From the Literature
Elyn R. Sak’s The Center Cannot Hold (2007) and Kay Redfield Jamison’s An Unquiet Mind (1995) are exemplars of a psychiatric confessional genre—first-person accounts of severe mental illness. Such narratives are manifold and extend back to classical antiquity. In the second century C.E., the Roman sophist Aelius Aristides wrote of his psychosomatic illness and its treatment. According to Rosen (1968) this was the first autobiographical account of mental illness. Some have made their authors famous. Daniel Schreber, a prominent 19th century German jurist developed a mid-life psychotic illness which led to his hospitalization for nine years. During the latter part of this period he published, to the dismay of his family, a memoir of his illness and treatment (Schreber, 1903/1955). His text indicates that he remained floridly psychotic. Freud (1911/1971) would use Schreber’s book as the scaffolding for his theory of the psychodynamics of paranoia and the mechanism of projection thus providing Schreber with enduring recognition (at least in psychoanalytic circles).
To this reader, what is compelling about Saks’ and Jamison’s memoirs, alongside the authors’ considerable literary talent, is an unflinching honesty concerning the subjective horrors of their illnesses. They are unsparing in describing the relentless, recurrent invasion of their rational minds by their psychoses. They are candid about the treatment, or lack of it, they received or repudiated. It is of interest to psychiatry to examine what was actually therapeutic for them and enabled them to not fatally succumb and to be able to enjoy ongoing productive and creative professional lives. It has to be acknowledged that both these authors are unusual people—intellectually gifted, capable of withering introspection, ambitious and, as their books demonstrate, able to use their traumatic personal experience of psychosis by writing about it. Not your average patient with severe, crippling mental illness. Nonetheless, certain elements of what helped them stand out and may have more general implications for therapeutic endeavors with the psychoses.
Saks is a professor of law at the University of Southern California. From her adolescence onwards she regularly fell apart psychologically. While in law school at Yale she was hospitalized, delusionally convinced that: “There will be raging fires and hundreds maybe thousands of people lying dead in the streets. And it will all—all of it—be my fault” (Saks, 2007, p. 4). She felt her hospitalization was “a brutal experience” (Saks, 2007, p. 6) because of the use of restraints and forced medication. (Some years later she wrote a scholarly text advocating for the civil rights of the mentally ill.) Despite recurrent, life-threatening psychotic episodes, Saks resisted for many years the belief that she had schizophrenia and suffered from a real illness. After multiple treatment failures her experience with an effective antipsychotic broke apart this denial:
The clarity that Zyprexa gave me knocked down my last remaining argument. There’s no way to overstate what a thunderclap this revelation was to me. And with it, my final and most profound resistance to the idea that I was mentally ill began to give way. Ironically, the more I accepted I had a mental illness, the less the illness defined me—at which point the riptide set me free” (Saks, 2007, p. 304).
Saks had many tempestuous, but generally helpful and sometimes life-saving engagements with psychotherapists:
Medication has no doubt played a central role in helping me manage my psychosis but what allowed me to see the meaning in my struggles—to make sense of everything that happened before and during my illness, and to mobilize what strengths I may possess into a rich and productive life—is talk therapy.—It is at the heart of things, a relationship and for me it has been the key to every other relationship I hold precious (Saks, 2007, p. 131).
By the time Jamison wrote her memoir she was the coauthor of the standard text on manic-depressive illness. When she was 28:
I was manic beyond recognition and just beginning a long, costly personal war against a medication that I would, in a few years’ time, be strongly encouraging others to take. My illness and my struggles against the drug that ultimately saved my life and restored my sanity had been years in the making (Jamison, 1995, p. 4).
Jamison’s first attack of manic-depressive illness occurred when she was a senior in high school. The ecstatic aspects of her mania were intoxicating: “I felt great. Not just great, I felt really great. I could do anything” (p. 36). The inevitable down-turn was horrifying: “…. my mind had turned on me—it no longer found anything interesting or enjoyable or worth-while.—I was going to die, what difference did anything make—why live” (p. 38). These excruciating cycles recurred throughout college and into her academic life. They are limned by her with evocative writing: “…. you are irritable, angry, frightened, uncontrollable and enmeshed totally in the blackest caves of the mind. You never knew those caves were there. It will never end, for madness carves its own reality” (p. 67). She notes:
… mania is not a luxury one can easily afford. It is devastating to have the illness and aggravating to have to pay for medications, blood tests and psychotherapy. They, at least, are partially deductible. But money spent while manic doesn’t fit into the Internal Revenue Service concept of medical expense or business loss. So after mania, when most depressed, you’re given excellent reason to be even more so (p. 75).
The efficacy of effective combined psychopharmacology and psychotherapy is captured by Jamison:
At this point in my existence I cannot imagine leading a normal life without taking lithium and having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs…. But, ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope of possibility of learning from it all. Psychotherapy is a sanctuary; it is a battleground; it is a place I have been psychotic, neurotic, elated, confused and despairing beyond belief. But, always, it is where I have believed—or have learned to believe that I might someday be able to contend with all of this (p. 88–89).
What can be gleaned from these two inspirational stories of living with ravaging mental illness? Not simply the obvious that skilled use of medication and psychotherapy works best (true in both cases). Saks and Jamison highlight the profound blow to their self-esteem and their identity that their illnesses engendered. Their initial intense desires to deny being ill is a common phenomenon in those who experience psychosis. Ultimately, it was healing [for them] to embrace the disease as part of themselves and not to sequester it as an alien invader. Saks (2007) observes: “…. my good fortune is not that I have recovered from mental illness. I have not nor will I ever. My good fortune lies in having found my life” (p. 336). Jamison (1995) notes: “The Chinese believe that before you can conquer a beast you must first make it beautiful. In some strange way, I have tried to do that with manic-depressive illness. It has been a fascinating, albeit deadly, enemy and companion” (p. 5). As these two memoirs suggest, bringing the demons of psychosis into the light of day, making the ‘enemy’ a ‘companion’, a dangerous one who needs to be constantly monitored, is itself therapeutic and helps to temper the profoundly demoralizing narcissistic injury that psychotic illness inevitably brings in its wake.
(1911/1971):
(1995). An unquiet mind. New York: Alfred A. Knopf, Inc.Google Scholar
(1968). Madness in society. New York: Harper & Row.Google Scholar
(2007). The center cannot hold. New York: Hyperion.Google Scholar
(1955).
