We understand Koznyshev and Varenka because we have been there, stumbling in a personal encounter, blurting out what wasn’t what we meant to say, and not saying what we really want to. But most of us haven’t been where those with severe psychiatric problems are. We do not have the same feel for their experience, and a first-person account can be a shock.

The poet Ivor Gurney fought in the First World War and was injured in a gas attack. His diagnosis, in the language of the time, was “nervous breakdown from deferred shell shock.” Later he was committed to an asylum, with auditory hallucinations and delusions of being tormented with electricity. A poem he titled “To God” both harks back to the cruelty of the war and expresses the intense horror of his condition:

Psychiatric Illness, “Strangeness,” and Personal Chemistry

People with psychiatric disorders can strike others as strange. Things they do may seem unintelligible. They may look odd or have an unusual posture or gait. They may laugh at unexpected times, or stare, or say things in ways that make it hard to have a conversation with them. At times it is hard to get through to them: they can seem unreachable. And the gulf may seem as wide from the other side too, so that even the dearest that I love the best are strange.

The inaccessibility has baffled families, friends, and psychiatrists. Eugen Bleuler, the inventor of the term “schizophrenia,” said that people with the disorder were stranger to him than the birds in his garden. Karl Jaspers said that people with schizophrenia were queer, cold, inaccessible, rigid, and petrified in ways that are peculiarly baffling: “We may think we understand dispositions furthest from our own, but when faced with such people, we feel a gulf which defies description.”2

People who have been hit by schizophrenia are not birds but persons, and therefore their problems may be compounded by our inability to reach them. Normally we reach people through smiles, frowns, irony, jokes, tone of voice, touching, meeting of the eye, and so on. In a thousand ways we share experience, and signal our shared or our disagreeing responses. Some of this is a shared human grammar. Some of it is shared within a culture or within a smaller group, such as football fans, or lesbians, or members of a religion. Some of it is the private language of a couple, a family, or a group of friends. The way people bond is often thought of as a matter of their “personal chemistry” with each other. Schizophrenia can disrupt this personal chemistry, adding isolation to illness.

Understanding “from the inside” someone with this loneliness matters independently of any contribution to developing a cure. It is also a serious intellectual challenge—to psychiatry, to psychology, and to philosophy. So far our theories about knowledge of other minds have not helped us much here.

Trying to Interpret “Strange” Inner Lives

I could tell them about school and home, and how I felt about the eating disorder, why I needed to self-harm. It was my way of communicating: my way of getting people to listen because I didn’t know how to find words, or how to get someone to listen to me.

—Anonymous: An autobiographical case study presented to a conference on child and adolescent psychiatry

A psychiatrist has three central tasks. There is seeing that someone needs psychiatric help: “not waving but drowning.” There is interpreting what is going wrong. And there is seeing what may help.

Seeing that someone needs help may draw on the psychiatrist’s own emotional reaction to the person. A general practitioner once said to me that “a doctor’s own response is his most sensitive instrument.”

There is the hope that interpreting what is going wrong may help to put it right. But there is also the hope—perhaps related—of finding an interpretation that can help break down the isolation, the “gulf beyond description.” This means trying to see how people who need help see themselves, to get an idea of their experiences. First-person accounts are a key to understanding the ideas and metaphors they use to describe and make sense of their own lives.

Giving appropriate help depends a lot on finding the right interpretation. (Only “a lot,” rather than “entirely.” Someone with a false theory might still help, simply through sympathetic attempts to understand. But the aim should be to make contact and to understand.) There are different possible explanations of a person’s emotional unreachability.

People who need help may not want to communicate. Depression or previous hurts may make them despair or hide behind the defensive wall.

Or the problem could be a failure of communication. Perhaps they are not interpreting other people’s signals correctly. Not noticing the reactions to bizarre clothes or to sudden inappropriate laughter, or being oblivious to someone else’s signals about having to leave, can all create an impression of strangeness. Or the failure can be in the other direction. Perhaps their own appearance, tone of voice, choice of words, or facial expression is sending the wrong signals to other people. Either interpretation suggests a poor sense of the small details of everyday life.

There may be remedies. Sending the right signals, and how to read signals sent back, are teachable skills. Some women with postpartum depression have difficulty bonding with their babies. It sometimes helps to show them videotape of how they and their babies interact. This can help them read and respond to the baby’s body language.3 Psychiatric “strangeness” might be helped by something like this.

Strange behavior can reflect an inner life that is hard for others to intuit. Karl Jaspers thought this: “When we trace back behaviour, activities and general conduct of life in an individual and try to understand all this psychologically and with empathy we always come up against certain limits but with schizophrenic psychic life we reach limits at a point where normally we can still understand … Why a patient starts to sing in the middle of the night, why he attempts suicide, begins to annoy his relatives, why a key on the table excites him so much, all this will seem the most natural thing in the world to the patient but he cannot make us understand it.”⁴

Such a different inner life raises deep difficulties. Biological psychiatry, citing such causes as abnormalities of brain chemistry, sometimes helps to cure or contain disorders. But it gives no intuitive understanding of how people feel from the inside. We need to start from our normal framework of interpretation and see if it can be extended to fit the people we are trying to understand.

This framework could be called “Aristotelian common sense.” Aristotle gave a systematic analysis of our everyday understanding of people: how beliefs and desires shape decisions and actions, how actions turn into habits, and how habits turn into character. He gave recognizable outlines of the framework—sometimes dismissed as prescientific “folk psychology”—which we still use in thinking about people and what they do.

Critics say this framework has not developed since ancient times. Our folk psychology is mainly informal and intuitive, so its growth can easily go unnoticed. Its extension by Freud is an instance. Of course, much Freudian theory is widely doubted: the Oedipus complex, the death instinct, “pale criminality,” and so on. So it is easy to overlook how such Freudian concepts as unconscious motives, repression, projection, and defense mechanisms have been absorbed into our folk psychology. In his poem on Freud’s death, Auden got the balance just right: “If often he was wrong and at times absurd / To us he is no more a person / Now but a whole climate of opinion.” The case of Freud highlights a question. What is progress here? Unconscious motives have entered everyday psychological thinking. The perhaps less plausible death instinct has not. But there is a lot to investigate about what the constraints of plausibility are here, and what their claim to be accepted comes to.

Our evolved skills of interpreting other people give a good reason for taking folk psychology as a starting point. But Aristotelian physics is a warning. Aristotle created a brilliant synthesis of the science and the folk physics of his time. In the seventeenth century it came to be accepted that bodies not interfered with may either be at rest or else be in a state of uniform motion in a straight line. Aristotle’s contrary view was that bodies must be at rest until some force moves them. His view, more than modern physics, reflects intuitive common sense. His commonsense psychology has not dated in the same way, but it also is challenged. Neuroscience may change our conceptual map of freedom of action and of personal identity. And common sense has difficulties with some of the complexities of many aspects of psychiatric disorder, such as delusions.

Psychiatry should be both conservative and revisionary. We need all our skills of human interpretation, and skepticism about some of the categories of thought they rely on. And there is a lot to learn from what people say about their own “strange” behavior.