A few months ago, while presenting a lecture at a school of public health on my research into the life of General William T. Sherman, who I believe had bipolar disorder, I was reproached by a senior psychoanalyst and historian. "Read Emily Martin's book about bipolar disorder," he told the audience. "Then you will see the dangers of this kind of labeling." I promised I would do so - and I did.
I find Martin's book to be excellent, but I am not sure the dangers she describes lead to the conclusions which my colleague made: namely, that it was inaccurate and even somewhat irresponsible to diagnose a historical figure like Sherman with bipolar disorder
The primary reason for the book's excellence, in my view, is that Martin has bipolar disorder, and she is up front about it. Serendipitously, she is an experienced anthropologist. She found herself, after her recent diagnosis, attending bipolar support group meetings, and suddenly she realized that she had been trained to study the anthropology of her own illness. This is good news for clinicians and patients, since she now has given us a detailed study of the condition from the inside. She describes her "fieldwork" of attending years of support group meetings in two different locations (Orange County, California and Baltimore, Maryland), as well as attending medical lectures and seminars as a guest in academic centers in both places (University of California, Irvine; and Johns Hopkins University), and attending and studying the content and behavior of participants at American Psychiatric Association meetings, and many other national psychiatric meetings. I also conduct this kind of fieldwork on a daily basis, as a practicing psychiatrist and researcher who specializes in bipolar disorder, but I do not have her added talents as an anthropologist or her added insights as a patient with this condition. So, all in all, she has the skills to do the job. (I would fault her in not seeming to have included any of the key current psychiatric leaders in bipolar disorder research; some of the persons she cites are academic leaders, but not currently active with work in bipolar disorder).
She then provides the following: an initial chapter briefly reviewing the concept of manic depressive illness (MDI) in human history, followed by part one examining "manic depression as experience", and part two examining "mania as a resource." Part one begins with a chapter on what it means for one's sense of personhood to be diagnosed with MDI; a chapter on the internal experiences of MDI ("multiplicity, interruption, style and manic performances"…); a chapter on how patients manage the ups and downs of their moods; a chapter on the sociological impact and meaning of receiving the MDI diagnosis (with numerous transcripts and commentaries on psychiatric case conferences where patients are interviewed); an analysis of the mechanisms of action of support groups and the role of DSM in patient's self-appraisals; and a chapter on the marketing of psychotropic drugs and their meaning in our culture. Part two begins with a chapter analyzing the concept of "mood charting" and how we seek to rationally contain manic-depressive symptoms; a valuable chapter on "revaluing mania", where Martin examines different perspectives on what mania is (an "asset" vs a "thing"), and a final chapter on how the manic-depressive metaphor has been used in our economic thinking about financial markets.
Readers will find something of interest somewhere in this wide range of analysis, including in the many interesting pictures of scenes at conferences or marketing advertisements. (I found her psychiatric anthropology to be both fair and as objective as possible, unlike other efforts, such as that of Tanya Luhrmann, which seemed to me to be affected by anti-biological predispositions.)
I was particularly interested in two things: (a) whether Martin would be another social science postmodern dogmatist, trying to show that mental illness is a creation of shrinks for their own pecuniary benefit; and (b) to assess the challenge that my colleague had put up, and see what Martin had to say about possible bipolar disorder in valued cultural and historical figures.
On the first matter, Martin comes from a world antipodal to the world of doctors. In the social sciences, among historians of medicine and psychiatry, the standard belief-system, derived from Foucault and others, is as follows: diseases are social constructions; they are either pure cultural constructs (fictions) or they may have some core biological reality with an extensive cultural superstructure. Most of the interactions between doctors and patients have to do with cultural and social relations (power, wealth), and are not straightforward assessments of biological disease. In the medical world, the standard belief-system is that diseases are autonomous biological realities, without any cultural variation of importance, and doctors interact with patients, following standards of medical ethics, solely in patients' best interests. Most of the individual Martin acknowledges as involved in her book come from the social science belief-system: they are not out-and-out anti-psychiatrists, but they are critics of mainstream psychiatry. Given that she has long practiced as an anthropologist, one would expect the book to be another anti-psychiatry tome, repeating the well-worn clichés of other such efforts.
But she was saved by having the illness, thus realizing that, at least, there is a core disease here, albeit one with many cultural hues. And that seems to be the ultimate message of her book, that bipolar disorder is a disease, but one which is very contextualized socially, and thus quite different in many of its presentations, and in the meaning of its experience, in the US than elsewhere, and even within the US, different based on variations in race, gender, and wealth. But it is a biological disease, not a pure cultural fiction, the implications of my colleague notwithstanding. Although Martin warns against this postmodern nihilism, it is highly likely that many readers will want to draw that conclusion from her book, mainly because they had it before they read her book.
This brings us to my second interest -- my colleague's challenge about making historical diagnoses. Martin points out that many cultural figures (especially CEOs and Ted Turner- types) are viewed in the bipolar community as role models, but she emphasizes that this estimation is based on our cultural value for high-energy capitalistic enterprise. Other features of bipolar disorder, especially its darker side and its realization of the fragility of happiness, are not well-valued, despite the beauty of poems like C. E. Chaffin's "Manic-depression":
The sun rises, stone walls dissolve.
I clench a marigold in my teeth
and tango on the flaming grass.
The soil beneath is balck with crematory ash.
I pray the lawn is thick enough
to hide the darkness I dance over.
Thus, she warns against the work of some, like Kay Jamison, who seek to read the diagnosis back into the behavior of historical figures (like van Gogh or Theodore Roosevelt). She rightly makes the point that if we think of MDI as an "experience" rather than a "thing", then there is no way that those 19th century figures could have had the experience of MDI, since the cultural category did not exist at that time. Yet, I might respond on behalf of Jamison, if we admit that bipolar disorder is not a pure cultural fiction, that it has a biological core, then it well may have been present 100 years ago, just as it was 10 years ago; even though its personal meaning was different, and its social context was different, its biological presence may not have been very different. Decreased need for sleep today likely varies little from decreased need for sleep 100 years ago (4 hours is 4 hours in both contexts).
So I appreciate Martin's clarification, but I do not grant my colleague's conclusion: Bipolar disorder, as a biologically-based disease, existed in Sherman's age as now, though its meaning for Sherman differed than it would today, and though some of its more subjective symptom presentations might have differed - just as pneumonia, when it affected Sherman or Lincoln or others, would have caused fever and chills and night sweats then as today, though its cultural meaning and other more subjective symptoms might have differed. Martin uses multiple personality disorder to highlight the dangers of retrospective inference regarding historical behaviors, but multiple personality is not a biological disease, I would hold; bipolar disorder is.
Deep down, I think some critics suffer from the postmodern disease that they do not believe in disease - any disease, or at least any mental disease. They feel everything should be culture and nothing else. This dogma, derived ultimately from Rousseau and transmitted to us via Marx and Lenin (though Foucault is more pleasing to Westerners), has many dangers. Martin manages to avoid that scholasticism, and gives us a book which, read honestly rather than rhetorically, adds to our knowledge about this condition.
Martin fails in helping readers avoid postmodernist extremism because she does not make an important philosophical distinction: The confusions that may arise, when the postmodern partisans get involved, has to do with a lack of appreciation of the difference between the domain of meaning and the domain of causation. Martin refers to Karl Jaspers a few times, but only as a "clinician" who describes mood states; although she refers to many others as philosophers (Heidegger, Foucault) or social scientists (Max Weber, Marx), she perhaps has not realized that Jaspers has elevated stature as a philosopher, and was indeed the prize disciple of Max Weber and erstwhile colleague of Heidegger. And Jaspers (with Weber's help) thought through this matter which Martin has not made explicit, and which I think is a key source of the confusion of many critics of psychiatry: psychiatric conditions are not simply exercises in personal meaning (Verstehen, or meaningful understanding), nor pure biological disease-entities (Erklaren, causal explanation); they are both. And if we ignore one or the other, we have missed the reality of -- we must call it by its name -- mental illness.
© 2008 S. Nassir Ghaemi
Nassir Ghaemi, M.D., M.A., M.P.H., Director, Mood Disorders Program, Tufts Medical Center, Dept of Psychiatry. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.