mood disorders and risk of suicide. So it is not surprising at all that Dr Jamison should have wished to die, or decided to kill herself, or even have made the attempt. The vast majority of people who commit suicide (and, one presumes, who attempt to do so) suffer from mental illness. One of the most famous suicides in my end of the world was that of Daron Richardson, a fourteen year-old girl. The organisation founded in her memory, Do It For Daron, is dedicated to 'transforming youth mental health'. Although there does not seem to be a specific diagnosis in her case, the fact that DIFD has to do with mental health and the fact that, in public statements regarding her suicide, Miss Richardson's family refers to mental health suggests that she may have suffered from depression or some other mood disorder - obviously there is no way to know for sure without further confirmation (which does not appear to be forthcoming).
The severity of Dr Jamison's depression is quite clearly indicated by the language by which she describes it: 'long and lacerating, black, [and] suicidal'; under its aegis she was 'unbearably miserable and seemingly incapable of any kind of joy or enthusiasm'; due to it '[e]verything... was an effort'; she found herself 'dull, boring, inadequate, thick brained, unlit, unresponsive, chill skinned, bloodless, and sparrow drab'; her mind, a 'wretched, convoluted and pathetically confused mass of grey worked only well enough to torment [her] with a dreary litany of [her] inadequacies and shortcomings in character, and to taunt [her] with the total, the desperate, hopelessness of it all.' She records notes her psychiatrist takes about the 'unrelenting, day-in and day-out, week-in and week-out, despair, hopelessness, and shame that the depression was causing.' 'Profound melancholia,' she writes, '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 horrible undercurrents of thought and feeling that dominate the horribly restless nights of despair.' Oddly enough, this reminds me of Gandalf's description of Gollum:

All the "great secrets" under the mountains had turned out to be just empty night: there was nothing more to find out, nothing worth doing, only nasty furtive eating and resentful remembering. He was altogether wretched. He hated the dark, and he hated light more: he hated everything, and the Ring most of all. [FR, I, p. 68]

Unrelieved emptiness, agonising, pitiless despair - and yet, and yet, all of it a sham. Dr Jamison's own telling reveals to what extent - against her own beliefs to the contrary - her family, friends, and psychiatrist valued her so highly: they had an informal 'suicide watch'; a good friend of hers kept a close eye on her and kept her spirits up after her suicide attempt; her brother called from Paris at all times of day or night to check on her; her psychiatrist was possessed of a 'granite belief that [hers] was a life worth living.' Depression creates in us the illusion that we are worthless, unloveable, hateful; our own mind, in effect, is telling us a lie. Depression says that others cannot possibly care for us; the reality is that they care for us more than words can say. Time and again, Jamison emphasises the point that suicidal ideation is fundamentally irrational.
If you clicked on the hyperlink just above, that goes to a video produced by a young man whose older sister committed suicide (this occurred in the United States, which is why the hotline provided is American). Now, one problem I can see with it is that, if I am clinically and chronically depressed (either suffering from depression simply or from manic-depressive illness), I am unlikely to respond well to claims that we must 'take the hits' so we can grow through them - even though, in fact, this is entirely true. Depression crushes our capacity for resilience; it erodes our ability to roll with the punches. This is why, if you think you may be suffering from long-term symptoms of depression, that you seek professional help immediately. With psychiatric (or psychotherapeutic) aid and medication, you will be able to build up your capacity for resilience and so face life more successfully; without, no matter how easy you appear to have it, or how successful you are (as in Dr Jamison's case), or how popular and promising (as in Daron Richardson's), you will find even the slightest setback beyond your ability to cope - and, it is not your fault, because your own mind is, in a depression, your own worst enemy. Incidentally, in Canada, this web page provides a comprehensive list of suicide hotlines.
Jamison's brief 'interlude', the section in italics in which she describes the moment immediately preceding her suicide attempt, is, for me, fascinating largely due to the literary allusion to Jekyll and Hyde: 'I understand why Jekyll killed himself before Hyde had taken over completely. I took a massive overdose of lithium with no regrets.' Robert Louis Stevenson's short story, 'The Strange Case of Dr Jekyll and Mr Hyde', is a seminal tale of double identity and self-murder. Little wonder Dr Jamison felt a connection to the story. Having no control over herself in either her manic or depressive moods, she must have identified with the loss of control experienced by Jekyll as his deterioration progressed: he became less and less able to 'control' Hyde (although in truth by concocting a serum that enabled him to transform into his shadow self Jekyll had abrogated control from the first). Indeed, she may have felt as though her behaviour in one or the other extreme state may have been very 'Hyde-like'. Jekyll, of course, was not mad; he did not suffer from a mental illness, and the author of the work a portion of which I provided a link to just above states that what Jekyll feared is not so much that Hyde would take over completely, as that his identification with Hyde would be discovered while he yet lived; Dr Jekyll arranged to kill himself rather than face discovery. I wonder how many people suffering from mental illness kill, or attempt to kill, themselves because they are, in the words of the Toto song 'Africa', 'frightened of this thing that I've become', and, moreover, frightened because others will see them for the ugly, distorted things that they believe themselves to be.
Finally, also of interest is the professional view of suicide that Dr Jamison discusses: '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. ... 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 of even getting their dying quite right.' I am not sure 'Puritan' is the right word to describe the application of any concepts to suicide, since the Puritans, like other Christians of the mediaeval and early modern periods, would have abhorred suicide. What they might have thought of Dante, as (what we would today call) a Roman Catholic, I do not know, but they would have likely approved of his imagining suicides (who, in Dante's scheme, number as the Violent against the Self) as weeping, bleeding trees in the Seventh Circle of Hell (cf. Inf. xii.). There nevertheless appears to persist a 'Romantic' notion of suicide, in which one who successfully commits suicide is somehow ennobled, particularly if his (or her) suicide can be seen to be a symbol or message speaking to society. One thinks of Cato the Younger, whose opposition to the dictatorship (in the strict sense) of Julius Caesar led him to kill himself after the latter's victory at the Battle of Thapsus, which secured Caesar's control of Rome (two of his assassins, Brutus and Cassius, of course, committed suicide following the defeat of their side against Caesar's heir Octavian in the Battle of Philippi; Dante, incidentally, places them, with Judas, at the very bottom of Hell, whence they are champed for ever in Satan's slavering mouths, as traitors against their lord). As for the view that failed suicides are 'weak' or 'incompetent', well, I suppose no one likes a failure of any kind. Yet, as Jamison writes (in an ironic and grim play on words), being a 'success' at suicide is one you can live without. In any case, the notion of successfully committing suicide as being an ennobling or strong act is probably more Stoic or Romantic than Puritan.
Finally, I am enthralled by Jamison's discussion of in what way her psychiatrist helped her through her suicidal depression: it was as much, if not more about what he didn't say (as she writes), as about his presence. This is something I have to keep in mind in my own professional practice (not that I am a psychiatrist or counsellor; but I am going to be, in effect, paid to listen to people). Dr Jamison's psychiatrist took a 'never say quit' view with respect to her as his patient. Not that he every said so, in so many words: in fact, had he been the kind of person to say 'never say quit' in the 'desperately optimistic' manner about which Jamison writes, we might not have An Unquiet Mind to read (or any of Dr Jamison's other works), for she may have been defeated, if not killed, by her depression. This is, perhaps, to put too much of the onus for her recovery on her psychiatrist, but, as she herself admits, it is to him, among a very few, that she most owes her life, and that her debt to him is 'beyond description.'

The last passage I shall quote returns to Dr Jamison's discussion of her aversion to taking lithium as prescribed, in this case having to do, in part, with her sister's curiously disapproving stance (italics and small caps original):

Psychological issues ultimately proved far more important than side effects in my prolonged resistance to lithium. I simply did not want to believe that I needed to take medication. I had become addicted to my high moods; I had become dependent upon their intensity, euphoria, assuredness, and their infectious ability to induce high moods and enthusiasms in other people. Like gamblers who sacrifice everything for the fleeting but ecstatic moments of winning, or cocaine addicts who risk their families, careers, and lives for brief interludes of high energy and mood, I found my milder manic states powerfully inebriating and very conducive to productivity. I couldn't give them up. More fundamentally, I genuinely believed—courtesy of strong-willed parents, my own stubbornness, and a wasp military upbringing—that I ought to be able to handle whatever difficulties came my way without having to rely upon crutches such as medication.
I was not the only one who felt this way. When I became ill, my sister was adamant that I should not take lithium and was disgusted that I did. In an odd reversion to the Puritan upbringing she had raged against, she made it clear that she thought I should "weather it through" my depressions and manias, and that my soul would wither if I chose to dampen the intensity and pain of my experiences using medication. The combination of her worsening moods with mine, along with the dangerous seductiveness of her views about medication, made it very difficult for me to maintain a relationship with her. One evening, now many years ago, she tore into me for "capitulating to Organized Medicine" by "lithiumizing away my feelings." My personality, she said, had dried up, the fire was going out, and I was but a shell of my former self. This hit an utterly raw nerve in me, as I imagine she knew it would, but it simply enraged the man I was going out with at the time. He had seen me very ill indeed and saw nothing of value to preserve in such insanity. He tried to deflect the situation with wit—"Your sister may just be a shell of her former self," he said, "but her shell is as much or more than I can handle"—but my sister then took off after him, leaving me sick inside, and doubtful, yet again, about my decision to take lithium.
I could not afford to be too near someone representing, as she did, the temptations residing in my unmedicated mind; the voice of upbringing that said one should be able to handle everything by oneself; the catnip allure of recapturing lost moods and ecstasies. I was beginning, but just beginning, to understand that not only my mind but also my life was at stake. I had not been brought up to submit without a fight, however. I really believed all of the things I had been taught about weathering it through, self-reliance, and not imposing your problems on other people. But looking back over the wreckage brought about by this kind of blind stupidity and pride, I now wonder, What on earth could I have been thinking? I also had been taught to think for myself: Why, then, didn't I question these rigid, irrelevant notions of self-reliance? Why didn't I see how absurd my defiance really was?
...
Part of my stubbornness can be put down to human nature. It is hard for anyone with an illness, chronic or acute, to take medications absolutely as prescribed. Once the symptoms of an illness improve or go away, it becomes even more difficulty. In my case, once I felt well again I had neither the desire nor incentive to continue taking my medication. I didn't want to take it to begin with; the side effects were hard for me to adjust to; I missed my highs; and, once I felt normal again, it was very easy for me to deny that I had an illness that would come back. Somehow I was convinced that I was an exception to the extensive research literature, which clearly showed not only that manic-depressive illness comes back, but that if often comes back in a more severe and frequent form.
It was not that I ever thought lithium was an ineffective drug. Far from it. The evidence for its efficacy and safety was compelling. Not only that, I knew it worked for me. It certainly was not that I had any moral arguments against psychiatric medications. On the contrary, I had, and have, no tolerance for those individuals—especially psychiatrists and psychologists—who oppose using medications for psychiatric illnesses; those clinicians who somehow draw a distinction between the suffering and treatability of "medical illnesses" such as Hodgkin's disease or breast cancer, and psychiatric illnesses such as depression, manic-depression, or schizophrenia. I believe, without doubt, that manic-depressive illness is a medical illness; I also believe that, with rare exception, it is malpractice to treat it without medication. All of these beliefs aside, however, I still somehow thought that I ought to be able to carry on without drugs, that I ought to be able to continue to do things my own way.
My psychiatrist, who took all these complaints very seriously—existential qualms, side effects, matters of value from my upbringing—never wavered in his conviction that I needed to take lithium. He refused, thank God, to get drawn into my convoluted and impassioned web of reasoning about why I should try, just one more time, to survive without taking medication. He always kept the basic choice in perspective: The issue was not whether lithium was a problematic drug; it was not whether I missed my highs; it was not whether taking medication was consistent with some idealized notion of my family background. The underlying issue was whether or not I would choose to use lithium only intermittently, and thereby ensure a return of my manias and depressions. The choice... was between madness and sanity, and between life and death. [pp. 98-102]

Commentary: The granite belief of Dr Jamison's psychiatrist in the value and worth of her life is again evinced in this passage: at no point will he countenance his patient doing otherwise than taking lithium as prescribed.
It also reveals an interesting point about life. All too often, people take an 'all-or-nothing' view of life. If they cannot have something, they desire that no one else may have it, either; neither will they share it if it is theirs. The crushingly statist moral absolutism of some is a species of this thinking. It derives, ultimately, from the irrational and primitive kinds of thinking exhibited in earliest childhood. One of the most famous quotes expressive of this way of thought is, of course, Hitler's famous utterance (according to this source, as an explanation to Albert Speer of a March 1945 directive to lay waste to Germany as part of a 'scorched earth' tactic), 'We will not capitulate - no, never! We may be destroyed, but if we are, we shall drag a world with us - a world in flames.'
The interesting point, though, is that there are times when it really is all, or nothing. The choice, as Dr Jamison so sharply puts it, 'was between madness and sanity, and between life and death.' Either she took lithium as prescribed, or her illness would destroy her - there was no middle ground, no room for equivocation or compromise.
We must be careful, however, not to extend the number of legitimate objects of such kinds of thought beyond a select few, which is tempting to do. For, once you have found one thing for which 'all-or-nothing' is appropriate, it is remarkable how many more things soon appear to be subject to the same judgment - yet in truth are not.
In this particular case, Dr Jamison's absolute position is rightfully taken. Many others with mental illness would be right to take the same position. 'My illness will kill me if I don't take my meds' - just as Hodgkin's disease or breast cancer (to use Jamison's own examples), left untreated, would.
Much of what Jamison writes in this passage echoes what she said in the passage I quoted earlier. It is almost incredible that, knowing what she knew about manic-depressive illness, about the efficacy of lithium, and knowing her judgment that it is malpractice not to prescribe medication for severe mental illness, she should still believe she could 'continue to do things my own way.'
'Somehow I was convinced that I was an exception to the extensive research literature.' This single sentence speaks volumes about what is, so to speak, the most damnable thing about human nature: our obsessive, destructive efforts to 'rise above' those things which, in fact, we cannot. The irony is, of course, that this destructive Titanism (or Prometheanism?) is merely the extreme of what is a desirable and healthy behaviour - the expansion of one's self. We must be able to 'rise above' our situations, or else we could not grow. Yet, this same motive, when coupled with a fundamentally irrational and prideful (not to say vainglorious) notion of our capacities as humans, creates an insidious, perhaps addictive, emphasis on willfulness. What sounds more impressive to one's self than to say, 'I will beat this without relying on medication; I can do this by myself.' But to make, and then to follow, such a commitment is not to decide to live wisely; it is to decide not to live wisely. To be willful rightly is to recognise the limits of the power of our will.
This is not to say that will is unimportant. If you take two patients suffering from cancer, both of whom undergo the same treatments, follow the same diets, and live the same healthy lifestyles, the one who displays more optimism, who expresses more willfully her desire to overcome cancer; that one is more likely to recover than the other (it is, of course, a matter of probability, not necessity; she may still die, and the other, more pessimistic person live). But neither patient would live, however much they willed to beat the cancer, if, having been diagnosed with cancer much advanced, they neither underwent medical treatment nor altered their lives to better care for themselves.
If you are not willing to will something, of course, it won't happen; but neither will it happen if that is all you do. Just like 'all-or-nothing' thinking, the notion that we can, by sheer will alone, overcome obstacles or illnesses probably stems from the magical notions of childhood omnipotence, when it appeared that the world adjusted itself to one's will.
That said, authors such as Edwin Friedman and (if memory serves) M Scott Peck have recorded in their works findings that one's mental approach to illness plays a great role in whether or not one recovers from illness. Regrettably, neither author provides much in the way of footnotes to such research, so I will have to do some digging around one of these days.
Dr Jamison's sister (at least in this passage; who knows what she thinks about it now) probably represents a silent majority of people. It is very likely that, in impugning 'Organised Medicine', and saying that her sister had 'capitulated' to it, accusing her of ' "lithiumising" away her feelings' and calling her a 'shell of her former self', her views represent the worst sort of attitude prevalent in some sectors of the (so-called) counter-culture. Jamison herself again takes the view that her sister's view originates in their Puritan upbringing; and this may have some weight. After all, God's grace is supposed to suffice; why, then, would you do anything that makes it seem as though it does not - such as, for example, taking medication? Of course this view is not really good theology - it is more a case of 'putting God to the test' in just the sort of way that Satan proposed to Jesus. That hospitals, nurses, doctors, medication, and all the rest, should be seen as anything but God's graceful provision (by indirect means), at least by those inclined to consider such things as God's graceful provision, is nonsense. In any event, the view that people somehow ought to be able to 'tough it out' without help, whether 'it' is mental illness or any other kind of obstacle, is commonly held, and not just by some Christians or some counter-cultural thinkers, but by a diverse range of people. All of them, in the last analysis, are wrong.

I think I have found a great deal about An Unquiet Mind worth reflecting on for anyone, not simply those who suffer from some kind of mental illness or who know someone who is. An Unquiet Mind I found to be well-written, and, most importantly, hopeful.