Divided Minds

Divided Minds is a literary duet between two almost certainly identical twins who relate a half-century saga of what it is like to be and what it is like to love a person with schizophrenia. Initially, Pamela was the preferred and the dominant twin, but around sixth grade she began a downward spiral culminating in alternate episodes of uncontrollable catatonia and extreme schizophrenic excitement. In junior high, Pamela had been beset by fears and later began a lifelong pattern of cutting and burning herself. After the two sisters entered Brown University, Pamela’s decline into paranoia accelerated. Pamela’s account details how it feels to hear voices and to suspect evil in everyone. In Divided Minds, Pamela vividly describes her struggles with her antischizophrenic medications, and with the unwitting cruelty of the hospital staff that cared for her.

In contrast, her twin, Carolyn, became a gifted chief psychiatric resident on a Harvard Medical School psychiatry service and grew into a thoroughly sane psychiatrist and mother of two children and a patiently caring sister. For 40 years, Pamela and Carolyn have been “best friends.”

Divided Minds is illuminated by the fact that Pamela and Carolyn have always had an unusual gift, as twins often do, for intimate conversation with each other. It also helps that both women are gifted writers, that both attended medical school, and that they both deeply love each other. Like the famous identical Genain quadruplets, Divided Minds illustrates beyond doubt that the schizophrenic syndrome is far more complex than a simple one gene disorder like Huntington’s or Downs syndrome; however crazy and in need of four-point restrains Pamela may have seemed to the rest of the world, the two twins could usually still talk sanely to each other. In the 1960s I remember Elvin Semrad, the Buddha-like clinical director at the Massachusetts Mental Health Center, astonishing us residents by his extraordinary ability to speak “the language of the heart” to reach the most isolated catatonic schizophrenic patients. To our dismay once the patients left his loving presence, the patient was again out of control. In similar fashion, to return to the outside world Pamela has always required sophisticated psychopharmacology as well as Carolyn’s empathy.

Divided Minds helps explain why for years, psychiatrists with a psychodynamic bent saw schizophrenia as reactive. Every stressful event (JFK’s assassination, Y2K, and serious interpersonal losses) led to Pamela decompensating into madness. The schizophrenic brain does not “fragment” a la Kohut, it decompensates into failure like a vulnerable heart. As in recovery from congestive heart failure, empathy and medicines are both important.

So much of our confusion about schizophrenia is the product of perceptual and cognitive distortions that occur when sane people get close to schizophrenic individuals. As the irrationality of much past research on schizophrenia suggests, these distortions may make the observer as mad as the “lunatic” (1). These distortions are silent, invisible, and undetected and yet they violate empathy irreparably. For example, just consult a first-year psychiatric resident or a standard psychiatric text for a description of the dominant affect in schizophrenia. “Blunted,” “depressed,” “angry” are the most common answers. Just consult any schizophrenic subject in remission of how they felt when psychotic and the answer is invariably “terror” or in the case of catatonia, “scared stiff.” Pamela Wagner’s description of her phenomenology drives this important insight unforgettably home.

Although I believe that the diagnosis of “schizoaffective” is rarely useful, Pamela Wagner’s brilliant portrayal of her inner state illustrates that the phenomenology of schizophrenia and bipolar depression overlap in ways that psychiatry has not yet unraveled (2).

I believe that Divided Minds is the best book on schizophrenia since Eugen Bleuler’s The Group of Schizophrenias(3). Nor is it coincidence that Eugen Bleuler’s genius in defining schizophrenia stemmed in part because several of his boyhood friends developed schizophrenia. In the preface to another influential book on the malady, Schizophrenia: A Review of the Syndrome (4), Leopold Bellak acknowledged that a life time spent reviewing the world’s literature on schizophrenia and treating them in his consulting room had not taught him as much as “feeding catatonic schizophrenics, attending to all their bodily needs, as well as living in the same small cottage with them” when he was a psychiatric nurse. Genetic analyses and fMRI may never teach us more than half the story about this complex illness.

The one facet missing from this brilliant narrative is the affective viewpoint of the parents. To both twins, their parents often appear harsh, cold, unforgiving, and narcissistic. But as I learned early in my psychiatric career, an empathic synonym for narcissism can be “in pain.” To live with an often angry and autistic adult child can be exquisitely painful. Parents react in ways that they later regret and that outside observers find easy to condemn. But the parents of schizophrenic individuals, like the parents of other brain-impaired children, deserve forgiveness. Let only those who have walked miles in their moccasins cast stones.

To understand how schizophrenic individuals really feel, every resident in America should read Divided Minds, a text significantly superior to Bell Jar, I Never Promised You a Rose Garden, and Autobiography of a Schizophrenic Girl (5–7). Divided Minds is the most lucid book on the schizophrenic experience that I have ever read, and I believe that it belongs on every psychiatrist’s bookshelf and on the shelves of as many relatives of schizophrenic individuals who have the courage to read it. For parents and siblings of schizophrenic patients, the brutal honesty of Divided Minds will be painful; but truth, however painful, can also set us free.