The Noonday Demon (59 page)

Griesinger was the first to present the idea that some mental disease is only treatable, while other mental illness is curable, and on the basis of
his work most asylums began to divide their patients, separating those who stood a chance of recovery and of return to functional life from the more desperate cases. Though the lives of the truly insane remained horrible, the lives of the other patients began to take on a greater semblance of normality. Treating depressed people once more
as people
kept them from descending into total dependence Meanwhile, research along the lines of Griesinger’s began to usurp religion; the change in social standards that began in the late Victorian period may in some ways be linked to the rise of the medical model of the brain.

In Griesinger’s hands, depression came to be fully medicalized. In the twentieth century’s most influential history of mental illness, Michel Foucault has suggested that this was part of a grand scheme of social control related to colonialism and the entrenchment of ruling wealth over a trampled underclass. By classing those who found life too difficult as “ill” and by removing them from society, the ruling class could impose levels of genuine social strain and difficulty that were in fact inhuman, and against which a less contained class of miserable people might have rebelled. If the proletariat of the industrial revolution were to be effectively oppressed, those among their number who were truly at the brink of self-destruction had to be removed, lest they serve as warnings to those around them and foment revolution.

Foucault makes good reading, but the influence he has had is much crazier than the people who are his subject. Depressed people cannot lead a revolution because depressed people can barely manage to get out of bed and put on their shoes and socks. I could no more have joined a revolutionary movement during my own depression than I could have had myself crowned king of Spain. The truly depressed were not made invisible by asylums; they had
always
been largely invisible because their very disease causes them to sever human contacts and allegiances. The general reaction of other members of the proletariat (or, indeed, of any other class) to people who are severely depressed is revulsion and discomfort. Those who are not themselves afflicted with the complaint dislike seeing it because the sight fills them with insecurity and provokes anxiety. To say that the severely ill were “taken away” from their natural context is to deny the reality, which is that the natural context rejected them, as it had always done insofar as it could. No conservative parliamentarians came into the streets of the cities soliciting patients for the asylums; the asylums overflowed with people being checked in by their own families. The attempt to define the social conspirators continues like an interminable Agatha Christie novel in which everyone has actually died of natural causes.

Busy asylums were in part a consequence of the general alienation of
late Victorianism, which was articulated in one form or another by everyone from the pillars of the social order (Alfred Lord Tennyson, for example, or Thomas Carlyle), to the ardent reformists (Charles Dickens or Victor Hugo), to those at the decadent fringe of society (Oscar Wilde or Joris-Karl Huysmans). Carlyle’s
Sartor Resartus
chronicles alienation from an overcrowded world, a kind of universal depression, foreshadowing Brecht and Camus. “To me the Universe was all voice of Life, of Purpose, of Volition, even of Hostility: it was one huge, dead, immeasurable Steam-engine, rolling on, in its dead indifference, to grind me limb from limb.” And later, “I lived in a continual, indefinite, pining fear; tremulous, pusillanimous, apprehensive of I knew not what: it seemed as if all things in the Heavens above and the Earth beneath would hurt me; as if the Heavens and the Earth were but boundless jaws of a devouring monster, wherein I, palpitating, waited to be devoured.”

How to endure life, itself so burdensome in this sorrowful time? The American philosopher William James most directly addressed these problems and correctly identified the apparent source of early modernist alienation as the breakdown of unquestioning faith in a supreme God benevolently disposed toward his creation. Though James himself ardently believed in a personal creed, he was also a sharp reader of the process of disbelief. “We of the nineteenth century,” he wrote, “with our evolutionary theories and our mechanical philosophies, already know nature too impartially and too well to worship unreservedly any God of whose character she can be an adequate expression. To such a harlot, we owe no allegiance.” Addressing a group of Harvard students, he said, “Many of you are students of philosophy and have already felt in your own persons the skepticism and unreality that too much grubbing in the abstract roots of things will breed.” And of the triumph of science, he wrote, “The physical order of nature, taken simply as science knows it, cannot be held to reveal any one harmonious spiritual intent. It is mere
weather.
” This is the essence of Victorian melancholy. Periods of greater and lesser faith had alternated through human history, but this relinquishing of the notion of God and of meaning opened the way to agonies that have endured since, far more plangent than the sorrow of those who thought that an omnipotent God had forsaken them. To believe oneself to be the object of intense hatred is painful, but to find oneself the object of indifference from a great nothingness is to be alone in a way that was in some sense inconceivable to the imagination of earlier eras. Matthew Arnold gave voice to this despair:

This is the form that modern depression takes; the crisis of losing God is far more common than the crisis of being cursed by Him.

If William James defined the philosophical gap between what had been thought to be true and what philosophy had revealed, then the eminent doctor Henry Maudsley defined the consequent medical gap. It was Maudsley who first described a melancholy that recognizes but cannot resolve itself. “It is not unnatural to weep,” Maudsley commented, “but it is not natural to burst into tears because a fly settles on the forehead, as I have known a melancholic man to do. [It is] as if a veil were let down between him and [objects]. And truly no thicker veil could well be interposed between him and them than that of paralyzed interest. His state is to himself bewildering and inexplicable. The promises of religion and the consolations of philosophy, so inspiring when not needed and so helpless to help when their help is most needed, are no better than meaningless words to him. There is no real derangement of the mind; there is only a profound pain of mind paralyzing its functions. Nevertheless, they are attended with worse suffering than actual madness is, because the mind being whole enough to feel and perceive its abject state, they are more likely to end in suicide.”

George H. Savage, who wrote about insanity and neurosis, spoke of the need, at last, to bridge definitively the gap between philosophy and medicine. “It may be convenient,” he wrote, “but it is not philosophical to treat the body apart from the mind, and the physical symptoms separately from the mental. Melancholia is a state of mental depression, in which misery is unreasonable either in relation to its apparent cause, or in the peculiar form it assumes, the mental pain depending on physical and bodily changes and not directly on the environment. A saturated solution of grief,” he wrote, “causes a delusion to crystallize and take a definite form.”

The twentieth century saw two major movements in the treatment and understanding of depression. One was the psychoanalytic, which has in recent years spawned all kinds of social science theories of mind. The other, the psychobiological, has been the basis for more absolutist categorizations. Each has at times seemed to have a more convincing claim on
truth; each has at times seemed positively ludicrous. Each has taken a certain quantity of real insight and extrapolated absurdities from it; and each has undertaken an almost para-religious self-mystification that, had it occurred in anthropology or cardiology or paleontology, would have been laughed out of town. The reality doubtless incorporates elements from both schools of thought, though the combination of the two is hardly the sum total of the truth; but it is the competitive gleam with which each school has viewed the other that has been the basis for excessive statements that are in many instances less accurate than Robert Burton’s seventeenth-century
Anatomy.

The modern period for thought about depression really began with Freud’s publication, in 1895, of the “Fliess Papers.” The unconscious, as formulated by Freud, replaced the common notion of a soul and established a new locus and cause of melancholia. At the same time, Emil Kraepelin published his classifications of mental illness, which defined the category of depression as we now know it. These two men, representing the psychological and biochemical explanations of illness, established the rift that the field of mental health is now trying to close. While the separation between these two versions of depression has been damaging to modern thinking about depression, the independent ideas themselves have considerable significance, and without their parallel development we could not have begun to pursue a synthetic wisdom.

The imaginative framework for psychoanalysis had been in place for years, albeit in a distorted form. Psychoanalysis has much in common with the bloodletting that had been popular some time before. In each instance, there is the assumption that something within is preventing the normal functioning of mind. Bloodletting was to remove malign humors by drawing them physically from the body; psychodynamic therapies are to disempower forgotten or repressed traumas by drawing them from the unconscious. Freud stated that melancholy is a form of mourning and that it rises from a feeling of loss of libido, of desire for food, or for sex. “Whereas potent individuals easily acquire anxiety neuroses,” Freud wrote, “impotent ones incline to melancholia.” He called depression “the effect of suction on the adjoining excitation,” which creates “an internal hemorrhage,” “a wound.”

The first coherent psychoanalytic description of melancholy came not from Freud but from Karl Abraham, whose 1911 essay on the subject remains authoritative. Abraham began by stating categorically that anxiety and depression were “related to each other in the same way as are fear and grief. We fear a coming evil; we grieve over one that has occurred.” So anxiety is distress over what will happen, and melancholy is distress over what has happened. For Abraham, one condition entailed the other; to
locate neurotic distress exclusively in the past or future was impossible. Abraham said that anxiety occurs when you want something you know you shouldn’t have and therefore don’t attempt to get, while depression occurs if you want something and try to get it and fail. Depression, Abraham says, occurs when hate interferes with the individual’s capacity to love. People whose love is rejected perceive, paranoiacally, that the world has turned against them and so they hate the world. Not wishing to acknowledge such hatred to themselves, they develop an “imperfectly repressed sadism.”

“Where there is a great deal of repressed sadism,” according to Abraham, “there will be a corresponding severity in the depressive affect.” The patient, often without realizing it, gets a certain pleasure from his depression as a result of his sadistic attitudes. Abraham undertook the psychoanalysis of a number of depressed patients and reported substantial improvements in them, though whether these patients were redeemed by true insight or comforted by the idea of knowledge is unclear. In the end, Abraham admitted that the kind of trauma that leads to depression can also lead to other symptoms, and “we have not the least idea why at this point one group of individuals should take one path and the other group another.” This, in his words, is “the
impasse
of therapeutic nihilism.”

Six years later, Freud wrote his brief, seminal essay “Mourning and Melancholia,” which has probably had more effect on contemporary understanding of depression than any other single piece of written material. Freud questioned the coherence of what is called melancholia; the definition of depression “fluctuates even in descriptive psychology.” And what, asked Freud, are we to make of the fact that many of the symptoms of melancholia, which we are so anxious to alleviate, occur also in grief? “It never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. . . . We look upon any interference with it as inadvisable or even harmful. . . . It is really only because we know so well how to explain it that this attitude does not seem to us pathological.” (This is not necessarily still the case;
The New England Journal of Medicine
recently published a paper that suggested that “since normal bereavement can lead to major depression, grieving patients who have symptoms of depression lasting longer than two months should be offered antidepressant therapy.”) Depressives, however, compromise their self-esteem. “In grief,” Freud wrote, “the world becomes poor and empty; in melancholia, it is the ego itself [which becomes poor and empty].” The mourner is distressed by an actual death; the melancholiac, by the ambivalent experience of imperfect love.

No man willingly gives up the object of his desire. A loss of self-esteem must result from an unwilling loss, which Freud assumed is also unconscious—
as the pain of conscious loss is usually ameliorated by time. Freud suggested that the accusations the melancholiac makes against himself are really his complaints against the world, and that the self has been divided in two: into an accusing self that threatens and an accused one that cowers. Freud saw this conflict in the melancholic symptoms: the accused ego wishes to sleep, for example, but the threatening ego punishes it with sleeplessness. Depression here is really a breakdown of the coherent human being or ego. Angry at the ambivalence of his love object, the melancholic undertakes revenge. He turns his anger inward to avoid punishing the loved one. “It is this sadism,” Freud wrote, “and only this that solves the riddle.” Even suicidality is a sadistic impulse against another that has been redirected at the self. The splitting of the ego is a way of internalizing the loved one. If you reproach yourself, the object of your feeling is always present; if you need to reproach someone else, who may die or leave, you are left with no object for your feelings. “By taking flight into the ego,” Freud wrote, “love escapes annihilation.” Self-accusatory narcissism is the result of intolerable loss and betrayal, and it causes the symptoms of depression.