Interview with Prof. Elyn Saks

Elyn Saks is the author of _The Center Cannot Hold: My Journey through Madness_, a memoir of living with schizophrenia that was published last year to great critical acclaim. She is a professor at the University of Southern California Gould School ofLaw, and an adjunct professor of psychiatry at the University of California, San Diego, School of Medicine. She is a research clinical associate at the New Center for Psychoanalysis. She graduated with a Master's degree from Oxford University, and a J.D. from Yale Law School, and was the recipient of the Marshall Scholarship. She is also currently collaborating on a research project that is studying the coping skills of high-functioning schizophrenics. She lives in Los Angeles with her husband Will.

The following is an abridged transcription of our telephone conversation.

SCS (me): I'm curious what the response from your colleagues and peers in academia and research has been -- how they have responded to the book? I know in your book you expressed qualms about "coming out of the closet".

Prof. Saks: The response has been overwhelmingly positive and supportive. Actually, The only negative response I've gotten was from an administrator who told me she wished she had known I had schizophrenia before dinner, and I said, "Why?" and she said, "Because I wouldn't have had dinner with you." ... I was in the closet for decades, I only told my closest friends about it.

SCS: How did the inspiration for the book come about? How did it come to fruition, come into being, in terms of process?

Prof. Saks: ...well, I certainly wanted to wait until I had tenure -- one day I woke up, and, you know, I said, "This will be a good thing to do". This is in the book -- I took my manuscript to a psychologist at UCLA who said, "Do you really want to do this?" -- she was the one who said, "Do you really want to become that schizophrenic with a job?" I thought, "You know, I really don't want to become known that way", and then I thought, "You know, there's really nothing else I could write that could potentially be more meaningful to people than this book. If there are risks, I'm willing to take them. And I really got behind the project.

SCS: What do you think about the idea that one of the greatest obstacles to recovery is the lack of hope in the discourse -- what you hear from psychiatrists?

Prof. Saks: I think it's a tragedy -- [at this point, I will summarize Prof. Saks' points, as the tape recorder becomes inaudible] Saks goes on to describe the importance of Steve Larder's concept of "quality of life", as an essential necessity to facilitate healing and recovery. "Quality of life" describes the importance of having meaning in one's life -- whether it be through a job, a relationship, or some other activity that brings a sense of fulfillment, well-being, or purpose.

SCS: Towards the end of the book, you talk about embarking on this training to be a psychoanalyst, through the New Center for Psychoanalysis -- how is that proceeding?

Saks completed her training, but because of her public life and since the publication of her book, which details her psychosis and divulges much about her inner self and private life through the years in its pages, there is a conflict of interest in becoming a practicing psychoanalyst, as a psychoanalyst ideally will function as a blank slate, that a patient can use as a mirror, to examine her own fears, desires, inner negativity or assumptions, and through this process of "using" the therapist to understand herself or, in other words, in the specific traits or feelings she ascribes to the therapist, can gain a better understanding of herself. As Saks is now a renowned public figure and author, this would distort the patient's process of transference -- the relationship with the therapist -- as the patient would ascribe attributes to her that would shut down this psychoanalytic process of projection, and a patient's full and open self-disclosure.

SCS: You also mention at the end of the book that you are working with, and on, a research project designed to study high-functioning schizophrenics. How is that going?

Prof. Saks: The study is almost finished recruiting subjects (15 of 20 spots). The research subjects are professionals in their respective careers, who also have schizophrenia. The subjects for this study are currently limited to those living in the Los Angeles area. Prof. Saks is both a researcher and a subject for this study, which is seeking to elucidate the subject group's successful coping strategies -- the thoughts, actions, or mechanisms that have enabled these people to successfully hold a job. The ultimate hope is that these strategies can then be described and outlined, for use in the general population of schizophrenics, to facilitate recovery for all schizophrenics.

SCS: Has the Clozaril helped to keep your negative symptoms at bay, or are there times when they sometimes come back?

Saks describes that sometimes the psychotic thoughts will start to return, but she can more easily dismiss these as psychotic, and doesn't feel overwhelmed by them, as she did in the past. She also points out that her symptoms are mainly positive, rather than the negative symptoms of avolition (lack of motivation), apathy (lack of feeling), and cognitive deficits (unclear thinking). She attributes her success in academia to this lack of negative symptoms. Positive symptoms include psychotic thinking, delusions, and hallucinations. Thus, she may remember the "evil beings in the sky", but would no longer, for example, hide under her desk to try and escape their immediate presence in the room. The clozaril -- in conjunction with therapy, which she goes to five times a week -- has made it easier for her to separate herself from the delusional thoughts.

SCS: Did you have to elide any experiences for personal or editorial reasons?

Saks didn't withhold any of her psychotic experiences, but the British publisher of the book asked her to change the name of the mental institution she stayed in while in Britain, because of her vivid descriptions of its uncleanliness.

SCS: Has your central thesis in your book _Refusing Care: Forced Treatment and the Rights of the Mentally Ill_ (published, 2002) changed or developed over the years?

Saks said that she feels the same way about the issues of forced medication, involuntary commitment, and the use of mechanical or other restraints (for example, seclusion, quiet rooms, denial of rights and privileges) as she did when she argued for greater dignity and rights on behalf of mental patients with the important legal arguments she elucidates in this book.

SCS: What is at the heart of the psychoanalytic relationship for you?

Saks notes that often, mental health providers don't feel psychoanalysis can be helpful to schizophrenic patients -- it is "not the treatment of choice" for schizophrenics -- an idea that goes back a hundred years to Freud. For her, psychoanalysis has been invaluable in many ways, three of which have been key: first, to help her identify, mitigate, or avoid stressors; second, to assuage the "narcissitic injury" being mentally ill -- "the injury to one's pride" or "wound to one's ego" -- that is caused by being schizophrenic; and third, therapy functions as a "safe place" where she feels she can divulge and discuss the contents of her psychosis, without fear of judgment. For Saks, the therapeutic relationship thus functions as a "release valve", to "let off steam", such that her psychotic thoughts don't erupt in the wrong place, for example, at work, or in front of others who don't know her. Also, the psychoanalyst is a kind, caring person with whom she has a strong personal connection, and whom she knows will be there for her in the event of difficult times. The therapist is ideally someone who is nonjudgmental: "who not only accepts the good, but also the bad and the ugly".

Saks: "You become more psychologically minded, so you query what your thoughts and feelings are about -- interpreting and detoxifying your symptoms -- for example, my analyst might say 'Elyn you're saying violent things because you're scared -- your violence is a defense against your fear'. And that made sense to me, and those symptoms went away."

Therapy has helped her to accept her illness as "part of me, but not the whole of me". "Therapy has really helped my quality of life -- for me, I was diagnosed schizophrenic with a very poor and grave prognosis. Both medication _and_ therapy have helped me".

SCS: Describe your experience of the "evil beings" you describe in the book -- are they actual entities -- spirit beings, or is it more of an palpable sense of the presense of evil that comes over you?

Saks describes how her therapist has helped her see the phenomenon of the "evil beings" that would hover above her and surround her during acute psychotic episodes, as a projection of her natural, instinctive feelings about others in her life -- specifically, feelings of fear or anxiety that others in her life might elicit, that she has pushed aside or failed to acknowledge as her own true feelings, and so have been displaced into an expression as a psychotic symptom.

SCS: ... thank you very much for your time today, and sharing your thoughts with our readers.

Saks: Thank you.