Determined, page 29
Nonetheless, there has been a massive shift from the past. After those four millennia, we’ve left behind the Mesopotamians and Greeks, Kramer and Sprenger, Lombroso and Beddoes. Most people in the Westernized world have subtracted free will, responsibility, and blame out of their thinking about epilepsy. This is a stunning accomplishment, a triumph of civilization and modernity.
So the shifting views of epilepsy provide a great model for the more global task that is at the center of this book. But that’s only half the challenge, because whether one thinks about witches or thinks about overly synchronized neurons, someone having a seizure can still be dangerous. It’s that canard again: “Oh, so you’re saying that murderers and thieves and rapists aren’t responsible for their behavior? You’re just going to have them out on the streets, preying on all of us?” No, that half of the issue has been solved as well, in that people with uncontrolled seizures are not supposed to operate dangerous things like cars. Someone who has a seizure in the sort of circumstance described would have their license suspended until they have been seizure free for an average of six months.[8]
It’s how things work these days. When someone has had a first seizure, mobs of parasite-riddled yahoo peasants with pitchforks don’t gather to witness the ritualistic burning of the epileptic’s driver’s license. The heartbreak of a tragedy doesn’t get translated into a frenzy of retribution. We have been able to subtract blame and the myth of free will out of the entire subject and, nonetheless, have found minimally constraining ways of protecting people who suffer—directly or secondarily—from this terrible disease. A learned, compassionate person from centuries past, steeped in Malleus maleficarum, would be flabbergasted at how we’ve come to think this way. We’ve changed.[*]
Sorta.
Putting Our Money Where Our Mouth Is
On March 5, 2018, Dorothy Bruns, driving her Volvo sedan on a commercial street in Brooklyn, had a grand mal seizure. She seemingly slammed her foot on the accelerator, and her car went through a red light, striking a group of pedestrians in a crosswalk. Twenty-month-old Joshua Lew and four-year-old Abigail Blumenstein were killed, and their mothers,[*] along with another pedestrian, were seriously injured; Bruns’s car dragged Joshua’s stroller 350 feet before it swerved into a parked car and stopped. In the altar of flowers and teddy bears placed there by community members, someone included a stroller painted white—a ghost stroller, akin to the ghost bikes that are often placed to mark where a bicyclist has been killed.[9]
There was initially some skepticism that she had actually had a seizure. One neighborhood resident stated that Bruns “didn’t look like she had a seizure at all. . . . She was saying, ‘Hello, hello, what happened? What happened?’ . . . When you have a seizure you’re out. And she was active.” But it was a seizure; Bruns was still twitching and foaming at the mouth when police got there, and she had two more seizures in the subsequent hours.[10]
Despite what was described in the preceding pages, Bruns was charged with involuntary manslaughter and criminally negligent homicide; eight months later, awaiting trial, she killed herself.[11]
Why the different outcome? Why not “It’s not her, it’s her disease”? Because Bruns’s case was not the hypothetical one outlined above, where the perfectly healthy individual, from out of nowhere, had a seizure. Bruns had a history of seizures that were resistant to medication (along with multiple sclerosis, strokes, and heart disease); in the previous two months, three doctors had told her that she was not safe to drive. And yet she did.
And there have been other versions of this theme. In 2009, Auvryn Scarlett was convicted of murder; he had failed to take his medications for his epilepsy, had a seizure, and struck and killed two pedestrians in Manhattan. In 2017, Emilio Garcia, a New York City taxi driver, pleaded guilty to murder; he hadn’t taken his meds for his disorder, had a seizure while driving, and killed two pedestrians. And in 2018, Howard Unger was convicted of manslaughter; he failed to take his meds, had a seizure, and lost control of his car, killing three pedestrians in the Bronx.[*],[12]
Look—if you’re taking even a single page of this book seriously (as I mostly do), it is clear where this must head. At every one of those junctures, these individuals had to make a decision—should I drive even though I didn’t take my meds? A decision like any other—whether to pull a trigger, participate in mob violence, pocket something that isn’t yours, forgo a party in order to study, tell the truth, run into a burning building to save someone. All the usual. And we know that that decision is as purely biological as when you fling your leg out when hit on the right spot on your knee (just vastly more complicated biology, most dramatically in its interaction with environment). So you sit at the juncture of deciding: “Should I drive without my meds or do the harder, right thing?” It’s back to chapter 4. How many neurons are there in your frontal cortex and how well do they work? What do the underlying disease and the drugs taken for it do to your judgment and frontal function? Is your frontal cortex a little light-headed and sluggish because you skipped breakfast and now your blood sugar levels are low? Have you had a sufficiently lucky upbringing and education to have a brain that has learned about the effects of blood sugar on decision-making and frontal function, and a frontal cortex functional enough to make you have decided to eat breakfast? What are your gonadal steroid hormone levels that morning? Has stress in the previous weeks to months neuroplastically impaired your frontal function? Do you have a Toxoplasma infection latent in your brain? At one point in adolescence were your meds working well enough that you could finally do the single thing that made you feel normal in the face of a shattering disease, namely driving a car? What were your adverse childhood experiences and ridiculously lucky childhood experiences? Did your mother drink a lot when you were a fetus? What sort of dopamine D4 receptor gene variant do you have? Did the culture that your ancestors developed glorify following rules, or thinking of others, or taking risks? On and on. We’re back to the table on page 104 in chapter 4—“having seizures” and “deciding to drive even though you haven’t taken your meds” are equally biological, equally the product of a nervous system sculpted by factors over which you had no control.
And despite that, this is so hard. When Garcia didn’t take his meds, one of those killed was a child. When Unger didn’t, it was a child and her grandfather, out trick-or-treating. It turned out that the reason that Scarlett wasn’t taking his meds was because it “interfered with [his] enjoyment of liquor”; the judge, at sentencing, called him an “abomination.” I feel crazy, embarrassed, trying to make the argument anchored in the last paragraph’s science and in chapter 4 that not only does someone not deserve to be blamed or punished for having seizures but it is equally unjust and scientifically unjustifiable to make someone’s life a living hell because they drove despite not having taken their meds. Even if they did that because they didn’t want those meds interfering with their getting a buzz when drinking. But this is what we must do, if we are to live the consequences of what science is teaching us—that the brain that led someone to drive without their meds is the end product of all the things beyond their control from one second, one minute, one millennium before. And likewise if your brain has been sculpted into one that makes you kind or smart or motivated.[13]
This multicentury arc of the changing perception of epilepsy is a model for what we have to do going forward. Once, having a seizure was steeped in the perception of agency, autonomy, and freely choosing to join Satan’s minions. Now we effortlessly accept that none of those terms make sense. And the sky hasn’t fallen. I believe that most of us would agree that the world is a better place because sufferers of this disease are not burned at the stake. And even though I am hesitant to continue this writing here—oh no, I’m going to alienate the reader into thinking that all this is simply too way out there—the world will be an even more just place when we make the same transition in attribution when thinking these people who drove despite not having taken their meds. There is no place for burning at the stake here either.[*]
* * *
• • •
This history of epilepsy frustrates me a bit. It is great to be able to pinpoint just when nineteenth-century physicians and legal scholars were first embarking on subtracting out responsibility, to track down the perfect paper in some 1860s French medical journal and get it translated. But simply because of the antiquity, there’s no way to know something even more important: When did the average person begin to think differently about epilepsy? When would someone at a dinner party have discussed a newspaper article about how epilepsy was being viewed in a new light? When did well-informed teenagers start feeling contemptuous that their clueless parents still believed that masturbation caused epilepsy? When did most people begin to think that “Epilepsy is caused by demons” was as silly as “Hailstorms are caused by witches”? Those are the transformations that matter, and to get a feel for what change like that looks like, we have to examine the more recent history of another tragic misconception.
Generators and Refrigerators
While every mental illness on earth exacts a massive toll, you really, really do not want to have schizophrenia. There have been idiotic, New Agey fads that have somehow arrived at a view of the disease as having all sorts of hidden blessings—notions of schizophrenia as being the label given to the truly sane people in an insane world, schizophrenia as a wellspring of creativity or of deep, shamanistic spirituality.[*] These pronouncements have the nostalgic neo-sixties tinge of people in cranberry bell-bottoms doling out a lot of bread for their primal-scream therapy; some are advanced by people whose credentials have made their prattling truly dangerous.[*],[*] There are no hidden blessings in schizophrenia; it is a disease that devastates the lives of its sufferers and their families.[14]
Schizophrenia is a disease of disordered thought. If you meet someone whose individual sentences sort of make sense but are juxtaposed with meandering incoherence where, after thirty seconds, you can already tell something is not right with them, there’s a good chance it’s schizophrenia (and if it is a homeless person, muttering in fragments of thought, they are likely to have been deinstitutionalized and dumped out on the streets, for lack of an alternative). It affects 1–2 percent of the population, regardless of culture, gender, ethnicity, or socioeconomic status.
A remarkable thing about the disease is that the chaotic thought has some consistent features to it. There’s tangential thought and loose associations, where a logical sequence of A to B to C instead veers off every which way, the person ricocheting about, pulled by the sounds of words, their homonyms, vaguely discernible leaps of connectiveness. Tangenting loosely, with elements of delusion, of paranoid persecution. Add to that the hallucinations. Most of them are auditory, taking the form of hearing voices—incessant, often taunting, threatening, demanding, demeaning.
These are some of the major “positive” symptoms of schizophrenia, traits that appear in its sufferers and are not normally found in others. The “negative” symptoms of the disease, the things that are absent, include strong or appropriate emotions, expression of affect, and social connections. Add to that high rates of suicide, self-mutilation, and violence, and the “hidden blessings” nonsense is hopefully expunged.
A strikingly consistent feature of schizophrenia is that the onset is typically in late adolescence or early adulthood. However, in retrospect, there were milder abnormalities stretching back to infancy. Individuals destined for a schizophrenia diagnosis have higher rates of “soft neurological” signs in early life, such as late standing and walking, delayed toilet training, sustained problems with bed-wetting. Moreover, there are behavioral abnormalities early in childhood; in one study, trained observers who watched home movies were able to identify children destined for the disease.[15]
Amid most people with schizophrenia being no more violent than anyone else, the elevated levels of violence take us in an obvious direction. If someone commits a violent act during a schizophrenic delusion, should they be held accountable? When did average people start thinking, “It’s not him, it’s his disease”? In 1981, John Hinckley, long suffering from schizophrenia, attempted to assassinate Ronald Reagan (which injured Reagan, along with a police officer and a Secret Service agent, and eventually caused the death of press secretary James Brady). When he was found not guilty by reason of insanity,[*] much of the country erupted in outrage. Three states banned the insanity defense; most other states made it more difficult to mount; Congress accomplished the same by passing the Insanity Defense Reform Act, signed into law by Reagan.[*],[16]
So we still have a ways to go. But the point of this section isn’t the demonization and criminalization of schizophrenia and its parallels to epilepsy. Instead, it has to do with its cause.
You’re a woman in the early 1950s. The war years were, of course, immensely hard, raising three small kids on your own with your husband in the service. But thank God, he came back safe and sound. You have a home in the new American Eden, the suburbs. The economy is booming, and your husband recently got a promotion as he’s rising up the corporate ladder. Your teenagers are thriving. Except for your oldest, the seventeen-year-old, who is increasingly worrying you. He’s always been different from the rest of you, who are so, well, normal—extroverted, athletic, popular. With each passing year since he was little, he’s become more withdrawn, disconnected, saying and doing odd things. He had imaginary friends until a much older age than his peers but hasn’t had an actual friend in years—you have to admit that it makes sense that he’s shunned, given his peculiarities. He talks to himself a lot, often showing emotions completely inappropriate to the circumstances. And recently, he has become obsessed with the idea that the neighbors are spying on him, even reading his thoughts. This is what finally prompts you to take him to the family doctor, who refers you to a specialist in the city, a “psychiatrist” with a stern manner and European accent. And after a variety of tests, the doctor gives you a diagnosis—schizophrenia.
You’ve barely heard of the disease, and the little that you know evokes nothing but horror. “Are you sure?” you ask repeatedly. “With absolute certainty.” “Is there a treatment?” You are given a few options, all of which will eventually turn out to be useless. And then you ask the key question: “What caused this disease? Why is he sick?” And there’s an assured answer: You did. You caused this disease because of your terrible mothering.
It was called “schizophrenogenic” mothering, and it had become the dominant explanation for the disease, rooted in Freudian thinking. The first wave of Freudian influences in America, early in the twentieth century, was a fairly inconsequential fad mostly for New York intellectuals, titillating and mildly scandalous because of its focus on sex; it was already waning by the 1920s. Then the 1930s brought the European intelligentsia fleeing Hitler, a bounty of refugees that turned the U.S. into the center of the intellectual universe. And this included most of the leading lights of Freudian thinking, the next generation of psychodynamic royalty. With their confident, authoritative air of European intellectual superiority, they proceeded to wow the yokels of American psychiatry and become the dominant model of thought. By 1940, the chair of every major American medical school’s psychiatry department was a Freudian psychoanalyst, a stranglehold that was to last many decades. In the words of the influential psychiatrist E. Fuller Torrey, “The transformation of Freud’s theory from an exotic New York plant to an American cultural kudzu is one of the strangest events in the history of ideas.”[*],[17]
And these were not the Freudians of yore, going on in a charmingly scandalous way about penis envy. Freud himself had little interest in schizophrenia or in psychoses in general, greatly preferring genteel, neurotic, educated clients who were the “worried well.” The next generation of Freudians, who helped instill what became the psychodynamic cliché of blaming your parents for your psychological problems,[*] had many in their cadre with a strong interest in psychoses. The schizophrenogenic-mothering notion emerged from a chilling hostility toward women, often propounded by female analysts. The refugee Freudian Frieda Fromm-Reichmann wrote in 1935 that “the schizophrenic is painfully distrustful and resentful of other people due to the severe early smothering and rejection he encountered in important people of his infancy and childhood—as a rule, mainly in a ‘schizophrenogenic’ mother.” The analyst Melanie Klein (a refugee in the UK rather than the U.S.) wrote of psychosis, “It arises in the first six months of life, as the child spits out the mother’s milk, fearing the mother will revenge herself because of his hatred of her.” Strange, toxic gibberish.[18]
Every accusing psychoanalyst had a slightly different notion of just what was pathological about schizophrenogenic mothering, but the general themes centered on mothers supposedly being rigid, rejecting and unloving, domineering, or anxious. And in the face of that, all the child can do is retreat into schizophrenic delusions and fantasy. A theoretical elaboration was soon added by the anthropologist Gregory Bateson,[*] working with psychoanalysts, in the form of the “double-bind” theory of schizophrenia. In that view, the core of all of those supposedly malign maternal traits became the generation of emotional double-binds, highly aroused circumstances where the child is damned if he does, damned if he doesn’t. This would be produced by the mother who harangues the child, saying, “Why don’t you ever say you love me? Why don’t you ever say you love me?” “I love you,” says the child, and the mother retorts, “How is that supposed to mean anything when I have to ask for it?” And in the face of unwinnable emotional assaults like that, schizophrenia serves as a protective retreat of a child into their own fantasy world.
