Hell and Back

by Tim Parks

  If asked to name the writer with whom Buzzati has perhaps the greatest affinity, one is tempted to say, Giacomo Leopardi, Italy’s great poet of a hundred years before. Leopardi, an early atheist, was obsessed by the role of hope in human life, a hope he remorselessly exposed as the product of illusion, yet saw, and occasionally celebrated, as ever ready to flower again even in the most barren places, the most unexpected forms. This incorrigible inclination to hope, Leopardi felt, was both the curse and salvation of the race: it guaranteed that the defining experience of human life would be disappointment, and allowed us to press on regardless.

  Buzzati’s intuition is that with the collapse of the great collective illusions - religion, national destiny - and the consequently intensifying sense of absurdity (there is no common enemy to sustain the fort’s purpose), the individual mind can only react with ever more frenetic attempts to generate hope, the most preposterous hopes, out of nothing, to enchant itself with whatever desert terrain is available. Certainly the final chapters of The Tartar Steppe present Drogo as somehow in complicity with novelist and reader to drag out a vain illusion, perhaps even a whole tradition of literary fiction, far beyond the limits of reason. There is one marvellous moment in particular when the authorities ban the use of telescopes. With the help of a powerful lens Drogo and a friend had managed to identify some tiny specks on the very edge of the visible horizon and had built around this mirage the fantasy of an approaching army that would at last bring to the fort the catharsis of war. Denied the collective pursuit of this fantasy by order of their superiors, Drogo nevertheless goes on staring into the empty desert until it seems his busy imagination, or Buzzati’s, or perhaps ours, at last wills the enemy into existence.

  For at the very end of The Tartar Steppe the prospect of real war finally does present itself. What a huge relief. How pleased, busy, even joyous everybody is! How eagerly the rusty military machine is set back in motion, how bright the faces of the young men as they march up the gloomy valleys to the fort! And the reader is implicated too. Because you too are relieved, happy that war has come, that the wait is over. Yes, the reader too has been enchanted by the mirage of release, the fantasy that it might all have meant something.

  Buzzati’s typescript of The Tartar Steppe was submitted to the publishers in January 1939. There is no need to comment on what followed. In any event the book still serves as an alarming reminder that the century that discovered nothingness would go to any lengths, however catastrophic, to fill that nothingness up.

  In the Locked Ward

  [Jay Neugeboren]

  ‘Throw away your Sigmund Freud, Mrs. Neugeboren … because I am going to cure your son!’

  It is 1968 and Dr Cott is offering massive doses of vitamins B6, B12 and C. One of the first of a score of psychiatrists to take charge of the schizophrenic Robert Neugeboren, whose story is told in Imagining Robert Cott’s confidence is, alas, unwarranted. Still, the same could be said of most of those who follow him, each with his own favourite wonder cure, whether it be electroshock, insulin, Adapin, Mellaril, lithium, Stelazine or any number of others. When one doctor announces with great excitement that he is going to try ‘the brand new’ anti-convulsant Depakote, Robert’s brother Jay, who is telling the story, has to remind him that actually Robert has already been on Depakote. He responded briefly, then relapsed.

  Jay, however, is ever willing to hope and in the early nineties when a psychiatrist decides that Klonopin is the way forward, the author welcomes the decision. A little later, however, he discovers that this is the same drug that has just been prescribed to their eighty-two-year-old mother who suffers from Alzheimer’s. Is it likely, then, that this will prove the promised ‘magic bullet’ for schizophrenia?

  In the meantime Robert is frequently deprived of his phone privileges. Why, Jay complains, ‘what possible medical reason can there be for depriving him of any contact with the world beyond the ward?’ Invariably he is told that ‘the staff like Robert’ but that he can be ‘impossible’ and even ‘dangerous’. ‘He curses loudly, screams at telephone operators, keeps demanding refunds from the phone company, spits at aides, scratches them, strikes other patients.’ Reading Imagining Robert, it soon becomes apparent that dealing with the schizophrenic from day to day is far more of a problem than the choice of his new medication.

  A novelist by profession, Jay Neugeboren is a constant thorn in the flesh of those who have treated his brother over almost forty years of mental illness. It is not that he has an axe to grind. On the contrary, he displays an exemplary openness to a wide range of points of view. No, Jay’s behaviour is irksome first because he just will not leave be. He continues to visit his brother, even when those visits leave Robert more agitated than they found him, and he always insists on knowing what medication is being offered, what therapy proposed.

  ‘Stop being so concerned about your brother,’ advises Dr Laqueur, a great advocate of coma-shock therapy (this back in the early sixties). ‘You should get on with your own life.’ From time to time - as the years go by, the dashed hopes, the violent crises - readers of Imagining Robert may be inclined to agree with Laqueur. Yet at the same time they would have to acknowledge the author’s constantly implied objection: “but how can my “own” life be separated from my brother’s? They are inextricable.’

  For another quality of Neugeboren’s that psychiatrists find unsettling is his memory. Not only does he recall every wonder drug and improbable therapy that has been tried on his brother, but he also remembers how his brother was before his illness and the dramatic family scenario in which the two of them came to consciousness. This is the story he tells in Imagining Robert and we cannot come away from it without reflecting that narrative and contemporary psychiatry are implacable enemies. With all its mess, waywardness and ambiguity, the well-documented narrative reminds readers of everything they intuitively know beyond psychiatry’s austere vocation for separating things out into demonstrable fact and repeatable results.

  The book begins with a crisis. Invited to attend his nephew’s high-school graduation ceremony, the fifty-year-old Robert (schizophrenic since twenty) disappears, stays out all night, returns distraught and belligerent, and two days later has to be forcibly hospitalised. The author then goes back half a century to give us the childhood of the Neugeboren brothers and proceeds by switching back and forth from past to present throughout. The method is dense with implication. Though the author never insists on links between now and then, it is clear that he finds it hard to uncouple his brother’s mental illness from the more general madness experienced in the family as a child. Is this a failing, or merely common sense?

  Born in 1938, Jay is five years older than Robert. The parents are Brooklyn Jewish. Relatives are legion, likewise arguments. In thrall to a shared vision of the happy family, Mother and Father are nevertheless in permanent conflict. Mother is strong, generous, impulsive, insatiable; Father, whining, intelligent, incompetent. Infallibly, his businesses fail. Jay must remove debtors’ letters from the mailbox before Mother sees them. Does she know he is in league with Father? ‘Robert is my love child,’ she declares cruelly. “That one,’ she points to Jay, ‘who could ever love that one?’

  A hospital nurse, Mother works night shifts to pay the bills, but also finds time to be involved in charities. She is greatly admired in the community, bitter and irritable at home. ‘What can I do to make Momma happy?’ Father asks. ‘You’re a bright boy, Jay … Please tell me what to do.’ The man is desperate. He goes down on his knees before the whole family, crawling across the floor to lick his wife’s shoes. ‘That’s how much I love her.’ But why does she insist on coming to the dinner table topless, fondling her breasts with her free hand? Why does she parade around naked? Jay watches enraged as Mother paints little Robert’s nails red, his mouth pink. Jay can’t play in the football team because that would dishonour the Sabbath. Jay must not date a goy! It will kill Mother if Jay dates a goy.

  Crushed by his wife’s
imperious hysteria, the father nevertheless refuses to get a steady job. Anything to please, but not that. So there is always something for her to demand that won’t be granted. The tension is extraordinary. The arguments escalate. Confused but compos mentis, Jay gives up trying to win his mother’s love and starts to detach himself. He’s an adolescent now. More amenable, darling Robert is entrusted with the task of keeping his parents together. Shall I divorce your father? Mother asks. No, you mustn’t! Robert learns to play the clown, to do music-hall acts. He performs in public. What has he spent his life doing if not watching one splendid performance after another? When he puts on a show everybody laughs, everybody claps their hands. The Neugeborens are a happy family with a charismatic child. It’s exhausting.

  In short, here is a group of people who thrive on what has come to be called in the mental health profession an excess of ‘expressed emotion’. Interested readers may find it instructive to turn for a moment to Julian Leff and Christine Vaughn’s book Expressed Emotion in Families where they can observe a research team ticking off boxes on interview sheets to establish the number of times the relatives of schizophrenics speak critically of each other, or make direct eye contact, or use coercive imperatives. Although a psychologist of the systemic school, which originally developed out of Gregory Bateson’s reflections on interpersonal relationships and mental health, Leff is one of those who accept that schizophrenia is basically an organic disease, but nevertheless notes that the sufferer’s families of origin tend to be characterised by high levels of confrontation and conflict, something that may trigger a crisis. In this scenario, the therapist’s role is thus to seek first to measure, then reduce that level of negative engagement by teaching relatives to avoid excessive eye contact, verbal criticism, and the like. Of one young woman who had a psychotic crisis only days after returning from the hospital to live with her mother, he remarks that the decision to spend the weekend on the family’s small cabin boat was fatal. Think of the constancy of eye contact in the cramped cabin of a boat!

  The subtext of Leff and Vaughn’s book is optimistic: this side of the schizophrenia problem is quantifiable and hence, we immediately assume, manageable. It can be tackled in an organised fashion if teams of researchers and social workers are sent out to train families to deal with their loved ones. But Imagining Robert reminds us that this is no ordinary form of stress whose reduction we might reasonably plan for. Here every expression of emotion is generated within the inexorable dynamic of the parents’ relationship which is also the crucible in which two young personalities are now being formed. Past decisions have determined present dilemmas. Entrenched positions have been assumed. Above all the emotions expressed frequently reveal contradictory states of mind. ‘How make sense of what made no sense?’ Neugeboren wonders, reflecting on the way declarations of love came simultaneous with gestures of cruelty. What behaviour can one learn in such an environment?

  Shortly after Jay manages to leave home - against his mother’s will - Robert begins to buckle. His schoolwork becomes erratic. He leaves home, declares he is homosexual, lives with an assortment of dropouts, does drugs. Then comes home again. Then leaves again. Intriguingly it is the mother who first suggests he go to mental hospital. What but mental illness could explain her darling boy’s sexual inclinations? Perversely eager to see what the inside of such an institution is like, Robert confides to his brother that he faked a test to be admitted. Jay insists he takes another. Now the doctors say Robert’s fine. No problem at all. Shortly afterwards he has his first psychotic breakdown. ‘You and Mother put me here,’ he tells Jay from his hospital bed in a locked ward.

  ‘While I am not surprised,’ Neugeboren remarks in a second book on his brother’s fate, ‘that mental health professionals disagree strongly with one another, I am startled, occasionally, by the virulence with which they attack each other.’ Having completed Imagining Robert with the compelling story of his brother’s slow decline into chronicity, Transforming Madness poses the question: regardless of the aetiology of schizophrenia, what if a new drug were to return Robert, and others like him, to a stable state of mind? How can such people resume ‘normal life’ when their identities are now so entwined around their illnesses, when, in particular, they have never formed an adult personality?

  Inevitably, as Neugeboren travels the United States looking at a variety of different rehabilitation programmes, this question brings the author up against the heated controversy: therapy versus drugs, which matters most? And this in turn, like it or not, cannot but reflect back on the problem of the aetiology of the illness (organic, relationship-based, or both) and indeed on our whole sense of what it is to have a self, to be a person.

  One anecdote will suffice to suggest the complexity of the issue. In 1997, fifty-four now, Robert is given the new wonder drug Clorazil. Albeit marooned in the locked ward of the Bronx Psychiatric Center, he has, mainly thanks to brother Jay, a new doctor and a new social worker. There is dedication and excitement. Fifty per cent of patients respond to Clorazil, a new generation of more carefully aimed and milder dopamine blockers. Some months into the treatment, the doctors remark ‘that Robert is making “slow and steady” gains - he is learning to control his rages, he is interacting more easily with others, he is not starting fights, he is being “realistic” and “appropriate” about most things’. Neugeboren himself notes that his brother seems to have overcome his ‘total self-absorption’ and is now sharing food, cigarettes and money with others on the ward and showing interest in their health. Encouraged by this progress, Robert’s social worker concentrates on preparing him for the move to the open ward and relative freedom. Everything seems set for at least partial recovery. But two weeks before that move is due, the social worker is abruptly transferred. Despite continuing with the drug, Robert rapidly deteriorates. He now refuses to consider moving to the open ward and becomes manic and enraged, particularly with his brother. When Jay phones, he shouts, ‘You put me here, so you get me out of here, you goddamned son of a bitch cocksucking bastard!’ and hangs up on him. Even when not enraged, Robert’s talk degenerates into streams of childlike associations. ‘When I visit him,’ Neugeboren writes, ‘and bring him the food he has requested, he refuses to eat it. “You eat it, Jay!” he yells, “I don’t want it. You eat it. Mother made it. Can’t you tell? Mother made it!”‘

  Questions: If the drug works, why does it appear to stop working on the departure of the social worker? Was it partly the atmosphere of ‘the great attempt’ that brought about Robert’s improvement? Might that explain the drug’s only 50% success rate? Or is the brain learning to rewire itself around the transmitters the drug blocks? Then, is the departure of the social worker the real cause of the relapse, or is this rather an excuse for Robert to avoid going to the open ward and a freedom he is afraid of? Does Robert want to demonstrate to his brother Jay, of whose authorial success he is openly jealous, that no amount of fraternal string-pulling will save him, either from the vagaries of the institutions, or his own self-destructive impulses? He is his own man. ‘This is my home, Jay,’ Robert insists referring to the closed ward with its harsh regulations and frightening inmates. ‘Why should I go anywhere else?’

  To return to Neugeboren’s surprise at the vitriolic exchanges between mental health professionals, the quarrel he is referring to is, of course, that between those who support exclusively organic approaches to schizophrenia, and those who would like at least to include reflections on family dynamics and other environmental factors. Curiously, the development over the last twenty years of the theory of neural plasticity would seem to have eliminated the need for this head-on (to risk a pun) collision. This is the idea, now supported by a large body of research, that while the brain is indeed subject to genetic factors (how could it be otherwise?), it also responds and changes according to environment and experience, the latter often being crucial in the triggering and even transformation of particular genes.

  In a recent paper delivered in Venice,
Glen Gabbard, Callaway Distinguished Professor at the Menninger Clinic, speaks of experiments indicating how psychotherapy can be shown to have altered both the chemistry and gene expression of the brain. Referring to work by Steve Hyman, Director of the National Institute of Mental Health, Gabbard goes on to suggest that gene-environment interactions give rise to a sort of ‘hall of mirrors’ in which it is far from easy to establish a single source for the multiplying reflections. He looks forward to the day when an awareness of the brain’s plasticity - its tendency to change in response to experience - might finally erode the ‘reductionism’ that has divided the mental health world into two hostile camps, the psychosocial and the neuroscientific.

  Yet the conflict continues as bitterly as ever. The disagreements are so heated, one suspects - and it is the great merit of Neugeboren’s books that they prompt the reader to ponder the matter at length and with plenty of material to chew over -because at the deepest level the non-organic approach threatens to undermine the very basis on which the advocate of the exclusively organic approach operates. Why so?

  Neugeboren quotes Harvard Professor of Psychiatry Leston Havens as remarking that despite their reputation for vanity, many mental health professionals and medical students in particular, fail to recognise their own importance. They ‘come and go among patients as if their knowledge and skills were all that counted, not their persons at all’. The remark is pertinent, for it points to the underlying vision that drives the profession. The medical students are not looking for personal engagement with the patient. They don’t really want their ‘person’ to make a difference. That is not the ‘importance’ they are after. Rather they want to learn (why not?) to heal the patient with a precise and controlled intervention, the exact dosage of the exact drug chosen after an exact diagnosis based on meticulous and exact analyses of spinal fluids and brain scans. They are in thrall, that is, to the great and creditable dream of Western medicine, a dream most powerfully represented in the image of the perfect surgical incision made in sterile conditions by the absolutely steady hand. It’s an idea that never fails to stir our imaginations. Not for nothing did we arrive at the aberration of lobotomy.