Month: April 2019

“Perceval’s Narrative: A Patient’s Account of His Psychosis, 1830-1832” (1979), is edited, with and Introduction by Gregory Bateson. This is likely the first account by a person with diagnosed schizophrenia, and it is a remarkable document. John Perceval was the son of a prime minister of England, who was assassinated when John was 9 years old. John, the fifth child of 12, was involuntarily incarcerated in an asylum in Bristol, England, when he was 27 years old. He was in the military. He was severely disturbed by religious conflict. He went briefly to Oxford, then joined an evangelical Christian cult. He began acting in a disordered manner and was placed under restraint in December, 1831. He remained in the Bristol institution until May, 1832 when he was moved to an asylum in Sussex, England. He remained there until the beginning of 1834.

Because of John’s intelligence and ability to articulate his journey into and out of his mental illness, we have his recorded narrative. I will share just some of his own descriptions of his mental state and insights into his condition and then comment on a few critical theoretical issues raised by Bateson in his Introduction.

The following is part of Perceval’s narration of the beginnings of his psychosis:

“I was tormented by the commands of what I imagined was the Holy Spirit, to say other things, which as often as I attempted, I was fearfully rebuked for beginning in my own voice, and not in a voice given to me. These contradictory commands were the cause, now, as before, of the incoherency of my behavior, and these imaginations formed the chief causes of my ultimate total derangement. For I was commanded to speak, on pain of dreadful torments, of provoking the wrath of the Holy Spirit, and of incurring the guilt of the grossest ingratitude; and at the same moment, whenever I attempted to speak, I was harshly and contumeliously rebuked for not using the utterance of a spirit sent to me; and when again I attempted, I still went wrong, and when I pleaded internally that I knew not what I was to do, I was accused of falsehood and deceit; and of being really unwilling to do what I was commanded. I then lost patience, and proceeded to say what I was desired pell-mell, determined to show that it was not fear or want of will that prevented me. But when I did this I felt as formerly the pain in the nerves of my palate and throat of speaking, which convinced me that I was not only rebelling against God, but against nature; and I relapsed into an agonizing sense of hopelessness and of ingraditude.” (p.x)

Bateson’s comment on this part of Perceval’s narrative, points to the impossible bind Perceval’s voices have put him in – a “double bind”. This notion refers to the choices presented to Perceval, that even if he does the “right” thing, he is blamed for doing it for the wrong reasons. Bateson suggests, “And his final word, ‘ingratitude’, suggests that this pattern of unconscious expectation- that every course will lead to rejection- has probably been early installed by the behavior of parents and siblings.”(p.xi) I will discuss the implications of Bateson’s suggestion and the larger context of his notion of the “double bind” in a follow-up post. For now, John Perceval’s narrative provides insights into his mental illness, but not necessarily it’s cause (we still do not know what may cause schizophrenia). Later in Perceval’s narrative his voices seem to offer alternatives to the double bind:

“At another time my spirits began singing to me this strain. ‘you are in a lunatic asylum, if you will’ – ‘if not you are in,’ &c.&c. ‘That is Samuel Hobbs if you will – if not, it is Herminet Herbert,’ &c.&c. But I had been so long deceived by my spirits that I did not now believe them when they spoke the truth. However, by listening and finding that the patients called him Samuel Hobbs, and by other accidents, I discovered at last that I was yet on earth, in natural, although very painful, circumstances in a madhouse. My delusions being thus very much abolished, I soon after got liberty during the day-time “(p.146)

Bateson comments, ” Here the voices are doing what Perceval wished his brother had done – accepting the fact of the delusion and reinforcing the doubt. They are also presenting real alternatives between which the patient can and must choose, while indicating their willingness to accept either choice. Perceval remarks that it was very unpleasant to have the voices do this, but he is honest enough to perceive that every time they do it he makes a step toward recovery. Here then Perceval presents, in two diagrammatic thumbnail sketches, the recipes, first for inducing his insanity, and then for curing it.” (p.xi)

Based on Perceval’s own narrative, it would seem that he “spontaneously recovered” from his schizophrenia and that the so-called curative factors were somehow built into his delutionary voices. Bateson even suggests that Perceval’s mental illness may have been an initiatory ceremony: “But it would appear that Perceval was a better, happier, and more imaginative man after his psychotic experience and I have suggested that the psychosis is more like some vast and painful initiatory ceremony conducted by the self.” (p.xix) This interpretation of Perceval’s journey provides the basis of lines of thinking about a psychotic experience as an almost sacred journey of discovery. And part of this line suggests that schizophrenia can be brought about by conflicts within families which may construct double binds, and that the way out of the conflicts may be to provide alternatives to the double binds. This line of thinking, which has been taken up by some family systems and family therapy approaches, and credited to Bateson, is still active, even in this era of bio-chemical-genetic interpretations of the causes and potential cures for psychoses.

Elyn Saks is a professor at the University of California Gould School Law and and adjunct professor of psychiatry at the University of California at San Diego School of Medicine. She is extremely accomplished by any measure. That she has done this while managing serious mental illness is remarkable. In a piece she wrote for the New York Times in 2013, she said,

“Although I fought my diagnosis for many years, I came to accept that I have schizophrenia and will be in treatment for the rest of my life. Indeed, excellent psychoanalytic treatment and medication have been critical to my success. What I refused to accept was my prognosis. Conventional psychiatric thinking and its diagnostic categories say that people like me don’t exist. Either I don’t have schizophrenia (please tell that to the delusions crowding my mind), or I couldn’t have accomplished what I have (please tell that to USC’s committee on faculty affairs). But I do have and I have. I am not alone. There are others with schizophrenia and such active symptoms as delusions and hallucinations who have significant academic and professional achievements.”

Saks provides some of the best descriptions of what living with schizophrenia has been like in her best selling book, “The Center Cannot Hold” (2007).

“This experience is much harder, and weirder, to describe than extreme fear or terror. Most people know what it is like to be seriously afraid. But explaining what I’ve come to call ‘disorganization’ is a different challenge altogether. Consciousness gradually loses its coherence. One’s center gives way. The center cannot hold. The ‘me’ becomes a haze, and the solid center from which one experiences reality breaks up like a bad radio signal” “No organizing principle takes successive moments in time and puts them together in a coherent way from which sense can made. And it’s all taking place in slow motion.” (p13).

Saks has become a significant spokesperson for combining medication and talk therapy for managing schizophrenia.

“Medication has no doubt played a central role in helping me to manage my psychosis, but what has allowed me to see the meaning in my struggles – to make sense of everything that happened before and during the course of my illness, and to mobilize what strengths I may possess into a rich and productive life- is talk therapy. People like me with a thought disorder are not supposed to benefit much from this kind of treatment, a talk therapy oriented toward insight and based upon a relationship. But I have. There may be a substitute for the human connection – for two people sitting together in a room, one of them with the freedom to speak her mind, knowing the other is paying careful and thoughtful attention – but I don’t know what that substitute might be. It is, at the heart of things, a relationship, and for me it has been the key to every other relationship I hold precious. Often, I’m navigating my life through uncertain, even threatening waters – I need the people in my life to tell me what’s safe, what’s real, and what’s worth holding on to.” (p.331).

Saks may be considered the ideal spokesperson for those who may believe one can overcome schizophrenia, but she honestly confronts that notion with her own experiences of both success in managing her illness and constant reminders of the limits and challenges she must deal with.

“My life today is not without it’s troubles. I have a major mental illness. I will never fully recover from schizophrenia. I will always need to be on antipsychotic medication and in talk therapy. I will always have good days and bad, and I will get sick.” (p.335).

A friend of Saks asked her if there were a pill that would instantly cure her, would she take it. She thought of the poet, Ranier Maria Rilke, who would decline psychoanalysis saying, ” don’t take my devils away, because my angles may flee too”. And she responds, “My psychosis is a waking nightmare , in which my demons are so terrifying that all my angels have already fled. So would I take the pill? In a heartbeat.” (p.336).