We set off for the Central Highlands, aiming first for Gondar, then the Simien Mountains en route to Axum where the Queen of Sheba is thought to be buried.
We stopped to walk through a market and were back 2000 years; donkeys, mules, blacksmiths, grain, herbs and spices, women inspecting a baking tray and then tying it on their backs. Children and more children. Severe irredeemable poverty marked the clothing, the skin and faces. The children talked gaily about football; Arsenal, Manchester United and Chelsea. They quoted names and the pedigree of the players and for the African players their nationality. Didier Drogba, Femi Martins, Babayaro, Adebayor, Kolo Toure, Kanu, Kalu, Obi Mikel, and Yakubu. Also Eto’o, Thierry Henry, Patrick Viera. Names of runners from my childhood: Abebe Bikila, KipKeino, Akii Bua and others. These names were chanted, repeatedly like talisman, to conjure with.
Next stop, Gondar. Fasalidas and his castles. The internecine and fratricidal wars with the ultimate decline in Gondar. The highlight was the frescoes. 400 years of Ethiopian interpretation of the scriptures. The young deacon reading aloud the scripture in Ge’ez. Most amusing were the tales of Roman Catholics discovering Gondar in the 1600s having come by way of South india and wanting to convert the Ethiopians who have been Christians since the 3rd century.
On Good Friday we arrived at the Simien Mountains, climbed all the way to the roof of heaven, 15,000 feet of it and then walked for 2 hours. The most breath taking views ever, the world opening out to the farthest gleam. The sun shone for the most part, a breeze cooled the skin. The effort of climbing at altitude, acting to quicken our breathing and to make the heart startle and skip.
This land, the whole of it given to us. The very poorest in their rags and dirt, their children’s unshod feet and their own, walking on and mapping each geological feature, inheritors of the place where us, all humans were born.
Our rest house in Debark, the most basic four walls and shared bathrooms and toilets.
It was a cold evening.
We drove 10 hours on a dirt track built by the Italians in 1930s. It was dusty and unending. Debark from which we set out was a dusty godforsaken station. Between Debark and Axum, the most desolate on the planet eke out a living. This is scrub land, with pebbles, and rocks, the basis of the land. For miles, in this infernal furnace, the people, men, women and children, walk with their donkeys and mules. The children in rags, more or less, their faces covered in dust and snot.
They walked barefoot, the men carrying their customary sticks.
The landscape is vast, dramatic, biblical. The potential for tragedy is ever present! Famine, monumental dying. All this has already come to pass.
Axum is the Queen of Sheba stellae, the Church of St Mary of Zion, Queen Sheba’s palace, the Ark of the Covenant. Here is Jordan, there Golgotha, across the way Calvary.
And, Lalibela! What can anyone say of Lalibela? You walk in silence, you marvel and stand in awe. You walk again: St Giorgis, Bet Medhane Alem, Asheten Maryam, Bet Makarios.
The poverty is in extremis. How is it that here, away from worldly goods, away from chatter, here where living is pared to its most basic, to the barest breath and even less, whatever it is that is soul rises and blossoms, and comes to know itself for what it is, something that is nameless, but real.
Photos by Jan Oyebode
I never thought that here in Addis, at a church, with the faithful kneeling and bobbing their heads, this week before Easter, I would come to see my relatives, my grandmother and her sisters, some of my cousins, even my own children, in the tone of skin, the slightness of frame, hook of nose. I started to imagine how the supposed Eastern origin of the Yorubas is ingrained, inscripted in the cells. That is what cellular memory is. The difference is that we Yorubas are taller, pagan even if Christian, and infinitely more aggressive.
Addis is built on and surrounded by mountains. At dawn the mist hangs on the peaks and in April, the air is cool like the Harmattan. It has the sleepy indolence of all African cities that have grown from villages.
Religious devotion marks the people out. Churches are places of worship, not museums to be visited and photographed. The attitude is of intense faith, meditative communion, humility, and modesty. These elderly, elegant women, chanting and bowing, typify the antiquity and beauty of Addis.
Talking about beauty, the women are the most beautiful of any in the world. The faces are symmetrical, the eyes bright, luminous and exciting, the features delicate and sensual. What flowers are these, planted as they are, in the horn of Africa?
All their movements are easy and effortless, not unlike a perfectly pitched voice, intimate, warm, full. Even in Cuba, where beautiful women abound, and the sexual and sensual intermingle, an absence of a rooted organic identity depletes somewhat what in all other respects is a temple to beauty.
Addis is perfect in this regard the miscegenation is as long as human history, whereas in Cuba, it is built on slavery and rape. Here it is the handiwork of history and evolution. Lust teasing out the most pleasing features, shaping the eyelids and eyebrows, tipping the bridge of nose forward, plane-ing the bones to a fine, no, the finest waist or ankle. Evolution always triumphs, it selects, it designs and re-designs, led by lust and desire to make what will last and endure, what will leave even more trace in the sand. Here evolution has made the feminine form fit for the male eye.
At Bahar Da, we arrive to a festival of birds. Uninvited, we arrive to witness the flashes of colour, radiant, iridescent colours. Not only colour but also the swoop and dive, the hanging in the air, the wings flapping or humming and the knifepoint beaks and bills. We watch and name, classifying, pointing, what a show, a gay exuberant play and the sky is African bright, a gentle caressing breeze blowing in from Lake Tana. I manage to identify a few weaverbirds, a glossy starling, a speckled dove, bird of paradise, sunbird, pied kingfisher, oriole. But was that a plover, a hoopoe or a bee-eater?
After lunch, we go to the monastery on the peninsula. This allows women in. The frescoes at Ura Kidaae Mehret are bright and vivid. The biblical stories, some familiar and others not, speak directly and simply: a cannibal who had eaten 76 people but was allowed into heaven because he gave drinking water to a leper & stories of Mary who was pregnant out of wedlock and would have been stoned to death but for the intervention of Gabriel. This is a tradition well before Nicea. And then for the male only Kebran Gabriel, an austere yet impressive monastery of 6 monks. 400 year-old manuscripts, illuminated and diligently copied, medieval crosses and silver goblets. Ethiopian Christians have a certainty and assurance that anchors their identity in a self-effacing, deeply modest self-confidence. They know who they are and have no need for muscular pretension.
At the Blue Nile cataract, the local men are far too desperate. They are like leeches or limpets, too close and for too long, unduly solicitous, importuning. They talked and pointed out all manner of things: “Walk here, don’t walk there, can I help you? Hold my hand, that’s the waterfall, that’s a bird and so on”. After a while it all becomes tiring, wearying and wearing. There are donkeys and donkeys, loaded with goods, and elderly women, bent over, truly mules, and children whose filth does not diminish their beauty.
Even more birds, glossy starlings, bee-eaters, carmine. Egrets everywhere and a nation of cattle- zebu with single humps, with ribs so visible that they might as well be skeletons.
The men and boys carry sticks everywhere for want of a gun. The people are in the main quite small and slim. Their colour ranged from the reddish brown of my cousins to a glossy black that does not exist among the Yoruba.
It is astonishing to see so many people living as we have done in Africa for millennia, walking briskly covered in shawls or blankets, gossiping and talking, living life without much luxury, actually without any luxury. Yet, modest and unself-conscious in the habit of work.
A beautiful, young woman spinning cotton with the cataract for background. A young man, sitting on a tree branch, playing a flute. These two iconic images of un-spoilt Africa, carefully and artfully orchestrated for the interested tourist’s camera, for a fee!
In Bahar Da, I was mistaken for an Ethiopian by an Ethiopian. I pointed out that I was considerably taller than most Ethiopians. There is something healing and healthy about coming to Ethiopia to see Africa, our continent, through unfamiliar landscape and to see the utterly indescribable beauty of the land, and the people. To see how, even the poverty fails to corrode dignity.
Photos by Jan Oyebode
I have just returned from Nice. European Psychiatrists were gathered together for 4 days talking about the issues that most concern us. At the heart of psychiatry is a concern for the individual who is in distress. The distress is subjectively experienced and has to be communicated in words, in language, in the main. But, there is a dilemma in that in contemporary society, the objective, the measurable has become the marker of significance and importance. Tumours are okay but hallucinations are not! So, there is an understandable search for independent markers, for surrogates, that itself speaks to the devaluation of what is authentically experienced by the person, the sole subject of our concern, another human being.
This problem of how to value the primary inner subjective experience that is the currency of our encounter with patients in the clinical space is the topic of this blog. But, only in an indirect way. I want to talk about Schreber’s accounts of his verbal hallucinations as an exemplar of the importance of attending to subjective experience.
Daniel Schreber (1842-1911) is regarded, by many people, as the most important psychiatric patient because of the range of his influence on psychiatric thinking, terminology and concepts: Bleuler (1911) Dementia Praecox or the group of schizophrenias, Freud (1911) Psychoanalytic notes upon an autobiographical account of a case of paranoia Jaspers (1913) General psychopathology, & Sass (1994) The paradoxes of delusion. He was a candidate for Reichstag in 1884, and promoted to the high office of President of Panel of Judges at Court of Appeal Dresden in 1893. He was 1st admitted into hospital December 1884 under Professor Fleschig, discharged fully recovered in June 1885. His 2nd episode was in 1893, six weeks after taking up the role of Senatsprasident. He was probably discharged in 1903. His final admission was ?1907-1911.
Schreber derived from an illustrious family: His father was Daniel Schreber (1808-1861) was physician & lecturer at Leipzig University where he founded Institute of Orthopaedics. Allotments in Germany are named after him Schrebergarten. His grandfather was a lawyer, Daniel Schreber (d 1777), Professor of Agriculture & Economics. Seventeen of his books are at British Museum. Daniel Schreber (son of above) (1739-1810), great-uncle, Professor of Medicine & Superintendent of the Botanical Gardens University of Erlangen He was knighted 1791 & was Fellow of Royal Society London, 31 of his books are at British Museum.
Schreber’s account is a rich source of psychopathology. He described his experiences of verbal hallucinations amongst other experiences. In the examples that follow below, Schreber details the characteristics of his experiences.
During several nights when I could not get to sleep, a recurrent crackling noise in the wall of our bedroom became noticeable at shorter or longer intervals; time and again it woke me as I was about to go to sleep. Naturally we thought of a mouse although it was very extraordinary that a mouse should have found its way to the first floor of such a solidly built house
But having heard similar noises innumerable times since then, and still hearing them around me everyday in daytime and at night, I have come to recognise them as undoubted divine miracles they are called “interferences” by the voices talking to me and I must at least suspect, without being too definite about it, that even then it was already a matter of such a miracle; in other words that right from the beginning the more or less definite intention existed to prevent my sleep and later my recovery from the illness resulting from the insomnia for a purpose which cannot at this stage be further specified
All these souls spoke to me as voices more or less at the same time without one knowing of the presence of the others. Everyone who realises that all this is not just the morbid offspring of my fantasy will be able to appreciate the unholy turmoil they caused in my head..for a long time now the talk of the voices has consisted only of a terrible, monotonous repetition of ever recurring phrases.
The “voices” manifest themselves in me as nervous impulses, and always have the character of soft lisping noises sounding like distinct human words with only the exception of the night, at the beginning of July 1894. Both their content and the rate at which they are spoken have changed considerably in the course of the years. The most important points about them I have already mentioned; predominant is their absolute nonsense as the phrases are stylistically incomplete, and many terms of abuse
The hissing of the voices is now best compared to the sound of sand trickling from an hourglass. I can distinguish individual words hardly at all or only with the greatest difficulty. Naturally I do not trouble to do this, on the contrary I try to ignore what is spoken. However, when I do hear individual words from well-known phrases, I cannot prevent my memory supplying the continuation so that the “automatic remembering-thought”, as this phenomenon is called in the soul language, itself causes my nerves to vibrate till the sentence is finished
I have quoted Schreber extensively to make the point, that ought not to need making, that psychopathology, abnormal phenomena are impoverished by an approach that relies on questionnaires and scales. That the unique experience of individuals is far from exhausted by a menu-driven, list-making orientation towards their inner subjective experiences.
But, Schreber’s account is not merely relevant as description of phenomena but his attitude to his verbal hallucinations is also instructive. See below:
I noticed therefore with interest that according to Kraepelin’s TEXTBOOK OF PSYCHIATRY (5th edition, Leipzig, 1896, p 110 ff) which had been lent to me, the phenomenon of being in some supernatural communication with voices had frequently been observed before in human beings whose nerves were in a state of morbid excitation. I do not dispute that in many of these cases one may be dealing with mere hallucinations, as which they are treated in the mentioned textbook. In my opinion science would go very wrong to designate as “hallucinations” all such phenomena that lack objective reality, and to throw them into the lumber-room of things that do not exist.
Science seems to deny any reality background for hallucinations…In my opinion this is definitely erroneous, at least if so generalised.
What one sees in Schreber is a surprising objectivity with regard to descriptions of abnormal phenomena. This requires a high degree of capacity for monitoring his internal life, standing back sufficiently to describe it, and retaining an objectifying stance that includes critically reading Kraepelin and rejecting his views. This is the enigma of schizophrenia: selective disordered thinking in the context of otherwise normal attitudes. Some people have called this ‘double orientation’. A patient of mine told me of how he was visited, nightly, by aliens in space crafts that could move through the solid walls and roof of his house. He believed this with extraordinary conviction but was also able to say that if someone else had recounted the same experience to him, he would regard it as evidence of madness. But, in his case it was true and not imagined!
Gilberto di Petta at the recent European Psychiatric Association conference in Nice likened psychotic experiences to addiction on drugs. He made the point that successfully treating these psychotic symptoms left a void in people’s lives, that the psychotic experiences had nostalgic value, and that these experiences are craved for. This argument is not novel but it is worth repeating. Schreber’s account shows how much emotional effort and personal time he had invested in thinking about and analysing his abnormal experiences. Treating Schreber successfully would need to include treating his experiences with respect.
This point is often lost on clinicians. John Nash whose life was described in The Beautiful Mind (biography and film) said
At the present time I seem to be thinking rationally again in the style that is characteristic of scientists. However this is not entirely a matter of joy as if someone returned from physical disability to good physical health. One aspect of this is that rationality of thought imposes a limit on a person’s concept of his relation to the cosmos. For example, a non-Zoroastrian could think of Zarathustra as simply a madman who led millions of naïve followers to adopt of ritual fire worship. But without his “madness” Zarathustra would necessarily have been another of the millions or billions of human individuals who have lived and then been forgotten’
The proper subject of psychiatry is the person, not the disease or indeed the concept that we reify.
Late August 2009 we returned from Glyndebourne, travelling via Virginia Woolf’s home, Monk’s House Rodmell Sussex. We had seen a revival of Handel’s Giulio Cesare and Wagner’s Tristan und Isolde. We stopped for picnic lunch at a field not far from Monk’s House and could see in the late summer light the River Ouse. Entering and walking through the Monk’s House made me think of suicide, in particular the nature of suicide notes. There is something that is very near sacred about utterances from the dying. When my own father died from heart disease I was away at boarding school and I wondered what his final words were. There is a sense in which final words carry weight, as if the presentiment of death gives the mere words a special meaning, imbuing them with mystery even magic.
There are different kinds of literary suicide notes. Baudelaire wrote one to his mother
I am killing myself without any sense of sorrow. I feel none of the agitation that men call sorrow. My debts have never been a cause of sorrow. It’s perfectly simple to rise above such matters. I’m killing myself because I can no longer go on living, because the weariness of falling asleep and the weariness of waking up have become unbearable to me. I’m killing myself because I believe I’m of no use to others – and because I’m a danger to myself. I’m killing myself because I believe I’m immortal and because I hope. At the time of writing these lines I am so lucid that I’m still copying out a few notes for M. Théodore de Banville and have the necessary strength to busy myself with my manuscripts. I give and bestow all I possess to Mlle Lemer, including my little stock of furniture and my portrait – because she’s the only creature who offers me solace. Can anyone blame me for wanting to repay her for the rare pleasures I’ve enjoyed in this horrendous world? I do not know my brother very well – he has neither lived in me nor with me – he has no need of me. My mother, who has so frequently and always unwittingly poisoned my life, has no need of money either. – She has her husband; she has a human being, some one who provides her with affection and friendship. I have no one but Jeanne Lemer. It’s only in her that I’ve found rest and I will not, can not bear the thought that people want to strip her of what I’m giving her, on the pretext that my mind is wandering. You’ve heard me talking to you these last few days. Was I mad?
In the event Baudelaire made a failed attempt. Yet the letter is a powerful piece of writing. There is clarity of thinking, a fastidious attention to disposing of his meagre worldly goods, and a pointed attack on his mother. This aspect of suicide notes is not remarked upon often enough: the desire even at the end to hurt, to cause pain to others.
Virginia Woolf’s suicide note to her husband is a quite different specie of suicide letter writing:
Dearest, I feel certain I am going mad again. I feel we can’t go through another of those terrible times. And I shan’t recover this time. I begin to hear voices, and I can’t concentrate. So I am doing what seems the best thing to do. You have given me the greatest possible happiness. You have been in every way all that anyone could be. I don’t think two people could have been happier till this terrible disease came. I can’t fight any longer. I know that I am spoiling your life, that without me you could work. And you will I know. You see I can’t even write this properly. I can’t read. What I want to say is I owe all the happiness of my life to you. You have been entirely patient with me and incredibly good. I want to say that – everybody knows it. If anybody could have saved me it would have been you. Everything has gone from me but the certainty of your goodness. I can’t go on spoiling your life any longer. I don’t think two people could have been happier than we have been. V.
It is tender, thoughtful and ultimately protective of him. But it also has the hallmarks of melancholia: the belief often erroneous that other people’s lives have been polluted. And there is the pessimism, ‘if anyone could have saved me it would have been you’, what is implicit here is her belief that she was irredeemable.
The final example is a diary entry from Dora Carrington’s journals. She was trained as an artist at the Slade School of Art, London. She lived in a ménage à trois with her husband Ralph Partridge and the writer and critic Lytton Strachey. Carrington wrote this diary entry in the spring of 1932, a few months after the death of Strachey and shortly before she took her own life. Where Baudelaire had addressed his mother and Virginia Woolf her husband, Dora Carrington wrote to her dead lover. There is grief, anguish, longing and yet the voice is strong, determined. The kind of determination that despair fosters and encourages.
At last I am alone. At last there is nothing between us. I have been reading my letters to you in the library this evening. You are so engraved on my brain that I think of nothing else. Everything I look at is part of you. And there seems no point in life now you are gone. I used to say: ‘I must eat my meals properly as Lytton wouldn’t like me to behave badly when he was away.’ But now there is no coming back. No point in ‘improvements’. Nobody to write letters to. Only the interminable long days which never seem to end and the nights which end all too soon and turn to dawns. All gaiety has gone out of my life and I feel old and melancholy. All I can do is to plant snow drops and daffodils in my graveyard! Now there is nothing left. All your papers have been taken away. Your clothes have gone. Your room is bare. In a few months no traces will be left. Just a few book plates in some books and never again, however long I look out of the window, will I see your tall thin figure walking across the path past the dwarf pine past the stumps, and then climb the ha-ha and come across the lawn. Our jokes have gone for ever. There is nobody now to make ‘disçerattas’ with, to laugh with over particular words. To discuss the difficulties of love, to read Ibsen in the evening. And to play cards when we were too ‘dim’ for reading. These mouring [sic] sentinels that we arranged so carefully. The shiftings to get the new rose Corneille in the best position. They will go, and the beauty of our library ‘will be over’. – I feel as if I was in a dream, almost unconscious, so much of me was in you. ***
And I thought as I threw the rubbish on the bonfire, ‘So that’s the end of his spectacles. Those spectacles that have been his companion all these years. Burnt in a heap of leaves.’ And those vests the ‘bodily companions’ of his days now are worn by a carter in the fields. In a few years what will be left of him? A few books on some shelves, but the intimate things that I loved, all gone. And soon even the people who knew his pale thin hands and the texture of his thick shiny hair, and grisly beard, they will be dead and all remembrance of him will vanish. I watched the gap close over others but for Lytton one couldn’t have believed (because one did not believe it was ever possible) that the world would go on the same.
These letters and the diary entry that is really a letter shine a light on an area of human life that is hidden. Those left behind are as ashamed as they ever were when it was still a criminal offence to kill oneself. But for the psychiatrist whose working life involves talking about and responding to these matters, these letters reveal something about the inner world of a person as they approach the decision to do something that is irrevocable but that is felt as urgent and compelling.
Photos by Jan Oyebode