Flights of the Mind

There is a particular kind of pain, elation, loneliness, and terror involved in this kind of madness. When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria pervade one’s marrow. But, somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humor and absorption on friends’ faces are replaced by fear and concern. Everything previously moving with the grain is now against—you are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of the mind. You never knew those caves were there. It will never end, for madness carves its own reality.

It goes on and on, and finally there are only others’ recollections of your behavior—your bizarre, frenetic, aimless behaviors—for mania has at least some grace in partially obliterating memories. What then, after the medications, psychiatrist, despair, depression, and overdose? All those incredible feelings to sort through. Who is being too polite to say what? Who knows what? What did I do? Why? And most hauntingly, when will it happen again? Then, too, are the bitter reminders—medicine to take, resent, forget, take, resent, and forget, but always to take. Credit cards revoked, bounced checks to cover, explanations due at work, apologies to make, intermittent memories (what did I do?), friendships gone or drained, a ruined marriage. And always, when will it happen again? Which of my feelings are real? Which of the me’s is me? The wild, impulsive, chaotic, energetic, and crazy one? Or the shy, withdrawn, desperate, suicidal, doomed, and tired one? Probably a bit of both, hopefully much that is neither. Virginia Woolf, in her dives and climbs, said it all: “How far do our feelings take their colour from the dive underground? I mean, what is the reality of any feeling?”

I did not wake up one day to find myself mad. Life should be so simple. Rather, I gradually became aware that my life and mind were going at an ever faster and faster clip until finally, over the course of my first summer on the faculty, they both had spun wildly and absolutely out of control. But the acceleration from quick thought to chaos was a slow and beautifully seductive one. In the beginning, everything seemed perfectly normal. I joined the psychiatry faculty in July of 1974 and was assigned to one of the adult inpatient wards for my clinical and teaching responsibilities. I was expected to supervise psychiatric residents and clinical psychology interns in diagnostic techniques, psychological testing, psychotherapy, and, because of my background in psychopharmacology, some issues related to drug trials and medications. I was also the faculty liaison between the Departments of Psychiatry and Anesthesiology, where I did consultations, seminars, and put into place some research protocols that were designed to investigate psychological and medical aspects of pain. My own research consisted primarily of writing up some of the drug studies I had carried out in graduate school. I had no particular interest in either clinical work or research related to mood disorders, and as I had been almost entirely free of serious mood swings for more than a year, I assumed that those problems were behind me. Feeling normal for any extended period of time raises hopes that turn out, almost invariably, to be writ on water.

I settled into my new job with great optimism and energy. I enjoyed teaching, and, although it initially seemed strange to be supervising the clinical work of others, I liked it. I found the transition from intern to faculty status far less difficult than I had imagined; it was, needless to say, one that was greatly helped along by an invigorating difference in salary. The relative freedom I had to pursue my own academic interests was intoxicating. I worked very hard and, looking back on it, slept very little. Decreased sleep is both a symptom of mania and a cause, but I didn’t know that at the time, and it probably would not have made any difference to me if I had. Summer had often brought me longer nights and higher moods, but this time it pushed me into far higher, more dangerous and psychotic places than I had ever been. Summer, a lack of sleep, a deluge of work, and exquisitely vulnerable genes eventually took me to the back of beyond, past my familiar levels of exuberance and into florid madness.

The chancellor’s garden party was given annually to welcome new faculty members to UCLA. By coincidence the man who was to become my psychiatrist also happened to be attending the garden party, having himself just joined the adjunct medical school faculty. It proved to be an interesting example of the divide between one’s self-perception and the cooler, more measured observations of an experienced clinician who suddenly found himself in a social situation watching a somewhat wild-eyed and frenzied former intern that he, as the recent chief resident, had supervised the preceding year. My recollection of the situation was that I was perhaps a bit high, but primarily I remember talking to scads of people, feeling that I was irresistibly charming, and zipping around from hors d’oeuvre to hors d’oeuvre, and drink to drink. I talked with the chancellor for a long time; he, of course, had absolutely no idea who I was, but he was either being exceedingly polite by talking to me for so long or simply holding true to his reputation as having a penchant for young women. Whatever he actually felt, I was sure he was finding me captivating.

I also had an extended and rather odd conversation with the chairman of my department—odd, but a conversation I found delightful. My chairman was himself a not unexpansive person, and he harbored a very imaginative mind that did not always keep within the common grazing lands of academic medicine. He was somewhat notorious within psychopharmacology circles for having accidentally killed a rented circus elephant with LSD—a complicated, rather improbable story involving large land mammals in must, temporal lobe glands, the effects of hallucinogenic drugs on violent behavior, and miscalculated volumes and surface areas—and we started a long, dendritic discussion about doing research on elephants and hyraxes. Hyraxes are small African animals that bear no resemblance whatsoever to elephants but, based on the patterning of their teeth, are thought to be their closest living relatives. I cannot begin to remember the detailed arguments and common interests underlying this strange and extremely animated conversation—except that I immediately, and with great gusto, took upon myself the task of tracking down every article, and there were hundreds, ever written about hyraxes. I also volunteered to work on animal behavior studies at the Los Angeles Zoo, as well as to co-teach a course in ethology and yet another one in pharmacology and ethology.

My memories of the garden party were that I had had a fabulous, bubbly, seductive, assured time. My psychiatrist, however, in talking with me about it much later, recollected it very differently. I was, he said, dressed in a remarkably provocative way, totally unlike the conservative manner in which he had seen me dressed over the preceding year. I had on much more makeup than usual and seemed, to him, to be frenetic and far too talkative. He says he remembers having thought to himself, Kay looks manic. I, on the other hand, had thought I was splendid.

My mind was beginning to have to scramble a bit to keep up with itself, as ideas were coming so fast that they intersected one another at every conceivable angle. There was a neuronal pileup on the highways of my brain, and the more I tried to slow down my thinking the more I became aware that I couldn’t. My enthusiasms were going into overdrive as well, although there often was some underlying thread of logic in what I was doing. One day, for example, I got into a frenzy of photocopying: I made thirty to forty copies of a poem by Edna St. Vincent Millay, an article about religion and psychosis from the American Journal of Psychiatry, and another article, “Why I Do Not Attend Case Conferences,” written by a prominent psychologist who had elucidated all of the reasons why teaching rounds, when poorly conducted, are such a horrendous waste of time. All three of these articles seemed to me, quite suddenly, to have profound meaning and relevance for the clinical staff on the ward. So I passed them out to everyone I could.

What is interesting to me now is not that I did such a typically manic thing; rather, it’s that there was some prescience and sense in those early days of incipient madness. The ward rounds were a complete waste of time, although the ward chief was less than appreciative of my pointing it out to everyone (and even less appreciative of my circulating the article to the entire staff). The Millay poem, “Renascence,” was one I had read as a young girl, and, as my mood became more and more ecstatic, and my mind started racing ever and ever faster, I somehow remembered it with utter clarity and straightaway looked it up. Although I was just beginning my journey into madness, the poem described the entire cycle I was about to go through: it started with normal perceptions of the world (“All I could see from where I stood / Was three long mountains and a wood”) and then continued through ecstatic and visionary states to unremitting despair and, finally, reemergence into the normal world, but with heightened awareness. Millay was nineteen years old when she wrote the poem, and, although I did not know it at the time, she later survived several breakdowns and hospitalizations. Somehow, in the strange state I was in, I knew that the poem had meaning for me; I understood it totally. I gave it to the residents and interns as a metaphorical description of the psychotic process and the important possibilities in a subsequent renewal. The residents, unaware of the internal flurry that propelled the readings, seemed to respond well to the articles and, almost to the person, expressed pleasure in the break from their regular medical reading.

During this same period of increasingly feverish behavior at work, my marriage was falling apart. I separated from my husband, ostensibly because I wanted children and he didn’t—which was true and important—but it was far more complicated than that. I was increasingly restless, irritable, and I craved excitement; all of a sudden, I found myself rebelling against the very things I most loved about my husband: his kindness, stability, warmth, and love. I impulsively reached out for a new life. I found an exceedingly modern apartment in Santa Monica, although I hated modern architecture; I bought modern Finnish furniture, although I loved warm and old-fashioned things. Everything I acquired was cool, modern, angular, and, I suppose, strangely soothing and relatively uninvasive of my increasingly chaotic mind and jangled senses. There was, at least, a spectacular—and spectacularly expensive—view of the ocean. Spending a lot of money that you don’t have—or, as the formal diagnostic criteria so quaintly put it, “engaging in unrestrained buying sprees”—is a classic part of mania.

When I am high I couldn’t worry about money if I tried. So I don’t. The money will come from somewhere; I am entitled; God will provide. Credit cards are disastrous, personal checks worse. Unfortunately, for manics anyway, mania is a natural extension of the economy. What with credit cards and bank accounts there is little beyond reach. So I bought twelve snakebite kits, with a sense of urgency and importance. I bought precious stones, elegant and unnecessary furniture, three watches within an hour of one another (in the Rolex rather than Timex class: champagne tastes bubble to the surface, are the surface, in mania), and totally inappropriate sirenlike clothes. During one spree in London I spent several hundred pounds on books having titles or covers that somehow caught my fancy: books on the natural history of the mole, twenty sundry Penguin books because I thought it could be nice if the penguins could form a colony. Once I think I shoplifted a blouse because I could not wait a minute longer for the woman-with-molasses feet in front of me in line. Or maybe I just thought about shoplifting, I don’t remember, I was totally confused. I imagine I must have spent far more than thirty thousand dollars during my two major manic episodes, and God only knows how much more during my frequent milder manias.

But then back on lithium and rotating on the planet at the same pace as everyone else, you find your credit is decimated, your mortification complete: mania is not a luxury one can easily afford. It is devastating to have the illness and aggravating to have to pay for medications, blood tests, and psychotherapy. They, at least, are partially deductible. But money spent while manic doesn’t fit into the Internal Revenue Service concept of medical expense or business loss. So after mania, when most depressed, you’re given excellent reason to be even more so.

Having a Ph.D. in economics from Harvard in no way prepared my brother for the sprawling financial mess he saw on the floor in front of him. There were piles of credit card receipts, stacks of pink overdraft notices from my bank, and duplicate and triplicate billings from all of the stores through which I had so recently swirled and charged. In a separate, more ominous pile were threatening letters from collection agencies. The chaotic visual impact upon entering the room reflected the higgledy-piggledy, pixilated collection of electric lobes that only a few weeks earlier had constituted my manic brain. Now, medicated and dreary, I was obsessively sifting through the remnants of my fiscal irresponsibility. It was like going on an archaeological dig through earlier ages of one’s mind. There was a bill from a taxidermist in The Plains, Virginia, for example, for a stuffed fox that I for some reason had felt I desperately needed. I had loved animals all of my life, had at one point wanted to be a veterinarian: How on earth could I have bought a dead animal? I had adored foxes and admired them for as long as I could remember; I thought them fast and smart and beautiful: How could I have so directly contributed to killing one? I was appalled by the grisly nature of my purchase, disgusted with myself, and incapable of imagining what I would do with the fox once it actually arrived.

In an attempt to divert myself, I began pawing my way through the credit card slips. Near the top of the pile was a bill from the pharmacy where I had gotten my snakebite kits. The pharmacist, having just filled my first prescription for lithium, had smiled knowingly as he rang up the sale for my snakebite kits and the other absurd, useless, and bizarre purchases. I knew what he was thinking and, in the benevolence of my expansive mood, could appreciate the humor. He, unlike me, however, appeared to be completely unaware of the life-threatening problem created by rattlesnakes in the San Fernando Valley. God had chosen me, and apparently only me, to alert the world to the wild proliferation of killer snakes in the Promised Land. Or so I thought in my scattered delusional meanderings. In my own small way, by buying up the drugstore’s entire supply of snakebite kits, I was doing all I could do to protect myself and those I cared about. In the midst of my crazed scurryings up and down the aisles of the drugstore, I had also come up with a plan to alert the Los Angeles Times to the danger. I was, however, far too manic to tie my thoughts together into a coherent plan.

My brother, seemingly having read my mind, walked into the room with a bottle of champagne and glasses on a tray. He imagined, he said, that we would need the champagne because the whole business might be a “bit unpleasant.” My brother is not one for overstatement. Neither is he one for great wringings of hands and gnashings of teeth. He is, instead, a fair and practical man, generous, and one who, because of his own confidence, tends to inspire confidence in others. In all of these things, he is very much like our mother. During the time of my parents’ separation, and subsequent divorce, he had put his wing out and around me, protecting me to the extent that he could from life’s hurts and my own turbulent moods. His wing has been reliably available ever since. From the time I started college and then throughout my graduate and faculty days—indeed, until now, and still—whenever I have needed a respite from pain or uncertainty, or just to get away, I have found an airplane ticket in the mail, with a note suggesting I join him someplace like Boston or New York, or Colorado, or San Francisco. Often, he will be in one of these places to give a talk, consult, or take a few days off from work himself; I catch up with him in some hotel lobby or another, or in a posh restaurant, delighted to see him—tall, handsome, well dressed—walking quickly across the room. No matter my mood or problem, he always manages to make me feel that he is glad to see me. And each of the times I went abroad to live—first to Scotland as an undergraduate, then to England as a graduate student, and twice again to London on sabbatical leaves from the University of California—I always knew that it would be only a matter of weeks until he would arrive to check out where I was living, what I was up to, take me out to dinner, and suggest we rummage together through Hatchards or Dillons or some other bookstore. After my first severe manic attack, he drew his wing around me even tighter. He made it unequivocally clear that if I needed him, no matter where he was, he would be on the next plane home.

Now he made no judgments about my completely irrational purchases; or, if he did, at least he didn’t make them to me. Courtesy of a personal loan he had taken out from the credit union at the World Bank, where he worked as an economist, we were able to write checks to cover all of the outstanding bills. Slowly, over a period of many years, I was able to pay him back what I owed him. More accurate, I was able to pay back the money I owed him. I can never pay back the love, kindness, and understanding.

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 thought I had manic-depressive illness, and he persuaded me to make an appointment to see a psychiatrist. Together we tracked down everything we could find that had been written about the illness; we read as much as we could absorb and then moved on to what was known about treatment. Lithium had been approved for use in mania only four years earlier, in 1970, by the Food and Drug Administration, and was not yet in widespread use in California. It was clear from reading the medical literature, however, that lithium was the only drug that had any serious chance of working for me. He prescribed lithium and other antipsychotic medications for me, on a very short-term, emergency basis, only long enough to tide me over until I saw my psychiatrist for the first time. He put the correct number of pills out for me to take each morning and evening, and he spent hours talking with my family about my illness and how they might best handle it. He drew blood for several lithium levels and provided encouragement about the prognosis for my recovery. He also insisted that I take a short time off from work, which ultimately saved me from losing my job and my clinical privileges, and arranged for me to be looked after at home during those periods when he was unable to.

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. I had been mildly manic many times before, but these had never been frightening experiences—ecstatic at best, confusing at worst. I had learned to accommodate quite well to them. I had developed mechanisms of self-control, to keep down the peals of singularly inappropriate laughter, and set rigid limits on my irritability. I avoided situations that might otherwise trip or jangle my hypersensitive wiring, and I learned to pretend I was paying attention or following a logical point when my mind was off chasing rabbits in a thousand directions. My work and professional life flowed. But nowhere did this, or my upbringing, or my intellect, or my character, prepare me for insanity.

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—by which I made my living and whose stability I had assumed for so many years—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—Thorazine, lithium, valium, and barbiturates—finally took effect. I could feel my mind being reined in, slowed down, and put on hold. But it was a very long time until I recognized my mind again, and much longer until I trusted it.

I first met the man who was to become my psychiatrist when he was chief resident at the UCLA Neuropsychiatric Institute. Tall, good-looking, and a man of strong opinions, he had a steel-trap mind, a quick wit, and an easy laugh that softened an otherwise formidable presence. He was tough, disciplined, knew what he was doing, and cared very much about how he did it. He genuinely loved being a doctor, and he was a superb teacher. During my year as a predoctoral clinical psychology intern he had been assigned to supervise my clinical work on the adult inpatient service. He turned out to be an island of rational thought, rigorous diagnosis, and compassion in a ward situation where fragile egos and vapid speculation about intrapsychic and sexual conflicts prevailed. Although he was adamant about the importance of early and aggressive medical treatments for psychotic patients, he also had a genuine and deep belief in the importance of psychotherapy in bringing about healing and lasting change. His kindness to patients, combined with an extremely keen knowledge of medicine, psychiatry, and human nature, made a critical impression upon me. When I became violently manic just after joining the UCLA faculty, he was the only one I trusted with my mind and life. I knew intuitively that there wasn’t a snowball’s chance in hell that I could outtalk, outthink, or outmaneuver him. In the midst of utter confusion, it was a remarkably clear and sane decision.

I was not only very ill when I first called for an appointment, I was also terrified and deeply embarrassed. I had never been to a psychiatrist or a psychologist before. I had no choice. I had completely, but completely, lost my mind; if I didn’t get professional help, I was quite likely to lose my job, my already precarious marriage, and my life as well. I drove from my office at UCLA to his office in the San Fernando Valley; it was an early southern California evening, usually a lovely time of day, but I was—for the first time in my life—shaking with fear. I shook for what he might tell me, and I shook for what he might not be able to tell me. For once, I could not begin to think or laugh my way out of the situation I was in, and I had no idea whether anything existed that would make me better.

I pushed the elevator button and walked down a long corridor to a waiting room. Two other patients were waiting for their doctors, which only added to my sense of indignity and embarrassment at finding myself with the roles reversed—character building, no doubt, but I was beginning to tire of all the opportunities to build character at the expense of peace, predictability, and a normal life. Perhaps, had I not been so vulnerable at the time, all of this would not have mattered so much. But I was confused and frightened and terribly shattered in all of my notions of myself; my self-confidence, which had permeated every aspect of my life for as long as I could remember, had taken a very long and disquieting holiday.

On the far wall of the waiting room I saw an array of lit and unlit buttons. It was clear I was supposed to push one of them; this, in turn, would let my psychiatrist-to-be know that I had arrived. I felt like a large white rat pressing paw to lever for a pellet. It was a strangely degrading, albeit practical, system. I had the sinking feeling that being on the wrong side of the desk was not going to sit very well with me.

My psychiatrist opened the door and, taking one long look at me, sat me down and said something reassuring. I have completely forgotten what it was—and I am sure it was as much the manner in which it was said as the actual words—but slowly a tiny, very tiny, bit of light drifted into my dark and frightened mind. have next to no memory of what I said during that first session, but I know it was rambling, unstrung, and confused. He sat there, listening forever, it seemed, his long six-foot-four-inch frame spread out from chair to floor, legs tangling and untangling, long hands touching, fingertip to fingertip—and then he started asking questions.

How many hours of sleep had I been getting? Did I have any problems in concentrating? Had I been more talkative than usual? Did I talk faster than usual? Had anyone told me to slow down or that they couldn’t make sense out of what I was saying? Had I felt a pressure to talk constantly? Had I been more energetic than usual? Were other people saying that they were having difficulty keeping up with me? Had I become more involved in activities than usual, or undertaken more projects? Had my thoughts been going so quickly that I had difficulty keeping track of them? Had I been more physically restless or agitated than usual? More sexually active? Had I been spending more money? Acting impulsively? Had I been more irritable or angry than usual? Had I felt as though I had special talents or powers? Had I had any visions or heard sounds or voices that other people probably hadn’t seen or heard? Had I experienced any strange sensations in my body? Had I ever had any of these symptoms earlier in my life? Did anyone else in my family have similar sorts of problems?

I realized that I was on the receiving end of a very thorough psychiatric history and examination; the questions were familiar, I had asked them of others a hundred times, but I found it unnerving to have to answer them, unnerving not to know where it all was going, and unnerving to realize how confusing it was to be a patient. I answered yes to virtually all of his questions, including a long series of additional ones about depression, and found myself gaining a new respect for psychiatry and professionalism.

Gradually, his experience as a physician, and self-confidence as a person, began to take effect, much in the same way that medications gradually begin to take hold and calm the turmoil of mania. He made it unambivalently clear that he thought I had manic-depressive illness and that I was going to need to be on lithium, probably indefinitely. The thought was very frightening to me—much less was known then than is known now about the illness and its prognosis—but all the same I was relieved: relieved to hear a diagnosis that I knew in my mind of minds to be true. Still, I flailed against the sentence I felt he had handed me. He listened patiently. He listened to all of my convoluted, alternative explanations for my breakdown—the stress of a stressed marriage, the stress of joining the psychiatry faculty, the stress of overwork—and he remained firm in his diagnosis and recommendations for treatment. I was bitterly resentful, but somehow greatly relieved. And I respected him enormously for his clarity of thought, his obvious caring, and his unwillingness to equivocate in delivering bad news.

Over the next many years, except when I was living in England, I saw him at least once a week; when I was extremely depressed and suicidal I saw him more often. He kept me alive a thousand times over. He saw me through madness, despair, wonderful and terrible love affairs, disillusionments and triumphs, recurrences of illness, an almost fatal suicide attempt, the death of a man I greatly loved, and the enormous pleasures and aggravations of my professional life—in short, he saw me through the beginnings and endings of virtually every aspect of my psychological and emotional life. He was very tough, as well as very kind, and even though he understood more than anyone how much I felt I was losing—in energy, vivacity, and originality—by taking medication, he never was seduced into losing sight of the overall perspective of how costly, damaging, and life threatening my illness was. He was at ease with ambiguity, had a comfort with complexity, and was able to be decisive in the midst of chaos and uncertainty. He treated me with respect, a decisive professionalism, wit, and an unshakable belief in my ability to get well, compete, and make a difference.

Although I went to him to be treated for an illness, he taught me, by example, for my own patients, the total beholdenness of brain to mind and mind to brain. My temperament, moods, and illness clearly, and deeply, affected the relationships I had with others and the fabric of my work. But my moods were themselves powerfully shaped by the same relationships and work. The challenge was in learning to understand the complexity of this mutual beholdenness and in learning to distinguish the roles of lithium, will, and insight in getting well and leading a meaningful life. It was the task and gift of psychotherapy.

At this point in my existence, I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But, ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary; it is a battleground; it is a place I have been psychotic, neurotic, elated, confused, and despairing beyond belief. But, always, it is where I have believed—or have learned to believe—that I might someday be able to contend with all of this.

No pill can help me deal with the problem of not wanting to take pills; likewise, no amount of psychotherapy alone can prevent my manias and depressions. I need both. It is an odd thing, owing life to pills, one’s own quirks and tenacities, and this unique, strange, and ultimately profound relationship called psychotherapy.

That I owed my life to pills was not, however, obvious to me for a long time; my lack of judgment about the necessity to take lithium proved to be an exceedingly costly one.