a may go through periods of crisis, where it is hard to see any coherent personality at all. There may be a torrent of words that do not make much sense, or which reflect some delusional state. Moods may oscillate between shallow, excited optimism and a sunken, withdrawn despair. Attitudes to people he or she knows may move, apparently randomly, from warmth and love to suspicious hostility expressed by a menacing stare.
But, as a result of medication or as a new phase of the condition, there can be long periods of stability. In these periods, the person may seem much as before the illness. But often there is a transformation of personality. Someone friendly, alert and with wide interests may have moved into a negative, strangely unreachable phase: slow, sullen, perhaps aggressive, usually uninterested in others, saying little and doing little beyond half-watching television. In these periods, friends and family may say, “it is like talking to a different person”.
For some people, the oscillation between periods of crisis and these negative phases may last a lifetime. Friends and family may have conflicting responses to the aggression they are sometimes shown. Should they react with exasperation or with detachment? Is it him or is it his illness?
There is a case for refusing to see the schizophrenic personality as the person’s real self. There is usually little doubt that the strangeness and the narrowing passivity are products of the illness. As a thought experiment, imagine that a treatment is developed that can restore permanently someone from this negative state to their original state before the onset of the illness. In the absence of other residual problems, this would be a cure for schizophrenia. It would then be natural to see the second personality as a product of the illness, and not as what the person is really like. This would be supported by the fact that many aspects of the second personality appear on lists of the “negative symptoms of schizophrenia”. In retrospect, difficulties in answering the question, “is it him or is it his illness?” would largely disappear. The decision to withhold the more critical reactive responses would seem to have been right. The person’s self-creative project would have been temporarily disrupted by an illness. The hostility or aggression they displayed should be put aside as not reflecting their real self.
Now imagine a scenario, more like the actual one for many people with schizophrenia, in which the original personality is not restored. Should we treat the current, schizophrenic, personality as not reflecting the person’s real self, but as merely the product of the illness? The case for this approach is that it is the one we would adopt if there were a cure. It seems puzzling that the schizophrenic personality should have a completely different status depending on whether we are making the decision before or after scientists have developed a cure.
On the other hand, where there is no cure, there is a case for accepting the schizophrenic personality as now being the person’s real self. This is not some brief coda at the end of life. His real self, if not reflected in the schizophrenic personality, is something hidden for decades. Can the real self of the forty year-old man really be that of the teenage boy before the onset of schizophrenia, a real self unlikely ever to be seen again? Would it not be more realistic to accept how he is now as his real self?
People confronted with this issue tend to be pulled both ways. The phrase “the real self” is of course vague and indeterminate, which makes it unlikely that the issue is one where the “right” answer can simply be read off from the evidence about the condition. Any answer seems at least as much a matter of decision as of discovery. And the reasons point in conflicting directions.
There is the desire not to give up on the possibility of a cure, a kind of keeping faith with the original person. This is given a degree of support by some of the cases in Oliver Sacks’s book Awakenings, in which he describes how people who had suf