{"id":17234,"date":"2026-05-28T19:32:27","date_gmt":"2026-05-28T19:32:27","guid":{"rendered":"https:\/\/niemanstoryboard.org\/?p=17234"},"modified":"2026-05-29T13:45:40","modified_gmt":"2026-05-29T13:45:40","slug":"rachel-aviv-pulitzer-finalist-story-schizophrenia-diagnosis","status":"publish","type":"post","link":"https:\/\/niemanstoryboard.org\/2026\/05\/28\/rachel-aviv-pulitzer-finalist-story-schizophrenia-diagnosis\/","title":{"rendered":"Annotation: Rachel Aviv on reporting and writing her Pulitzer finalist story about a schizophrenia diagnosis"},"content":{"rendered":" \n
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As a longtime New Yorker staff writer Rachel Aviv<\/a> has covered some of the more fascinating topics in mental health: what happens when people reject their diagnosis<\/a>, the challenges of going off psychiatric drugs<\/a>, and whether suicidal students should be forced to leave college campuses<\/a>.<\/p>\n\n <\/div>\n <\/div>\n \n

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In one of her latest stories, \u201cMary Had Schizophrenia and Then Suddenly Didn\u2019t<\/a>,\u201d Aviv examines a phenomenon that doctors have only recently begun to uncover: Some people who experience psychosis are misdiagnosed with schizophrenia when in fact they have treatable autoimmune conditions that attack the brain. <\/p>\n\n <\/div>\n <\/div>\n \n

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Earlier this month, Aviv\u2019s story was named<\/a> a Pulitzer Prize Finalist in Feature Writing for its \u201cextraordinary exploration\u201d of two daughters\u2019 search to understand why their mother was relieved of her 20-year-long psychosis and what it was like to observe her recovery. <\/p>\n\n <\/div>\n <\/div>\n \n

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Aviv said she was surprised when the piece was selected as a finalist, largely because of the challenges she had writing it. \u201cOf all the stories I’ve written in the last however many years, it had been the one that caused me the most grief in terms of the actual writing process,\u201d she told me. \u201cI had structured it one way, and then maybe five days before the piece closed, I just felt like the structure was not serving the story as well as it could, and I was in a state of despair.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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With her editor\u2019s support, Aviv restructured the story \u2014 a process she explains in greater detail in the annotation below. As I heard her recount this last-minute pivot, I was reminded of the value in acknowledging when a story\u2019s structure isn\u2019t working as well as we hoped and acting accordingly \u2014 even when it requires a last-minute scramble.<\/p>\n\n <\/div>\n <\/div>\n \n

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The final structure that Aviv arrived at reflects a masterful blend of historical context, immersive reporting, and rich source materials that help us see how a single diagnosis can alter the course of a life and shape one\u2019s identity. Several related questions drove Aviv\u2019s reporting, both in terms of the science behind a new category of illness referred to as\u201cautoimmune psychosis,\u201d and the family at the heart of the narrative. <\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cThere were the scientific questions, which were pretty straightforward: Is this real? What is happening? Why don’t we know about this? Why has it taken so long? How many people is this affecting?\u201d Aviv told me. <\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cAnd then there were the more personal questions of: What is the experience of a mother who has been in another reality for an entire lifetime for her children, and then they’re coming back to her as this person who is suddenly sane? What does that feel like to be returned to consensual reality, both for the person who has been ill and for the people who loved her and couldn’t relate to her in that previous state? How do you rebuild a relationship when your past feels so split in terms of perspective and memory?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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The story\u2019s driving questions and themes dovetail with Aviv\u2019s bestselling book, \u201cStrangers to Ourselves<\/a>,\u201d in which she writes about the limits of psychiatric explanations and the ways in which people can feel trapped or freed by stories of mental illness. Aviv\u2019s next book,\u201cYou Won\u2019t Get Free of It: Stories of Mothers and Daughters<\/a>,\u201d comes out this summer. <\/p>\n\n <\/div>\n <\/div>\n \n

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To learn more about Aviv\u2019s writing process and interest in psychiatry, I asked her to annotate her award-winning story and offer a behind-the-scenes look at how it took shape. Her responses have been lightly edited for length and clarity. <\/p>\n\n <\/div>\n <\/div>\n \n

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Mary Had Schizophrenia\u2014Then Suddenly She Didn\u2019t<\/h2>\n\n <\/div>\n <\/div>\n \n
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By Rachel Aviv, The New Yorker (July 21, 2025)<\/h4>\n\n <\/div>\n <\/div>\n \n
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When Christine was nine years old, her mother, Mary, said, \u201cCome here. I want to tell you a secret.\u201d They sat on a brown couch in their living room, in Santa Ana, California. Mary, who was forty-three, said that a man she had known in medical school, a professor, was sending her messages about a plan to take her away and live in a mansion together. \u201cI remember feeling really excited, because that fit with my sense of what should be happening,\u201d Christine said. \u201cI was really into \u2018Harry Potter\u2019 and the idea that, if you are part of the select, you can see a bigger story happening out there.\u201d <\/p>\n\n <\/div>\n <\/div>\n \n

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Mary leaned over and began separating strands of Christine\u2019s hair, as if searching for lice. \u201cDoes he put listening devices in your hair?\u201d Mary asked, about the professor. \u201cDoes he ever ask you to say things to me?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine, the older of two sisters, said, \u201cI believed everything she said until she accused me of something that I knew wasn\u2019t true.\u201d Mary had always been tender and doting and practical, and, Christine said, \u201cI just had this feeling in my body that she was not the same.\u201d <\/a>MT: How did you find Christine and Angie as sources?<\/span>RA: I had read a story in The Washington Post about this center at Columbia University where they were looking for other conditions (often autoimmune conditions) that were masking as more typical mental illnesses.<\/span><\/span> [Read the Washington Post story<\/a>.]<\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>I had called the center and just talked to them about the work they were doing, and I remember thinking they were doing something that felt close to a paradigm shift in psychiatry. Having covered psychiatry and written about it for many years, I thought it felt very new. I had asked them if there were any current or former patients who might want to speak. They got back to me and said that Christine had been wanting to tell her story.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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Her sister, Angie, who is seven years younger, learned to follow their mother\u2019s instructions, whether or not they made sense. \u201cI was taught the rules of her delusions at the same time as I was taught other rules and norms about the world,\u201d Angie said. She came to view her mother\u2019s stories about the professor, and about friends who were part of his mission, as akin to tales in the Bible. \u201cIt\u2019s kind of like, O.K., some of these people are real, and some of these people aren\u2019t real,\u201d she said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine was often cast in the role of the villain. Her mother would yell at her for poisoning her pizza or hiding her keys or other menacing deeds, even as Christine tried to explain that she hadn\u2019t done them. Sometimes Mary smacked her. (Mary doesn\u2019t remember this.) <\/a>I appreciated this simple sentence, both because it shows the reader early on that you spoke with Mary and because it signals the importance of being transparent about memories that don’t align. Why was it important to you to include this line?<\/span>The story felt like it was so much about memory and perspective in general. One of the most traumatizing aspects of this experience for Christine and Angie was that they felt like they were living in a reality that was very different from their mother’s reality, and that their complaints for years couldn’t be validated. And then they had gotten to this point when I met them, where their mother was lucid and receptive. And anytime they would mention something that had been painful for them, she would be encouraging them to share what that experience had been like.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>But it felt like they could never quite figure out whether she was in denial or evading painful experiences, or whether she truly had some sort of cognitive dysfunction where she could not remember. That felt like the trickiest part in the whole piece \u2014 having conversations around this memory hole.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>As we continued with our conversations over the course of a few months, I think we all had a clearer sense of the contours of that hole and what it was that she couldn’t remember. And then toward the end, we started really talking about the actual things in that hole. There was a way in which their mother would say, ‘I don’t remember this’ (but not as a way of saying ‘I didn’t do that.’) And so I think with something as serious as a mother smacking her child, it felt important to make it clear whose memories these were.<\/span><\/span> Christine began to mistrust her own memory, too. \u201cMy mom would accuse me of things, and then I\u2019d be, like, Maybe I did do these things,\u201d she said. In fifth grade, she asked Santa Claus for a polygraph machine. <\/a>This detail made me think about how, when reporting on people’s childhoods, it could be revelatory to ask: What did you want for Christmas when you were X years old? Did you ask a question along these lines, or did this detail come about more organically?<\/span>That wasn’t my question. That was something Christine told me about how unbearable it was to feel like her mother was doubting her \u2014 she had an excruciating desire to prove to her mother that she was reporting reality honestly. The polygraph detail captured so much about Christine’s desperation \u2014 if only she could prove to her mother that she wasn’t doing the things her mother was accusing her of.<\/span><\/span> \u201cI just had this baseline sense of: I could be doubted at any time.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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She felt that people might help her mother if she could just find the right language to describe her transformation. By high school, she was spending so much time studying the Diagnostic and Statistical Manual of Mental Disorders<\/em> that she texted a friend that she had actually \u201cmarried the dsm-iv.\u201d <\/a>Did you ask to see the text messages? For this story, how did you go about establishing trust so that Christine and Angie would will feel comfortable sharing personal correspondences with you?<\/span>They had read the previous New Yorker piece I had written about Alice Munro and the sexual abuse that was hidden in her family, and it actually had resonated with them previous to even my getting in touch. I think they were familiar with my approach, and that helped a lot. Christine had this archive of childhood materials that she’d been keeping. She jokes that it was like she had been waiting her whole life for a fact checker. She had sent me a Word document of the diary she had been keeping from that time, and she had included the text conversations in that diary.<\/span><\/span> She explained that her mother suffered from the \u201cfregoli delusion,\u201d a belief that strangers were disguised as doubles of people she knew. In her journal, Christine wrote, \u201cMy mom has erotomanic delusion disorder with a splash of persecutory delusions.\u201d She asked for help from teachers and a school counsellor, but, she said, the \u201cmessage I got was, basically, Everybody has their shit, and you have to just deal with it and keep getting good grades.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary, who was from India and had worked as a physician there for a decade, spoke so much about the professor that her husband, Chris, who worked at the California Department of Motor Vehicles, eventually found the professor\u2019s number and called him. \u201cHe said, \u2018I am not in contact with her,\u2019 \u201d Chris recalled. \u201c \u2018I didn\u2019t even know your wife came to America.\u2019 \u201d At the professor\u2019s suggestion, Chris scheduled an appointment for Mary with a psychiatrist. Christine sat in the waiting room, hoping that this would be the beginning of getting back the mother of her early childhood, whom she remembered as a \u201cmagical, glowing figure.\u201d But when Mary finished the appointment she said that the psychiatrist thought she was fine. Not long afterward, Mary kicked Chris out of the apartment and barricaded the door with a desk and two heavy suitcases. Christine and Angie allotted extra time to get to school each morning so they could remove the obstacles.<\/p>\n\n <\/div>\n <\/div>\n \n

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Karl Jaspers, the German psychiatrist and philosopher, has described what he calls the \u201cdelusional atmosphere,\u201d a profound alteration in the way certain people experience the world. \u201cThere is some change which envelops everything with a subtle, pervasive and strangely uncertain light,\u201d he wrote. People in this state search for a story that explains why everything suddenly feels uncanny and ominous. The \u201cvagueness of content must be unbearable,\u201d he wrote. \u201cTo reach some definite idea at last is like being relieved from some enormous burden.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary had landed on a story that overwrote the reality of her daughters\u2019 lives, but they also recognized in it a kind of emotional logic. Mary had been pressured to marry Chris, in an arranged match, and, when they settled in America, he had traditional ideas about a woman\u2019s role and restricted her freedom to pursue her career. Christine and Angie came to feel that their mother\u2019s delusions\u2014that her former colleagues would free her from marriage and she\u2019d be restored to her place in the medical community\u2014were \u201ca way of explaining how she ended up trapped in this position,\u201d Christine said. \u201cWe theorized that psychosis was almost a reasonable response.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine moved to New York after high school, because her favorite book, \u201cUnderworld,\u201d by Don DeLillo, was set there, and because it seemed like the city where people went to escape their homes. She lived in the Bronx, near her father\u2019s brother, and got a job at Planet Hollywood. She wanted to be a novelist, and obsessively re-read \u201cUnderworld,\u201d covering the pages with determined annotations: \u201cintegrated dialogue\u201d; \u201cmeta commentary\u201d; \u201csensation of young immediacy.\u201d <\/a>This is another great example of how you use source materials to fill in gaps and add color to the piece. Did you ask to see her copy of the book?<\/span>She was in London at the time, so she just took photos of her book. I thought it was so interesting that \u2018Underworld\u2019 had been such a meaningful book for her, and I couldn’t quite see the line of continuity in terms of her own life. So I did ask her a lot of questions about what that book meant to her. In general, I always love to know what people are reading at particularly pivotal moments in their lives.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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Angie and her mother would text Christine asking for groceries or pizza, and she would order the food for them from across the country. Mary was still barricading the door. Chris slept in his car. (Eventually, he moved in with a girlfriend.) Christine worried that Angie, who was eleven, was growing up in a kind of folie \u00e0 deux, a delusional system that structures two lives. Angie said, of her mother, \u201cI could never figure out why she was doing these things to me, and I had this kind of emotional explanation: Other things are just more important to her. I\u2019m only there as a vessel for the magical thinking.\u201d After about a year, Christine arranged for her mother and Angie to move to New York, too. (Mary asked me to use only her middle name, to protect her privacy.) <\/a>Why did you think it was important to heed this request and protect her privacy?<\/span>Because she was sharing very private medical information, as well as medical records, which made her feel vulnerable.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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Mary moved into an apartment in the Bronx, in the same building as her brother-in-law, and plastered the walls with tape, to prevent reality-TV shows from recording her and Angie through the cracks. Angie tried to bathe while her mother was asleep because Mary believed there was a camera in the showerhead, and had covered it with a sock. Angie felt as if she were living in a kind of urban version of \u201cGrey Gardens,\u201d a formative movie for her. The documentary chronicles the lives of a mother and daughter, relatives of Jacqueline Kennedy Onassis, who live together for years, piles of trash accumulating around them, social conventions becoming remote.<\/p>\n\n <\/div>\n <\/div>\n \n

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After two years in New York, Mary seemed increasingly unable to care for herself, so Christine, who had enrolled at Columbia, called the city\u2019s mobile crisis unit, a team that assesses people in psychiatric distress. The crisis unit knocked on Mary\u2019s door, and, after a conversation in which she described receiving electric transmissions through a filling in her tooth, she was admitted to Mount Sinai Beth Israel hospital, in Manhattan.<\/p>\n\n <\/div>\n <\/div>\n \n

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Psychiatrists there petitioned a judge for permission to hospitalize her for a month and treat her with antipsychotics, over her objections. \u201cI believe that she has no judgment concerning the nature of her illness,\u201d one of them wrote. On an evaluation form, another psychiatrist initially wrote that Mary had an \u201cunspecified psychotic disorder.\u201d Then, perhaps uncomfortable with such a vague diagnosis, she crossed out the phrase and wrote, \u201cSchizophrenia.\u201d <\/a>This detail that really illustrates the uncertainty surrounding Mary’s illness. Can you talk about how you happened upon this detail, and why you knew it needed to be in the piece?<\/span>I think I saw it upon second or third read of her medical records. The first time I didn’t quite grasp how interesting it was that the psychiatrists needed to get her committed against her will, so they were looking for a diagnosis that was serious and concrete enough that, from a judicial perspective, they could justify committing her. And then they had given her this diagnosis, and it seemed like no one had re-evaluated it. Once she had that diagnosis, it just stuck, and that seemed really tragic. It stuck for a decade.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>There is this sense that you’re being told schizophrenia is somehow part of your essence, when actually it’s part of this arbitrary bureaucratic process where a psychiatrist has to come up with something in the spur of the moment, and schizophrenia feels like the least worst match.<\/span><\/span> Mary was fifty-five years old, and her symptoms had begun in her early forties, which is unusual for schizophrenia. Most people are diagnosed in their twenties or early thirties.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine moved into her mother\u2019s apartment and filed a petition for joint custody of Angie. Their father, who was living in California, did not contest the petition. \u201cI make breakfast in the morning,\u201d Christine wrote in her journal, describing her new routine with Angie. \u201cI wash the dishes. I lock the door at night. I have established, kicking and screaming, my own rightful place as an active agent in the universe.\u201d <\/a>You effectively used journal entries here, and I’ve seen you do it in other stories as well. When you read Christine’s journal, what were you looking for as a journalist? And why do you think journal entries can be so effective in stories?<\/span>We discussed it fairly early. Over the course of a few conversations, Christine sent installments. Some of her journals were written for a class at Columbia, and I felt like I was looking for the less \u2018written\u2019 parts.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>There was a way in which, for her class, she was seeing herself as a writer seeking meaning from a hard situation. And in some ways, I was more interested in the rawer, less processed moments that she could not convert into meaning right away. Retrospective writing or talking can’t capture that immediacy.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>I did tell her that I would check to make sure she felt comfortable with what I decided to quote, because obviously it’s a very vulnerable thing to just hand over your journal.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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When Mary was released from the hospital, she stopped taking her medications. Neither she nor her daughters thought they had helped her. For about a third of people with schizophrenia, antipsychotics do not work. \u201cI wish my mother\u2019s delusions and paranoia were treatable,\u201d Angie wrote, in a college-application essay. \u201cHowever, she has lived with them for 12 years, and her institutionalization last year had no effect.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary\u2019s admission to Beth Israel was the beginning of a nine-year cycle in which she was sent to psychiatric hospitals for weeks at a time before being released, unchanged. Mary said that each time she was admitted to a hospital the staff \u201ckept asking the same questions, and it never made anybody have a different outlook on the situation. Everyone stayed with the same thing. It was schizophrenia.\u201d <\/a>This is the first time we directly hear the words \u2018Mary said.\u2019 Was it a deliberate choice on your part to initially tell her story through her daughter’s voices before introducing us to Mary’s voice?<\/span>Somewhat, and I think there was also the issue of Mary actually not remembering. I was telling their perspective, and if I had told it from Mary’s perspective during those years, it would have been very different and more confusing because her memories of that time were jumbled. I felt like it was more coherent to just start with the daughters’ perspective and then bring in Mary’s perspective once she’s chronologically in a state where she is more lucid and able to acknowledge the difference in her daughters’ experiences.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>In that way the structure reflects the experience of the daughters: they had a mother who was unreachable in some way, and then with this sort of accidental cure, she becomes reachable. That’s the moment at which Mary enters the story and has more of a speaking presence.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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After five hospital stays, including one in which the police led her to an ambulance in handcuffs because she wouldn\u2019t leave her apartment, Mary was transferred to the Bronx Psychiatric Center, a state facility that provides long-term care. She observed that when patients refused medications staff would sometimes call security, and the patients would be injected with drugs, a prospect that terrified her. \u201cI would take the medication without any question, because I\u2019m not risking fighting with security,\u201d she told me. \u201cThese people are very sensitive to what they call \u2018challenging authority.\u2019 \u201d She spent her days dreading the moment when she\u2019d be forced to swallow her pills.<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary sometimes imagined that God had a reason for keeping her in the hospital, but, she said, \u201cI did not even want to go there, because the reasoning mind makes you feel very nervous and uncertain.\u201d Her daily life became so narrow that she stopped noticing the weather. \u201cThey don\u2019t remind you about the changing season\u2014that spring is coming into summer or the winter is coming into spring,\u201d she said. \u201cYou just pass the days as quickly as possible.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine, who spoke to her mother every week, said that Mary never articulated her sorrow at the time. \u201cI would have wanted to engage on the level of \u2018I\u2019m sorry you\u2019re there, do you feel sad?\u2019 And I\u2019m sure she was having those emotions, but she wasn\u2019t able to express them. It was always \u2018I\u2019m being attacked. I\u2019m being held like a prisoner here.\u2019 \u201d Christine felt that her mother was safer at the Bronx Psychiatric Center than she would be anywhere else, but she felt guilty for hoping that Mary would stay there for the rest of her life.<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary was discharged in September, 2023, after a year. <\/a>Reading this made me wonder: Did you create a timeline of events when working on this story? And can you talk more about the structural challenges you faced?<\/span>Any time I write a story, I’m always writing down the dates that are relevant and creating a timeline. I had originally started the piece with Mary’s cure and then had gone backwards into her daughters’ childhood. But then the cure felt less meaningful without the context of understanding what they’d been through in their childhood. But if I started with their childhood, the reader had to wait a long time to discover what this story was actually about \u2014 so that was the dilemma, and I basically emailed my editor, Willing Davidson, asking him if it was OK to try switching it up last minute, and he encouraged me to try.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>Usually when I’m writing a piece, it’s the structure that I figure out first. I had to rework it all at the last minute, and that was an uncomfortable experience.<\/span><\/span> A week later, she collapsed in her bathroom and struggled to move. She was taken to a hospital in Brooklyn, where the doctors told her to stop taking antipsychotics, because they thought her condition may have been a side effect of the drugs. Then they discovered that she actually had lymphoma, a sometimes fatal form of cancer. She began seven cycles of a treatment that combined chemotherapy with rituximab, a medication that targets antibodies involved in the body\u2019s immune response.<\/p>\n\n <\/div>\n <\/div>\n \n

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When Christine and Angie visited her at the hospital, Mary responded to their questions with one-word answers. Her face had a vacant expression. Christine and Angie thought she was dying. Mary did, too. She dreamed about being a child, playing with her sister and four brothers, in Kolkata, where she grew up. \u201cI told myself, \u2018This must be the end of it,\u2019 \u201d Mary said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Angie, who was now twenty-two and had recently graduated from Dartmouth, prepared in therapy for her mother\u2019s death. She said, \u201cI had multiple sessions where I was just crying about the fundamental things I wish she had given me, like \u2018I wish she could have told me what was going on in her head,\u2019 or \u2018I wish she could have told me she was sorry for what she did.\u2019 \u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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By Christmas, two months after beginning chemotherapy, Mary was moving a little more freely, and she had begun to carry on conversations. Christine and Angie noticed that her personality seemed different: she was calm, outgoing, and polite, and she often expressed gratitude. Angie texted Christine that Mary seemed peaceful, as if maybe she was \u201cgetting some post-life or death clarity?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine, who was twenty-nine and had settled in London, having moved there for a master\u2019s degree in psychology, was struck by her mother\u2019s ability to watch the news and absorb the information on its own terms. For years, the television had been a source of agitation; Mary had said that people were using her ideas and repeating her lines.<\/p>\n\n <\/div>\n <\/div>\n \n

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One day, when Christine was visiting the hospital, Mary asked for a phone. \u201cI sort of teased her, \u2018Now you\u2019re asking for a phone?\u2019 \u201d Christine said. \u201cI wasn\u2019t really making much of it, but then afterward I thought, Why has she asked for a phone? That\u2019s quite unusual.\u201d Mary already had a phone, but it was in storage because she\u2019d told Christine that it contained spyware.<\/p>\n\n <\/div>\n <\/div>\n \n

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Angie gave her a flip phone and, to be safe, covered the camera with a piece of tape. \u201cShe seemed fine using it, which was odd,\u201d Angie said.<\/p>\n\n <\/div>\n <\/div>\n \n

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In May, a month after Mary finished chemotherapy, Christine and Angie asked a psychiatrist at the hospital to examine her. Christine said, \u201cThe psychiatrist was, like, \u2018Why have you called me here? I don\u2019t understand. She has no symptoms.\u2019 And we were, like, \u2018Yeah, that\u2019s the reason we\u2019ve called you here.\u2019 \u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine had the same feeling in her body that she\u2019d had when her mother first became ill\u2014the sense that something at Mary\u2019s core had changed. She tried to get the doctors to grasp the scale of her mother\u2019s recovery. By the summer, her cancer was in remission. She hadn\u2019t taken antipsychotics for months, and yet \u201cher psychotic symptoms are gone,\u201d a doctor wrote. Christine told the doctors, \u201cShe had a twenty-year psychiatric history. Have you heard of this? Could any of her medications have caused this?\u201d She spoke with a neurologist at the hospital, but he didn\u2019t have an answer. Omid Heravi, one of Mary\u2019s oncologists, didn\u2019t understand what had happened, either. \u201cMedicine is very specialized\u2014we don\u2019t get involved in other fields,\u201d he said. He guessed only that one of the cancer drugs she\u2019d been given had had collateral benefits. \u201cIn medicine, all side effects are not bad,\u201d he offered.<\/p>\n\n <\/div>\n <\/div>\n \n

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When a person recovers from an illness, it is usually seen as the end of the story. <\/a>This line made me think about one of my favorite lines from your book \u2018Strangers to Ourselves\u2019: \u2018There are stories that save us, and stories that trap us, and in the midst of an illness it can be very hard to know which is which.\u2019 What compels you to want to explore the narrative aspects of illness and recovery?<\/span>I think I had to justify why the story wasn’t ending with this unlikely recovery, but why it kept going. I had to explain that what I was interested in was not just, ‘here we have this amazing new way of seeing mental illness,’ but also, ‘here’s an opportunity to understand what recovery means.’<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>We don’t often get to see recovery from psychosis in this way, and, at my editor’s suggestion, I was trying to alert the reader that there was still a third part coming \u2014 that there is real work to be done, after you’ve recovered from a long illness, to make sense of what has just happened and to integrate it into your sense of identity.<\/span><\/span> But becoming sane also causes a kind of narrative collapse, a confrontation with a personal history that is no longer recognizable. Christine encouraged her mother\u2019s friends and siblings, whom she\u2019d been estranged from for years, to get back in touch. She wanted to restore her mother\u2019s sense of connection, but, she said, \u201cI also wanted them to be able to tell me\u2014outside of my childhood memories\u2014if this is the person she used to be.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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For years, Christine\u2019s friends had known little about her mother beyond the details of her mental illness. \u201cSuddenly, I was, like, \u2018Hey, my mom\u2019s better now. Would you like to call her up and talk to her?\u2019 And that was a shocking concept for them,\u201d she said. \u201cI mean, there are a lot of people who wouldn\u2019t necessarily be open to jumping on a call without planning, but my mom was now the type of person who is quite flexible and responsive and conversationally fluid.\u201d Christine described her as a \u201cpsychological d\u00e9butante.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Angie, who was living in Queens and working at a firm where she analyzed data on sexual violence, felt skeptical that their mother\u2019s transformation was real. Christine said, \u201cI felt like, If Mom can disappear, then she can come back.\u201d But Angie didn\u2019t have memories of Mary from before the illness, and it felt to her like she was being asked to believe that her mother had become a new person. \u201cI tend to choose security over the process of discovery,\u201d Angie told me. \u201cI didn\u2019t have a curiosity that felt worth the emotional risks.\u201d Angie had always felt that, on some level, her mother had \u201cchosen her delusions\u201d over her children. She didn\u2019t want to experience that choice being made again.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine searched for medical papers that might explain her mother\u2019s recovery and allow Angie to believe in it. She read about each of the medications that her mother had taken and concluded that the key drug may have been rituximab, the immunosuppressant. \u201cI have a new working theory,\u201d she texted Angie, in May, 2024. \u201cTheoretically her chemo could have incidentally cured\u201d her.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine found a handful of recent case studies that documented drastic psychiatric recoveries after people were treated with drugs that dampen immune activity. A 2017 study in Frontiers in Psychiatry<\/em> described a woman with a twenty-five-year history of schizophrenia. She also had a skin disease, for which she was given drugs that reduced inflammation and suppressed her immune response. Her doctors noticed a pattern: when they treated her skin lesions, her psychosis went away. They hypothesized that the rash and the psychosis had been caused by a single autoimmune disorder, and were cured by the same drugs. Another paper in Frontiers in Psychiatry<\/em> described a man with \u201ctreatment-resistant schizophrenia\u201d who developed leukemia. After a bone-marrow transplant, which reconstituted his immune system, he startled his doctors by suddenly becoming sane. Eight years later, the authors wrote, \u201cthe patient is very well and there are no residual psychiatric symptoms.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine also discovered a Washington Post<\/em> article from 2023 about a woman named April, who had fallen into a catatonic state at the age of twenty-one and been diagnosed with schizophrenia. Sander Markx, a professor of psychiatry at Columbia, first encountered April at a psychiatric hospital on Long Island when he was a medical student; twenty years later, he was dismayed to find her at the same hospital, in the same condition. \u201cShe has not been outside for twenty years\u2014out of sight,\u201d he said, at a symposium at Weill Cornell\u2019s medical school. He and his colleagues gave her an extensive workup and found that she had lupus, an autoimmune disorder that, in rare cases, can induce inflammation in the brain, causing symptoms that are indistinguishable from those of schizophrenia. After undergoing immunosuppressive therapy, including rituximab, April emerged from, essentially, a \u201ctwenty-five-year-long coma, and was able to tell us everything,\u201d Markx said. \u201cWe don\u2019t have a script for this. We don\u2019t see patients coming back from this condition.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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April\u2019s case helped give momentum to the founding, in 2023, of the Stavros Niarchos Foundation (S.N.F.) Center for Precision Psychiatry and Mental Health, at Columbia, which is working to uncover biologically distinct subtypes of illness that have been obscured by the broad categories in the DSM.<\/em> Christine sent an e-mail to Markx, a co-director of the S.N.F. Center, with a brief time line of her mother\u2019s life. \u201cHer psychiatric symptoms disappeared and have yet to resurface months later,\u201d she wrote. \u201cBut her current clinicians are stumped as to why it has happened.\u201d When Markx didn\u2019t respond, Christine, who was visiting New York, decided that she and Angie should go to Columbia to introduce themselves in person. Markx wasn\u2019t in his office\u2014he had just begun an ongoing medical leave\u2014but they slipped a handwritten card in a pink envelope under his door and used inter-campus mail to send cards to the other directors of the center. They tried to think of this step, Angie said, as \u201cthe part in the documentary where the cameras go all shaky and you get the sense that someone is about to break a hole in the case.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Emil Kraepelin, who developed psychiatry\u2019s first modern diagnostic system, in the eighteen-nineties, defined the disease we now know as schizophrenia largely in terms of its hopelessness. <\/a>Throughout the piece, you sprinkle in historical context related to the field of psychology. Do you outline your pieces ahead of time to figure out where to include context and research?<\/span>I go through every single note I have, whether interview, research, whatever other personal documents, and then over the course of several days I go from top to bottom and place each relevant detail or quote or fact into the section that I think it will appear in.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>When I then go to write, I am starting with all the material that I think will go in the first section. So that’s how I structure it, and it always changes it, but at least I’m working with more contained material as I move to each new section. I’m always thinking about, when is the moment when the reader in the narrative needs and actively desires some context?<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>With this piece, there was so much research and context that I wanted to put in, and I wanted it to occur at the moment in which the reader actually wanted it, as opposed to too early when they’re not ready to do that kind of work without the narrative, or not too late when they needed it earlier to understand something.<\/span><\/span> The diagnosis allowed hospital administrators to separate patients with \u201cperiodic insanities\u201d (like depression and bipolar disorder) from those who were believed to be incurable and belonged in asylums. Kraepelin hoped that schizophrenia would eventually reveal itself to be a disease like neurosyphilis, which was then responsible for a large portion of the cases of insanity in psychiatry wards. In 1913, scientists demonstrated that bacteria had infected the brains of these patients. \u201cThe diseases produced by syphilis are an object lesson,\u201d Kraepelin wrote, four years later. \u201cIt is logical to assume that we shall succeed in uncovering the causes of many other types of insanity that can be prevented\u2014perhaps even cured\u2014though at present we have not the slightest clue.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Psychiatry and neurology were originally one medical discipline, but gradually neurologists took responsibility for diseases like neurosyphilis and dementia, in which the pathology could be seen in an autopsied brain, and psychiatrists handled the illnesses that were left behind, their causes still a mystery. <\/a>I like that your transitions never feel forced or overdone.<\/span>I guess the ideal situation is you do not need a transitional sentence, because you’ve structured the paragraphs in such a way that it feels fluid. I actually never want to find myself in a situation where I’m like, ‘my job right now is to write a transition sentence,’ because that sort of means that I’m juxtaposing two things that don’t flow together naturally.<\/span><\/span> Schizophrenia, which affects roughly one per cent of the population, became the disorder through which psychiatry worked out its identity, in part because it seemed to embody the mystery and intractability of madness, presenting basic questions about what it means to have a self. \u201cThe history of modern psychiatry is, in fact, practically synonymous with the history of schizophrenia, the quintessential form of madness in our time,\u201d the psychologist Louis Sass has written.<\/p>\n\n <\/div>\n <\/div>\n \n

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But psychiatrists struggled to pinpoint a single feature that unified the diagnosis. \u201cThe great question is what is this \u2018something\u2019 that underlies the symptoms,\u201d Karl Jaspers wrote, in 1963. <\/a>You do such a good job of including research that advances the storyline. Can you pull back the curtain on your process for finding relevant research for this story?<\/span>I spent a long time just trying to even find the small field that I was looking at and figuring out who the people who specialize in it are. So a lot of that was just searching for any terms related ‘autoimmune.’ Then I noticed there were a couple of researchers who had honed in on this area, and then I called them and asked them for reading recommendations.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>And then there’s historical context, which in a way is more fun, because it’s like, ‘OK, now that I know what the current research is, what sort of lines can I trace in terms of the history of psychiatry?’ There are certain thinkers (Karl Jaspers is one of them), and I’ll think: What would they say about whatever issue I might be thinking about? I’ll often look up and see if they have ever written about the issue.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>For this piece, because the research area was so new, a lot of it did come from interviews with researchers and then asking them to point me to whatever the most relevant recent specific research was. It often involved a very small sample size.<\/span><\/span> Three decades later, the psychiatrist Ian Brockington warned that the obsession with schizophrenia had stifled clinical curiosity. \u201cSmaller, more homogeneous entities have been sucked in by the gravity of the big idea, and annihilated,\u201d he wrote. For decades, scientists have been searching in vain for a biological marker that would confirm whether someone has schizophrenia. Last year, in a paper in Schizophrenia Research<\/em>, seventeen international experts concluded that schizophrenia was defined by no single etiology, symptom, or biological mechanism. \u201cIt is prudent to wonder if the construct around which we are organizing this information is fundamentally flawed,\u201d the authors wrote.<\/p>\n\n <\/div>\n <\/div>\n \n

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Perhaps the most vivid disruption to the idea of schizophrenia as a monolithic concept began in 2007, when Josep Dalmau, a neurologist at the University of Barcelona, started publishing papers with his colleagues which described young patients with delusions, hallucinations, and sudden changes in their behavior, like agitation and inappropriate giggling. Within days or weeks, they deteriorated, developing seizures, losing consciousness, or struggling to breathe. Dalmau discovered that they had a form of encephalitis, inflammation of the brain. Their immune systems had misidentified the NMDA receptor\u2014a protein in the brain that affects mood and memory\u2014as foreign and produced antibodies that attacked it. When these patients were treated with immunotherapy, the majority of them recovered completely, sometimes within a month.<\/p>\n\n <\/div>\n <\/div>\n \n

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Thomas Pollak, a neuropsychiatrist at King\u2019s College London and the Maudsley Hospital, told me that treating patients with the condition was \u201crevelatory and disquieting, because some of them looked exactly like the people I\u2019d been seeing in the psychiatry ward. It was uncanny to see that a presumably totally different pathway could lead to this.\u201d Their illness, which was named anti-NMDA-receptor encephalitis, usually began in their early twenties, just as schizophrenia often does. The discovery of the illness put pressure on the artificial division between psychiatry and neurology\u2014the only two fields of medicine that focus on the same organ. \u201cMany of the symptoms are shared, but we are using different words,\u201d Pollak said.<\/p>\n\n <\/div>\n <\/div>\n \n

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In \u201cBrain on Fire,\u201d a memoir from 2012, the journalist Susannah Cahalan\u2014the two hundred and seventeenth person in the world to be diagnosed with anti-NMDA-receptor encephalitis\u2014describes how for a month, in which she swung between paranoid aggression and euphoria, some doctors treated her as if she were just a difficult psychiatric patient who drank too much. \u201cIf it took so long for one of the best hospitals in the world to get to this step,\u201d she wrote, \u201chow many other people were going untreated, diagnosed with a mental illness or condemned to a life in a nursing home or a psychiatric ward?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Since Dalmau\u2019s discovery, scientists have identified more than twenty new antibodies linked to psychiatric symptoms. In 2020, in a paper in The<\/em> Lancet Psychiatry<\/em>, some two dozen researchers proposed a new category of illness called \u201cautoimmune psychosis,\u201d which may look like a milder or incomplete form of encephalitis, the illness never progressing beyond psychiatric symptoms. Christopher Bartley, the chief of a unit at the National Institute of Mental Health which investigates the role of immune dysfunction in mental illness, said that the twenty known antibodies may be a \u201cdrop in the bucket.\u201d There could be countless targets in the brain that antibodies attack, some subset of which may alter people\u2019s perceptions and behavior. \u201cWe have to have epistemic humility and accept that there are alternative models of disease,\u201d Bartley said.<\/p>\n\n <\/div>\n <\/div>\n \n

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To find psychiatric patients who might benefit from immunotherapy, researchers have set up centers, roughly similar to the one at Columbia, at Baylor College of Medicine, in Texas; King\u2019s College London; Uppsala University, in Sweden; and the University of Freiburg, in Germany, among other places. Some of the best research into the phenomenon has been conducted in Germany, where it\u2019s more common for patients in a first episode of psychosis to have lumbar punctures to access their spinal fluid, which can reveal the presence of antibodies. Bartley estimates that between one and five per cent of people who have been diagnosed with schizophrenia actually have an autoimmune condition\u2014a figure he based on his own lab\u2019s research, which has not yet been published, and also on a German study of a thousand patients, the most extensive study of autoimmune psychosis so far. \u201cEven one percent ends up being almost a million people in the world who should be treated with a different kind of medicine,\u201d he said. <\/a>I found this quote really helpful because it contextualizes a statistic and helps put it in perspective. As a journalist, what are you looking for when determining which quotes to include in your stories?<\/span>I really did want to make it clear that there were real stakes \u2014 that yes, this is very, very rare, but the worldwide implications are quite significant.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>With quotes, it’s often question of, \u2018What is someone else able to say that I couldn’t say myself?\u2019 either because it lends credibility or authority, or because there’s a level of specificity or vividness, or emotional immediacy that just straight narration wouldn’t achieve.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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The pharmaceutical treatment for schizophrenia has not meaningfully changed in three-quarters of a century. Many pharmaceutical companies have left the field entirely. To get approved for the market, a medicine that works for one schizophrenic patient must have a reasonable chance of working for another. But only blunt instruments have been effective in treating an illness that takes such varied forms. Newer antipsychotics are more refined than earlier ones, with fewer side effects, but almost all of them work in the same broad way, alleviating some symptoms, like hallucinations and delusions, but not other common ones, like lack of motivation and an inability to experience pleasure. Andrew Miller, the vice-chair for research in the psychiatry department at the Emory University School of Medicine, said that the field is haunted by the early success of antipsychotics, which were discovered by serendipity, in the nineteen-fifties. \u201cYou get lulled into this sense that, because the drugs are one-size-fits-all, the disease is also one-size-fits-all,\u201d he said. \u201cWith autoimmune psychosis, it\u2019s so clear that there is something different. And then you start to say, \u2018Hey, is it possible that there are other clear-cut mechanisms to pathology that we\u2019re missing because we\u2019re lumping everyone together and saying they all have the same illness?\u2019 \u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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The S.N.F. Center is embarking on a project, beginning this fall, to screen all the patients hospitalized in the New York State mental-health system for autoimmune, metabolic, and genetic disorders, to see if there are people whose symptoms can be traced to a distinct biological mechanism. \u201cI\u2019ve always been aware of the possibility that there are treatable causes for psychosis lurking in chronic long-term patients,\u201d Joshua Gordon, the executive director of the New York State Psychiatric Institute and a former director of the N.I.M.H., told me. \u201cBut the notion that we could make this work practically\u2014that we could test for it\u2014has really only become apparent in the last few years.\u201d The S.N.F. Center will do blood work for everyone in the state\u2019s psychiatric institutions, offering follow-up testing, such as lumbar punctures, to those with unusual results. Gordon said that, if the S.N.F. Center identifies a few dozen patients who can be treated effectively enough to leave the hospital, \u201cwe will be able to start answering the question of whether this is worth trying across the whole population of people with schizophrenia.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Psychiatry has a legacy of implementing drastic procedures, like lobotomies, that later come to seem like folly. But it also has a history of proffering psychological theories for illnesses that are not yet understood on a biological level. Several psychiatrists told me that they\u2019d found themselves rereading the history of the discipline, wondering, for instance, if some of those patients of Emil Kraepelin\u2019s whose symptoms helped define schizophrenia might actually have had encephalitis or autoimmune conditions\u2014specifically, a subset he described as having \u201cspasmodic phenomena in the musculature of the face\u201d and an inability to walk without falling. There were also questions about whether these diseases could explain a condition called \u201clethal catatonia,\u201d which was frequently described as a manifestation of schizophrenia: these patients became extremely agitated, and then slipped into a stupor. In 1986, in a study that inadvertently revealed the dangers of conceptual inertia, the American Journal of Psychiatry<\/em> reviewed nearly three hundred cases of lethal catatonia. Nearly all the patients in the study had been treated with antipsychotics, and more than half of them died.<\/p>\n\n <\/div>\n <\/div>\n \n

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After reading Christine\u2019s description of her mother\u2019s case, Steven Kushner, a co-director of the S.N.F. Center, arranged a meeting with her and Mary and Angie. Mary was living at a rehabilitation center in the Bronx while she regained her muscle strength. She was reluctant to meet another psychiatrist, she told me, but she felt she needed to \u201crise up to the level of my daughters\u2019 studiousness.\u201d In October, 2024, Kushner and three colleagues came to the rehabilitation center and spoke with Mary for three hours. \u201cHer psychosis was gone,\u201d Kushner said. \u201cThere was no other conclusion. There was no way that she could have the quality of the conversation that we had and willfully suppress psychotic symptoms.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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In the conversation, Mary recounted intimate details about her daughters\u2019 pasts\u2014what they would eat for breakfast, their arguments at recess\u2014but she made no reference to the delusional beliefs that had dominated their lives. When Angie told the doctors that her mother had sometimes prevented her from going outside, even to do homework with classmates, Mary offered a practical explanation: there was crime in the Bronx, and she worried about Angie\u2019s safety. To explain why she put a sock over the showerhead in her bathroom, she said that she\u2019d hoped to filter sediment from the water. She seemed to have filled in gaps in her memory in a way that was consistent with her current identity, as a sane person. <\/a>I noticed you’ve used the words \u2018sane\u2019 and \u2018sanity\u2019 at various points throughout. It seems these words used to be more commonplace than they are now. Why did they feel appropriate to use in this story?<\/span>I felt it was the plainest word to use in this context. I like that it does have a bit of an old-fashioned feel; I also like that it isn\u2019t clinical. It describes a particular way of relating to and being seen in the world.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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In 1911, the psychiatrist Eugen Bleuler described how schizophrenic patients are capable of a kind of \u201cdouble bookkeeping\u201d: they may simultaneously live in two \u201cdisjoint\u201d worlds, one grounded in shared reality, the other in private delusions. They might believe that they are the center of a conspiracy involving nearly everyone they see but also make small talk at a deli and remember to give the correct change. <\/a>I appreciate how, throughout the piece, you introduce us to complicated concepts and then explain them comprehensibly. One of the ways you do this is by providing related examples that ground the concepts in everyday life. Do you have any tips for other journalists who want to take a similar approach in their own work?<\/span>I just found ‘double bookkeeping,’ to be a very beautiful idea. I’ve been drawn to it in a lot of different ways, but it’s hard to understand.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>In general, I don’t like examples that much because it takes you away from the narrative. But here, it’s such a profound phenomenon that I thought a sentence would illuminate the strange contradiction in which people can live in two modes of reality, which I think all of us do in some way \u2014 but not with such starkness.<\/span><\/span> It\u2019s as if the delusions occupy their own ontological category, sealed off from the logic used to move through the world. Now, when Mary recalls her decades of illness, it is as if she is accessing only the shared-reality side of the ledger. When she talks about her time at the Bronx Psychiatric Center, her memories sound like those of a person trapped in an environment where she doesn\u2019t belong. \u201cAngie and I treat it as if she had two selves,\u201d Christine said. \u201cBut Mom describes her self as continuous.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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The S.N.F. Center arranged for Mary to have a lumbar puncture, to see if she had any antibodies associated with known neuropsychiatric conditions. During the procedure, Kushner said, he could sense that Mary had once had a \u201cfantastic professional identity: she was holding court, telling stories about the lumbar punctures she used to perform, how many patients she used to see in a day.\u201d The test came back negative. Kushner tried to recover a frozen sample of Mary\u2019s cerebral-spinal fluid from when she was ill\u2014a test done on that fluid would have been more revealing\u2014but the fluid had been discarded. He believed that the most likely explanation was that she\u2019d had a form of autoimmune psychosis for which the associated antibody has yet to be discovered. \u201cI think the consensus is that we are probably only aware of the tip of the iceberg of different kinds of antibodies that can produce autoimmune diseases, and certainly that holds for autoimmune psychosis,\u201d he said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Some people, when they recover from psychosis, understand that the strange enemies who plagued them never actually existed. Others say that they are relieved their enemies stopped pursuing them, but do not disavow the reality of the experience. \u201cWe don\u2019t know what happens for someone who was in a psychosis for twenty years and then they are\u2014let\u2019s call it \u2018cured,\u2019 \u201d Kushner told me. \u201cAnd I hesitate to use that word, because the idea that this word is ever used in psychiatry is so exceptional.\u201d But, he said, \u201cthe treatment modified Mary\u2019s biology such that the disease is basically gone.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Kushner began meeting with Mary and her daughters every few weeks, in part to help monitor for possible signs of relapse. At the meetings, they mostly avoided talking about Mary\u2019s delusions. When the subject came up, Mary was quiet, or responded in a tangential way, changing the subject. \u201cShe has this extraordinarily pleasant way of disarming the situation,\u201d Kushner told me. The thought of having caused her daughters suffering seemed too painful to allow into her conscious awareness. \u201cThere\u2019s not an appointment that goes by where she doesn\u2019t remark, spontaneously, that her daughters are doing well,\u201d he said. \u201cI don\u2019t think that\u2019s by accident.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Kushner did not believe that Mary\u2019s memory gaps reflected cognitive impairment\u2014on a neuropsychological exam, her memory was better than average\u2014but he also didn\u2019t believe that she was purposely not remembering. \u201cTo look back and say, basically, \u2018Twenty years of my life were out of reality\u2019\u2014that would be a fundamental blow to her identity as a physician and mom,\u201d he said, a challenge to \u201cone of our most primitive instincts, that we can discern what is real.\u201d When I expressed concern about how to present the disparity in memories sensitively, he told me, \u201cI think that is the story. How do you reconcile with, and compensate for, all those missing years?\u201d <\/a>This passage is striking, both because you’re giving us a first-person, behind-the-scenes look at your conversation with Kushner and you’re revealing the heart of the story (at least according to Kushner). I’m curious, did this conversation change or crystallize your thoughts about the deeper meaning and\/or focus of the story?<\/span>I felt like I needed to know from him that it was OK to ask these questions of Mary, and I think Christine and Angie also needed to know that. We wanted to make sure it was safe for us to be thinking about this with someone who had been so vulnerable. And so it was very helpful to hear that Kushner, too, felt this was an integral part of the story, if not THE story.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>There was a lot of concern that it was this taboo subject, and that talking about it would do something harmful to their mother’s mind. He really was like: No, it’s OK, she can handle it; she’s strong.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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When people emerge from chronic delusional states, the work of psychiatry is considered complete. They are largely left on their own, with two irreconcilable views of reality. \u201cWe need to really start thinking about what happens the morning after these disorders are treated,\u201d Kushner said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine wasn\u2019t sure if she could call her mother \u201ccured\u201d simply because she lacked her previous symptoms. \u201cShe\u2019s not fixated on things like contamination and surveillance, but at no point has she said she\u2019s left those beliefs behind,\u201d she said. Christine felt that it was taboo to talk to her mother about who she had once been. She suffered from the intrusive thought that if she confronted her mother with destructive things she had done, Mary would somehow revert back to the patterns from that time and become psychotic again. \u201cIt is quite a traumatized-kid thing to say, but I sort of feel like, How greedy can you get? Don\u2019t look a gift horse in the mouth,\u201d she told me.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine didn\u2019t know how to have an ordinary conversation with her mother. For twenty years, Mary had been suspicious when Christine asked her questions about her life. Christine now felt like an adopted child \u201cmeeting my biological mom for the first time,\u201d she said. She bought a book by an anthropologist called \u201cThe Essential Questions: Interview Your Family to Uncover Stories and Bridge Generations\u201d to help guide their conversations. \u201cIt says, \u2018Allow them to talk about what\u2019s important,\u2019 \u201d Christine said, reading from the book, during a visit to her mother\u2019s rehabilitation center. \u201cIf no one has ever let you speak about yourself, it can be hard,\u201d Christine went on. \u201cYou have to kind of\u2014\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cThink,\u201d Mary said.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cMaybe practice\u2014gain your voice,\u201d Christine said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine, who recorded the conversation, began with warmup questions: \u201cWhen you were a kid, what was your favorite activity?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cRunning,\u201d Mary answered immediately.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cWhat did you like about running?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cIt makes you feel you have wings.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cWhat is your favorite TV show?\u201d Christine asked.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201c \u2018Seinfeld.\u2019 \u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201c \u2018Seinfeld\u2019!\u201d Christine said. \u201cWhat did you like about \u2018Seinfeld\u2019?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cThe absurdity.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Every few weeks, they tackled a new theme outlined in the book: time, identity, body, belief, possessions, memory, fear. Initially, Mary answered in few words, but eventually she became much more expansive. During one session, she offered that her views on physical discipline had evolved: she no longer thought that smacking was acceptable. Christine said, \u201cWithout relating it to me or Angie, she sort of said, \u2018That\u2019s what we were taught when we were younger, but I don\u2019t think that\u2019s the right way to raise a kid.\u2019 \u201d Christine felt that her mother may have been reflecting, obliquely, on what had happened in their home. \u201cThe ability to say, \u2018I\u2019ve changed my mind\u2019 felt like as much as I could ask for,\u201d Christine said.<\/p>\n\n <\/div>\n <\/div>\n \n

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For years, Christine had been documenting her life\u2014keeping a journal, saving records, recording important conversations\u2014to compensate for the fact that she, too, had blank periods in her memories, coinciding with traumatic events. <\/a>Prior to picking Christine as one of your main sources, did you know that she had been documenting her life so meticulously? I’m curious as to whether you ever select sources based on the kinds of access you’ll have to source materials like this.<\/span>When she told me about the records she kept, that solidified my feeling that I could write a piece about her. Sometimes it’s just not possible because there just aren’t enough records or material, or you’re relying so heavily on someone’s memory that it becomes very hard. So that is definitely a large factor.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>With the piece I’m writing right now, for instance, there were many different subjects I could have chosen who had gone through a similar experience, but it was the person who had kept journals who I decided to focus on \u2014 and also the person who felt he had a story to tell and wanted to tell it.<\/span><\/span> She wasn\u2019t sure if her mother\u2019s breaks in memory\u2014what she and Angie called \u201cthe missing years\u201d\u2014were different from her own. Recently, she had come across a proverb: \u201cThe axe forgets, but the tree remembers.\u201d She felt that maybe she and her mother had reached an impasse that was actually universal\u2014children have always formed their identities around blows that their parents don\u2019t even realize they inflicted.<\/p>\n\n <\/div>\n <\/div>\n \n

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Angie felt less accommodating: \u201cI\u2019m happy that my mom is normal now, that we can have a deep connection and I can share my life with her. And, at the same time, I want justice for the child who was hurt by that other mother.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary\u2019s sister, Nima, told me that before her illness Mary was \u201cvery enduring, very patient.\u201d Mary\u2019s recommendations from professors at medical school describe her as \u201ckind and sympathetic,\u201d always \u201cwilling to shoulder any extra work.\u201d When she came out of her psychosis, Mary returned to this dutiful version of herself. She and her husband, Chris, began speaking on the phone every day. Chris told me that he felt as if he were re-meeting the woman he had known in the early years of their marriage. \u201cHow come I lived all these years of darkness, and she suddenly looks normal to me?\u201d he said. \u201cShe gives me comfort. She gives me emotional support.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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He asked her to do things, like travel to India to resolve a family financial dispute, that Christine and Angie found inappropriate. They encouraged Mary not to comply with the request. Mary had let go of her paranoia that everyone was targeting her, but they wished she could retain a wariness about people who had hurt her in the past. \u201cNow that she\u2019s better, you can see how the delusions protected her from people stepping on her boundaries\u2014and she doesn\u2019t have a replacement strategy,\u201d Christine said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary readily agreed to speak with me for this story, but she struggled to imagine that she could be anything more than a marginal presence in it. For years, she had described how people on TV were lifting ideas and plots from her life story. \u201cIt was like she was saying, \u2018I\u2019m important,\u2019 \u201d Christine said. \u201c \u2018I have value. I have things to say.\u2019 And now we\u2019re saying, \u2018You\u2019re important. You have value. You have things to say.\u2019 And she can\u2019t access that sense of deserving to be the main character.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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When I first met Mary, on a Zoom call with her and Christine and Angie, I asked if I could read her psychiatric records. <\/a>This paragraph, and the two that follow, are so telling \u2014 in part because they reveal how trust evolved over the course of your reporting process. Why did you think it was important to 1.) highlight Mary’s ambivalence and 2.) to insert yourself in the story while doing so?<\/span>I think because the ambivalence felt like it was so much a part of the experience \u2014 the experience of reckoning with one’s life, and reckoning with the profound impact an illness has had on a person.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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<\/a><\/span>I also felt it was expressive of Mary’s love for her children \u2014 that even though she had these conflicted feelings about it, she really wanted to do it for her children. And I did feel like she cared about the scientific record and had an altruistic desire to help others. So I thought that working through the various dynamics that were both keeping her from wanting to look at those records, and then ultimately allowing her to share them, was part of the story.<\/span><\/span> She said yes but warned that they would be very boring, adding that she couldn\u2019t remember any of her psychiatrists. \u201cI left the memories long before I left the place,\u201d she said. Christine suggested that we interpret this as her mother\u2019s gentle way of saying no.<\/p>\n\n <\/div>\n <\/div>\n \n

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A few weeks later, Christine told me, Mary found a pile of psychiatric records in her room: \u201cShe was, like, \u2018I don\u2019t want to see them anymore, so Rachel can have them and can get rid of them.\u2019 And I was, like, \u2018Yes, Mom, but Rachel is a journalist. She\u2019s not just a professional shredder.\u2019 \u201d She said that her mom responded, \u201cI just don\u2019t want to see them myself.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary seemed to be working out her ambivalence about her memories through this pile of papers. After speaking on Zoom every week for two months, Mary and I met at her rehabilitation center, along with Christine and Angie. <\/a>How long did it take you to report this story?<\/span>I think my first conversation with Christine was maybe in late March, and then the piece was published mid-July. We were all talking (on Zoom and in person) regularly throughout that period.<\/span><\/span> Toward the end of our conversation, she stood up without explanation, walked to a cabinet, retrieved the psychiatric records, and gave them to me. \u201cI felt like what happened was a miracle,\u201d she told me. \u201cIf it will give anyone else confidence, I\u2019ll go with it.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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There is almost no medical literature about the afterlife of madness, the experience of letting go of what Jaspers called the \u201cdefinite idea.\u201d Autoimmune psychosis raises the possibility of a swift, full recovery\u2014a trajectory not typically seen in schizophrenia\u2014and in doing so supplies a new category of witness: a person who can describe what it feels like to look back on a self that is, in some sense, defunct. And yet sanity does not mean that a person views the past without defensiveness or distortion. (To see too clearly can lead to a different kind of insanity, depression.) One of Christine\u2019s fears was that, in talking with her mother about what she and Angie had been through, she would \u201crob her of the human capacity for denial.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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During one of my visits to the rehabilitation center, I asked Mary if she\u2019d like to know how I was writing about her daughters\u2019 memories of her illness, or if she\u2019d prefer not to listen to that part of the story. Christine and I sat in chairs, and Mary sat on the edge of her bed, beside a wooden table on wheels that she used both for eating and as a desk. Mary quickly responded that she wanted to know what her children recalled. \u201cI\u2019ll go with that, because that way it will help me to remember,\u201d she said.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cYou remember things very differently, and it might be painful,\u201d Christine said, gently. \u201cDo you feel comfortable emotionally with that?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cYeah, go ahead!\u201d Mary said. \u201cI\u2019ll remember like a mother. I won\u2019t remember from your point of view.\u201d She told her, \u201cThis is the best time for me to relate to these memories and make amends.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine shared her first memory of the illness: sitting on the couch as her mother told her that the professor from medical school was in love with her.<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary sat straight up on the bed, holding her arms over her stomach, staring intently at Christine. She had the bearing of a diligent student determined to pass a difficult test.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cYou asked if they had ever put things in my hair so that\u201d\u2014<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cMicrophones,\u201d Mary said quickly. \u201cMicrophones.\u201d She said that the professor and his friends kept urging her to leave her husband: \u201cThey said, \u2018Don\u2019t worry about the in-laws and all\u2014just move away and begin on your own.\u2019 \u201d The friends were trying to help, but they were also harassing her, and she had no one to confide in. \u201cI felt like she was supposed to be there for me,\u201d Mary said, gesturing toward Christine. \u201cBut she was talking on behalf of my friends.\u201d <\/a>The dialogue here and in the next few grafs helps us to better understand how Mary and Christine interact. Dialogue can be a powerful tool, but only if it reveals something about the sources. How did you decide which lines of dialogue to include in this story?<\/span>I initially included a lot of dialogue because when I was there, I was amazed by the experience of Mary remembering and addressing directly these memories. It was so profound to sit there, and I felt so personally invested, that I initially included too much. My editor cut some of it, which was helpful because it made me realize I was spending too many sentences sort of reinforcing, layering onto, ideas or moments that could be revealed in one or two sentences.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cYou would think that I was repeating phrases that were said to me by other people.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cI remember that very well,\u201d Mary said.<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cAs a kid, I found it very hurtful.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cI never blamed you,\u201d Mary said. \u201cBut my classmates\u2014I trusted them so much.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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\u201cI was not in contact with your classmates,\u201d Christine said, in a measured tone. \u201cI would explain that to you, but it felt like you didn\u2019t believe me at that time.\u201d She asked, \u201cNow that I\u2019m older, do you trust me when I say they weren\u2019t talking to me?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary said it was possible that Christine had been reading her e-mails, rather than talking directly to the classmates, or that Christine\u2019s father was the one telling Christine what to say. \u201cShe was very articulate,\u201d Mary said. \u201cShe would do everything he would tell her.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary explained that the feeling of being harassed\u2014sometimes by people from her past, sometimes by strangers\u2014continued until several weeks after her cancer diagnosis. \u201cI felt like they were working through the doctors, and I had to take the chemotherapy just to hurt me and make me bald and make me lose weight and humiliate me,\u201d she said.<\/p>\n\n <\/div>\n <\/div>\n \n

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But then, a few weeks into her treatment, her dreams became uncharacteristically pleasant. She kept dreaming of her sister and brothers, and they were so sensitive and loving that she thought maybe this was the prelude to a kind of heavenly afterlife. In time, the dreams began to feel more conscious, as if she were guiding the scenes herself. Lying in her hospital bed, she tried to recall details about her childhood home which she hadn\u2019t thought about in years. \u201cWhatever I could catch on to, I would collect,\u201d she said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Her re\u00ebmergence seemed to have occurred weeks before her daughters grasped what was happening. Her muscles were so weak that she couldn\u2019t say more than a word at a time, and she wished she could communicate to her daughters, \u201cI\u2019m smiling. I\u2019m all right with this.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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The thought that people were secretly trying to punish her hadn\u2019t completely disappeared, but it felt distant, a relic of a different era. When the thought resurfaced, she said, \u201cI take myself out of it, and I say, \u2018It\u2019s not my burden.\u2019 I put the whole thing, like a gift basket, to God.\u201d She\u2019d been taught this coping mechanism as a schoolgirl, but until recently it hadn\u2019t worked.<\/p>\n\n <\/div>\n <\/div>\n \n

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Christine felt both validated and disoriented by the idea that, between her and her mother, the facts were never really in question. \u201cIt is painful to hear that she still thinks I was spying on her all those years, but now she says, \u2018I am so proud of my daughters\u2014they take care of me,\u2019 \u201d she said. \u201cMaybe her interpretation is that through the power of forgiveness she can now interact with me as her loving daughter. So can I make do with that?\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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For a year, Christine and Angie had been speaking on Zoom with a family therapist, to help process the changes in their mother. Recently, Mary had begun participating in the conversations, too. During a session, Christine suggested that the three of them begin a process of sharing grievances, each taking a turn. \u201cThere were different times when each of us was a flawed caretaker,\u201d Christine said. She knew that her mother must have felt betrayed when she called the mobile crisis unit. Mary agreed: \u201cI felt very let down because nobody trusted me enough to share that information.\u201d Christine began by telling her, \u201cI did my best, and yet I\u2019m sorry I hurt you.\u201d<\/p>\n\n <\/div>\n <\/div>\n \n

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Although Christine and Angie felt they had already worked out the conflicts in their own relationship, they tried \u201cperforming a kind of play,\u201d as Christine put it: they shared resentments\u2014Angie\u2019s feelings of abandonment, Christine\u2019s sense that Angie didn\u2019t want her help\u2014and then apologized, \u201cso that at some point she can say the words to us.\u201d Each emphasized that she didn\u2019t think the other was a bad person, and that it was O.K. that they remembered things differently. They tried any exonerating phrase they could think of, \u201cin case these might be the mental blocks for her,\u201d Christine said.<\/p>\n\n <\/div>\n <\/div>\n \n

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Mary was enthusiastic about the process, but Christine sensed that she didn\u2019t quite know what to say when it was her turn. A lifelong student of her mother\u2019s mind, Christine had several justifications for her mother\u2019s failure to respond in kind: she had not grown up in a culture where regrets were aired in this way; the inability to see her daughters\u2019 perspective was a lingering cognitive symptom; in her fragile state, apologizing required a level of confidence she didn\u2019t yet have. \u201cAt this stage of my life, I need to feel like my mother is back,\u201d Christine told me. Later on, maybe in a few years, she said, \u201cI\u2019ll deal with the fact that it was an imperfect mother who was returned to me.\u201d <\/a>I found this quote so striking because it’s both familiar and unfamiliar; many of us know what it’s like to have an imperfect mother, but fewer of us can relate to the experience of having our mother \u2018returned\u2019 to us. I’m curious to hear your thoughts about this quote and why you decided to end with it.<\/span>A few days before the piece closed, I still felt discontent with the way the piece ended, and I decided to call Christine and talk through some lingering questions. It was in that final conversation that she said the thing about having an imperfect mother returned to her. By that point I had a much clearer sense of the tension and uncertainty that the ending seemed to point to\u2014I’d had a friend read the piece and she left it with certain questions, and I basically relayed those questions to Christine in that last conversation.<\/span><\/span><\/p>\n\n <\/div>\n <\/div>\n \n

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***<\/p>\n\n <\/div>\n <\/div>\n \n

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Mallary Tenore Tarpley<\/em><\/a> is a journalism professor at the University of Texas at Austin and the award-winning author of the new memoir <\/em>SLIP: Life in the Middle of Eating Disorder Recovery<\/a>. She publishes a weekly newsletter, <\/em>Write at the Edge<\/em><\/a>, featuring writing tips and best practices.<\/em><\/p>\n\n <\/div>\n <\/div>\n","protected":false},"excerpt":{"rendered":"

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