The Wood for the Trees

www.thelancet.com/psychiatry Vol 2 January 2015 23 In 1999 I was preparing for the Royal College of Psychiatrists’ membership exams. I remember reading up on schizophrenia and going through the list of Schneider’s fi rst rank symptoms. The way the disorder was described struck me as odd from the very start. I looked at the list and thought two people with completely diff erent symptoms—no overlap at all—could both have the same disorder. They could also have the exact same symptoms, but one person could have developed them in their teens and the other person in their 50s; no problem. I dismissed this thought as an idle musing and went back to revising. At that time I was working at an innerLondon rehabilitation ward that catered to patients who had a history of homelessness. It was then that I met Jacks and Mr B. I spent a lot of time with them, talking to their families and friends, and interviewing them about their experiences. I did my best to see things from their point of view. Their presentations resonated with my intuition. Here is what I believe their experience of their illnesses was like. I don’t presume to speak for them, but I will use their language rather than that of the diagnostic manuals. * Jacks is 46 years old when I meet him. His bloodshot fearful eyes remain fi xed on mine for longer than is comfortable. It is August and he wears dark brown corduroy trousers and hiking boots. He also sports a green knitted cardigan, a grey suit jacket shiny with age, a woollen multicoloured hat, and a bright purple padded coat. He slowly stands up and comes towards me warily. He is trying very hard to smile but only manages a brittle, forced expression closer to a grimace. I shake his hand, which feels dry and too warm. I introduce myself and we sit down to talk. We do this many times over months. I want to think he is less scared of me as time goes by, but I am not sure. Jacks lost control of his life in 1989, just after his 35th birthday. The whites in the satellite, he tells me, could not do much at fi rst, but it didn’t take them long to start eroding his defences. They zapped him with laser beams, sapping his strength and made it clear that he was not wanted where the whites lived. This was no place for him—no place for his people. Eventually, the whites in the satellite learned how to use its laser beams to control almost every aspect of Jacks’ life. They could crush his lungs or block his liver; they could even make his heart stop at any moment if they wanted. They also did things to his mind. They would suppress and take away any thoughts they did not like and they would put in the thoughts they wanted him to have. They made Jacks say mad things and act in mad ways, so eventually he drove away his wife and daughter. The whites in the satellite pushed him onto the streets to punish him. Who did Jacks think he was? He should not live in a nice home. He should not have a nice family. They punished him for his audacity. He should be out on the streets; that was all Jacks deserved. Every time Jacks tried to get in touch with his family, the beams of the satellite would make his lungs collapse and his heart race. He felt like his chest would explode. When he changed his mind, the satellite would ease off and he would be able to breathe again. Because Jacks kept defying the satellite it sent him to a bus stop, out in the cold. The satellite chained him to it with its laser beams and only allowed him to go a few steps away, into the park behind the bus stop, when he wanted to use the bathroom. Eight winters went by. A kindly couple brought food to the bus stop for him. He could see the laser beams zapping them, making them give him food so he would not die and thus be free of the torture. He could not blame them—they did not know any better. He tried to talk to them and ask them to leave him, but the satellite zapped his voice away. * I meet Mr B as he talks animatedly with one of the ward nurses. He looks like he is in his late 60s, but on his fi le it says he is 55 years old. The tone of voice is that of someone narrating an amusing anecdote, but the words he speaks are completely divorced from one another. He is standing with his back to me—too thin and too tall for his clothes. He moves in a constant dance, his movements arranged to some fast-paced unheard music of erratic tempo. The fi rst few times I stand beside him to talk—he never sits for any length of time—I make the mistake of thinking his speech is all nonsense. I persevere and gradually I am rewarded with a glimpse. I discover it is possible to play Tetris with his words until they make some sort of sense. He tells me he used to be a doctor. He also used to be an army offi cer, a robber, a husband, someone called “Scampi Jack”, a prison warden, and a motorcycle rider, among other things. He was all these things. He actually is all these things. He, they—when he was in Plymouth or America or maybe Rome, he was so much more. He collects £3 a day. He used to be rich, didn’t he? He feels happy and angry and dejected and cheated and lost and ecstatic and betrayed and runover. He remembers being very intelligent—the most intelligent man there was. But then they got jealous, or maybe envious, or both. He was in the army doing medicine then, he remembers that. They took him away; lots of them, faceless grunts dressed in white. They took him, strapped him, held him down, and violated him. They shocked his brain and took away his intelligence, his memory, and his knowledge. Now he cannot think Essay The wood for the trees