The Center Cannot Hold: My Journey Through Madness (42 page)

"We're not getting anywhere," he'd say. "This isn't even therapy
we're doing." It had been going badly for two years, he said—since
around the time of my diagnosis with cancer and my engagement to
Will. I'd been aware that we were somewhat at odds, but I'd thought it
had only been for a couple of months.

And then Kaplan threatened to tell the Institute that I was no
longer having analysis. My Institute (like most these days) is
"non-reporting": that is, your analyst does not report on your progress
(in analysis) to the Institute's Progression Committee. But he does
report "analytic hours" to the Institute, so he holds in his hands a
roundabout way of signaling that you're not quite up to standard.
Eventually, I told my advisor at the Institute what Kaplan had
threatened to do. A few sessions later, he told me he no longer needed
to do what he'd threatened. Still, I wasn't reassured. I couldn't jump
through the right hoops for him, and finally, I couldn't handle it
anymore. I decided I needed a consultation with someone who might
be able to be objective, and scheduled an appointment with Dr. Freed,
whom I had seen as Dr. Kaplan's backup once and whom I knew from
the Institute.

"You've done years of good work with him, Elyn," Freed said.
"Relationships go through transitions; perhaps this is one. You really
should try to work it out with Kaplan. It's vital that you do."

I wasn't sure I could; I wasn't sure I wanted to even try. "If we
can't—if I can't—would you consent to be my analyst if I can't continue
with Dr. Kaplan?"

He shook his head. "It's unethical for me to even discuss that with
you, as long as you're in treatment with him. Go back and discuss this
with him, Elyn. You need to come to a resolution."

I went to my office to draw up a plan, some kind of negotiation.
What had to change, I wondered, in order for me to stay with Kaplan?
I made a list: I needed him to stop saying we weren't getting
anywhere. I needed him to stop threatening "termination." I needed a
lessening of the physical restrictions. None of these seemed onerous. I
told Kaplan I would need these things to change in order to keep
working with him.

Kaplan flat-out refused to change a thing.

I was stunned. "I'm sorry," I said. "I guess that means we'll have to
end our work together."

For the rest of that session, it was as though there were an EXIT
sign hanging just over the door. Once we'd finished and I prepared to
walkthrough that door, I turned back and looked at him. "Good-bye,"

I said. "Thanks for everything. I'll see you around." And then I saw
Kaplan flinch.

I then called Dr. Freed and told him that I'd left Kaplan. I don't
know what I might have done if Freed hadn't agreed to become my
analyst, but he did.

A few days later, Kaplan called. "Where have you been?" he asked.
"You've missed two scheduled appointments."

I took a deep breath. "I told you that I was terminating with you,
and I meant it," I said. "I've transferred myself to Freed."

There as a moment of silence at the other end of the line. Of
surprise? Of anger? "I think you need to come and speak with me
about this," Kaplan said.

"No, I don't," I said, but I already felt myself starting to shake. I'd
never been very good at confrontation. Maybe I'd moved too fast.
Maybe I was
WTong.

"We can negotiate the changes you asked for," Kaplan said. "In any
case, this is too abrupt. If we're going to end our time, it should be
with some resolution, some agreement."

       I agreed to meet with him twice a week while we wrapped up;
simultaneously, I met with Freed. Maybe it was overload, or the pain
of the transition, but for the next four weeks, I spent every session
with Kaplan weeping—which, in spite of being a fairly emotional
person, I don't do. I'm just not a crier. But something about being in
that room with him tore me up, every single session. I felt sad, and
vulnerable; I was leaving someone important,
something
important,
and what I felt was grief.

To his credit, Kaplan didn't use the time to try to coerce me into
coming back, and when I told him I was indeed going to continue to
see Freed, he told me Freed was a wonderful clinician and he wished
me well. And then it was over.

Dr. Kaplan probably helped me more than anyone else in my life,
and I love him today as much as I have ever loved anyone. For a long
time, I carried inside me a palpable sense of loss. The decision to leave
him was so awful, but I couldn't see any way around it; besides, it
always felt like he'd made that decision first. By refusing to negotiate
with me, by threatening me and pushing me, he had in fact fired me.
He'd rejected me, he'd betrayed me. And why I didn't end up
hospitalized as a result of the upheaval, I don't know to this day.

Yet even now, when I am in a bad way, the first thing I think of is
to call Kaplan. In fact, I often call his answering machine still, just to
hear his voice. But I don't leave a message. That time is over.

Dr. Freed is about sixty, I would guess, and kind-looking. Unlike
Kaplan (who, like my father, has a very strong personality), Freed has
a certain softness and gentleness about him. At the same time, he
stands his ground. He doesn't pull his punches with me; he homes
right in on what I'm feeling, and helps me to understand how I
sometimes use my psychotic thoughts to avoid the ordinary bad
feelings that everyone experiences—sadness, rage, garden-variety
disappointment.

Freed also has more faith in the analytic process than I do; he even
thinks I might be able to get off meds entirely someday. In addition, he
tries to understand my psychotic thoughts as unconsciously motivated
and meaningful (which of course they are). Sometimes, interpreting
them, he refuses to discuss a diagnosis. "Schizophrenia is just a label,"
he says, "and it isn't helpful."

Both of these views stir me up quite profoundly. I spent years
fighting the idea that I was schizophrenic and needed medication.

Now that I acknowledge that I am and I do, he raises the possibility
that things may not be so clear. I believe that Freed is, in part, trying
to give me hope and, in part, not appreciating the very real biological
component to my illness. His primary area of concern is the
psychoanalytical side; because of this, he referred me to a
psychopharmacologist, Dr. Gitlin—internationally known in his
field—to manage the medicine-cabinet aspect of it. Gitlin believes that
I wall need to be on medication the rest of my life.

Recently I've had to change drugs again. Zyprexa became
somewhat less reliable, and I started having a lot of "breakthrough"
symptoms. Raising the dose wasn't an option; as it was, I was on twice
the highest recommended dose. So Gitlin suggested clozapine, a drug
usually prescribed to those who are, to some degree or another,
treatment-resistant, and he put me on a hefty dose, six hundred
milligrams. Clozapine's a cumbersome drug to use; at the beginning, it
requires a weekly blood test to monitor side effects and watch for signs
of agranulocytosis, a precipitous drop in one's white blood count that
can be fatal. However, it works, and it works well; there are days now I
feel almost guilty for feeling so good.

But that did not happen overnight. Indeed, transitions from one
drug to another can be difficult, as happened when I first started
seeing Gitlin and we tried to switch meds. In short order I was very
psychotic.

"Elyn, what's going on?"

"Are you the real Dr. Gitlin or the marionette Dr. Gitlin?"

"Why, I'm the real Dr. Gitlin," he said.

"That's just what the marionette would say."

Dr. Gitlin later told me he seriously considered hospitalizing me as
a result of this episode. Thankfully, instead of doing the easy thing, he
did the hard one, and waited me out.

So: Medication changes can set off psychosis, because the
biochemical transition in my body from one drug to another can take
time. Abrupt change can set it off as well; that's why familiarity is my
touchstone. And stress—from outside sources, pressure, or events I
can't control—can have the effect of someone hitting the evil "start"
button that reignites my symptoms.

As had happened with the breast cancer diagnosis, a routine
checkup indicated there was a possibility that I had ovarian cancer.
And once again, quickly, reality receded and the devils came in. There
was a two-week wait before surgery; after surgery, I'd have to wait
another two weeks for final results. I'd heard that there was only a 20
percent survival rate after three years with this kind of cancer. I was
desperately afraid, even sad; had I come this far, fought this hard, only
to be defeated again by my unreliable body?

Once again, the apartment filled with flowers; once again, Will
never wavered in his tenderness and his steadfast belief that all would
be well. My friends rallied around me; Steve came from Washington;
even someone I'd dated briefly at Yale—a psychiatrist and lawyer who
continues to be a good friend—came to see me and offer support. But
my parents were among the missing.

Well, not technically; they were on the phone. My father did not
want to come and would not explain why. My mother said, with a
notable lack of enthusiasm, "Maybe I can come for couple of days. And
Dad will come if the diagnosis is a bad one."

My parents not coming to see me was a major blow. All my life, I'd
idealized them, even though there were many complexities to our
relationship. When I felt at death's door, and their first and last
impulse was to stay where they were, I was crushed. I could no longer
deny they're flawed (as are we all), and that sometimes they've
deliberately chosen to be unavailable to me. Maybe that's part of their
own coping mechanism; maybe it's that the disease itself is just too
enormous for them. Or maybe it's a result of the signals I send them:
I'm fine, I'm strong; I don't need you. I'm not sure; we've never really
had that conversation.

It occurs to me that there are often two sets of trickery going on in
my life. The illness—the entity—is always just off to the side, just
barely out of my sight. But I know it's there. And it tries to trick me
into believing this isn't the real Will, this isn't the real Steve, that
reality isn't reality, that I can kill thousands of people with my
thoughts, or that I'm profoundly evil and unworthy.

At the same time, I'm trying to trick the people around me. I'm
OK, I'm functional, I'm fine. And maybe, sometimes, this determined
effort to trick them tricks the illness itself. It's like one big con. Steve
says he's never seen anyone who fights as I do. I don't consider myself
a fighter (and I certainly don't come across as ferocious). But if he's
right, then perhaps in my childhood, and in this push-pull with my
parents, one can see not only the beginnings of my illness, but the
seeds of my health and strength as well. If I'm a fighter, perhaps it's
because that's who they taught me to be.

"Never mind," I said to my mother. "Don't come. We'll call you
when it's over."

The final results were very good, although all the warning signs
were there; as a result, I had a complete hysterectomy and
oophorectomy (removal of ovaries). Unlike the sadness and loss that
many women might feel after such an overwhelming procedure, what
I felt was almost relief. The danger was gone. And since I'd long since
come to terms with the reality that I—and Will and I—would never
have children, I was at peace with it.

What is schizophrenia? In the United States, diagnoses are mostly
made according to categories established by the American Psychiatric
Association's
Diagnostic and Statistical Manual of Mental Disorders.
The
DSM
makes a rough distinction between disorders of
thought
and
disorders of
mood.
Schizophrenia is an example of a disorder that
affects thinking, and so it is referred to as a thought disorder. Bipolar
disorder (what used to be called manic depression) is an example of a
mood or "affective" disorder—a disorder that rests primarily in how
one feels.

The
DSM
places schizophrenia among the thought disorders
characterized by psychosis. Psychosis is broadly defined as being out
of touch with reality—'what one of my professors at Yale once referred
to as "nuts."

Schizophrenia, the most severe of the psychotic disorders, seems
to affect about one out of every hundred people. Some researchers
think that it may actually be a whole set of diseases, not just a single
disease, which would explain why people with the same diagnosis can
seem so different from each other. In any case, whatever
schizophrenia is, it's not "split personality," although the two are often
confused by the public; the schizophrenic mind is not split, but
shattered.

A common misunderstanding is that people with schizophrenia
are wildly psychotic all the time. Most, like myself, are not. When I am
symptomatic, I suffer from delusions and hallucinations, and my
thinking becomes confused and disorganized. Though I do not
hallucinate much—sometimes I see things, sometimes I hear things—I
often become frankly delusional. The disorganized thinking I suffer is
also a core feature of schizophrenia.

These symptoms are examples of "positive" symptoms of
schizophrenia, i.e., things you have but don't want. Many people with
schizophrenia also have "negative" symptoms, some sort of deficiency
or lack, such as apathy and withdrawal, a profound "not caring," or
perhaps more to the point, not caring about not caring. Save for my
first few years at Oxford, I've been fortunate largely to escape the
negative symptoms.

What's important in all of this is that I have a thought disorder. I
am not someone whose illness consists primarily of having high and
low moods. And that aspect of my illness—its cognitive nature—was
central in my decision to write this book.