In the community of people with severe mental illness—now commonly called “consumers” (i.e., of mental health services) or “peers” (i.e., of others with mental illness, as opposed to the rest of humanity)—it has become accepted that auditory and visual hallucinations, such as hearing voices and seeing people and things that others cannot, represents a form of reality, a “lived experience.” It is no longer acceptable to tell consumers that the voices and the people are “all in your head” or that they are “not real.”
I am of two minds about this state of affairs. On the one hand, it really is condescending and paternalistic for the rest of us “normals” to tell people who are having visions that their reality is a delusion and the visions don’t exist. We are imposing our interpretations and prejudices on another human being, which is generally a bad way to act. On the other hand, if we accept that such a thing as “severe mental illness” exists and represents a pathology, a departure from health and the natural, unaffected operations of mind and brain—and not simply “another way to be”—then accepting, condoning, and even participating in the patient’s experience of hearing voices and having visions would seem to be anti-therapeutic. If the patient is struggling for recovery, which would be a return to health and “normal” brain function—and not just a pleasant accommodation of the illness’s symptoms—then it would seem obvious that the patient must acknowledge the common interpretation of human reality and accept that the voices and visions are a product of illness. Indeed, they are “all in your head” and “not real.” And does the notion of illness mean anything if its symptoms are promoted as simply another way of looking at the world?
From both a physiological and a philosophical point of view—that is, both neurology and psychology—we now understand that what a person sees and hears is more than just the light waves entering the eyeball and sound waves entering the ear canal.1 Our eyes and ears are only the signal inputs, reporting all received sensations to the brain centers—the occipital cortex for sight, the superior temporal gyrus in the temporal lobe for sound—where these inputs are then processed, interpreted, compared to prior experience, and coordinated with other sensory inputs.
Our sensory apparatus receives much more information than the signals that eventually become processed as experience and enter into our awareness. As you sit reading this, your brain focuses your attention on your visual cortex and on interpreting the symbols written in emitted light on a computer screen or reflected light on the paper page—if you happen to have printed out this blog. While your awareness is so engaged, your ears continue to absorb sounds from the room around you, including the soft hiss of air molecules impinging on your ear drums. Your skin records the temperature of the air around you, the weight of your clothing, and the pressure of your body on the chair or other furniture. Your limbs are sending signals about orientation and muscle tension, and your brain responds unconsciously by adjusting your position. Your nose records random smells, most of which don’t rise to the level of awareness unless they are strong or correlate with remembered experience, such as a dangerous and disagreeable odor like the sulfurous mercaptans added to natural gas for easy detection, or the pleasant aroma of someone nearby cooking a favorite food for dinner. If you take a sip of the beverage at your elbow, your taste buds will signal the drink’s flavor, which your brain in its concentration on reading may or may not accept into awareness.
Every sense is receiving and forwarding to the brain its thousands or millions of messages every minute. It is the business of the brain, both in its processing centers like the occipital cortex and the temporal lobes, and in its control of consciousness in the brain stem and forebrain,2 to interpret these signals, accept which among them are significant at the present moment, and which can be safely ignored—perhaps to be stored for later analysis, perhaps lost for all time. It is my contention that the hallucinations experienced by people with a severe mental illness, as well as the visions experienced by normally healthy people in temporary states of ecstasy, drug and alcohol intoxication, extreme agitation, overstimulation, intense fatigue, impending starvation, or some other impairment of normal function, are related to these otherwise ignored or misinterpreted sensory signals.
In my novel The Professor’s Mistress, I portray a young woman experiencing the progression of schizophrenia and veering toward her first psychotic break. As she sits in a chair in her living room, the furnace comes on and the air register issues a soft, barely heard whisper. She interprets the sound as the spoken words “fish knives.” This conjures in her memory a moment of embarrassment during her wedding reception when she opened a gift of silver fish knives and, in her naïeté, didn’t know what these strange implements were used for and so clowned around with them. Later, when she is deeper into her psychosis, she mistakes a shadow in a darkened bar for the ghost of her long-dead mother and carries on a macabre conversation.
We know from brain imaging technologies that it’s a myth we humans only use about ten percent of our brains. All of our brain is functioning and active most of the time, although not every function or activity rises to the level of our awareness. And our awareness is divided into the main focus on what we are doing—like reading or driving or holding a conversation—and a roving, restless, unmindful subsidiary awareness in which random thoughts, uninvited notions, and unrecognized sensations will announce themselves—like the smell of dinner cooking or the idea that a normal household sound is actually someone whispering “fish knives.” It is with this subsidiary non-focus of awareness that the subconscious intrudes on our daily thoughts. This is where, in my own case, the solution to a problem that I’ve put aside from active contemplation will suddenly rise into active focus. It is also where a rustle in the grass will put us in mind of a lurking tiger, and moonlit shadows of the leaves stirring overhead will make us think of ghosts. And in this not-quite-focused mental state, the rustling may actually be perceived as the approach of a tiger or the leaf shadows as the presence of an invisible spirit.
As a writer, I experience voices and visions all the time. My process of writing—and it may be different for some other writers—is, first, to read over and absorb the materials I will need to work on before sitting down at the keyboard. That is, I will look at the notes I have taken from an interview or research on an article assignment, or the outline with plot points, dialogue cues, and imagery suggestions for the next scene in a novel. These notes constitute the universe of things I know about the subject. Second, I also need a starting point for the article or scene, which might be a question to resolve in the article or a sound, image, a line of dialogue from the scene. I call this starting point the “downbeat.” But then, with all these elements floating loosely in my mind, I put my fingers on the keys and just start writing. Other than the fragments in my outline—which may or may not subsequently appear—none of what comes out is exactly planned. I am hearing the narrative voice in my head speak the prose, seeing and hearing the imagery that the characters experience, and hearing them speak the dialogue as it develops. In this process of revelation, I give my subconscious wide scope to intrude with random imagery and associations.
The difference between my seeing visions and hearing voices during the writing process and the experience of someone with schizophrenia or other mental illness is that I know where the sights and sounds originate. I know that I am indulging the “self-talk” that we all carry in our heads. This is the articulate stream of conscious that uses language to express thoughts. It is the voice in our minds that exclaims “What’s that?” when we hear a strange sound—even if we don’t say the words out loud. Most literate people think in words rather than raw emotions and reactions. I, by long practice, have trained this self-talk to speak in complete, grammatical sentences and have lent it to my subconscious to conjure up action, imagery, adopted personas, and extended conversations in the case of my novels, or lines of argument and paragraphs of orderly explanation in the case of my blogs and articles. This talent is not unique: I’m sure every writer exercises his or her imagination in this way to some extent.
Scientists have begun to understand3 the cognitive and emotional impairments that mark schizophrenia and the other psychotic illnesses which develop in late adolescence. They attribute at least some of these symptoms to an overaggressive form of the natural paring of excess neuron connections which have grown out during the brain’s development. A certain amount of paring is normal in the maturing brain, but the brains of schizophrenics seem to take away too many connections, damaging the brain’s functions. In such a case, reasoning ability and emotional stability are lost. It’s not too much of a stretch to think that a similar impairment takes place in the brain’s ability to process sensory inputs in an orderly fashion and distinguish between what is actually perceived and the false interpretations supplied from the imagination: the ghosts, the tigers, and the fish knives.
Is it possible that a person with severe mental illness might not know that this substitution of sensory imagination for actual experience is taking place? I offer three possible explanations. The first is that the brain can certainly hide whole areas of experience from active awareness. We see this in amnesiacs who can’t access their past experiences. We also see it in people with what is now called “dissociative identity disorder” and was previously known as “multiple personality disorder.”4 The second explanation is that psychologists are beginning to understand the mind’s recall of experience is actually a fairly slippery and inexact process. We analyze and change a memory slightly every time we bring it forward into awareness. This is one of the reasons false memories are so easy to implant: the mind can incorporate notions and suggestions about an experience into every rendition of it until the false elements become as real in the awareness as an actual occurrence. And third, mental illness tends to protect itself with a symptom called “anosognosia,” in which the mind denies that it is experiencing anything unusual or out of the ordinary.5
Given all these clues to the unreliability of actual experience versus scrambled sensory inputs mixed with active imagination and impaired perception, is it really so strange that people who have visions and hear voices might insist these experiences are real and separate from their own mind? But that does not make the experience real. And it does not make the illness disappear.
1. Along with chemical traces impinging on sensors in the nose (i.e., smells) and on the tongue (tastes); mechanical and thermal stimulation of sensors in the skin (touch, pain, temperature); the pull of gravity on liquid in the inner ear (balance); and strains on muscles and tendons (body position). All of these are as subject to confusion and hallucination as the senses for sight and sound.
2. The exact location in the brain of our “consciousness” is still a matter of study and conjecture. The simple act of being awake and aware, as opposed to asleep and “unconscious,” belongs to a cluster of neuron cells in the brainstem called the reticular activating system. These cells work with other parts of the forebrain such as the hypothalamus, basal forebrain, and thalamus which participate in various pathways identified by their particular neurotransmitters—the chemical governors of the nervous system—including acetylcholine, dopamine, norepinephrine, and serotonin. These pathways access higher parts of the cerebral cortex where processing of sensory inputs, controlling motor function, executing planning and projection functions, and other discrete processes occur. For a deeper discussion of how these systems contribute to consciousness, see for example, Brain Stories, by Teddy Poh.
3. See “Scientists Move Closer to Understanding Schizophrenia’s Cause,” by Benedict Carey, The New York Times, January 27, 2016.
4. See for example, “Dispelling Myths about Dissociative Identity Disorder,” by Margarita Tartakovsky, MS, at Psych Central, or “Dissociative Identity Disorder (Multiple Personality Disorder)” at WebMD.com.
5. See I Am Not Sick, I Don’t Need Help! by Xavier Amador on the poor insight of people with a mental illness.