As with many of the big decisions in life, my choice of psychiatry as a career was complicated: more a case of gradual acceptance than an overwhelming sense of rightness. And truth to tell that sense never came. A love affair with literature prevented that. I also preferred the insights of psychotherapy to the neuroscience and pharmacology of the medical model. I vividly remember being fascinated and mystified by “madness” after spending time with very deluded and institutionalised patients on a back ward at Bexley Hospital in Kent as a medical student. How different was my response to that of a surgical colleague, with whom I discussed this years later. He could find little of interest in these sad, grey shambolic figures. The big puzzle for me was how to connect these tragic frustrated lives to the accounts of acute and more episodic madness in Shakespeare’s tragedies and Dostoevsky’s novels. And later as a junior psychiatrist to the acute presentations of young people detained against their wishes under the Mental Health Act, who usually recovered over a matter of weeks with anti-psychotic medication. I began to realise that in those individuals who had repeated relapses, a chronic disability ensued. I should add that in my second year as a psychiatrist, I myself had an acute psychotic episode while working in a very challenging therapeutic community. The upshot of this is that I do believe I am able to understand the world of the insane when I have been allowed into an individual’s private hell of hurt, humiliation and despair. (I exclude from this organic causes of mental deterioration).
And there are many literary accounts of developing or established madness which are outstanding in their insights. Shakespeare’s tragedies, Dostoevsky’s four great novels , Pirandello’s Henry the Fourth, Schaffer’s Equus, Ayckbourn’s Woman In Mind. In Pirandello’s Henry Fourth and in Don Quixote, the protagonist casts off his madness at the end, suggesting that after the acute storm which plunged the person into madness, there may be a later choice to remain insane as a convenient role in which to meet the world. An art therapist told me of a patient who had been in a group of long stay residents in a Victorian Psychiatric Hospital who had attended to paint for some years. His paintings were little more than scrawls and his verbal communications were negligible too. One day he produced a picture of a house on a hill, and that night he died.
We know that schizophrenia (personally I don’t like the concept) tends to occur in young people. So does anorexia nervosa. The challenges of moving from adolescence to adulthood are: 1. Separating from parents 2. Being accepted by a peer group 3. Achieving a functioning sexual identity 4. Establishming financial independence through work. These are the areas where there are problems when young people become psychotic.
Whenever a professional interviews a patient with a psychosis, it is important to recognise that the patient is assessing the interviewer as surely as the other way round, and sometimes tests the perceptiveness of the interviewer by throwing in bizarre or irrelevant responses. Highly literate and comic effects are achieved by Shakespeare as Hamlet sends up Polonius. However with his true adversary, Claudius, he is more wary and not so openly contemptuous.
I will post a poem about psychosis on my next blog.