Twenty-seven years old and in her first semester at Yale Law School, Elyn Saks had days when, she writes,
I feared that my brain was actually heating up and might explode. I visualized brain matter flying all over the room, spattering the walls. Whenever I sat at a desk and tried to read, I caught myself putting my hands up to either side of my head, trying to hold it all in.
She was especially concerned, should this happen, about who might get hurt. “The innocent bystander problem,” she notes (italics in original).
The fear did not go away. A few weeks into the semester, after gibbering away on the roof of the law school—believing both that people are out to kill her and that she has killed others (“Don’t try to fuck with me, Richard,” she tells a friend, “I’ve killed better men than you.”)—she is taken to Yale–New Haven Hospital where she surrenders her telephone-wire belt and a roof nail, after which, she writes, “it was all over.”
Within seconds, The Doctor and his whole team of goons swooped down, grabbed me, lifted me out of the chair, and slammed me down on a nearby bed with such force that I saw stars. Then they bound both my legs and arms to the metal bed, with thick leather straps.
While in restraints, Elyn is force-fed an antipsychotic drug—the first she has ever had. Transferred by ambulance to Yale Psychiatric Institute, she asks that a blanket be put over her face so nobody can see her. “Maybe,” she thinks, “this is what it feels like to be dead” (italics in original).
There is a long tradition, published and unpublished, of first-person accounts of madness—from John Perceval, Daniel Paul Schreber, and Vaslav Nijinsky to William Styron, Kay Redfield Jamison, and Andrew Solomon—but of those I’m familiar with, Elyn Saks’s The Center Cannot Hold is the most remarkable of all. I know of no other account that, by its recall of each moment of short- and long-term crises, allows us to begin to experience what being in this condition must be like and feel like to the person suffering it.
“As frightened as I was,” she writes,
I was equally angry, and frantic to find a way to show defiance. So I inhaled as deeply as I could, and started belting out some beloved Beethoven. Not, for obvious reasons, “Ode to Joy,” but rather Beethoven’s Fifth Symphony. BABABA BA! BABABA BA!…
For hours, I sang it and shouted it and hollered it with all the power remaining inside me. I fought off the beings who were attacking me, I yanked against the restraints, and I sang my heart out. Every once in a while, a nurse came by with another little demitasse of antipsychotic liquid. I swallowed it passively, then fought to swim above the fog it created. BABABA BA!
Elyn is transferred to Yale’s Psychiatric Evaluation Unit, where she jabbers away at her psychiatrist, Dr. Kerrigan, confiding that she used to be God (but was demoted), telling him she has killed hundreds of thousands of people with her thoughts. He tells her he thinks it “a good idea” for her to spend more time in restraints. “We believe they help patients feel safe, more in control,” he says.1
Two weeks later, for the first time in her life, Elyn receives a diagnosis: “Chronic paranoid schizophrenia with acute exacerbation.” Her prognosis is listed as “grave,” the staff believing that her “next hospitalization would be measured in years, not weeks or months.”
I’d always been optimistic that when and if the mystery of me was solved, it could be fixed; now I was being told that whatever had gone wrong inside my head was permanent and, from all indications, unfixable…. For the rest of my life. The rest of my life. It felt more like a death sentence than a medical diagnosis.
In addition, she discovers that the Psych Unit, without her permission or knowledge, has informed the law school that she will not return that year, or possibly ever.
Although Elyn has had bizarre thoughts and hallucinations since childhood (believing that buildings talked to her, seeing a man coming at her with a knife when no man is there), and although she’s known that her behavior has often been unacceptable, she has also believed that “everyone thought this way”—scrambled, hallucinatory, paranoid, destructive—the difference being that others were better at masking the thoughts, “much as everyone passes gas, but not incompany.”
Before the episode at Yale, Elyn (who grew up in North Miami: “my family was solidly in the middle class, and as time went on, our means increased”) had spent time in a rehab center as a teenager (for smoking pot), had finished first in her class at Vanderbilt University, had been a Marshall Scholar at Oxford University, had been hospitalized twice for floridly psychotic episodes, and had, for two years, undergone a five-times-a-week psychoanalysis.
But the analysis, which she believes saved her life, has, during her hospitalizations at Yale, accustomed her to express herself in ways that cause difficulties. “Any expression of anything that I was feeling,” she writes, “fear, anguish, restlessness, disorganized and delusional thoughts—led to immediate restraints.”
Part of the problem is that she has been behaving like a patient in psychoanalysis—saying exactly what’s on her mind, no matter how crazy it sounds. “That was how analysis worked,” she explains. “That was the point. Otherwise, how would [my analyst] know what was going on inside me? But the people at [Yale] didn’t want to know.”
While Elyn tells the story of her life in beautifully observed detail, she also steps outside it to become the most trustworthy of participant-observers, and to provide us with an ongoing and shrewd commentary on the ways we have, historically, treated people with severe mental illnesses, and the rationales and efficacies of these treatments.
Thus, at Yale, she is able to extrapolate from her own experience to describe a familiar and deadly “classic bind” for most psychiatric patients:
They’re struggling with thoughts of wanting to hurt themselves or others, and at the same time, they desperately need the help of those they’re threatening to harm. The conundrum: Say what’s on your mind and there’ll be consequences; struggle to keep the delusions to yourself, and it’s likely you won’t get the help you need.
From Yale, Elyn goes to the Institute of Pennsylvania Hospital, where she remains hospitalized for the rest of the academic year. In May, she returns home briefly, then travels to England, where, throughout the summer, she sees her analyst, Mrs. Jones, three times a week. In the fall she reenrolls at Yale Law School.
Although Elyn will, during the next quarter-century (she is now fifty-two), suffer several major psychotic episodes, she will never again be hospitalized for psychiatric reasons. She will also, if with occasional lapses, come to accept the fact that she is schizophrenic and that she will probably have to take antipsychotic medications for the rest of her life. Whenever, “believing that the less medication I took, the less defective I was,” she stops taking them, she relapses severely. She will also continue, year upon year, three, four, and five times a week, in psychoanalysis.
Despite debilitating side effects of medications (including early signs of tardive dyskinesia, a movement disorder caused by antipsychotic medications), despite acute psychotic episodes and the fear of their recurrence, despite major medical problems (breast cancer, brain hemorrhages, a hysterectomy, and the removal of her ovaries following the appearance of warning signs of ovarian cancer), and despite repeated confirmation by doctors of a diagnosis of schizophrenia, Elyn continues to achieve at the highest levels. She graduates from Yale Law School (where she becomes an editor of the Yale Law Journal) and goes on to teach at the University of Southern California Law School, where she is appointed the Orrin B. Evans Professor of Law, Psychiatry, and the Behavioral Sciences. She’s also appointed an adjunct professor of psychiatry at the University of California, San Diego, School of Medicine (“I’ve infiltrated the enemy!” she announces to a friend). She publishes numerous articles and several books, becomes a research clinical associate at the New Center for Psychoanalysis. She falls in love and marries.
She has those things that, in her words, “make life wonderful—good friends, a satisfying job, loving relationships”—but that very few people with schizophrenia ever have. She is an “exception to a lot of rules,” she knows, and much of her good fortune is about luck—“about the ticket I drew in the lottery: parents with resources, access to trained and talented professionals, and a frequently unattractive stubborn streak that’s worked in my favor as often as it has against me.”
Her exceptional intelligence has contributed mightily to her ability to survive:
My brain was the instrument of my success and my pride, but it also carried all the tools for my destruction…[for] if the fire that burned me signaled my destruction, it was also the same fire that got me out of bed in the morning and sent me to the library even on the most frightening days.
But central to her ability both to survive and to thrive, she believes, have been two things: medications and—rare in the chronicles of schizophrenia—psychoanalysis.
“While medication had kept me alive,” she writes, “it had been psychoanalysis that had helped me find a life worth living.” In a passage one might post on the door of every psychiatrist who believes patients can live by medications alone, she explains:
Medication has no doubt played a central role in helping me manage my psychosis, but what has allowed me to see the meaning in my struggles—to make sense of everything that happened before and during the course of my illness, and to mobilize what strengths I may possess into a rich and productive life—is talk therapy. People like me with a thought disorder are not supposed to benefit much from this kind of treatment, a talk therapy oriented toward insight and based upon a relationship. But I have. There may be a substitute for the human connection—for two people sitting together in a room, one of them with the freedom to speak her mind, knowing the other is paying careful and thoughtful attention—but I don’t know what that substitute might be. It is, at the heart of things, a relationship, and for me it has been the key to every other relationship I hold precious. Often, I’m navigating my life through uncertain, even threatening, waters—I need the people in my life to tell me what’s safe, what’s real, and what’s worth holding on to.
The prevailing view, beginning with Freud, is that when it comes to schizophrenia, psychoanalysis and most forms of talk therapy invariably cause relapse and regression. As Saks notes, Freud
My brother Robert was hospitalized, put in a straitjacket, and force-fed medications when he had a psychotic episode similar to Elyn's. He was nineteen years old at the time. In a subsequent hospitalization, he was frequently placed in isolation, twenty-four hours a day, day after day, in a room that contained only a sheetless bed and an empty dresser. This was called "reduced stimulation" by his doctor, who informed me that "in retrospect patients come to appreciate the reduction in stimulation—the limits and boundaries that have been set for them."↩
My brother Robert was hospitalized, put in a straitjacket, and force-fed medications when he had a psychotic episode similar to Elyn’s. He was nineteen years old at the time. In a subsequent hospitalization, he was frequently placed in isolation, twenty-four hours a day, day after day, in a room that contained only a sheetless bed and an empty dresser. This was called “reduced stimulation” by his doctor, who informed me that “in retrospect patients come to appreciate the reduction in stimulation—the limits and boundaries that have been set for them.”↩