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The Center Cannot Hold: My Journey Through Madness
Reviewed by JUSTIN SIMON
Am J Psychiatry 2008;165:402-403. doi:10.1176/appi.ajp.2007.07111814
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by Elyn R. Saks. New York, Hyperion, 2007, 340 pp., $24.95.

This is the autobiography of a gifted woman with schizophrenia whose story is nothing short of legendary. At the age of 7 or 8, in response to a rebuke from her father, Elyn Saks has a terrifying experience that is a harbinger of the illness which will shape her life: “My mind feels—like a sand castle with all the sand sliding away in the receding surf…The ‘me’ becomes a haze, and the solid center from which one experiences reality breaks up like a bad radio signal…the center cannot hold” (p. 12).

Through her early years Saks suffers from night terrors, compulsive rituals, anorexia, and the experience that houses are putting ideas into her head. In college she has outbursts of bizarre behavior and regressive periods of withdrawal with lapses in personal hygiene. In her early twenties she has two psychotic episodes, each requiring months of hospitalization. She is gravely ill with a poor prognosis. Subsequently, even when she is better, she suffers frequent intrusions of delusional thinking and fragmentation. In short, she manifests four of the five cardinal symptoms of schizophrenia—delusions, hallucinations, disorganized speech, and disorganized behavior. Any two symptoms can establish the diagnosis.

However, although one center doesn’t hold, others do. Saks’s remarkable intellect is never permanently compromised, nor does she ever relinquish her ferocious determination to defeat her demons. She battles through a schizophrenic fog to win academic honors at every educational institution she attends: Vanderbilt (where she is class valedictorian), Oxford (where she obtains a graduate degree in philosophy), and Yale Law School (where she obtains a juris doctorate). Given the severity and chronicity of her illness, it is nothing short of astounding that she is presently a married professor at the University of Southern California Gould School of Law (in an endowed chair), adjunct professor of psychiatry at the University of California, San Diego, and a research clinical associate at the New Center for Psychoanalysis. She has published four books and two dozen papers, and survived two major life-threatening illnesses without falling apart.

Reading The Center Cannot Hold is, for us in psychiatry, more than a busman’s holiday, though that it is. The fact that the patient with schizophrenia who wrote this autobiography is also a scholar of philosophy, law, and psychoanalysis draws us into the phantasmagoric world of schizophrenia quite differently from our ordinary exposure. It is a sophisticated insider’s view of her illness, which hones the edges of identifying both the disorganizing and curative forces of grave mental illness. The latter include, unexpectedly and prominently, psychoanalysis.

Saks’s stubbornness as a child morphs in her adulthood into a gritty determination to get well, but that determination cuts in two directions. Early on she adopts the view that drugs compromise one’s strength and integrity, and so she doggedly opposes antipsychotic medication. Consequently she falls into an all too common cycle—when she seriously regresses she is too ill to oppose taking medications, and when the medications enable her to regain her sanity, she resists taking them. She has bitter, extended battles with her therapists over the drugs, and after one particularly fierce struggle she decides, on her own, to slowly taper off thiothixene. Halfway to her goal, she falters. “The sheer physical effort of containing my body and my thoughts felt like trying to hold back a team of wild horses” (p. 272). However, she goes on to reduce the dose further and quickly becomes floridly psychotic, spouting delusions in a word salad. Under threat of rehospitalization she abandons her project. “For days afterward, I felt like the survivor of an accident” (p. 277). At first she feels like a failure, but on reflection she comes to acknowledge the absolute truth of her need for the drugs. As she does, “almost immediately, I felt quite good” (p. 282).

Although shy, Saks always has one or two very close friends; they and new ones remain close throughout her lifetime. She also forms intense attachments to the analysts with whom she works—usually five times a week—over a period of many years. Each termination, occasioned by moving away, is gut-wrenchingly difficult. It follows that the most predictable disorganizing influence is change. Her first psychotic breakdown happens soon after she leaves Vanderbilt for Oxford, her second after moving to Yale. Relocation creates complex pincers of stress, breaking attachments and confronting the unfamiliar. Diminished self-esteem is collateral damage of her illness. Despite her raft of accomplishments, every success is marked by surprise—now, maybe I AM worth something! Conversely, any hint of failure kindles self-recriminating voices, inviting regression and psychosis.

Elyn Saks snatches a life from the jaws of psychotic chaos through a symmetry of curative forces which fuel and sustain her determination. “Medication kept me alive; psychoanalysis…helped me find a life worth living” (p. 298). A host of other factors contribute to her survival. She was born into an intact, caring family with the means to afford whatever treatment and education she needed. She has an incredible intelligence and a voraciously inquiring mind, which enables her academic mastery in stabilizing environments, with tangible rewards. She has the wisdom and capacity to form and keep an ever widening range of friendships that foster trust in others and herself.

There is something of the fable in this autobiography, as it evokes comparison to the fairy tale of Rumpelstiltskin, the dwarf who spins gold from straw to save the miller’s daughter. Saks spins her own gold. In one acute psychotic state, she has to be placed in restraints and has the delusion that she is a bug impaled on a pin, struggling helplessly while someone contemplates tearing her head off. That terror of loss of autonomy transforms into an ardent advocacy for patients’ rights (Sak’s third book is Refusing Care: Forced Treatment and the Rights of the Mentally Ill). To carry the metaphor further, Saks writes, “psychosis sucks up energy like a black hole in the universe” (p. 272). In her journey through madness she gathers light from many corners of the healing universe: psychoanalysis, psychopharmacology, philosophy, law, friendship, and collected forms of caring, patience, love, and kindness. She, in turn, becomes a sort of brilliant star who walks proudly among us, lighting an optimistic path and making us proud of the profession which shepherds her journey. She is not the first person to sail a ship through this terrible storm, but she has made a major contribution to the cartography of the ordeal. I am grateful for the opportunity to congratulate her success and applaud her book.

+Book review accepted for publication December 2007 (doi:10.1176/appi.ajp.2007.07111814).




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