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There is a long tradition, published and unpublished, of first-person accounts of madness—from John Perceval, Daniel Paul Schreber, and Vaslav Nijinsky to William Styron, Kay Redfield Jamison, and Andrew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
believed that psychosis was too narcissistic, too inward-looking, to allow the patient to develop a transference relationship with the analyst, and without that transference, there would be no grist for the psychoanalytic mill.
There have been dissenters, especially in the decades immediately following World War II (among them Frieda Fromm-Reichman, Otto Will, Harold Searles, and Otto Kernberg). More recently, especially given the ascendancy of evidence-based medicine and its emphasis on “recovery”—on measurable reduction of symptoms that provides evidence of improvement—analysis and talk therapy have plummeted from favor.2
An influential article that reviews two decades of the relevant literature, for example (one often cited to me by psychiatrists), concludes by proposing “a moratorium on the use of psychodynamic treatments for schizophrenia.”3 In Surviving Schizophrenia: A Family Manual, E. Fuller Torrey writes that
psychoanalysis is to schizophrenia as Laetril is to cancer. Both have enjoyed surprising popularity considering the fact that they lack scientific basis, are completely ineffective, and still attract persons who are willing to pay vast sums of money for a cure.
“Successful treatment,” Torrey declares, “means the control of symptoms,” and this view prevails in the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Schizophrenia (2004), where the only type of talk therapy recommended is the brief, “evidence-based practice” of cognitive behavioral therapy (CBT), a short-term form of psychotherapy created by Aaron Beck, himself trained as a psychoanalyst, which—his novel contribution—emphasizes the role of conscious thought processes in mental disorders. By identifying and addressing negative beliefs, thought processes, and behaviors independent of unconscious conflicts and replacing them with positive beliefs, Beck and his colleagues discovered, patients could become capable of developing effective skills with which to cope with their problems.
In the final report of the President’s Freedom Commission on Mental Health, the emphasis, to the exclusion of all traditional forms of talk therapy (supportive psychotherapy, psychodynamic psychotherapy, insight-oriented psychotherapy, etc.), is on medication, on improving and disseminating evidence-based practices, and on short-term forms of psychotherapy such as CBT and interpersonal psychotherapy.
But consider what happens to someone suffering from schizophrenia for whom neither medications nor short-term therapies lead to a reduction in symptoms sufficient to make recovery possible. Consider, that is, the usual alternative: what treatment—and life—is like for most people who suffer from mental illness, and who do not have Elyn’s luck or intelligence, her will or her wherewithal.
Schizophrenia affects about three million Americans (approximately 1 percent of the population worldwide), yet despite our progress in research and treatment, Elyn writes, “recent statistics indicate that only one in five people with schizophrenia can ever be expected to live independently and hold a job.”
Like Elyn, my brother Robert was a bright young man (winning a New York State Regents scholarship to college) who was diagnosed at nineteen as a chronic paranoid schizophrenic. Like Elyn, he thrived on talk therapy. Chosen during his first long-term hospitalization to participate in insight-oriented psychotherapy three times a week for nine months, Robert was able to recover sufficiently to live independently in New York City, and to complete his second year of college. But when he relapsed and was rehospitalized, and rehospitalized repeatedly—more than fifty times in the ensuing decades—he came to spend most of his years in state hospitals (our family’s wherewithal being well below that of Elyn’s), where he received abundant medications and no talk therapy at all.
During these years he deteriorated terribly, and when, in 1997, thirty-five years after his first hospitalization, he was transferred to Bronx Psychiatric Center, it was the consensus of the staff that even were he able one day to live outside a locked ward, he was destined to be repeatedly rehospitalized.
At Bronx State, however, the director of psychology, Dr. Alvin Pam, disagreed with the staff, and saw him as a candidate for supportive psychotherapy in which the therapist worked with Robert to enable skills that would prove helpful in the present, while helping him make realistic plans for the future. For most of the next two years, Robert met with a therapist once a week, and once again he thrived. He was discharged after two years, and for the ensuing eight years he was not hospitalized for even an hour for emotional or psychiatric reasons.
Despite living, during these years, in two excellent group homes in the Hell’s Kitchen section of New York City, where the staff at each residence has been kind, devoted, and attentive, the quality of his life has declined steadily. Largely due to side effects of antipsychotic medications, his physical condition has become grave: he has gained an enormous amount of weight, he has major cardiac and pulmonary problems, and he suffers from drug-induced Parkinsonism (trembling hands, shuffling feet, drooling, diminished impulse control). To counteract the Parkinsonian symptoms, he must take drugs that blunt the effectiveness of the antipsychotic medications, one result being that he is, by turns, lethargic and agitated, irritable and bored, and often, especially to staff, nasty.
While medications may reduce symptoms, what, for a person who has lived for any extended period of time with madness, of the fear and the shame, the isolation and the feelings of worthlessness that invariably accompany madness? And what is it like, day after day and year after year, to be treated essentially as a set of symptoms that must be managed?
When, several years after his discharge from Bronx State, Robert’s irritability reached levels that left him inconsolable and the staff at his group home exasperated (and threatening him with expulsion), I asked the staff psychiatrist if it were possible for Robert to talk with somebody—once a week, or once every other week—and said that Robert was eager for talk therapy. Having somebody to talk to might also provide a practical dividend by giving him a place to vent his anger, and to deal with behavior and obsessions that were making life for him and the staff increasingly difficult. The answer Robert and I received was the same we’d received from this psychiatrist several years earlier: “No resources.”
Elyn writes movingly of her first analytic therapy with Mrs. Jones, who believed people with psychosis could benefit from analysis. “It was her theory,” Elyn writes, “that psychotic individuals are filled with (even driven by) great anxiety, and that the way to provide relief is to focus directly on the deepest sources of that anxiety.”
The story of Elyn’s relationship with Mrs. Jones is as poignant a tale of the healing powers of the doctor–patient relationship—of the difference that “tolerance, patience, and understanding” can make in a vulnerable, wounded person’s life—as one is likely to find. “For two straight years, I did my work,” Elyn writes, “met my obligations, made it through the day as best I could, and then fled to Mrs. Jones, where I promptly took the chains off my mind and fell apart.”
Is there an evidence-based way to measure the benefits to someone suffering the pain of psychosis of feeling free to simply let go—to let symptoms, along with aberrant, wild, destructive, and shameful thoughts, fly—and to trust that when you do, you won’t be punished or stigmatized or brutalized? On several occasions when Elyn’s analysts recommended that she go to the hospital and she refused, they didn’t, Elyn has recently written in private correspondence, “take the easy way out and require me to go. They tolerated a good deal of anxiety by doing that, but it was a great gift to me.” Among the benefits of letting go, Elyn notes, is seeing that others can be tolerant of “the bad in you”—of what you’re ashamed of—and that this “in itself makes people feel safer.”
When, several years later, Mrs. Jones died after being badly injured in an automobile accident, “the grief at her loss burrowed deep into my soul,” Elyn writes. “This was, in every way that mattered, a death in the family. For so long, through everything that had happened to me, I’d taken courage in knowing that Mrs. Jones was there, in her house, in that office. She knew me like no other.”
Elyn is eloquent about the crucial importance to one’s well-being of being known. “One of the worst aspects of schizophrenia,” she writes, “is the profound isolation—the constant awareness that you’re different, some sort of alien, not really human.”4 Hospitalized for the first time during her stay in Oxford, Elyn thinks:
What was happening to me? Why had it happened? And who would help me? But no one came. No one will ever come, I thought. I am worthless, I cannot even control my own mind. Why would anyone want to save me?
Conversely, at Yale, when friends come by, she is “both comforted and moved that they’d come at all.” She shows a friend the leather straps used to tie her to the bed, and he winces and shakes his head. “He got it,” she writes.
And that gave me courage. It was so easy to feel isolated and alone here; each one of these people who cared enough about me to come and visit gave me reason to hope that I was worth saving.
Medication and talk therapy may allay the terrible feelings of isolation that accompany schizophrenia, “but friendship,” she writes, “can be as powerful as either.”
Elyn continues, to this day, to have difficult times and psychotic flare-ups, but the love and companionship that come with friendship, and with her marriage to Will, get her through. “Sometimes, even now, when I’m going into an episode,” she writes,
I don’t tell [Will]—not to keep secrets, but so as not to burden him. Nevertheless, he almost always knows. He can tell from my silence—or a certain kind of silence. It’s a gift to have someone know me so well.
Robert’s cousins and former friends, dozens of them, often ask about him, but during the eight years he’s been living in New York City, outside hospitals, I can count on the fingers of one hand the number of visits he has had from these friends and cousins. In this, alas, Robert is not alone, for I almost never, even on weekends, see visitors in the residences in which he’s been living.
Many chronic illnesses and disabilities—heart disease, diabetes, multiple sclerosis, emphysema—require lifelong medication and treatment, and, often, housing in special facilities—but rarely do these conditions carry with them the lifelong penalty that comes with mental illness: isolation from the ordinary world, and from those who have known us. “When you have cancer,” Elyn writes, “people send flowers; when you lose your mind, they don’t.”
The Nobel Prize–winning neuroscientist Eric Kandel has written that when he began his residency in psychiatry fifty years ago, he “sensed that psychoanalysis could be immeasurably enriched by joining forces with biology,” and that if “the biology of the twentieth century were to answer some of the enduring questions about the human mind, those answers would be richer and more meaningful if they were arrived at in collaboration with psychoanalysis.” He goes on to articulate the basis for his ongoing optimism:
I believed then, and I believe more strongly now, that biology may be able to delineate the physical basis of several mental processes that lie at the heart of psychoanalysis—namely, unconscious mental processes, psychic determinism (the fact that no action or behavior, no slip of the tongue is entirely random or arbitrary), the role of the unconscious in psychopathology (that is, the linking of psychological events, even disparate ones, in the unconscious), and the therapeutic effect of psychoanalysis itself. What particularly fascinated me, because of my interest in the biology of memory, was the possibility that psychotherapy, which presumably works in part by creating an environment in which people learn to change, produces structural changes in the brain and that one might now be in a position to evaluate those changes directly.5
But Kandel’s optimism remains just that: a hope for the future, since we cannot yet describe or evaluate the structural changes he alludes to. Still, he is impressed by the results cognitive behavioral therapy has produced in people suffering from chronic mental disorders. Although such therapy often achieves results, especially with respect to depression, he adds, “the improvement is not always long-lasting.”
Indeed, it would appear, Kandel writes, that for some patients to achieve sustained improvement, short-term modes of psychotherapy (fewer than twenty sessions) such as CBT, “interpersonal psychotherapy,” “brief dynamic psychotherapy,” and “transference psychotherapy,” all of which derive from psychoanalysis, must continue for one or two years, perhaps because treating symptoms of their disorder “without addressing the underlying conflicts is not always efficacious.”
In the meantime, what we know, with CBT as with psychoanalysis, is that some treatments, whether evidence-based or not, and whether psychological or pharmaceutical or a combination of the two, work for some people, and that some don’t. We are, that is, far from having adequate answers to the treatment of psychoses, though in many instances, a happy set of convergences—of medications and therapists—can bring about beneficial results that transcend the usual, pessimistic prognostications. What is clear from Elyn’s life, as from Robert’s, then, is that to deprive patients of the possibility of extended talk therapy is to deprive them of treatment that not only may be helpful psychiatrically, but that can, in lives more isolated and meager than Elyn’s or Robert’s, be a source of comfort, meaning, and well-being.
Elyn Saks may be anomalous in many ways—in her will, her illness, her treatment, her luck, and her exceptional gifts—but she is not anomalous in her own sense of human experience, and one great virtue of her book is that it reminds us of what, to use her words, makes our lives worth living. She makes us aware, that is, of the sources of health and happiness—of resilience—within us, even in the darkest of times. “Whenever I was out someplace and heard people laughing together,” she writes at a time when she feared she might never be well or happy again,
I’d turn toward the sound in much the same way a flower turns to the sun. To laugh, to tease; not to be afraid of saying or doing something stupid or clumsy, because even if you did, you’d be loved anyway, and you’d always know it. What might it be like, to be completely at home in one’s life, and not be alone?
April 17, 2008
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.” ↩
Evidence-based medicine attempts to assess the quality of evidence relevant to risks and benefits of treatment (including lack of treatment). The term first appeared in medical literature in 1992; the most common definition is David Sackett’s: “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al., “Evidence-Based Medicine: What It Is and What It Isn’t,” British Medical Journal, Vol. 312, No. 7023 (1996), pp. 71–72). One problem, when evidence-based medicine is applied to chronic mental illness, is that it is easier to measure—to quantify—symptoms and symptom reduction, and, thus, the efficacy of medications, than it is to measure intangibles that, in often grim, unenviable lives, pertain to quality of life, however diminished the quality of those lives may be. ↩
Kim T. Mueser and Howard Berenbaum, “Psychodynamic Treatment of Schizophrenia: Is There a Future?” Psychological Medicine, Vol. 20 (1990), pp. 253–262. ↩
On her wedding day, alone with her closest friend, Steve, she writes that “a serious question had been troubling me for hours, and finally I just had to ask it. ‘Will aliens be attending the reception?'” Steve holds her hand, tells her that they won’t, and she tells us that she “needed to hear that reassurance from him, and having heard it, I happily went on with the day.” ↩
Eric R. Kandel, In Search of Memory: The Emergence of a New Science of Mind (Norton, 2006), p. 367. ↩