George’s black eye was almost perfectly oval, as if he’d made himself up as a mime artist. He stood there in his empty flat, eerily unmoving and at an uncomfortable-looking angle, frozen somewhere in between meaningful gestures. It occurred to the young psychiatrist visiting him that sometimes the mentally ill really did look mad. After a dozen or so meetings, he still wasn’t sure exactly what he felt about his patient. Every time something was subtly different. What he felt now was an odd, and unprofessional irritation at George’s inability, or refusal, to explain how he got the black eye.
The young psychiatrist had got to know George a few months earlier, while he was plunging through a florid, psychotic episode. Their meetings at the time seemed memorable because the two of them looked so alike—both professional men in their mid 30s, the same height, a similar wiry build, blond hair, and some faint quality of mutual recognition. In his twenties, George had been an estate agent. But the sharp suits had gradually become crumpled, the behaviour increasingly erratic, the absences from work longer, and he had ended up in a locked ward after ransacking one of his old offices at night and hoarding up the window cards, oblivious to the burglar alarm he had triggered off.
By the time he was referred to the young psychiatrist, George had written out pages of notes gleaned from estate agent windows and websites. These looked like dense equations of property prices, postcodes, square footage, distance from tube stations or schools, and a variety of other increasingly bizarre items of urban data. George had at one point claimed that, out of these equations, he could identify a set of codes for what he called his “caste system” for Londoners. Properties under £75,000, depending on location, would generally condemn their owners to “untouchable” status; over £5m, and they would likely belong to a secret sect whose members possessed mystical powers.
But the young psychiatrist was now uncertain whether this wasn’t just his own interpretation of a garbled mix of meaningless ideas—an attempt to make sense of George’s illness in familiar terms. The delusions went further, involving a conspiracy in which he either had the power to create the codes himself, or was being pursued by higher beings seeking to destroy his system. The psychiatrist might want to perceive in this a distorted response to the stress and paranoia of the London property market, but George’s mindset probably just belonged to a general form of paranoia and solipsism common to schizophrenia.
The likeliest explanation for George’s illness was the simple, old, fatalistic one—that madness ran through his family. His uncle and more than one of his grandparents had been diagnosed with schizophrenia; and there were stories going back a couple of generations about family members who would disappear with “funny spells.” Prescribed the antipsychotic drug Quetiepine, George’s more extreme symptoms abated, and he was able to move out of hospital into a small flat. It was in an area that he might previously have described as “untouchable,” but on medication he was indifferent to it.
Yet the young psychiatrist couldn’t help feeling that his job should involve a deeper capacity for empathy than that. One of the most influential pioneers of 20th century psychiatry, the German philosopher Karl Jaspers, had distinguished between two kinds of madness: that which could be understood, and that which could only be explained. In some kinds of mental illness it is possible to recognise familiar emotions, even if exaggerated and distorted. And it is therefore possible to empathise with the sufferer. Yet there are other kinds, particularly types of schizophrenia, in which a complete psychotic break has taken place and the sufferer is propelled, like an outlying planet, into a remote and unreachable mental orbit. Jaspers called such states “autochthonous,” because they seemed to have arisen out of themselves. They are “un-understandable.”
What does it mean to know how someone else feels? Two years ago, neuroscience discovered what was marketed as an empathy cell—the mirror neuron. This tiny structure suggests the possibility of finally unravelling the hard wiring behind human understanding. Italian researchers had observed that monkeys used the same neuron to reach for a peanut as when they watched the peanut being taken by another monkey. Performing an action and seeing someone else perform it fires the same cell. In humans, these cells can be traced to the brain’s limbic system—the centre of our emotional responses. There is a seductive idea in this: that when we see somebody else’s tears, the same cells are being fired up as when we ourselves cry.
Sometime after leaving hospital, George had stopped taking his antipsychotic medication. But instead of again being beset by delusions, he had disappeared into the “negative” symptoms of schizophrenia—an emptiness left behind in a retreat from the world and the self. Glancing around George’s flat, the young psychiatrist looked for a point of conversation. But it was all just as the builders had left it. It was neat, and newly painted, but empty. No curtains or furniture; in one corner there was a mattress and an old suitcase. Without thinking, the young psychiatrist found himself tilting sideways into the same awkward posture as George, like another mime artist, trying to extract a reaction. “It’s a nice place you’ve got here,” he said.
Suddenly, George jolted out of position. “I introduced myself to the neighbours last night,” he said.
“Oh really? What time was that?”
“About three.”
“In the morning?” The young psychiatrist pointed to George’s black eye. “Did someone hit you?”
George ignored the question. “I think I might be getting sick again.”
The young psychiatrist and his patient looked at each other, as if they were both standing in a hinterland between what made sense and what didn’t. “How have you been feeling recently?” the young psychiatrist asked.
“I don’t know,” George replied. “I mean, I can’t remember. I think my problem is actually a memory problem.”
Then he shuffled over to the suitcase in the corner and began pulling out his notebooks. The young psychiatrist drew breath, anticipating a cascade of luridly distorted estate agents’ data. Instead, George handed him a piece of paper with a couple of lines neatly written on it.
“I read this somewhere, and I thought you might like it,” he said.
What George had written was: If in life we are surrounded by death, so too in the health of our intellect we are surrounded by madness.
It was a quotation that the young psychiatrist knew well; but now it wrong-footed him. When George wrote it down, he hadn’t been thinking of his own condition; he’d been thinking of his psychiatrist’s. Schizophrenics find empathy as difficult as it is for others to understand them. Thinking about someone else was a good sign.
“Would you like to come back to hospital for a bit?” the young psychiatrist asked.
“Ok,” George replied.
