What it's like to be psychotic

Elyn R. Saks knows what it's like to be psychotic and she wrote about it vividly in her 2007 memoir, The Center Cannot Hold: My Journey Through Madness. Her schizophrenia blossomed in her late teens and for twenty years she lived her life on two paths. On one, she was a high-achieving student, teacher, legal scholar, and tenured professor; a graduate of Vanderbilt University, Oxford University, and the Yale School of Law.

On the other path, she was a crazy woman, unable to distinguish delusion from reality, terrified by the voices in her head, babbling nonsense. What makes the book extraordinary is that Saks is able to show the reader what it's like to have a mind one cannot trust: "For some reason," she writes late in the book, "I decided that Kaplan [her psychoanalyst with whom she'd been working for years] and Steve [her oldest and closest friend] were imposters. They looked the same, they sounded the same, they were identical in every way to the originals—but they'd been replaced, by someone or something. Was it the work of alien beings? I had no way of knowing, but I was terrified."

Notice that in her psychosis she doesn't—she can't—question the reality of this switch. The two people closest to her have been replaced, and so she can no longer trust anything they say or do. No logic, no evidence will convince her otherwise. In this situation, psychoanalysis, the talking cure, is no help.

Fortunately there are drugs. Unfortunately the drug have side effects (although apparently pharmaceutical companies continue to improve the effectiveness and reduce the side effects). For years, however, Saks was convinced against all evidence to the contrary that she could control the voices in her head if she just tried harder. She was profoundly afraid of the drugs, both for the genuine harm they could do over time and because she would not admit she had a genuine disease that required drugs to ameliorate. She repeatedly took antipsychotic medication, felt better, and tried to taper off because she felt better and became an unwashed, babbling, terrified crazy lady.

The Center Cannot Hold is so powerful in places where Saks is almost entirely out of control, I wondered how she was able to write the book at all. This must be what it was like to have delusional thoughts about your therapist, who is only kind and helpful: "She is evil and she is dangerous. She keeps killing me. She is a monster. I must kill her, or threaten her, to stop her from doing evil things to me. It will be a blessing for all the other people she is hurting."

Because Saks is now a psychoanalyst herself, and because she has always been a high achiever when she could function, her memoir is both a personal story, which is fascinating, and a report on how people with mental health problems were treated in the 1980s and 90s, which is sobering. (One can only hope that the situation in American mental hospitals has changed.) She points out a classic bind for 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."

Saks was lucky. She managed to get the help she needed, and she's written a powerful book about a pernicious disease.