How can an understanding of the kinds of creative thinking involved in art, literature, or science apply to our treatment of mental illness? Not just the performance of any specific therapy, but medical management of mental and emotional illness? The answers to this question will take me into the nature of mental illness impairments, the definition of creativity and creations, and also into the dark pathways of destructiveness in relation to creativity in art and life. To illustrate these matters, I shall conduct a critical and hopefully meaningful investigation of the final poetry of the star crossed Sylvia Plath, and relate the story of the treatment of a self destructive mental patient who strove mightily to be a creative writer. Most salient of all, I shall consider the difference between, on the one hand, the control and suppression of feelings, and on the other the unearthing with self knowledge that is intrinsic to the creative process. I shall not—it has become important nowadays to say—propose that mental illness produces artistic creativity, a rather popular current notion for which there is no scientific basis at all.^1–3 First, however, to present an approach to all these matters, I shall adopt a broad perspective on the nature of pathology in both psychiatric and general medical illness.

NORMALITY, CREATION, AND TREATMENT

Let us look at the fundamental issue of normality, a fairly straightforward physiological matter but more complicated for psychiatry. When a patient has pneumonia with cough, sputum, and fever, the patient and his or her organs are not functioning normally. To be normal, they must get back to their prepneumonia state. When the deficiency is corrected, patients will be “like everyone else”, their lungs functioning healthily, just like the average—or just like the vast majority of people of their age. With the treatment of mental and emotional illness, however, the notion of the average or the majority as normal (even in equality loving and democratic cultures) is acceptable neither to patients nor practitioners. Mental health is not considered equivalent to being average or to being the same as everyone else. Moreover, returning to average functioning or to a previous state may not suffice for ameliorating the illness. Once one develops a mental illness, almost invariably there are continuing problems. In a lesser way, this also applies to pneumonia. After having the infection and being effectively treated, the patient is never exactly the same as before. The diseased lung area is permanently scarred. Although minuscule, the residual scar remains for life.

Lung scarring is a deficiency but the pneumonia will not by and large recur unless there is exposure to the infectious organism, this can, with reasonable precaution, usually be prevented. With mental and emotional illness, on the other hand, the recurrence threat is greater because human beings up to the present time have never been able to prevent exposure to the social and environmental stresses and threats of everyday life. In attempting to help a patient return to functioning or coping or adapting, more is needed than can be accomplished with medication alone. With the scar of mental illness, patients need to be able to adapt better to their environments than others who have not been scarred at all.

Even if practitioners do not see things this way, patients inevitably do. Although it is difficult therapeutically to define what it means to adopt the goal of helping any given individual patient “to function,” that patient most often has already rejected such a goal or the term itself out of hand. Nor do patients accept the aims of “coping” or “adjusting” or even “adapting” very readily. They want to be better than they were, better than others, and thereby better able to deal with the constantly problematic circumstances in which human beings live, at that time or in the future. Both patients and therapists are oriented to, and engaged in, facilitating creation. Both are focused on the patient’s creation of his or her self or aspects of self—an ongoing process of self creation.⁴

By self creation, I mean something directly analogous to creation in the arts and sciences. In these fields, creation is most meaningfully defined as the production of something both new and valuable.⁵ In the process of achieving self creation through systematic case management, adjunctive or intensive psychotherapy, something new and valuable is also produced. Patients make themselves, or aspects of themselves, better than before. They break away from the past and produce features that are new. Medications provide reduction of symptoms and conjoint psychotherapeutic approaches should be intrinsically processes of facilitating self creation for patients—the better the psychotherapy, the greater the degree of self creation. A focus of choice on the patient’s present life may include a large measure of the past if the past has become restrictive. To the extent that patients become free from the past, and face the present more effectively, they are able to make new choices and adopt new alternatives. These choices arise from patients’ active decisions about what type of persons they are and what type of persons they want to be. There is freedom from the past, but there is also continuity with the past; patients create partly on the basis of what they know or sense to be the predetermined aspects of themselves. They accept factors in their past which cannot, or need not, be changed. When a radically innovative artist, such as Cezanne, creates a new mode of painting, the work of art as a whole is not totally divorced from anything that was ever done before. We appreciate and understand the accomplishment of Cezanne partly because of ways that his paintings have links and continuity with the works of the Impressionists and other past artists. Many of Shakespeare’s most creative works also convey the meanings and the structure, as well as some of the drama, of the earlier stories on which they are based (Rothenberg and Hausman,⁵ pp 21–6).

Self creation is a potentiality for everyone throughout the course of life development. Whenever we actively make choices leading to increased independence and to better definition of our selves, including our wishes, strengths, and goals, and whenever we achieve improved personal integration—all matters of producing both newness and value—we engage in self creation. Creativity of all types is also often a response to upheaval and stress. This has appeared historically on a broad social scale when, in all fields, creative persons and events have arisen during times of chaos, war, and social disintegration. At the personal level, stress and upheaval, may often, as in mental illness, be a special spur for self creation during the course of treatment.

When, in the treatment phase, the patient is thinking and choosing in a way that involves active self creation, it is incumbent on practitioners to be facilitative or, at least, not to interfere. Such times are not always easy to identify; they are manifest when the patient indicates thoughts and feelings involving freedom from past restrictions, and an active pursuit of self directed and self defining goals. When such thoughts and feelings emerge, the helping practitioner knows to listen and allow them to develop and evolve.

SELF DESTRUCTION AND SELF CREATION

The process of self creation is not necessarily a smooth or constantly fulfilling experience. The chaos and stress that initiates self creation may, prior to its flowering, give way to greater disturbance. Harrowing therapeutic experiences may, in fact, occur. This is because creation and destruction, though opposites, are closely related to each other. Patients engaged in any therapeutic management may come to a point where they become preoccupied with destructive thoughts of suicide. Yearnings for death, oblivion, escape, or feelings of unbearable struggle and surrender, of total collapse punctuate their communications. It is a frightening time for patients and can be for the practitioner as well. These thoughts, however, may often signal a turning point; patients are confronting basic conflicts and the full brunt of fear of change. With sudden impact, they have come to see that the locus of difficulty is within themselves. Although the source of their problems may originally have been external—harried by an overbearing wife or husband, cursed by bad breaks or by faulty upbringing by unfeeling parents—they realise that only they can set things right. They know they must change themselves and they are terrified of change; death seems a preferable alternative. For patients in the throes of this experience, the options are overwhelming. They feel total dissolution of the persons they have been and a simultaneous sense that they could make themselves totally into a person they wish to be. In the face of such unlimited potentiality and freedom, there is a yearning to retreat into oblivion, a hovering between self creation and self destruction.

Creation and destruction are intimately related to each other both in life and artistic production. Artists knowingly set out to destroy a previous style by the creation of a new one, and producing anything radically new, in an essential sense, always involves destruction of the old. Although, as I said earlier, works of art evolve from and connect with their precedents, their creative aspect, according to my definition, always involves newness and destruction of the modes and forms of the past and our ordinary ways of looking at the world. Creative images and formal aspects of poetry shock our sense of grammar and syntax view, musical harmonics our sense of sound, and all forms of art, even representational productions, may change our view of colour, shape, or simply the highpoints and relationships of a face or scene. Scientific creation, ranging from groundbreaking Einsteinian or Copernican theories to important and new understandings of immunosuppressive mechanisms, even more clearly results in radical change and destruction of existing beliefs and practices. While destruction, in this sense, may seem somewhat abstract and impersonal, there is a personal and concrete relationship between destruction and creation in art as well. Artists frequently must cope with destructive feelings, both consciously and unconsciously, while they are engaged in creating. Destructive feelings, wishes to hurt, maim, humiliate, even to annihilate other persons often provide fuel for the creative process.

A key motive for engaging in creative activity is often an attempt at working through and unearthing the sources of destructive feelings.⁶ In other words, artists and other types of creators frequently create in order that they not destroy. Or, they explore a scientific problem, literary theme, visual image, or poetic metaphor as an unconsciously motivated means of unearthing the sources of stressful and disturbing feelings, frequently destructive ones. A poet research subject of mine, for example, was moved by the experience of seeing a horse appear suddenly at a barren desert site. He decided to write a poem about the incident, designating the animal as a stallion and emphasising the breaking of an implicit bond between humans and horses. As the writing progressed, he had the impulse to change the horse’s gender to a female, a mare, and became dimly aware of hostile feelings toward women. He sensed that, in some way, the breaking of the bond pertained to disappointment with his mother (in French, he said “mère [pronounced like mare in French] meant mother”) and other women in his life.⁷ Also, a novelist research subject writing a novel about college students gradually became aware of a resemblance between one of the characters he created and his own brother. Unwittingly, he had given his highly negative character—the villain of the piece in fact—some of his brother’s attributes. Realising this, he became aware of some longstanding feelings of sibling rivalry and hostility. As a third example, a scientist—here my data is inferential rather than direct—shifted to a dramatic and creative solution to a problem in the presence of someone toward whom he had destructive feelings. Working in his laboratory, he at one point looked up because he heard someone come in. Rather than his expected collaborator, it was a representative of his scientific rival, a man who had criticised him sharply. While the man worked in another part of the laboratory, the scientist arrived at a groundbreaking solution of a problem he had worked on for years.⁸

Scientists seldom become aware of the unconscious roots of any of their ideas because of the nature of the scientific enterprise. The problems they deal with seem completely external to themselves and there is rarely a reason to explore a specific idea or image in a way analogous to the extrapolations and explorations of art. Creation is, however, a healthy means of dealing with destructive feelings in any field. Because creation has the potential for increasing self knowledge, there is the possibility of creative persons freeing themselves from their psychological past and making themselves, or aspects of themselves, anew. In other words, creation in the arts and sciences can also facilitate self creation. As Yeats wrote:

Those friends that have it I do wrongWhenever I remake a songShould know what issue is at stakeIt is myself that I remake.⁹

THE CASE OF SYLVIA PLATH

Destructiveness may, however, sometimes seriously disrupt and interfere with both artistic creation and treatment. Destructive feelings may become overwhelming and lead neither to self creation in treatment nor to artistic creations, even by the highly skilled. Instead, these feelings may be dealt with by uncreative attempts at control and stasis. An example comes from the late poetry of Sylvia Plath. Some critics see the poems she wrote shortly before her tragic suicide at the age of thirty one to be especially powerful, consisting of strong protests against the subjugation of women, lyrical but unflinching confrontations with death poignantly realised in her own suicide,¹⁰ and as poems that make “her readers feel the amplified sense of their humanity”.¹¹ Others have decried the confessional nature of this poetry, the cultism that has construed her suicide to infuse her poetry with special meaning, or they have, in the main, criticised such matters as her “failures of language, moments in which …the words become ‘riderless’”.¹² I shall attempt to explain some of the reasons for some of the failures; these are not simply lexical blunders but, as the latter type of critic suggests, they are “riderless” deficits of poetic creation.

Sylvia Plath was ultimately unable to turn creation into self creation. Although she was a successful poet and much of her poetry is full of vibrant and beautiful images, a problematic strain can be detected, especially in the later works that, I think, foretells, and in some way contributes to, her suicide. Strong drives to destruction as well as creation appear in these poems. There are new images often of the ominous, deadly side of homely kitchen things and of living bodies and flowers. These images transform both the living and the deadly; they make death seem beautiful and life seem threatening. The quiet, resigned rhythms of her lines contrast with the bitterness, resentment, hatred, and destructiveness in and behind the words, producing a strange excitement and vitality. While her destructive feelings are, however, often fused into poetic writings, there is little working out of these feelings and little indication of any insight and unearthing of the unconscious sources of her concerns. In—for example, one of the poems she wrote shortly before she took her life, Edge, there are striking excesses:

EdgeThe woman is perfected.Her deadBody wears the smile of accomplishment,The illusion of a Greek necessityFlows in the scrolls of her toga,Her bareFeet seem to be saying:We have come so far, it is over.Each dead child coiled, a white serpent,One of each littlePitcher of milk, now empty.She had foldedThem back into her body as petalsOf a rose close when the gardenStiffens and odours bleedFrom the sweet, deep throats of the night flower.The moon has nothing to be sad about,Staring from her hood of bone.She is used to this sort of thing.Her blacks crackle and drag.¹³

The lines beginning the poem are beautiful, but chilling: “The woman is perfected/Her dead/Body wears the smile of accomplishment”. Looking at these lines retrospectively, with knowledge of her suicide shortly thereafter, we can, of course, see a clear statement of her intent. This is not, however, the excess I am talking about, because there is poetic creation in these lines despite their macabre tone. They are paradoxical, exciting, and stimulate a progression of thought, but soon after these lines, there are the strange and disjunctive ones: “Each dead child coiled, a white serpent,/One at each little/Pitcher of milk, now empty./She has folded/Them back into her body as petals/Of a rose close when the garden/Stiffens and odours bleed…”

I believe these latter lines to be uncreative because, in them, destructiveness has become excessive and gotten out of hand. The children are returned into the mother’s body simply because she can give no more. She and her breasts—the pitchers of milk—are empty and dried up. The children are enfolded back into her womb, back into the past, because that is where they came from. They are destroyed simply because she is destroyed. Furthermore, they are described as serpents, coiled serpents, an image whose negativity is only slightly modulated in this context by the adjective “white”. In parallel with the destructive excesses in these lines, the poetic images introduced are inconsistent and jarring. Serpents do not go metaphorically with pitchers of milk and the petals of the rose do not close as other flower petals sometimes do. It seems that the rose is used primarily because of its rhyme with the word “close”; such rhyme disjoined from meaning is, I think, distinctly unpoetic and uncreative. The images and metaphors are fragmented and the ideas expressed, destructive.

Other interpretations of these lines may be considered, such as seeing the unfolding back into the womb as an expression of protective motherhood, the closing rose as a fantasy symbol rather than a simile or metaphor, or the giving of form to other kinds of defined or undefined ideas and feelings. I, however, see disjunctions of the poet’s creative capacity and call attention to the lines to show how precarious is the balance between destruction and creation in art, just as the balance between self creation and self destruction may be precarious in life. Plath begins her poem with an assertion of triumph over death, the “smile of accomplishment”, but she cannot carry her triumph further. A sense of triumph over death is, and should be, associated with a subjective sense of freedom—for most of us, that is. In this poem, however, there is no freedom; there is only the bringing of the children back to their origins, back to entombment in the past.

There is reason to believe that the problem with destructive feelings contained in this poem closely reflected Plath’s problems with destructive feelings in her life. She committed suicide approximately seven months after her husband, the poet Ted Hughes, separated from her. Left with the total responsibility for the care of her two very young children, she seems to have been constantly embroiled in a struggle with hostile feelings toward them. Many of her unfinished poems (unrevised fragments very likely close to conscious revelations) during this period suggest such a struggle and some salient circumstances of her suicide indicate it as well. Here is an excerpt:

She hatesThe thought of a baby—Stealer of cells, stealer of beauty—She would rather be dead than fat,Dead and perfect, like Nefertit¹⁴

Turning on the gas in the kitchen stove early in the morning while the children were sleeping nearby, she made little provision for protecting them from the fumes that took her own life. They only survived by chance when an au pair woman came to the house. It is impossible to know now whether or not she had consciously intended to murder her own children, but there is little doubt about the open expression of that type of destructive feeling toward children in the poem, Edge. The “serpents” are white and are unbrutally enfolded into the mother, but they are murdered nevertheless.

I believe that Sylvia Plath could not turn her destructive feelings into poetic creation in these lines because she was using poetry primarily to control rather than create. In other words, she attempted to express destructive feelings in poetic form in order to expel them. Such an attempt at expiation and indirect expression functions only for controlling feelings rather than changing them. It strives for a stand off, a static rather than progressive state. Good poetry does not do this; it attempts to get beneath the feelings, to understand them or to use them in a progressive way. The writing of good poetry involves the poet’s freeing her or himself up from the past through attaining a degree of understanding and a movement into the future. One of the sources of our own enjoyment of poetry is our vicarious identification with the poet’s struggle for understanding and freedom. In the case of this particular poem, Sylvia Plath could not fully turn destructiveness into creation and could not free herself enough from the past to move toward the future. As we now know, this state portended her self destruction.

Just as a need to control interferes with turning destructiveness into creation in art, so it interferes with turning self destructive feelings into a process of self creation in life. The following case of a patient yet unable to create any type of art illustrates this.

A SUICIDAL PATIENT

A seventeen year old college girl sat on the ledge of her window on the second floor of the dormitory. It was pitch dark and no one saw her sitting there, including those in the nearby dormitory room. For a long time, she sat there thinking about jumping and flying and vaguely about killing herself. Several times, she wondered whether anyone would come by and notice her there. For what seemed like hours, nobody did; she jumped.

Although she did not kill herself, she seriously injured her back and pelvis. Immobilised in a body cast for seven months, she also began intensive psychiatric treatment. Prior to the jump, the girl had suffered from symptoms of incipient schizophrenia for some years. She had experienced severe disturbances of thinking, including both religious delusions and delusions about food. Following her jump, she began the heavy use of psychotropic drugs such as marijuana, LSD, and amphetamines. Finally, drug use and schizophrenic disturbance led to the need for psychiatric hospitalisation.

She was a highly intelligent girl, able to maintain excellent grades at a very competitive Ivy League college in spite of her symptoms and drug taking. Her ambition was to become a great writer, but unlike Sylvia Plath, she had done very little actual writing. The few poems she had completed showed some measure of talent, but she had never made any sustained effort at the novel she hoped to write. In the course of psychotherapy, she revealed that she hated her body but engaged in sexual activity because “others” wanted her to. At the time she jumped from the window ledge, she fully believed that she might fly and did feel while falling a distinct sense of control over both her body and the environment.

As this patient improved, she gradually became aware that one of the underlying reasons for her jump that night was an overwhelming fear of death. Paradoxical as this sounds on the surface, she felt so much at the mercy of death, so much at the mercy of forces outside of her control, that committing suicide was for her a means of establishing control. Rather than waiting for death to claim her, she would establish control and do it herself. Either flying through the air or choosing her own death would amount to the same thing: she herself would be in control.

Persons who engage in rational discussions of suicide often insist that killing oneself is an act of freedom. Arguing that self destruction is a basic human right, they push further to assert that it is also an act of free choice.¹⁵ While not intending to enter here into a discussion of the morality of suicide, I will assert that it seldom results from a state of subjective freedom. Almost invariably, it is an attempt to control psychological forces over which one feels one has no control. It is a state of subjective fatalism or determinism, wherein no alternatives are conceived to be possible except those already given. One merely thinks of controlling the given, rather than transforming it. Destructive feelings toward others—for example, are turned against the self rather than being understood and thereby overcome. Sylvia Plath’s destructive feelings toward her children could have resulted from conscience motivated enslavement in her motherhoodi.

Knowing this, and forgiving herself for it, she might have been able to become a different kind of mother.

SELF CREATION

As the patient I have described continued to improve, she again became preoccupied with thoughts of suicide. Now, however, she was hovering between self destruction and self creation rather than only trying to control feelings and impulses derived from the past—that is, her dependent need to feel and do only what others wanted. I say this because she experienced an important turning point toward self creation when she became aware, in a therapy session, that one of her reasons for wanting to give up and not change was her fear of death, the same fear previously underlying her suicide attempt. If she did not change—if, in other words, she never grew up—she would never have to face death. Irrational as such a position is, it can be one of the unconscious bases throughout life for a fear of growing up and changing.¹⁶

Death is the ultimate and absolutely fated event in life. When we feel totally at the mercy of forces from the past in our life, we fear death most intensely. Under complete sway of the past, we feel neither present nor future freedom. Life is restricted and there is little sense of personal mastery over ourselves and the events of the world. Death’s domination can only be an extension of the pains and inadequacies of living, a final unyielding absence before any fulfilment occurs. Moreover, the inevitability of death, and what we may believe comes after death, are punishments similar to but greater than the punishing chains of the past. In such a subjective state, rather than one where we feel the strength of a sense of freedom, we resort to attempts at control. These attempts may consist of controlling destructive feelings (overwhelming destructive feelings are almost invariably derived from past attitudes and orientations) by denying them, turning them against the self, or trying to control death by choosing one’s own time to die. Attempting to gain power in these ways results only in a false sense of freedom. This type of control, as I have said, is static; it keeps past forces in check but does not change them.

Nothing can, or will, change the fact of death, of course: and that is just the point of engaging in self creation, choosing to make oneself into the person one wants to be. Self creation does not deny the fact of death, rather it removes death’s determining effect on life. In opting for self creation, we accept the inevitability of death, but move on through our exercise of freedom to experience life fully. Recognising and accepting fear of death as underlying her fear of change, the patient began, slowly and arduously, to explore new situations, to try new ways of reacting to people, and to make choices that would help her to define herself.

Self creation develops with diverse types of activities. As I pointed out earlier, it may occur throughout development and the life cycle, not necessarily as a result of psychotherapy. Seldom, in fact, except in psychotherapy, is self creation dramatically opposed to self destruction in the manner I have described. Engaging in artistic creation often facilitates self creation because good artists use their art to help them progressively define themselves and achieve better understanding of their own feelings and thoughts. The making of art by those who are not artists aids individualisation, because it is a valued activity that enhances self worth. In addition, because frequently it is an exercise in experiencing a subjective sense of freedom, it may be used to facilitate self creation. This is one reason why persons facing death are well advised to engage in artistic activities, even if they have never done so before.

Making or creating art can, however, offer traps for self creating as well. If art is used primarily for control of unacceptable feelings, as in the lines I presented from Edge, it serves a constrained and constricted subjective state rather than a free one. Furthermore, if artistic creation is undertaken primarily for its effect on others, primarily to get something from others that one cannot find in oneself—I am not now talking simply about getting accolades or recognition of artistic achievements—it defeats self creation. Such a purpose is evident in the accomplished poet Plath’s poem Edge and, up until the present time, the young patient’s ambition to be a great writer.

The final portion of the poem Edge, “The moon has nothing to be sad about/Staring from her hood of bone./She is used to this sort of thing,” reads, to me, like a simultaneous cry of anguish and a cry for help. The poet was bewailing an indifferent universe, a universe that does nothing about death or destructive feelings or acts. In this poem, as in many of the others written shortly before her death, she was writing a kind of suicide note. By “suicide note” I do not mean something written that explains a person’s self destructive act after the fact, but one that is meant to be discovered. Such a suicide note is a cry for help that says, “Please stop me”. Another such poem, The Detective, was first published posthumously:

What was she doing when it blew inOver the seven hills, the red furrow, the blue mountain?Was she arranging cups? It is important.Was she at the window, listening?In that valley the train shrieks echo like souls on hooks.That is the valley of death, though the cows thrive.In her garden the lilies were shaking out their moist silksAnd the eyes of the killer moving sluglike and sidelong,Unable to face the fingers, those egotists.The fingers were tamping a woman into a wall,A body into a pipe, and the smoke rising.This is the smell of years burning, here in the kitchen,These are the deceits, tacked up like family photographs,And this is the man, look at his smile.The death weapon? No one is dead.There is no body in the house at all.There is the smell of polish, there are plush carpets.There is the sunlight, playing its blades,Bored hoodlum in a red roomWhere the wireless talks to itself like an elderly relative.Did it come like an arrow, did it come like a knife?Which of the poisons is it?Which of the nerve-curlers, the convulsors? Did it electrify?This a case without a body.The body does not come into it at all.It is a case of vaporization.The mouth first, its absence reportedIn the second year. It had been insatiableAnd in punishment was hung out like brown fruitTo wrinkle and dry.The breasts next.These were harder, two white stones.The milk came yellow, then blue and sweet as water.There was no absence of lips, there were two children,But their bones showed, and the moon smiled.Then the dry wood, the gates,The brown motherly furrows, the whole estate.We walk on air, Watson.There is only the moon, embalmed in phosphorous.There is only a crow in the tree. Make notes.¹⁷

Knowing that she did show some of this type of poem to others before she died, it is reasonable to assume a cry for help along with the artistic purpose.¹⁵ I do not, however, mean to pass a moral judgment for having such a purpose in these poems; I want to point out how the writing of the poem subverted self creation rather than facilitated it. Writing a suicide note in the form of a poem is a self destructive act: while crying out against people’s misunderstanding and indifference (as one reference, the “crow” in the last line refers to a theme of Ted Hughes’s poetry), it creates further misunderstanding. If a person hearing the poem calls it a suicide note, the poet as artist is misunderstood; if it is heard exclusively as a poem, the person crying for help is misunderstood, and ignored.

This is an extreme example, but as I have pointed out about schizophrenic patients’ creative writing, artistic works often fail when they make an undue demand on their audience (Rothenberg,⁶ pp 57–67).Works that in large measure display the conflicts and disturbances of their authors, works that invite the audience to justify or accept them rather than be stimulated or learn from them, are failures as artistic creations and subversions of self creation.

Because of her need to affect others and control her feelings, the young patient’s ambition to be a great writer has not yet served her turn toward self creation. She has felt she must become a great writer in order to prove her worth to the world. Her feelings of worthlessness have been so great that nothing short of overwhelming greatness could make her feel worthy at all. As with her fear of death, she has sought to control and compensate for feelings of worthlessness through fantasies of greatness.

Some day, she may be able to use artistic creation in the service of self creation; but there are many other routes available to her and to all of us as well. Primarily, we continue to create ourselves in the everyday choices that move us on in life. We create ourselves when we risk an alternative that closes off the manifold potentialities of childhood. We create ourselves when we strive for understanding rather than control. In the face of powerful urges to adopt a stagnant, backward looking subjective state ultimately connected to self destruction, we create ourselves in our acceptance of our freedom and our death.

Self creation is a choice goal of mental illness treatment. Like successful artistic creation, self creation involves newness and value, the achievement of new and effective ways of coping, adapting, understanding, and enjoying. In both art and conditions of stress or mental illness, feelings of destructiveness may power creativity. If such feelings are simply controlled rather than understood for use in the service of newness and change, inhibition and inversion will occur, and both artistic and self creation will be disrupted and blocked. In the case of art, there will seldom be a creative result if the artistic work is used primarily in the service of dependency, to get from others what one cannot find in oneself. Independence of thought, new and integrated constructions, enjoyment of the artistic medium for its own sake, are both ingredients and sauces of effective artistic creation. And with self creation, whether achieved during the course of growth and personal development or through the changes actively produced during treatment for mental illness, individual independence, self integration, and appreciation of freedom and autonomy are the adaptive constituents for meeting and overcoming stress and the inevitable tugs of life.