A First-Rate Madness Read online

  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.

  The most popular psychological theory about depression these days is the cognitive-behavioral model, which views depression as distorting our perception of reality, making our thoughts abnormally negative. This model, the basis for cognitive-behavioral therapy, is contradicted by another theory that has a growing amount of clinical evidence behind it: the depressive realism hypothesis. This theory argues that depressed people aren’t depressed because they distort rea
lity; they’re depressed because they see reality more clearly than other people do.

  The notion of depressive realism implies that the disease has an upside, but I don’t want to misrepresent how deeply dangerous and painful depression is. If untreated, it becomes a game of Russian roulette, with nature pulling the trigger when she decides, and with suicide the outcome. “Depression is a terrifying experience,” said one of my patients, “knowing that somebody is going to kill you, and that person is you.” Suicidal thoughts occur in about half of clinical depressive episodes.

  The anger and despondency of depression (as well as the impulsivity of mania) can also cut a person off from the people he loves most. Divorce and broken relationships are the rule. Said one patient, “The illness is a kind of robbery; it robs you of those you love. I don’t want money or power or fame. I just want to keep those I love. And this illness robs them from me. They wake up one day, and I am not the same person, and they say, ‘Who is this?’ And they leave.” The benefits of depression come at a painful, if not deadly, price.

  IF THE NUANCES of depression are confusing, mania seems even more complicated. Here mood is generally elated, even sometimes giddy, often alternating with anger. One doesn’t need to sleep much; four hours can do it. While the rest of the world is sleeping, one’s energy level is as high as it might be at 11 a.m. Why not clean the entire house at 3 a.m.? Things need to get done, even if they don’t. Redecorate the house; do it again; buy a third car. Work two or three extra hours every day: the boss loves it. One’s thoughts pour forth; the brain seems to be much faster than the mouth. Trying to keep up with those rapid thoughts, one talks fast, interrupting others. Friends and coworkers become annoyed; they can’t get a word in edgewise. This may make one more irritable; why can’t everyone else get up to speed? “Mania is extremity for one’s friends,” Robert Lowell remarked, “depression for oneself.”

  Self-esteem rises. Sometimes it leads to great successes, where one’s skills are up to the task at hand. But often it leads to equally grand failures, where one oversteps one’s bounds. But for someone in a manic state, there is no past; there is hardly today; only the future counts, and there, anything is possible. Decisions seem easy; no guilt, no doubt, just do it. The trouble is not in starting things, but in finishing them; with so much to do and little time, it’s easy to get distracted.

  Mania often impairs one’s judgment, and bad decisions typically fall into four categories: sexual indiscretions, spending sprees, reckless driving, and impulsive traveling. Sex becomes even more appealing; one’s spouse may like it, or tire of it. The urge is so strong that one might look to satisfy it elsewhere; affairs are common; divorce is the norm; HIV rates are high. Divorce, debt, sexually transmitted diseases, occupational instability: mania is the perfect antidote to the cherished goals of most people—a family, a home, a job, a stable life. The depressed person is mired in the past; the manic person is obsessed with the future. Both destroy the present in the process. In the worst-case scenario, the depressed person takes her life, the manic ruins hers. In manic-depressive illness, one suffers from both tragic risks.

  Yet for all its dangers, mania can confer benefits that psychiatrists and patients both recognize. A key aspect of mania is the liberation of one’s thought processes. My patients are sometimes eloquent when describing this freedom of thought (which psychiatrists label “flight of ideas”):

  “Everything was swirling like a whirlwind; you just had to reach up to grab a word. You could see it, but you couldn’t say it, like the word ‘flower.’ But when it got faster, you couldn’t even see it.”

  Or: “My thoughts were like fireworks, going up and then exploding in all directions.”

  This emancipation of the intellect makes normal thinking seem pedestrian: “It felt like my mind was a fast computer,” said one patient.

  This produces the swell of creativity that only great poets who have themselves been manic can describe. Like William Blake:

  To see a world in a grain of sand

  And heaven in a wild flower

  Hold infinity in the palm of our hand

  And eternity in an hour.

  Or Robert Lowell:

  For months

  My madness gathered strength

  To roll all sweetness to a ball

  In color, tropical . . .

  Now I am frizzled, stale and small.

  THEORIES OF MANIA do not abound. It’s as if traditional psychiatry saw the condition as too superficial to merit explanation.

  The psychoanalytic view, which sees mania as a defense against depression, is the most coherent but probably the most wrongheaded. Some of my own patients offer a version of this explanation. “Sometimes I think I make myself become manic to ward off a depression,” one patient told me. “I make myself be happy about everything and I do a lot of things and I stop sleeping because I know if I don’t do this, I’ll become depressed.” Such rationales seem logical, but I’m skeptical about them. Mania often occurs without any preceding depression, and in fact more commonly, depression follows mania, suggesting that mania causes depression, rather than the reverse.

  For psychoanalysts, depression was respectable; mania was not. Freud at least was honest about this: he wrote practically nothing about mania, and he admitted that psychoanalysis had no role in understanding or treating manic-depressive illness. His followers spoke where he was silent, blaming manic patients for being too childish to face their depressions. Mania does seem to hamper self-awareness, perhaps another reason why psychoanalysts looked askance at it. In my practice, I often see patients who are manic but don’t realize it. Some others only see the benefits of mania: enhanced creativity, energy, sociability. Mania becomes a kind of temporary “personality transplant” where people take on the kind of charisma that our society rewards. But they don’t fully realize the negative aspects of the disease, which are usually even more pronounced than its benefits: irritability, promiscuous sexuality, and lavish spending.

  Mania is like a galloping horse: you win the race if you can hang on, or you fall off and never even finish. In Freudian terms, one might say that mania enhances the id, for better or worse. All energies, sexual and otherwise, overwhelm the usual controls that we learn to impose over a lifetime. The core of mania is impulsivity with heightened energy. If to be manic means to be impulsive, then perhaps the expression of mania depends on how far the civilized veneer that holds our lives together is stretched. If it is stretched only a little, manic-depressive persons may function fine and actually be rewarded for their creativity and extraversion. If it is stretched too much, society disapproves, and tragedy may ensue.

  SOME PEOPLE ARE neither depressed nor manic, but they aren’t mentally healthy either. They have abnormal personalities or temperaments. Personality or temperament is just as biological as mental illness, though most of us think otherwise. Our basic temperaments are set by the time we reach kindergarten; studies show that those basic temperaments measured at age three persist and predict adult personality at age eighteen. From then onward as well, despite what many intuitively believe, our basic personality traits change little throughout adulthood and into old age. We may get wiser as we get older, but we do not become less introverted, or more open to experience, or less neurotic (to mention three basic personality traits).

  Usually we don’t think about personality in relation to mental illness. Indeed, my main focus in this book will be to apply the psychiatric concepts of depression and mania to history. But many leaders, though not manic-depressive, have abnormal temperaments that are mild versions of manic-depressive illness.

  Personality traits are like height and weight—variables that describe the shape of our minds, just as height and weight describe the shape of our bodies. A century of research on personality has produced some consensus. Most studies on personality identify at least three basic traits common to all people: neuroticism, extraversion, and openness to experience. One of these traits is anxiety—we’re al
l more or less anxious (neuroticism). Another is sociability—some of us are more extraverted, some more introverted (extraversion). Another is experience seeking—some of us are curious and take risks, others are more cautious (openness to experience). We each have more or less of these traits, and, with well-designed psychological tests, one can establish how they’re distributed among thousands of normal people. One can then know where any single person stands on each trait, near the middle of a normal curve—and thus near the average—or toward the extremes.

  These traits can combine to form specific personality types. Some people are always a little depressed, low in energy, need more than eight hours’ sleep a night, and introverted. This personality type is called dysthymia. Other people are the opposite: always upbeat, outgoing, high in energy. They need less than eight hours’ sleep a night and have more libido than most of us. This type is called hyperthymia, and it occurs often in great leaders, like Franklin Roosevelt and John F. Kennedy. And some people are a little of both, alternating between lows and highs in mood and energy. This type is called cyclothymia.

  These abnormal temperaments are mild versions of depression, mania, and bipolar disorder; as such, they’re abnormal personality traits, which a person has all the time, not mood episodes that come and go. They can occur by themselves, without any episodes of mania or depression, or they can occur alongside bipolar disorder or severe depression (for instance, someone might have episodes of mania or depression every other year, and in between those episodes have a dysthymic personality). In fact, these abnormal personalities occur more often in those with bipolar disorder or severe depression than they do in people without mental illness. They also occur much more frequently in relatives of people with severe depression and mania than in the normal population.