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By Adrienne Onofri

Playwright Sarah Ruhl on Losing the Ability to Smile Due to Bell's Palsy

Ruhl describes what she learned during her prolonged recovery from the condition.

Playwright Sarah Ruhl wearing a black button down shirt
Sarah Ruhl developed Bell's palsy after delivering twins in February 2010. Photograph By Rebecca Greenfield For Signature Theatre

The plays of Sarah Ruhl have been widely produced at theaters around the country over the past 20 years. But Ruhl, twice a finalist for the Pulitzer Prize for Drama, chose a different form of writing to chronicle her experience with Bell's palsy. Her book Smile: The Story of a Face was published in 2021, then reissued in paperback in 2022 with the title Smile: A Memoir and an added afterword. “This illness is not theatrical, which is why I wrote a book about it instead of a play,” says Ruhl.

Bell's palsy is the most common cause of facial paralysis, according to the National Institute of Neurological Disorders and Stroke, which estimates that around 40,000 people in the United States each year develop the condition. It is characterized by drooping of one side of the face, trouble closing the eye or mouth, and making common facial expressions such as smiling, frowning, raising an eyebrow, and puckering. People of any age might get Bell's palsy, and it is experienced nearly equally by men and women. But among women, it is two to three times more likely during pregnancy.

Ruhl did not know any of this when a lactation consultant who came to her hospital room the day after she gave birth to twins in February 2010 told her that one of her eyes looked droopy. Ruhl hadn't felt anything unusual, but when she looked in the mirror, as she recounts in Smile, she saw that “the left half of my face had fallen. Eyebrow, fallen; eyelid, fallen; lip, fallen, frozen, immovable.... I tried to move my face. Impossible. Puppet face, strings cut.”

She was quickly diagnosed with Bell's palsy by a neurologist at the hospital after he ascertained that she had ringing in her ears and couldn't raise her left eyebrow or the left side of her forehead—a major differentiating factor from a stroke, when usually only the lower part of the face is affected. He prescribed the steroid prednisone.

Bell's palsy is believed to be triggered by damage to the seventh cranial nerve, which controls facial muscles, and typically affects only one side of the face. In most cases, Bell's palsy comes on without any warning. It usually disappears within one to three months, even in people who don't take prednisone. But Ruhl's facial paralysis did not resolve.

Ruhl, now 49, spent more than 10 years “chasing symptoms one by one,” as she puts it in Smile. She saw multiple neurologists, physical therapists, acupuncturists, chiropractors, and other health care providers, including a sleep specialist. She did regain the ability to close her left eye and to blink, and some problems associated with eating and drinking subsided—she was able to take bigger bites of fruit, to drink from a mug without drooling, to eat toast with something spread on it that didn't end up smeared on her face.

Yet nine years after the onset of Bell's palsy, a physical therapist estimated that Ruhl had regained only 70 percent of her muscle movement back. After a year of physical therapy, that had improved to 82 percent. Now that a few more years have passed, Ruhl says she's doing pretty well. “I feel like I can smile; I can communicate affect.” Bell's palsy no longer has a big impact on her daily life.

For the better part of a decade, however, that wasn't the case. Ruhl couldn't smile at her babies. In 2012, she started teaching playwriting at the Yale School of Drama and realized that her “poker face might falsely indicate dislike, disinterest, or judgment” to her students, she says in Smile. When her epic drama Passion Play had its New York premiere three months after her Bell's palsy onset, she dodged photographers on opening night.

A few weeks later, she had more photography-related angst when she walked the red carpet at the Tony Awards, where she was up for Best Play for her Broadway debut, In the Next Room. She also did a photo shoot for a Vanity Fair piece on Tony nominees and hated the picture: “My face looked like water that was going downhill and then stopped.... I looked existentially pained,” she writes in Smile.

Ripple Effects

As the paralysis persisted, Ruhl became acutely aware of all the everyday moments when people convey thoughts or feelings through facial expressions—and frustrated that she couldn't do so, or that her look would be misinterpreted. “You don't want to be communicating things you don't intend,” she says. “Someone might not notice something is wrong with your face and might interpret something differently, as if you're unfriendly or weird.” The emotional toll went deeper, though. “There's a mind-body connection that happens when you have a big smile on your face—it makes you feel a certain way,” says Ruhl. “I've wondered whether it internally affects me, in terms of depression, that I can't smile fully.”

She expects that many others with unresolved Bell's palsy also have experienced depression. “To look in the mirror and not recognize yourself, and not be able to put joy on your face—they've done studies about depression and Bell's palsy, and the rates are very high,” Ruhl says. She battled other negative feelings as well: anger, shame, helplessness, alienation. “I think the lowest point was when I had no physical or emotional energy, and my face was crooked, and I was trying to care for my kids and really didn't feel up to it,” says Ruhl, who also has a daughter three years older than the twins.

The condition didn't interfere with Ruhl's work. “I was pretty productive throughout this time,” says Ruhl, who lives in Brooklyn. “Writing was one thing I could do. It was a life raft that kept me afloat during that time.”

Two of her plays, Becky Nurse of Salem and Letters from Max, debuted off-Broadway in the past year, but finishing her memoir was a special kind of achievement. “It was a healing turning point for me,” Ruhl says, “partly to take control of the narrative.”

Sarah Ruhl's plays The Oldest Boy (top) and Becky Nurse of Salem (bottom) were both produced at Lincoln Center in New York City. Photographs by T Charles Erickson (top) and Kyle Froman.

During her experience with Bell's palsy, Ruhl dealt with other health issues. A neurologist diagnosed her with essential tremor following some episodes of clumsiness and imbalance. After she mentioned an unintentional weight loss to him, he tested her for celiac disease. When the results came back positive, Ruhl felt she had an explanation for various ailments throughout her life—from frequent illness while growing up to the sluggishness and exhaustion she'd had since getting Bell's palsy. She'd thought the occasional tingling in her feet was related to Bell's palsy, but the neurologist diagnosed her with peripheral neuropathy, which can be associated with celiac disease.

Ruhl also developed synkinesis, which often occurs in people with Bell's palsy. In synkinesis, a voluntary muscle movement triggers an involuntary muscle movement—an eye closes when a person smiles, for example, or an eyebrow raises when a person puckers his or her lips—as the result of nerves regrowing but going to the wrong muscles. The condition can be treated with botulinum toxin, which Ruhl has had once. She also goes to physical therapy, where the focus, Ruhl says, is “to try to rewire my brain not to recruit the wrong muscles when I smile.”

In earlier sessions with a different physical therapist, Ruhl would practice frowning, squinting, pursing her lips, and other facial movements. “After three months...I noticed a profound difference,” Ruhl writes in her memoir. And thanks to that physical therapy, she stopped covering her mouth when she laughed and started smiling again.

Her current physical therapist had herself experienced Bell's palsy after giving birth to twins. “I found [her] from someone reading the book and saying, ‘I need to connect you with this woman who has a very similar story,’” says Ruhl.

New Revelations

During her experience with Bell's palsy, Ruhl has made some life-changing discoveries.

Ruhl's medical odyssey has taught her things about herself. “My various medical problems sometimes made me feel like Job—one thing after another—and I think it caused me to fall back on some kind of spiritual stamina that I wasn't aware of. I feel like I learned about resilience and patience and compassion. I realize that my interior experience can be joyful again, whether or not it shows on my face.”

Not being able to communicate emotion with your face is lonely and isolating, Ruhl says. “I recommend people finding each other for support and sharing knowledge. Meeting other people who have it is really healing.”

She also offers advice for friends and family members: “Make an effort to care for and support people with Bell's palsy, because often they won't even talk to you about what they're feeling,” she says. “Tell people you love them and they're beautiful and you love their face. ”

Now that Ruhl is finally making progress, she's ready to become an advocate. “As I get through the tunnel of being a patient, I would love to be involved in advocacy,” she says. “I would be so happy to meet any group or talk to more people.”

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