Sunday, March 31, 2013

Divinest Sense

Much Madness is divinest Sense -
To a discerning Eye -
Much Sense - the starkest Madness -
’Tis the Majority
In this, as all, prevail -
Assent - and you are sane -
Demur - you’re straightway dangerous -
And handled with a Chain -
--Emily Dickinson

I read an amazingly good book this weekend: Elyn R. Saks' autobiography, The Center Cannot Hold (2008).

Saks holds an endowed professorship at the University of Southern California's Gould School of Law. She has written extensively on the legal and civil rights of both children and the mentally ill. Upon being awarded a 2010 MacArthur Foundation fellowship (known as the "genuis grant"), she established The Saks Institute for Mental Health Law, Policy, and Ethics.

In her early twenties, Saks was diagnosed with schizophrenia. Despite being given a "grave" prognosis and warned that she would never be able to hold down a job or have a family, Saks has had an extremely successful career and is happily married.

Her autobiography documents her decades-long struggle with psychosis, forced hospitalizations, medications (and their side effects), and the stigma of mental illness.

Saks is an amazingly eloquent writer. As she points out, individuals who suffer from schizophrenia often suffer from an inability to connect to others, a symptom that frequently manifests itself in extreme apathy. Saks notes that luckily, she does not experience this symptom.

I think her luck is ours too.

Saks offers a compelling insight into what it means and how it feels to experience the complex illness that is schizophrenia. Well over halfway through her autobiography, she writes,
Right now, wherever you are--in your room, in a library, on a park bench, on a bus--literally hundreds of things clamor for your attention. On the outside, there are sights, sounds, and smells; on the inside you have your thoughts, feelings, memories, wishes, dreams and fears. Each and every one of these, both inside and out, is knocking at your door all at once. 
But you have the power to choose which thing, or combination of things, to give your attention to. (228)
But what if you could no longer choose? In schizophrenia, Saks observes, the brain's sensory "regulator" no longer functions correctly and as a result, the individual is bombarded with input--sounds, smells, thoughts, memories, ideas, feelings--that cannot be ignored, organized, or sorted.
Immediately, every sight, every sound, every smell coming at you carries equal weight; every thought, feeling, memory and idea presents itself to you with an equally strong and demanding intensity. (228-229)
People with schizophrenia often suffer from psychosis: they may see and hear things that aren't there. Sometimes, they suffer from paranoia as well: they fear the things they see and hear, even though those things may not really be there for you and I to see and hear.

As Saks simply and poignantly puts it, "Psychotic people who are paranoid do scary things because they're scared" (97).

That said, as Saks points out, most people who suffer from schizophrenia harm no one except themselves. And the things they would most benefit from--friendship, understanding, connection, predictability, support and affection--are often the very things they are denied by virtue of their illness.

Saks describes being forcibly medicated and put in four-point restraints at one point during her psychosis. She also points out that, in Great Britain, physical restraints of the kind that are standard practice in the United States have not been used in over 200 years.

One sentence in Saks' account particularly resonated with me: "When you're really crazy, respect is like a lifeline someone's throwing you. Catch this and maybe you won't drown" (79).

We rarely respect the dignity of the mentally ill: we assume the right to judge and prescribe what's best for them, based on appearances. We don't bother to ask what they want, because we assume they can't ("won't") tell us.

But more often than not, it is perhaps simply the case that they won't tell us what we want to hear, or that we won't take the time to try to understand what they're saying.

One of the things I found most compelling about Saks' autobiography is that, given the chance to spend time "inside her mind," many of the components of her psychosis make complete sense. They have their own logic, perhaps, but they can be decoded.

Stress often triggers schizophrenia. At one point, Saks describes being overly stressed by the law memo she needed to write during her first year at Yale Law School.

In her psychosis, she talked about "lemons." Law memo. Lemons. When I see the words, I see the connection. But if I simply saw a law student suddenly ranting about lemons, I would assume, "They're crazy. They're not making sense. Watch out. Lemons? What the hell is that about?"

Saks also describes how, in her own case, she will frequently invoke images of violence and speak threateningly when she herself feels stressed out and threatened. It's an unusual, but in many ways understandable coping mechanism, given the faulty functioning of her brain's "regulator": respond to feelings of being threatened with overt threats to others.

As Saks repeatedly points out, she is by no means suggesting that we should simply ignore the potentially dangerous behaviors of the mentally ill. Rather, we should try to understand them in order to better support and protect everyone involved.

All too often, American hospitals forcibly restrain the mentally ill in the absence of any signs of danger, to a degree that can be quite absurd. Thus, Saks describes how, working as an advocate, she once encountered a mentally ill patient who was put in restraints because he refused to get out of bed.


Who's the crazy and illogical one in that scenario?

Saks tells a similarly sad and amusing story of a mentally ill patient who was systematically documented as "delusional" because, although he refused to speak to the doctors or hospital staff, he spent hours on the phone talking to his "imaginary lawyers."

Imagine their surprise when Saks and a co-worker introduced themselves as the man's legal counsel.

At the end of her autobiography, Saks cautions against an overly optimistic reading of her story and her experience. Like every brain, every experience of mental illness is different. She cannot speak for "all" of the mentally ill, because mental illness is not a single, simple thing--although many often treat it as such.

How many people know the difference between schizophrenia and bipolar disorder? Between multiple personality disorder and schizophrenia? Too few. And even fewer realize that what a diagosis "means" for one person's quality of life is in no way predictive of what it will "mean" for another.

This is the note that Saks' autobiography ends on: the challenge of finding one's life. As she points out, "If you are a person with mental illness, the challenge is to find the life that's right for you. But in truth, isn't that the challenge for all of us, mentally ill or not?"

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Ralph Waldo Emerson once wrote, "Life is short, but there is always time for courtesy."