Who Gets To Be The "Good Schizophrenic"?
When you're labeled as crazy, the "right" kind of diagnosis could mean the difference between a productive life and a life sentence.
Every morning, I take a small pink pill; every night, I take one-and-a-half of the same pink pill. This is, my psychiatrist reasons, what has kept me functioning for the last two years without hallucinations or delusions. But for most of 2013, I was a psychotic wreck. I refer to it as My Death Year. My beloved grandfather died, and I was too crazy to attend the funeral; also, the year ended with a serious bout of psychosis called Cotard’s Delusion that led me to believe that I was dead. I spent most of that year spinning in and out of different harrowing beliefs: there were spiders in my brain, my husband had poisoned my tea, there were cameras spying on me in every corner of the flat, and so on.
2013 was also the year that I surrendered my last benchmark of sanity, otherwise known as my full-time job at a fast-paced startup company. For years, holding down an office job had been what I believed sincerely, and perhaps a bit desperately, separated me from others of my ilk, but I stepped away from my 9-to-5 because my job, despite its accommodations and allowances, exacerbated my illness.
In 2006, as a senior at Stanford who had transferred from Yale, I began to exhibit symptoms of schizoaffective disorder, bipolar type, which can be described as a marriage of schizophrenia and bipolar disorder. Schizoaffective disorder is listed under Schizophrenia and Other Psychotic Disorders in the DSM-5 and is not one of the five subcategories of schizophrenia itself. However, they both share the 295 designation, of which there are three disorders — schizophrenia, schizophreniform disorder, and schizoaffective disorder — and are therefore considered closely related.
And yet my official diagnosis — the one recorded in my HMO’s vast database of patient information — didn’t change to schizoaffective disorder until I became so desperately ill that I was referred for an electroconvulsive therapy consultation. The disorder had been suspected, but not recorded, in part because schizoaffective disorder has a gloomier prognosis and stigma than bipolar disorder does, and even psychiatrists are susceptible to being swayed by the implications of a different DSM code; also, psychiatry operates by treating symptoms and not a root cause, and so my psychopharmacological treatment was not impacted by the change in my chart.
In Blue Nights, Joan Didion remarks, “I have not yet seen that case in which a ‘diagnosis’ led to a ‘cure,’ or in fact to any outcome other than a confirmed, and therefore an enforced, debility.” Living under the shadow of a new “code” bore no curative function, but it did imply that to be high-functioning would be difficult, and it warned me that to live beyond that code would be a tricky gambit. A therapist had already told me in my mid-twenties that I was her only client who was able to hold down a full-time job. Having a job, among psychiatric researchers, is considered one of the major characteristics of being a high-functioning person.
During my first inpatient experience at a psychiatric hospital, I met two patients who were treated as markedly different from the rest of us — I will call them Pauline and Laura. Pauline was middle-aged and chatty; Laura was the only other Asian woman on the ward, and spoke to no one. We patients rarely spoke of our diagnoses — at the time, I was labeled as having bipolar disorder, with traits of borderline personality disorder — but everyone knew that Pauline and Laura were the two with schizophrenia.
Pauline was friendly and would roll up in her wheelchair speaking disjointed monologues about the psychiatrists’ “mind control experiments” — her ramblings paranoid enough to be considered psychotic, yet realistic enough to be unsettling to a vulnerable mind. In less coherent periods, her stories dissolved into the verbal nonsense known as “word salad,” in which one word was only tenuously related to the one that came before it, and the lot of them as a whole meant nothing at all. These problems with communication caused her to be excluded, by doctors’ decree, from otherwise mandatory group therapy sessions. I treated Pauline as though she had a contagion; after every interaction, I was contaminated by the anxiety that I was just like her even though I hadn’t, at that time, yet experienced psychosis. Perhaps I sensed it thrumming in myself even back then.
And then there was Laura, whom I never interacted with, because I was afraid of her and what madness her existence implied; but I remember her yelling as she was pulled out of the hall bathroom, interrupted in an attempt to vomit up her medications. “They’re poison!” she screamed as two nurses yanked at her arms. “They’re trying to poison me! They’re trying to kill me!”
A natural hierarchy arose in the hospital, guided by both our own sense of functionality and the functionality perceived by the doctors, nurses, and social workers that treated us. Depressives, who constituted most of the ward’s population, were at the top of the chain, whether or not they were receiving ECT (electroconvulsive therapy). Because we were in the Yale Psychiatric Institute (now known as the Yale Psychiatric Hospital), many of those hospitalized with depression were Yalies, and therefore considered bright people who’d simply wound up in a bad situation. In the middle were those with anorexia and bipolar disorder — two disorders not necessarily linked by nature, but lumped together from a lack of other diagnoses on the ward. I was considered to be in this group, and perhaps even as highly ranked as the depressives because of my status as a student at Yale. The ones with schizophrenia, on the other hand, landed at the rock bottom — excluded from group therapy, seen as lunatic and raving, and incapable of fitting into the requirements of normalcy.
I’ve seen the psychiatric hierarchy elsewhere — a hierarchy of who can be seen as high-functioning and “gifted,” and who can be seen as not being capable of either. A much-liked meme on Facebook circulated months ago, in which a chart listed so-called advantages to various mental illnesses. Depression bestowed sensitivity and empathy; ADHD allowed people to hold large amounts of information at once; anxiety created useful caution. I knew before reading it that schizophrenia wouldn’t make an appearance. As with most marginalized groups, there are those who are considered more socially appropriate than others. Being seen as inevitable failures by the dominant culture causes a desire to distance yourself from other, similarly marginalized people who are seen as even less capable of success.
The book Furiously Happy: A Funny Book About Horrible Things, by Jenny Lawson, was recommended to me over and over again as a hilarious book that embraced those with mental illness. Lawson, the beloved blogger behind The Bloggess, has been diagnosed with a variety of conditions, including depression and avoidant personality disorder. Yet she explains early on in Furiously Happy that she is on antipsychotics — not because she is psychotic, but because it decreases the length of her depressive episodes. “There is nothing better than hearing that there is a drug that will fix a terrible problem,” she writes, “unless you also hear that the drug is for treating schizophrenia (or possibly that it kills fairies every time you take it).” That line, for me, drew a line in the sand: My psychiatric condition, and the medications I take for it, make me as bad as a fairy killer; but if I were taking Haldol as a “side dish” for depression, I’d remain on the proper side of crazy.
Lawson, I’d like to believe, is trying to be honest rather than mean-spirited. No one wants to be crazy, least of all truly crazy — as in, psychotic. According to stereotype, schizophrenics are seen as some of the most dysfunctional members of society: We are homeless, we are inscrutable, and we are murderers. We are mass shooters like James Holmes, Jiverly Wong, Maj. Nidal Hasan, and Jared Loughner. Less headline-grabbing are people such as Elyn Saks, a recipient of the MacArthur “genius” grant who is a University of Southern California law professor, advocate, and author of a critically acclaimed memoir about life with schizophrenia. In a 2008 paper, Saks recalls, “When I was examined for readmission to Yale Law School, the psychiatrist suggested I might spend a year working at a low-level job, perhaps in fast food, which would allow me to consolidate my gains so that I could do better when I was readmitted.” The criteria for being able to return to a top-ranking law school, it seems, is being able to have a job, thus proving that you’ve returned to productivity — yet having schizophrenia is seen as canceling out the abilities that allowed someone like Saks to get into law school in the first place.
But Saks is exceptional. My desire to put myself on par with a genius grant winner says something about my ambition; it also says something about my desire to separate myself from the reality of those who are not living well with schizophrenia, and who would struggle to work in any capacity. While fighting with my insurance company over disability benefits, I tearfully tried to explain that I can’t work at McDonald’s, but I can run a business based on freelance work; place me in a high-stress environment with no ability to control my environment or my schedule, and I will rapidly begin to decompensate vis-à-vis demonic hallucinations. Being able to work for myself, while still challenging, allows greater freedom in my schedule and exerts less pressure on my mind. Like Saks, I am high-functioning, but I’m a high-functioning person with an unpredictable and low-functioning illness. I think of this while contemplating Susan, a woman described in Andrew Solomon’s book Far From the Tree, who is described as responding well to antipsychotic medication: “Intermittently, I have little things trigger here and there, but they only last a day or two. ... Some people get stressed and their back goes out. I get stressed and my mind goes out. But then it comes back.” I may not be the “appropriate” type of crazy. Sometimes, my mind does go out, leaving me frightened of poison in my tea or corpses in the parking lot. But then it comes back.
Because I am capable of achievement, I find myself uncomfortable around visibly psychotic people, or people with schizophrenia who are expected to never rise above a certain level on the Global Assessment of Functioning. My tendency to avoid the Paulines and Lauras of the world remains with me, and has in fact strengthened, even after my diagnosis shifted to more closely match theirs. I’m uncomfortable because I don’t want to be lumped in with the screaming man on the bus, or the woman who speaks in loose associations at the mental health clinic. I’m uncomfortable because I know that these, in many ways, are my people in ways that those who have never experienced psychosis can’t understand, and to shun them is to shun a large part of myself. In my mind, there is a line between myself and those like Pauline and Laura; to others, that line is thin, or is so negligible as to not be a line at all.