The Unholy Darkness: An Autobiography • Sightlines: The View of a Valley Through the Voice of Depression • How I Stayed Alive When My Brain Was Trying to Kill Me: One Person's Guide to Suicide Prevention • The Thief of Happiness: The Story of an Extraordinary Psychotherapy • Detour: My Bipolar Road Trip in 4-D

In the books reviewed here, five individuals talk about what they learned about their own and others' affective disorders.

In The Unholy Darkness: An Autobiography, Sheila Quinlan Williams, Ed.D., provides an autobiography through which the reader is exposed to many facts but in some ways learns very little about the author. We know Williams grew up in a household with two parents and a brother two and a half years her senior, who was the favored child. Her father was a school principal in a school district in Westchester County, New York, and then superintendent of a school system outside Chicago before moving to California, where he was dean of the School of Education and then academic vice-president at a university. He died in 1984 and Williams' mother in 1990. We learn that Williams has struggled with a lifelong stuttering disorder, that she had a prolonged medical illness with hospitalization for mastoiditis in the third and fourth grades, that she was married twice and divorced twice, and that she had five miscarriages and one daughter.

Williams informs the reader that she has a significant psychiatric history. The diagnoses she mentions include depression, schizoid personality disorder, and posttraumatic stress disorder. One diagnosis that she did not receive but perhaps should have is alcohol abuse. She has had one state hospital admission, four private psychiatric hospital admissions, and a number of admissions to general hospital psychiatric units. She had 50 electroconvulsive therapy treatments over a four-year period.

We learn that Williams was sexually abused by her father at two points in her life. We learn that she struggled and succeeded in obtaining a bachelor's and master's degree in English, literature, and history and somewhat later an Ed.D. from the University of San Diego.

But we don't know much about Williams' affective responses to much of what has happened in her life. She writes about them often as if she were writing about another person or about someone about whom she has limited information. Most of her psychiatric hospitalizations are glossed over. The psychological and physical abuse by her father is never explored.

Williams' style is sometimes confusing in that she conveys some information as an aside while reporting on her life chronologically. When she reaches the events of the aside in her sequential tale, she repeats the information, but in more detail.

Williams sums up her life by indicating, "I look back as I approach another year and feel a sadness as to the waste my life has been. Born with potential but always having to fight the endless sadness, isolation, and despair. Instead of continually growing, it took all my energy to keep going and that road was always cloaked with fear." In the life that Williams portrays in The Unholy Darkness, the reader is informed about sadness, isolation, and despair but doesn't really feel these with the author. It is as if Williams has demons to tell us about but has not yet faced those demons sufficiently to feel comfortable truly sharing them with us. This first-person account simply doesn't measure up to many others that are currently in print.

In Sightlines: The View of a Valley Through the Voice of Depression, Terry Osborne, a faculty member in the English department in the environmental studies program at Dartmouth College, has written a personal account that explores the environment—in this case the Connecticut River Valley in Vermont between East Thetford and Fairlee—as well as Osborne's own psychological condition. The book alternates between the inner and the outer, linking them with sensitive and astute observations. Combining philosophy, archeology, geology, and psychology, Osborne presents a romance in which the land is colored not only by its natural beauty but also by the author's mood swings.

Sightlines recounts events that occurred during the ten-year period between 1987 and 1997. Throughout these years Osborne kept journals, and it is from these that his text is derived. Osborne also liberally quotes from others' works, drawing from such diverse sources as Leonardo da Vinci's notebooks and The Origin of Consciousness in the Breakdown of the Bicameral Mind (1).

Osborne uses interesting techniques in a book that is unusual in its subject matter. He presents internal monologues as dialogues, with depression cast as a voice. Osborne states, "What distinguished my internal influences from the norm was this: they coalesced into an unrelenting voice that spoke inside my head and sometimes took it over and judged everything harshly and directed those harsh judgments at me and seemed intent on bringing me down and from time to time actually could do it, could get me to believe that what it said about me was true." Osborne demonstrates this for the reader in sections of the book that go on for pages recounting the dialogue between Osborne and Osborne. The reification of depression in Sightlines works very well.

Osborne does not hesitate to wax poetic. For example: "Perhaps he could come to understand through his own experience what he had dared to believe for a moment one afternoon on a hilltop: that a living thing could find fertile ground where you might least expect it, in the invisible firmness of air." Discovery for Osborne is everywhere—around a hill, under a tree, in a swamp—observing the world from a hot air balloon and looking inward.

Osborne skillfully uses simile and metaphor to describe the state of depression. He indicates, "Suddenly I'd feel tired and pressed flat, like glued linoleum." Or, in describing living with depression, but not really being aware that one is depressed, Osborne writes, "It was just a familiar, recurrent voice in my head, like a human-shape of heat lingering in an abandoned bed. Invisible but very present."

Osborne's treatment for depression includes psychotherapy and antidepressants. He is, however, almost entirely through his tale before he takes his first antidepressant. With the medication comes a profound fear of change: "I'm afraid of a change I can't guess, afraid the person who looks in the bathroom mirror after swallowing the pill won't be familiar to me, won't remember me. Although I have no loyalty to the voice, I'm afraid that in creating somebody new and improved, someone happier, this me will die."

There is no mystery in Sightlines, because the story's end is presented at the beginning of the narrative. Osborne says he was naive at the beginning, wise at the end—as any reader who takes Osborne's trip with him will know. It is not an easy journey, and Sightlines is not a book that one will breeze through quickly. Osborne makes the reader work hard, but for anyone who is interested in a sensitive, observant, educated man's struggle through depression, Sightlines is well worth the read.

Susan Rose Blauner's book is written as both a first-person account and "one person's guide to suicide prevention." How I Stayed Alive When My Brain Was Trying to Kill Me is more or less a self-help book for individuals struggling with suicidal ideation. Blauner presents her own story as illustrative of one person's struggles.

Blauner had suicidal thoughts over an 18-year period that was punctuated by overdoses in 1991, 1992, and 1998. She had three psychiatric admissions and twice made trips to an intensive care unit. After ten years of therapy, Blauner finally understood that it was "ok to have suicidal thoughts, just don't act on them." Blauner indicates that she "romanticized my death by suicide" and held on to "the fantasy of killing myself because it was a habit and addiction." Besides overdoses, she stood under trees with a noose in her hand, stuffed her head into trash bags, poked at her wrist with razor blades, begged God to have her heart stop beating, wrote good-bye letters, composed wills, and "spent hundreds of hours planning my funeral." Her worst suicide attempt was when she ingested handfuls of lithium, fluoxetine, and nortriptyline. Blauner's diagnoses included major depressive disorder, borderline personality disorder, and posttraumatic stress disorder. The onset of her depression occurred at age 14. The traumas of her childhood were childhood sexual abuse and the death of her mother, also when she was 14.

Blauner provides insight into the affective states of a suicidal individual. She writes, "Tortured. That's the only way to describe life inside a suicidal mind: both hostage and terrorist was I." Blauner, who describes herself as a "Jewish Unitarian Zen-Quakerist, earth loving type," emphasizes the importance of finding a therapist with whom one can connect. She has earned her credentials in this endeavor, having seen over an 18-year period ten different therapists, at least five psychiatrists for medication, and two group therapists.

Unlike many who respond with defeat or disgruntlement at being hospitalized, Blauner says, "I loved being hospitalized in the psych ward. Why not? Stripped of all personal responsibility and the stress of daily life, I readily accepted my role as a live-in patient. Like a kid, I soaked up the round-the-clock attention on the ward. I needed the structure and feeling of protection." During the course of her life, Blauner spent 40 days in the hospital; the longest admission was 21 days. Many might argue that she has no idea what it means to be locked up as a long-term state hospital patient.

Mixed in with Blauner's autobiography are hundreds of guidelines, exercises, tips, quotations, tricks, situations, behaviors, physical changes, thoughts and emotions, and alternatives. These parts of the book are confusing. For whom are they written? Blauner talks directly to the reader, assuming the reader is him- or herself suicidal. Her approach is a cognitive-behavioral one in which she endorses the concept that changing ideas can change behavior. However, it's hard for me to imagine a suicidal individual actually sitting down and reading this book. The book will perhaps be more useful for therapists to use as a source that they can refer to in the presence of patients, pointing out specific concepts or ideas or maneuvers. For many patients, hearing the message once from a therapist and once from a fellow sufferer may have a more profound impact than hearing it solely from either. When dealing with an individual who is suicidal, one can draw wisdom from Oscar Wilde (as quoted by Blauner): "One can survive anything these days except death."

Short sections of the book are written by Blauner's therapist, her brother, her sister-in-law, and her friends. Blauner includes a resource guide that lists crisis hotlines and relevant organizations in the United States and Canada. She also includes a bibliography of books that may be useful to mental health care professionals and some that will be useful for "survivors."

In summary, How I Stayed Alive When My Brain Was Trying to Kill Me can occupy a useful place on the therapist's bookshelf, to be used as a reference and to share with patients when explaining a specific technique, a specific concept, or a specific experience.

Bonnie Friedman's The Thief of Happiness: The Story of an Extraordinary Psychotherapy might better have been titled "The Story of Wacky Psychotherapy."

Friedman was an author who could not write. She describes herself at the outset of The Thief of Happiness as "thirty-two, happily married, and living on the ground floor of a sunny Victorian house in Salem, Massachusetts." In addition to desiring to get on with her writing, Friedman wants "something original! It was the only way not to disappear into the general aspic of life, the general lemon Jell-O tallow."

Friedman engages in psychotherapy with Harriet Sing, a psychologist who has not yet completed her training. Despite Sing's status, there is no evidence throughout the book of any supervision. Sing makes a promise that no therapist should make: "Enter treatment with me and you will write your book." Friedman engages with Sing in psychotherapy over a seven-year period, during which Friedman lives in Salem, Massachusetts, then Connecticut, and then Manhattan. Throughout these moves she commutes to Sing's office in Brunswick, Maine. Her sessions range from one and a half hours once or twice a week to longer sessions. Although she is not engaged in psychoanalysis and there is no evidence that Sing has any training in psychoanalysis, Friedman's treatment has her lying on the couch.

In Friedman's reconstruction of the dialogue between herself and her therapist, Sing infrequently makes statements such as "I understand you perfectly." Any informed reader would pause here, saying to him- or herself, "Oh really." Another such questionably informed comment by Sing: "I know you, Bonnie." Throughout the therapy Friedman pleads, begs, and grovels while Sing is—in a false way at best—erudite, omniscient, omnipotent, and alternately warm and engaging and condescending and distancing.

In retrospect, Friedman is able to describe her psychotherapist as "truly withholding, exhausting, cold, insensitive, greedy for money, insufficiently approving, and above all, that she reduced me to a state of aching dependence." Friedman explains, "I was a doll whose windup key was tucked in her pocket." Throughout her treatment, Friedman progressively loses herself, while simultaneously losing virtually all her friends and distancing her husband.

Friedman describes some interesting family dynamics and her trials and tribulations with peers. The focus of the book, however, is the dyad of Friedman and Sing. Friedman makes some minimal attempts to escape, but when she suggests to Sing that she might find a new therapist, Sing's response is "switching therapists is like switching mothers." Again, the informed reader sighs, "Oh really."

As the therapy ages, Friedman cuts down to two-hour sessions every other week with telephone contact in between. However, by now the reader is hard pressed to understand why Friedman continues, given that the therapy seems destructive and traveling to Maine has become a significant task, not only in terms of distance but in terms of some of the weather Friedman encounters while driving. As treatment is winding down Friedman is despondent and disappointed that she didn't get more from treatment but kept going because of "the belief that I could get something in return better than I could even conceive." Friedman finally separates from Sing with comments such as, "She seemed addicted to our mutual fantasy of her."

It is not hard to imagine that for Friedman, writing The Thief of Happiness was good therapy and perhaps the termination from treatment she really needed. However, it's not at all clear why she chose to have the book published. This book is no way for Friedman to have solved her writer's block. The Thief of Happiness is a tale of an idiosyncratic therapy with a naive patient and an apparently ill-informed therapist, told from the patient's point of view. What would Sing's song be?

Detour: My Bipolar Road Trip in 4-D is a book-length series of snapshots or, more accurately, old-time telegraph messages. The book is a zippy read and often exudes hypomania.

The author, Lizzie Simon, was born on March 23, 1976, the product of a father who was a pediatrician and a Little League coach and a mother who was a sex expert, a college administrator, and a coordinator with Haitian voodoo priests in their native land and tongue. She has a paternal grandfather who was a successful orthopedic surgeon and a closet sufferer of bipolar affective disorder. Simon notes that her grandfather received an official diagnosis of the disorder the year she was born and that she received her own diagnosis of the disorder the year he passed away. She says, "We passed the baton."

The road trip part of Detour refers to Simon's project of traveling throughout the United States interviewing young people with bipolar disorder—people between the ages of 17 and 30, all of whom have been successfully treated for the disorder and lead "highly functional lives." Because of the large number of detours Simon makes, the number of interviews she actually completes is fairly small.

Between Simon and her subjects, insights about what it means to have bipolar disorder and about the subjective experiences from this disorder abound. Simon herself is the beneficiary of extensive psychotherapy and psychopharmacologic treatment. She indicates that she had "at least a dozen therapeutic interventions dating back to almost prelingual times." Her major struggle was with "intense and inexplicable mood swings." Her deterioration progressed through pervasive confusion to frank psychosis. In this state, when she was first told she had bipolar disorder, Simon though it meant she "was a Hermaphrodite." At the time, she was suffering from a belief that she had been turned into a cat. Simon provides an interesting perspective on treatment: "I imagine the brain like an outer space cosmos, with little ships and beams of light zipping around carrying messages and directives. I imagined my universe at the time in utter chaos, and the antipsychotics as a nuclear bomb. Like we haven't developed humane, sophisticated ways to deal with disorder so let's melt the whole thing down."

Another comment about treatment comes from Simon's boyfriend, Nick, after he almost dies from an overdose of antidepressants: "If I'm gonna die I don't want to die because I'm so smothered by your medication that my heart stops beating. I want to die in a blaze of glory. The only way to describe Depakote is that it put me under water. I felt like I was submerged. No one heard me. I didn't hear them. I didn't know where I was. I was absolutely motionless and lifeless."

Simon tries a support group and comes away turned off. She indicates that she doesn't like support group meetings, and elaborates, "People in great need sit in a circle and share unscientific dangerous information."

As the book progresses, Simon focuses more on the purpose of her road trip. She expresses fears about the project, including fears about support groups, feeling sorry for persons with mental illness, being alone as much as she will be, a fear of the South and of motels, of running out of money, and of what the people she interviews will be like. Of the prospective interviewees, she says, "I'm afraid they'll speak and make no sense. I'm afraid the old men will hit on me." She gets better at interviewing and in the last quarter of the book records moving observations and reactions by individuals with bipolar affective disorder. As a 29-year-old graduate student in art history tells Simon, "I felt so much shame in every place that I was where I broke down and people saw me. When I bump into people that have seen me it is so painful. I still can't cope with that. I see people that have seen me, and I know they think I'm a freak."

Extracting themes from the road trip, the detours, and the interviews, one realizes that fundamental costs even to successful individuals who have bipolar affective disorder are loneliness, shame, pain, disappointment, and isolation.

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School in Worcester.