Addiction & the Humanities, Vol. 5 (9) – “Putting the monster in the box”: Mental illness, substance abuse, and self-medication in Carrie Fisher’s “Wishful Drinking”

Although Carrie Fisher is best known for her iconic portrayal of Princess Leia in the Star Wars films, she is also a successful novelist and screenwriter. In 2008 she published Wishful Drinking, a history of her life, first as the child of celebrities, and then as a celebrity in her own right. In it, she candidly (and comically) details her ongoing struggle with substance abuse and mental illness. In this week’s Addiction and the Humanities, we discuss how Fisher’s thoughtful description of her substance abuse and mental illness brings to life accumulated scientific knowledge related to the tendency for people to self-medicate the symptoms of their mental illness with drugs and alcohol.

Carrie Fisher has bipolar disorder. The disease, she says, makes her highly emotional. Fisher presents this insightful description of her unusual emotional intensity: it “revs up the motor of misery, guns the engine of an unpleasant experience, filling it with rocket fuel and blasting into a place in the stratosphere that is oh-so-near to something like a suicidal tendency—a place where the wish to continue living in this painful place is all but completely absent” (p. 14). Her depressive episodes are offset by bouts of mania, during which she talks non-stop, shows remarkable creativity, and makes poor (and lasting) decisions for herself.

When she was first diagnosed as having bipolar disorder at the age of 24 (five years after she first donned her Princess Leia side-buns), Fisher refused pharmacological treatment. Instead, she controlled her psychological pain—and her emotional intensity—with the help of drugs and, to a lesser extent, alcohol.  She writes that her mood disorder was “at least in part why I ingested chemical waste—it was kind of a desire to abbreviate myself. To present the CliffNotes of the emotional me, as opposed to the twelve-volume read” (p. 117). The drugs were partly successful in suppressing her symptoms; they allowed her to “put the monster in the box” (p. 117).

 
Unfortunately, as generally happens, Fisher built up a tolerance to the “chemical waste,” having to consume more and more to achieve the same psychological state. She accidentally overdosed at age twenty-eight. The overdose convinced her that her drug and alcohol addiction—not her bipolar illness—was her main problem. So, she dedicated herself to achieving and maintaining sobriety. But then her bipolar symptoms re-emerged. She writes that “without the substances I had used to distort and mask my symptoms, it was now all too clear that I was a bone fide, wild-ride manic-depressive” (p. 121). In other words, the monster was back out of the box. After a year of “erratic sobriety” she finally decided to address her bipolar illness head-on. Over the next twenty-plus years, Fisher has relied on a combination of psychotherapy, drug therapy, and electro-convulsive therapy to manage her mental illness. She has had “four or five” episodes of drug-use relapse.

Fisher’s history of suppressing the symptoms of mental illness with substance abuse is consistent with the self-medication hypothesis of substance abuse (Khanztian, 1985, 1997). Khantzian (1985) first developed the self-medication hypothesis on the basis of a long series of conversations with patients struggling with substance use disorders. Khantzian often asked his patients, “What did the drug do for you when you first used it?” He discovered a trend in their responses: one after another, they indicated that they used substances in part to alleviate their psychological suffering. Subsequent research has supported this idea. For instance, there is a strong and consistent association between substance abuse and psychiatric disorders; people who are dependent on drugs or alcohol are disproportionately likely to experience psychiatric conditions (as reviewed by Khantzian, 1997). This is especially true in the case of bipolar disorder (see Weiss et al., 2004). Of course, simple co-occurrence does not indicate whether substance abuse is a cause or a consequence of mental illness. Patients’ retrospective reports of using substance abuse to relieve psychological distress (Weiss et al., 2004) provides support for the notion that, at least in some cases, people use drugs to “put the monster in the box.”

Several other aspects of Fisher’s story coincide with trends identified in the scientific literature. First, the self-medication hypothesis states that people choose the particular classes of drugs that are most successful in ameliorating their painful feelings. Khantzian (1997) specifically predicts that opiates will be the drug of choice for people who seek to attenuate their intense emotions. Consistent with this, Fisher mainly used opiates to calm her moods after experimenting with a range of other drugs.  Second, the self-medication hypothesis predicts that a particular character trait—a tendency to be unable to tolerate discomfort—helps set the stage for substance abuse (Khantzian, 1997). Along these lines, Fisher observes that her “compulsion for comfort ” (p. 105) helped propel her toward drug abuse. She has long struggled to deal with life’s minor setbacks and through therapy she has learned to tolerate discomfort. Finally, Fisher consistently uses humor as a potent coping mechanism. She discusses how finding something humorous about a painful experience takes some of harm out of it. “If my life wasn’t funny,” she writes, “it would just be true, and that is unacceptable” (p. 17). The scientific literature is replete with references to the use of humor to cope adaptively with the stress of negative life events (e.g., McCrae, 1984).

In summary, Carrie Fisher’s Wishful Drinking presents a refreshingly honest and insightful glimpse into the world of an individual struggling with both mental illness and substance abuse. It moves the reader out of the solitary clinical setting and into the rich and complicated life of a single individual. In doing so, it provides an in-depth illustration of the self-medication hypothesis. In the next edition of Addiction and the Humanities, we will explore the themes in another celebrity memoir, Mackenzie Phillip’s High on Arrival, and how they relate to the scientific literature on addiction. 

–Heather Gray

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References:

Fisher, C. (2008). Wishful Drinking. New York: Simon and Schuster.

Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142(11), 1259-1264.

Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-244.

McCrae, R. R. (1984). Situational determinants of coping responses: Loss, threat, and challenge. Journal of Personality and Social Psychology, 46(4), 919-928.

Weiss, R. D., Kolodziej, M., Griffin, M. L., Najavits, L. M., Jacobson, L. M., & Greenfield, S. F. (2004). Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence. Journal of Affective Disorders, 79(1), 279-283.