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THE FLIGHT OF THE MIND: VIRGINIA WOOLF'S ART AND MANIC-DEPRESSIVE ILLNESS.

Berkeley: University of California Press, 1992.

INTRODUCTION

This book examines Virginia Woolf's bipolar disorder (mood swings) and her fiction in light of recent medical discoveries about the genetic and biological nature of manic-depression--findings allied with drug therapies that today help nearly one million American manic-depressives live happier and more productive lives.  In the real world of the clinic, treatments using lithium, anti-depressants, and anti-psychotics have revolutionized psychiatric care for mood swings and produced miracle remissions for cases that thirty years ago would have been considered hopeless. But in the rarefied atmosphere of literary academia, many critics still cling to the Freudian model of this disorder as a neurotic conflict that the patient is unwilling (either consciously or unconsciously) to resolve.

I challenge the past and often disparaging evaluations of Woolf's life and art, setting limits for the practice of reading all symptoms or texts as neurotic disguises supposedly obscuring a causative origin. Freud was a great pioneer in the study of the human psyche, but it is time to move on--as certainly he would have done, given today's new knowledge about the brain--incorporating his best, enduring insights with ongoing research in contemporary neuroscience. We literary scholars can no longer afford to remain comfortably ignorant of the mechanisms of the brain. When we blame Woolf for her illness, we simplify our work by reducing her work.

The biological realities of manic-depression limit the critic's freedom to tie any event in Woolf's life to symptoms that seem metaphorically similar.  I argue that her fiction was not produced by hypothetical unconscious conflicts, her "fear" of sex, or her supposedly morbid preoccupation with death--all the favorite Freudian themes that coincidentally fulfill sexist assumptions about the nature of creative women. I posit that a responsive and insightful Woolf wrote her novels--hardly a surprise since most people suffering from bipolar disorder are thoughtful and perceptive when they are not ill, just like "normal" individuals. Bipolar disorder (mood swings) is periodic; it comes and goes, and when it is gone, individuals are not sick or insane (unlike neurotics, whose unconscious conflicts seep into and determine even "normal" behavior). By remembering this, we can hear what Woolf wants to say without thinking it must somehow be implicated in a twisted desire to remain ill.

Chapter One places Woolf's disorder in an historical context: how biological and psychological models manic-depression have changed since Woolf's time and how outmoded attitudes have infected biographies of Woolf. Chapters Two and Four present current knowledge about mood swings, their genetic transmission, symptoms, and cognitive distortions. Chapter Three discusses the implications of biology for psychoanalytic criticism, the function of bipolar cognitive style in creativity, reader-response theory, and the principles of literary modernism. In Chapters Five and Six I show how Woolf learned important object-relations lessons from her experience of mood swings and that she used this knowledge creatively in her theories about fiction, thinking, and the structure of the self.  Previous studies of her life and work by psychoanalytically inclined literary critics often reduce the surface "multiplicity" of her fiction, imposing coherence upon what seems deliberately incoherent or disjointed, in the service of a psychological model that is no longer relevant to her illness. I contend that her work is not a neurotic evasion or a loss of control but an intelligent and sensitive exploration of certain components of her mood swings that undermines our traditional approach to reading a text, inviting us to question how we construct "meaning" from a text.

Chapters Seven through Eleven deal with five of Woolf's novels: The Voyage Out, Jacob's Room, Mrs. Dalloway, To the Lighthouse, and The Waves.  These novels dramatize her creative struggle to "read" her perceptions and establish a bipolar, inclusive sense of identity rather than the narrow, purely rational model offered by her doctors. Her understanding of her bipolar disorder was also influenced by her parents' responses to loss and by her own childhood traumas.  Woolf's lifelong quest for a "moment of being" aimed to integrate divergent thought patterns, reconciling conflicting patterns in family relations and in modern art. In assuming the role of mediator between fictionalized representatives of her family and her divided self, Woolf discovered the power and self-understanding that creativity brings to the artist. By imagining and mastering psychic fragmentation in fiction, she restored form and value to her self. Today's research into how the two hemispheres of the brain interact suggests that the same may be true for readers who respond to a text by successfully entertaining other selves and various reading strategies in order to explore and enjoy the brain's potential for multiple domains of consciousness.

Chapter 1

"I owned to great egotism":  The Neurotic Model in Woolf Criticism

Although sufficient evidence exists in Virginia Woolf's biography, diaries and letters to convince psychologists and psychiatrists Kay Redfield Jamison (MDI 347),1 Sherman C. Feinstein (334), Phillip R. Slavney, and Paul R. McHugh (31) that she suffered from a "classical case of manic-depressive illness," which, Feinstein adds, "fulfills every criterion" (339), psychological studies of her life and art by literary critics have shied away from the genetic and biological implications of such a diagnosis, focusing instead on her childhood traumas and explaining her mental breakdowns as a neurotic response to the untimely death of her mother, the patriarchy of her father, and the sexual abuse inflicted by her half-brothers. Quentin Bell, for instance, regards his aunt's symptoms as manifestations of a profound virginity tied to a morbid guilt and repressed sexuality. Jean O. Love, Betty Kushen, and Susan Kenney and Edwin Kenney, Jr., conclude that Woolf did not grow beyond her preoedipal attachment to her mother, and thus, they contend, her lifelong grief and desperate fears about coping with adult sexuality alternately produced novels and madness instead of full womanhood. Simon O. Lesser speculates that Woolf might have been driven mad by a "profound but unconscious guilt" inspired by oedipal jealousy and an unacknowledged wish that her mother would die (50). Roger Poole, Mark Spilka, and Murray Sherman theorize that her fiction functioned as a defense mechanism against grieving, against confronting unresolved feelings of guilt, defilement, anger and loss. Given Woolf's suicide, James Naremore worries that her much touted "moments of being" may not be epiphanies at all but dark dissolutions of the self, flirtations with death disclosing a misguided desire to escape her own individuality, her own self.

Most recently, three book-length psychobiographies have consolidated these arguments and perpetuated the myth that manic- depressive illness is caused by unconscious conflict. In Virginia Woolf and the "Lust of Creation": A Psychoanalytic Exploration (1987), Shirley Panken portrays Woolf as "self-destructive, masochistic," "deeply guilt-ridden" because of her early closeness with her father, humiliated by her sexual inhibitions and victimized by a "passive aggression [that] masks oral rage" (4, 13, 68-71). For Panken, even the physical symptoms of Woolf's breakdowns must be seen as psychosomatic, a "channeling of her guilt, grief, and anger" (36). Alma H. Bond, in Who Killed Virginia Woolf?: A Psychobiography (1989), acknowledges the fact that science has shown how "manic-depression has an inherited, probably metabolic substructure" (23) but then inexplicably dismisses its implications and hunts for oedipal and pre-oedipal origins of Woolf's symptoms: a mother's ambivalence, a child's masochistic wish to surrender to an idealized mother, a daughter's jealousy of the father's penis. Because psychoanalysis privileges mentation over metabolism, Bond concludes that Woolf "chose" to become manic or depressive as a way of avoiding growing up (43), and because early events are given etiological priority over later, Bond reverts to an unsupported speculation that Virginia's lifelong sense of failure and self-hatred "probably" resulted from her mother's having "devalued" her daughter's feces (38-39). Working backwards, Bond uses adult breakdowns to prove the existence of childhood trauma, which then is cited as the cause of future psychosis. At a critical juncture, having found numerous psychological similarities between family members (which should prompt her to reconsider the importance of genetic inheritance in mood disorder), she contorts logic by arguing: "as a result, although father and daughter in a genetic sense resembled each other uncannily, it seems unnecessary to postulate a biochemical factor as the major 'cause' of Virginia Woolf's manic-depressive illness" (68).

Finally, Louise DeSalvo, in Virginia Woolf: The Impact of Childhood Sexual Abuse on her Life and Work (1989), follows the old formula of explaining complex mental states in terms of simple trauma because of a metaphorical similarity between the two. DeSalvo argues that, since Woolf was sexually abused as a child, and since victims of childhood abuse often develop depressive symptoms as adults, we may therefore conclude that her "madness" was not really insane but only expressed a "logical" reaction to victimization. But DeSalvo's theory cannot account for full-blown mania, nor for the cyclic and often seasonal form of bipolar breakdowns, nor for their severity (to her psychotic behavior is merely amplified anger), because she does not venture beyond a narrow theoretical context: the reactive depressions of incest victims. Certainly, victims of childhood abuse do suffer depressions later in life; her book eloquently presents their pain and eloquently argues for our understanding. But she also oversimplifies etiology, for she does not discriminate between different types of depression: 1) those depressions which result from psychological conflicts (e.g., created by the trauma of sexual abuse), 2) those which are inherited genetically and/or physiological in origin (such as manic- depressive illness), and 3) those which involve both psychological and physiological causes that interact. DeSalvo dismisses "inherent madness" as an "archaic" notion (xvi) and so frees herself from reading all the recent biological research into depression. Unwilling to consider an imposed mood disorder, she looks instead for reasons why Woolf would want to die, and incest serves as a reasonable cause. Because we lack specifics about Woolf's victimization (Was it rape or unwelcome caresses? Was it frequent or rare? Was it long-term or short? The evidence is scarce and ambiguous), DeSalvo uses the severity of Woolf's adult depressions as proof that her childhood abuse must have been rape, quite frequent, and chronic. The problem here is that inherited biochemical depression can be very severe without any childhood traumas preceding it. Suicidal impulses cannot, by themselves, serve as a reliable indicator of the significance of early or late trauma because despondency results from different conditions, some merely biochemical. And when severe depression alternates with mania in a family with a history of inherited mood disorders, unconscious conflict resulting from trauma is the least likely origin. DeSalvo's rubric for judging mental states fails to differentiate between the despair of a molested daughter and the despair of a manic- depressive because it ignores the inconvenient complexity of mind/brain interaction.

Why do psychobiographers ignore psychobiology? In part, they are afraid of having to undertake a whole new program of self-education-- reading up on biological texts, digesting unfamiliar jargon, and, perhaps worst of all, pouring through psychiatric journals for late- breaking developments (nearly 1,200 reports on manic-depressive illness appear each year worldwide in medical journals). Psychoanalytic literature, while daunting enough in both jargon and esoterica, evolves more slowly over time, is frequently taught in graduate school, and is already readily adaptable to literary study. It also gratifies common cultural stereotypes about artists. Underlying Freudian thinking is the unspoken (and even unconscious) assumption that Virginia Woolf became a great artist because she was a neurotic, that her books are filled with references to death and strange desires for a depersonalized union with the cosmos because, like all neurotics, she was afraid to live fully. Books were her lonely refuge, plaintive elegies sung by the confined but poignant Lady of Shallot, half mad, half magical, more beautiful dead than alive, especially for critics. Once neuroticized, Woolf becomes the target for all sorts of accusations. Picturing her as "a damaged thing, a spoilt, wingless bird" (180), Roger Poole casts the sexist accusation that Virginia "would take refuge in nervous stress" (130) to escape her marital problems. Critics need only point to her suicide as proof of a lifelong morbidity, some even arguing that Woolf unconsciously chose drowning in the "boundaryless waters" of the Ouse to symbolize her repressed wish to merge with her dead mother (Wolf and Wolf 44; Panken, Lust of Creation 17; Kushen Communion 165; Bond 152). Biographers value continuity in the inconvenient anarchy of an artist's life, and so Woolf's death is viewed almost as if it were a work of art itself and her novels elaborate drafts of a suicide note.

Why should psychoanalytic criticism be so morbid? Freud's ideas about art were closely tied to the Romantic tradition, which stressed the irrational, unconscious, and reputedly insane states of mind that artistic inspiration can induce. But Freud the scientist was a thoroughgoing materialist who sought to reduce mental operations to a question of drives and defenses. However mysterious the appeal of art, he focused his analytic attention on instinctual demands and infantile traumas, viewing art more as a fearful evasion than as a joyous exercise of skill and perception (Spector; Segal "Aesthetics"), an attitude that led one ardent devotee, Frederick Crews, to have serious misgivings about the psychoanalytic method itself: Indeed, because the regressiveness of art is necessarily more apparent to the analytic eye than its integrative and adaptive aspects are, psychoanalytic interpretation risks drawing excessively pathological conclusions. When this risk is put together with the uncertainties plaguing metapsychology itself, one can see why Freudian criticism is always problematic and often inept. (System 81)

Since Crews's denunciation, revisionists like Meredith Skura, Steven Marcus, and Christopher Bollas have begun to offer intriguing approaches to patients and/or texts in nonreductive ways. But with the exception of feminist criticism (e.g., Elizabeth Abel, Jane Marcus, and Patricia Waugh), little new light has fallen on Woolf studies, which still harbors what Crews aptly calls "the anaesthetic security" of the old Freudian bias toward the neurotic-artist model. In inexpert hands, this paradigm invites misdiagnosis because it reinforces the biographer's wish to explain mentality through events, which are, of course, the staple of life histories. Neurosis readily provides coherence for biographical data, but in past Woolf criticism it has often been a reductionistic order that points backward, emphasizing the infantile and evasive in art rather than the adult and adaptive. Inevitably, it is the critic who plays the role of the adult and fancies the artist to be the sick child. This was certainly not the way Virginia's friends felt about her, as Rosamond Lehmann remembers.

She had her share of griefs and bore them with courage and unselfishness. It is important to say this in view of the distasteful myths which have risen around her death:"the conception of her as a morbid invalid, one who "couldn't face life", and put an end to it out of hysterical self-pity. No. She lived under the shadow of the fear of madness; but her sanity was exquisite" (Noble 63). Clive Bell also objected to the tendency of biographical post-mortems to depict Woolf as "the gloomy malcontent": ". . . let me say once and for all that she was about the gayest human being I have known and one of the most lovable" (99).

But psychobiographers find well-adjusted subjects dull material, and there is the great Freudian temptation of explaining even Woolf's happy periods as the result of a defensive repression of those shameful horrors that were unleashed suddenly during her breakdowns.

The problem of pathology is compounded by Woolf's own misdiagnosis which was affected by both her experience of the disorder and the alternative explanations available to her. In her letters she sometimes described her illness in terms of the prevalent model of her time--the neurotic artist. When Walter Lamb confronted her with "dreadful stories" of bad behavior, she quickly confessed guilt as well as madness: Lamb "was puzzled by parts of my character. He said I made things into webs, & might turn fiercely upon him for his faults. I owned to great egoism & absorption & vanity & all my vices" (Q. Bell 1: 171), the same self-accusation she made to Leonard during their courtship (L. Woolf, Letters 169). In a letter to Vita Sackville-West, she again blamed herself for suffering mood swings:

And I haven't said anything very much, or given you any notion of the terrific high waves, and the infernal deep gulfs, on which I mount and toss in a few days. . . . and I'm half ashamed, now I try to write it, to see what pigmy egotisms are at the root of it, with me anyhow-- (3: 237)

Manic-depressives themselves typically confuse mood swings with egotism because the initial (and usually mild) symptoms often mimic it; patients may become overly concerned with themselves (e.g., hypochondria), draw attention to themselves through boisterous behavior, or misinterpret events solely as they relate to them (e.g., feelings of persecution). Such an impression was evidently shared by the specialists of the time: in 1931 a psychologist, Helge Lundholm at Duke University, argued that egotism was an integral component of manic- depressive illness and that it played the part of a precursor, marking the loss of psychic inhibition and the beginning of an increased vulnerability to a major breakdown--just as Woolf thought.

And there was a much nearer "nervous" model for Woolf to base her diagnosis on: the style and even the content of her self-analyses resemble the self-descriptions of her "hypochondriacal" and "egotistical" father, Leslie Stephen, with whom she identified not only as a parent but as the source of her disorder: "But--oh damn these medical details!--this influenza has a special poison for what is called the nervous system; and mine being a second hand one, used by my father and his father to dictate dispatches and write books with--how I wish they had hunted and fished instead!--I have to treat it like a pampered pug dog, and lie still directly my head aches" (Letters 4: 144-45). In Leslie's "violent rages and despairs" (Letters 4: 353), his feelings of failure and his self-abasements alternating with excitement and satisfaction, Virginia saw milder forms of her own symptoms and could have reasoned that the cause of both was "an egoism proper to all Stephens" (Diary 1: 221). Manic-depressive children do tend to over-identify with any close family member whom they think also has the disorder, particularly if it is a parent (Jamison MDI 733). The family doctor, George Savage (1842-1921), reinforced the neurotic-genius model in Virginia's mind by diagnosing her illness as "neurasthenia," the same label he had earlier given Leslie's complaints. Although Virginia experienced much more severe manias and depressions, Leslie's nervous breakdowns from 1888 to 1891 were accompanied by "fits of the horrors" and "hideous morbid fancies" of despair and death--feelings his daughter2 certainly could have recognized (Hyman, "Concealment" 128).

Ascertaining just what Woolf did think of her illness is complicated by Savage's inconsistent explanations of nervous disorders. Neurasthenia ("nerve weakness") was a convenient Victorian euphemism that covered a variety of vaguely recognizable symptoms, just as the term "neurosis" lumped together various disorders for much of this century (today, in psychiatry, neurosis is considered an outmoded category and is no longer listed in the current statistical manual of the American Psychiatric Association as the basis for establishing a diagnosis) (DSM-IIIR xxiv). On the one hand, neurasthenia was a thoroughly materialistic theory. The essential elements of the Silas Weir Mitchell (1829-1914) rest cure that Savage prescribed for Woolf's breakdowns were extended sleep and "deliberate overfeeding to stabilize the irregular brain cells supposedly responsible for the illness" (Goldstein 445). Later nineteenth century neurologists such as Savage were "deeply antagonistic, not merely to psychological explanations of insanity, but to any sustained or systematic attention to mental therapeutics" (Scull 19). Savage himself believed that patients who came from "neurotic stock," especially those families which produced geniuses or ambitious intellectuals (an apt description of the Stephen family), were more likely to go out of their senses periodically for purely biological reasons. He was particularly convinced that patients who experienced auditory hallucinations (Virginia heard birds speaking Greek and King Edward shouting obscenities in the garden bushes) had inherited their madness. Because he believed in the somatic basis of insanity, Savage saw a connection between mental breakdowns and physical stress, especially that caused by influenza, fatigue, fever, alcoholism, and irregular temperature (J. Marcus, "Violin" 35; Trombley 137), an association both Leonard and Virginia discussed:

If Virginia lived a quiet, vegetative life, eating well, going to bed early, and not tiring herself mentally or physically, she remained perfectly well. But if she tired herself in any way, if she was subjected to any severe physical, mental, or emotional strain, symptoms at once appeared which in the ordinary person are negligible and transient, but with her were serious danger signals. The first symptoms were a peculiar "headache" low down at the back of the head, insomnia, and a tendency for the thoughts to race. If she went to bed and lay doing nothing in a darkened room, drinking large quantities of milk and eating well, the symptoms would slowly disappear and in a week or ten days she would be well. (L. Woolf, Beginning Again 76)

I pass from hot to cold in an instant, without any reason; except that I believe sheer physical effort and exhaustion influence me. (V. Woolf, Letters 1: 496)

My soul diminished, alas, as the evening wore on; & the contraction is almost physically depression. I reflect though that I'm the sink of 50 million pneumonia germs with a temperature well below normal. And so these contractions are largely physical, I've no doubt. (Diary 2: 236)

Significantly, recent medical research suggests that influenza, fevers, a variety of infections and physically stressful disorders may indeed be 3 associated with the timing of manic-depressive episodes (Winokur 88), but even in 1921 Emil Kraepelin reported that headaches were "extraordinarily frequent" among his patients (Wolpert 42). Manic-depressive illness, perhaps more than any other psychiatric disorder, exemplifies the close connection between brain and mind: it is, as Thomas Wehr maintains,

a kind of biological rhythm. Episodes of mania and depression remit and relapse spontaneously, and recur in a quasi-periodic manner. Also, the occurrence and severity of affective [emotional coloring and responsivity with which people view the world] symptoms sometimes seem to be strongly influenced by normal biological rhythms. For example, the classical feature of diurnal variation in mood in endogenous [biochemical] depression suggests that some daily physiological rhythm aggravates or mitigates the depressive process. The association of exacerbations of affective symptoms with phases of the menstrual cycle and seasons of the year has been repeatedly observed by physicians treating individual patients and by epidemiologists surveying populations of patients. In recent years experimental evidence has accumulated that shows that rhythms in the body, especially the daily sleep- wake cycle, may be centrally involved in the processes responsible for depression and mania.(61)

Moreover, depressive symptoms can manifest themselves as physical disorders: that is, the depression can express itself in bodily disturbances, hypochondria, and other psychosomatic illnesses before its psychological effects become noticeable (Pichot and Hassan): such symptoms would indeed seem like precursors to a breakdown--to Savage as well as to many other doctors. According to Leo Hollister,

The initial complaint of depressed patients is quite often likely to be some common physical complaint rather than one of sadness, hopelessness, or a feeling of failure. Some of the manifestations, such as fatigue, headache, insomnia, and gastrointestinal disturbances are similar to those produced by anxiety; others are more distinctive, such as anorexia and weight loss, bad taste in the mouth, chronic pain, loss of interest, inactivity, reduced sexual desire, and a general feeling of despondency. It can be appreciated readily that anxiety-depression can mimic many diseases or disorders. (393)

This affiliation of depression and headaches, toothaches, neuralgia, asthma, constriction of the chest, eczema, gastric distress, and general malaise, and a score of other complaints, would certainly have argued for a somatic origin in Savage's (and Woolf's) mind, and Woolf did suffer mood swings that often coincided with headaches, toothaches, influenza, and fatigue. Nor can we dismiss the possibility (as yet inconclusively researched) that depression affects immune function, rendering its victims more susceptible to infection, which might then exacerbate the mood disorder (Levy and Krueger; Goodwin, MDI 533-34). Shirley Panken's remark that Woolf's physical symptoms were "unconsciously resorted to in hope of restoring or appeasing her mother," or that they were an "attention-getting" device to regain her father's love, is therefore likely wrong (Lust of Creation 38-39). Panken assumes that Woolf's incomplete mourning for her dead mother and a neurotic "channeling of her grief, guilt, and anger" produced the somatic disturbances of her manic-depressive breakdowns (36), but a disease with such potent metabolic changes may very well affect bodily health and mental functioning without involving self-destructive wishes. So, too, biology should dissuade us of Louise DeSalvo's speculation that Woolf feared becoming sick because she had once been molested by Gerald Duckworth while recovering from whooping cough (Sexual Abuse 111). There is much more than simple association working here.

Despite his arguments for biology and heredity, Savage also had "psychological" opinions of mental illness, though they are hardly more than the products of personal bias and culturally prescribed Victorian stereotype. He believed, for instance, that spoiled children were likely to develop unsound minds and that too much education was mentally harmful for the lower classes and for intelligent young women rebelling against their natural roles as wives and mothers (Trombley 115; J. Marcus, "Violin" 33-35). But, what was perhaps worse, in his published essays Savage explained some kinds of mental disorders generally as a "defect" in "moral character," and he expressed irritation at what he perceived to be his patients' self-indulgence in their illnesses (especially when they did not get well under his care), a reaction he may have picked up from Silas Weir Mitchell himself, who believed that "yielding too easily to the expression of all and any emotion" was a predisposing cause of nervous disorders. Both physicians advocated "order, control, and self-restraint" as a cure for mental illness (Bassuk 143), an attitude not uncommon among Victorian doctors (Skultans 14). Savage should have had little difficulty convincing Virginia that her excessive emotionalism fit the bill, especially since her own father, Leslie, adopted Savage's line when he referred to his first daughter's (Laura) mental difficulties as a moral deficiency caused by "willful perversity" (Love, Sources 161), an obstinate waywardness he thought he could cure by imposing "a stronger will and greater self- discipline" (Hyman, "Concealment" 126). Consequently, in the first year of their marriage, Leonard found that he had to reassure Virginia that an episode of depression was merely "illness & nothing moral" (L. Woolf, Letters 191). Virginia had learned early on to acquiesce to family genes and yet blame herself for losing control of her emotions, as is illustrated in the following diary entry and three apologetic letters, two to Violet Dickinson, and the third to her sister Vanessa:

--a little more self control on my part, & we might have had a boy of 12, a girl of 10: This always rakes me wretched in the early hours. So I said, I am spoiling what I have. . . . No doubt, this is a rationalisation of a state which is not really of that nature. Probably I am very lucky. (Diary 3: 107)

I know I have behaved very lazily and selfishly, and not cheerfully as Ozzy [Dickinson] would have me. I feel numb and dumb, and unable to lay hands on any words. (Letters 1: 279)

When I hear of your worries and wishes--I dont know if a pen is as fatal to you as it is to me--I feel positively fraudulent--like one who gets sympathy on false pretenses. (Letters 1: 280)

Oh my beloved creature, how little use I am in the world! Selfish, vain, egoistical, and incompetent. Will you think out a training to make me less selfish? It is pathetic to see Adrian developing virtues, as my faults grow. (Letters 1: 411)

Psychoanalytic critics like Spilka, the Wolfs, the Kenneys, and Panken have only detected the obvious without questioning its context when they see her as both perversely resistive to self-insight and yet riddled with guilt--convenient signposts of neurosis.

Savage's dualistic attitude was typical of many Victorian doctors. As Michael J. Clark has shown, the nineteenth century developed these two lines of psychiatric thought, each having its vogue for several decades, that insanity was either so biologically based that it was not intelligible at all (and so patients were warned not to think about their "ill" experiences) or that madness resulted from a weak character and immoral decisions freely made (271-75). Symptoms of madness, therefore, were either meaningless epiphenomena of underlying morbid states or representations of one's sinful nature. Patients could feel either disconnected from their own illness or ashamed for failing to control themselves, and Woolf, at times, did feel both.

As a woman, Woolf faced an additional challenge. Her illness and her femaleness both threatened her with a profound sense of powerlessness and depersonalization. In her own family her mother Julia and her half-sister Stella had shown her what it was like to be sacrificed to the Victorian god of feminine decorum. She instinctively rebelled against what she called "non-being," that selfless emptiness enforced by a sexist society--and by her depressions. But open rebellion was risky. Under the Lunacy Act of 1890, 70% of Britain's mentally ill were certified and committed by 1900, most often for suicide attempts, leading Carol Ann Morizot to conclude that

If Virginia Woolf had been certified and admitted to an asylum in the hopeless condition in which we find her in 1912, it is possible she could have been lost on the back wards and even her private physicians would not have been able to legally obtain her release. (116)

As long as Woolf cooperated with what was essentially an unacknowledged parody of Victorian stereotypes about femininity, she could remain safe from institutionalization (Showalter, "Victorian Women" 321-23).

It was a ticklish situation. Both her feminism and her manic- depressive experiences urged her to further exploration of the mind, but overt self-assertion or preoccupation with symptoms was viewed either as self-indulgence or as evidence of madness. Savage, like Mitchell, considered his patients' recoveries in terms of their submission to his conservative views of reality: the patient was told to relinquish control to him and follow directions without question (Bassuk 141). Because Savage identified sanity with social conformity, he denigrated the value of self and brushed aside the patient's experience of her illness (Trombley 150-51). After Woolf's "summer madness" in 1904, which included an unsuccessful suicide attempt (she threw herself out of a second story window), Savage pronounced her "cured" by January and had no more advice for Virginia than to disregard what had happened:

I am discharged cured! Aint it a joke! Savage was quite satisfied, and said he wanted me to go back to my ordinary life in everything and to go out and see people, and work, and to forget my illness. (Letters 1: 175)

Indeed, Victorian physicians generally discounted the content of female complaints and judged them by the patriarchal mythology of the nature of femininity, as Elaine Showalter maintains:

Expressions of unhappiness, low self-esteem, helplessness, anxiety, and fear were not connected to the realities of women's lives, while expressions of sexual desire, anger, and aggression were taken as morbid deviations from the normal female personality. The female life cycle, linked to reproduction, was seen as fraught with biological crises during which these morbid emotions were more likely to appear. . . . The menstrual discharge in itself predisposed women to insanity, since it was widely believed that madness was a disease of the blood. ("Victorian Women" 322-23)

Thus, the theory of female insanity reduced women to their most basic biological functions and social roles, to their usefulness in society, not as persons seeking self-discovery but as submissive wives and selfless mothers. An independent will in a woman "could be regarded as a form of female deviance that was dangerously close to mental illness," a rebellion which invited censure and control by the physician:

The traditional beliefs that women were more emotionally volatile, more nervous, and more ruled by their reproductive and sexual economy than men inspired Victorian psychiatric theories of femininity as a kind of mental illness in itself. As the neurologist S. Weir Mitchell remarked, "The man who does not know sick women does not know women." ("Victorian Women" 325-30)

As ridiculous as these opinions appear today, the threat was quite real then. As the nineteenth century progressed, more and more women were institutionalized: by 1875 females made up a majority of asylum inmates, and some physicians put the blame on the growing feminist movement that advocated intellectual achievement for young women (Scull 24). The remedy for such assertive selfhood was enforced femininity: "as the Victorian asylum became more overtly benign, protective, and custodial, it also became an environment grotesquely like the one in which women normally functioned. Such factors of asylum life as strict chaperonage, restriction of movement, limited occupation, enforced sexlessness, and constant subjugation to authority were closer to the 'normal' lives of women than of men. . ." (Showalter, "Victorian Women" 321). Although in private Woolf ridiculed Savage as "tyrannical" and "shortsighted" and rightly questioned his chauvinistic assumptions of what "coherence" was (Letters 1: 147, 159), she submitted to rest cures when ordered.

Later the Woolfs encountered psychoanalytic theory. Leonard read the first English translation of The Interpretation of Dreams in 1913 and published Freud's "Mourning and Melancholia" in the Collected Works in 1925, and this helped him to recognize the bipolar significance of Virginia's symptoms and diagnose her disorder correctly as manic-depressive illness:

When I cross-examined Virginia's doctors, they said that she was suffering from neurasthenia, not from manic- depressive insanity, which was entirely different. But as far as symptoms were concerned, Virginia was suffering from manic-depressive insanity. In the first stage of the illness from 1914 practically every symptom was the exact opposite of those in the second stage in 1915. In the first stage she was in the depths of depression, would hardly eat or talk, was suicidal. In the second she was in a state of violent excitement and wild euphoria, talking incessantly for long periods of time. In the first stage she was violently opposed to the nurses and they had the greatest difficulty in getting her to do anything; she wanted me to be with her continually and for a week or two I was the only person able to get her to eat anything. In the second stage of violent excitement, she was violently hostile to me, would not talk to me or allow me to come into her room. She was occasionally violent with the nurses, but she tolerated them in a way which was the opposite of her behavior to them in the first stage. (Beginning Again 161)

Leonard must also have learned a good deal of symptomatology from Karl Abraham (1877-1925), who published essays on manic-depressive illness in 1912, 1916, and 1924, incorporating all three in a 1927 edition of his papers put out by the Woolfs' Hogarth Press. And there were other sources: between 1919 and 1925 the British press published 400 articles, editorials, news items and reviews on Freud and his followers. Psychoanalysis had become a fad, a "popular craze" discussed at dinner: "every moderately well-informed person," one reviewer in 1920 claimed, "now knows something about Jung and Freud" (Rapp 191), as Leonard himself claimed for Virginia (L. Woolf, Letters 522). But with all this discussion of mental illness, why didn't she seek psychotherapy? Was it a kind of neurotic cowardice, as at least five Freudian critics have already suggested (Goldstein 447-50; Panken, Lust of Creation 5; DeSalvo, Childhood 128-34; Trombley 175-82; Kushen, "Dr Freud" 37)? Was she afraid of discovering the truth about her illness because that truth was connected to deeply repressed conflicts? Did she prefer to be ill because it brought her attention and love? Doesn't the fact that she avoided psychoanalysis prove that she was hiding something neurotic or forbidden? Or was her rejection of Freud merely childish, vindictive and small-minded, due to her childhood hostility to her brother Adrian, who grew up to become a practicing psychoanalyst (Panken, "Lust of Creation" 5; Kushen, "Dr Freud" 40)?

I don't believe she could have held out much hope of finding a sympathetic ear in Freud. He also saw abnormality in social nonconformity. And, as feminist psychoanalytic critics have cogently argued, Freud's own case history of Dora, which was published by the Woolfs' Hogarth Press, displayed his rather rigid, patriarchal attitude about organizing a patient's symptoms--especially when that patient happened to be a woman. He completely failed to understand why the adolescent Dora was not sexually excited by the clumsy attentions of an older married man (whose wife was having an adulterous affair with Dora's father) when he had grabbed her suddenly and kissed her, pressing his body to hers. Freud reasoned that she must have felt K.'s erection through their clothing, and that she was denying she had responded in kind. This conclusion Dora flatly rejected; she found Herr K.'s actions repulsive. But Freud was unaware of his own unconscious identification with K., or that he felt her rejection of K. was linked to a repudiation of himself. He defensively concluded that her feelings of repulsion were evidence of neurosis. How could a normal girl resist an older man? And beneath that lay another question: how could Dora resist Freud's masterful diagnosis? The answer was, she couldn't; therefore, she must be sick. He refused to accept at face value her version of what had happened and how she felt, turned her reproach against her father's duplicity into self-reproach, and acted as if Dora's mother were of no consequence--indeed, Freud generally minimized the role of women, particularly in his equation for the Oedipus complex (Sprengnether; Collins et al.). In the 1920's, Karen Horney clearly discerned Freud's "phallo-centric" view of women and objected to his having relegated them to a passive-masochistic sexual role (Garrison). Among feminists, it was becoming evident even in Woolf's lifetime that Freud imposed his own unexamined views upon women, invalidating the coherence he thought he had discovered underlying the seeming incoherence of women's symptoms.

Moreover, we cannot regard Savage's rest cure as so completely ineffective that only a neurotic would continue treatment. Recent studies at NIMH (the National Institute of Mental Health) show that restructuring a manic-depressive's sleep cycle can, indeed, effect at least a temporary remission of symptoms: in 60% of patients sleep deprivation causes switches from depression to normal or manic states (Goodwin MDI 551), and sleep itself (recovery sleep after sleep deprivation) can trigger switches out of mania. The success achieved with both "phase-advance" sleep (going to bed four to six hours earlier and rising earlier) and sleep deprivation has led NIMH researchers to speculate that manipulating the 24 hour clock sleep-wake cycle may, in some patients, either replace or enhance drug therapy (MDI 635-36). Such a hypothesis implies that a genetic defect in the brain's internal circadian (24 hour) clock is involved in the etiology of manic- depressive illness. Studies show that nights of total insomnia often precede mania, acting either to trigger an episode or exacerbate one already begun (Goodwin, MDI 554). Consequently, clinicians warn that patients need to be alerted to environmental changes leading to insomnia (e.g., anxiety, excitement, grief, travel, hormonal changes). Even a single night's sleeplessness "should be taken as an early warning of possible impending mania." Patients should be counseled to avoid stressful or stimulating situations "likely to disrupt sleep" routines, and physicians should consider prescribing sedatives (such as clonazepam) to prevent significant sleep loss (Wehr et al. 66-68; Georgotas and Cancro 312-31). Overall, "the regularization of circadian rhythms through the regularization of meals, exercise, and other activities should also be stressed to patients" (MDI 738). Leonard specifically acknowledged his belief in this premise in his autobiography, and he offers details in a 1929 letter to Vita Sackville-West:

It was a perpetual struggle to find the precarious balance of health for her among the strains and stresses of writing and society. The routine of everyday life had to be regular and rather rigid. Everything had to be rationed, from work and walking to people and parties. (Downhill all the Way 49)

Virginia has been a good deal better the last two days though she is still not right & is more or less in bed. The slightest thing is apt to bring symptoms back. But this has always been the case when she has been so near breaking point, & I think, if she keeps quite quiet, for another week, it will pass away. She has not really had such a severe attack as this for the last 3 or 4 years. It was not, of course, due to anything like influenza or sea- sickness cures, but simply to her overdoing it & particularly not going to bed at 11 for all those nights running. It has been proved over & over again in the last 10 years that even 2 late nights running are definitely dangerous for her & this time it was 7 or 8. (L. Woolf, Letters 236)

Since Victorian medicine believed that stress triggered "neurasthenic" episodes, Leonard followed Savage's orders and kept visitors, activities, and household stress at a minimum when Virginia was ill; he made sure she ate well and rested regularly. From 1913 (the beginning of a two year period of affective episodes) to the end of 1919, he kept an almost daily journal of her moods (time of onset, duration, and intensity), her sleeping and eating patterns, temperature, weight, dose of drug taken, and date of onset of menstruation; correlations between bodily rhythms and mental states helped him anticipate what level of care she needed. In later years, whenever Virginia felt ill, Leonard returned to his monitoring, using his measurements as a predictor of impending breakdowns. When she suffered from intractable insomnia, he gave cautious doses of hypnotic sedatives (listed as chloral[hydrate]," "veronal," "medinal," "potassium bromide," and "sodium bromide" in his personal diary in his Monks House Papers, now housed at the University of Sussex). Choral Hydrate was widely prescribed for inducing sleep and calming the insane, especially manics, whose metabolism could be so hyperenergized that neither sleep nor self-control was possible.

Obviously, as with any sedative, it is important to recognize just how much is too much, and both Leonard and Dr. Savage evidenced appreciation of this fact. In 1879, Savage wrote a paper entitled "Uses and Abuses of Chloral Hydrate," in which he warned that the drug should not be chronically applied and that the advantages of sedation must be weighed against the disadvantages in each particular case (Trombley 139- 40). By "cautious doses" I mean that Leonard recorded a fairly conservative drug schedule. Virginia took sleeping draughts when insomnia persisted but stopped when full sleep returned. Often Leonard noted that Virginia needed only half a dose, regarded this as a positive sign, and began tapering off. Thus, in 1914, after a year of recurrent affective episodes, Leonard recorded in his diary that Virginia took sedatives only eight times, on 1/10, 1/17, 1/24, 4/17, 5/15, 6/20, 7/19, and 7/22, but no more for the rest of the year when manic symptoms remitted. Early 1915 marked the return of mood swings, and dose frequency rose accordingly: 2/18, 2/22, 2/23, 2/24, 2/25, 2/26, 2/27, 2/28, 3/1, 3/5, 3/7, 3/9, 3/11, 3/13, 3/16, 3/17, 3/19. On March 25 Virginia became so ill that Leonard decided to move her into a nursing home. Since symptoms preceded medication, they could not have been induced by the drugs themselves, as Louise DeSalvo speculates (Sexual Abuse 211). Sedatives may indeed exacerbate a depressed mood already present, as Woolf herself noticed on one occasion in 1938: "I knew the break [a short vacation at Rodmell] would be a jangle; but not that I should feel the mixture of humiliation & dissolution wh. I feel today, after a sleeping draught" (Diary 5: 181). But for manic episodes in prelithium days, hypnotic-sedatives were often helpful and sometimes life-saving. This is not the case with those manic- depressives who indiscriminately abuse drugs, both legal and illegal, to intensify the pleasant "highs" of hypomania or as a form of self-medication (Jamison, MDI 223). Using "uppers" (e.g., cocaine, amphetamines, or alcohol) to combat depressive lows and "downers" (e.g., barbituates, tranquilizers, or alcohol) to dampen manic flights is no substitute for lithium therapy because these drugs are short-acting and cannot be accurately correlated to unpredictable mood swings. This was, perhaps, why Leonard so carefully charted the timing and intensity of Virginia's mood swings.

Whatever we may think of Leonard as a person (and opinion varies widely among critics between those who admire him as a loving saint and those who condemn him as a petty tyrant), we must remember that it is not easy to live with a manic-depressive who may, without self- awareness, judge a situation, desire, or destiny, in one mood in ways that diverge considerably from a judgment made in some other mood. Love of life, of spouse, and of self may change in one day to hideous, suicidal despair, paranoid hostility, or grandiose self-indulgence without warning. Subtler shifts can be even more alarming and destructive of trust in personal relationships. The domestic and personal tribulation wreaked by bipolar disorder, Jamison reports, "inevitably has powerful and often painful effects on relationships," particularly marriages, and yet it is precisely a stable relationship that these patients need (MDI 301). Those who lead chaotic lives or have poor or unpredictable social support systems usually fare badly (MDI 83). Manic-depressives find they must rely on guidance from their families during difficult times, but the benefits go both ways: "The involvement of family members and friends can lessen the need for hospitalization and increase the family's and patient's sense of control over a potentially catastrophic situation" (MDI 774), even if control can be exerted over only seemingly minor events vaguely presaging major repercussions. A memory from Angelica Garnett, Virginia's niece, testifies to this effect:

Leonard and Virginia's relationship was above all comradely: deeply affectionate and indivisibly united, they depended on each other. They knew each other's minds and therefore took each other for granted--they accepted each other's peculiarities and shortcomings and pretended no more than they could help. . . . Leonard never failed in vigilance and never fussed; neither did he hide his brief anxiety that Virginia might drink a glass too much wine or commit some other mild excess; he would say quite simply, "Virginia, that's enough," and that was the end of it. Or, when he noticed by the hands of his enormous watch that it was 11.00 in the evening, no matter how much she was enjoying herself, he would say, "Virginia, we must go home," and after a few extra minutes stolen from beneath his nose, she would rise and, as though leaving a part of herself behind, follow him and Pinka to the door. (113)

And Louie Mayer, the Woolfs' cook at Rodmell from 1934 to 1969, remembers:

Sometimes Mrs Woolf was quite ill while working on a book and had acute headaches. Mr Woolf then had to ration the number of friends who came to the house. Or, to those who did come, he had to say that she would only be able to talk to them for a short time. He did not like doing this but he knew that if she did not have enough rest she would become very ill. (Noble 158)

To some readers, Leonard's behavior looks petty and tyrannical, but since alcohol, fatigue, and changes in sleep patterns do affect a manic- depressive's vulnerability to breakdowns, and since Virginia's doctors presented Leonard with a similar cause-effect relationship in their theory that mood swings resulted from weakened nerves (L. Woolf, Letters 228; 236), both husband and wife seem to be acting responsibly here (whether Leonard is doing it out of love for his wife or for domestic peace, I cannot divine). It is unfortunate that in this particular case it is the woman depending on the man (who acts as the restraining authority), for that inflames the readers who are justifiably moved by Virginia's eloquent appeals for women's liberation. The mistake here is in automatically assuming that a serious psychiatric disorder like manic-depressive illness adds nothing to the dynamics of a relationship. It is, after all, common to find bipolar husbands relying on their wives for the same sense of order, continuity, and judgment. Woolf knew that "as for reason, when the mood's on, as soon might one persuade a runaway horse" (Diary 2: 53). She was not happy about periodically requiring supervision, but she also learned that, at times, she needed it to shorten episodes and to avoid state involvement in the form of enforced institutionalization. To their credit, neither Leonard nor Virginia let supervision get out of hand and distort other aspects of their lives that had nothing to do with mood swings. They respected each other's autonomy, desires, and ideas--a difficult task since manic-depressive illness temporarily destroys the individual's control over just these aspects of self. Clearly, couples must discuss this issue and agree to discriminate between a marital power play and a practical solution to periodic affective episodes.

Ironically, then, Savage's rest cure regime may well have provided Woolf some relief, as Barbara Bagenal remembers:

I saw her only once near to a mental breakdown. We were laughing and joking at lunch one day when suddenly she began to flip the meat from her plate on to the table- cloth, obviously not knowing what she was doing. Leonard at once asked me not to comment on her action and to stop talking to her. Then he took her upstairs to rest and stayed with her until she fell asleep and the danger was passed. At tea-time she was quite happy and composed and did not remember the incident. (Noble 152)

Woolf herself seems to indicate as much in two entries to her diary:

What a gap! . . . . 60 days; & those days spent in wearisome headache, jumping pulse, aching back, frets, fidgets, lying awake, sleeping draughts, sedatives, digitalis, going for a little walk, & plunging back into bed again--all the horrors of the dark cupboard of illness once more displayed for my diversion. Let me make a vow that this shall never, never, happen again; & then confess that there are some compensations. To be tired & authorised to lie in bed is pleasant. . . . I feel that I can take stock of things in a leisurely way. (Diary 2: 125)

I am taking, this is the last day--my weeks holiday, with very good results. My brain is soft & warm & fertile again, I feel fresh & free with energy for talk. Yes, I can even envisage "seeing" people without a clutch & a shudder. Odd how I drink up rest--how I become dry & parched like a withered grass--how then I become green & succulent. (Diary 4: 42)

Unless I weigh 9 1/2 stones I hear voices and see visions and can neither write nor sleep. (Spater and Parsons 73)

Body weight can drop rapidly during manic episodes, out of proportion to the reduced intake of calories, and so Woolf's association here of food and hallucinations is not unreasonable. The rest cure and its emphasis on overfeeding did sometimes restore her, and even today an increase in the patient's weight is often regarded by physicians as a herald of recovery (Jamison, MDI 24, 39). We can certainly criticize Savage's abilities as a psychologist, but his medical concerns about Virginia's weight and response to stress did have a practical benefit for her.

Besides the limited efficacy of Savage's rest cures, Woolf may have also avoided psychoanalysis because both Freud and Abraham thought of manic-depressive disorder as regressive behavior, as an inability to cope with traumatic losses in childhood. Regression has been defined generally as a retreat of the libido to an earlier period in the individual's life because he is unable to function at a higher level, but some analysts in the past have phrased it more indelicately: "Regression means failure" (Witzel 386). Manic speech--energized, extravagant, loosely associated, sometimes even rhyming--was seen as "a childish babyish vocabulary" (396), and the exuberant physical behavior of manics--the frenetic or outlandish movements, gestures, and spontaneous dances--were compared to "the behavior of primitive man" (397). Metaphorical similarity implies identity, but also operating here is psychoanalysis' preoccupation with the pathological, as Woolf noted in 1918 in her diary after a discussion of Freud with Lytton Strachey: "It's unfortunate that civilisation always lights up the dwarfs, cripples, & sexless people first" (1: 110). Early Freudian theory would have only ratified Woolf's fear that her breakdowns revealed a self-indulgent defect of character, a narcissistic weakness exacerbated by the loss of her mother, the sexual abuse inflicted by her half brothers, and so on. By this time she was already exploring her illness through her fiction, seeing provocative connections between madness and modernism. She would not be likely to seek out rehashed Victorian reproofs of her own inadequacies.

Unfortunately, not all biographers and critics have likewise advanced beyond Freud's orientation. Quentin Bell downplays Woolf's assertive political and feminist beliefs, as well as her apparently passionate love affair with Vita Sackville-West, and prefers to portray his aunt as childlike, ethereal, and terrified, frozen in defensive panic by sex (Rogat 112). The result is a Woolf who is not a "heroine" but, as one of Bell's reviewers put it, a "stubborn and sometimes querulous self-starving madwoman" (Ozick 44). This bias has seriously affected the literary criticism of Woolf's novels. When Louise DeSalvo and Elizabeth Heine, for instance, trace the manifold revisions of Woolf's first novel, The Voyage Out, they see not evolution of method but dilution of a deeply fantasized self-annihilation that kept seeping its way into her writing: the novel's puzzling equivocations and subterfuges can therefore be regarded as an elaborate masquerade to disguise forbidden desires (First Voyage 154-59; 312). Sometimes critics must contradict Woolf directly to fit her life and her fiction into their psychodynamic theories. When Mark Spilka puzzles over Rachel Vinrace's "odd," "mysterious," and "senseless" death (18), he looks to Woolf's own suicide (occurring 26 years after the publication of The Voyage Out) for an answer, concluding that both author and character must die because they could not face "painfully blocked emotions" (6); he argues that Woolf's intense, sexual, and apparently unblocked feelings for Violet Dickinson and Ethyl Smyth should be devalued as "neurotic attachments to older women," poor substitutes for her dead mother (8). Behind this reasoning lie unexamined and unenlightened attitudes about women, older women, gay women, and sexual love that seem strikingly opposed to Woolf's professed beliefs (Cook). But neurotics are not expected to be consistent, and so her passion for women is replaced by frigidity. As the archetypal neurotic female, Woolf has, indeed, become in literary journals what Jane Marcus rightly calls "a case study of female failure," a bogeywoman used to frighten little girls who flirt with the idea of becoming artists themselves. How can we celebrate the life of a woman whose vision is disparaged as "deadly" and "disembodied" ("Quentin's Bogey" 487-89; "Tintinnabulations" 145) because she decided when to die, whose passion is neuroticized because it is given to women, and whose veracity is continually questioned because it is assumed that such a defective person could not, or would not, discover the truth about herself? Once again, the patient is presented as a kind of moral lesson on how not to behave--Dr. George Savage all over again.

Besides the convenience of neurosis as a suitable explanation for a woman's art and behavior, the formidable difficulties of recognizing manic-depressive illness also affect our ability to diagnose accurately. Woolf's various doctors failed because, until 1904, no one had even been able to catalog the numerous and often bewildering array of symptoms which, in many ways, seem to mimic those of neurosis. Although some of the symptoms of mood disorders have been observed and discussed since Hippocrates first coined the term "melancholia" in the fourth century B.C. (Arieti and Bemporad 12-13), by the end of the nineteenth century, psychiatric workers "were floundering helplessly around in a morass of symptoms for which they were unable to find any common denominators" (Braceland 872). The great German psychiatrist, Emil Kraepelin (1856- 1926), head of the Department of Psychiatry in Munich, studied hundreds of manic-depressive patients and was the first to recognize a pattern in the manic-depressive illness that distinguished it from schizophrenia and melancholia, but as a clinical tool his diagnosis was slow to spread; an English translation of his book, Manic-Depressive Insanity and Paranoia, was not available until 1921.

Kraepelin's model also suffered stiff opposition from the Freudians because it described manic-depressive illness not as an unconscious conflict but as a familial disorder resistant to psychoanalysis. Kraepelin, a meticulous and objective observer of behavior, limited himself to phenomenological descriptions of clinical data and questioned the validity of intuitive hunches about unseen mental events. Although he did not exclude psychological or social stresses as triggers of mood swings, and although his diagnostic system eventually prevailed (and is still used today largely intact), his "disease model" of manic- depressive illness struck Freudians as too conservative because he noted symptoms at their face value, organizing and categorizing them according to observable data. He did not discuss symptoms as encoded emblems of a pathological "meaning," nor did he consider "the talking cure" an effective treatment for a disorder that clearly could run through family lines (Arieti and Bemporad 14).

In contrast, the early twentieth century thrilled at Freud's provocative "psychological" model promising to explain behavior in terms of a patient's unconscious thoughts, feelings, and reactions to life events. According to Freudian theory, a neurotic tries to "forget" his past by repressing it, but then he is condemned to repeat these old patterns of behavior (the "repetition compulsion") in the form of symptoms that reassert the traumatic scene in a cleverly disguised form- -so clever, in fact, that the patient is blind to the meaning of those symptoms (Goldberg 34). Freud felt that an illness that seemed meaningless could nevertheless be read for its unconscious message, and that once the patient realized what it meant to him personally, he would be cured. Reading an illness involved deciphering the symptom's symbolic component. And so everyone became a text awaiting an authoritative reading--a welcome respite from the age of the machine which darkly hinted that people were also but a biological mechanism. Freud's cure brought art back into life and reassured us that "mind" held creative primacy over body. Often Freud's therapy worked: one of his patients, for instance, suffered from facial neuralgia and felt what seemed to be true organic pain, but Freud could find no organic basis for it. During analysis, while exploring a remembered argument with her husband, the patient suddenly realized that something he had said had bitterly insulted her, had felt "like a slap in the face," whereupon she put her hand to her cheek and made the psychic connection: her facial pain was a metaphor for her psychological pain. The insult had become "inscribed" in facial neuralgia, displacing affect from psyche to soma (Goldberg 37).

Initially, the "talking cure" offered what seemed to be the primary key to understanding and curing all abnormal behavior. The promise, however, led to misapplication. Freud himself could not resist seeing a "psychological" meaning in symptoms which we know today are purely or largely neurologically based. And his followers continued that tradition. Earlier in this century, syndromes such as schizophrenia, autism, Gilles de la Tourette syndrome, rheumatoid arthritis, tuberculosis, tertiary syphilis, parkinsonism, neurodermatitis, ulcerative colitis, essential hypertension, temporal lobe and petit mal epilepsy, and premenstrual syndrome were thought by some to be psychological in origin and therefore suitable subjects for psychoanalysis (Cooper et al. 216). Psychoanalysis has no built-in mechanism for correcting this kind of "overreading," the almost literary activity of viewing physical symptoms as metaphors for mental states--a kind of pathological transcendentalism. Freud hoped that eventually neurology and psychology would converge, but biotechnology was so primitive then that he had little data on which to propose a model that might incorporate the two. Metapsychology, however, needed not wait.

Perhaps the best example of Freud's overreading is his 1928 speculation that Dostoyevsky's epilepsy was neurotic, an hysterical expression of a repressed wish too terrible to be brought to consciousness. Because he saw symbolic meaning in the violent convulsions and muscular rigidity of an epileptic seizure, Freud concluded that the writer's physical symptoms served as a metaphorical self-punishment for having wished his father were dead; falling helplessly ill, therefore, was a symbolic form of self-castration, which further suggested sexual ambivalence and a desire for a homosexual union with the father (21: 173-94). In this sense, Dostoyevsky, and indeed every patient, desired to be ill. Freud arrived at this conclusion by tying symptoms together, for he assumed that the same desire powered all of them. Individual symptoms that seemed meaningless could be deciphered and interpreted if they could be related to other symptoms or aspects of the patient's life. As Steven Goldberg has recently argued, building a case history is essentially an exercise in fiction: fitting disparate phenomena into some organized and comprehensible whole with a beginning, middle, and ending (and a satisfying ending at that), relies upon the analyst's narrative abilities as well as his scientific knowledge. Since the patient's verbal report is assumed to be itself symptomatic of his illness, and therefore insufficient due to distortion or amnesia, it is up to the analyst to find the buried or missing threads to the story and weave them into a "compelling" explanation (Goldberg 47-49).

Freud's handling of Dostoyevsky's life followed this theory exactly. He tied together epileptic symptoms with what he knew about Dostoyevsky's relations with his cruel father, and his subsequent hostility for father- figures (including the Tsar), which vanished mysteriously after he was imprisoned. Unconscious conflict does seem to explain his unexpected submission to authority as symbolic of his having accepted guilt for his parricidal wishes, and so psychobiographers since Freud have generally depicted Dostoyevsky as a man with strongly repressed violent drives which erupted spasmodically and elicited various self-destructive reactions, including his nearly fatal seizures. Now I do not argue against the legitimate psychoanalytic view that Dostoyevsky was parricidal or that his gambling implies self-hatred: the biographical evidence does seem to support these interpretations. But Freud confused this "psychological" explanation with Dostoyevsky's neurological symptoms. Seizures are not symbolic: they involve a paroxysm of uncontrolled electrical discharges in brain cells that typically produces the symptoms Freud observed but misinterpreted. Today we no longer consider the epileptic patient to be guilty of having wished his disorder into existence: rather, we regard him as a victim of a neurological disease that can produce psychological disturbances as well--disturbances we have learned to separate from the physical (Stevens). This new knowledge has led psychobiographers to re-evaluate Dostoyevsky's illness, most notably James Rice, who massively details how medical history and literary history have intertwined.

Such has also been the case with manic-depressive illness. While Kraepelin patiently studied family histories, the Freudians embarked on the more colorful hunt for elusive latent meanings or unconscious conflicts that presumably "caused" mania and depression, conflicts which the disorder seemed to suggest in its abundant and varied symptoms: Freud argued that depression was a self-destructive act by the ego, which hurt itself with despair in order to punish the lost love object (usually a parent) with whom it unconsciously identified; Abraham focused on a blocked libido at the oral-sadistic phase of development expressed in the depressive's excessive neediness and dependence upon others for affection and consolation (Gaylin 26-49); other analysts blamed unrestrained narcissism (108-53), disappointment with and/or idealization of one's parents in infancy (338-52), a sadistic fixation of the ego to the state of infantile helplessness (154-81), unpardonable sexual sins in childhood to explain the depressive's pervasive guilt feelings (Stern), inappropriate infantile adaptive patterns extending into adult life (Rado), and anxiety and aggression (Anthonisen). As descriptive categories, none of these theories is without basis: they are vivid metaphors for very real behaviors. When a depressed patient, for instance, appeared to regress even to the point of allowing himself to be destroyed by his own passivity, preoccupied with his endless pain, it seemed logical to analysts that a masochistic wish tied to neurotic guilt had caused the depression and its physical symptoms--a general psychomotor slowdown (Witzel 395). Could not physical symptoms be viewed as a kind of metabolic suicide? Since the patient acted like a dependent infant starved for love and reassurance, it seemed reasonable to suppose an infantile origin, for it is in infancy that self-esteem begins. And when a depressed patient suddenly switched into a highly energized, euphoric manic mood that appeared to free him from despair and dissolve his guilty thoughts, psychoanalysts theorized the obvious: that the patient consciously or unconsciously wished mania into existence in order to escape or deny the painful depression. Clinicians read intent in manic-depressive symptoms, assuming they were tied to unconscious wishes or conflicts by more or less direct, logical lines of cause and effect. It made dramatic sense that a person who unconsciously felt inadequate, evil, or unworthy would act out this self-hatred in the form of a self-destructive depression; it made more sense than reasoning the other way around--that a depressed person would experience his mood as negative perceptions and feelings and consequently see himself as inadequate, evil and unworthy--because then a non-psychological origin would have to be found, and that would not only postpone closure but also devalue the psychoanalyst's therapy. For much of this century, analysts followed Freud's formula, probing the minds of manic-depressives for ideas that could cause mood shifts. Thus, Simon O. Lesser could confidently argue that Virginia Woolf's suicidal depressions were caused by a self-destructive desire for punishment, aroused by "self-dissatisfaction, self-reproach, and guilt" (55). As in the case of Dostoyevsky, psychological origins were presumed to produce physiological disturbances. After all, that is how metaphors usually work in literary texts--turbulent skies express turbulent emotions in overwrought protagonists--it was natural to regard psyche as text. In French psychoanalytic circles, it is de rigeur.

But in the real world of the clinic, cure rates were disappointing: some manic-depressive patients never improved; others would seem to recover and then periodically relapse after repeated and seemingly authentic theory-compatible insights were gained after months or years of psychoanalysis. The rise of biological psychiatry changed all that with an unexpected therapeutic discovery. In 1949, an unknown Australian psychiatrist named John F. Cade, working alone in a small hospital, made a startling discovery: that administration by mouth of lithium carbonate, not a drug but a common mineral salt, produced a significant remission of symptoms in his manic patients. One of these patients, a 51 year old man who had been hospitalized for five years for chronic mania, and who was regarded by the staff as "the most troublesome patient in the ward," got well so fast he was discharged in three months and returned to his family and his job (Cade 350). American clinicians, at that time largely Freudian, dismissed this development, but Mogens Schou was intrigued and began tests in Denmark in 1954, and by 1958 initial trials were begun in the United States. Word of lithium's success began to spread. Ronald R. Fieve recalls that one patient,

an uncontrollably manic Texas professor, simultaneously writing ten books and forty research papers, was sent to New York for lithium treatment. He responded astonishingly well . . . . He was sent back to Texas "cured" on lithium, much to the amazement of the Texas psychiatrists who had been unable to subdue his frenetic, psychotic high for the better part of a year. They were so amazed at his rapid recovery that experiments in Galveston were then begun. . . . Few experiences in psychiatry are so dramatic as watching lithium carbonate in one to two weeks utterly transform a manic-depressive personality. (211-12)

In the 1960's, psychologists, pharmacologists, and psychiatrists joined forces in the expanding field of psychopharmacology (Goodwin, MDI 403), and by 1969 enough genetic and pharmacological evidence had been accumulated to persuade the American Psychiatric Association to recommend lithium to the Food and Drug Administration for treatment of manic-depressive illness (Fieve 11). Today over 700,000 manic- depressive Americans take lithium. Further evidence came in 1987 when the first gene implicated in the transmission of the illness was identified, a discovery predicted by biochemical theory (Baron et al.). (4)

Although its specific actions on brain chemistry are not yet fully understood, clinically lithium dampens severe mood swings, shortening attacks, lengthening remissions, and reducing the number of relapses, thus fostering a relatively stable position between the "highs" of mania and the "lows" of depression in roughly 70% of patients. One study showed that patients who relapsed once every 8 months fell ill only once every 60 months when taking lithium, and the average "psychotic time" fell from 13 weeks per year to 1.5 weeks per year (Georgotas and Cancro 63-64). If a patient taking lithium develops depressions (for some people, lithium is less effective against depression than it is against mania), antidepressants (such as MAO inhibitors or tricyclics) can be added to achieve a better balance acceptable to the patient (Swann 36). Conversely, for individuals with more severe mania (gross hyperactivity and psychotic features), neuroleptics (such as chlorpromazine or haloperidol) may be added to lithium to bolster its moderating effects (Goodwin and Byrne 82). For those whose bodies cannot tolerate lithium, carbamazepine also shows promise as an anti-manic agent, as do Valproic Acid and Clonazepam (Swann 97; Georgotas and Cancro 410-38).

Psychotherapy or Drugs?

Since there are different types of depressions with different etiologies, no one type of therapy is applicable for all patients. For cases that do not involve genetically imposed, biochemically produced depressions, psychotherapy is appropriate and usually helpful, whether it be psychoanalysis, cognitive psychology, behavioral therapy, interpersonal, group, or any of a number of the 250 psychotherapies existing today (Davis and Maas 409; Jamison, MDI 725-27). But clinicians must be careful; Ronald Fieve estimates that only 10% of his depressed patients could be accurately called "neurotic" (214), so the question of which type of therapy to use is important. Further, many supposedly non-endogenous depressions respond to drug therapy (Georgotas and Cancro 339). In one study of 100 outpatients with mild depressive states labeled "neurotic," "reactive," or "situational," 40 developed a major affective disorder within four years, nearly half of these bipolar (MDI 76).

Psychotherapy (particularly psychoanalysis) is especially inadequate if applied as the sole therapy for manic-depressive illness (Fieve 150). For the most part, manic-depressives do not exhibit secondary illnesses once their mood disorder has been managed by lithium. Jamison reported in the American Psychiatric Association's 1987 Annual Review that in-depth psychoanalysis is not effective in the treatment of manic-depressives; the misinterpretations and subtle fluctuations of mood states usually bewilder the analyst attempting to establish a stable relationship for analyzing transferences ("Suicide Prevention" 121). If, after being stabilized by lithium, a bipolar patient has lingering problems, psychoanalysis can be tried, but manic- depressives run no more risk of being neurotic than do non-manic- depressives (Keller 22). At best we may say that most patients need short-term psychotherapy to help them examine how the disease has affected their judgments, memories and emotions of the past, and encourage them to rebuild a coherent self-structure destroyed by the disease--if, indeed, it has been destroyed. Both mind and body must be treated to achieve a meaningful cure, but bodily intervention must come first, and mind intervention need not involve the Freudian exhumation of unconscious conflicts. Good prophylactic (preventive) management (whether it employs cognitive, interpersonal, or behavioral therapies) helps patients recognize mood swings and their effect on self-esteem, cognition, interpretation, and interpersonal relations (Jamison, "Suicide Prevention" 109-110; Davis and Maas 409-18). As one patient puts it:

At this point in my life, I cannot imagine leading a normal life without both taking lithium and being in 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. (Jamison, MDI 725)

It is usually not enough merely to prescribe lithium or antidepressants for mood disorders; an entrenched pattern of mood-induced misinterpretations will not be dissolved by drugs alone. Patients must explore those cognitive patterns and correct memories of previous experiences before they can reformulate other, more beneficial object- relations (Rush et al; Ruehlman et al; Beck and Greenberg). But once on lithium, most manic-depressives are no longer "sick."

Copyright 1992 - ISBN 0-520-20504-9         by Thomas C. Caramagno
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