During interviews with people who had suffered atrocities at the hands of the Khmer Rouge, I found that most preferred to look forward. When I pressed them on personal history, however, they would slip into the mournful past tense. The stories I heard were inhuman and terrifying and repulsive. Every adult I met in Cambodia had suffered such external traumas as would have driven most of us to madness or suicide. What they had suffered within their own minds was at yet another level of horror. I went to Cambodia to be humbled by the pain of others, and I was humbled down to the ground.
Five days before I left the country, I met with Phaly Nuon, a sometime candidate for the Nobel Peace Prize, who has set up an orphanage and a center for depressed women in Phnom Penh. She has achieved astonishing success in resuscitating women whose mental afflictions are such that other doctors have left them for dead. Indeed her success has been so enormous that her orphanage is almost entirely staffed by the women she has helped, who have formed a community of generosity around Phaly Nuon. If you save the women, it has been said, they will in turn save the children, and so by tracing a chain of influence one can save the country.
We met in a small room in an old office building near the center of Phnom Penh. She sat on a chair on one side, and I sat on a small sofa opposite. Phaly Nuon’s asymmetrical eyes seem to see through you at once and, nonetheless, to welcome you in. Like most Cambodians, she is relatively diminutive by Western standards. Her hair, streaked grey, was pulled back from her face and gave it a certain hardness of emphasis. She can be aggressive in making a point, but she is also shy, smiling and looking down whenever she is not speaking.
We started with her own story. In the early seventies, Phaly Nuon worked for the Cambodian Department of the Treasury and Chamber of Commerce as a typist and shorthand secretary. In 1975, when Phnom Penh fell to Pol Pot and the Khmer Rouge, she was taken from her house with her husband and her children. Her husband was sent off to a location unknown to her, and she had no idea whether he was executed or remained alive. She was put to work in the countryside as a field laborer with her twelve-year-old daughter, her three-year-old son, and her newborn baby. The conditions were terrible and food was scarce, but she worked beside her fellows, “never telling them anything, and never smiling, as none of us ever smiled, because we knew that at any moment we could be put to death.” After a few months, she and her family were packed off to another location. During the transfer, a group of soldiers tied her to a tree and made her watch while her daughter was gang-raped and then murdered. A few days later it was Phaly Nuon’s turn. She was brought with some fellow laborers to a field outside of town. Then they tied her hands behind her back and roped her legs together. After forcing her to her knees, they tied her to a rod of bamboo, and they made her lean forward over a mucky field, so that her legs had to be tensed or she would lose her balance. The idea was that when she finally dropped of exhaustion, she would fall forward into the mud and, unable to move, would drown in it. Her three-year-old son bellowed and cried beside her. The infant was tied to her so that he would drown in the mud when she fell: Phaly Nuon would be the murderer of her own baby.
Phaly Nuon told a lie. She said that she had, before the war, worked for one of the high-level members of the Khmer Rouge, that she had been his lover, that he would be angry if she were killed. Few people escaped the killing fields, but a captain who perhaps believed Phaly Nuon’s story eventually said that he couldn’t bear the sound of her children screaming and that bullets were too expensive to waste on killing her quickly, and he untied Phaly Nuon and told her to run. Her baby in one arm and the three-year-old in the other, she bolted deep into the jungle of northeastern Cambodia. She stayed in the jungle for three years, four months, and eighteen days. She never slept twice in the same place. As she wandered, she picked leaves and dug for roots to feed herself and her family, but food was hard to find and other, stronger foragers had often stripped the land bare. Severely malnourished, she began to waste away. Her breast milk soon ran dry, and the baby she could not feed died in her arms. She and her remaining child just barely held on to life and managed to get through the period of war.
By the time Phaly Nuon told me this, we had both moved to the floor between our seats, and she was weeping and rocking back and forth on the balls of her feet, while I sat with my knees under my chin and a hand on her shoulder in as much of an embrace as her trancelike state during her narrative would allow. She went on in a half-whisper. After the war was over, she found her husband. He had been severely beaten around the head and neck, resulting in significant mental deficit. She and her husband and her son were all placed in a border camp near Thailand, where thousands of people lived in temporary tented structures. They were physically and sexually abused by some of the workers at the camp, and helped by others. Phaly Nuon was one of the only educated people there, and, knowing languages, she could talk to the aid workers. She became an important part of the life of the camp, and she and her family were given a wooden hut that passed for comparative luxury. “I helped with certain aid tasks at that time,” she recalls. “All the time while I went around, I saw women who were in very bad shape, many of them seeming paralyzed, not moving, not talking, not feeding or caring for their own children. I saw that though they had survived the war, they were now going to die from their depression, their utterly incapacitating post–traumatic stress.” Phaly Nuon made a special request to the aid workers and set up her hut in the camp as a sort of psychotherapy center.
She used traditional Khmer medicine (made with varied proportions of more than a hundred herbs and leaves) as a first step. If that did not work or did not work sufficiently well, she would use occidental medicine if it was available, as it sometimes was. “I would hide away stashes of whatever antidepressants the aid workers could bring in,” she said, “and try to have enough for the worst cases.” She would take her patients to meditate, keeping in her house a Buddhist shrine with flowers in front of it. She would seduce the women into openness. First, she would take about three hours to get each woman to tell her story. Then she would make regular follow-up visits to try to get more of the story, until she finally got the full trust of the depressed woman. “I had to know the stories these women had to tell,” she explained, “because I wanted to understand very specifically what each one had to vanquish.”
Once this initiation was concluded, she would move on to a formulaic system. “I take it in three steps,” she said. “First, I teach them to forget. We have exercises we do each day, so that each day they can forget a little more of the things they will never forget entirely. During this time, I try to distract them with music or with embroidery or weaving, with concerts, with an occasional hour of television, with whatever seems to work, whatever they tell me they like. Depression is under the skin, all the surface of the body has the depression just below it, and we cannot take it out; but we can try to forget the depression even though it is right there.
“When their minds are cleared of what they have forgotten, when they have learned forgetfulness well, I teach them to work. Whatever kind of work they want to do, I will find a way to teach it to them. Some of them train only to clean houses, or to take care of children. Others learn skills they can use with the orphans, and some begin toward a real profession. They must learn to do these things well and to have pride in them.
“And then when they have mastered work, at last, I teach them to love. I built a sort of lean-to and made it a steam bath, and now in Phnom Penh I have a similar one that I use, a little better built. I take them there so that they can become clean, and I teach them how to give one another manicures and pedicures and how to take care of their fingernails, because doing that makes them feel beautiful, and they want so much to feel beautiful. It also puts them in contact with the bodies of other people and makes them give up their bodies to the care of others. It rescues them from physical isolation, which is a usual affliction for them, and that leads to the breakdown of the emotional isolation. While they
are together washing and putting on nail polish, they begin to talk together, and bit by bit they learn to trust one another, and by the end of it all, they have learned how to make friends, so that they will never have to be so lonely and so alone again. Their stories, which they have told to no one but me—they begin to tell those stories to one another.”
Phaly Nuon later showed me the tools of her psychologist’s trade, the little bottles of colored enamel, the steam room, the sticks for pushing back cuticles, the emery boards, the towels. Grooming is one of the primary forms of socialization among primates, and this return to grooming as a socializing force among human beings struck me as curiously organic. I told her that I thought it was difficult to teach ourselves or others how to forget, how to work, and how to love and be loved, but she said it was not so complicated if you could do those three things yourself. She told me about how the women she has treated have become a community, and about how well they do with the orphans of whom they take care.
“There is a final step,” she said to me after a long pause. “At the end, I teach them the most important thing. I teach them that these three skills—forgetting, working, and loving—are not three separate skills, but part of one enormous whole, and that it is the practice of these things together, each as part of the others, that makes a difference. It is the hardest thing to convey”—she laughed—“but they all come to understand this, and when they do—why, then they are ready to go into the world again.”
Depression now exists as a personal and as a social phenomenon. To treat depression, one must understand the experience of a breakdown, the mode of action of medication, and the most common forms of talking therapy (psychoanalytic, interpersonal, and cognitive). Experience is a good teacher and the mainstream treatments have been tried and tested; but many other treatments, from Saint-John’s-wort to psychosurgery, hold out reasonable promise—though there is also more quackery here than in any other area of medicine. Intelligent treatment requires a close examination of specific populations: depression has noteworthy variants particular to children, to the elderly, and to each gender. Substance abusers form a large subcategory of their own. Suicide, in its many forms, is a complication of depression; it is critical to understand how a depression can become fatal.
These experiential matters lead to the epidemiological. It is fashionable to look at depression as a modern complaint, and this is a gross error, which a review of psychiatric history serves to clarify. It is also fashionable to think of the complaint as somehow middle-class and fairly consistent in its manifestations. This is not true. Looking at depression among the poor, we can see that taboos and prejudices are blocking us from helping a population that is singularly receptive to that help. The problem of depression among the poor leads naturally into specific politics. We legislate ideas of illness and treatment in and out of existence.
Biology is not destiny. There are ways to lead a good life with depression. Indeed, people who learn from their depression can develop a particular moral profundity from the experience, and this is the thing with feathers at the bottom of their box of miseries. There is a basic emotional spectrum from which we cannot and should not escape, and I believe that depression is in that spectrum, located near not only grief but also love. Indeed I believe that all the strong emotions stand together, and that every one of them is contingent on what we commonly think of as its opposite. I have for the moment managed to contain the disablement that depression causes, but the depression itself lives forever in the cipher of my brain. It is part of me. To wage war on depression is to fight against oneself, and it is important to know that in advance of the battles. I believe that depression can be eliminated only by undermining the emotional mechanisms that make us human. Science and philosophy must proceed by half-measures.
“Welcome this pain,” Ovid once wrote, “for you will learn from it.” It is possible (though for the time being unlikely) that, through chemical manipulation, we might locate, control, and eliminate the brain’s circuitry of suffering. I hope we will never do it. To take it away would be to flatten out experience, to impinge on a complexity more valuable than any of its component parts are agonizing. If I could see the world in nine dimensions, I’d pay a high price to do it. I would live forever in the haze of sorrow rather than give up the capacity for pain. But pain is not acute depression; one loves and is loved in great pain, and one is alive in the experience of it. It is the walking-death quality of depression that I have tried to eliminate from my life; it is as artillery against that extinction that this book is written.
CHAPTER II
Breakdowns
I did not experience depression until after I had pretty much solved my problems. My mother had died three years earlier and I had begun to come to terms with that; I was publishing my first novel; I was getting along with my family; I had emerged intact from a powerful two-year relationship; I had bought a beautiful new house; I was writing for The New Yorker. It was when life was finally in order and all the excuses for despair had been used up that depression came slinking in on its little cat feet and spoiled everything, and I felt acutely that there was no excuse for it under the circumstances. To be depressed when you have experienced trauma or when your life is clearly a mess is one thing, but to sit around and be depressed when you are finally at a remove from trauma and your life is not a mess is awfully confusing and destabilizing. Of course you are aware of deep causes: the perennial existential crisis, the forgotten sorrows of a distant childhood, the slight wrongs done to people now dead, the loss of certain friendships through your own negligence, the truth that you are not Tolstoy, the absence in this world of perfect love, the impulses of greed and uncharity that lie too close to the heart—that sort of thing. But now, as I ran through this inventory, I believed my depression was both a rational state, and an incurable state.
I have not, in certain crucial material ways, had a difficult life. Most people would have been pretty happy with my cards at the start. I’ve been through some better times and some worse times, by my own standards, but the dips are not sufficient to explain what happened to me. If my life had been more difficult, I would understand my depression very differently. In fact, I had a reasonably happy childhood with two parents who loved me generously, and a younger brother whom they also loved and with whom I generally got on well. It was a family sufficiently intact that I never even imagined a divorce or a real battle between my parents, who loved each other very much indeed; and though they argued from time to time about this or that, they never questioned their absolute devotion to each other and to my brother and me. We always had enough to live comfortably. I was not popular in elementary school or in junior high, but by the end of high school I had a circle of friends with whom I was fairly happy. I always did well academically.
I had been somewhat shy as a child, fearful of rejection in highly exposed situations—but who is not? By the time I was in high school, I was aware of occasional unsettled moods which, again, seem not unusual for adolescence. At one period, in eleventh grade, I became convinced that the building in which I went to classes (which had been standing for almost a hundred years) was going to collapse, and I remember having to steel myself against that strange anxiety day after day. I knew it was peculiar and was relieved when, after about a month, it passed.
Then I went on to college, where I was blissfully happy, and where I met many of the people who are my closest friends to this day. I studied and played hard and woke up to both a range of new emotions and the scope of intellect. Sometimes when I was alone, I would suddenly feel isolated, and the feeling was not simply sorrow at being alone, but fear. I had many friends, and I’d go visit one of them, and I could usually be distracted out of my distress. This was an occasional and not crippling problem. I went on to do my MA in England, and when I finished my studies, I went relatively smoothly to a career as a writer. I stayed in London for a few years. I had a lot of friends, and some dalliance with love. In many ways, all of that has stayed
more or less the same. I have had a good life so far, and I’m grateful for it.
When you start having major depression, you tend to look back for the roots of it. You wonder where it came from, whether it was always there, just under the surface, or whether it came on you as suddenly as food poisoning. Since the first breakdown, I’ve spent months on end cataloging early difficulties, such as they are. I was a breech birth, and some writers have linked breech birth to early trauma. I was dyslexic, though my mother, who identified the problem early, began teaching me ways to compensate for it when I was just two, and it has never been a serious impediment for me. As a small child, I was verbal and uncoordinated. When I asked my mother to identify my earliest trauma, she said that walking had not come easily to me, that while my speech seemed to have been no effort at all, my motor control and balance were late and imperfect. I am told that I fell and fell and fell, that only with great encouragement did I even attempt to stand upright. My subsequent unathleticism determined my unpopularity in elementary school. Of course not being condoned by my peers was disappointing to me, but I always had a few friends and I always liked adults, who also liked me.
I have many odd, unstructured memories from my early childhood, almost all of which are happy. A psychoanalyst I once saw told me that one faint sequence of early memories of which I could make little sense suggested to her that I had once been subject to juvenile sexual abuse. It is certainly possible, but I have never been able to construct a convincing memory of it or adduce other evidence. If something happened, it must have been fairly gentle, because I was a child much scrutinized, and any bruise or disruption would have been observed in me. I remember one episode at summer camp when I was six, when I was suddenly and unreasonably overcome with fear. I can see it vividly: the tennis court up above, the dining hall on my right, and some fifty feet away, the big oak tree under which we sat to hear stories. Suddenly, I couldn’t move. I was overcome with the knowledge that something awful was going to happen to me, now or later, and that, as long as I was alive, I wouldn’t be free. Life, which had until then seemed to be a solid surface upon which I stood, went suddenly soft and yielding, and I began to slip through it. If I stayed still, I might be all right, but as soon as I moved, I would be in danger again. It seemed to matter very much whether I went left or right or straight on, but I didn’t know which direction would save me, at least for the moment. Fortunately a counselor came along and told me to hurry up, I was late for swimming, and the mood broke, but for a long time I remembered it and hoped it wouldn’t come back.
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