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September 10, 2012

“The Eden Express”: An Inside Look at Schizophrenia

When reviewing novels to read for the memoir project, I hoped to find a first person account of a serious and persistent mental illness. Working at Assertive Community Treatment (ACT) for my field placement, I am engaged with this client population daily. However, understanding the diagnostics of a disorder is quite different from understanding the actual client’s experience and thought processes. By reading a memoir that features a first person narrative of mental illness, I hoped to become more aware and empathetic to the experiences of my clients. After perusing the list, I chose to read “The Eden Express” by Mark Vonnegut.

“The Eden Express” chronicles Vonnegut’s post-collegial journey (moving to British Columbia, creating a commune, and trying to be a “good hippie”) during the late 1960s and early 1970s. Throughout this journey, Vonnegut becomes symptomatic and is hospitalized twice and diagnosed with schizophrenia. In the afterward, Vonnegut describes the changes in DSM criteria and states that if diagnosed today, he would be diagnosed with “manic depressive” disorder. However, the symptoms that Vonnegut describes appear to be more closely related to schizophreniform disorder due to his extreme yet short-lived psychosis. For example, Vonnegut’s psychotic episode lasts less than six months and much more positive symptoms are described than negative symptoms. After his recovery, friends and family believe that he has returned to baseline; this indicates that he has not decompensated nor retains negative symptoms.

Other prominent symptoms of schizophrenia spectrum disorders that Vonnegut experiences include visual hallucinations of a face, auditory command hallucinations, ideas of reference, paranoia about being poisoned, and grandiose delusions of being the messiah and of having killed his father and girlfriend (Virginia). Cognitively, he experiences difficulty inhibiting sensory stimuli, and difficulty with attention. Vonnegut also engages in clang associations, neglects hygiene and groom, has lack of sleep and lack of appetite, is catatonic at times, and is suicidal in regard to delusions of his death saving the world. While Vonnegut does exhibit some symptoms of depression, it is in response to the anxiety and grief that his delusions cause.

Vonnegut’s behaviors while psychotic are similar to the types of behavior that I see at ACT. Many of my clients do not maintain hygiene and groom and are often naked (just as Vonnegut runs through the neighborhood in the nude). Vonnegut made an insightful observation while hospitalized, stating that: “most of how you’re treated…is determined by how you are dressed. If you have on a suit and tie, there’s no such thing as a locked door. With nothing but a sheet, there’s no such thing as an open one” (195). When I visit a client, I conduct a mini mental status exam and hygiene and groom is the first aspect that I notice. Other similarities include difficulty paying attention to the conversation, staying on a specific topic, and processing multiple questions at once. Although, I have yet to experience a client who clangs, I do see clients who have grandiose delusions about living in a palace, being a king, a messiah, or a rock star. Many of my clients also endorse auditory hallucinations, most of which are persecutory like Vonnegut.

Being able to observe so many similarities between the behaviors of Vonnegut and my clients makes me wonder what their internal experiences are like. Some clients seem quite stable, but when asked more about their history, will speak at length about their views of the world, most of which are extremely disorganized, tangential, delusional, and paranoid. I really appreciated this memoir because I can see how difficult it might be to focus on a conversation with a care provider while there are so much internal stimuli and at the same time, there is a sensory overload. It was also interesting to read that Vonnegut felt as though everything in his mind was coming together to give him the knowledge of the world, and that it all made sense. It is easy to see how difficult it can be to do reality testing and challenge these strong ideas which are blossoming in the mind, while it is difficult to process what the clinician is saying.

When Vonnegut was finally hospitalized, his initial treatment was shocking because he was not informed about his treatment at all. He was given Thorazine three times a day but was not told what it was or why it was necessary. His illness was not described to him or even officially diagnosed. Also, he was released with no aftercare plans, medications, or even a prescription. It seems quite obvious that he would quickly relapse, and he was hospitalized again weeks later. This time, he was court ordered to receive treatment due to aggression and hostility. The same doctor (Dr. Dale) was his attending clinician, but was much better the second time around. He described schizophrenia as biochemical and described the effects of the Thorazine. After being stabilized in the hospital, Vonnegut had another episode, and after being isolated, a patient came to him and told him that he was freeing him from his power. Vonnegut states that this was the most helpful treatment that he ever received because he felt relaxed and released from his grandiose delusions of controlling the world. He was also given electroshock therapy and Thorazine.

I find it interesting that Vonnegut attributes his sustained recovery to his counseling sessions with Dr. Dale and the incident with the patient. Because of nature of the illness, a medication regiment is extremely important in maintaining mental health, but clients often choose not to see this because it strips them of power over themselves. I have often heard clients voice concern over lack of control of their body and mind and the need for medication to sustain this control, but Vonnegut either does not recognize this or he is an exception to what many clients experience.

Throughout the memoir, Vonnegut reflects on his cultural identity, stating “I am a white middle-class American heterosexual male… I am a down-under hippie revolutionary, alienated from the reins of power and persecuted by cops” (182-183). Although Vonnegut would be considered in the majority in all cultural categories, he often struggles with this because of his “hippie” status and desire to be one with others and one with the oppressed populations. After his first psychotic break, he even admits to being prideful because he feels that he has attained a heightened self-awareness by being a minority and oppressed in the realm of mental health.

As a member of the middle class, Vonnegut had used money from his parents to attend college, where he studied liberal arts and became quite political. He then purchased land and organized a commune to run the land and live and work together on the farm. When Vonnegut needs to be hospitalized, he does not have the burden of finances for the stay, the aftercare, or the medications because his parents are able to support him financially. Being a white male, he was also able to receive adequate care and was not discriminated against for his cultural identity. Throughout his psychotic episode, Vonnegut explores and agonizes about his “repressed sexuality” but he does not make this known to his friends or clinicians, so he is not stigmatized for straying from the norm (by having group sex or sex with an animal). Because of living in a commune, the client has surrounded himself with open and accepting friends who are able to support him through his illness.

As a part of greater society, Vonnegut would likely have had a very different experience and be stigmatized, but since he was living on his self-made commune with other hippies, he had a very different experience. Vonnegut’s culture is deeply tied to the hippie movement in the United States. He describes the hippie movement and the commune as all being one and aiding each other. Because of this, he believed that his friends would take care of him. He says, “There are lots of pressures in the hip community that make that sort of decision even harder to come to than normally. Doctors don’t know anything, mental hospitals are repressive, fascist, etc. Hippies are supposed to be able to take care of their own” (164). The cultural norms of the historical time period and the type of environment in which they lived made a strong support network but made treatment difficult. Vonnegut’s friends believed that his psychological distress was not negative but that he was enlightened. At many times, Vonnegut’s symptoms were even further exasperated by marijuana use on the commune. It is because of the hippie community’s societal norms that Vonnegut was untreated for such a great length of time; his friends did not believe in mental hospitals until he was too ill to function.

Seeing Vonnegut in a full blown psychotic episode made his friends question their beliefs regarding mental illness. While they originally believed that “ ‘schizophrenia is a sane response to an insane world’. ‘Mental illness is myth’. [and] The Sanskrit word for crazy means touched by the gods” (164). They later reflected that, “this whole thing is really giving me a whole new outlook on mental illness” (156). The hippie community that Vonnegut was a part of believed that it was ideal to try to achieve a higher level of awareness. Many experimented with drugs to try to become more self-aware, and many of Vonnegut’s early symptoms demonstrated some of these unusual and philosophical ideas. The early symptoms were then positively reinforced by both self and friends because it was desirable to learn to think differently and see the world in a new way. Thus, the time period, life experiences, and social network made a huge impact on Vonnegut’s course of illness and treatment.

One of the most positive aspects of commune living was that Vonnegut had many social supports. Vonnegut’s main social supports were his girlfriend (Virginia), dog (Zeke), and core commune companions (Simon, Mary, Joe, Sarah, Kathy, and Jack). Also, although Vonnegut did not see his family often, they were supportive in visiting him at the hospital, assisting with aftercare, and wrote him letters while he was living at the commune. Because of the many social supports, Vonnegut was able to receive great monitoring by his friends. There were times when he refused to eat, and they would sneak protein and vitamins in his beverages to help sustain him. They also took turns watching him 24/7 when he became suicidal before his hospitalization. After he was hospitalized, they all assisted with aftercare in reminding him to take medications and helping him get to and from his biweekly psychiatrist appointments. While these same supports had not been helpful in recognizing a need for more serious care, they did provide quality care to Vonnegut throughout the course of his illness.

Throughout the memoir, Vonnegut described a feeling of disconnectedness when it came to his girlfriend and their sexual relationship. While Vonnegut does explore some same-sex feelings while psychotic, he later denies them and believes that Virginia has difficulty with intimacy. Maintaining intimate relationships can be quite difficult for clients with schizophrenia because of repeated episodes, retained negative symptoms, and a general decompensation of the mind. However, although Vonnegut and Virginia do eventually go in separate directions, Vonnegut writes in the afterward that he is happily married with two children. As Vonnegut is most likely wrongly diagnosed and actually has schizophreniform disorder, it would be easier to have an intimate relationship, especially once he is stable.
Although Vonnegut’s friends faced many challenges in caring for him, especially when he was suicidal, they were able to work together and provide 24/7 support. They were also able to support one another and relieve each other of care taking responsibilities due to their living arrangement. This is not the case for many care givers. Many clients with schizophrenia live isolated lives because their care givers become exhausted and frustrated and eventually leave their loved one. This is harmful for both parties, and it is the reason that family group therapy was created, to support the care giver and client.

The memoir is also a historical piece in that it reflects the culture of mental illness during the late 1960s and early 1970s. The DSM II would have been the clinician’s main tool (Castillo 1997). The DSM II was similar to the DSM I except that it took a more biomedical approach, where the DSM I integrated biopsychosocial. This change was due to the new advances in medications, primarily the discovery of lithium and neuroleptic medications. The DSM II also was more disease-centered and the paradigm shifted even more towards this approach in the 1970s. The view of schizophrenia as a brain disease and a chemical imbalance is certainly seen in the memoir as Dr. Dale describes the illness as “biochemical” and treats Vonnegut primarily with Thorazine. It is, however, quite progressive that Dr. Dale also utilized therapy sessions, which is more client-centered, and was not as utilized during this cultural period.

Overall, Vonnegut allows readers to enter the mind of a client with schizophrenia and to understand psychiatry in its early stages. Vonnegut’s experiences are also unique as his social network is rather unusual and demonstrates that there are both positive and negative aspects to any culture.

References
Castillo, R. J. (1997).Why culture? Culture & Mental Illness, 1-22.

Vonnegut, M. (1975). The Eden Express: A Memoir of Insanity.

Posted by desolada at September 10, 2012 08:32 PM

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