65 pages • 2 hours read
Elyn R. SaksThe Center Cannot Hold: My Journey Through Madness
Nonfiction | Autobiography / Memoir | Adult | Published in 2007A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Themes
Sense of Self and Identity
The book opens with a vivid scene of Elyn having a psychotic episode, introducing two seemingly disparate aspects of Elyn’s identity: she is a student at a prestigious law school, and she has a severe mental illness. The choice of scene to include in the prologue is significant, especially as throughout her journey, Elyn grapples with reconciling these different selves for herself. Throughout, the book explores ideas of self and identity in the context of mental illness.
Early on, Elyn is presented as someone who is strong-willed and independent. This is reiterated by her display of defiance in situations where she sees her autonomy being threatened, even when her defiance causes her own suffering. It is what solidifies her image as a difficult patient, as she chooses to sing all night long when she is put in restraints. Elyn’s extraordinary intelligence (as evidenced by her numerous academic and professional achievements) contributes to her feelings of self-worth. Being a high-achieving scholar is the most important identity she inhabits, and anything that threatens this causes her deep anxiety. Hence, Elyn’s initial struggles with her illness beyond its direct symptoms is the threat it poses to her sense of self.
Elyn cannot reconcile herself as both a mental patient and a scholar, and she even avoids psychiatric help initially, refusing to accept that she has an illness. It is only Dr. Storr’s recommendation that she ought to continue her degree that leaves her amenable to his other recommendations of therapy. That he sees and acknowledges Elyn as someone beyond her illness is of vital importance to her.
This need for autonomy and an identity beyond her illness is reiterated by Elyn’s descriptions of her hospitalization at Yale-New Haven and YPI. The most troubling parts of these incidents are the lack of personhood and autonomy she experiences, when she is forced into restraints and made to take medication. Although the medication is effective, Elyn personally responds best to therapists who see her as a person, and not a case study. Mrs. Jones and Dr. White are both examples of this, allowing different parts of Elyn to co-exist and helping her work through their relationships with each other. Kaplan characterizes these in his description of the three identities Elyn inhabits: Elyn, Professor Saks, and the Lady of the Charts.
Even when Elyn begins treatment, one sees how she initially attempts to erase the “Lady of the Charts”, while simultaneously working to elevate “Professor Saks.” Her attitudes towards mental illness, born out of her upbringing and experiences with Operation Re-Entry, contribute to the misconceptions she has about the illness, and she cannot accept it as part of who she is. Eventually, Elyn is able to reconcile these seemingly different selves.
It is Elyn’s experience of learning to maintain an identity that is larger than her illness that eventually drives her to write the book. She presents the idea that rather than rejecting one’s mental illness or having one’s identity be subsumed by it, it is possible to have the illness exist in tandem with other identities. Elyn integrates her illness into her larger identity while ensuring that it is not the most important part. Her experience suggests that to live a fulfilling life, one’s sense of self must be grappled with and understood.
Standard of Care for Mental Illness
An important theme explored throughout the book is the standard of care for psychiatric illness. In the prologue, the reader is made privy to the fact that this is not Elyn’s first hospitalization; however, it is described as her worst experience with it, signaling that there are variations in how mental illness is addressed in different places.
Elyn’s first hospitalization at Warneford is starkly different from the experience she describes in the prologue. Elyn retrospectively reflects on how she was treated with great respect and dignity, with no interventions being forced on her or any other patient. She explains this to be an important difference between American and English psychiatric institutions. Legal and cultural differences ensure that individuals with the same mental illness are meted out vastly different treatment depending on where they receive it,
Another aspect of psychiatric care that Elyn touches on is the existence of blind spots even within the medical profession. She elaborates on Jefferson’s case, a misdiagnosis of mental illness that leads a man with intellectual disability to receive inadequate care for many years. Elyn herself receives a “severe” or “grave” prognosis multiple times, and some professionals believe she has an intellectual disability. Elyn uses these examples to reiterate the importance of looking past labels. Stereotyping and misperceptions lead professionals to ignore important information; the individual aspects and nuances of a case are vital for the individual to receive the right diagnosis and subsequent treatment.
With respect to psychiatric care, other ideas explored in the book are about the approaches to treatment, including medication and therapy. Elyn describes the different kinds of analysis she undergoes including psychoanalysis, Kleinian analysis, and cognitive behavioral therapy. She details the different medication she is prescribed over the years, including the side effects she experiences from each. By describing her treatment regimen and its varying efficacies over her journey, Elyn highlights how treatment approaches to mental illness can differ not just based on the treating professional’s background, but also what works best for each individual case.
Ultimately, Elyn uses her journey to present the realities and possibilities of the standard of care in addressing and treating mental illness. The theme also reiterates other related ideas of paying attention to the individual and not the case, as well as taking care to avoid stereotypes when engaging with mental illness.
Stereotypes and Stigma Surrounding Mental Illness
Throughout the book, Elyn attempts to explore and dismantle some of the stereotypes and stigma surrounding mental illness. She does this not just by describing and countering the attitudes and responses of various people (including herself) but also by candidly describing her psychosis and the thought processes she experiences during each episode.
When Elyn’s first signs of mental illness appear as quirks during childhood, they are not initially seen as abnormal; Elyn only identifies them as the first sign of her illness in retrospect. When she describes her delusion about houses sending her messages, the experience is believed to be a result of drug use and is dismissed. The implication is that mental illness remains absent from the radar of the adults Elyn grew up with. This is despite the fact that her Uncle Norm suffers from depression. The avoidance of anything related to mental illness is complemented by the attitudes towards the same that Elyn develops during her time at The Center. She mistakenly grows to believe that any non-physical illness can be overcome sheerly by force of will.
Elyn carries this misconception about mental illness for years to come. She does not disclose her history with psychosis to the people in her life for a long time, partly fearing the reactions she will get and partly because she is ashamed of and in denial about her condition. In addition to her specific childhood experiences and ideas of self and identity, Elyn credits this with the media portrayal of psychosis that was prominent during her time.
Stereotypes and stigma surrounding mental illness are embedded in Elyn’s own consciousness. Even medical professionals trained to deal with mental illness are seen as exhibiting and perpetuating stereotypical behavior that stigmatizes illness. For example, Elyn and Steve’s client is believed to have psychosis when he is overheard talking to lawyers on the phone, simply because he is a psychiatric patient. Similarly, Elyn’s headaches, later diagnosed to be caused by a brain hemorrhage, are initially dismissed by doctors when they learn about her history of psychosis.
In her account, Elyn chooses to detail the violent content of her thoughts and delusions, while simultaneously explaining her internal dialogue and intent throughout. She looks to dispel the specific misconception that individuals with mental illness are usually violent. She also details her many academic and professional achievements, as well as the friends she makes and healthy relationships she forms, to highlight how individuals with mental illness are capable of living full and satisfying lives. Elyn presents a holistic and multifaceted picture of a life with mental illness that is not entirely defined by it.
