Bipolar Disorder, Creativity, and Treatment
Creativity requires an absence of impeding bipolar symptoms.
Posted Sep 13, 2018
A number of creative people in the arts have been reliably diagnosed as having bipolar disorder (formerly manic-depressive illness) such as writers Ernest Hemingway, Robert Lowell, Theodore Roethke, and Virginia Woolf, composers Robert Schumann and Hugo Wolf, artists Jackson Pollock, probably Vincent Van Gogh, Edvard Munch, and Arshile Gorky, actors Vivian Leigh, Dick Van Dyke, Jason Robards, and Robin Williams. To know that such highly valued achievement is possible should therefore be encouraging for people suffering from the disorder and, as some have argued, might even help dispel some of the heavy layer of stigma connected with mental illness in general. On the other hand, it has been alleged that the depressive illness makes creative persons more sensitive and more productive while undergoing manic episodes. These allegations represent an unreal romantic notion about creativity—the saga of the suffering artist—with little evidence to support them. Only comedians such as Jackie Gleason and Dick Van Dyke have seemed to derive direct benefit in their work from their manic and hypomanic tendencies. Artistic products containing depressive or manic flight of ideas content have, only at particularly disjunctive times in history, been of social and aesthetic interest. Robert Lowell, who periodically checked himself into the Hartford Institute for Living when he was manic or depressed and was there able to write, told the interviewer Ian Hamilton, "One wakes, is happy for about two minutes, probably less, then fades into dread of the day [Depression being] no gift from the muse [I was unable at all to write]."
Despite the erroneous emphasis on the advantages of bipolar illness, its presence and the effects among highly creative persons are of medical and social importance. For instance, several of the eminent creators I mentioned—Schumann, Woolf, Hemingway, Van Gogh, Gorky, Pollock—reached premature deaths through suicide or preventable accident, at great losses to society. Mental suffering and debilitation are intrinsic factors in such illness and appropriate treatment and treatment approaches are required. Such treatment and approaches, however, are a challenge requiring knowledge of creativity and the creative processes in conjunction with the course and permutations of the disorder. Moreover, it is important to emphasize that creativity is something all prize very highly. A while ago, in a special issue of the New York Times Magazine on the next millennium, a feature article asked, “What separates humans from animals and ever more advanced machines?” and gave the answer: “We make art.” The production of art, literature, music of all types, dance, motion pictures, great inventions, scientific discoveries, political breakthroughs, exceptional business enterprise, all are due in large degree to creativity. Creative people are admired and prized, and creative achievement is widely appreciated. The creative process inspires awe and is sometimes considered virtually miraculous—many people believe it to be totally mysterious. Therefore, as the discussion to follow pertains to all levels of creativity, from everyday creativity in living, cooking, spare time painting and writing all the way to the achievements of Einstein and Shakespeare, it is focused on a highly valued and complicated process.
In previous investigations, I have found evidence for specific forms of creative cognition, the janusian, homospatial, and sep-con articulation processes (see articles in Psychology Today blogs). The janusian process consists of actively conceiving multiple opposites or antitheses simultaneously. During the course of the creative process, opposite or antithetical ideas, concepts, or propositions are consciously conceptualized as simultaneously co-existing. Although seemingly illogical and self-contradictory, these formulations are constructed in clearly logical and rational states of mind in order to produce creative effects.
The homospatial process consists of actively conceiving two or more discrete entities occupying the same space, a conception leading to new identities. In this process, concrete entities such as rivers, houses, human faces, as well as sound patterns and written words, are superimposed, interposed, or otherwise brought together in the mind and totally fill its perceptual space—the subjective or imaginary space experienced in consciousness. Superimposed images may be derived from the visual, auditory, gustatory, olfactory, or tactile sensory modes. The sep-con articulation process consists of consciously constructing separation and connection co-ordinately. These processes have been identified in the creative work of Nobel laureates in science and literature and other outstanding creative people. Although they are unusual and difficult to use, the evidence definitively indicates that they are adaptive and conscious healthy processes. Despite a given artist’s mental illness, therefore, and despite the suffering it may cause, creative production is carried out by healthy mental processes during periods of lowered symptom activity and anxiety.
In the cases of bipolar disorder artists, writers and other types of creators, a struggle away from illness may give power to their work; this is sometimes true for emotionally ill creative persons in general. However, such illness itself is neither causative nor facilitative of creativity and it incurs a serious loss to society. Effective psychiatric treatment is therefore vital. One of the impediments to such treatment is that many creative people often erroneously believe in an intrinsic connection between suffering and mental illness. They too have followed the romantic myth of Western society that tampering with or ameliorating their illness will damage their creative talent. As a result, they often resist seeking treatment or if they eventually accept it, they are openly or covertly non-compliant. Robert Lowell, for example, frequently stopped taking lithium carbonate for extended periods of time, with resulting severe manic episodes. One approach I have found to such non-compliance, either with medication regimens or with psychotherapy or both, is to apprise such patients that, by and large, creativity is improved with proper treatment rather than impeded.
Another type of treatment issue is the tendency for practitioners either to overestimate or to underestimate the creative patient. Underestimation occurs when there is lack of appreciation for the complexities of creative work, the special difficulties in achieving success in artistic fields, the patient’s need for extraordinary persistence, or simply an absent aesthetic sensibility. This underestimation results in biases and faulty or even destructive therapeutic intervention and support. Overestimation may also be destructive when a therapist withholds needed interventions and courses of treatment or otherwise suspends sound clinical judgment either out of excessive fear of undermining creative work or because of awe or misassessment of the patient’s accomplishments.
For example, the famous Ernest Hemingway was apparently prematurely discharged from the Mayo Clinic because of an overestimation of his judgment and capacities. Shortly after, the author returned home and shot himself. A major treatment issue for creative persons with bipolar disorder is the risk of cognitive impairment resulting from otherwise effective treatment modalities. By and large, high levels of cognitive capacity are required for creative activities and some possible deleterious effects to this capacity result both from ECT and lithium carbonate treatment.
With ECT, sometimes a critically important and life-saving treatment in bipolar disorder, there is an attendant memory loss and dysfunction which is usually short-lived but may become prolonged and to some degree permanent. With lithium carbonate, there have been valuable lithium effects with creative patients: some improvement in the severely ill; a decline in productivity in those who believed their creativity depended on mania; no decrease in productivity but some qualitative changes in their work in a small number of patients.
Unless lithium carbonate and ECT are necessary for the treatment, it is usually preferable to use anticonvulsants for bipolar disorder in creative people. Carbamazepine, valproate, and lamotrigine have clinically demonstrated high levels of effectiveness with no definite evidence of accompanying cognitive impairment. Calcium channel blockers such as verapamil have also been used with some benefit and little side effect.
Psychotherapy, with or without medication use, remains a treatment of choice for creative patients with bipolar disorder. Once myths about connections between creativity and mental illness are dispelled, creative persons do especially well in psychotherapy. They generally prize exploratory activity and are independent minded and therefore benefit both from the opportunity for self-exploration and the intrinsic and detailed freedom of choice about change. For both highly creative persons as well as lesser ones, psychotherapy helps to resolve the conflicts and anxiety connected with creative work, bipolar disorder, and everyday life; it promotes medication compliance when necessary, and also may function as a support for the development and maintenance of a creative identity, the inner confidence and belief in one’s creative capacities, an all-important factor in creativity.