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Esmé Weijung Wang’s The Collected Schizophrenias: Essays (Gray Wolf Press, 2019: 210 pp.) are an articulate and clarion cry to bring empathy to an arena in mental health where it has been missing.
My take on it? Ms Wang seems not to have been one of those survivors whose mental disorder is inextricably entangled with her genius. She was already talented and successful, studying at Yale, before her first breakdown.
The disorder was a major curve ball, delivered at high velocity, and hitting her in
the head – and heart. She gets up, dusts herself off, and, with writing that knocks it out of the park, recovers her own humanity with compelling accounts of her experiences, both humorous and heart-rending, thereby enriching ours and expanding our empathy.
At risk of mixing the metaphor, life handed her lemons. By my estimate, about a bushel. She did not merely make lemonade. She has concocted a kind of electric cool-aide. This is a beverage which perhaps will leave one feeling a tad trippy and vertiginous, but one which expands one’s empathy, not only for survivors of mental illness, but for our humanity at large. The rumor of empathy in Wang’s work is no rumor – empathy lives in Wang’s The Collected Schizophrenias.
The celebrated psychiatrist-philosopher Karl Jaspers (1883–1969) wrote in his seminal two volume psychiatric text General Psychopathology (1913/1959) that lack of empathy was diagnostically significant for a diagnosis of schizophrenia. If one is having trouble empathizing with the other person, the diagnosis of schizophrenia is by no means certain, but belongs on the short list.
The doctor and therapist struggle to have empathy for the often-bizarre constellation of symptoms characteristic of schizophrenia – hallucinations, delusions, incoherent “word salad” speech. The care-takers, from their own perspective, experience a lack of out-bound empathy from the patient, whose suffering is thereby aggravated in being further cut off from human connectivity and isolated.
One thing Ms Wang’s memoir of her disorder makes crystal clear is that her empathy is functioning full throttle. Even if her empathy is sometimes inaccurate (as is everyone’s) or misfires (as does everyone’s), Wang’s empathy lives as a commitment to appreciating the other’s point of view and relating to the other with affinity and appropriate affection. Wang fully experiences the dignity violations, lack of respect, and objectifications on the part of the medical system and professionals trying to help her, leaving her alternatingly in despair and enraged.
Paradoxically a dimension of her reality testing continues to function even as she is fearfully hiding in the closet due to psychotic symptoms that demonstrate to her the break down of her reality testing.
While it is true that most sufferers and survivors of the collected schizophrenias do not present as “high functioning” as Ms Wang, growing evidence is available that, even in the acute phase of the disorder, most psychotic persons appreciate that the hallucinated voices and ideas of reference are somehow subtly and significantly distinct from everyday reality. This awareness, however tentative it may be, can be leveraged and made the target of therapeutic conversation. This has clinical significance for cognitive behavioral and emotional interventions in the acute and the survivor phase. This is the empathic moment of which even so celebrated a shrink as Jaspers missed.
“High Functioning” is itself the title of an chapter in which Ms Wang is in recovery. She is giving presentations on mental health to interested citizens and professionals as part of some gig and good work she has landed after her professional career was ruined by the disorder. The reader gets background on Wang’s earlier career as a fashion journalist. We get a reading list of other “high functioning” individuals who have struggled with mental illness and go on to get PhDs, McArthur “Genius” Grants, and endowed chairs in psychiatry at major universities such as Kay Redfield Jameson, Elyn Saks, and other notable authors of “pathographies.” Pathographies are an emerging but not really new category of biographies and memoirs of survivors of mental illness.
This paradox of reality testing within the breakdown of reality testing has also been pointed out by thinkers whose critical inquiries into mental illness need to be better known. I am thinking especially of the work of Louis A. Sass (1) and Matthew Ratcliffe (2), whose books are cited at the bottom of this review. (See also my related blog reviews of Ratcliffe: https://wp.me/pXkOk-8g and Sass: https://wp.me/pGb20-pp.)
There is something for everyone in Ms Wang’s collection.
She acknowledges that she takes her anti-psychotic medications on schedule, and, moreover, the medications that work for her right now are so-called first generation, haloperidol and quetiapine (Seroquel). She argues that the National Alliance on Mental Illness (NAMI) takes positions dear to the heart of the families of the mentally ill (take your meds, allow for involuntary incarceration in an emergency (5150: code for involuntary commitment), be a good “mental patient” conforming to the hierarchy in which psychiatrists are I authority).
At the same time, Wang is an evangelist and a strong advocate for RAISE (Recovery After an Initial Schizophrenia Episode) and the need for autonomy for the mentally ill: “Rarely did I experience such a radical and visceral imbalance of power as I did as a psychiatric inpatient amid clinicians who knew me only as illness in human form (p. 57).
The anti-psychiatry movement will find comfort and is well-represented in Wang’s work. Not only do the mentally ill have to survive the illness, they also have to survive the system that is supposed to help them: “Though nearly all the statements a psychiatric patient can make are not believed, proclamations of insanity are the exception to the rule” (p. 101). Crazy making rules and treatments. If that is not a double bind, I would not know one.
Wang takes a position: “I maintain, years later, that not one of my three involuntary hospitalizations helped me. I believe that being held in a psychiatric ward against my will remains among the most scarring of my traumas” (p. 110). A bold statement of the obvious: That is tragic – and an outrage.
The honest broker, Wang then reports on individuals who committed violent crimes and/or killed themselves while in the grips of psychotic episodes. No easy answers here.
The social justice dimension is not pervasive in Wang’s memoir – perhaps because Wang’s family and husband were able to be supportive enough to arrest her slide into the abyss of insanity just short of the edge – but explicitly surfaces periodically and powerfully: “nearly 1.3 million people with mental illness are incarcerated in state and federals jails and prisons” (Department of Justice) (p. 110). Wang does not say what percentage is getting the treatment they need in accordance with professional diagnostic guidelines. I am going to be optimistic: 25%?
Since this is not a softball review, a point occurred at which I was about to put down the book with the admittedly devaluing, objectifying judgment: This individual is a walking laboratory of psychiatric (and medical) curiosities.
Wang endorses the Cotard delusion, in which the person claims that I part of his
body does not belong to him or that he as a total person is dead and should be disposed of properly. My empathic understanding of this disorder – and this is not the truth with a capital T but consider the possibility – is that the person’s emotional life has been short-circuited. The person is emotionally “dead,” for without emotions and affects we lack vitality and aliveness. Wang’s credibility (with this review) is restored as she reports she was so desperate she was considering ECT (electro shock therapy), but did not go through with it. The disorder spontaneously remits.
In an ongoing and increasingly desperate search to regain her power over the seemingly endless series of (un)related disorders, Wang suspects she may have an autoimmune disorder. Whether late stage Lyme disease is one of those, I do not know.
By this time, Wang is a relatively well-informed professional patient with limited but apparently sufficient resources, and she manages to go on a kinda of new age medical retreat to Santa Fe, New Mexico, for the treatments with a “lyme literate” medical doctor (LLMD).
Always the honest broker, Wang reports the writings of Leslie Jamison, author of The Empathy Exams, in which Wang compares Lyme is to the problematic, hard-to-pin-down, possibly delusional disorder, called having “Morgellons.” Jameson gives an account of the person who has Morgellons, in which the individual experiences worms or worm-like sensations, crawling beneath his flesh, which, apparently, sometimes pops out. Yikes.
At this point, I abandon any skepticism I might have about Wang’s suffering as a medical patient as my own limitations or arrogance. I decide to acknowledge once again there are more things in heaven and earth than are dreamt of in our philosophies (note: “philosophy” meant “natural science” in Shakespeare’s time).
(1) Louis A. Sass, (1994), The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind, Ithaca, NY: Cornell University Press.
(2) Matthew Ratcliffe, (2017), Real Hallucinations: Psychiatric Illness, Intentionality, and the Interpersonal World, Cambridge, MA: MIT Press, 290 pp.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Real Hallucinations by Matthew Ratcliffe [book review] – Okay, so what would FAKE hallucinations be?
“Reality testing” is a distinction that is in the background of Matthew Ratcliffe’s penetrating and incisive book Real Hallucinations: Psychiatric Illness,
Intentionality, and the Interpersonal World(Cambridge, MA: MIT Press, 2017, 290 pp.). Disturbances of the sense of reality are among the key phenomena that cause people who suffer from hallucinations or delusions to be referred to psychiatrist professionals.
Ratcliffe takes pains to work through the various senses of reality that confront one as soon as one wishes to assert that something = x is not real. For example: “Illness or jet lag can involve an all-enveloping and lingering sense of one’s perceptual experience as somehow lack, not quite right” (p. 44). But that is just the beginning.
The memoires of psychiatric patients, who have survived psychosis – as well as thought experiments invented by philosophers and Ratcliffe’s own survey research – are full of examples where the distinctions between perceiving, imagining, remembering, anticipating, and experiencing, begin to break down and actually do break down. All these are engaged in the narratives of those who have survived psychosis such as Elyn Saks, M. Sechehaye, or reports from a survey collected by Ratcliffe.
Ratcliffe collects extensive evidence of the intermittent flexibility of the boundary between imagining that something happened and remembering that something happened; between intending to fill up the gas tank of the car and remembering that I did so (but did not); between perceiving the bear at the window of the cabin and imagining the bear at the window, and so on. I look into the mirror and see a face that does not look anything like my own (my example, not Ratcliffe’s). The face is so different that I realize I must be dreaming, and wake up. If I do not wake up, and the face still looks frighteningly different, then modes perception and imagination have gotten mixed up, I am having a psychotic breakdown and need help.
These considerations result in Ratcliffe’s innovative account of hallucinations and delusions. Ratcliffe’s nuances, conditions, and qualifications are many, but they boil down to: in hallucinating, content is framed using an intentional mode at variance with what it might be anticipated to be. Thus, a voice that is remembered or imagined is misconstrued as being actually perceived in the here and now; in delusions such as thought insertion, a thought that is imaginary or remembered or otherwise fictional is misframed as an occurring belief. The misframing, slippage, or “going off the rails,” occurs because of an anxious anticipation of something = x, including the possibility that what the individual is fearing is fear itself.
This account finds strong support in the works of R. Bentall, L. Sass, and the reports of survivors of psychosis, distinguishing between hallucinations as having an experience versus having a sense of an experience. (The reader may usefully consult the book itself for the excellent bibliography.) In hallucinating, one is having a “sense of an experience.” And, notwithstanding the insistence of the psychotically disturbed that they are really experiencing what they are experiencing – which is what makes it so frightening – a moment often comes in which the [psychotic] individual acknowledges he or she can distinguish the voices or anomalous beliefs from everyday, standard situations, places, and practices.
This leads to what is sometimes described as “double bookkeeping” – the psychotic person seems to inhabit two worlds – the standard, shared world and his own special, different one. Or the psychotic person may feel that the standard world has been completely annihilated and he is the only survivor or feel that he is already dead. In either case, the individuals looks carefully both ways before crossing the street. Curious. Yet this is the disorder itself.
Ratcliffe also finds support in the work of Marius Romme and Sandra Escher, who are credited with giving rise to the Hearing Voices Movement (p. 30 – 33). This is not just a theory or collection of data, but a normative position about how those who have anomalous experiences such as hearing voices should engage with their voices and engage with the medical community. In so far as I understand it, Ratcliffe is a fellow traveler with the view that voices with distressing content are socially embedded and events such as trauma, neglect, abuse, adult social isolation, and so on, are important determinants of the anomalous experience.
Often the disordered individual’s sense of reality is demonstrably in breakdown, but differences and variations in the degree of disorder are of the essence in description, diagnosis, and treatment.
You and I – as average ordinary everyday citizens – have trouble communicating with psychotic individuals because we no longer share the same methods or procedures for reality testing. The psychotic’s reality testing is producing a different result than yours and mine. The result may be so vastly different that we say the psychotic has no sense of reality at all. None. The individual is banging his head against the wall. However, fortunately, that is rarely the case. Most often a form of “double bookkeeping” is occurring, and sense can be made out of the seemingly senseless.
This is where Ratcliffe’s powerful contribution comes into its own and makes a difference. Inquiring minds want to know: what the heck is going on with hallucinations and delusions such as thought insertion?
Ratcliffe’s contribution is an important, even outstanding one; but this reviewer is at pains to create a context for a review that will connect with the prospective readers.
Yet another digression must be bracketed before one can engage the book in context and on its own merits.
To be sure, the biological explanation of hallucinations and delusions looms large. But Ratcliffe does not go there, and the reader will find none in this text, though their appropriate applicability is acknowledged. The conventional wisdom is: dopamine up, hallucinations up. Take a bunch of cocaine. Do this enough (or sometimes only once) and the brain is flooded with dopamine (and related, activating neurotransmitters). The person is hearing and seeing all sorts of stuff that is not really there. We call this stuff = x “hallucinations and delusions.”
This neurotransmitter imbalance explanation is evidence-based and pharmacological interventions that reduce the ratio of available dopamine to dopamine-receptors really do seem to restore equilibrium to the brain.
However, something seems to be missing from the neurological discussion – an account that puts the suffering, struggling human being in a personal world that is able to support and sustain his recovery and return to humanity. Hence the need for Ratcliffe’s contribution, which lays the foundations for such a conversation (without, however, actually completing the journey).
Ratcliffe’s account begins by taking issue, cautiously, with Dan Zahavi’s (and other’s) approach to the minimal self. Key term: minimal self. At the risk of oversimplification, psychosis is then hypothesized to be a disorder of the integrating and synthesizing capabilities of the minimal self. Ratcliffe generally endorses what Zahavi has to say but is at pains to include the requirement that the minimal self emerges out of a social matrix: “Our most basic sense of self is developmentally dependent on interactions with other people” (p. 16). Thus, when the social milieu is disrupted – through trauma, adverse childhood experiences, metabolic disorders, or addiction – the minimal self and its meaning making and integration capabilities also break down. Viola! Psychosis.
How minimal is the minimal self, asks Ratcliffe? He answers that it includes the sense that the individual is having a pre-reflective sense of “mineness” in perceiving, imagining, engaging in inner speech, moving around in the space, and remembering.
These immediate prereflexive, unproblematic acts of seeing, imagining, verbal thinking, moving, and remembering are called “modalities of intentionality” in the phenomenology of Edmund Husserl. These acts of intentionality have a temporal form. Anticipation is one of the fundamental forms of intentionality along with retention (recollection) and being present. (Note this material is technical and not for the faint of heart, but will be of interest to many readers.)
This analysis of intentionality opens up deep philosophical issues at this point, and Ratcliffe engages with them. The bottom line for Ratcliffe is that an intentional analysis of consciousness is on the critical path to providing an account of hallucinations and delusions.
For example, is the intentional act of seeing distinct from the content of consciousness? Can an individual disentangle the sense of seeing a tree from the shape, color, location in space, and so on, of the experience, leaving us with access to an act of perceiving in itself? Is the form separable from the content? It seems that it is, though their togetherness is such that one can only get access to the form through and by means of the content.
Since this is not a softball review, one may ask: So what? Hard working, dedicated, committed psychiatrists are taking arms against a seeming epidemic of psychotic disorders using the tools with which they have been trained – second generation anti-psychotic drugs. If a person comes in claiming to hear things that are not there and the person does not have a metabolic disorder, then the doctor is probably going to err on the side of caution and start him on a low does of one of those anti-psychotic medications. So why do we need a phenomenological analysis of real hallucinations – and “real hallucinations” as opposed to what? Fake hallucinations?
It turns out that, for the most part (and absent a study such as Ratcliffe’s and a few others like it), we do NOT know what hallucinations are. Even more problematically, we think we know, but we do not. We may usefully take a step back here to put the matter in context.
The average person, for example, thinks of hallucinations the way they occur in the Hollywood movie A Beautiful Mind (my example, not Ratcliffe’s). In the movie, the Nobel Prize winning mathematician and economist John Nash is having a conversation with his roommate. The audience sees the roommate, hears him and Nash talking together, and the scene is portrayed as if Nash sees and relates to the roommate the way we, the audience, see and relate to him.
Ratcliffe does not mention the Nash movie, and I bring it up to relate Ratcliffe’s contribution to the average, everyday misunderstanding of hallucinations. This academy award-winning movie about Nash contains many compelling performances, much engaging narrative, a good example of an elaborate, delusional system, but what it does NOT contain is an example of a real hallucination. (By the way as regards Hollywood fictions, The Black Swan (2010) with Natalie Portman does a much better job of capturing what psychotic hallucination are like as the lace of a ballet costume seems to grow like a malevolent fungus.)
Nash’s roommate does not exist – the audience eventually learns (to their astonishment) that the roommate is a hallucination. The roommate is part of Nash’s elaborate delusional network, resulting in Nash’s being given a diagnosis of paranoid schizophrenia – along with electroshock therapy and first generation antipsychotics (but that is another story). Meanwhile, if one gets inside the experience of the person who is having conversation with someone who is not really there, the experience is nothing like an ordinary experience. Okay, so what is it like? Hollywood gives us examples of fake hallucinations. Hence, the need for Ratcliffe’s Real Hallucinations.
(c) Lou Agosta, PhD and the Chicago Empathy Project