The Self in Connection: Exploring Relational Psychodynamic Therapy in The Center Cannot Hold

Elyn Saks’s Story

The author and subject of the memoir The Center Cannot Hold, Elyn Saks, was diagnosed with schizophrenia during her first year of law school at Yale University. Despite her overall ability to achieve both academic and professional success over the course of her life, during psychotic episodes her level of functioning within her work, self-care, and relationships was markedly impaired and threatened the integrity of both her self and her endeavors. In the height of a psychotic episode her behavior often became erratic and disorganized, including periods of catatonia and vivid hallucinations.

By the time Saks became a freshman in college, she began experiencing brief psychotic episodes, usually lasting about an hour, characterized by odd, frenzied, and manic behavior. Concurrent with these behaviors, Saks’s invading sense of her own “badness” precluded her right to exist, preventing her from active participation in life. As her inner self split, it became itself unreal and fantasized, resulting in a “deliberate cultivation of a state of death-in-life as a defense against the pain of life” (Laing, 2010, p. 138); and as she withdrew further into herself, isolating herself away from first her family and then relationships with others by whom she could be known, her self became unable to preserve the last fleeting sense of aliveness that it possessed. This element of relation to others would later become central in her treatment.

Saks’s relationship with her psychoanalyst, Mrs. Jones, was the first step in a long road to recovery. Jones was able to communicate her understanding of Saks’s existential position with her perspicacious interpretations. More importantly, Jones modeled a relationship in which Saks could feel known without being destroyed by her firm and unflinching presence and love in the face of Saks’s most violent, bizarre, and ashamed aspects. This attitude of refusing to be scared off, quite contrary to the attitudes she faced in society, allowed Saks a catharsis of her privatized torment and made space for her entire being unconditionally: “She was not afraid; she did not look at me with alarm in her eyes. She did not judge, she only listened, and reflected back to me what she heard, telling me what she thought it meant” (Saks, 2007, p. 185). This relationship marked a shift where Saks was able to exist safely in relation to another, a dynamic that then began to bleed into the rest of her relationships. This marked a shift in attachment and relational capacity, serving as a powerful touchstone in her psychoanalytic work.

Much of Saks’s illness was exacerbated by a lack of access to care that resulted from shame and a subsequent need to hide her illness, both from herself and others. The myth of meritocracy in which she was raised, which emphasized hard work and the power of will, likely fed beliefs of her own “evil” nature (i.e. lack of willpower = bad). The shame associated with a lapse in willpower, and the social condemnation and stigma surrounding her diagnosis, set the stage for particular elements that characterized Saks’s battle with schizophrenia. She slowly withdrew into herself, internalizing the belief that speaking was “bad.” Thus, her battle against schizophrenia often manifested as a battle against her self, against her medication, and against the very existence of her illness. It wasn’t until she experienced relationships in which her illness was explicitly acknowledged and accepted that she began to acknowledge and accept the reality of it herself. Her relationships with others, including her friend Steve, her colleagues, psychoanalysts, and finally her future husband Will—relationships characterized by trust—ultimately acted as a safety net when psychosis inevitably reared its ugly head. In this sense, it was her relationships that became her healing.

Relationally Focused Psychodynamic Therapy

The healing work of Saks’s therapeutic relationship with Mrs. Jones can be conceptualized through the lens of Relationally Focused Psychodynamic Therapy, which emphasizes a primary need of relatedness that organizes mental life. This approach centers the deep bonding that occurs when two lives intersect, and sees these moments of psychological contact as sacred, holding a deep capacity for dyadic healing in which the client’s internal world and working models of attachment can be uncovered and reimagined (Barsness, 2021). What is most salient in Saks’s therapeutic relationship was Mrs. Jones’s therapeutic presence, which conveyed a resolute attitude of “I’m coming in no matter what you feel” (Laing, 2010, p. 167). This treatment focused on allowing Saks a space to exist in relation to another unconditionally, specifically in the midst of her deepest psychotic symptoms and states.

Therapy was later used not only as a space to give voice to psychotic elements but also to centralize her most coherent aspects and future goals, bolstering the elements of the self that Saks wished more to embody. Central to the therapeutic approach were the relational aspects, since “[a] sense of identity requires the existence of another by whom one is known” (Laing, 2010, p. 139). Ultimately, Jones’s approach emphasized an endeavor to truly grasp how Saks experienced herself and the world, with one foot in the world of her psychosis, and another planted firmly in sanity; for as Jung held, “The schizophrenic ceases to be schizophrenic when he meets someone by whom he feels understood” (Laing, 2010, p. 165).

References

Barsness, R. (2021, February 22). What is relationally focused psychodynamic therapy? The Seattle School of Theology & Psychology. https://theseattleschool.edu/blog/relationally-focused-psychodynamic-therapy/

Klein, M. (1946). Notes on Some Schizoid Mechanisms.

Laing, R. D. (2010). The Divided Self: An Existential Study in Sanity and Madness. Penguin.

Saks, E. R. (2007). The Center Cannot Hold: My Journey Through Madness. Hachette Books.