Another Kind of Madness

by Stephen Hinshaw

  On the Ohio State Oval I witnessed a golden twilight as the warm May evening waned. I hurried to the faculty club and reached Dad on the front steps, where he was talking with colleagues. I tapped him on the shoulder. “What are you doing here!” he cried, beaming.

  Filling the evening were speeches and the reading of laudatory telegrams and letters from philosophers around the world. Dad gave generous remarks about his 35 years at OSU, with the promise of more to come. Yet just prior to the festivities the current department chair pulled me aside, whispering that it was a blessing Dad had decided on early retirement. Other faculty members had been lobbying for him to step down; he was beginning to be a liability. “He admires you, Steve, enormously. Maybe you can help him deal with his new status. Good luck.” Weighed down with burden, I faced the evening.

  Mom was working through her crippling arthritis every day, preparing for surgeries to replace, with implants, major bones in both of her hands and both of her feet. Eventually both of her knees were replaced, too. Her energy and activity level never abated, but the pain was relentless. And as Dad’s partial retirement loomed, Dad seemed to be drifting. Watching my parents in their separate orbits, how could I provide any gravity, any stability? The shadow of stigma had shielded our family from the light of open communication for its entire existence.

  I stayed on for a few days after the ceremony, the skies rank with humidity. When I talked with Dad in his study he seemed blank and devoid of energy. Was this the product of his now-official retirement or instead the form of depression that often follows mania?

  During the internship Jamison had each Affective Disorders Clinic trainee sit in on a clinical interview she performed, an old-school method but one that can be utterly compelling. The patient she interviewed in my presence had experienced a lifetime of bipolar disorder, with wildly productive and sometimes destructive manic states but now in a severely depressed phase. I’d been expecting cries of despair, but instead, this distinguished-looking man didn’t move a muscle for the entire 50 minutes. His face was as blank as granite while he described, with chilling distance, his lifetime of huge dreams, inventions, ruined business ventures, and failed marriages. All emotion had leached from his body. This is bipolar depression, I told myself, with newfound respect for the utter severity of mental illness. It helped me understand Dad’s blank, rigid periods of low mood.

  Crossing the line once again between son, medical consultant, and advisor, I begged Dad to contact his doctor, pushing for the addition of an antidepressant medication to his lithium dose. It was increasingly known that lithium was better for squelching manias than lifting depressions. I couldn’t stand to see Dad fading in front of my eyes. But as I implored he just stared. Powerlessness clung to me like the fetid air all around.

  Once I was back in California, Dad finally relented and contacted his psychiatrist, who wrote a prescription for a new antidepressant, which lacked a proven track record. Soon after, I received a panic-stricken call. “I can’t see well,” Dad said. “Driving is now a hazard. My ophthalmologist suspects macular degeneration, and the new medication may be partly to blame.” Indeed, it emerged that some of the newer antidepressants of that era could produce exactly this side effect. Specific medications for the depressions that linger following manias weren’t uncovered until the twenty-first century. The most established of these is lamotrigine (Lamictal), which lifts bipolar depression in many individuals.

  Ominous signs had been appearing. During a visit to Southern California with Mom when I was in grad school, Dad seemed lethargic and even confused. His hand tremor was worse than usual. Because one of lithium’s effects is to suppress kidney functioning, lithium levels may climb because the chemical is not cleared adequately, especially for older patients. The following morning Mom told me that things were getting worse, as he couldn’t even manage to put a key in a lock and had vomited during the night. I hurriedly called UCLA hospital, where he was admitted. With grim resignation, I realized that his confusional state, lethargy, and nausea were all signs of a lithium overdose.

  There are few, if any, magic bullets in mental health. I was going it alone in advocating for Dad, but my solo act was teetering. Like battery acid, bitterness and self-blame seared my skin. Often the silent third party during our conversations, Dad’s bipolar disorder had reared its head once more.

  *

  I received a post-doctoral fellowship at the Langley Porter Institute of UC San Francisco. When I arrived, the psychiatry department chair was the eminent psychoanalyst Robert Wallerstein. As I was finishing two years later, he yielded to the equally eminent biological psychiatrist Sam Barondes, who studied basic cellular processes. Their approaches were diametrically opposed. Everywhere I looked, the splits in the mental health field seemed unbridgeable.

  Roberta had already moved up to Berkeley, to begin her social welfare Master’s degree. We rented a house together and finally decided to get married. Who else would have ever supported me? But I was continuing the patterns I’d developed as a boy, too often lacking the spontaneity to go beneath the surface of my routines and control. I had opened up with Jay and a few other friends, I played touch football and basketball as much as I could, and I continued to search for the grand scheme that might solve the riddle of mental illness. But within the most important areas of my life I felt closed off rather than expansive. Far from soaring, I was slowly sinking.

  Even so, my academic record continued to grow. My dissertation research, now getting published, revealed that for children displaying major problems with attention and impulse control, the combination of biological treatments (medication) and psychosocial interventions (behavioral and cognitive therapies) made the biggest difference, especially for their social interactions. I applied for a few faculty jobs, turning down several offers because, by now, Roberta was pregnant. Instead I accepted a visiting lecturer position at Berkeley. In the fall I walked excitedly to campus to teach courses and pursue my research, a newcomer with a temporary job amid giants of the field. I knew that it wasn’t wise to stay in such a non-tenured position, so the following spring I accepted an assistant professorship back at UCLA. There, at least, I was a known quantity, and we could stay in California. With seven-week-old Jeffrey in the car seat, we drove down Interstate 5 at the tail end of 1986, back to the arid Southern California landscape.

  The previous spring, Dad had joined Mom in Palm Springs, where they rented an apartment for several months. As the March days lengthened and the early sunrise suffused their upstairs bedroom with searing light at 5:30 a.m., Dad’s mood soared. While visiting them I heard him talk nonstop, unable to rein himself in. Back in Columbus Dr. Southwick had been worried about the side effects of Dad’s now-tiny lithium dose and had pulled him off altogether the year before. All spring I hoped beyond hope that Dad’s symptoms would stop at the milder phase of hypomania. It was touch and go. Sometimes people with bipolar disorder witness a fading of their cycles later in life, but in other cases, things only intensify. As of yet there’s no certain prediction.

  Back in Columbus a month later, Dad eagerly attended a talk at Ohio State by R. D. Laing, whose book The Divided Self had been the Christmas present I gave him several months before our first major talk. Laing was influential in both psychiatric and existential philosophical circles; Dad had continued to follow his work. After the lecture, he introduced himself and invited “Ronnie” to the house. Somehow, Laing accepted. They drove back and after a brief hello to Mom, Dad pulled out gin, bourbon, and two glasses from the cabinet. Closing the sliding door to the study, he engaged Laing in drink and talk until quite late, before Laing caught a cab back to his hotel.

  By that point, Laing had been open in print about his own psychotic experiences, and Dad undoubtedly divulged some of his journeys. I would give a large sum for a tape recording of their discussion.

  Dad remained elevated for several months but escaped a major escalation into full-blown mania and hospitalization. Absent lithium an
d any real therapeutic support, he managed—through pure luck—to stay sane.

  By this time my talks with Dad were changing form. As we sat in his study he began to pull letters and handwritten journal entries from manila folders in his packed file drawers, spreading them across his desk. Some were handwritten notes on yellow legal pads; others were exquisitely typed, double-spaced documents. How long had he been keeping these writings? Who had ever seen them?

  In many of them he focused on his boyhood. One entry described how, after his father remarried, his stepmother secured Virgil Sr.’s permission to be the one to look after Junior’s discipline. The other boys were getting older, and she saw in him a boy young enough and pliable enough to engage in firm control. Dad reminded me that she’d been a missionary to Latin America, in charge of a religious school. He told me that she praised him in front of houseguests for his academic skills and religious faith but held him to a high standard.

  It might start with a small infraction, like failing to put down the toilet seat or talking impudently. She would confront him and order him to her room to await stern punishment. Dad had saved a letter she’d written to her sister in 1925:

  One day this week I was out in front, buying vegetables from the vegetable man, when I saw the children coming home from school down the street. I heard Junior’s voice ring out roughly, “Shut up! Don’t blow your nose so loud. I’ll knock you in the bean!” I came in thinking that was pretty rough and strong coming from one five year old, so as soon as he came in, I asked him, “Junior, were you saying all those things to the little boy down the street that you play with?” He looked a little blank, and then shook his head and said, “No, I didn’t say it to him.” Then I asked, “Who did you say it to? They were pretty rough sounding words to anybody.” He then said, “I didn’t say it to anybody.”

  And then he began to cry … and amid his sobs he said, “I said it to the wind.”

  Would that not get to you? The wind! Anyway, even to the wind they were not nice words to be yelling on the street.

  In the margins of the letter, Dad had added a handwritten note:

  When I had finished crying, I was asked to go to the bathroom and bare my buttocks in the corner for spanking. “Never say shut up to anyone or anything,” said my stepmother.

  A hard switching followed.

  Many of Dad’s typewritten journal entries focused on the spankings, which grew more intense as he got older. He began one with a recollection of first grade:

  Accustomed to stern discipline at home, I found the open classroom atmosphere at the progressive school a welcome change. I soon took advantage of this freedom by acting … as I would never dare to act at home in front of my stepmother. In short, I soon became a smart alec. One day as I persisted in talking and laughing with my seatmates (in French class, which was taught in a more structured than open manner), our teacher became exasperated and said: “I don’t like your attitude.” Whereupon, quick as a wink, I stood up, climbed onto and stood on my desktop, and replied to her: “Well, how do you like my altitude?”

  The students laughed and, carried away by my spontaneous outburst, I was unconscious of my rudeness or at least of its possible long-run consequences. Little did I know …

  He was sent to the principal’s office, where a call was made to the family home to report the misdeed. His stepmother answered.

  When I got home the whole situation suddenly changed … No one else was at home; so she seized that moment for purgative punishment. This spanking was surely the longest I had ever received. “We’ll do this once a week until you have learned your lesson,” she softly but sternly said. “Plan to be spanked, just like today, for the next three weeks. You may pick the day of the week and the time of the day.”

  And so it was to be: I asked her for a spanking three more times.

  From a continuation of the typed essay, I read the following:

  Minor offenses were at first simply verbally corrected after a hard slap or two on each cheek. If such offenses were repeated, I would be asked to go to the bathroom and wait. Out would come the bar of soap and a wet wash cloth while my mother proceeded to vigorously wash out my mouth with soap. The actual washing was not so bad, but her righteous indignation and her size (about five feet four inches tall, but over two hundred pounds in weight) made even such punishment frightening … When I was a little older she gave up the soap for castor oil … Greater offenses always merited spankings, always bare, at first in the bathroom downstairs and later in my bedroom upstairs … The spankings were always hard and always hurt (about 15 to 20 spanks at first), yet even as a five year old I never cried during or after such discipline [as] a matter of pride, defiance, and masochism …

  Dad wrote in one of his journal entries that although the term was not used at the time and although Nettella’s intention was to shape his moral behavior, he came to believe that he was a victim of what today is called child abuse.

  I quickly recalibrated. It wasn’t just the loss of his mother when he was three; it wasn’t just the make-up of his DNA. Something in those punishments had molded his view of himself and the world. What he particularly recalled was that, after a transgression, his stepmother would make him go upstairs and wait for the inevitable punishment.

  Sometimes the wait in bed was short, sometimes long (an hour or more), but it usually seemed long. Her eyes and face were always very stern at such times, but her manner was that of a high school principal about to punish some tenth-grade girl for breaking rules … She spoke calmly but with moral fervor, knowing that no infraction of rules she had laid down was to go unpunished … At length, she would always ask: “Do you think you ought to be punished?” I would meekly assent … I would then climb on the bed on my knees (in the punishment position) … In righteously indignant gestures [she] proceeded with the inevitable—the rhythmic, hard spanking. I can still vividly hear and feel the spank! spank! spank! of this and the many other spankings that were to follow …

  … I believe that it was the first time I was razor strapped that she suggested it would be better if I were tied when strapped so as to avoid injury from my involuntary movements while being whipped … As her father, an upright, German-American Methodist, had strapped her, now she must strap me. I am convinced she loved me deeply, and that she thought strapping was necessary to shape me into a good man.

  As she initiated the punishments, recalling her missionary days in Latin America, she invoked Spanish to initiate the ritual.

  “Presentame, por favor, tus naglas desnudas para zurrarte” or “Please present to me your nude buttocks so I may spank (or whip) you.”

  “Immediatamente, Madre,” I would reply.

  Early on, his older brother Bob was occasionally punished alongside him. Dad wrote about their difference in attitude.

  When I was young she expressed some astonishment when, on being spanked in turn with my next-older brother, I never cried or cried out even though he did. Later on, she commended me for not crying out when she strapped me harder than she had her senior girls. Astonished though she might have been at my early stoicism, she frequently praised me for it, chiefly because, I have come to think, my silence insured even greater privacy since the ongoing ritual … was less likely to be overheard.

  Right after a particularly hard spanking or strapping, Dad told me, she would rub olive oil into his wounds, providing some relief. The feeling turned into sensual pleasure as he attained puberty, when he began to associate sexual release with his being bound and punished—and then soothed—by his stepmother.

  Important research reveals that for bipolar disorder, despite its extraordinarily high heritability, maltreatment can also be a major part of the equation. Individuals with the propensity for manic-depression who also experience trauma tend to have earlier onsets and more frequent, difficult-to-treat episodes. Such experiences predict a worse course of their illness. Simple answers and miracle cures are not in the cards. Integration rather than division is essentia
l.

  *

  As a new parent, I couldn’t get over seeing Jeffrey’s almost infinite number of changes of expression in the course of an hour, much less a day. UCLA had an infant-care center right in the psychology department, a floor down from my office, so I could feed him while I was at work. But Roberta, now in a new Master’s program in public health, longed to return to Northern California. I was ambivalent. UCLA had resources galore, and I was well regarded there. Yet several faculty, despite their best intentions, treated me as a continuing apprentice. Nothing seemed easy.

  Research was emerging in the late 1980s that the specific genes responsible for schizophrenia and for bipolar disorder were on the verge of being discovered. The excitement was palpable, but it would take several decades for the sobering truth to emerge that no single gene is responsible for any form of mental illness. Complex gene combinations, in interaction with the environment, yield vulnerability. Emerging knowledge of the ways in which genes are activated epigenetically—through chemical and other environmental signals—has shattered the “nature versus nurture” perspectives so strongly promoted throughout the history of psychiatry and psychology. In the ultimate argument against such a simplistic dichotomy, it may well be the case that the genetic vulnerability for certain forms of psychiatric illness is, in fact, an acute sensitivity to the effects of maltreatment, life stress, or other forms of contextual influence. With such facts in mind, either-or arguments no longer make sense. In short, to understand the origins of mental disorder and to overcome stigma, we have to think broadly and with a multidisciplinary perspective.

  *

  Once I’d begun grad school at UCLA in the late 1970s, Mom began to make winter trips to Palm Springs, to help with her severe, systemic rheumatoid arthritis. The warmth will do you good, her rheumatologist had said. Dad could join her in a few weeks once he finished his winter-quarter teaching. Mom loved the desert, its indigo sunsets and Native American art. Whenever possible I made the two-hour drive from LA to see her on weekends. During afternoon drives outside the city limits she opened up. The vast sands beneath the towering peaks all around provided the right context.