Toward a Pathology of the Possessed

Schizophrenia’s Effects Are Often Discussed in Metaphors. What Is It like to Live with Those Metaphors?
The Murder of Malcoum Tate, Victorian-Era Neurology, Atypical Antipsychotics, A Forest Fire in the Brain, The Elephant’s Foot, California Assembly Bill 1421, Ultimate Evil, The Burden of Care, A Stranger on Social Media, Poor Insight, Noncompliance, A Therapeutic Dose, Regan MacNeil’s Inner Life

Toward a Pathology of the Possessed

Esmé Weijun Wang
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Of the details reported about the murder of Malcoum Tate, in which Malcoum was killed by his younger sister at the side of the road while their mother waited in the car, the most striking is the fact that she shot him thirteen times. On December 19, 1988, Lothell Tate, thirty-two, used a .25-caliber weapon that required her to shoot, reload the seven-shot clip, and shoot again in order to hit him a full thirteen times in the head and back. The two women checked for a pulse; then they rolled Malcoum’s body into an embankment before driving home to Gastonia, North Carolina.

It was a receipt found at the crime scene that ultimately identified Malcoum Tate’s body. His mother and sister were arrested two days later. As word of the crime spread, headlines from newspapers, such as the Lakeland Ledger, the Herald-Journal, and the Charlotte Observer, and from the Associated Press provided a framework for Lothell Tate and Pauline Wilkerson’s motivations. Headlines read: NC FAMILY’S FINAL SOLUTION WAS MURDER, FAMILY’S NIGHTMARE ENDS WITH SLAYING OF PROBLEM CHILD, and DEATH ENDS FAMILY’S NIGHTMARE. The “nightmare” was a life starring their blood relation as a persistent threat—a man diagnosed with severe paranoid schizophrenia who had been jailed for assault and hospitalized again and again, but who resisted medication and, according to anecdotes, repeatedly threatened his family like a ghoulish specter. It was reported that Malcoum claimed Lothell’s two-year-old daughter had the devil in her, and that God had sent him to kill her. Allegedly, Malcoum loomed over their beds at night until either Lothell or Pauline was startled awake, when he would laugh a “strange laugh” and leave the room.

There isn’t much in the way of public information about Malcoum Tate from before he was diagnosed with schizophrenia, in 1977. Young Malcoum received high marks in school. He was good at reading and enjoyed it—then he went crazy. His mother was driving with seventeen-year-old Malcoum on Wilson Street in Baltimore when Malcoum spotted a mailbox with “Wilson” written upon it. This coincidence triggered him to escape from the car, break into the house, and brutally beat the man he found inside, leading to the first of his five reported hospitalizations.

Schizophrenia’s unpleasant prognosis today is essentially the same as it was during the time of Emil Kraepelin, an early twentieth-century German psychiatrist credited with much of the medical community’s initial understanding of schizophrenia. Though his predecessor, Victorian-era neurologist John Hughlings Jackson, proposed that the disease was caused by a “broken brain” that led to the presentation of so-called “negative,” or deficit, symptoms (that is, symptoms that represent, relative to normal functioning, a reduction or diminishment of some kind, such as the severe lack of motivation known as avolition), Kraepelin took Jackson’s hypothesis a step further. “Dementia praecox,” as Kraepelin knew it, was a progressive and neurodegenerative disease. Kraepelin is credited with figuring out that manic depression (now referred to as bipolar disorder), which may also include psychotic symptoms, is a fundamentally different illness from what’s now called schizophrenia, and also does not lead to a permanently damaged brain. He also believed that schizophrenia was close to, if not completely, incurable.

Swiss psychiatrist Eugen Bleuler, who coined the term schizophrenia (or “the schizophrenias”) to replace dementia praecox, conceived of the disease as one disorder along a spectrum. A “schizophrenia spectrum” continues to appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM). My own diagnosis of schizoaffective disorder, which includes a mood disorder alongside basic symptoms of schizophrenia, is listed under “Schizophrenia Spectrum and Other Psychotic Disorders” in the DSM-5, but it is considered a different disorder than schizophrenia itself. However, it shares the “295” classification, which comprises three disorders (schizophrenia, schizophreniform disorder, and schizoaffective disorder) that are therefore considered closely related. Though my diagnosis lies at a different point on this conceptual spectrum than schizophrenia, this does not exempt me from the neurological damage commonly associated with the disease.

In 2013 I experienced a seven-month-long psychotic episode as a symptom of schizoaffective disorder. Beginning in 2002, I had tried every atypical antipsychotic on the market—atypical antipsychotics being the pharmaceutical family of choice for psychosis, proving less likely to cause the severe side effects of their predecessors—and yet none of those medications worked for me. Even Clorazil, considered to be the powerful anti­psychotic of last resort due to its ability to cause a lethal plummet in white-blood-cell count in some people, hadn’t been effective in eliminating my delusions. I was terrified and concerned; my family was worried and concerned; my doctor was perplexed and concerned. She told me that the longer each episode lasted, and the more frequently the episodes occurred, the more damage was done to my brain.

National Book Award–winning author Andrew Solomon describes schizophrenia in his 2012 book Far from the Tree as “like Alzheimer’s… an illness not of accrual but of replacement and deletion; rather than obscuring the previously known person, this disease to some degree eliminates that person.” Though there is no direct reference for this statement in the book’s extensive notes, his description is a lyrical summary of how schizophrenia is commonly understood. Imaging studies of patients have shown a reduced volume of gray matter as well as an enlargement of the brain’s four cavities, called ventricles. In a BBC interview with Professor Paul Thompson from UCLA, such examples of tissue damage are described as “[moving] across the brain like a forest fire, destroying more tissue as the disease [progresses].”

It is disconcerting for anyone to be told that her brain is being damaged by an uncontrollable illness, whether it is by Andrew Solomon or by her own psychiatrist. It might have been especially disconcerting to me because since childhood my brain was one of my more valuable assets. I began to read at two; I was the first student, boy or girl, to finish every available math textbook in my elementary school; I went to Yale and Stanford and graduated from Stanford with a 3.99 GPA, after which I took a job as a lab manager and researcher at one of the university’s brain-imaging labs. My anxiety about a loss of gray matter fed a variety of delusions: one afternoon I frantically called my husband while he was getting an oil change to babble about spiders eating holes in my brain. I’d been intrigued by the Far from the Tree excerpt published in the New York Times, about raising children with genius-level IQs, and my research background in the science of mother-daughter genetics and depression meant that I was particularly excited about Solomon’s book. But his words about those diagnosed with schizophrenia hit me like a punch in the gut, with two basic reactions: an angry “What the fuck?” and a terrified “What if it’s true?”

Solomon’s statement about “replacement and deletion” reflects a common possession narrative about schizophrenia, a narrative unlike those about psychiatric diagnoses such as depression or obsessive-compulsive disorder. The story of schizophrenia is one with a protagonist, the schizophrenic, who is at first a fine and good vessel with fine and good things inside of it that then becomes misshapen by the ravages of psychosis into a vessel prone to being filled with things that are not so fine and good. The wicked thoughts and behavior that may ensue become the vessel itself, which is now an unrecognizable form of what it once was. In the end, the person is taken over; the individual has become possessed.

The Chernobyl disaster resulted in the creation of the Elephant’s Foot, a mass of hundreds of tons of hardened nuclear lava. So named because of its wrinkled appearance, it was not discovered until months after the April 1986 disaster. Its radioactivity meant certain death to any person who approached it. It’s now encased in what is known as the Chernobyl sarcophagus, a concrete vessel haphazardly built after the explosion in an attempt to surround what had once been the nuclear power station. However, the walls of the sarcophagus have started to erode. The Elephant’s Foot is still unapproachably radioactive.

As the metaphors and narratives suggesting an otherwise ordinary person’s radical departure from her original self indicate the drastic impact of schizophrenia, so the societal and legal responses to dealing with its effects are understandably complex. One group that addresses the everyday concerns of those touched by schizophrenia is the National Alliance on Mental Illness (NAMI), self-described as “the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.” NAMI is also known in the community of mental health advocates as the first place that scared and often desperate families go for support and validation.

On the group’s website is a headline: “We like to call it the NAMI effect.” Below, the “NAMI effect” is described as such:

Every time you offer your hand to pick someone up.
Every time you share your strength and ability to persevere.
Every time you offer support and understanding to a family who is caring for a loved one.
You help change lives.
Mental illness affects everyone. With your help, we can reach more people in need of help and hope.

The description seems to address anyone who might be reading it. However, given the third line, I find it unclear if the targeted “you” is supposed to include me or anyone else diagnosed with mental illness.

Though NAMI’s services include referrals and information regarding employment, hospitalization, and housing, the organization also prides itself on its activism; its “About NAMI” page states that “NAMI shapes the national public policy landscape for people with mental illness and their families…” Such shaping is described in a 2012 report, under “Policy Topics.” Under “Legislation to Improve Mental Health Care in America,” the group lists causes including the Helping Families in Mental Health Crisis Act (HR 3717) and the Strengthening Mental Health in Our Communities Act of 2014 (HR 4574). “NAMI parents,” as the advocacy jargon describes parents of a child or children with mental health issues who are involved in NAMI-sanctioned activism, recently spoke out at 2014 committee meetings regarding California’s Assembly Bill No. 1421. Counties across California deliberated over whether or not to adopt AB 1421, created in 2002 as a way to open the door for “assisted outpatient treatment,” or “the involuntary treatment of any person with a mental disorder who, as a result of the mental disorder, is a danger to others or to himself or herself, or is gravely disabled.” AB 1421 “would [also] create an assisted outpatient treatment program for any person who is suffering from a mental disorder and meets certain criteria.” Like the Strengthening Mental Health in Our Communities Act, AB 1421 appears, in many ways, unassailable: who wouldn’t want to give help to people who need it?

And yet the debate over AB 1421, as I discovered in San Francisco, touched upon issues of autonomy and civil liberties. The bill makes the crucial assumption that a person who displays a certain degree of mental disorder is no longer capable of choosing his own treatment, including medications, and therefore must be forced into doing so. Sartre claimed, “We are our choices,” but what has a person become when it’s assumed that said person is innately incapable of choice?

The Exorcist is a Hollywood touchstone of possession narratives. As the first horror film to be nominated for the Academy Awards’ Best Picture, it’s also an American narrative about more than just demons. The film made its debut in 1973, four years before Malcoum Tate was first hospitalized. Named the scariest film of all time by Entertainment Weekly, The Exorcist is described by Warner Bros. as a movie about “an innocent girl inhabited by a terrifying entity, her mother’s frantic resolve to save her[,] and two priests… joined in battling ultimate evil…”

The “innocent girl” is Regan MacNeil (Linda Blair), who becomes possessed by the “terrifying entity” after using a Ouija board; the mother is Chris (Ellen Burstyn), a busy actress who receives invitations to the White House and purposefully bustles across crowded film sets. We first meet Regan as she bounds onto the screen, all blunt bangs and big eyes, to give her mother a kiss hello. How was her day? Well, she played a game in the backyard, there was a picnic, and she also saw a “beautiful gray horse,” playing up her role as a sweetly privileged, all-American girleen as she wheedles, “Oh Mom, can’t we get a horse?” Even her use of the doomed Ouija board smacks of whimsy: when she first uses it on-screen, with Chris by her side, she demonstrates the spirit’s presence by asking, “Do you think my mom’s pretty?”

Once possessed, Regan all but vanishes. She hits her doctor; her face seems plastic; her voice is an unrecognizable growl. “Keep away!” she screams. “The sow is mine! Fuck me!” Chris, frustrated by the doctor’s explanations of her daughter’s behavior, demands, “What are you talking about, for Christ’s sake? Did you see her or not? She’s acting like a fucking out-of-her-mind psychotic or a split personality…”

As with Chris’s story in The Exorcist, Pauline and Lothell’s story is about a family that is both terrified and consistently let down. The doctor, a figure of authority and a source of hope, is useless. Malcoum Tate was repeatedly released from jails and hospitals once he was determined by authorities to be better, or “not a danger to himself or others.” After a yearlong hospitalization, in 1984 in Baltimore, Malcoum’s condition improved, but it regressed approximately two years later, after he stopped taking his medication—and this kind of decline, pro–AB 1421 advocates would argue, is a key reason for forcing treatment. According to Lothell, Malcoum kicked down an apartment door one morning in the fall of 1988, causing the family to be evicted. We have a sense in both Regan’s and Malcoum’s cases, fictional and real, of familial desperation, of not knowing what to do.

In searching for local NAMI members who advocated for AB 1421, I was put in touch with someone I’ll call Beth. A chatty, impassioned woman who asked to remain anonymous, Beth has been a NAMI member since the mid-’90s. She talks about mental health public policy in the manner of someone who is both well informed and highly opinionated; her many thoughts about jails and 5150s—the California code for an involuntary psychiatric hold—as well as the dramatic story of her own mentally ill family member, come out in a rush of statistics and policy talk.

Beth’s relative, an adult male, lives with schizoaffective disorder. In describing the development of his illness, she says, “He was an excellent student, and the following year he started having these rage attacks.” She tried to get him treatment. The system, a mess of private facilities, hospitals, and HMO-­limited therapy sessions, has resulted in his being hospitalized over seventy times, says Beth, and has repeatedly put her in dire financial straits. She continues to fight for the laws that she believes will help him, including AB 1421: “If you have a history [like he does]… of when he’s off medicine, of getting so manic and so violent that nine times in one year he’s called the police himself, saying, ‘Please take me to the hospital; I want to kill [Beth],’ then that person should be on medication, not after he kills me or himself.”

I find myself nodding when I talk to Beth. I say “Yeah” a lot. I find myself thinking, How can anyone possibly argue against this woman, who has found herself in desperate circumstances as she tries to help someone she loves?

Testifying on the stand, Lothell Tate explained, “I was just saying to myself this is the only thing I know to do, that we done asked people to help us and we done begged people to help us and nobody did anything, and I was scared that one day Malcoum was going to lose his mind and harm me and my daughter.”

The Tate-Wilkerson family was of lower socioeconomic means than Beth, though she has had to take out a second mortgage on her home to pay for treatment-based private housing. The family in The Exorcist is assuredly upper-class. All three suffer, or suffered, from an inability to adequately contain the possession despite their class status. It is impossible for me not to feel sympathetic toward Beth. It’s even impossible for me to feel completely antagonistic toward Lothell, who was found guilty of murder after only one hour of jury deliberation. I hear the bewilderment in Beth’s voice when she talks about how there are no options for long-term care. When I ask, “In San Francisco?” she replies, “All over the nation. Unless you have enough money.” To say that the options are limited for families with severely mentally ill and psychotic relatives is a comical understatement. People like Beth go to NAMI because they feel that there’s nowhere else to go.

“Family-to-Family” is NAMI’s signature program, developed in 1991 by psychologist Dr. Joyce Burland. The twelve-part course, which has had over three hundred thousand participants, addresses families’ emotional and practical needs in dealing with their loved ones’ mental illness. Although it now stands alongside the newer “recovery education course” called NAMI Peer-to-Peer, which is designed for “anyone experiencing a mental health challenge,” the influence of Family-to-Family is felt in the purpose statements of every single other one of NAMI’s five education classes, all of which are designed for either caregivers, friends, partners, or providers.

In describing the reasons one might attend NAMI’s Family-to-­Family course, the organization’s national director of peer education, Colleen Duewel, told me, “One of our fundamental beliefs… is that it can be a traumatic event to have a diagnosis of a mental health condition. And what we do is provide that light at the end of the tunnel of recovery, of You can do this, and You’re not alone, and You have the support and the tools and the skill set you need.”

As she described the traumatic experience of someone receiving a mental health diagnosis, I realized that she was describing not the patient but the patient’s family. NAMI specifically states that the Family-to-Family program is based on “a trauma model of family healing.” When I asked Duewel if the majority of the people coming to Family-­to-Family feel “desperate,” she paused. Carefully, she replied that “a fairly universal feeling is feeling alone… How do I take care of me? How do I take care of my loved one? How do I find resources?” In speaking about research into the trauma model, she says that Family-to-Family has been found to decrease the “burden of care” one feels as a result of having a mentally ill relative. (This is not NAMI-only terminology; “burden of care” is a term used in scientific literature addressing caregiver mental health.)

I was once asked by a stranger on social media to describe my husband’s experience as the partner of someone with schizoaffective disorder. It seemed like it would be so difficult, she said, concluding that she didn’t think she could do it—“it” meaning be in a relationship with someone like me. This woman knew me only through what I published online and couldn’t have known that I’ve spent plenty of time in tears with my husband, my mother, and my therapist during conversations about being a burden. How many times has my husband had to visit me in a psychiatric ward, seen me unwashed and unglued, or listened to agitated babbling from my scrambled brain? What kind of marriage would he have had—what kind of life would he have had—if not for a wife diagnosed with severe mental illness? When I hear the phrase “burden of care,” I recognize that the care is not the real burden; even if my symptoms come and go, I am the burden.

NAMI has made a strong effort in recent years to address consumer concerns with resources such as NAMI Connection, a consumer support group, and NAMI Smarts for Advocacy, a peer-to-peer advocacy training program, among others. Considering NAMI’s origins, however, it’s not surprising that many know it as an organization whose focus veers toward the family members who support a person with mental illness. The Family-­to-Family program was founded in 1991.As Duewel puts it, NAMI began when a couple of “mothers sitting at their kitchen table said, ‘We’ve learned our lesson the hard way. How can we share this with other people, so they don’t have to go through what we did?’” As in organizations such as Mothers Against Drunk Driving (MADD), it was the grassroots power of mothers caring for their children that fueled NAMI’s creation. Beth calls her group “the NAMI Mommies.”

Men are conspicuously absent from these stories. “You know, all these support groups seem to be female-­dominated,” Beth said to me as an afterthought, “and the men just… We have one male.” In The Exorcist, Chris is a single mother to Regan. Lothell Tate and Pauline Wilkerson struggled alone with Malcoum. Under such circumstances, “NAMI Mommies” becomes more than a glib nickname. According to the National Alliance for Caregiving and the AARP, more women (60 percent) than men are caregivers in general. Duewel emphasized that “one of the most profound things that people get from [NAMI] is a sense of ‘I’m not alone.’”

Julian Plumadore, the manager of the speakers’ bureau of the anti-stigma organization Sharing Our Lives, Voices, and Experiences, and a former community advocate of the Mental Health Association of San Francisco, describes MHASF as a “peer-run, recovery-oriented organization.” I know Plumadore because I’ve been a speaker for SOLVE since 2013. I give talks at San Francisco schools and clinics as a mental health advocate and have heard through Plumadore’s talks how he understands his own schizoaffective disorder recovery story. He describes how he was targeted as the “identified patient.” The term is based on research about family homeostasis and describes a pattern of behavior in which a dysfunctional family identifies one of its members as mentally ill, though his or her symptoms are actually manifestations of the family’s own pathology.

“‘If only I could have gotten my shit together, everybody else’s lives would have been fine’ was the message that I was getting constantly, and so I was responsible for other people’s happiness,” he said.

Plumadore, following MHASF’s official stance on AB 1421 and other similar policies, is against forced treatment. He’s civil but clearly in disagreement with “NAMI parents.” I don’t think I’ve ever seen him in anything but a button-down shirt, tie, and slacks, which is a conscious choice on his part; it’s what he wears to meetings like the AB 1421 hearings, where the visual difference between the pro– and anti–AB 1421 constituents was obvious. “The rooms were divided,” he said. “They were visibly split in two, and the power imbalance in those rooms was tangible. On one side of the room you’d have the people who basically hold the power in society. Generally white, upper-middle-­class, well-dressed professional people, the family members; and then on the other side of the room you’d have a much more diverse group, generally more dressed down. And,” he finished wryly, “you could see who was actually having the mental health issues and who were the people who were essentially trying to get them committed.”

He told me about a mother he spoke to at an AB 1421 hearing. She told him about her forty-year-old son, who was “living at home… where he belongs.” She seemed to believe she was “his only hope.” He highlights both of these phrases with horror. “They’re so afraid of something bad happening to [their loved ones] out on the street, or out in the rest of the world, or [their loved ones] can’t take care of themselves, [so] they guard them and keep them home. And that situation becomes increasingly tense and frustrating for everyone involved.”

He knows about these situations because he was one of those patients who couldn’t take care of themselves. The people who support forcible treatment sometimes don’t believe him when he talks about how he was homeless, how he used to abuse substances and act “scary in public.” He’s better now, he tells me, because he was finally told that he himself knows better than anyone else what he needs. For him, treatment included learning harm-­reduction techniques—which focused on lessening, without necessarily eliminating, negative consequences of his own actions—instead of involuntary rehabilitation, as well as estranging himself from the rest of his family. Because he was able to find his own method of recovery, he believes that the issue of personal and bodily autonomy needs to be respected above all. He talked about how those with mental illness almost universally experience the effects of trauma when they are forced into treatment, and he has doubts about the concept of “hurting someone to help someone.” “We have the ultimate decision about what we’re going to allow into our bodies, what we’re not, and the decisions that we make about our own lives,” he said.

In discussing schizophrenia, psychotic disorders, and treatment, it’s important to consider how far the possession goes—or, in psychiatric terms, the level of “insight” the individual is capable of. To have poor insight is to have a lack of awareness about one’s own condition. A fundamental argument for forcible treatment is that the patient simply doesn’t understand that she’s ill and therefore lacks the ability to decide for herself whether or not to accept the prescribed treatment. Patients refusing to take their medication is a recurring issue in families (Malcoum Tate decided to stop taking his medication six months to a year after his yearlong hospitalization in Baltimore). Psychiatrists use the pejorative term medication noncompliance to describe this refusal, no matter the reason for the patient’s decision.

I asked Beth what she wishes people would better understand, or currently misunderstand, about psychotic disorders. “There’s all this stuff about ‘Give people information and they’ll seek help on their own,’” she said. “Somebody who has a mind that they cannot trust, because it’s been taken over by whatever chemicals are not allowing them to think straight, needs help in getting care, and they might need to be forced into it. It’s comparable to Alzheimer’s. Not to say that people with paranoid schizophrenia are demented or stupid, but they lose the ability to make rational decisions.”

The mind has been taken over. The mind has lost the ability to make rational decisions. There’s something or someone in there, but it’s not whoever we formerly believed it to be. Depression is often compared to type I diabetes: it’s not your fault if you get it, and you’ll be fine as long as you take care of it. Schizophrenia, on the other hand, is compared to Alzheimer’s: it’s not your fault if you get it, but there’s no fixing it, and though you may not intend to be a burden, you’ll still be one until you die.

I do have experience with the loss of autonomy that comes with involuntary treatment, as well as the status that comes with being described as lacking a sense of one’s own illness: I was hospitalized against my will in 2002, 2003, and 2011, and the records from my first involuntary inpatient psychiatric hospitalization stated that I had “poor insight.”

That hospitalization occurred in the spring of 2002. I was a freshman at Yale. I’d been diagnosed with bipolar disorder the summer before, and come spring I’d become manic, then depressed. I received a call from the clinic laboratory about my mood-stabilizer blood work, and the technician asked if I knew that my levels had never been therapeutic—apparently, I’d never been prescribed a therapeutic dose. By then, I was frustrated and flirting with the idea of suicide, and so I walked to an urgent-care center, at which point I was involuntarily hospitalized for being a danger to myself.

It is hard to convey the horror of being involuntarily committed. First, there’s the terrifying experience of forcibly being put in a small place that you’re not allowed to leave and where you’re also not allowed to know how long you’ll stay, because no one knows. You don’t have the things that you love with you: your journal, the bracelet your grandmother gave you, your favorite socks, your teddy bear. There are no computers. In the hospitals where I’ve stayed, the only phones allowed were the landlines, which could be used at certain times of the day for a certain period of time, causing patients to jockey for position and to bicker over who’s been taking too long. Sometimes someone will be allowed to bring you something you cherish during visiting hours, although this must take place after a nurse inspects the goods; a lot of the time, your possessions won’t be permitted into the ward because they include a sharp point or a wire coil or a dangerous piece of cloth. You’re not allowed to choose what you eat, and within the limited choices that do exist, you’re forced to choose only between things that are disgusting. You are told when to sleep and when to wake up. If you spend too much time in your bedroom, it indicates that you’re being antisocial; if you do sit in the common areas but don’t interact with the other patients, you’re probably depressed or overly inward or perhaps even catatonic.

And yet I found the lack of freedom much less distressing than another key feature of psychiatric hospitalization: while institutionalized, you will not be believed about anything. Whoever you were outside of the hospital does not exist. Wherever you went to school, whatever awards you’ve won, however you make your living—all of it can be interpreted as a delusion. However, such things can (though they won’t) be fact-checked, whereas whatever you claim to be thinking or feeling is assumed to be not what you’re actually thinking or feeling, unless the stated thoughts and feelings fall into a category that the doctors and nurses deem within the realm of possibility; when it comes to your headspace, there’s no hope of “proving” oneself right. When last incarcerated in such an institution, I told the doctor that I was a writer and had studied psychology at Yale and Stanford, which, in terms of believability, was akin to saying that I was an astronaut and an identical triplet born to a Russian ambassador. In a fit of childishness, I later trounced the other patients in a mandatory “group therapy” word-game session.

During my first hospitalization, a nurse stopped me to ask how I was feeling. I’d spent the week feeling angry, and afraid of not being allowed to go back to school, but at that moment I felt all right. When I said that I was feeling OK, the nurse said, “No—how are you really feeling?”

At this point, I should have invented something. But I was a stubborn young adult, and so I said again that I was fine, which the nurse told me wasn’t true. I presume that it was interactions such as this one that led them to record what “poor insight” I had. Humans might all be ciphers to one another, but people with mental illness are seen as particularly opaque because of our broken brains; we cannot be trusted about anything, including our own experiences.

We do get a brief sense of Regan’s internal life before she is possessed. Chris spends one scene raging down the hall from Regan, who is in the foreground and in another room. When Chris screams, “Don’t tell me to be calm, goddamn it!” the camera lingers on Regan, who glumly sits herself down. In another scene, the camera lingers on Regan’s frightened face as Chris investigates a banging sound in the attic. We don’t know what happened inside Malcoum’s mind, other than hearsay about some anguished confusion about his mental state, and what he was reported to have said when the shooting began, which was “Whatcha doing? Whatcha doing?” Instead, we see the nightmares that need to be erased. We see the possessions that have subsumed the sweet girl or the bookish boy, who are understood to be long gone. In the stories of who they were before the illness, or the evil, or the possession, there is an expectation of not only normalcy but goodness.

At this point, the comparison between possession and schizophrenia runs into complications. In The Exorcist, Regan is taken over by the demon Pazuzu but is ultimately saved by an exorcism. Though both Father Karras and Father Merrin die as a result, Regan emerges relatively intact; the priests’ goal was never to harm Regan’s body—though Karras does punch her repeatedly, shouting, immediately before the demon leaves her body to jump into his—but to save her body, mind, and soul. Unlike the possession of someone with schizophrenia, whose brain is a “forest fire” ravaged by disease, a possession like Regan’s can be undone. According to Andrew Solomon and my psychiatrist, even if my psychotic delusions are tamped down, they still have done irreparable damage. Lothell Tate and Pauline Wilkerson ultimately felt that the only way to defeat schizophrenia was to destroy the ruined vessel itself.

But when I say that Solomon is incorrect when he speaks of the “likely reality” of schizophrenia as deletion, I recognize that it sounds like a form of denial. In speaking to a friend about the theory, she suggested that I might simply be parsing an inaccuracy: “How do they know?” she asked. And, more to the point, “Is anyone the same as they were ten years ago?” Of course, the fact that I don’t listen to Yo La Tengo anymore isn’t the same as fully believing, as I have done, that there are cameras installed in my shower, or that everyone I love has been replaced by a robot double who wants to hurt me. It’s not the same as hallucinating, in daylight, about a maggot-ridden corpse in a car. Yet I recognize the ability to make a choice: to reject an image or perception of what my experience of schizophrenia looks like, and as far as I can tell, it does not look like Malcoum Tate’s experience, whatever his experience actually was. I won’t permit myself the audacity of presumption, but I particularly can’t presume to have the experience of someone whose complicated humanity is now reduced to anecdotes of “the problem child,” “the nightmare,” the reason why a sister shot her brother while her mother waited in the car.

Malcoum Tate’s murder is an extreme example of what happens when a family caring for a relative with schizophrenia feels that they have run out of options—that they have become overwhelmed by a force larger than themselves. The burden of care becomes the burden that breaks people. On the stand, Lothell Tate described the crime as an act of love: “I said to Malcoum, I said, ‘Malcoum, I love you, and I only want what’s best for you, and I’m sorry,’ and I shot him… And I told him again, ‘Malcoum, I love you, and I’m sorry,’ and I shot him again until he quit moving.”

And yet jurors spent only a single hour deliberating before returning with the verdict: Lothell Tate was sentenced to life in prison; later, her mother was sentenced to ten years as an accessory, reduced to one year with five years’ probation. Judge Don Rushing told Lothell, upon her sentencing, that the manner in which she killed Malcoum “truly was horrible,” and “as brutal and dispassionate a murder as I’ve had a chance to see as a trial judge.”

Lothell appealed once locally and then to the South Carolina Supreme Court, where her appeal was dismissed in 1990; she appealed again in 1991; her last appeal was dismissed in 1992. With that final rejection, Lothell stopped her diabetes treatment and died in South Carolina State Prison in 1994. I can’t speak to her now, but I do imagine what it was like to be her on the night she killed her brother. When I think about the murder, I think about how excessive thirteen shots is. I also think about how a man who loomed over your bed in the middle of the night, a man who claimed to be sent by God to kill your daughter, might seem like a man possessed by evil, and therefore capable of anything, including surviving multiple gunshot wounds—even if you once loved him, or still do.

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