Where My Heart Used to Beat

  For a time, I considered steering my career into this path. The talking cure, however, seemed for some reason to be a battlefield of fierce ideologies and I would have to choose which little god to follow: Perls, Freud, Adler, Jung … All of these schools were convinced of their own teachings and scornful of the others; it was worse than the civil war between different types of Marxists. And it seemed to me that what these patients needed was not a dogmatist but someone who could listen.

  There was a further problem for a young man still ambitious: it was clear that the patients who could be helped by talking were not the most severely ill. That challenge lay with what had been known to previous generations as the lunatics: people who raged and shouted. Over the centuries they had been offered some more polite names but no cures.

  I thought of myself as bold; I was someone who had survived a war and learned not to fear the impact of shells and bullets—or rather, to live with the fear. It seemed feeble to opt for a sideline when the Everest of human illness cast its shadow over the profession. No one had conquered that peak and few had reached the foothills, but young men are not deterred by the failure of their fathers. So it was in good heart that I moved to one of the chronic wards. All such places are more or less the same, and Epsom Wing, though in a brighter building, resembled the first one I’d been sent to in the north-country asylum where I had what I thought of as my “success” with the demented Reggie.

  If Reggie provided one half of my early understanding of madness, it was a man called Diego who gave me the other. Diego was about forty, with thick, dark, curly hair and a swarthy complexion. He wore a blue windcheater whose layered grime made its collar shine under the lights of the dayroom. He sat on the floor with his arms round his knees and his head lowered in an attitude of resignation; he looked well defended but still just willing to hope. His notes said he was a native of Vigo in Spain but gave no detail of how he had arrived in Bristol; he was said to speak good English, though he rarely did.

  Diego had been in the hospital for three years, diagnosed “schizophrenic with acute auditory hallucinations.” What was remarkable about him was that he had periods of remission. Most patients with his illness had some phases less acute than others, but Diego had periods when he was apparently cured: he not only read the newspaper and talked coherently but also showed some understanding of his own condition.

  In the three months I was there, Diego was very unwell, stuck in his trance, but when I left I asked my successor, a hard-working woman called Judith Wills, to let me know if he showed any of these alleged signs of remission. About six weeks later, she telephoned and asked me to come over.

  She took me to a side room where Diego was sitting in an armchair. I had never previously seen him off the floor.

  I held out my hand. “Dr. Hendricks,” I said.

  “I know,” said Diego. “You were here before.”

  “Yes. I wasn’t sure you’d noticed me.”

  I offered him a cigarette. We talked for an hour about how he was and how he felt. There were times when he clearly found it hard to concentrate, and I presumed that he was distracted by the voices he was hearing. For the most part, however, he was able to communicate clearly: he told us he had come from Spain soon after the war because both his parents were working in the catering business in London and had told him it was easy to find work there. He had had some jobs as a waiter himself but was unable to resist the instructions of the voices that told him what to do. Much of what they suggested was harmless, but it seldom included waiting tables or clearing up.

  One day, when I had to be on duty elsewhere, Diego enlisted Judith’s help in setting up an experiment; the following morning I was invited into the same side room to take part in it. Two chairs were placed in the middle of the floor, facing one another. Behind one chair there were two tables, each with three radios. These varied from small transistor sets to large wirelesses, for which they had scoured the hospital.

  “We’re going to do a role play,” Judith said. “You’re going to be someone who’s come to apply for a job as a waiter in a restaurant. Diego is the boss, and he’s going to interview you.”

  Although the ideas of “psychodrama” had been around in the United States for a long time, it was not something we practiced in Bristol, and I felt cautious about it because Diego was so unwell. It turned out, however, that it was I who was cast as the main actor.

  “Right,” said Judith. “Go outside, wait a minute, then knock on the door. Let’s do this properly.”

  I did as I was told.

  “Come in.”

  Diego shook hands and indicated my chair. Judith stood behind me. I heard her switch on two of the six radios. One was tuned to the Home Service and one to what sounded like a lecture on the Third Programme.

  “How far you come this morning?” said Diego.

  “Just from Redland,” I said.

  “I see. And have you got experience in catering?”

  “A fair amount,” I improvised. “In London mostly.”

  The speech from the radios grew louder as Judith adjusted the volume. After every question from Diego, she turned them a little more, but I could manage.

  “Do you pour some wine from the right side or the left?” Diego was saying.

  I hesitated. A third radio had started up. “The right,” I said.

  Within a couple of minutes, there were six different speech stations, some in foreign languages, playing behind my head; a short while after that the volume was such that I couldn’t hear Diego’s question.

  “I beg your pardon?”

  “I said,” Diego repeated, “who is the prime minister?”

  “Winston Churchill.”

  He asked something else, but even by looking at the shape of his mouth I couldn’t make out what it was. The sound of the radio voices was more than off-putting, it was beginning to upset me.

  “What?”

  “I said, ‘Who was the prime minister before him?’”

  I could no longer concentrate. “Can we turn this bloody noise off now?” I said.

  Judith switched off the radios and pulled up a chair. The quiet was a relief, but I felt uneasy about what had taken place.

  “So,” said Diego eventually, “who was the prime minister before Mr. Churchill?”

  “Clement Attlee.”

  “Yes, but you didn’t know that when I asked you just now.”

  “I couldn’t concentrate,” I said. “The voices were too loud.”

  “That’s what it’s like,” said Diego.

  I looked at Judith, who raised her eyebrows.

  “Are you hearing voices at the moment?” I said.

  “Yes,” said Diego.

  “Are they loud?”

  “Like the radio when we start.”

  “How many are there?”

  Diego cocked his head and listened. “Two. No, three.”

  “What are they saying?”

  “I don’t want to listen, Doctor. They’re louder than your voice, and what they saying is more … important. Excuse me.”

  “It’s all right. Is there any difference between their voices and my voice? In the way you hear them?”

  “No. Is exactly the same.”

  “And when your illness is bad?”

  “Then they are loud like the radios at the end, just now. And they order me about. They swear, they say bad things. It’s not just talk, like what you heard.”

  I thought about this for a moment.

  Diego said, “Do you know that for the last minute you were trying to lip-read?”

  “Was I? Well, it was because the noise was so loud it was my only chance of understanding you.”

  “That’s what it’s like.”

  I looked at Judith for help.

  “So, Diego,” she said, “what you’re saying is that there is no difference in the voices you hear when you are alone and the voices of Dr. Hendricks and me now. The experience of hearing is the same.”

  “Is
exactly the same. No difference at all.”

  “Except,” I said, “that there is no human being in the room when you are alone.”

  Diego picked up one of the radio sets and held it up in the air. “There is no human being in this box,” he said. “Are you saying you don’t hear a human voice?”

  “No,” I said. “I heard six. Loud and clear.”

  “That’s what it’s like,” said Diego. “And if the voices, when they are very loud, they are telling you to go into the town and stand by the fountain with no clothes on, what you do?”

  “I think I’d go. If only to shut them up.”

  “Of course you go. And if someone you meet on the way tells you not to go, you don’t listen. You can’t hear him anyway. That’s what my life is like.”

  * * *

  FOR MANY WEEKS I thought about this exchange. One thing I couldn’t get out of my mind was how very much Diego’s experience was like that of Ezekiel, Amos, and John the Baptist: men afflicted by “divine” voices their leaders no longer cared to consult. The early Israelites had considered that such people were the messengers of God; later generations had left them in the wilderness. We had put them in the back wards of our county asylums.

  As I had long ago pointed out in my college room to Donald Sidwell, there is no mind, only matter. But just how entirely physical madness could be I had not grasped before Diego.

  What I knew about hearing was that areas on both sides of the brain became active when receiving input from the auditory nerve; I used to think of it back then as the lights on a Christmas tree being switched on. And this was what was happening in Diego’s brain. He was hearing. The only difference was that the current that lit the Christmas tree bulbs was being supplied not by the auditory nerve but by a different power source. So what?

  This was what Diego taught me: that people with his affliction did not “imagine” things; they experienced them. He did not “think he heard” voices; he did hear voices. The fact that sound waves had not originated in the diaphragm and larynx of a nearby human was irrelevant.

  Judith Wills agreed with me. “I suppose it’s a question of whether the voices are distressing him,” she said. “Whether he asks us to help or not.”

  “What if they represent his conscience or his parents? We all draw on external advice, after all. Whether I ‘recall’ this advice or ‘hear’ it is beside the point. You’d have no right to deny me access.”

  Judith looked at me sternly. “Are you saying it’s his conscience or his late mother that told him to go and stand by the town fountain with no clothes on?”

  “No, not literally. But I think it’s unlikely that a voice or its content can originate inside him without being shaped by things he’s known. It’s likely to come from his experience. At a verbal level, I guess it’s using words and phrases he knows.”

  “We should ask him that.”

  “I’m also saying we should be careful how we intervene. It’s not like sewing up a wound. It’s more like reshaping what Diego is.”

  At this period, the idea that we might intervene was hypothetical, because we then had no means of altering, let alone stopping, what was happening in Diego’s brain. I had read reports of a drug being developed in France that seemed to blunt some of the most florid hallucinations, but for patients like Diego there was little yet on offer. They could be put into a deep coma using insulin. Under local anesthetic, you could drive a small metal pick up through the eye socket into the front of the brain and snip a couple of connections. The lobotomy was an easy procedure for a surgeon to perform and left the patient more biddable but not in any case I’d seen “better” or cured.

  Or you could talk to them, as I had with Reggie; you could engage with the content of their lives and try to understand. This was the course I favored at this stage, not only because it was the least risky but also because I was drawn to the idea that each patient was an individual and that the content of his delusions was likely to have been shaped by his experience.

  The great task was to reconcile this with the lesson I had learned from Diego: that the condition appeared so biological. Tubercular patients were individuals, but the bacterium caused near-identical symptoms in most. So it was with Diego. Given the millions of different experiences of each patient and the billions of different effects these experiences might have had in combination with one another, what was remarkable about people with Diego’s problem was how similar the texture of the illness appeared to be. When two of us were examining a distressed patient referred to us by a GP, there always seemed to be a moment when we’d catch each other’s eye, as if to say “Here we go.” A familiar pattern had revealed itself, and you knew what sort of thing was likely to come up next.

  For many evenings I pondered these contradictions, sometimes talking to Judith Wills, sometimes alone in my office. Whatever the similarities, the voices that spoke to a university professor had a different content from those that spoke to a road digger; I felt that fact was worth holding on to.

  There were moments when I was sure I was close to making a breakthrough; there were other times when I thought we must all have overlooked something obvious or made a simple error of logic. I remembered reading of the panic when Morgan’s fruit flies seemed to buck Mendel’s basic theory of genetics until someone raised the gender question: it became clear that the eye-color gene was transmitted on the sex chromosome, and all was well again.

  At just this time, the early 1950s, the Linear B tablets from Knossos were being deciphered after a half century of brain ache. Here too there had been a moment when it was clear that even the best scholars had missed something. They had spent years on the assumption that the base language of the code was the classical or Attic Greek that was known to the world through Greek literature. But it wasn’t; it was an older language. And Michael Ventris, a man six years my junior who had served as a navigator in Bomber Command, cracked it by first taking a flying guess that some chains of symbols referred to places on Crete. “Eureka!”—as the later Greeks might have said.

  The work of such people was inspiring to me, as it was to others in my field, as we pounded our way down the asylum corridors among the wails and shouts and banging doors, hoping for a similar moment of enlightenment.

  At other times, when I returned via the last bus, exhausted, to the cheese sandwich in my room at Redland, I felt I was simply wearing out my mind’s ability to think.

  * * *

  AFTER BRISTOL, MY willingness to work with intractable cases, to labor in the field with no outcomes, brought me a promotion. In 1961 I was asked to run the chronic wing of a large hospital near Birmingham. I was appalled to discover that more than half the patients had been born there. One old man had been in since the nineteenth century. As far as I could see, there was nothing wrong with him, but it was too late to send him out into the world. His entire life had burned itself out in the shadow of Victorian brick and closed doors. A Roman candle in a forest unvisited by man.

  My deputy was a Londoner called Simon Nash. He was tall, with brown curly hair and glasses; he wore ties with geometric patterns. To begin with, I found him unbearably solemn, but after a few weeks I began to glimpse a subversive side to him. Like me, he was skeptical of the treatments on offer and unwilling simply to medicate or stun the patients. He wanted to try more interesting things, if only for the sake of his own amusement. At this time the health service, after the euphoria of its first decade, was starting to ask if it was spending its money in the right way, and Simon was able to secure funds for a research project.

  It was about inheritance. If one of your parents was mad, you were much more likely to be mad yourself. If you had a mad grandparent, it seemed, that was also bad news. Simon proposed that we should do tests on twins. What they unsurprisingly showed was that having a mad twin hugely increased your own chances of being mad, even more so in identical than in dissimilar twins. However, it was possible that one identical twin would become severely ill while the ot
her would escape, and this put our research in line with other studies, which concluded that there was more at stake than simple inheritance. The added factor was termed environmental—a confusing word, I always felt, for life experience, the most important aspect of which was the intake of drugs and alcohol.

  Our paper bore the hideous title “Psychosis and Heritability in Monozygotic and Dizygotic Twins: A Longitudinal Study in Warwickshire and Four Other English Counties, 1962–3.” I pointed out that it wasn’t really “longitudinal” because we hadn’t returned to these people over the years; we had simply taken their and their parents’ word for it. “Yes,” said Simon, “but I don’t think ‘an anecdotal report’ carries quite the same weight, do you?”

  There was a graver problem that I never had the heart to tell poor Nash about. I was fairly certain that most of the so-called identical twins weren’t. They were fraternal twins who happened to look identical, but in 1963 there was no quick way to establish that. I thought it better to say nothing. And I was secretly pleased by the idea that we were not slaves to our inheritance but free to take a chance in life, so I was happy to go along with the suggestion of “environmental factors.”

  A happier moment came with the publication the following year of a paper I wrote alone. It was called “Rex and Antonio: Listening to Their Voices.” It had a medical subtitle, but essentially told the stories of Reggie and Diego. The word listening was meant to refer both to what the patients did and to what their doctors ought to do. A general interest magazine bought it from the academic journal that first published it. They cut some of the medical bits, and I was paid five guineas for the second serial rights.

  Two weeks later, I received a letter from my old Bristol colleague Judith Wills. She had become frustrated in her work and proposed setting up a completely different kind of treatment center in which there would be no rules, no hierarchy, and, from what I could gather, little distinction between doctor and patient. She had found a building, an empty factory in Bristol that had once produced biscuits, and had been promised a grant from the local health authority. She was also confident of having financial backing from a private individual whose son had fallen ill at the age of twenty. She asked if I would join her as codirector. I said that, when I’d worked out my notice, I would.