Horatio Clare's account of his episode of severe psychosis is in two parts. In the first part he describes in granular detail the deterioration of his mental state. This is a harrowing and grim account that is lucid and gripping. The architecture, structures and inner furnishings of madness are exposed to our gaze. In some respects, it is far too detailed, far too uncompromising in its honesty, making for hard reading. It is a tribute to Clare that he is able to recall the minutiae of his abnormal reasoning, the idiosyncratic meanings attributed to ordinary and trivial incidents and objects. Even at his worst, when his thinking is entangled, bizarre and chaotic, he retains an intense observing self that is steadfast and unblinking in its pursuit of witnessing his situation.
The examples of psychopathology are a gift to a psychopathologist like me:
‘Notice that man touching his hat, indicating that person over there making a strange flicking gesture? Follow the gesture and you come to that young woman's raised hand – she's pretending to stretch but now looks far across the room at that chap, who catches the flick and passes it to the sharp-looking woman over there who nods it to the military-looking man over there who, returns it to me […]’.
The intricacies of the reasoning and experiences underlying potentially dangerous acts are made comprehensible such that it is clear how close he came to disaster, if the foregoing had not been disastrous enough:
‘The radio tells me to leave a candle burning and a cushion near it. I distinctly remember asking aloud if I should burn the flat down and the answer coming back, partly from the radio, partly from my thoughts, no, leave that to the professionals. They will take care of all the bugs and cameras. You get out of the house. Leave the door unlocked’.
The adverse impact on family life, the manner in which the disruptive and unpredictable behaviours ate at the seams of relationships, causing turmoil, worry, terror but also how love, friendship and family sustain what had become a tenuous and precarious existence are all described. He shows how social class, standing and a cultured use of language can distort perceptions, ameliorating what is overtly serious as well as protecting from the worst possible outcomes. In other circumstances this would have been an outright, irredeemable tragedy.
This book is a modern version of John Perceval's 19th-century account of his mental illness and, like Perceval, Clare combines an account of inner subjective experience, of associated behavioural anomalies and the experience of in-patient care. In addition, there is in the second part an inquiry into the nature and qualities of care offered by psychiatric institutions. This second part is of interest to psychiatrists because it illustrates what is unsatisfactory about psychiatric care. It is extraordinary that the medical treatment that practically saved his life, within 10 days, is not given much due regard. In fact, it is given short shrift. The tenacious desire for moral explanations, both as causal and therapeutic agent, is explicit. In the pursuit of healing, Horatio Clare is in the hands of the purveyors of EMDR, disruptive agents and others, whose methods and beliefs fly in the face of what we know to be true. Hence, explanations that avoid the language of trauma are viewed as alienating. Particularly missing is the solemn but authoritative voice of clinical knowledge.
It ought to be read by all clinicians who work under increasing stress but whose goal is to make a difference. There is much here that will sustain their quiet determination to do good.
Declaration of interest
F.O. is a member of the BJPsych editorial board and did not take part in the review or decision-making process of this review.
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