An Unquiet Mind

  After I was assigned to the adult inpatient service for my first teaching and clinical responsibilities, I soon grew restless, to say nothing of finding it increasingly difficult to keep a straight face while interpreting the psychological test results of patients from the ward. Trying to make sense out of Rorschach tests, which seemed a speculative venture on a good day, often made me feel as though I might as well be reading tarot cards or discussing the alignment of the planets. This was not why I had gotten a Ph.D., and I was beginning to understand Bob Dylans lines “Twenty years of schoolin’ and they put you on the day shift.” Only it was twenty-three years, and I was still pulling a lot of night shift as well. My intellectual interests were widely and absurdly scattered during my early years on the faculty. I was, among other things, starting up a research project on hyraxes, elephants, and violence (a lingering remnant of the chancellor’s garden party); writing up findings from the LSD, marijuana, and opiate studies I had done in graduate school; contemplating a study, to be done with my brother, that would examine the economics of dam-building behavior in beavers; conducting pain research and studies of phantom breast syndrome with my colleagues in the anesthesiology department; coauthoring an undergraduate textbook on abnormal psychology; acting as co-investigator on a study of the effects of marijuana on nausea and vomiting in cancer chemotherapy patients; and trying to figure out a legitimate way to do animal behavior studies at the Los Angeles Zoo. It was too much and too diffuse. My personal interests eventually forced me to focus on what I was doing and why. I gradually narrowed down my work to the study and treatment of mood disorders.

  More specifically, and not surprisingly, I became particularly interested in manic-depressive illness. I was absolutely and single-mindedly determined to make a difference in how the illness was seen and treated. Two of my colleagues, both of whom had a great deal of clinical and research experience with mood disorders, and I decided to set up an outpatient clinic at UCLA that would specialize in the diagnosis and treatment of depression and manic-depressive illness. We received enough initial funding from the hospital to allow us to hire a nurse and buy some file cabinets. The medical director and I spent weeks developing diagnostic and research forms and then put together a teaching program that would qualify as a clinical rotation, or training experience, for third-year psychiatric residents and predoctoral psychology interns. Although there was some opposition to the fact that I, as a nonphysician, was the director of a medical clinic, most of the medical staff—especially the medical director of the clinic, the chairman of the psychiatry department, and the chief of staff of the Neuropsychiatric Institute—backed me up.

  Within a few years, the UCLA Affective Disorders Clinic had become a large teaching and research facility. We evaluated and treated thousands of patients with mood disorders, carried out a large number of both medical and psychological research studies, and taught psychiatric residents and clinical psychology interns how to diagnose and take care of patients with mood disorders. The clinic became a popular choice for training. It was a scurrying, busy, emergency- and crisis-filled rotation due to the nature and severity of the illnesses being treated, but it also was generally a warm and laughter-filled place. The medical director and I encouraged not only hard work and long hours, but after-hour partying as well. The stress of treating suicidal, psychotic, and potentially violent patients was considerable for all of us, but we tried to back up the clinical responsibility carried by the interns and residents with as much supervision as possible. When the relatively rare catastrophe did occur—an extremely bright young lawyer, for example, refused all efforts to be hospitalized and then committed suicide by shooting himself through the head—the faculty, residents, and interns would meet, in small and larger groups, in order to figure out what had happened and to support not only the devastated family members, but the individuals who had borne the primary clinical responsibility. In the particular instance of the lawyer, the resident had done everything that anyone could possibly have been expected to do; not surprisingly, she was terribly shaken by his death. Ironically, it is usually those doctors who are the most competent and conscientious who feel the most sense of failure and pain.

  We placed a strong emphasis upon the combined use of medications and psychotherapy, rather than medications alone, and stressed the importance of education about the illnesses and their treatments to patients and their families. My own experience as a patient had made me particularly aware of how critical psychotherapy could be in making some sense out of all the pain; how it could keep one alive long enough to have a chance at getting well; and how it could help one to learn to reconcile the resentments at taking medication with the terrible consequences of not taking it. In addition to the basics of teaching differential diagnosis, psychopharmacology, and other aspects of the clinical management of mood disorders, much of the teaching, clinical practice, and research revolved around a few central themes: why patients resist or refuse to take lithium and other medications; clinical states most likely to result in suicide, and how to mitigate them; the role of psychotherapy in the long-term outcome of depressive and manic-depressive illness; and the positive aspects of the illness that can arise during the milder manic states: heightened energy and perceptual awareness, increased fluidity and originality of thinking, intense exhilaration of moods and experience, increased sexual desire, expansiveness of vision, and a lengthened grasp of aspiration. I tried to encourage our clinic doctors to see that this was an illness that could confer advantage as well as disadvantage, and that for many individuals these intoxicating experiences were highly addictive in nature and difficult to give up.

  In order to give the residents and interns some notion of the experiences that patients went through when manic and depressed, we encouraged them to read firsthand accounts from patients and writers who had suffered from mood disorders. I also started giving Christmas lectures to the house staff and clinic staff that focused on music written by composers who had experienced severe depression or manic-depressive illness. These informal lectures became the basis for a concert that a friend of mine, a professor of music at UCLA, and I subsequently produced in 1985 with the Los Angeles Philharmonic. In an attempt to raise public awareness about mental illness, especially manic-depressive illness, we proposed to the executive director of the Philharmonic a program based on the lives and music of several composers who had suffered from the illness, including Robert Schumann, Hector Berlioz, and Hugo Wolf. The Philharmonic was enthusiastic, cooperative, and generous in the fees they negotiated. Unfortunately, a few days after I signed the contract, the University of California announced that it was beginning a major financial development campaign and that individual members of the faculty no longer would be able to solicit funds from private donors. I was left with a personal bill for twenty-five thousand dollars, which, as one of my friends pointed out, was a lot of money for concert tickets. Still, the concert filled UCLA’s huge Royce Hall and was a great success; it also turned out to be the beginning of a series of concerts performed across the country, including one that we did a few years later with the National Symphony Orchestra at the John F. Kennedy Center for the Performing Arts in Washington, D.C. It was also the basis for the first of a series of public television specials that we produced around the theme of manic-depressive illness and the arts.

  Throughout the setting up and running of the clinic I was fortunate to have the support of the chairman of my department. He backed my being director of a medical clinic despite the fact that I was not a physician, and despite the fact that he knew I had manic-depressive illness. Rather than using my illness as a reason to curtail my clinical and teaching responsibilities, he—after being assured that I was receiving good psychiatric care and that the medical director of the clinic knew about my condition—encouraged me to use it to try and develop better treatments and to help change public attitudes. Although he never said, I assume my chairman found out about my illness after my first episode of severe psychotic man
ia; my ward chief certainly knew, and I imagine that the information quickly drifted upward. In any event, my chairman treated the issue strictly as a medical one. He first broached the subject by coming up to me at a meeting, putting his arm around me, and saying, “I understand you have some problems with your moods. I’m sorry. For God’s sake, just be sure to keep taking your lithium.” Now and again, after that, he would ask me how I was doing and make sure that I was still taking my medication. He was straightforward, supportive, and never suggested for a moment that I stop or curtail my clinical work.

  My concerns about openly discussing my illness with others, however, were enormous. My first psychotic episode occurred long before I received my license from the California Board of Medical Examiners. During the period of time between starting lithium and passing my written and oral board examinations, I observed many medical students, clinical psychology interns, and residents denied permission to continue their studies because of psychiatric illness. This happens far less often now—indeed, most graduate and medical schools encourage students who become ill to get treatment and, if at all possible, to return to their clinical work—but my early years on the faculty at UCLA were plagued by fears that my illness would be discovered, that I would be reported to one kind of hospital or licensing board or another, and that I would be required to give up my clinical practice and teaching.

  It was a high-pressure existence in many ways, but mostly I loved it. Academic medicine provides an interesting and varied lifestyle, lots of travel, and most of one’s colleagues are bright-eyed, bushy tailed, and generally thrive on the stresses of having to combine clinical practice with publishing papers and teaching. These stresses were compounded by the fluctuations in mood, however attenuated, that I continued to experience while on lithium. It took several years for them to truly even out. For me, when I was well, it was a wide-open opportunity to write, think, see patients, and teach. When I was ill, it was simply overwhelming: for days and weeks at a time, I would put up the DO NOT DISTURB sign on my door, stare mindlessly out the window, sleep, contemplate suicide, or watch my guinea pig—a memento of one of my manic buying sprees—furiously scurrying around in his cage. During those times I could not imagine writing another paper, and I was incapable of comprehending any of the journal articles that I would try to read. Supervising and teaching were ordeals.

  But it was a tidal existence: When I was depressed, nothing came to me, and nothing came out of me. When manic, or mildly so, I would write a paper in a day, ideas would flow, I would design new studies, catch up on my patient charts and correspondence, and chip away at the mindless mounds of bureaucratic paperwork that defined the job of a clinic director. Like everything else in my life, the grim was usually set off by the grand; the grand, in turn, would yet again be canceled out by the grim. It was a loopy but intense life: marvelous, ghastly, dreadful, indescribably difficult, gloriously and unexpectedly easy, complicated, great fun, and a no-exit nightmare.

  My friends, fortunately, were either a bit loopy themselves, or remarkably tolerant of the chaos that formed the basic core of my emotional existence. I spent a great deal of time with them during those assistant-professorship years. I also traveled frequently, for business and pleasure, and played squash with interns, friends, and colleagues. Sports were fun only up to a point, however, as lithium threw off my coordination. This was true not only for squash, but particularly for riding horses; I finally had to stop riding for several years, after falling off one too many times while jumping. I can look back now and think that perhaps all of that wasn’t so bad, but, in fact, each time I had to give up a sport I had to give up not only the fun of that sport, but also that part of myself that I had known as an athlete. Manic-depressive illness forces one to deal with many aspects of growing old—with its physical and mental infirmities—many decades in advance of age itself.

  Life in the fast track, the dashing about and scrambling for tenure and for recognition from one’s peers, continued at a frenetic pace. When I was manic, the tempo seemed slow; when I was normal, frenetic seemed fine; when I was depressed, the pace was impossible. Other than my psychiatrist, there was no one I could talk to about the real extent of the difficulties I was having. Or perhaps there was, but it never really occurred to me to try. There were next to no other women in the adult psychiatry division; the women that did exist in the department all clumped together in child psychiatry. They were no protection against the weasels in the woodwork, and, besides, they had weasels enough in their own quarters. Although most of my male colleagues were fair, and many were exceptionally supportive, there were several men whose views of women had to be experienced to be believed.

  The Oyster was one such man, one such experience. Named for his smooth and slithery essence, the Oyster was a senior professor: he was patronizing, smug, and had all of the intellectual and emotional complexity of, as one might expect, a small mollusk. He thought of women in terms of breasts, not minds, and it always seemed to irritate him that most women had both. He also thought women who strayed into academic medicine were fundamentally flawed, and, as I was particularly disinclined to be deferential, I seemed especially to annoy him. We served together on the Appointments and Promotions Committee for the department, where I was the only woman among the eighteen members. On the occasions when he would actually show up for meetings—the Oyster was notorious for earning a maximum amount of money for spending a minimum amount of time in the hospital—I would try to sit directly across the table from him and watch his failed attempts to be unfailingly polite.

  I always had the sense that he thought I was a bit of a mutant but, because I was not absolutely hideous, that I might yet be saved by a good marriage. I, for my part, would randomly congratulate him on his efforts to recruit more women into the department. His lack of gray matter was ably matched by his lack of wit, and, as he of course had never made any attempts whatsoever in that direction, he would look suspiciously in my direction and then dart me a baffled and irritated smile. He would have been likably goofy except that he had real power in the department, and he made clear his views about women every step of the way: his sexual innuendos were deeply offensive, and his level of condescension whenever he spoke with me, or women interns and residents, was infuriating. He was a caricature of himself, in many ways, but it was clear that being a woman on his service meant starting ten seconds late for a hundred-yard dash. Fortunately, the tenure process has many checks and balances built into it, and, at least in the two universities that I know best—the University of California and Johns Hopkins—the system seems to me to be a remarkably fair one. Entities like the Oyster didn’t make it any easier, however.

  Finally, after much rodenting along and through the tenure maze, I received my letter from the regents notifying me that I had been promoted to the next set of academic mazes: the holding pattern, the Inferno-land of Associate Professordom. I celebrated for weeks. One of my best friends had a lovely dinner party for about thirty people, on a perfect California night; the terraces in her gardens were filled with flowers and candles; it could not have been more beautiful. My family provided the champagne, along with their gift to me of Baccarat glasses for the champagne, and I had a wonderful time. More than anyone, my family and friends knew how much the tenure party was a celebration over years of struggling against severe mental illness, as well as a celebration of the major rite of academic passage.

  Tenure really sank in, however, when one of my colleagues, a member of the all-male Bohemian Club, came over to my house with some wine from his club. “Congratulations, Professor,” he said, handing me the bottle. “Welcome to an all-men’s club.”

  Part Three

  THIS MEDICINE, LOVE

  An Officer and a Gentleman

  There was a time when I honestly believed that there was only a certain amount of pain one had to go through in life. Because manic-depressive illness had brought such misery and uncertainty in its wake, I presumed life should therefore be kinder t
o me in other, more balancing ways. But then I also had believed that I could fly through starfields and slide along the rings of Saturn. Perhaps my judgment left something to be desired. Robert Lowell, often crazy but rarely stupid, knew better than to assume a straight shot at happiness: If we see a light at the end of the tunnel, he said, it’s the light of an oncoming train.

  For a while—courtesy of lithium, time’s passing, and the love of a tall, handsome Englishman—I caught a glimpse of what I imagined to be the light at the end of the tunnel, and I could feel, however elusively, what seemed to be the return of a warm and secure existence. I learned how marvelously the mind can heal, given half a chance, and how patience and gentleness can put back together the pieces of a horribly shattered world. What God had put asunder, an elemental salt, a first-rank psychiatrist, and a man’s kindness and love could put almost right again.

  I met David my first year on the faculty at UCLA. It was early in 1975, six months after I had gone barkingly manic, and my brain had gradually knit itself into a rather brittle, but vaguely coherent, version of its former self. My mind was skating on thin ice, my emotions were completely frayed, and most of my true existence was lived within the narrow range of very long-cast inner shadows. But my overt actions were within the conservative range of my so-called normal colleagues, so—at least professionally speaking—all was ostensibly well.