It might be useful to interpret these curious phenomena in the light of current neuroscientific thinking in an attempt to diminish the otherness, the stigmatising pathology, of these altered states. Light is without colour. The redness of the apple is not inherent in the apple. The colour of red is not generated in my mind as an outcome of a series of complex processes beginning with light waves of various frequencies, but without colour, impinging on the rods and cones of my retina. This same apple is without taste or flavour until it enters my mouth and its purgency activates taste buds and olfactory cells. These sensory experiences are complex and intensely subjective.
Either we need to come to terms with a possibility that we are all in some ways a little bit mad, which is a cliche, or we need to consider a much more inclusive, less discriminating attitude towards experiences we do not share or understand.
Binary thinking might appear to make things simple, but in all likelihood the issues become more muddled and distorted.
The way we think about these matters is further confused by the assumptions we make about causation being linear and unidirectional.
Perhaps we complicate things for ourselves by trying to see things in linear terms when a rather more messy complex of interacting factors might be a more valid interpretation.
If symptoms do represent tentative steps to recovery, the elimination of these symptoms would not necessarily be helpful and would instead leave a void.
Acknowledging and affirming a person’s vivid experience and the struggle towards recovery - and simultaneously seeking to modulate or attenuate the intense distress and confusion that is part of the process - requires a difficult and time elusive balance.
We need something more, perhaps something transcendent and unconfined by reason to grant some necessary meaning to our lives. That need seems to be something quite fundamentally human, whether or not we are considered mad.
We need to acknowledge the strange wonderfulness of these accounts, and the wonder of resilience in circumstances of extreme adversity, and the wonder, sometimes, of recovery.
It is not simply to be unafraid of otherness - it is to seek out and attach value to otherness and in this way to extend ourselves and assert our humanity.
We need to be willing to accept the need for change in the way we see ourselves and the way we behave towards others.
Perhaps especially in this divided and fractured country we need urgently to extend and complicate our lives by engaging with otherness, rather than retreating into familiar territories that can no longer be consoling: the precarious and absurd identities of race and nationality and normality or sanity.
Of the ten leading causes of disability, five were neuropsychiatric disorders. In the projected estimates of the disease burden for 2020, depression was only second to ischaemic heart disease.
I am not sure what might or should be the most appropriate language. ‘Madness’ is problematic. ‘Mental illness' confines a wide and complex range of symptoms and signs of distress to a medical subspecialty. Underpinning whichever terms we use is the need to acknowledge pain and suffering, and not to dismiss these human experiences with cliches and platitudes.
A therapeutic alliance ought to be integral to an aspirational standard of best clinical practice.
There might be some link between creativity and being of a unquiet and troubled mind, but that is not madness.
This circus of cliches and caricatures affords vicarious pleasures but also does harm. It is seldom that we read textbooks or scientific articles to inform ourselves about mental illness. Intentionally or not, we become informed by accounts in literature and film and theatre.
Jonathan was once a talented artist. When he is well he makes delicate, exquisitely crafted ink drawings, some of which he has given me and which I have proudly put up on the walls of my office. When he is unwell the nature of his art changes. He becomes more prolific, but the precision and clarity are lost. Lines become scrambled and entangled, the colours lurid, and over the images he compulsively scribbles reams of indecipherable prose and poetry. There is no sign at all of the graphic skill and the almost cold formality of the works he produces when he is well. He creates these mad works in an apparent frenzy and foists them on me with enthusiasm. On one admission he decides to transform his bed in the dormitory of the admission unit into an installation. He collects branches and bits of wire and string and other random objects that he finds in the ground of the hospital and constructs an elaborate canopy over the bed. It is a ramshackle mess and requires considerable agility on his part simply to get access to the bed. I am deeply impressed that the nursing staff and cleaners allow this. The other patients are bemused, but despite their disorganised behaviour they make no attempt to interfere with this delicate and bizarre construction. There seems to be some shared acknowledgement that this is a project, a work in progress - and that, however incoherent, is important to Jonathan.
His different, distinct ways of expressing himself seem to reflect in an eloquent way his shifting states of mind. It is not simply that when he is well his art is good and when he is sick his art is bad - not art at all, just incoherent ravings and scribblings. This elaborate, intricate, chaotic installation that he has constructed with such painstaking care in the ward suggests a quite desperate determination to give a three-dimensional form to something that is menacing and that could otherwise overwhelm him. He seems compelled. The task is urgent.
The finely executed drawings he creates when he is well seem to serve another function, to be necessary in a different way. There are in these images another type of need, a careful imposition of order, of precision, of the clear demarcation of spaces. It is as if there are two different strategies for dealing with his madness. When he is ill in hospital, the spontaneous uninhibited process of giving form to inner turmoil with the hope of gaining control ins in tension with the formal mastery he displays when he is well - a determination, having regained control, to maintain it, to keep at bay the disorder of psychosis.
I don’t know which criteria are used to decide what might constitute good or significant art, but in some way what is valuable is the sense that it is necessary, authentic, disconcerting, and possibly dangerous.
We are afraid of our own vulnerability. We are afraid of our being in part mere machines, things, bodies, and that fear is compounded by the knowledge that machines can, and often do, malfunction. This of course applies to any form of illness and is not confined to madness. It is understandable - surely not ridiculous and pathetic - and it is a reflection of a human fear of unavoidable death.
The mind cannot escape the brain. We are bound to the machinery of ourselves.
Being bound does not entail being confined. While there might be a tension or some uncertainty as to who or what is in control, I do know that I do not feel as if I am a function of an algorithm, and that this is irreducible and uncontestable, whether or not at some other level of analysis it is illusory.
We live in a world increasingly preoccupied with information or data. We attach value to the accumulation of more and more information. We believe that this will grant us greater control over the circumstances of our lives, or enable us to reach beyond ourselves.
How to process the escalating torrent of information available to us in a useful way is not clear, but the predicament is a way of imagining madness.
I rarely encountered a patient in our unit with a diagnosis of a personality disorder who had not been profoundly damaged by life circumstances. These extreme behaviours did not arise from nowhere. The usual trajectory was from a broken home, an absent or abusive father, a neglectful mother and a total absence of any form of support or nurturing, to a profound lack of self-esteem and a grim descent into drug abuse, gangsterism and criminality. These patients, and that is how they were described while in the unit, provoked an anger and a moral indignation that too often deflected attention away from the tragedy of these abject histories.
The neurobiology of fear is to some extent understood. A threat in some form is perceived, and in very broad terms two systems are activated: one rapid and more or less unconscious and mediated at lower levels of the central nervous system, the other slower and conscious and mediated at higher levels.
Rather than informing an appropriate course of action, the more immediate, visceral, intensely powerful, emotional - possibly blunter - response can overwhelm the slower, more elaborately calibrated, evaluative system. We become paralysed by fear. We lose a sense of control and panic ensues. Our thoughts are distorted and we become disorganised by fear. In this frenzied state of mind we cannot respond to reason.
My sense of myself had become disorganised: one self was telling me that I was all right and in control, and another - more embodied - self was sending me very clear signals that I was most emphatically not all right.
It is understandable that socioeconomic ills or bereavement are unlikely to be ameliorated by a chemical agent, whereas the more severe form of depression - which seems more probably to have a biological basis - should be more likely to respond.
Treating the hardships of life with an antidepressant medicine fails to acknowledge difficult and complex life circumstances, offering rather a simplistic, paternalistic, pharmacological sop, and can undermine the necessary and more constructive process of developing the resources to cope with adversity as best as possible.
Based initially on electrophysiological studies, signals of brain activity are observable prior to the conscious decision to perform a single action.
Whether we are free from this empirical, objective sense does not detract from the feeling of being free to choose how to act in one way or another, or to choose to act or not to act.
Through the loss of an effective filtering, there is a surfeit of redundant connections leading to a storm of signals to the higher centres. We are incapacitated; attaching meaning or attributing salience is random and all becomes noise.
It is a curious paradox that schizophrenia might be imagined as a condition of being both less or too much of whomever we might be. An intricate balance is lost.
A paradox seems to have arisen in that the high accord attached to the self appears to be associated with an increase in misery and insecurity, if the relatively recent increase in self-harm, depression and suicide among young people may be considered indicators of this disturbing trend.
... certainly among the vulnerable, and vulnerability and a lack of self-confidence, may be regarded almost as defining characteristics of young adolescents, those most engaged in the tangled web of social media.
Describing these phenomena as auditory hallucinations seems inadequate. The aridly objective, notionally academic term gives no indication of the distress associated with the voices or the behavioural consequences. The associated phenomena are closer to the core of what a patient might be experiencing and closer to what might be considered to be the priorities in terms of a therapeutic intervention.
It was not the voices in themselves that prompted such anguish with disastrous consequences, but the disruption of something beyond, and something that might be considered innate and particularly human: a sense of self, of the privacy of the self, and a precarious notion of free will.
There is neural activity but a loss of signal. Music might be a useful metaphor. What is perceived as synchronous or beautiful or joyful is the expression of an extremely complex orchestrated process. A symphony, for example, consists of a wide range of instruments being played with great skill to a score and under the supervising coordination of a conductor. In the audience we do not attend to the component parts, except perhaps when things go wrong. We embrace the totality of it.
The percussionist, eager to impress the pretty second violinist, overreaches himself on the kettle drum. The delicate balance is lost. The music becomes noise.
The voice I hear and that speaks to me in a coherent and meaningful way is not a vibration of air molecules or the agitation of hair cells in the inner ear. The voice and the meaning I attach to its utterances are internally represented or constructed. It seems that this inferential process is what goes awry in psychotic states.
This is contingent upon a particular set of cultural beliefs, of course, but the implication in general is that it might be more helpful and useful to our patients for us to listen to what they are telling us, rather than simply to suppress the symptoms of psychosis.
There is a world of difference between hearing and listening.
Yet things could not be the same again. Everybody involved had become vigilant, anxious. What would happen? Would he be able to cope with the academic demands of his engineering course? Would it all be all right in the end? Would he follow the course of his younger brother? The family had coped with that as best they could, but also could not regard these events as anything but a sad and profound disappointment.
If any light or hope can be found in this profoundly sad expression of the human predicament, it might be in the way that, as these determined and desperate acts of self-harm arise in some, they as mysteriously pass. I remain nevertheless haunted by the events I have described.
Thabo was bought to the hospital by the police. He had presented himself at the Houses of Parliament earlier in the day and declared to the bemused security officers that he had come to take over the government that in his mind was corrupt and incompetent. It is not clear why this should lead to the conclusion that he was mentally ill but he was referred to our unit to be assessed. He was not an angry man. He was not violent in any way. For him overthrowing the government was more of a duty than a self-righteous insurrection. We did not think he was dangerous and he was moved to an open ward. I found him sitting at the fence looking at the birds on the river. He said ‘Our time will come. We will have to be patient. My army of birds are awaiting my command. Then we will take over the government. My birds are ready. Our time will come.’ He was calm. He was at peace with himself. He had a plan and he believed it was just a plan. The birds drifted in the shallow waters of the river, unperturbed.
In this state all is noise and chaos and devoid of meaning. It is difficult to imagine: our lives are so much more made up of light and sound and thoughts and feelings that form meaningful patterns and which help us to make sense of our lives and may grant us pleasure. The patient experiencing a psychotic episode is robbed of these harmonies. We cannot know the mind of another, and certainly not the mind of a psychotic other, but we can imagine that such noise, such a dissolution of meaning, would be intolerable. In this context it becomes understandable that a person in such a state should urgently seek to find or construct meanings and, in this process, to employ themes that are culturally or spiritually familiar - albeit often in deeply strange ways, given the disorder of mind.
One critical step in this process is to re-imagine the symptom not merely as a sign of a pathological process but as an endeavour to find meaning and regain control. This would entail acknowledging rather than dismissing these often bewildering symptoms.