A First-Rate Madness (2 page)

In the course of my research, it became clear to me that mental illness was even more influential in historical terms than I had first imagined. Several major Civil War leaders were mentally ill or abnormal: Lincoln and Sherman, as will be shown later, but also Ulysses S. Grant, the alcoholic; possibly Stonewall Jackson; even, according to some evidence of depression and a family history of mental illness, Robert E. Lee. All the major leaders of World War II can be shown, with reasonable evidence, to have been mentally ill or abnormal: Churchill, FDR, and Hitler, as we will see; as well as Stalin and Mussolini, each of whom had severe depressive episodes and probable manic episodes. Two key figures in the American civil rights movement, John Kennedy and Martin Luther King, were also mentally abnormal.

I believe these examples are more than coincidence, and more than a historical oddity. They suggest a relatively consistent pattern that, if true, has been largely ignored by historians and the public, but that may have in fact shaped the second half of the twentieth century more than any other single force. Once we start to see history through this lens, the reach and import of madness and leadership become hard to deny.

 

 

THIS IS A BOOK of psychology and of history; it sits at the long-disputed intersection of two different disciplines. But this book is not psychohistory. Psychohistory is a discredited discipline, and with reason. One need only read the book that started it all, written by the founder himself, Sigmund Freud's
Woodrow Wilson,
cowritten with the American politician (and one of Freud's patients) William Bullitt. There one finds passages like this:

No wonder historians are allergic to psychological interpretation. The book was so weak psychologically that Freud's daughter and his closest disciples suppressed its publication, and when it finally appeared in 1967, they tried to argue that Freud wrote very little of it. For many historians, psychiatry and psychology are synonymous with psychoanalysis, and any psychological interpretation seems bound to end up in fruitless speculation about the early childhood traumas of historical figures. Indeed, until recently historians were correct. Psychiatry and psychology, in the United States, have long been infatuated with psychoanalysis. Only in the last two decades has psychoanalysis been put in its proper place—not simply discarded, but no longer seen as necessary and sufficient in itself. (Imagine if all of economics was thought to be contained in Marxism; psychiatry was that dependent on psychoanalysis until recently.)

This psychoanalytic obsession has been replaced by a perspective on mental illness that is scientifically and medically sound. This psychiatry, stripped of its psychoanalytic faith, can be an extremely useful tool for historians.

 

 

THE NEW PSYCHIATRY begins where modern medicine began, with the search for objective ways to diagnose illness. In internal medicine, doctors get a “case history”—a story of signs and symptoms and their course over time. Psychiatrists and historians do the same. Yet the internist has one resource that that historians and psychiatrists do not: pathology. Physicians have long disagreed with each other; one could diagnose a patient with a certain illness, and another could offer a quite different diagnosis, even given the same case history. But medicine changed dramatically when the pathologist could take a piece of tissue and determine which doctor's diagnosis was right. The doctors would discuss the case in an auditorium, with students watching, each providing a rationale for a diagnosis. At the end of an hour's debate, the pathologist would stand up, put a slide under a microscope, and reveal the right answer.

Sometimes other tests are done: an analysis of blood chemistry, or an MRI scan of an organ. Yet sometimes these tests don't give a definitive answer; sometimes tests can even be wrong. And good doctors know that tests help us get to the right answer by adding to the evidence gathered in the case history; alone they are hardly foolproof ways to diagnose illness. Of course, tests for physical conditions are often conclusive, but the problem with psychiatry—and with history—is that there's no conclusive test. One can't prove that a patient has schizophrenia with a blood test or a brain scan; and if this is true with a living patient sitting in front of me, it is obviously so with a dead historical figure.

Yet medicine has long faced and solved this problem. Many illnesses outside of psychiatry can only be examined based on the case history—migraine, for example, and rheumatoid arthritis, and many forms of epilepsy. In these cases, doctors are in the same boat as are those who study mental illness—there's no definitive test. The solution comes from the field of clinical epidemiology, the same discipline that teased out the link between cigarette smoking and lung cancer. When there's no single proof, the solution is to obtain several independent sources of evidence. No single source is enough to prove a diagnosis, but all of them can converge to make a diagnosis likely.

Four specific lines of evidence have become standard in psychiatry: symptoms, genetics, course of illness, and treatment.

Symptoms
are the most obvious source of evidence: most of us focus only on this evidence. Was Lincoln sad? That symptom could suggest depression, but of course one could be sad for other reasons. Symptoms are often nonspecific and thus not definitive by themselves.

Genetics
are key to diagnosing mental illness, because the more severe conditions—manic-depressive illness in particular—run in families. Studies of identical twins show that bipolar disorder is about 85 percent genetic, and depression is about half genetic (The other half, in the case of depression, is environmental, which is why this source of evidence is also not enough on its own.)

Perhaps the least appreciated, and most useful, source of evidence is the
course of illness
. These ailments have characteristic patterns. Manic-depressive illness starts in young adulthood or earlier, the symptoms come and go (they're episodic, not constant), and they generally follow a specific pattern (for example, a depressive phase often immediately follows a manic episode). Depression tends to start somewhat later in life (in the thirties or after), and involves longer and fewer episodes over a lifetime. If someone has one of these conditions, the course of the symptoms over time is often the key to determining which one he has. An old psychiatric aphorism advises that “diagnosis is prognosis”: time gives the right answer.

The fourth source of evidence is
treatment
. This evidence is less definitive than the rest for many reasons. Sometimes people never seek or get treatment, and until the last few decades, few effective treatments were available. Even now, drugs used for mental illnesses often are nonspecific; they can work for several different illnesses, and they can even affect behavior in people who aren't mentally ill. Sometimes, though, an unusual response can strongly indicate a particular diagnosis. For instance, antidepressants can cause mania in people with bipolar disorder, while they rarely do so in people without that illness.

 

 

IT'S IMPORTANT TO NOTE that the psychiatrist's method is exactly the same as the historian's. In other words, what the psychiatrist does when evaluating a living patient is no different from what a historian can do when evaluating the psychological makeup of a dead historical figure. The case history approach is the same: one assesses the person's past, based on his or her own report and that of third parties (families and friends and colleagues). The only difference is that the living patient can speak to the psychiatrist, while the dead historical figure speaks only through documents like personal letters. This difference is not as much of a drawback to the historian as it might seem. Living patients are often inaccurate or reticent about their symptoms during interviews with psychiatrists. In fact, some mental illnesses are characterized by how difficult they are to diagnose through interviews: for instance, about half the time, people with bipolar disorder deny having manic symptoms that they've actually experienced. In medical parlance, a patient's “self-report” is often inadequate and insufficient; psychiatrists should get information from family and friends as well. Historians faced with a dead figure are only at a partial disadvantage; even if that figure were alive, much of what he or she might say about potential psychiatric symptoms would be wrong.

Whether dealing with the living or the dead, third parties are often better sources than subjects themselves. In that sense, historians and psychiatrists are working with the same material: the case history of a living person being evaluated by a psychiatrist isn't fundamentally different from the history of a dead person being studied by a historian.

 

 

THIS BOOK DESCRIBES conditions that have applied to many leaders throughout history, and no doubt the reader can think of contemporary leaders to whom they apply as well. I'll focus primarily on a handful of historical figures whose lives spotlight different aspects of the relationship between mental health and leadership, and for whom there is particularly strong documentary evidence. General Sherman and cable entrepreneur Ted Turner exemplify how the symptoms of bipolar disorder can enhance creativity. The careers of Abraham Lincoln and Winston Churchill show the special relationship between depression and realism. So too do Mahatma Gandhi and Martin Luther King Jr.; their lives also highlight the strong link between depression and empathy. Franklin D. Roosevelt and John F. Kennedy, both of whom had hyperthymic personalities (that is, mildly manic traits), demonstrate the close connection between mental illness and resilience. Kennedy's experiences with medication also show the dramatic power of drugs to enhance the positive aspects of mental illness—or to make those illnesses even worse. Adolf Hitler's treatments provided similar, and more horrible, lessons.

To sharpen our understanding of successful crisis leaders, I will compare several of them to well-known, mentally healthy contemporaries who failed in crises. So, for instance, I'll contrast Sherman with General George McClellan, who thrived in the Union army before the Civil War but failed notoriously and repeatedly during the war. And I'll show how Churchill's realistic assessment of the Nazi threat contrasts with the infamous inability of his eminently sane colleague Neville Chamberlain to recognize that threat.

I focus on historical leaders because, as a psychiatrist, I am eager to understand the benefits, as well as drawbacks, that can accompany mental illnesses. Clinical research has demonstrated these benefits—resilience, realism, empathy, and creativity. Yet most people haven't taken much note of this research. Showing the link between these strengths and madness in several of our most celebrated leaders could raise our awareness about the strengths that some mental illnesses can bestow on anybody who suffers from them. Furthermore, going back into history, rather than simply discussing contemporary figures, offers the advantage of hindsight. We see the past more clearly than the present; our current biases and hopes and uncertainties make our grasp of today much less solid than our hold on yesterday. If I were to focus on the current president or prime minister, my readers and I would automatically apply many of our own biases to those people. On the other hand, we can all be more objective about Churchill and Lincoln, much more so than their contemporaries were. (This doesn't mean we can make no inferences at all about contemporary leaders, as I'll do in chapter 15, but that such inferences are less definitive than with prior historical figures.) Historical perspective may allow us to perceive the impact of mental illnesses on leadership more clearly, not less so, than analyzing today's leaders.

 

 

BEFORE WE EXPLORE the links between mental illness and leadership, it's essential to understand what mental illness is—and is not.

First and most important, mental illness doesn't mean that one is simply insane, out of touch with reality, psychotic. The most common mental disorders usually have nothing to do with thinking at all, but rather abnormal moods: depression and mania. These moods aren't constant. People with manic-depressive illness aren't always manic or depressed. Thus they aren't always insane; in fact, they're usually sane. Their illness is the
susceptibility
to mania or depression, not the fact of
actually
(or always) being manic or depressed. This is important because they may benefit as leaders not just directly from the qualities of mania or depression, but also indirectly from entering and leaving those mood states, from the alternation between being ill and being well.

Contrary to popular belief, the psychiatric concept of clinical depression is different from ordinary sadness. Depression adds to sadness a constellation of physical symptoms that produce a general slowing and deadening of bodily functions. A depressive person sleeps less, and the nighttime becomes a dreaded chore that one can never achieve properly. Or one never gets out of bed; better sleep, if one can, since one can't do anything else. Interest in life and activities declines. Thinking itself is difficult; concentration is shot; it's hard enough to focus on three consecutive thoughts, much less read an entire book. Energy is low; constant fatigue, inexplicable and unyielding, wears one down. Food loses its taste. Or to feel better, one might eat more, perhaps to stave off boredom. The body moves slowly, falling to the declining rhythm of one's thoughts. Or one paces anxiously, unable to relax. One feels that everything is one's own fault; guilty, remorseful thoughts recur over and over. For some depressives, suicide can seem like the only way out of this morass; about 10 percent take their own lives.