The Person or the Illness?
Was’t Hamlet wronged Laertes? Never Hamlet.
If Hamlet from himself be ta’en away,
And when he’s not himself does wrong Laertes,
Then Hamlet does it not, Hamlet denies it.
Who does it then? His madness. If’t be so,
Hamlet is of the faction that is wronged;
His madness is poor Hamlet’s enemy.
—William Shakespeare, Hamlet
The boundary between the person and the illness is harder to draw in schizophrenia. Dementia mainly (but not always) comes on late in life. This makes it easier to see the demented period as a coda: something after the main part of someone’s life. But the radical personality changes of schizophrenia usually come on relatively young.
Here I will put aside such issues as whether schizophrenia is a unitary condition or should be divided into subgroups, or whether it is a properly empirically based scientific concept.1 At the start of this book I expressed my hopes that we might eventually achieve finer-grained, and possibly more biologically based, diagnostic categories. The objects of those hopes include schizophrenia. But to talk about common features shared by many people with the diagnosis, the word has to be used—with an appropriate tinge of skepticism.
The question of the boundary between the person and the illness hardly arises in acute schizophrenic crisis. Little coherent personality may show through the torrent of words, the delusions, the suspicious hostility, or the menacing stare. Most of this has all too clearly more to do with the illness than with a person’s own characteristics.
In the periods of relative stability the boundary question is real. Even in stable periods, the person may still hear voices and behave strangely. The conjectures put forward in the discussion of delusions included a disruption of emotional intuition. This, if correct, could be linked to the weak grasp of the small change of everyday life that is part of the strangeness. When someone has been changed profoundly by psychiatric illness, it matters that the person underneath the changes is still recognized. There is something like this in Tove Jansson’s magical book Finn Family Moomintroll. In a children’s game of hide-and-seek, Moomintroll hides under the Hobgoblin’s hat. He comes out radically changed.
“You aren’t Moomintroll,” said the Snork Maiden scornfully. “He has beautiful little ears, but yours look like kettle-holders!”
Moomintroll felt quite confused and took hold of a pair of enormous crinkly ears. “But I am Moomintroll,” he burst out in despair. Don’t you believe me?”
“Moomintroll has a nice little tail, just about the right size, but yours is like a chimney sweep’s brush,” said the Snork.
And, oh dear, it was true! Moomintroll felt behind him with a trembling paw.
“Your eyes are like soup plates,” said Sniff. “Moomintroll’s are small and kind.”
“Yes exactly,” Snufkin agreed.
“You are an impostor!” decided the Hemulen.
“Isn’t there anyone who believes me?” Moomintroll pleaded. “Look carefully at me, Mother. You must know your own Moomintroll.”
Moominmama looked carefully. She looked into his frightened eyes for a very long time, and then she said quietly, “Yes, you are my Moomintroll.”
And at the same moment he began to change. His ears, eyes, and tail began to shrink, and his nose and tummy grew, until at last he was his own self again.
“It’s all right now, my dear,” said Moominmama. “You see, I shall always know you whatever happens.”2
It would be wonderful if such recognition could dispel psychiatric changes in this way. It cannot, of course. But the recognition can still be a lifeline.
Sometimes the person may seem much as before the illness. But often there is a deep transformation.3 Someone friendly and humorous, lively and alert, may have become strangely unreachable: taciturn, sullen, uninterested in others, perhaps aggressive, and doing little beyond half-watching television. This new burnt-out personality may last a lifetime, either uninterrupted or alternating with acute episodes. Friends and family may have conflicting responses to the aggression the person they have known sometimes shows toward them. Should they react with exasperation or detachment? Does the aggression reflect the person or the illness?
Jay Neugeboren discusses this in his account of Robert, his younger brother with schizophrenia. Neugeboren would sometimes break down after painful visits to his brother in the hospital. For a time he got through the visits by thinking there were two Roberts. There was one he grew up with, and one now in the hospital: “It was as if, I would say, the brother I grew up with had died.” This made things easier because it reduced blame or disappointment: “I could spend time with him without making him feel that he had, by becoming a mental patient, somehow failed me, or himself, or life.”4
To see the original person as having died is extreme. But there is a strong case for the thought that the schizophrenic personality expresses the illness rather than the person’s real self. The reasons are partly conceptual and partly moral.
The conceptual case starts by accepting that the strangeness and narrowing passivity are caused by the illness. As a thought experiment, imagine a treatment that, without other side effects, restored people from this negative state to how they were before the illness. This would be a cure for schizophrenia. It would then be natural to see the second personality as a temporary product of the illness. The hostility and aggression displayed during the illness would be put aside as not reflecting the person’s real self. But if that would be the approach if there were a cure, why should the status of the schizophrenic personality be so different now? Should not what counts as a feature of an illness be independent of whether a cure is available?
The moral case for seeing the schizophrenic personality as reflecting the illness rather than the person is linked to the desire not to give up on the possibility of a cure, a kind of keeping faith with the original person. There is the hope that the original version of the person might not be lost. On the analogy of a television screen where the picture has been replaced by visual chaos, there is the hope that, if only we could get the neurological or neurochemical tuning right, the original picture might be restored.
As with dementia, the new personality is the product of the illness rather than of any self-creative process. It does not reflect the choices or values of the person before the onset. It seems unfair that people’s personalities have been so distorted by factors outside their control. Refusal to see the new personality as really reflecting them is a recognition of this. And blaming the person for things that reflect the new personality seems particularly unfair.
But there is also a strong case for saying that the schizophrenic personality is now the person’s real self. Perhaps the personality of the 18-year-old before the onset of the illness is irretrievably lost. At least it may have been hidden for years. Refusal to recognize the new personality leaves the person as he is now in limbo, perhaps for the rest of his life. Jay Neugeboren recognizes this: “The sad truth is that who he is—his identity as Robert Neugeboren and nobody else, a human being forever in process, forever growing, changing and evolving—is made up, to this moment in time, largely of what most of us have come to call his illness. And if he gives that up … and does not hold on to his illness and its history as a legitimate, real, and unique, part of his ongoing self—what of him, at fifty-two years old, will be left?”5
The dilemma is acute. Is the schizophrenic personality an authentic expression of the person? To say yes seems to ignore how it was forced on the person by the illness. To say no seems to locate the authentic person in a distant past and to deny recognition to the only person actually here.
How should those close to a person with schizophrenia react to bursts of unprovoked hostility and aggression? Are reactive attitudes such as anger and resentment appropriate? Of course these attitudes are not entirely under our control. But to the extent that we can choose, either alternative is troubling. To have these responses seems unfair, for all the reasons that make it doubtful that the behavior reflects the person rather than the illness. But to inhibit the reactive attitudes, especially where the actions that trigger them are typical of the new personality, may be to exclude the person from the deeper emotional relationships.
The question “Is he really like that or is it just his illness?” reflects a contrast between an aberration and something central or deep in a person. But the words “central” and “deep” are vague. What kinds of psychological changes support the view that something reflects not the person but the illness? What kinds of continuity support the alternative view? What makes up someone’s individuality and uniqueness? The question “Is this the real person?” is not like the question whether a banknote is genuine. In the psychiatric case the tests of authenticity are multiple and conflicting. Deciding between them might be, not a matter of discovering some deep metaphysical truth, but of deciding which one, or which combination, best captures the things that matter most.
There are at least three different tests for authenticating a person’s present character or personality as “really them.” The first two are:
1. The original person test
2. The predominant person test.
These two names are self-explanatory. Take the person greatly changed by schizophrenia, but whose new character and personality have been stable for many years. Does the new personality reflect the real person? The original person test gives the answer no. The predominant person test gives the answer yes. This pair of tests can be called “external.” It is largely possible to apply them from outside, without calling on the person’s own view.
By contrast, the third, an internal test, appeals to the person’s own perspective:
3. The self-creation test: Deep endorsement and active autobiography
Two things are relevant: the person’s own reflective endorsement, and his or her active autobiographical story.
First, endorsement. In an approach to identity that takes the person’s values seriously, people’s own feelings about what they are really like are central. Taken off Prozac, Peter Kramer’s patient Tess said, “I’m not myself.” Her own endorsement of how she was on Prozac rather than her other state has to be taken seriously.
Not any endorsement is enough. People with mood disorders sometimes seesaw backward and forward between two states, giving different accounts of what their “myself ” is in the different phases. What is needed is what can be called “deep endorsement”: a relatively stable endorsement that reflects the person’s deeper values, rather than the shallow, breathless endorsement given only in a manic phase. Deep endorsement can be hard to be sure about. The problem is like that raised by a person’s mood swings when one is trying to evaluate the authenticity of that person’s expressed wish not to be kept alive.
Also relevant is autobiography. The present character or personality is authenticated to the extent that there is a coherent autobiographical story of how it emerged. How I am now need not be the same as how I was. But there has to be an evolution of one out of the other. The demand for an autobiographical story may seem to exclude nothing. Surely any change in character can be recounted as a first-person story? (“He forced me to undergo surgery to remove bits of my brain, and since then he has given me daily injections of this drug. Now I do nothing at all except look forward to the next injection.”) A merely passive story does not authenticate the new personality. Authentication needs an active, self-creative autobiographical story, at least in the minimal Aristotelian sense in which my new character or personality grows out of actions that I chose.
Some unself-conscious Aristotelian self-creation is the minimum required by the autobiographical test. Stronger authentication comes from more substantial forms of self-creation. Perhaps I set out to become the kind of person I am now. If the project reflects my deepest values, this support from the endorsement test greatly strengthens the authentication. Some suggest, plausibly, that our deepest values are decisive in settling such questions of identity. Viktor Frankl, reflecting on his experience of how even in the Nazi concentration camps people sometimes gave meaning to their lives, said promptings of conscience came from interpreting the situation in the light of a set of values: “These values, however, cannot be espoused and adopted by us on a conscious level—they are something that we are.”6
All three tests are relevant. But there is a case for giving priority to the self-creative test. This comes from the point of asking the question about “the real me.” A large part of its point comes from the way people value the more substantial kind of self-creation: being shaped by what they care about. Psychiatry, in its concern with the good life, should be shaped by the value people place on this.