Thursday, May 20, 2010

The Center Cannot Hold

When I read a book about schizophrenia, I am always looking to see what things that I can emulate in order to help my son get through his own particular version of schizophrenia. This kind of guidance is virtually non-existent unless you read about it from people who have been there themselves.

It is easy to dismiss Elyn Saks as an over-achieving drama queen. Many people think that hers must be a mild case of schizophrenia since she is such a high achiever. I am amazed that she racked up all the credentials that she has while clearly psychotic much of the time. However, by doing this she has also demonstrated the elasticity of this diagnosis, and she has anecdotally pointed out some valuable insights for the rest of us. Her story will be disappointing for people who see getting off medications as a pathway to recovery because she finally admitted to herself, after years of refusing to take them, that she needed the medication to function. It just goes to show that there is no one size fits all solution.

When I read these first person narratives, I always ask what information is available now that wasn't available then or what did the person not do that might have helped? None of this guarantees, of course, that the outcome would have been any different. Elyn Saks did not explore vitamin therapy. Vitamins in large doses such as vitamin B3 (niacin) act like drugs and there are no negative side effects. Energy medicine, which has also helped my son, was not widely known back then, and so there is no mention is this book of therapies that could correct an energy imbalance

I have learned enough through my own investigations to see that certain factors were in her favor outside of just being female. One is that her family let her do her thing. It is sometimes said that the family has to be involved but not over-involved. This is what is called Expressed Emotion (EE). Patients with families exhibiting low EE are found to have better outcomes when it comes to schizophrenia. When I first was trying to find out some useful information about what to do for my son, I was intrigued to read that many doctors feel that people do best whose families don't seem to notice that their relative is ill. Elyn Sak's parents win top prize in that category, though it probably wasn't a deliberate strategy on their part. Once I caught on to this simple but elegant idea, I began practicing it with my son. It seems to work because it thrusts a certain responsibility on the person while they remain clueless about how really worried you are. They are less anxious this way. You will eventually be less anxious, too, by practicing low EE.

People who get labelled schizophrenic are often overly attached to their family. They are usually the dutiful, thoughtful, "good as gold", achieving child. This almost guarantees that their passage into adulthood will be troublesome in really weird ways. Becoming an adult and leaving the framework of the family frightens them. Rather than get angry and rebel (a time-honored method of achieving independence), many go psychotic. Highly sensitive to begin with, they simply freak when it becomes apparent that soon they will soon be venturing further into the world or that the world is putting more demands on them. They are, of course, way too "considerate" of their parents. German theologian and counsellor Bert Hellinger says that individuals with schizophrenia are particularly sensitive to (though consciously unaware of) family trauma often originating four generations in the past. They "self-sacrifice" for a parent as a way of atoning for past family trauma. In this case, Elyn Saks is no exception. Early on, she told a therapist that she no longer wanted to see her (Karen) because her parents were upset that the therapist hadn't figured this out and come up with a plan, and that it cost them too much money to continue to see her. "It never occurred to me back then (and if it occurred to Karen, she didn't say so) that I was taking better care of my parents than I was of myself."

The drug rehab program that she was forced into in high school by her parents left her no time to think for herself beyond the confines of what she was told to do and how to act. This may have worked to her advantage, not because she was abusing drugs (she wasn't) but because it gave her a framework of hard work and structure to her day that she was able to use throughout her psychosis. She always reached out for someone to hang onto, like clinging to a doorframe in a high wind, using that person as a frame of reference for her day. In her Oxford years she allowed time for herself to be clearly psycho within a framework of rigorous Kleinian psychotherapy, and then sobered up somehow during the rest of the day and went back and racked up more academic credentials. It was astonishing to me that the analysis that she underwent on a daily basis for three years in England didn't seem to lift her psychosis. She literally clung to the analyst right up until the day she left to go back to the United States, weeping and being her usual psychotic self. She had unknowingly done what psychiatrist Thomas Szasz advises. She found herself a contractual psychiatrist unconnected to an institution. She paid out of pocket for the privilege and she got what she wanted, rather than having the State force its one size fits all approach on her.

The high school drug rehab program also gave her a lifelong aversion to taking any drugs, whether legal or illegal. If you read Robert Whitaker's new book, Anatomy of an Epidemic, you will see that her success, messy as it is, may be in large part because she continually refused to take the antipsychotics that were offered her. Whitaker's book extensively documents that long term use of psychiatric drugs leads to poorer outcomes. Psychiatrist Daniel Carlat says: "We often talk about neuro-transmitters like serotonin and noroepharin. But that really ends up being neurobabble. It sounds impressive to patients and it makes them think we know what we're doing when we're prescribing the medications. But we don't really know how these meds work." Side effects, said Carlat, can be serious or in some cases, unknown. "We don't know enough about the side effects to know how many people we're putting at risk."

Elyn Sak's very messy psychotic life almost tempts me to say that an antipsychotic introduced earlier would have helped get her life together, and I am someone who is not at all in favour of relying on drugs to solve personal problems in living. Reading this book I am tempted to think "oh, please, just try an antipsychotic," but I am only too aware that psychiatric drugs can put you in a never-ending nightmare. They are major tranquillizers that set most people spinning off into long periods of relapse, weight gain, apathy, and unemployment. Should Elyn Saks have chosen the drug route, my guess is that she would not be where she is today, but there is also the possibility that had she received drugs earlier, she may have pulled herself together sooner and spared herself years of agony.

Another affirmation I got from this book is, if someone tells you that a certain therapy worked for them, then don't wait for the latest "scientific" evidence or psychiatrists to give it their blessing as a therapy in order to try it for yourself. Everybody "knows" apparently, that psychoanalysis "doesn't work for schizophrenics." Elyn Saks gives Kleinian psychotherapy (think Freud) major credit in helping her cope. Freud has been routinely trashed by modern psychiatry as unhelpful for schizophrenia. However, as her therapist pointed out to her back in the early 1980s, therapists have built on Freud's work as the basis of their work with schizophrenia. This influence doesn't seem to be well recognized today in an age where people think Freud has no relevance. Luckily for Elyn Saks, she didn't know what everybody else knows.

One can quibble by saying that since she still suffers from psychosis, then what good did psychotherapy do? I understand that she is now in training to be a psychoanalyst so she must believe in it strongly. People say the same things about cognitive behavioural therapy, which is finally getting a rethink after many years of being dismissed for schizophrenia. Most psychiatrists don't want to get that involved with their psychotic patients. It's easier and more financially rewarding to medicate them than to do the really hard work of getting to know them. I can't believe the number of people who won't try something because "there is no scientific evidence" that it works for schizophrenia. Well, individuals are not statistics, you are the persons most interested in your own recovery and you should do whatever it takes to get there. I have introduced to my son some truly unusual therapies, short of dancing on a toad's grave, but if I thought that might work, I'd be game. I noticed that most of these non-sanctioned therapies moved him forward in some way. The bottom line here is think for yourself. You are you, but you are simply a statistic to the medical profession as it stands today.

To make a long story short, I think this is a great book with a lot of insight.


  1. In actual fact Freud was convinced that psychotherapy was of no benefit to those experiencing psychosis. He advocated that these individuals cannot form a transference and as a consequence therapy would not work. The truth was Freud's psychotic patients frightened him thus he focused his attention on neurosis. It was only when some of Freud's contemporaries (most notably Freida Fromm-Reichmann) began working with psychosis that psychotherapy for this group began to take form.

    Clearly a psychotic patient can form a transference once their delusional belief system is broken into.

  2. I have never liked Freud because I feel he is not "schizo positive." Yes, he was afraid of schizophrenics. So much easier to work with rich neurotic women. Elyn Saks undertook analysis in England with a follower of Melanie Klein. According to Wiki:

    "Although she questioned some of the fundamental assumptions of Sigmund Freud, Klein always considered herself a faithful adherent to Freud's ideas. Klein was the first person to use traditional psychoanalysis with young children. She was innovative in both her techniques[2] (such as working with children using toys) and her theories in infant development. Strongly opinionated, and demanding loyalty from her followers, Klein established a highly influential training program in psychoanalysis. She is considered one of the co-founders of object relations theory."

    Klein's theoretical work incorporates Freud's belief in the existence of the "death instinct", reflecting the fact that all living organisms are inherently drawn toward an inorganic state, and therefore, in an unspecified sense, contains a drive towards death."

    Dr. Saks describes her therapy sessions in great deal. It is evident from her constant babble about killing people that she had a drive towards death. She also formed a transference with her therapist.

    Chris's therapist is a Freudian. Ian and I have scheduled a Family Constellation session with her that will be delving into the pre-birth and early childhood environment.

  3. I think, the maybe biggest problem with analysis as well as psychotherapy in general (as developed out of analysis) is the interpretation-technique. It doesn't work for "psychosis". People who are "psychotic" usually can't deal with being told truths about themselves, they can't contain it, as Laing points out in The Divided Self. I know, that I couldn't. Often "psychotic" people's truths are a lot more terrifying (to them) than "neurotic" people's. If you confront these people, all that will happen is "symptoms" (= fear, possibly aggression - as self-defence -, and "paranoia", which will kill any transference instantly). To a far greater extent than "neurotic" people, "psychotic" people need to find and name their truths themselves. So, in practice, questions work, statements don't. Meanwhile, the classic technique in analysis (and many forms of psychotherapy) is to ask questions in order to be able to come up with re-interpretations in the shape of statements.

    The problem is that if you can't make any statements, this means that you can't define the other, that you'll have to leave it to the other to define him-/herself. And that is indeed frightening. Especially to someone who chose to be a therapist or an analyst because they see a possibility to compensate for their own lack of self-confidence in defining others with professional authority...

    I must admit that I don't believe in the death drive. I believe in a drive to, constantly, create change, transformation, and death is a symbol for transformation. From this perspective, death is not the opposite of life (as in death drive vs. libido), but (an inevitable) part of it. So, even wanting to kill people, or oneself, is not based on a wish or need to end all life, and return to an inorganic state, but, on the contrary, on a need to make (new) life possible. I certainly didn't want to kill myself to achieve an inorganic, lifeless state. I was told that, in order to become alive, I'd need to get rid of my physical body, in itself a symbol for all the conditioning I'd experienced that prevented me from becoming alive, and thus become able to leave the physical world in which I was a prisoner (= not alive).

  4. Thanks for some very interesting comments. I am a bit confused about your saying analysis and psychotherapy don't work for schizophrenia. If questions work and statements don't and the person has to come up with their own truths themselves, then is there any kind of therapy that actually does work well for schizophrenia?

  5. Rossa: Yes of course there is. But it's definitely not the kind we see practised mostly where the professional is the expert who has all the answers (more or less). It's really like Joanne Greenberg says in Take These Broken Wings, that it was her who had the map, while all Frieda Fromm-Reichmann did was holding the light. That's why I think, professionalism often is more of a hindrance than an advantage when it comes to helping people find their own truths. You don't need a lot of theoretical knowledge about all the different models of how the human mind works, or about different therapeutic techniques. All you need is a genuine curiosity, enough humility to accept that nobody is as much expert on crisis as the person who experiences it herself, and the courage to accept someone else's truths unconditionally, no matter how terrifying they might be for you yourself.


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