Finding the way back to reality

What is reality? How is it that some of us are sometimes told that what we are experiencing is not real or true when our own experience tells us otherwise? Is reality a thing, a quality of the world, or is it more a sense that one has about events, things, people, or oneself? The findings of physical science, which enables us to use its methods for measuring mass or space displacement and the movement and properties of electromagnetic waves, seems to suggest that physical reality is a fairly reliable and practically useful concept. Conversely, social scientists have observed that different cultures may hold unique beliefs about the basis, purpose and meaning of life. Culturally sensitive clinicians understand that patients from around the world may experience reality and derive meaning in ways that are different from our own, leading to quite different courses of action and conduct. In this sense we have come to recognize that some aspects of reality may differ from one culture to the next. The expressions of poets and artists reveal a myriad of ways for putting into context our relationship to our ever-changing social and technological landscape. Before Albert Einstein, no one ever thought about “relativity,” and the theoretical possibility that two people traveling at different speeds across the universe might age at different rates. In a world that is so dominated by change, the idea of a singular, fixed reality may indeed be a welcome thought. A person’s reality sense may be temporarily impaired by a variety of causes. In dreams, one may experience oneself going to fantastic places never before seen; doing things he or she has never done with people who may be at once both strange and familiar. Following surgery, some patients may experience moments of delirium, suffering a temporarily inability to understand their circumstances, sometimes accompanied by confusion, disorientation, and fearfulness. Thankfully, such things pass – we awaken from our dreams to find ourselves at home and in the same old bodies that we fell asleep in and our brains eventually come out from the anesthesia-induced deliriums that briefly held our minds in check and in chaos. One of the distinguishing symptoms of serious neurological or psychiatric illness is the loss of the ability to “test reality.” In the standard, DSM diagnostic system, updated periodically by the American Psychiatric Association, psychosis is typically defined in terms of the presence of prominent hallucinations or delusions, sometimes accompanied by disorganized or incomprehensible speech or behavior and negative symptoms, so-called because of the absence of motivation, movement, and verbal or emotional expressiveness. It is a longstanding part of any psychiatric examination to test for one’s capacity to function within the constraints of physical and social reality. Hallucinations and delusions are the boundary crossing experiences of reality. Strictly speaking, hallucinations are misperceptions of an extraordinary magnitude, while delusions are tenaciously held false beliefs. Both hallucinations and delusions tend to be experienced as true, especially in the moments that they are activated in consciousness. A common, healthy, misperception might be, for example, to hear one spoken word incorrectly as another. Such errors are readily corrected when the speaker’s context suggests another word or when the listener’s response suggests that he or she has not understood what was said to begin with. However, when a hallucination is present, in this case, an auditory one, the individual may “hear” a word or a sound that is, by socially objective criteria, not really there. I recall sitting in a room with a young man, who moments before had hallucinated a voice uttering a negative remark about him. The man, in the midst of his second, serious, psychotic breakdown in the past year, looked at me rather quizzically and asked, “Did you hear that?” I responded, “What was it that you just heard?” He said, “I heard someone calling me a creep.” I replied, “No I didn’t hear that. Is this something that you have experienced before?” “Yes,” he answered. Delusions often appear as desperate attempts to organize and understand a life that has suddenly gone out of control, resulting in personal and spiritual crisis, chaos and dread. A older female patient, who had been struggling to understand why people had not been as warm and open to her as she had been accustomed to, experienced a sudden, fateful insight, “I realized that they were all in this together,” conspiring to make her lose her job, her home and her family. As more time passed, her beliefs grew until she eventually stated with an increasing sense of certainty, “The FBI and the CIA are in on it too,” subsequently revealing her newly realized belief that her food was being contaminated and her room had been bugged with a listening device, leaving her unsafe and without privacy. How do we find our way back, from the horror and the isolation of our lost realities? First, we must be mindful that a lost sense of reality is a real loss, evoking a sense of grief and bereavement. A further loss of hope leads to inactivity and disengagement from the very social and personal activities that tend to be most fulfilling and reality affirming. Once lost, we must re-build our connectedness to the world – to the cycles of life and activity that would sustain us. Such a re-building is often best realized in an interpersonal context, through our participation in the family (that which is familiar, with people who love us), nature (that which grows and gives life and beauty), and in society (the broader context of all relationships). One must go where other good and accepting people are to be found. Sometimes this means attending support meetings, sometimes group therapy, sometimes church or synagogue or other activities. Once begun, remaining engaged in the world and with ones family and peers is essential. In cases involving severe mental illnesses, such as schizophrenia or bipolar disorder, medication is almost always necessary, to help re-build the bridges in our brain’s circuitry that may have been shorted out, so to speak, by neurological illness, developmental crisis, or persistent life stress. Participating in psychotherapy, in a relationship that builds on unconditional acceptance and deeper knowing, can help the process of re-awakening of ones relational, reality-focused self. Like the mirror in the Snow White story, the therapist reflects back to the participant, here with a compassionate purpose, what is revealed and true in him or her, re-affirming the physical and the interpersonal reality and pointing to and cultivating the individual and spiritual bases for his or her progressively healing sense of self and world.

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