In Part 4 of her memoir, Jamison discusses her relationship with her illness post-healing, particularly in regard to how the illness affects her professional life. This section of her memoir reads like a collection of mini-essays, where she ruminates on the more recent considerations and complications of her illness.
Speaking of Madness
Jamison begins Part 4 by recalling "the most vituperative and unpleasant letter that anyone has ever written me" (179). The letter comes from a woman who is outraged that Jamison would use the word "madness" in the title of an upcoming lecture of hers. The woman accuses Jamison of being insensitive and unattuned to the issues of the mentally ill and claims that it is terribly apparent that Jamison has never struggled with mental illness herself. Although the letter shakes Jamison, it does cause her to consider the language we use to discuss madness today. According to Jamison, when discussing and describing mental illness, the many different terms and definitions available for the same condition can cause confusion and misunderstanding. She acquiesces that it is no longer clear how much space words like "mad," "daft," or "crazy" should have in a society that is increasingly more concerned with the rights of the mentally ill. There are reasonable arguments for the avoidance of certain words, as the pain of hearing them can be sharp, and the memory of prejudice lasts in victims for a long time. Furthermore, the perpetuation of certain words contributes to a damaging stigma.
On the other hand, Jamison doubts that rigidly rejecting words that have existed as long as our language has will have much influence on public attitudes on mental illness. A war against words creates the illusion that there is an easy solution to the dangerous problem of stigma. Ultimately, Jamison argues that the appropriateness of words can be determined by time and place. Jamison points to confusion over the term "bipolar disorder" in order to support her argument. Although bipolar disorder has become the leading manner in which scientists discuss manic-depressive illness (now considered a dated term), Jamison finds this term offensive. She believes that it works to "obscure and minimize the illness it is supposed to represent" (181). She prefers manic-depressive as it captures both the seriousness and the nature of the disease she has. Furthermore, she questions the claim that destigmatization of mental illness can come about merely from a change in language. She argues that it comes about instead from "aggressive public education efforts," "successful treatments," "discovery of the underlying genetic or other biological causes of mental illness," and from "legislative actions" (183).
The Troubled Helix
In this next section, Jamison discusses the inheritable nature of manic-depressive illness. She has spent much of her late career in the world of molecular biology. The section opens on a set of meetings focused on the genetic basis of the illness, which brought together clinical psychiatrists, geneticists, and molecular biologists, including the famous John Watson. On a screen at the front of the room is projected pedigree after pedigree of affected families whose genetic material is being analyzed. The pedigrees have a particular notation: squares and circles blackened in, indicating men or women who suffered from the illness, half-blackened squares and circles to depict depressive illness, and a small s to indicate individuals who have committed suicide. Jamison is certain that sometime soon the location of the gene or genes responsible for manic-depressive illness will be found. This is an exciting thought, as with the isolation of this gene will come faster diagnoses and more effective treatment.
But the fact that manic-depressive illness is a genetic disease has complicated emotional implications for Jamison. On one hand, it can cause someone who has it to feel shame and guilt at wanting to have children of their own. Not only does she have to face the reality that her children, too, will likely struggle with the disease, but Jamison also has to ask herself whether she is capable of being a good mother 100% of the time. What would happen to her children if she got manic, and her judgment became impaired? Furthermore, Jamison has concerns about other unintended consequences of finding the genes. She questions what the dangers of prenatal testing for the disease might be. She asks: "Do we risk making the world a blander, more homogenized place if we get rid of the genes for manic-depressive illness?" (193). Jamison admits this is an impossibly complicated question. She wonders: "what are the risks to the risk takers, those restless individuals who join with others in society to propel the arts, business, politics, and science?" (194).
In this passage, Jamison ruminates on the difficulties she has had in telling others about her illness, as well as complications that arise at the point of interaction between her illness and her professional career. Although the majority of the people she has disclosed this information to have been supportive, Jamison remains haunted by those who have reacted negatively to the news. She recalls an interaction with Mouseheart, a former colleague from her time in Los Angeles. Upon learning about her illness, Mouseheart tells Jamison that he is "deeply disappointed" to learn of it—he had thought she was so strong and could not conceive of how she might have turned to such a cowardly and selfish act as attempting suicide. He questions the validity of what she told him as well as her ability to handle the stressors of academic life. Jamison leaves this interaction feeling humiliated and infuriated.
Jamison moves into a discussion on the professional reasons she has hesitated from telling her colleagues of her illness. Early in her career, these concerns focused on the California Board of Medical Examiners, which she worried might not give her her license if it knew about her manic-depression. Later, the concern shifted towards her ability to effectively teach and do research, and worries about whether her professional anonymity might be compromised by the label of manic-depressive. Furthermore, Jamison holds concerns about her past work and worries that her scientific objectivity will be questioned upon people learning of the clear connection between her personal life and intellectual pursuits. These concerns cause her to keep her identity close to her chest. When she transfers to Johns Hopkins, the issue of her clinical privileges within the hospital arises. An application for said privileges includes a section in which Jamison might disclose any disability or illness that would "impair the proper performance of your duties and responsibilities" at the hospital (205). This question terrifies her, and she refuses to answer on the application itself, responding instead "Per discussion with the chairman of the Department of Psychiatry" (205). She makes a lunch appointment with the chairman and lives in fear that her illness will hinder her ability to work at Johns Hopkins University. When she finally tells him of her illness, he responds kindly, telling her "I know you have manic-depressive illness... If we got rid of all of the manic-depressives on the medical school faculty, not only would we have a much smaller faculty, it would also be a far more boring one" (209).
A Life in Moods
In the last passage of her memoir, Jamison ruminates on the effect that manic-depressive illness has had on her life. Thirty years of managing the disease, she writes, has made her "increasingly aware of both the restraints and possibilities that come with it" (210). The dark feelings of knowing death that she first encountered as a child when she saw the young pilot crash are always there, tinging the vitality of life and the possibility represented by the sky with the constant threat of destruction. The darkness of that knowledge is "an integral part" of who Jamison is, and it will never be truly abolished nor forgotten. But however dreadful these moods have been, they have always been accompanied by "the elation and vitality of others." And just as depression is always there, so is mania. Jamison still feels the seduction of her past moods and acknowledges that she will never regain the passion she once knew. She has a nostalgia for these lost moods: "I miss the lost intensities, and I find myself unconsciously reaching out for them" (212). But these longings must remain longings, for the consequences of recreating mania will always be too destructive.
Jamison writes that we all "build internal sea walls to keep at bay the sadness of life and the often overwhelming forces within our minds" (214). Some choose "love, work, family, faith, friends, denial, alcohol, drugs or medication" to build these walls, but Jamison builds her own through a combination of medication and love. Love, for Jamison, is the most extraordinary part of her sanctuary, as it shuts out terror and awfulness while still letting in life and vitality.
If Jamison's psychosis and attempted suicide were the climax of this narrative, then this last part is the resolution of her story. She adopts a tone of recollection as she looks back upon her life. She paints a picture of a woman who has successfully learned to manage her demons, but not without struggle or sacrifice. She adopts a point of view similar to that of a war-weary general upon the cease-fire: all that is left to do is survey the damage and determine where to go from here. Jamison makes it clear that she will always miss her most fantastic manias, and will therefore always battle the inclination to succumb once again to her more unstable ways. Medication and love keep her grounded and protect her from the dark.
In the final part of her memoir, Jamison discusses the complications that arise from living with manic-depressive illness and walks us through the ways that she has been able to live her life fully despite, and in some ways because, of the influences of the illness. The first section, "Speaking of Madness," introduces an important discussion of terminology in reference to Jamison's work. Within this discussion, Jamison pegs herself against stigma, and openly addresses one of the largest underlying conflicts in the whole memoir. It can be argued that stigma, rather than manic-depressive illness or depression itself, is the main antagonist of the memoir. Stigma inhibits Jamison from getting help when she needs it, and once she does obtain that help, stigma inhibits her from living an honest life. Jamison feels forced to lie about her illness and keeps it as close to her chest as possible in an effort to avoid any serious professional reprisals for her condition. Stigma is as large and uncontrollable as her own moods, and even though it originates outside of the self, it enters her system and undermines all processes and attempts at success. It tears her down both internally and externally. Ultimately, much like with her moods, Jamison can't rid herself of the effects of stigma. She can only learn how to cope with its weight and do what she can, personally and socially, to diminish both the weight it burdens her with and the weight with which it burdens others. We are once again reminded why Jamison wrote An Unquiet Mind.
Understanding Jamison's final metaphor, which attempts to sum up the larger message of her entire memoir, is vital for our comprehension of her story. Jamison ends her memoir on a piece of advice learned from Robert Lowell: "There will always be propelling, disturbing elements, and they will be there until, as Lowell put it, the watch is taken from the wrist" (215).