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The Center Cannot HoldReview - The Center Cannot Hold
My Journey Through Madness
by Elyn R. Saks
Hyperion, 2007
Review by Tony O'Brien RN, MPhil
Jan 22nd 2008 (Volume 12, Issue 4)

Every memoir of mental illness is a testament to human resilience in the face of that dread experience: the loss of the very faculties that make us what we are. Reason, emotion, volition, memory, thinking, the sense of oneself as a person, the sense of belonging in the world; any or all of these can be eroded in mental illness, along with the sense of hope that they will repair, and that we will return to ourselves. There are as many paths to recovery as there are individuals affected by mental illness, and the literature in this area is notable for its diversity. Autobiographies feature individuals who would be unknown if they had not published an account of their experience, as well as individuals who are already well known, but whose mental illness has previously been generally unknown. Elyn R Saks is one of the latter category. Saks is an academic author with several books to her credit (Jekyll on Trial: Multiple Personality Disorder and Criminal Law (1997); Interpreting Interpretation: The Limits of Hermeneutic Psychoanalysis (1999); Refusing Care: Forced Treatment and the Rights of the Mentally Ill (2002)). To this is impressive collection is added something less academic, and altogether more remarkable, a personal memoir of mental illness. The Center Cannot Hold. My Journey Through Madness covers Saks' life so far, from her childhood in Florida to her current life as Professor of Law in Southern California.

Saks' life makes an interesting study even without her lifelong encounter with mental illness. Academic achiever of the first order, Marshall scholar, holder of separate academic appointments in law and psychiatry, and psychoanalyst, Saks is well placed to offer a unique perspective on mental health issues. Five years ago I read her Refusing Care, and found it a nicely balanced account of issues relating to mental health law. While I admired the range of that book, and the depth of analysis, I put that down to careful and dispassionate analysis, and a willingness to examine issues from all sides. I had no idea that the book was informed as much by personal experience of coercive measures such as forced medication, mechanical restraint, legal coercion, the debilitating effects of stigma, and having to face the consequences of actions made under the influence of illness. While The Center Cannot Hold places the arguments of Refusing Care in a new context, it is my guess that Saks would want those arguments to be evaluated in their own right, not as views having a special warrant as those of a 'mental health consumer'. And when Saks speaks as a mental health consumer she does not lean on her academic status to support her position; her views are those of a young and mid-life woman eager to succeed in her chosen career, but dogged by frightening and disorienting experiences.

The book begins with Saks' early family life in Miami. She recounts her 'family myth': the account we all have of how our families formed, developed and changed. In Saks' case there are her parents and two younger brothers. The family lead an ordinary enough life "a Norman Rockwell magazine cover or a gentle fifties sitcom". Family times were interspersed with times the parents reserved for each other, there was sibling rivalry, and formative experiences at the movies. There is a sense of strong fundamental values, material comfort, and encouragement to succeed. The childhood years contain what may have been a hint of things to come when Saks became preoccupied with the minutiae of preparations for outings, and became convinced that the family home was staked out by a malevolent figure. Then again, these could also be the passing anxieties of a young girl. Saks reflects of her parents: "they taught me what I needed to make the most of my talents and strengths…they gave me what I needed to survive."  Neither they, nor Saks, had any idea just how those strengths would be tested.

From this beginning the book proceeds in developmental sequence. A key early event is Saks' adolescent confession of cannabis experimentation. This led to several years of compelled enrolment in an after school drug education program which sounds severe by any standard. Absolute rules, humiliating discipline, restricted friendships, and a code of conduct many fundamentalists would be proud of; all a far cry from the experimental spirit of the times. Saks credits this time, too, with helping her develop strength of character, although perhaps at the expense of a degree of social sophistication.

At university, Saks was a gifted student. Achieving As for almost everything, as well as many comments noting the high quality of her academic work, it is no surprise to the reader, although it was for Saks, to learn that she had been granted a Marshall scholarship to study Classics at Oxford, England. A measure of her application is that having already mastered Greek, she taught herself French in order to study commentaries in the original. This study was followed by acceptance to law school at Yale, where Saks again succeeded with distinction. Through all these years Saks had intermittent experiences with expansive mood, paranoia, delusions, voices and disturbing perceptions. There were admissions to hospitals in both the United States and England, admissions that involved experiences of traumatic treatment by clinicians, kind and compassionate care, relief from social stressors, and her own grave doubts about her future. In addition to her direct experiences with mental illness, readers are given an insight into the stigma of mental illness when Saks' symptoms of a developing brain aneurysm are dismissed by Emergency Room staff as an indication of mental illness.    

Saks describes in some detail her experience in psychoanalysis with the remarkable, if austere, Mrs. Jones: "She was, without question, the ugliest woman I'd ever seen". Mrs. Jones was a classical analyst, deeply committed to the analyst's personal opacity, so it comes as some surprise when, long after termination, Saks contacts Mrs. Jones from the other side of the Atlantic, and arranges to visit. One of the tragedies of the book is Mrs. Jones' eventual loss of memory. Not only does she not remember Saks, who she had told she loved, her amnesia is more poignant given the role of memory in analysis. Psychoanalysis has continued to play a part in Saks' mental health. Never one to accept a field of knowledge as simply 'there' Saks studied and trained as an analyst, gaining admission to the Los Angeles Psychoanalytic Society and Institute.

A feature of this book is Saks' personal struggle with the idea of herself as a person with mental illness. From her time in drug rehabilitation as an adolescent she developed a deep aversion to any role for drugs in her life. She experimented many times with reduction in prescribed antipsychotic agents, especially when on one agent she developed early symptoms of tardive dyskinesia. These days she accepts that without medication she is vulnerable to relapse, and that unwanted side effects are the lesser evil.

There is much to learn from this brave personal account of mental illness. Saks has spared little in describing deeply personal aspects of her life. She is aware that as an educated middle class woman she has advantages in managing her recurrent episodes of distress that others don't have. She is typically modest in her hopes for the book: "I hope that by writing this book I help others to take some of what they need to lead a life worth living." The candor and accessibility of the book will go a long way to realizing that hope. Anyone with a clinical, academic, or personal interest in mental illness will find this book both compelling and rewarding. There is even a romantic ending as Saks falls in love and marries. The Center Cannot Hold is written in an engaging manner, and is replete with keen observations and first hand accounts of Saks' experiences which lift the book into the category of notable memoirs of mental illness.           

© 2008 Tony O'Brien

Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz

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