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Getting to Grey

Liam Hennessy

The Examined Life, by Stephen Grosz, Chatto & Windus, 240 pp, £14.99, ISBN: 978-0701185350
Strictly Bipolar, by Darian Leader, Penguin, 112 pp, £5, ISBN: 978-0241146101

Stephen Grosz is a very experienced American psychoanalyst, psychotherapist and commentator who has practised for many years in these fields in London. His first book – The Examined Life – is a distillation of the wisdom he has garnered from his patients in the over 50,000 hours they have spent on his couch. The book has been a popular commercial success, having been read on BBC 4 and having topped the Sunday Times bestseller list. Why would this be the case?

The answer possibly lies in Grosz’s repeated affirmations that his descriptions are “stories” which evoke the spirit and wisdom of his contacts with his patients dealing, as they do, with the perennial human themes of love, loss, sadness, change and anger. “Stories” is, indeed, apt as the vignettes resonate with the power of the best short stories. In fact in what Grosz might well regard as a manifestation of the classical psychoanalytical technique of free association, this reviewer, when reading his book, was reminded of an exemplar of the work of a master of the art of the short story, Sean O’Faolain’s Lovers of the Lake and Other Stories. What they seem to have in common is recognition of the fragility, beauty and, yes, sadness of those things in life that are valuable and that, ultimately, make us human. Moreover, most of Grosz’s “stories” conclude with the near standard short story device of an apophthegm. A couple of examples will illustrate this point.

In a “story” with the paradoxical title of “The gift of pain”, Grosz concludes with “At one time or another, we all try to silence painful emotions. But when we succeed in feeling nothing we lose the only means we have of knowing what hurts us and why.” In “How paranoia can relieve suffering and prevent catastrophe”, Grosz ends with “Her paranoia shielded her from the catastrophe of indifference.”

Of course, what also may have contributed to the success of The Examined Life is that it eschews the often arcane and impenetrable discourse of psychoanalytical language which can be so offputting to the lay reader – think cathexis and parapraxis for example. There is also the charming feature that Grosz is as much the learner as his patients, giving a touching humility to the practice of psychoanalysis, which oftentimes seems beset by dogma and (clinical ?) distance on the part of the analyst, who is assumed to share the dispassionate objectivity of, say, the surgeon in physical medicine.

However, perhaps the best way to gain an insight into Grosz’s acquired wisdom is to trawl among his stories for some of those insights already alluded to. He facilitates this by his fivefold division of his book into the thematic categories of “Beginnings”, “Telling Lies”, “Loving”, “Changing” and “Leaving”. Thus, for example, in the case which he describes as “On bearing death”, he discusses one of his patients who had unresolved issues related to her father’s death and was uncertain about her own ability to conceive. But, she did, in fact, become pregnant and Grosz notes that “I felt she was right, she was changed – and the end of our work had begun.”

While The Examined Life is largely an unalloyed pleasure, one or two small criticisms are possible. Notwithstanding the general tone of benign humility, Grosz cannot resist the temptation to belittle other approaches to mental health. He specifically targets the very powerful recovery model that is a growing phenomenon in mental health care worldwide. That model is “powerful” because it empowers the patient and diminishes the longstanding feature of paternalism in the clinical professions dealing with mental health problems. The emphasis is on partnership between the patient and clinician. One would like to think that the features of empowerment and partnership would also reside at the heart of psychoanalysis.

Finally, with psychoanalysis, there is the elephant in the room that is the cost and the length of time of analytical treatment. Grosz casually mentions on more than one occasion that his patients can spend over two years and sometimes much longer in analysis, being seen five times a week for fifty minutes at each session. As such treatments would not be covered by most health insurance policies and certainly not by the NHS (or the HSE) with their focus on evidence-based, value for money treatment programmes, it is hard not to conclude that psychoanalysis may only be open to the “worried well” and worried well-off. This may seem a little harsh, and it would be unfair not to recognise that Grosz’s case studies empathetically embrace the lives of people who are suicidal and deeply depressed.

Strictly Bipolar (a bad populist pun) by Darian Leader – an earlier work of his, What is Madness?, was also reviewed in these pages – although coming from a similar psychoanalytical perspective to that of Grosz does not share his humility. The book ‑ a short Penguin Special – addresses what Leader believes is the explosion in diagnoses of bipolar depression in its various manifestations. This is in keeping with his theoretical perspective and his view that modern psychiatry has arrogated this condition to biology and labelled it Bipolar 1, 2 and 3, whereas he prefers to call by its original and less specific name of manic depression.

Leader makes his intentions clear very early on when he suggests that:

Where drugs aim to control and manage behaviour, an analytic approach aims to understand it and, hopefully, use this understanding to find new ways to help the person on the knife-edge of experiences that can be both so terrifying and so exhilarating, so life-affirming and yet also lethal.

The use of the adverb “hopefully” is a curious interpolation here and perhaps one which would not afford much optimism to a patient in the mire of the depressive phase of bipolar illness. Leader recognises the pain of such depression when he cites Spike Milligan’s bleak near-haiku:

The pain is too much
A thousand grim winters
grow in my head
In my ears
the sound of the
coming dead.

All this is not to suggest that medication or other psychotherapeutic approaches provide all the answers either but arguably there is an exclusivity on the part of the “analytic approach” which may not always be in the best interests of the sufferer.

Leader elegantly identifies the poles of manic depression, that is, “the person sees themselves as worthless and alone in the low phases and as supremely capable and powerful in the highs”. In keeping with views expressed by him in earlier works, Leader sees the need for connectedness (or lack of it) on the part of the sufferer being expressed through extravagant language and behaviour when manic and by the absence of language and motivation when depressed. He also repeats his theme of the importance of mollifying the Other (or symbolic paternal figure, a variant of the Freudian Oedipus complex) as a motivation in the behaviour of manic depressives. Moreover, he suggests that the experience of bipolar behaviour is an attempt to create a world which is black and white without shades of grey and that the illness can only be ultimately addressed where a third element is introduced to mediate in this almost Manichean conflict.

Where, in this reviewer’s view, Leader fails is in his alternate celebration and questioning of Sue Radfield Jamison’s understanding of her own bipolar condition and her ability to manage it. Jamison, who is professor of psychiatry at Johns Hopkins University, is, perhaps, unique in this field in that she is a long-term sufferer of severe bipolar illness and a recognised world authority on the subject (she has spoken in Ireland about her experience and professional insights). Her book on her own illness – An Unquiet Mind – can probably be regarded as a classic. Leader uses material from this memoir to describe the manifold experiences of bipolar depression yet he goes on to say that “Jamison’s work, for example, is in many respects a sustained apology for lithium (a mood stabilizer often prescribed for those suffering with bipolar illness), with an idealization of ‘Science’ and good doctors”. It is hard not to see this as at best damning with faint praise and at worst arrogant.

That apparent arrogance is summed up in one of Leader’s concluding passages where he suggests that recovery rates from manic depression were better in the pre-drug era. In contrast, nowadays, he argues, a diagnosis of manic depression is almost certain to lead to a heavy regime of medication and, in many cases, prognostic bleakness. One wonders if Leader has ever made this case to Jamison or the thousands of others whose lives have been ameliorated immeasurably by using stabilising medications, among other things. It is curious indeed that, in his last words, Leader argues for a return to an earlier, more humane approach, one which attends to the particularity of each case. Humanity and humility in the area of mental health and its practitioners go hand in hand. An integrative, non-dogmatic approach to this burgeoning field would not go amiss.

15/07/2013

Liam Hennessy is a former teacher. senior civil servant and currently works as a social policy and mental health researcher.