The screenplay for A Beautiful Mind, inspired by but very different from the book of the same name, has been criticized by some as whitewashing the hero’s faults to keep the audience sympathetic and promote a more understanding view of schizophrenia. One reviewer claimed that it was pure Hollywood to depict Nash as lonely and socially excluded, claiming he was more a monstrous bully in his own right than a victim of bullying. But I found biographical details elsewhere supporting the movie’s portrayal of Nash, at least for capturing the spirit of his story, though important themes were re-imagined through fictitious events to streamline the plot.
These themes touch on a now-marginalized approach to understanding schizophrenia that focuses on the correspondence, however seemingly distant, between the content of delusional beliefs and hallucinations and the patient’s real life experiences, and looks into the subjective stress levels during real life events triggering psychotic episodes as being disproportionate not only because of genetic vulnerability but also for experiential reasons, with special attention to pre-existing cognitive processes that enable these events to have such catastrophic consequences. What sets this approach to understanding schizophrenia apart is simple: the accounts given by the patient, even during a psychotic break, are not considered “un-understandable,” and treatment enlists the patient’s own cognitive powers, instead of suppressing cognition by refusing to listen to psychotic ramblings and using powerful sedative drugs or newer antipsychotics designed to inhibit the experience of “salience,” the perception that something (any observation, internal or external to the mind) matters, has significance, or holds meaning.
Representing these now-subversive themes and what they meant to John is important, considering how other discrepancies between the screenplay and events in his life conceal one of his most remarkable accomplishments. In reality he did not give an acceptance speech when he received the Nobel, as the organizers lacked confidence in his state of mind. He had not been in treatment for decades, and the line in the movie attesting to his use of newer antipsychotic drugs was inserted out of deference to the views of the screenwriter’s mother, a mental health professional who feared the movie would inspire other patients with psychosis to refuse these drugs. Nash is one of the rare survivors of schizophrenia known to have gone into remission despite refusing antipsychotics since his last discharge from involuntary inpatient care in 1970.
Dr. Rosen: You can’t reason your way out of this!
Nash: Why not? Why can’t I?
Dr. Rosen: Because your mind is where the problem is in the first place!
This exchange privileges the conventional wisdom that the schizophrenic mind is the patient’s own worst enemy, and not a potential ally in treatment. At other moments, the screenplay credits Nash with waging a tenacious battle to turn his mental prowess to his advantage through introspective critical thinking, despite the handicap of sedative drugs and entrenched self-defeating thinking patterns underlying his delusions and hallucinations. But Nash is held to be almost alone in having succeeded along these lines, and it is unheard of to counsel schizophrenic patients to try.
I think what Nash achieved through his own efforts is more widely attainable than most experts believe, particularly if supportive talk therapy is available. My account of schizophrenia draws on two bodies of research on psychosis that fall outside the traditional realm of genetic explanations and drug therapies: traumagenic models of psychosis and newer research linking lifelong social cognitive deficits to vulnerability to psychosis and treatment outcomes. I don’t want to discount the potential benefits of biomedical treatment altogether, but I do not believe these treatment strategies are always necessary or ever sufficient on their own. I have not delved into the literature arguing that the heritability of psychosis is less clear than is widely supposed, or research on the limitations and side-effects of anti-psychotic drugs. But I am familiar with research showing that many psychotic patients find little relief using the available medications, those who do experience relief are at significant risk of frequent relapse even if they adhere to treatment guidelines, and some of the most common medication side-effects are more immediately stigmatizing than the illness itself, particularly movement disorders (ticks and tremors) that unlike psychotic symptoms can be ever-present and impossible to conceal.
The conventional wisdom is now scathingly against traumagenic models of psychosis, but retains the theory that psychotic patients erupt into delusions and hallucinations in response to stressful life events – the key to maintaining both views is to always maintain that the events in question are in no way traumatic, and that the patient has a hair-trigger response to seemingly ordinary sources of stress. This only makes sense if you utterly ignore how clearly distressed the patient has become, treating the subjective experience of distress as meaningless in the same way the delusions and hallucinations are considered meaningless. It makes more sense when you look at how trauma is defined in the diagnostic manual of psychiatry, quite unlike the dictionary definition, with the criterion that unless the situation is life-threatening or threatens bodily harm, it is not trauma. Leaving aside how often assault histories recounted by psychotic patients are dismissed out of hand by treatment providers quick to infer that these are artifacts of psychobabble and not real events, this definition of trauma was designed to rescue combat veterans with PTSD from being lumped in with schizophrenic patients with whom they might have many symptoms in common, recognizing that schizophrenia is perhaps the most stigmatizing diagnosis of all.
The expert community is more receptive to new approaches to linking psychosis to ordinary cognition by calling attention to the mediating role of social cognition, that is, the patient’s grasp of ordinary rules of human behavior and their ability to make accurate inferences about the intentions and dispositions of others. Without social skill it is not unusual to make mistakes when trying to read other people’s minds from their nonverbal cues and sometimes oblique statements about what they’re thinking, feeling or doing. And without close human contact, it is impossible to check one’s own speculations and ruminations against alternative perspectives, a process called “reality-testing” that keeps all of us from becoming profoundly out of touch. Without social skill, it is easy to fall short of opportunities for reality-testing and live increasingly in one’s private thoughts, which can steadily grow less and less realistic. In fact, living alone is a known risk factor for developing full-blown psychotic symptoms even in people with no history of mental illness.
I see both these factors in biographical details about John Nash before he attended Princeton as a promising mathematics student. His brilliance as an original thinker was not quickly recognized in real life, and for his social awkwardness he was in fact bullied and socially excluded, experiences that would have reinforced the tendency he showed at an early age of being a loner with little sympathy for others. I imagine his commitment to intellectual challenges in childhood was in part compensation for his lack of social skill, as a source of pride and as something his parents and teachers, when they recognized his potential, warmly encouraged him to pursue. And I question whether his childhood was peaceful because of his bisexuality, with many who knew him as a boy attesting to his having been bullied for showing homosexual interest in other boys. Later in life he was dismissed from his first job as a professional mathematician because he was caught in a police action targeting homosexual activity in public bathrooms, a blow predating any sign of his psychotic symptoms that could only have been humiliating in the extreme. In this context, his later grandiosity seems in part justified by his intuition about the significance of his own work, which would not soon be acknowledged, and in part a natural defensive maneuver he needed to overcome shaming experiences that had undercut his sense of dignity.
The traumagenic model of schizophrenia does two things differently: it looks at trauma histories as factors in the patient’s biological and cognitive vulnerability to psychotic episodes, and it looks at the subjectively traumatic nature of stressful life events that trigger psychotic episodes in adulthood. Childhood trauma can lead to some of the same brain abnormalities related to heightened sensitivity to stress observed in schizophrenia, suggesting life experience, particularly during the brain’s early development, can lead to biological differences conventionally attributed strictly to genes. And recent histories of interpersonal victimization are very common in acute psychotic patients, as well as being prominent themes in the content of delusions and hallucinations for many patients, not unlike intrusive trauma memories or experiences of reliving traumatic events in patients with PTSD. The literature on social cognition in psychotic patients, on the other hand, points to many areas of continual misunderstanding that, in a patient with hyper-arousal and inner fears of victimization, would allow paranoid ideation to arise when no real persecution is evident. A real history of being bullied could create these conditions of hyper-arousal and inner fear of victimization, and without good social cognition the beginnings of paranoia need not be utterly bizarre. By the time psychosis is discovered, however, delusions are by definition bizarre. Even so, I am convinced these beliefs are organic cognitions that can be explained, if the patient will enter into a therapeutic dialogue about the content of their delusions reflectively, and help develop a narrative about how they arose. Left to one’s own ruminations in a state of paranoia that discourages reality-testing, I think bizarre beliefs could find a prominent place in one’s day to day thoughts and become fixed and unshakable because of the way their emotional intensity bends other thoughts toward them and allows them to become organizing principles in making sense of the outside world.
In attacks on A Beautiful Mind that focus on how much more endearing the movie’s hero was than the real life John Nash, I will ignore horrified reactions to homosexuality and a deficit of patriotism, and focus on tales of the mathematician’s ego-centricity and mean-spiritedness. Egotism and cruelty are often ascribed to another patient population known chiefly for their poor performance at social cognition, people on the autism spectrum. A central idea explaining these traits is their inattention to the perspectives of others – in the extreme case, they seem unaware of other minds, and at minimum they find putting themselves in other people’s shoes counterintuitive and demanding of concentration, unable to readily guess where someone else is coming from if they have a disagreement. The jargon for perspective-taking is “theory of mind,” and new research is showing that patients with psychotic symptoms also have pronounced difficulties in this area. This makes reality-testing especially difficult, in the sense that one would not readily believe anyone else who contradicted their preconceived ideas, and would not seek out alternative perspectives to keep oneself from getting “out of touch”. Maintaining seemingly bizarre delusions hinges on the patient’s ability to avoid contradictory evidence and privilege any perceptions that seem to reinforce the delusion somehow. Utter reliance on one’s own perceptions to evaluate the world without critical feedback from others can make this possible.
What could possibly short-circuit this self-reinforcing delusion, except change from within? Cognitive behavioral therapies offer a way to harness the authority of the patient’s own thoughts by teaching them to do their own reality-testing with limited and abstract guidance that allows them to continue to trust themselves as interpreters of their own lived experience. It appeals to their capacity for rational cognition instead of assuming they have none, teaching flexible methods for reality-testing instead of telling them what is real and what is not. The appeal of these methods above the status quo, from the patient’s perspective, is that they are offered as adaptive tricks to question the validity of distressing, potentially immobilizing perceptions instead of being tormented by one’s thoughts. Thus the patient’s distress is validated and the therapeutic alliance is focused on relieving this subjectively real distress, no matter how bizarre the patient’s account of private torments. The content of the delusions may be insurmountable in some respects, for no one in their right mind can shake the convictions of private knowledge – much of what we experience in life that matters to us is not witnessed by others, verifiable with evidence, or easy to validate with external sources. It is in the nature of memory to be rich in utterly private knowledge to which we can testify only on our own personal authority. Hopefully the cognitive distortions driving disproportionate reactions to seemingly minor sources of day to day stress can be redressed effectively enough to minimize the patient’s recourse to flight (out of the here and now, into a private and unreachable reality) and reduce their avoidance of potentially stressful social situations that, more than anything else, can distract them from their inner world and at times offer critical feedback they can accept.
Nash: I’ve gotten used to ignoring them and I think, as a result, they’ve kind of given up on me. I think that’s what it’s like with all our dreams and our nightmares, Martin, we’ve got to keep feeding them for them to stay alive.
This moral of the story in A Beautiful Mind is not so far removed from what the real Nash says for himself. He was pleased with the movie (though he thought the music was too loud). In real life Nash concedes that returning to mathematical work and finding distraction from his delusional beliefs has been a recovery process, with the caveat that recovery from grandiose delusions is bittersweet. Yet in an interview with Schizophrenia Bulletin, he argued that the only way to de-stigmatize psychotic experiences would be to do away with the diagnosis schizophrenia itself. I agree with him that the biomedical paradigm does not, as its proponents claim, reduce stigma at all. If anything it elevates the disdain of the treatment provider for the patient’s accounts, and in the presence of such disdain there is no therapeutic alliance at all.
What would that leave us with in the way of understanding? Some experts in mental health would argue that “it is more productive, theoretically and clinically, to research specific behaviours and cognitions than the heterogenous and disjunctive construct of schizophrenia, which has poor reliability and validity” (Read et al. in Trauma and Psychosis, eds. Larkin and Morrison 2006, citing Bentall 2004 and Read et al. 2004). I would not go as far as Foucault in stripping madness of objective validity and treating it as a relative category always socially constructed for political purposes, because I take issue with the postmodern project of understanding medicine as a political discipline that can best be critiqued with liberation ideologies that privilege every marginalized position above the claims of the hegemony of consensus. I should think the choice to have someone institutionalized in a psychiatric hospital against their will is often about containing (and trying to correct) behaviors that are objectively an imposition on others, if not as a forensic patient then because the behaviors seem self-destructive and intractable and are so difficult to understand. Involuntary hospitalization may not be the most constructive solution to containing or correcting such behaviors, but resort to these tactics is testimony to how readily others can agree that the behaviors are problematic. Only radical subjectivity would argue against understanding that something is wrong, and I doubt honest subjectivity would credit the person in question with freedom from distress brought on by these provocative behaviors, or the cognitions behind them.
That said, I will point out that hallucinations and delusions are not uncommon in healthy people who will never seek help for mental illness, and the best way to reduce stigma against people who do suffer from psychosis is to normalize these experiences and focus on therapies that improve quality of life outcomes, rather than treating any recurrence of hallucinations or delusions as symptoms of relapse in their own right. Nash thinks of mathematics as an art, and of madness as something great artists risk by virtue of their gift for originality, and their willingness to seek new ideas by taking unconventional perspectives. So I will close with some lines from the poetry of Paul Celan, one of my favorite writers, and an artist who did not survive his battle with psychosis:
“Autumn eats its leaf out of my hand: we are friends.
From the nuts we shell time and we teach it to walk:
then time returns to the shell.”
– from Corona, translated by Michael Hamburger
Unreal as this experience sounds, it is objectively magical, and enchantment with such otherworldly experience is surely not wrong in itself.