Reflections on alcoholism and mental illness inspired by Esmé Wang’s The Collected Schizophrenias.
This past week, I finished reading Esmé Wang’s graceful and unmooring collection of essays, The Collected Schizophrenias. Diagnosed with schizoaffective disorder (roughly speaking, a fusion of bipolar disorder and schizophrenia), Wang grew up in northern California and studied at Yale, where she experienced her first episode of hallucinatory psychosis while showering in a dorm. After misdiagnosis by the university’s mental health services, the administration permanently “suspended” her studies on medical grounds, in effect expelling her. She finished her undergraduate degree at Stanford, where she majored in psychology and conducted research in clinical trials on bipolar disease. Over the course of these essays, she founds a fashion blog (“militarized fashion” is one of her carefully honed survival strategies), completes her MFA at Michigan, suffers from persistent delusions that she is dead and her loved ones have been replaced by doubles, negotiates the mental health system, gets married, finishes her first novel, finds herself forcibly institutionalized three times, and grapples with sexual trauma. Filaments of memoir, medical history, cultural critique, and reportage: these styles interweave in her writing and burn together in a pale, limpid flame. Wang is unnervingly adept at self-observation and she utilizes this technique to reverse the polarity of the essay based on reflective introspection. Self-searching autobiography normally provides an immersive experience by inviting the reader’s identification. In contrast, Wang’s essays are subtly telescopic: they bring experiences into proximity in a way that enforces their distance. This effect allows her to explore her relationship with schizophrenia—she oscillates between understanding the illness as fundamental to her psyche and seeing it as an alien encroachment—as well as the surrounding world’s response to her.
Her most powerful theme is the limits and complexity of empathy. In an essay that provides a template for reading the collection as a whole, Wang discusses the 1988 murder of Malcom Tate by his younger sister alongside the movie Exorcist and the dilemmas surrounding voluntary versus involuntary treatment of people with psychosis. After being diagnosed with severe paranoid schizophrenia in 1977, Tate cycled in and out of hospitals, brutally attacked another man, resisted treatment, and terrorized his family for years—including threatening the life of his sister’s two-year-old daughter. Tate’s sister and mother drove him out of town in the middle of the night and, with his mother waiting in the car, his sister shot him thirteen times in the head and back with a .25 caliber weapon. As Wang observes, she had to stop and reload with each shot. Before his sister pulled the tigger, he reportedly asked “Whatcha doing?” and she replied “Malcom, I love you, and I only want what’s best for you, and I’m sorry.” Wang writes with solicitude for the torment of Tate’s family as well as other families that run out of options—they have precious few to begin with—and collapse under the burdens of care for the mentally ill. She also refuses direct identification with Tate, whose complicated humanity “is now accessible only through anecdotes of ‘the problem child,’ ‘the nightmare’.” Nevertheless, an unstated kinship with Malcolm underwrites the essay and it becomes increasingly palpable the more that she works to imagine the pain of his killers. He is, to borrow language from another chapter, one of her “people.” The questions forced by this almost unbearable tension reappear throughout the book. Why do we so often fail to empathize with the “insane”? Why does this failure manifest as fear and contempt? Does empathy require distinguishing the suffering person from the dominating illness? What happens when this distinction seems to disappear? Can we empathize with forms of suffering that we are incapable of understanding? Can we empathize with the suffering of those whose actions are violent, cause harm?
I bought the Collected Schizophrenias with trepidation. Not because of the book itself: my interest was snagged by its title and the smartly designed, faux composition book cover. (Wang writes about desperately holding on to a notebook during an episode of inpatient treatment.) After seeing the collection on the new releases table of my campus bookstore, I picked it up and walked to the register, then turned around and returned it to the stack of identical copies. My wife told me—tenderly—that it was alright. I could buy it. Since my first week of sobriety, I have known that the question of my own mental illness was waiting, in particular the possibility that I have (suffer from? live with? each verb is inexact and ionized) bipolar disorder. I was sitting across from my doctor, answering questions about drinking patterns and staring distractedly at the mountainside outside his office window, when he asked about my experiences on antidepressants. My response was automatic, as if itemizing trivia learned by route: “Twice, I have had manic reactions to prozac, both times while under observation in inpatient settings” I hadn’t given these events any weight—or even much thought—for years. I recall him looking up from his computer screen, but that is probably a post facto insertion. He did, however, make the following observation: a manic response to anti-depressants is considered diagnostic of bipolar disorder. One driver of my alcoholism (or, in his carefully precise words, substance use disorder) may have been self-medication for untreated mental illness. He prescribed an antipsychotic as well as an antidepressant that I have tolerated reasonably well in the past. For days afterwards, this idea—bipolar disorder—felt ambient, insurmountable. I was looking at the world through glass. It was too much. I somehow pushed it aside, transforming it—a secret from myself.
Only a few friends know the story of my institutionalizations. On Easter Sunday of my fourteenth year, I slit my wrists, inhaled home-made chlorine gas, and ate an assortment of pills. I remember feathery clouds of black sliding through bathtub water. I remember pellets of mucus lodged in my chest while I dry heaved through staccato wheezing. The next morning, I walked down stairs holding a blood-clotted sock against my arm and said, “Mother, I need to talk with you.” She immediately took me to the emergency room and then—following an argument with her insurance company—a residential treatment facility, Willowview. Given how many adolescents find themselves in these places, I wonder at their pop-culture invisibility: where is the Netflix show set on the ward of Oak Crest or Valley Falls? The one-story, branching 1970s structure overlooked a predictable vista of lazy hills and an oak-lined fish pond. The ward itself consisted of a hall of bedrooms culminating in the nurse’s station, a pingpong table, and an abutting television lounge: the mid-Western panopticon. I spent the next three months of my life here. Famously, we refashion our memories to match peak and final experiences. The intervals slide into orbit behind our most powerful or recent emotional impressions. At Willowview, I learned to meditate while listening to New Age synth music and painted acrylic copies of Roman Beardon’s Harlem during art therapy sessions. I played serial games of chess with the staff, read Thomas Merton, and scrawled pretentiously derivative poetry in a cloth-bound, pink floral covered notebook. I caught tiny grey perch with a toy rod as they swam in the shadows of the tree roots that reached out from the shore. I walked in the spring rain and confided my few adolescent secrets to friends that I would never see again. Other memories are more difficult to locate, fugitives. There was the hollowed-out fear of staring into the darkness while falling asleep on an institutional mattress my first evening; the loss of privacy and freedom; the detonations of other patients into—inwardly or outwardly directed—violence. I spent an entire night holding a boy, Lewis, as his body convulsed, sobbing, after he told me that he had shot and killed another child. Overall, I was fortunate. The facility’s staff was sympathetic and competent. The hard-nosed, no bullshit psychiatrist easily saw through my adolescent efforts at manipulation and deflection. With time, I started to heal.
Shortly after coming home from college my freshman year, I ate eleven tabs of LSD and—following days of damage on the world around me—I disintegrated. Again, I turned to my mother for help and (following another argument with an insurance company) she drove me to the psychiatric ward at a nearby hospital. This experience was closer to episodes of forced institutionalization that Wang describes. Although I had technically committed myself, my instability and threats of suicide meant that I could not leave without a psychiatrist’s approval. And so I began a daily, hourly, minute-by-minute wait for release. I recognize the details of Wang’s experiences: eating greasy institutional food with a plastic spoon, staring blankly at the ward television, and being surrounded by other highly medicated patients who drifted in-and-out of conversation and focus. Immediately after arrival, I was informed that any self-destructive act would result in restraints and transfer to the high security wing, where I would find myself surrounded by violent and other “non-compliant” patients. It was not a subtle threat. So I tried to read Deleuze. I stared out the window at the grass of a small, concrete-lined courtyard and thought about Augustine’s conversion experience. I looked at my reflection for hours in the shatter-proof, slightly convex bathroom mirror and surrendered to the void that emerged when I could no longer identify with the waxen, uncomprehending image. I paced and hoped for visitors. Much like Wang, I mobilized my education to distance myself from the other patients. Unlike Wang, my psychiatrists—in part, surely, because I was an intellectually gifted white male similar to them—tended to identify with me and treated these episodes as aberrations or phases that I would outgrow.
During both hospitalizations, I was prescribed a selective serotonin re-uptake inhibitor (a kind of antidepressant) and went manic. Sleepless, walk-on-walls, runaway-train, lightening speech, grandiose, ricocheting manic. I slid into this state without awareness, and beyond what others later described, I only remember the expansive urgency, the rapidly shifting points of focus, the pulsating sensation of outgrowing my own body and being larger the surrounding world. These memories are a strained, burnt yellow. At one point, a visiting friend asked me about my institutionalization and I responded with a long, megalomaniacal excursus about my unique insights and extraordinary powers that continued until I was interrupted several minutes later with “Do you remember the question?” I drew a blank. According to the DSM 5 (the standard diagnostic manual for mental health), a manic reaction to an antidepressant—when full manic episodes not otherwise present—is diagnostic of bipolar type II in patients who suffer from major depressive episodes. This correlation has certainly been questioned: why attribute the reaction to an underlying, otherwise undiagnosed condition and not the drug itself?
Bipolar type II is characterized by at least one episode of major depression and the presence of hypomania, a mood state that shares the characteristics of mania, but is less intense and disruptive. There is no question that I suffer from recurrent episodes of major depression. During the last event (which started after I stopped drinking and lasted about four months), I regularly slept for fourteen to sixteen hours each day, struggled to accomplish simple tasks such as eating or reading, and spent weeks where I couldn’t talk beyond formulating short, single-sentence replies to questions. Not everyday was this bad, but the majority were. I bordered on aphasia. I could not explain basic concepts in my area of research expertise. There is a quality that the world assumes when it has been evacuated of hope—as if all that exists is the repetitiveness of small, overwhelming efforts and an inert physical exteriority, dully crystalline and devoid of meaning. I have visited this realm many times. When I am there, it feels normal, almost welcoming. I also experience some degree of hypomania: week-long bursts of effervescence, galloping thoughts, the conviction of indestructibility and ineffable greatness. I launch dozens of new projects at once and take pages of notes as revelation after intellectual revelation erupt like cloud bursts. Frequently, these periods are genuinely productive. At other times, I am seized with the realization that everything that I have ever thought is inwardly connected. I erect magnificent sand castles in which each silica grain is secured by a conceptual leap so grandiose or tenuous that it is impossible to reconstruct. Piecing through these notes later, I watch palaces and citadels dissolve into the surf. In both scenarios, elation precedes despondency, the conviction of failure, and worthlessness. I have never—at least, not without chemical instigation—confronted an occurrence of full mania, that is, mania so sever that it results in psychosis or hospitalization. However, when I review the list of symptoms, I wonder if my drinking did not sometimes trigger manic episodes: delusions of grandeur, barrelling monologues, out of control financial extravagance, reckless sexuality, sleeplessness, hyperactivity. Sometimes, I became paranoid while drunk. I thought that my phones were tapped and that I was going to be arrested for undefined transgressions.
The neuroscientist Carleton Erickson remarks that the pure alcoholic is a rare creature. Most of us also use other substances or struggle with diagnosed or undiagnosed mental illnesses. The overlap between addiction and mental illness is so prevalent that some researchers, perhaps most famously the Canadian physician Gabor Maté , explain addiction as a form of destructive self-medication for untreated psychiatric conditions, such as childhood trauma. Maté writes with eloquence and great spiritual insight into the labyrinths of addiction, but I believe that he misses something. I certainly drank and used drugs as a palliative. Alcohol, especially, released me from fear, social anxiety, loneliness, and shame. It calmed bursts of excitability and made depression more endurable. It vanquished stress. As that first sip of booze touched my lips, I could feel the iron rod wedged between my shoulders soften and then dissolve. It provided temporary freedom from myself. At various points, watching television, overeating, and bulimia served the same purposes. And some of what I was fleeing does reach back to traumatic experiences during my childhood. However, self-medication doesn’t explain how I actually used. If my addiction was reducible to the misdirected fulfilment of psychological need, three, four, or even ten drinks would have been enough—and some evenings, I could stop there. If I wasn’t an alcoholic, I can imagine indulging in this kind of therapeutic grazing for the rest of my life, gradually increasing intake to offset tolerance. But no psychodynamic theory explains the destructive excess of a true binge. Once or twice a week, something inside my head would click and restraint vanished. I would down drink after drink, completely oblivious as to how much I had consumed, until I passed out, ran out of money, or the bars and liquor stores closed. As Maté describes, capitalist culture encourages a futile recourse to external stimuli—shopping, food, gambling, drugs, alcohol, sex, power—that function as both emotional anesthetics and means of filling a spiritual or existential emptiness. Addicts like me get locked into this cycle, but we also bring something else into the mix. We suffer from a spiralling, exorbitant compulsion that—if we don’t find a way to manage it—eventually kills us.
And that, at least in part, is what makes recovery so difficult. The first step involves recognizing this compulsion and accepting that nothing we do will ever master it. Many addicts chose death over accepting this reality. We can’t accept that we have completely lost control. No matter what we try, once we start using the gates are thrown open and we will follow our cravings until the bitter, brutal end. We can, however, change our lives so that we avoid taking that first drink or hit. This transformation entails identifying the functions that drugs and alcohol did serve, however perversely, and finding other ways to address these needs. Ultimately, our escape from active addiction requires cultivating a new ethical framework or spiritual mission that transcends the narcissistic satisfaction of our own desires. Because our lives were completely reorganized and subordinated to the service of our illness, we must find a stronger, more powerful goal than the pursuit of our own appetites. In other words, we are struggling on three levels: physiological, psychological, and existential. (This is one of the central insights of Alcoholics Anonymous.) We have to monitor an irrational urge. We have to heal the emotional pain that found solace in self-annihilating behaviour. We have to discover meaning, purpose, and beauty in the world where before we had stared into the vastness of an unfathomable, inner void.
Eventually, for me, this ongoing work broke through the fear, shame, and guilt that dominated my interior universe during early sobriety and created space for something new: vulnerability. I knew something had shifted when I began to feel a tender, tentative openness toward other people and, perhaps especially, my own past. I began to look beyond the immediate emotional drivers of my drinking—stress, social anxiety, isolation, guilt, and resentment—and address questions, like trauma and depression, that long predated my drug and alcohol use. It was like a dust cloud beneath the surface of a lake slowly cleared and I could see into the icy depths. I made another doctor’s appointment (to ask for a referral to a psychiatrist) and sought out a therapist that specializes in trauma work. This felt momentous, scary. After nineteen months of sobriety, I was returning to a much early time to confront things that I have been fleeing for almost twenty years. Addiction is characterized by a particular modality. In the grip of active use, addicts inflict enormous harm against themselves and, blinded by their own pain, fail to see the ways that this violence radiates, twisting their relationships and wounding the people around them. I understand my program of recovery as, first and foremost, arresting the psychic, chemical, and physical violence against myself. This remission makes room to explore and understand the emotional dynamics that structure my relationship with the world. As understanding increases, I can use a range of techniques—twelve step work, therapy, yoga, antidepressants—to transform them and therefore the reality that I create through my actions. If I fail to confront my mental illness at this point, the untreated pain will eventually seep into every area of my life, risking my sobriety—which means, quite literally, risking the well-being and safety of people around me. Yet the idea of bipolar disorder still terrifies me.
Why am I so afraid of this possibility? After reading Wang, I would ask this question differently. Why can’t I feel empathy for this version of myself? Wang describes the way that health professionals and the mentally-ill create hierarchies among sufferers, reinscribing stigma in spaces and discourses of recovery. As a “high functioning” schizophrenic, she feels discomfort with “the screaming man on the bus, or the woman who claims she is God.” She knows, in a way that outsiders cannot possibly know, that these people are her own. To shun them is deny part of herself. Still, Wang admits, she holds onto the differences between her and them, shielding her self image by drawing a wavering line. With addicts, I have abandoned this defence. When I see someone passed out on the street or meet a fellow traveller just released from prison, my sadness or empathy are not a reflection of distance. I have either been there or, had a thousand situations taken a slightly different turn, might have been. Every morning, when I get out of bed, I remind myself that I could be there today.
What am I guarding against bipolar illness? Since childhood, I have relied on the acuity of my mind in every area of my life. Intelligence has been the one attribute that I have valued, trusted, and—over and against every other aspect of being human—used to define my worth (although not, in general, that of others). I have subsisted on a personalized idolatry. The possibility that, at least in some mood states, I cannot trust my mind risks my sense of personhood. Yet, as I write these words, I know that this fear is no longer the main issue. Confronting addiction, I have become acutely aware of the pervasive role of denial, self-deception, and rationalization in maintaining my disease. When unchecked, my ability to twist reality to self-centred ends is fairly limitless. More to the point, I now find companionship and belonging within communities where my intellectual abilities and achievements carry no weight. No, I am reacting against something else. At some level, I thought that sobriety would allow me to evolve into my Ego ideal: the rarified idealization that I cultivated as a bulwark against actual life. At some level, I believed that—underneath the alcohol and drugs—I would find the person that I once thought I was. Whole, and unwounded.
I need time to mourn this illusion.