Running head: SCHIZOPHRENIA 1

The Center Cannot Hold: A Literary Analysis on Schizophrenia

Jacqueline Lagman

Rush University

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The Center Cannot Hold: A Literary Analysis on Schizophrenia

“But if, as our society seemed to suggest, good health was partly mind over matter, what

hope did someone with a broken mind have?” (Saks, 2007, p. 255) In her memoir, The Center

Cannot Hold, Elyn R. Saks helps restore hope to this forlorn mentality toward the mentally ill.

As humans, we fear the unknown and Saks not only dissipates that fear by shedding light into the

most severe psychotic illness, she establishes order in a tempestuous existence to discredit any

stigma held against a broken mind.

Mental Illness

Elyn R. Saks lives with schizophrenia, a thought disorder characterized by a loss of touch

with reality. According to Boyd, to be diagnosed schizophrenic by the Diagnostic and Statistical

Manual of Mental Disorders, the first criteria is to exhibit delusions, hallucinations, disorganized

speech, grossly disorganized behavior or negative symptoms for a significant portion of time

during a one month period; at least two of these symptoms must be present and one must be of

the first three (2013). This was witnessed during Saks’ hospitalization at Yale-New Haven

Hospital and Yale Psychiatric Institute, where she describes herself “floridly psychotic” during

the first six weeks. During this time she exhibited reference delusions and disorganized thinking,

characterized by flight of ideas, word salad and loose associations, “Voices went, tabernacle, out

to the edge of time. Time. Time is too low. Lower the boom. The TV is making fun of me. The

characters are laughing at me” (Saks, 2007, p. 92). She entertained grandiose and persecutory

delusions by continually warning of the devastations and horrible things she could do to

everyone with the power of her mind, and experienced illusions as she witnessed the walls

collapsing and ashtrays dancing. There were times that she hallucinated, seeing a man in the

kitchen with a knife that did not really exist (Saks, 2007). Even more notable were her consistent

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negative symptoms, easily confused with depression. She exhibited anhedonia, as few things

brought her pleasure, avolition, where she lacked motivation in certain areas such as self-care,

affect flattening and limited emotional range which took a toll on her relationships. For a

significant portion of her life she displayed apathy and social withdrawal, for instance, she

usually ate her meals alone in the dining hall (Saks, 2007). The isolation, limited ability to

communicate, stereotypy, and alogia could be seen in her everyday life as well as her

hospitalizations, “Disengaged from my surroundings, I sat in the dayroom for hours at a time,

jiggling my legs (I couldn’t sit still, no matter how I tried), not noticing who came in or out, not

speaking at all” (Saks, 2007, p. 65).

The second diagnostic criteria holds that in one or more social or occupational areas,

there is a decreased level of functioning markedly below the level achieved prior to onset (Boyd,

2007). While Saks was completing her undergraduate degree at Vanderbilt, the first symptoms

began to appear and her level of functioning in self-care began to decline. She was approached

by Susie, her roommate, with a hypothetical story of a girl that needed to shower more often,

brush her teeth and change her clothes; Susie’s story was in reference to her, but at the time, she

did not realize it. At Vanderbilt, and even more so during her graduate studies at Oxford, she had

trouble with interpersonal relationships. She could not hold conversations with new friends and

felt she did not deserve to speak with her family over the phone. She isolated herself, “With no

reference point outside my head (friends, familiarity, being able to accomplish anything at

school), I began to live entirely inside it” (Saks, 2007, p. 55). Saks’ illness had a huge impact on

her level of functioning at school. Due to her hospitalization, she was forced to withdraw from

her first year at Yale Law School. At this time she was given an IQ test and received a verbal

score of “dull normal” and a quantitative score of “borderline mentally retarded” (Saks, 2007).

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Other criteria includes continuous signs of the disturbance for at least 6 months (Boyd,

2013), Saks experienced symptoms for more than 6 months during acute episodes and has

continuously struggled with disturbances for the majority of her life. According to Boyd,

schizoaffective and depressive or bipolar disorder with psychotic features, and physiological

effects of a substance or medical condition must be ruled out (2013). She does not exhibit a

substantive mood disorder or experience a manic state, nor use a substance or have a medical

condition. Through her detailed memoirs, we recognize that she deals primarily with a thought

disorder, the symptoms she describes are congruent with schizophrenia.

Risk Factors and Etiologic Theories

There is no single known cause of schizophrenia, but there are biological theories.

According to Boyd, people with schizophrenia have a small total brain volume where the

thalamus, hippocampus, superior temporal and prefrontal cortices are smaller than usual, and the

lateral and third ventricles are larger. Positron emission tomography scans show decreased blood

flow and glucose metabolism in the prefrontal cortex, as well as dopamine hyperactivity at the

mesolimbic tract. Memory and emotion are regulated in this region, therefore the increased

dopamine is thought to cause hallucinations and delusions. The dysregulation of norepinephrine,

serotonin, glutamate, gamma-aminobutyric acid (GABA) are thought to be involved with the

symptoms of schizophrenia as well (2013). Risk factors pertaining to Saks are a genetic

predisposition and stressful life events (Boyd, 2013). Though no one else in her family deals

with schizophrenia, she does note that serious mental illness is common in her extended family

(Saks, 2007). Stressful life events can contribute to the development of the disorder and she

explains how moving and starting anew ranks high on the list of life stressors, similar to divorce,

serious illness, and death in the family (Saks, 2007). Saks experienced this for the first time

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when moving away to college where her first symptoms peaked through, and subsequently

whenever she packed up and moved to a new place, each of which caused her to relapse and

experience a psychotic episode.

Impact of Mental Illness

Mental illness can have a profound impact not only on the one suffering, but on friends

and family as well. Saks’ illness had no significant impact on her immediate family because she

stayed distant and kept her illness hidden. They did visit her during a few of her hospitalizations

and advocated for her transfer when she was mistreated at Yale-New Haven Hospital. Saks was

cautious with her friendships and disclosure of her mental illness, which lead to strong, solid

bonds among the relationships she formed. Her illness impacted Steve Behnke, her closest

friend, the most. They met in law school and found a common interest in serving the mentally ill.

Steve helped her through acute psychotic episodes, helped her make sense of things, brought her

to the hospital, and took care of her activities of daily living whenever in recovery. He constantly

provided support, be it with school, work or making decisions to go off medication. Even after

they were in separate cities, he continued to look out for her and talk to her every day. Jean and

Richard, friends living in London, would often get calls from confused acquaintances back in the

U.S whenever Saks would experience an acute episode. They would then make

recommendations to contact her therapist or bring her to a hospital. At present, her illness is well

managed, as it was by the time she met her husband, Will. The impact on him includes not being

able to have children together and, being that her threshold for unfamiliar environments is four

day, not being able to vacation longer than that. Whenever her psychosis breaks through, he is

there with support and love.

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Strengths

There is no recovery with schizophrenia, but with many internal and external factors,

Saks has been able to manage her illness quite successfully. Externally, Saks is fortunate to have

access to resources that many people do not. Her parents sent her to a prestige college where she

received an exceptional education. She had the resources to receive treatment and medication,

and access to talk therapy with trained and talented professionals. She has superb friends and

family that continue to help and support her day to day. She also spent two years at The Center,

where much credit of her willpower can be given as it “drilled into [her] an unflinching attitude

toward illness or weakness” (Saks, 2007, p. 32). Internally, among the willpower, she had a great

deal of stubbornness that worked in her favor. She would not let herself fail at anything, be that

graduating from college and law school with honors, acquiring tenure or being defeated by her

illness. Eventually she gained insight into her illness, she came to accept her diagnosis and

recognized that she needed medication. This insight brought forth the current maintenance phase

with few serious psychotic episodes allowing her to focus on matters she finds most important.

With her extraordinary intellect, she has built a successful career that not only provides the

structure she needs to stay sane, but gives purpose as she impacts the lives of others.

Response to Literature

Indeed my curiosity was sparked by many issues presented in this book. First the issue of

restraints, Saks’ encounter with restraints was inhumane and the thoughts and feelings she

experienced were horrid. It makes me wonder how many other people have and will go through

something similar. I found it interesting that British hospitals rarely use restraints and have not

for over a hundred years (Saks, 2007). Are the psychiatric patients different in Great Britain, or

is it the staff? Laws are put in place to protect patients, but humans carry out the tasks and, in

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that present moment, hold the power. She also brought up the issue of the right to refuse

medication. Both of these issues sparked my interest in questions concerning philosophy and

morality. Health care providers can decide whether a person is competent to make decisions for

him or herself, these decisions range from refusing medication to signing advance directives.

Seeing Saks’ side of these events made me question, at what point should someone be allowed to

make these decisions for another? It seems as if we hold a paternalistic stance when dealing with

difficult, mentally ill patients, a “we know what is best for you” approach and often use restraints

and medication because it is easy and efficient. Does every mentally ill patient that goes through

the health care system deserve the time and energy of the therapeutic care provided in the

hospitals of Great Britain, as portrayed in this book? Absolutely, but with few resources and little

funding, how do we find a balance? I am curious to discover how Great Britain’s system differs,

and that of other countries as well.

The Center Cannot Hold peaked my interest because schizophrenia is the most severe of

the psychotic disorders. Thought disorders are much less relatable than mood disorders, as many

of us have experienced depression symptoms and can relate in some way. Losing touch with

reality is a far-fetched concept that is difficult to grasp creating challenges for both patient and

health care provider. Through Saks’ memoirs of living with schizophrenia, I have gained insight

into how difficult it is living day-to-day life and how frightening it would be to have psychotic

thoughts, unable to distinguish what is real and what is not. I now see how vital a therapeutic

relationship is when working with psychotic patients. I have come to recognize how small a role

the actual diagnosis should have; mental illnesses can overlap, care should be patient-centered

and individualized. This book, coupled with being in the presence of psychotic patients on the

inpatient unit, has yielded me less frightened and more compassionate. Our society needs to be

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educated to assuage the fears and stigma, and consider Elyn Saks’ (2007) words, “The humanity

we all share is more important than the mental illness we may not” (p. 336).

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References

Boyd, M. A. (2013). Psychiatric nursing: Contemporary practice (5th ed.). Philadelphia:

Lippincott, William, Wilkens.

Saks, E. R. (2007). The Center Cannot Hold. Hyperion. Kindle Edition.