MemoirAsked by a friend, on the last page of this book, "If there were a pill that would instantly cure me, would I take it?" the author, Elyn Saks, replies: "In a heartbeat." This is one of a number of internal contradictions in a memoir that describes a 30-year history of acute schizophrenic relapses. These relapses usually occur when Saks decides to stop the medication which enables her to function.
Now a professor in both law and psychiatry at the University of Southern California, Saks's career pathway evolved from her experience of mental illness and the loss of control that came with it. In her encouraging memoir, written with the help of a professional writer, regaining that control is a core theme. One of her first journal publications was entitled: The Competency to Refuse Medication. The key to Saks's preoccupation with autonomy may, however, lie as much in her childhood as in her illness - although she does not portray it that way.
Born to East Coast parents who had settled in Miami, she describes an enviable, idyllic, privileged family life. Leisure time, with her Jewish lawyer father who loved jazz, her outgoing, pretty mother and two brothers, was spent by the pool or boating and water-skiing. On the face of it, as she says, it was "a Norman Rockwell magazine cover or a gentle 1950s sitcom".
This profile gives no hint of an authoritarian parenting style, so it comes as something of a surprise when, in response to their daughter's pre-pubertal weight gain, they "spoke constantly about the need to count calories . . . and monitored very closely every single thing each of us ate". By then her parents had stopped eating bread entirely: being overweight denoted "someone who was either greedy or lacked control".
Perhaps this attitude kept everyone on-track in middle adolescence - Saks's brothers have only walk-on parts in this book - but by the late 1960s, smoking pot was becoming a rite of passage in American high schools. Aged 17, Saks accepted a tablet of mescaline - a hallucinogenic - from a school friend at a drive-in movie. A few days later, scared by the hangover effects and in need of advice and reassurance from her parents, she decided to disclose, not the mescaline incident, but a previous experience of sharing a joint on a recent school trip. When her father issued an ultimatum that, unless she pledged to avoid all further experimentation, he would have to "take steps", she rebelled, citing her good school grades and otherwise trouble-free behaviour.
WITHIN A WEEK her world "flipped upside-down" as she found herself being driven by her parents to enrol in a "no-nonsense tough-love" rehab programme which she would attend every day after school for the next two years . The programme drilled home her father's message, to fight any weakness and "never use drugs". It took a long time to unlearn this lesson.
So what were her parents so frightened of? While Saks does not want to contribute to a history of schizophrenia "that is rich in blame for families", one of the established facts about the illness is the importance of genetic influences. Yet we are halfway through this book before we are told that: "As with many families there is serious mental illness in my family as well." Earlier, there is a brief mention of her mother's younger brother, who qualified in medicine but never practised because of "serious psychological problems". He later committed suicide at the age of 47. Apparently these issues were "never discussed" in the family.
One might have expected that the decision to write about her illness would have provided an opportunity for a sensitive exploration of family history, but if it did, Saks clearly does not feel free to reveal it.
During her undergraduate years at the old-fashioned Vanderbilt University, Saks's summer vacations at home seem to have been relatively bleak and joyless: and she was beginning to have some worrying symptoms. Academically, however, she excelled, winning a scholarship to Oxford, where, within a short period of her arrival, she had her first serious breakdown.
DISCHARGED AFTER TWO weeks in hospital she met up briefly with her parents in Paris. They "seemed relieved" that the problem was "now fixed". Understandable then that, when eight months later she is readmitted - this time for four months - she made a weekly journey to a public phone booth to call Miami, collect, so that they wouldn't suspect the truth.
It was at this point that a significant intervention occurred which would remain a therapeutic resource for the rest of her life. When her symptoms failed to respond to antidepressant medication, her psychiatrist at Oxford's Warneford Hospital arranged a consultation with Dr Anthony Storr, the well-known psychoanalyst.
Although recognising the severity of her illness, he recommended her discharge from hospital, and to her relief, advised that she resume her studies. The condition attached was that she would start psychoanalysis and see her therapist every single day for the foreseeable future.
Had the diagnosis been one of Chronic Paranoid Schizophrenia - which was to remain unidentified for a further five years - it is unlikely that psychoanalysis would have been the treatment of choice. Once described by Dr Anthony Clare as the most expensive treatment in psychiatry, best suited to the least ill, it would not now be considered good practice to offer analysis to a psychotic patient, unless they were stabilised on medication.
Saks's analyst introduced herself as Mrs Jones, explaining she was not a doctor. A follower of Melanie Klein, she believed, unlike analysts of the Freudian school, people with psychosis could benefit from analysis. But she had possibly more important attributes. A motherly figure, she was tolerant and understanding, "calm, she didn't frighten easily, was empathic and rigorously honest". Saks's thoughts were "neither good nor bad, they just were" - just as well, because, for four years, Mrs Jones was at the listening end of a lot of florid psychotic thinking.
While credited with rescuing her from the dark and giving her hope in the future, it could also be argued that Mrs Jones postponed the diagnosis, which, when it did come, Saks regarded as "a death sentence". Although medication was dramatic in its effects, it took a further 15 years and countless acute breakdowns before she learned the lesson of what would happen when she withheld the drugs. By then even her most loyal friend, Steve, had had enough. On the phone to Saks, he certainly spoke for this reader: "It's tiring," he said, "aren't you tired too?"
Her then analyst's patience had also run out and, to Saks dismay, he told her: "If you reduce your meds again, or even talk about it, you can't stay in treatment with me."
In between and sometimes in parallel with psychotic episodes, a brain haemorrhage and two operations for cancer, Saks slowly but successfully pursued her career ambitions. Using her mind "to heal her mind", she converted her experience of mental illness into a critical evaluation of mental health legislation.Aware that early diagnosis can contribute to a more progressive outcome, Saks admits that by not being diagnosed early, she lost years of her life. However, she remains ambivalent about medication concluding that, while it kept her alive, it was "psychoanalysis that gave her a life worth living". All the evidence is that it was medication that allowed her to live it.
I had expected an acknowledgment for Yeats's Second Coming - "Things fall apart; the centre cannot hold" - but instead it is the publisher, Robert Millar, who is thanked for coming up with "a great title"!
Eimer Philbin Bowman is a consultant psychiatrist
The Centre Cannot Hold: A Memoir By Elyn R Saks Virago Press, 313pp. £17.99