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OPEN DIALOGUE - PROBLEM-HEURISTIC METHOD OF TEACHING PSYCHIATRY ON THE BASIS OF THE MATERIALS OF THE MUSEUM OF MENTAL PATIENTS’ CREATIVE WORKS

  1.  D. Muratova

Methods of open dialogue can be used not only in therapeutic context. Open dialogue can be used in many forms of work. We used open dialogue in pedagogic process when teaching Psychiatry to 4-5 year students of the NSMU and psychiatrists from the Faculty of Doctors' Advanced Training at the Museum of Mental Patients' Creative Works.
We have been giving such classes for a long time, actually more than for 10 years, but called them in the curriculum as problem-heuristic. We learnt about the large-scale programme of international collaboration between professionals in the sphere of psychiatry “Utviklings - prosjekt pa Nordkalotlen” and took part in the training programme “Open Dialogue” in Arkhangelsk under the leadership of T. Andersen. Then we came to a conclusion that our method of teaching Psychiatry using the creative works of mental patients should be defined as open dialogue because it is more adequate for students and doctors. The name itself “open dialogue” mobilizes activity and responsibility of every member of the team. So, the two methods are combined naturally in practical classes in psychiatry at the Museum of Mental Patients' Creative Works of the Northern State Medical University. One class lasts 5 hours. The theme is schizophrenia.
Usually a lecture is read before the class “Schizophrenia: etymology symptomatology, psychopathology and psychology”. Before the class a number of practical classes in general Psychopathology are also given at the clinic including supervision of mental patients.
This is reasonable because one should know the symptoms of schizophrenia - peculiarities of thinking disorders, emotional-volitional disorders, image-emotional interpretation of “schizis”, “autism”. Only then one can look closely at the pictures made by patients with schizophrenia with “a penetrating” eye and having “opened” schizophrenia in one’s own way leave the Museum with an oppressing feeling of sympathy.
A teacher (the patient’s doctor), a patient’s picture, the patient if she/he is at the hospital at that time and can attend the class (this is very seldom) take part in the practical class at the Museum of Mental Patients’ Creative Works on equal. When the patient is not present, “retrospective” takes part in the dialogue (the disease case, comments, patient’s remarks concerning the picture told to the doctor during confidential conversations) if the picture is referred to the past. A group of students or doctors (8-12 people) make up a “reflective team”.
At the very beginning of the class the teacher says that creative works of mental patients are somewhat “mysterious” in spite of the fact that these people use the same working methods as healthy people do. Any creativity contains many mysteries.
The Swiss psychiatrist and psychologist Carl Gustav Jung have noticed the fact that some creative works contain the things that the author did not experience, that the author was not aware of them not because they had been displaced but because they never entered his/her life. Such works are some essence that “uses people and their personal situations as a culture medium, distributes their power in accordance with its own laws and makes itself the way it wants to be” (Jung C.G., 1992).
A creative work contains images very often that cannot be comprehended and decoded to a full extend. C.G. Jung found the source of such symbols in the sphere that he defined as “collective unconscious“ keeping people away from their personal unconscious. Jung believed that archetypes are situated in the “collective unconscious” that start living, are the basis of myths, appear in dreams and are reflected in the works of art.
We can tell you about one of our patients now as an example. When she was 12 she suddenly felt that she could write poems. She started writing poems actually non-stop. But there was one thing that surprised. Every time when she finished a poem she found the words and terms in it “that she had never heard of or did not know their meaning”. She had to look them up in the dictionary to learn their meaning.
“Eureka!” since the old times people have been using this short word at the moments in their life when a wonderful ideas came to mind, creative elevation showed the solution of the problem that they were working on during many years and a great discovery. “Eureka!” - exclaimed Arhimed when he was taking a bath on a hot summer day having realized, seen a close connection between the two phenomena.
We know very well the cases of sudden, independent of will or conscious strike of a thought that unexpectedly allows finding the solution of a difficult problem that seemed to be beyond understanding. This happens not only with great scientists, inventors and poets. Every person experienced this wonderful state of shrewdness at least once that is usually accompanied by the feeling of triumph. This “sudden understanding, strike, revelation” characteristic for the human creative process is one of the biggest mysteries that science ever faced.
A sudden leap from dead end to problem solution, absolute understanding is often called intuition without any attempt to find out what this word really means. This process is incomprehensive. Its sudden manifestation, its vague connection with will and consciousness made some people think of intuition as about some independent power like “demon” that acts as he will. However, certainly, this explanation cannot satisfy science and for many years scientists have been analyzing their own and others' discoveries, looking for scientific explanations of their mechanisms.
In reality intuition is one of the forms of information processing on the level of unconscious psychic activity intuitive thinking.
Intuitive thinking playing an important role in creative process and taking place in the unconscious level differs from logical, verbal, conceptual thinking in a number of peculiarities.
It does not use concepts, this is a feeling-image thinking without words using a special type of connections between different psychological contexts and ignoring logical connections. Thoughts-images, graphic symbols prevail in this case, graphic schemes, visual and sometimes rather distant analogues are used, conclusions without prerequisites or deductions coming directly from prerequisites ignoring intermediate stages are characteristic.
As we can see, here comes out the fundamental fact that the conscious logical thinking process is shifted, pressed back to the concluding fazes of thinking activities.
A vivid example of changes in psychic functioning (normal functioning!) is self-observation of A. M. Kharletsky (by means of a long-term training) in the process of falling asleep when consciousness and logic thinking loose control and “subconsciousness” comes into its own.
“When falling asleep the logical order of thoughts is braking. At the same time we do not see any absurd in word combinations and word formations. Quite the other way around, subjectively they are comprehensive as if within the context and they are really correct thoughts and phrases. A ridiculous phrase, distorted image seem to be quite natural and full of sense. The thoughts are transferred into words, they become visual, they can be felt in the oral cavity, there is a speech echo and echo of movements. The images of the drowsiness period are often thought of but do not exist in reality. Besides, things and images are visible behind the field of vision like during extracamping visual pseudohallucinations. Especially interesting is the fact that some movements belonging to living figures are projected in the field of vision, and also the their sounds are simultaneously felt in the speech apparatus and own hands. This can be referred to the person’s own image (duplicate of “I”) and movements.
The described observations give rise to the discussion of some problems of psychic activity” (Kharletsky A. M., 1970).
A. M. Kharletsky believes that the stage of drowsing consciousness differs significantly from the state when dreams appear.
During the drowsy state thoughts are automatic (but without the feeling of influence). The coming up incidental thoughts, distorted, senseless words are accepted with the same simple natural feeling as the normal train of thoughts. Visual and acoustic perceptions are close to pseudohallucinations but they lack the element of “falseness”.
As the psychic production of drowsy state concerns it is closer to schizophrenic dissociation with splint thinking process. Actually this is the manifestation of deautomation of thinking, psychic activity on general.
Thus, the phenomenon of activity “splitting off’ from consciousness in a drowsy state reveals psychic dissociation that looks similar to the problems m schizophrenia. However we should take into consideration the peculiarity of “splitting off' in the norm and disease. The difference between the norm and pathology is, as F. B. Bassin said, that in the disease “splitting off' is an inert phenomenon, changing a little depending on the character and psychological structure of the activity or even irreversable. At the same time in the norm it constantly keeps sharp dynamic and reversable forms, functioning as one of the most important mechanisms of adaptation activity and making the latter automatic at certain stages of its development. The normal role of “splitting off' can be clearly seen when studying the participation of “the unconscious in the functional organization of psychic activity” (Basin F.B., 1968).
The experiments of doctor Raikov with patients under hypnosis show the potential of artistic creative work and even revelation of hidden reserves of human capacities on the level of unconscious psychic activity.
During a session of hypnosis Raikov suggested a patient that he/she was a great poet, artist, singer. The patient who did not have such talents made poems, painted, sang on a rather high level in hypnotic state. Raikov compared creativity with self-hypnosis.
No matter how colourful and brightly a person can describe creative process he/she cannot report on even on one hundredth of the reasons that caused it because he/she is not aware of them.
But that is not the point. When creativity is concerned we often come across paradoxical, illogic, absurd phenomena. To understand the meaning of such creative works people should find the reasons different from the standard logic, connections between facts and phenomena that cannot be detected in the rational way.
The tradition of the European culture is to teach reasoning, discussion based on logical, formalized to some extent systems. “Science explores the world” in this way. However they forget that the greatest scientific discoveries sometimes seemed to “appear themselves”, when a thought stroke one's mind, they were seen with inner sight. The intuition is manifested in this way!
It is possible to teach understanding of the world using another method. The traditions of a number of eastern schools are based on teaching intuitive thinking. One should overcome the logic laws, learn thinking beyond them. That is why they pay much attention to metaphors, paradoxes, illogic ways, development of conclusion schemes according to analogy and associations in the teaching methods, discussions. The more far apart these analogies or associations the more successful the education is considered (Zen Buddhism, the Ridsai school). In other words, something different is behind the text, something that is directly expressed in it.
Peter Fateev, the founder of the group Amaravella that united painters who started painting Space for the first time in Russia, expressed this idea in his credo formulated in 1914: “There should be something in the picture that there is not in it”. This seems to be a paradox but it has been confirmed many times. S. Esenin can be an example. In one of his poems “There is only one thing I can do” he wrote: “... since devils have been occupying my soul, then angels were living there”. D. Kharms, V. Viand, L. Carroll surprise readers with a cascade of paradoxes and illogic things in their books. E. Ionesco, the founder of the theatre of absurd, beats all the records in this field, his characters express complicated paradoxes, illogic things, absurd ideas.
If only it concerned just the sphere of art and literature! It reminds us of the famous aphorism of the Danish physicist N. Bohr who said when discussing one new theory: “Everybody agrees that this suggested theory is crazy. The question is whether it is crazy enough to be right at the same time.”
In other words, now scientists consider hypothesis contradictions with “common sense” not the defect but rather an advantage. Modern physics operates “hard to imagine and paradoxical notions”. As the English physicist Dirac said, the quantum theory was based mainly on such notions that could not be explained by means of well-known notions and even could not be explained adequately with words at all.
As a matter of fact, the manifestation of creativity in the human psychic cannot also be explained just on the basis of reasons. It is no mere chance, obviously Jung’s psychology and modern logic apply one and the same epithet to all the questions that cannot be answered but only “experience”. This epithet is transcendental (Jacobi I., 1996).
In short, science itself leads people to the fact of paradoxical super-intellectual structure of the world. Everything that contains inherent contradictions for common sense can be confirmed in the higher type of physical- mathematical and philosophic thinking.
Vas Nicker suggests original and bold statements concerning the nature of creative thinking in his book “Crazy Wisdom”. V. Nicker discusses the questions: Where are die roots of wisdom and knowledge? What is on the other side of the usual things? How to walk on the blade edge separating insanity from genius?”
To find the answers to these questions V. Nicker “gathered at the round table” of his book famous wise men of all times and peoples having given them the opportunity to share their ideas with one another. From Socrates to Einstein, from Daosism to Dadism one finds out that paradoxical thinking is at the basis of the great, genius - “crazy wisdom” which mechanism is very close to the things that mental diseases include.
In its turn we can see “the crazy wisdom” in the creative works of mental patients.
C. Lombroso gives many examples in his monograph “Genius and Insanity” when quite new abilities and even genius appear in different kinds of creative work when a mental disease starts developing (Lombroso C., 1892).
P.M. Karpov describes a boy, housepainter, who was drawing a lot in a certain state of mind on the background of exalted-ecstatic mood (he suffered from epilepsy). At the same time one can detect a talent of a gifted painter in the manner and plot of the pictures. When the boy came out of the psychotic state he used the pencil and paint unskillfully, his pictures were primitive and infantile. As P. M. Karpov wrote, the boy “became an average house-painter again” (Karpov P.M., 1926).
A. Kampinsky points out that a schizophrenic strike of idea opened A. Kubin the world of psychotic experience and defined the direction of his further creative and literary activity. “It seems that without psychotic experience he could not create such a strange, horrible and grotesque vision that he depicted in his “Other Side”. “During psychosis Hill and Jefferson experienced the change in style as if the disease gave freedom to their original talent that had been enslaved by the canons of academic art” (Kampinsky A, 1998).
C.G. Jung experienced paraphrenic psychotic disorders and lived till inspired old age. Observing his acute psychotic fabulous hallucinations-experiences, studying them Jung opened the existence of “collective unconscious” with archetypes at their bases, founded the developing world wide famous school of “analytical psychology”. He boldly described his meeting with the “collective unconscious”, “Anima” and “Animus”, and psychotic hallucinations, experiences of different life periods in his publications and made discoveries.
“It took me 45 years, - wrote old C. G. Jung, - to transfer all my experiences into strict forms of scientific works”. However this happens with mental diseases seldom, more often mental diseases kill or “freeze” creative abilities with time: a fairy tale comes to an end...
Homo sapience should know that only in the natural combination of experience, abstract thinking and intuition the higher integral type of creative cognition in born where “Great Intellect”, as N. Berdyaev defined it, prevails. It does not limit itself by the narrow frames of common sense and can reach the sphere of paradox and antimony. This allows to understand the nature phenomena and the maximal borders of being (Berdyaev N., 1989).
Theory makes only first timid steps trying to explain paradoxical, illogic, “crazy wisdom” in the creative process and intellectual systems are absolutely unaware of many mysteries of our psychic.
Perhaps we can open a little the heuristic valve and peep into these mysteries with the help of psychopathological experience, for example creative, expressed in pictures, in the form of symptoms of “passive inspiration”, “schizophrenic knowledge”, “schizophrenic understanding”, “ecstasy”, “genius and madness” (like some small windows).
Obviously, schizophrenia is sometimes called “Delphian oracle” because of its mysterious nature: important problems of human psychic are concentrated in it, all the features of human nature, its mysteries can be seen on catastrophic scale in the incredible variety of its symptoms.
The Museum of Creative Works of Mental Patients at the NSMU was established in 1974. However, the patients’ pictures have been being collected since 1968. When selecting the pictures for the museum we kept to the following criteria: firstly, different kinds of psychopathological experiences should be reflected in them; secondly, these pictures should be expressive. However on the whole one should not always expect artistic expressiveness. There are very different works among them, both primitive and talented. We should say that some pictures do not need special comments because they talk about themselves, others contain many meanings, symbolic, they cannot be understood without additional explanations and interpretations.
Pictures of mental patients, as Yu. A. Alexandrovsky said, whether they are creative works of masters or unskillful drawing of a person who used pencil for the first time, they are often the direct and genuine “copy” of their state. Naturalness in spite of the strange plot attracts many people to the mental patients’ pictures. However the evaluation should differ from the evaluation of creative work of healthy people. Painting, sculpture, music by A mental patient is a kind of “speech”, means of communication and expression of something mysteriously fantastic, mystic, transcendental sense of being, attempt to put in order the chaos in soul, say something that cannot be expressed in words... “Signs” and “symbols” ... in these pictures are strictly individual which means that they cannot be decoded in any standard way” (Alexandrovsky Yu. A., 1999).
There are works mainly by patients with schizophrenia at the Museum of Creative Works of Mental Patients of the NSMU. We can give grounds to this. Schizophrenics show high productiveness and bent for art in the beginning of the disease. At the same time in these cases hidden artistic talent is revealed. Sometimes patients with chronic disease make creative works during a long period of time. However this is very seldom: usually when emotional-volition defect progresses their “talent” disappears.
The schizophrenic patients’ pictures have something in common: breaking connections with the outer world, “estrangement”, splitting, pretentiousness and paralogic images that show the peculiarities of the autistic world of patients’ imagination. Their psychic escapes the control of consciousness and logic thinking.
In open dialogue we should transfer the inner experiences, sorrows, distorted by the disease world into “a real form”.
We suppose that during open dialogue you’ll see that dull word descriptions of such symptoms like “passive inspiration”, “schizophrenic knowledge and understanding”, splitting, autistic thinking, etc. cannot show the whole range of emotions, images that fill schizophrenics’ souls. You will see everything with your own eyes when you analyze our patients’ pictures. Our analysis will help you to understand the disease called schizophrenia.

We are starting our “Open Dialogue ”, our trip inside schizophrenia .

Teacher. The first patient is Alexander Sh. His staying at the Arkhangelsk Psychiatric Hospital and painted pictures refer to 1968. At that time the patient was 19. He was born in Moscow. He was recruited to the army and was sent to Arkhangelsk. He stayed at the Arkhangelsk Psychiatric Hospital about three months.
From the medical history we can learn the following: he did not have any relatives with mental diseases. In childhood Sasha did not differ from other children. He showed good progress at school. Obviously the disease started developing when he was 12-13 years old when changes in character took place. He became reserved, lost contacts with friends and relatives, quitted school, ran away from home, spent time at churches, monasteries, libraries where he “studied philosophy”, he was reading Hegel, Kant, Feuerbach, Nietzsche and others. He began writing philosophic works where he “told about the depth and wide range of world perception and philosophic sense of being”, “he worked out his own conception of world perception”. He found out that there was no person who could think “like him”, he felt sometimes that it was difficult for him to understand the variety of life contradictions, two persons were living inside him, later he lost interested in the outer world and he “remained in his own world”. Since that time he started painting his “philosophic thoughts”. His parents said that Sasha had never painted. The son’s talent surprised them and his pictures were strange.
In spite of all those changes in behaviour the parents did not notice the beginning of the mental disease, they “blamed the transitional age”.
When he was 18 he was recruited to the army and started his service in Arkhangelsk where the disease manifested itself. He had delirious ideas of attitude and influence, hallucinations, depression, tried to commit suicide many times. Other solders were afraid of him because he was “gloomy, tense and suspicious”. When he had free time he painted but the main theme of the pictures was suicide.
He was placed into the psychiatric hospital. It was practically impossible to establish any contact with him, he did not tell about his psychological experiences. He talked a little only with the doctor. He painted a lot, some pictures he brought to the hospital, some of them were made at the hospital. His doctor allowed him painting and even always encouraged him providing him with a place, paper, pencils and paint. When he was finished with every picture, the doctor and patient were both interested in establishing a confidential “creative” dialogue”. When leaving the hospital the patient gave the doctor his collection of pictures as a present. More over he gave comments to those pictures.
The patient was treated with insulin. His psychotic state was over: depressions, delirious ideas, hallucinations disappeared but he still had moderate emotional-volitional decrease.
Sasha was sent home. Leaving for Moscow he was going to continue painting and even take part in exhibitions. He said: “I would not mind even if the exhibitions will be at psychiatric hospitals”. He promised to send one or two pictures to his doctor. But ... there was no pictures received from Sasha... Perhaps the picture “Medicine, Me and a Lemon Bird” given as a present before the departure can explain everything?
Pay attention to the fact that the image of “a lemon bird” can be very often seen in Sasha’s pictures. This is a symbol of his inner world, this is was he is living with keeping away from the real world. This is his thoughts, feelings, troubles, fears and perhaps happiness. In other words, this is the content of his autistic world. And this world as you will see exists autonomously and “by itself” apart from the reality.
Now let us take a look at the Sasha’s pictures.
Teacher. The first picture is called “Self-portrait”. On the back side of the picture there is an inscription: “he’ll die soon”. What can you say about the picture? How do you understand it?
Student A. First of all, the inscription draws our attention: “he’ll die soon”. The person says about himself in the third person as if regarding himself in a detached spirit, e.g. estrangement from himself is clearly visible.
Student B. But the most important is the face as it is depicted: one half of it is alive though there is some tension in it. One can assume that certain thoughts and feelings are hiding behind this part of the face. The other half of the face is without skin and muscles, this is a bare half of a scull with an empty eye-socket. This is a split personality “presented here as an image”.
 Student V. But why “is he going to die soon?’ who is “he”? is it the patient himself or the surrounding world?
Teacher. As Sasha said “he” was the surrounding world (reality) that had partially died for the inner life of the patient, that did not cause any emotional resonance and “was not giving anything”, the patient escaped from it because “he did not need it”. However partially this world “concerned ”the patient” and it interfered with him in an unpleasant way and with hostility. Thus, we can see the autistic point of view in this self-portrait. The closer look we take at another picture and more we think about it, the more we are confirmed in the latter statement. This picture is called “Painter’s Nature” (the essence of the inner world of the patient, his soul).
Student G. If we consider everything m this picture symbolic then, obviously, soul is depicted as a vessel-amphora. The picture is divided into two halves like the first picture, e.g. we face splitting again but now on the level of spirit.
Student V There is one interesting thing. One side of the picture (soul) is dark, secret. Since there are no organs of feelings, the influence of the outer world is not allowed or it is “dead” for emotions coming from outside. And in this part of the soul a hand holds a bird with care. It looks like a nestling - “the lemon bird”. Take a look at the nestling! “An independent tree of knowledge” is growing from it.
Teacher. Here is the image (at the very begging) of autism. Autistic world exists autonomously from reality: knowledge, psychic context come “from itself’, independent of reality. Let us continue with “understanding”.
Student D. The second half of the soul is not protected from reality. What the palm means here?
Teacher The palm is a symbol of reality, collector of outward impres- sions-influences.
Student D. Then I can understand. Do you see that the palm is marked with three 6 - the symbol of devil? In other words, the growing autistic world of Sasha does not need the impressions of the reality and they are even hostile for his world. A symbolic sword is “thrown out” of the empty eye-socket, the secret world and it strikes the palm of reality.
Teacher Don’t you think that Sasha vividly depicted splitting of soul, spitting between the inner world and reality leading to antagonism, to “the war with swards”?
Now let us take a look at the third picture. It is called “Reality and I”, at the very beginning Sasha told his doctor: To strike brain with some idea or feeling, creativeness the lemon bird should pour a drop of special creativeaerial liquid торга on the brain”. You know that we come across the so called “thickening” or “infiltration” of notions and images when two-three notions are united in one word. What does this neologism торга mean? On one hand, it is the “brain prana” and one the other hand, it is a “grand-brain”. In other words, “торга” is something that in its content and energy higher than brain, and is older in its origin than brain, e.g. “spirit”.  If we accept the religious idea about human trinity then a human being is the body, soul and spirit. Spirit connects us to the Higher Intellect - God. Contact with God is in creative work. What thoughts, questions, opinions do you have after a close examination of this picture?
Student B. There is a beautiful flourishing “lemon bird” in the picture. In the centre there is some distorted, “Jesuit”, wine-red face. What does it mean?
Teacher. Sasha used wine-red colour (irritant colour) with everything that was referred to reality, outer world that was hostile to his autistic inner world.
Student В. I understand. I suppose he himself is depicted at the bottom of the picture.
Student E. Pay attention that the “lemon bird” is separated from the reality with a clour spectral gamma. Reality and “the lemon bird” exist in parallel worlds!
Teacher. This is really so. At present a new science virtualistics is being developed that will study parallel worlds of reality and virtual reality. More over scientists jointly with narcologists have developed a conception of virtual psychology of alcoholism, new methods of treatment (“Forsazh” method) at the laboratory of virtualistics of the Russian Academy of Science (Nosov N. A., Yatsenko Yu. T., 1996). Many scientists agree to refer the autistic world of schizophrenic patients to virtual reality.
Student E. Since we have touched upon virtual reality, we can find other proofs of it in the Sasha’s picture. The head of I is depicted in a very strange way: only the face scull is clear and its is open where brain is. However we do not see the brain convolutions there but some channels, directing lines, thе left and right parts of thе brain are separated. The left part is protected by the lemon bird’s wing. A drop of “liquid” from thе mouth of reality is pushed away by thе lemon bird’s wing to thе directing channel of the right part of thе brain. Splitting and “two worlds” are thе split brain, thе real and virtual world...
Teacher. Yes, Sasha commented this picture in this way. But thеn he tore it apart for some reason. We have restored this picture and now you can take a look at it... But why did Sasha destroy thе picture? It was a secret that Sasha never told his doctor. Perhaps he thought that he showed too much, exposed thе lemon bird. Perhaps during thе dialogue he was ashamed of his pride that he was going to change thе reality as if he was “thе one who fulfilled thе will of God”. Lev Tolstoy wrote in his will: “I had those times when I felt that I was becoming thе one fulfilling thе will of God.” But as G. Flober said, painters are “thе organs of God by means of which He Himself opens His nature”. Our thοughte are just reflections but what Sasha really thought we do not know.
Instead of thе destroyed picture Sasha painted a new variant of the picture “Reality and I”. What do you see in this picture? How do you understand it?
Student Z. I think this picture is more natural if compared to the previous picture that is all symbolic and mystic. A living being is struggling in the liquid wine-red mud (reality), it may be a human being - our Sasha. This mud sucks him in and he is trying to get out, to escape into another reality beyond this reality.
Teacher. You have correctly understood the symbolic meaning of this picture. Sasha commented it in the following way: the reality with its marsh routine was sucking him up, defiled his soul. He wanted to get away from the reality, to go to another world. He said: “There is no Blue on the Earth”. And then added: “I am trying to get away from it (reality), to go up to another world, to the world of blue”. And again in another image we come across to autism and split characteristic of schizophrenia.
One more picture “Painter and Lemon Bird”. When giving it as a present to his doctor Sasha said unusually thoughtfully and in a low voice: “You know, it seems to me that I am the only one thinking and living person in the whole Universe, and there is nothing else, only the emptiness”. His doctor replied: “But we are sitting now together, talking, there are different things around us, there are trees, houses, people outdoors... What are these then?” And Sasha said: “I think it is only my imagination...”
I remember Burno’s words who said at one of his lectures: “An autistic person believes that his inner, subjective, autistic world is the initial and the only one real world, and all other things are derived from this subjective world”. And then added as if making a joke: “In this case an autistic person is the primary, natural subjective idealist”.
And now let us discuss the picture. What do you see in it?
Student Zh. There is a lemon bird in the picture, a painter is on its background, there are some masks and a man with a wind-instrument.
 Teacher. It is difficult to understand without Sasha’s comments. For instance, what does the man with a wind-instrument mean? It turns out that this is not a man this is a spirit. Remember that in schizophrenia notions are shifted, replaced, abstract notions are clumsily concretized, concrete notions are made abstract and so on. Here the lemon bird shows us how the reality is made. The painter works with the spirit, he thinks, imagines and images come, portray and inspire, they “create everything in reality”. Reality is only a poor copy of inner images of the autistic world of the patient. Images and thoughts of the autistic world come to reality, the existence of reality is replaced in his perception of the world. The borders separating Me and Not Me disappear. This is the manifestation of depersonalization- derealization experience. The patient is alone in the emptiness.
Please, note the fact that the circle is closed: in “Self-portrait” “he’ll die soon”, there is no reality, outer world in the picture “Painter and lemon Bird”, there is only the primary spirit forming everything.
Student A. I am somewhat perplexed with everything I’ve seen and heard here. If the schizophrenic patients can “fly so high” in their imagination then we are just primitive people and even fools!
Teacher. I do not know what we are but the schizophrenic patients are not fools at all. If I recall the names of the great people who suffered from schizophrenia, you may have a shock from the number of the names. We can find the reflections of their disease in their creative works. Here are the examples from the book by Kretschmer: painters - Bosch, Durer, Goya, Fedotov, Vrubel, Van Gouge; writers and poets - Dante, Tasso, Gelderlin, Gofman, Batoushkov, Gogol, Strindberg, Kafka and others; composers - Schumann, Guno, Skryab- in; scientists - Swedenborg, Kiergegard (Kretschmer E., 1958). The list of such names can be made longer.
And now the most interesting thing. Sasha will “tell” us about the origin, mechanisms that caused the “development” of the quite new ability, the talent of painting at the beginning of the disease. Let us take a look at the picture called “Orator. He knows the transcendental, he invites them there”.
Student V. I wish I knew who this “orator” is who knows the transcendental.
Teacher. The orator is the author of the picture depicted himself in this unusual form. He “knows the transcendental”, e.g. something goes beyond the feelings and empiric knowledge. But how does he get this knowledge? How does this knowledge come to him? Take a closer look at the picture, think it over and discuss...
Student D. What do I see here? A wrist is thrown out of the pupil of the right eye, it must be sending “them” to the world of transcendental. Another wrist cuts the pupil of the left eye with a sharp thing. What would this mean?
Student Zh. Probably this means that knowledge about the transcendental comes to the orator by means of contemplation.
Student B. One can also say by means of the strike of ideas, revelation.
Teacher. You are quite right. Contemplation, strike of ideas, revelation... We call this “symptom of passive inspiration”, “schizophrenic knowledge”, “schizophrenic understanding” in the psychiatric language. In these cases patients say with surprise and admiration that they had “a lucid interval”. They obtained the most profound philosophic knowledge, laws of space, nature, human relations and even birds and animals’ language, language of inanimate things.
Thus, Sasha “told” us that “passive inspiration”, “schizophrenic knowledge, understanding is at the base of his new abilities, e.g. we see the prevalence of intuitive thinking over logical, prevalence of images and symbols. Sasha had also delirious experiences reflected in some of his pictures. One of them he called “What does he want from me?” the delirium of influence is reflected in it. The patient thought that other people try to get inside his inner world, to deform it and influence it.
Student E. We can see in this picture a face, a deformed flat face. There is another face built in one of the cheeks, it seems to be strange, made of wood as a sculpture.
Teacher. Why is this deformed face flat as if on a board or thick glass? Can other people, objects of reality get into the face?
Student E. Certainly they cannot. Something strange gets inside the soul.
Teacher. Then is this flat face somehow referred to the soul? Let us use Sasha’s prompt who said many times: “Eyes are the soul’s mirror”. Let us pay attention to the eye in the picture. A deformed soul is reflected in the eye like in a mirror. And we can clearly see that the soul is deformed for those who live in reality and see the soul as if reflected in a distorting mirror. Something strange in its form and material has got inside the soul.
Student I. But it is impossible to understand from the point of view of “common sense”.
Teacher. But we are dealing with paralogic thinking, as Bleuler called it, with “surreal” symbolic. We should not forget that a patient’s psychic is explored by a psychiatrist’s psychic. Psychiatrists do not have other instruments to understand souls of patients. Certainly there are also knowledge, intuition and empathy. By the way, M. E. Bumo defines clinical psychiatry as “a sphere of medicine that professionally and clinically treats with doctor’s soul capacities”. Soul to soul!
And finally the last Sasha’s work that he gave his doctor as a present before leaving for Moscow having taken a course of therapy and coming out of psychotic state. He called this picture “Medicine, Me and lemon Bird”. What do you think about your picture?
Student К. I just want to cry looking at this picture. The lemon bird has lost its lemon colour, faded away, it must be even dying...
Student B. An ugly face is in the centre with tears of sorrow (black drops). This must be Sasha crying over his lemon bird.
Student G. Why is the lemon bird dying? Who is to blame? Automatically a conclusion comes - this is medicine. Do you see that white bird, I think, it is a symbol of medicine. A hand is thrown out of the beak that drops a red drop of reality into the brain. Medicine is from the reality world. These two worlds, the inner world of Sasha and outer world, are clearly separated with a spectral colour line in the picture.
Student Z. And I think that Sasha after therapy did not come back to reality though he did not have delirium, hallucinations, depression any more. He is still separated from reality with the same colour spectrum - the wall. The lemon bird is in another place different from his place. It is either dead or dying. Sasha did come back to the real world, his emotional adequate reality was not restored. There is also no his lemon bird, the world where he was living with “that special talent”.
Teacher. Sasha did not give any comments to this picture. He just gave to his doctor as a present. I believe your comments reflect the reality. We used active methods of therapy for Sasha because he was dangerous for himself (attempts of suicide) and others (delirious ideas, hallucinations). After therapy he did not have delirious ideas and hallucinations. But he did not come out of psychosis and emotional-volitional defect took place. Sasha’s disease had a non-stop progredient course and it started when he was 13. It means that when we started therapy the disease was “6 years old”.
You are asking what happened with the lemon bird. The thing is that autism has two sides - positive (this is often whimsical, fantastic, transcendental experiences) and negative (estrangement from the reality). Obviously our therapeutic methods took away the positive delirious, hallucination symptoms and at the same time the golden colour from the bird. “Empty autism” was left.
Student Zh. Was it possible to let Sasha live without therapy? Couldn’t he live with his lemon bird?
Teacher. People ask such question very often. Once a journalist was present at one of the classes at the Museum of Mental Patients’ Creative Works. Sasha’s story impressed her so much that she wrote an article for the newspaper that she called “Where does the Lemon Bird Flies?” She thought she heard repentance in my voice concerning Sasha’s therapy. However we were obliged to use therapy with Sasha because, as I have already told you, he was socially dangerous for himself and other people due to the peculiarities of psychopathologic experiences. Another question is what I think about the modem methods of treatment, to what extend they are perfect because our souls are not always in peace even if the things that we do are right...
This what M. E. Bumo, the author of the book “Therapy with Creative Self-Expression”, about such doubts:
“Psychotropic medicaments in reasonable dozes are certainly necessary when treating psychosis. However in paraphrenic cases (when patients are seldom dangerous for themselves and other people) it is good to combine medicaments with complicated psychotherapy. I believe that in such cases we should encourage useful psychotic creativity of patients: let him talk with the monk (this is about the story of A. P. Chekhov “Black Monk” - author’s note), write philosophic essays, paint and etc. Any way do not interfere with the nature... Sometimes patients find their own talented curing creativity. Actually, the real great creative work is always a remedy for suffering, disorders including acute psychosis... The state of psychotic paraphrenic disorder can be creatively genius, talented, however it is more often mental, spiritual philosophically fabulous treasure only for the patients themselves. For this purpose psychiatrists should help the patients professionally-clinically, very carefully to survive this disorder in a creative way..., to help the Nature in its psychotic protection.
However in paraphrenic cases the usual psychotherapeutic methods do not work as a rule, then we should help the patients in other ways: understanding their psychotic state as a fairy tale that can seriously help to cure. Patients who accept doctors during their paraphrenic psychosis trust them, share their problems, ask for advice. In this way doctors can stop perhaps dangerous actions like friends” (Bumo M.E., 1991). “I am talking only about the cases of psychot- ically paraphrenic however comparatively not dangerous for the patients and society. Certainly, doctors act in a different way prescribing strong medicaments when a patient is dangerous for himself and other people, in depressive- suicide cases” (Bumo M. E., 1998).
This is what C. G. Jung writes: “Due to the fact that the “inner” world is not visible and cannot be imagined though it influences the consciousness, I recommend those my patients who especially suffer from the influence of the “inner world” trying to paint it as they can. The purpose of this creative method is to show the unconscious content that a patient can easier understand. The therapeutic effect of this method prevents the dangerous splitting of unconscious and conscious psychic processes” (Jung C. G., Neuman E., 1996).
I believe that a reasonable psychiatrist understands well that we know little about psychic and mental diseases. Nobody of clinical psychiatrists would refuse to apply any adequate including unconventional for our medicine methods of psychotherapy when treating mental diseases. Open dialogue can be referred to one of such methods. It's being gradually introduced into Russian psychiatry. The experience shows that dialogues are especially effective when combined with art therapy. On the example of Sasha’s pictures you saw that the innermost, secret thoughts hidden in the soul of a suffering person are depicted on paper. Careful, tactic, “tender” touch of another soul of either a doctor, friend or relative helps the patient to get free from the agonizing thoughts and to find rest.
Student A. You are saying that a patient’s psychic is explored by a doctor’s psychic. But Bumo says that psychotherapy is a sphere of medicine that professionally-clinically treats by means of doctor’s soul capacities. Will a professional psychiatrist have “a burning out syndrome”, empty soul as a result of many years work?
Teacher. No, he will not. Soul does not burn out because of kindness and empathy? Soul gets burnt out with different “satanic” feelings like anger, envy, hate, hostility, cruelty, etc. I think that it is even beneficial to be kind because giving away the warms of your soul, love, compassion, sympathy to someone else you enrich, make your soul better, grow spiritually. Spirituality is a powerful, specific human protecting-adaptation mechanism. It protects people from a number of neuropsychic and psychosomatic diseases. Do not be afraid to be kind, do not be afraid to give the warmth of your soul to your patients. The evil bums out soul not the kind!
Student Zh. You know, I’ve read the words by Korsakov, just simply remembered them and only now I understand them. He said that “psychiatry satisfies many needs of a human mind... and clever people devote their lives to it eagerly”. Now I think that the psychiatrist’s soul should be clever.
Student K. My attitude to mental patients has completely changed. I understand now that they people and suffering people. I cannot help sympathizing them.
Teacher. I would like to quote the words of M. Bleuler now from the article about the II Congress of Psychiatrists in Zurich: “They thought that schizophrenics are not people any more. Forel called them mere vegetative creatures. He compared schizophrenics’ life with plant life... However schizophrenics turn to be amazing in the process of treatment, like people with intensive tragic, who you can understand as your healthy friends... We see the same people like us but suffering”. I’d like to add: people with “insanity wisdom”, genius.
Student Z. I do not know what’s happening with my soul but I’m feeling something good, that I’ve seen the truth. I am leaving this Museum like a temple.
Teacher. Your example confirms Vygotsky words who said that contact with creativity, art arises not only good esthetic feelings but also catharsis.
Now we should mention the tragic side of the schizophrenic process. We have been talkinh about “philosophically colourful” schizophrenia, but the schizophrenic process when progressing leads to emotional-volitional decrease, emptiness, “empty autism”. 24 years old patient A. D. can be the example of this. We have two his pictures in our Museum. They are both without titles. Let us take a look at one of them that can be called “Emptiness”. The author himself called his world perception. He had delirious ideas, depressions and other signs of disease when he was 20. He was a third year student of Medical Institute at that time. Since that time he was painting a lot automatically. At first his pictures were very bright but frightening themes like cruelty and sadism prevailed in them.  With the increase of emotional-volitional defect colours faded and finally the pictures were black and white. The themes changed too. As author said the prevailing theme was emptiness.
This is one of his poems:
White nights go away,
They reveal the Emptiness,
There is a lamp-post instead of Sun, The entrance to the Emptiness is free.
From birth till death
A man is alone on his own and with the Universe.
I wish l could get control over this Abyss
To see everything in myself...
Student Z. The pictures of this patient make an horrible, depressing impression but arise pity too. Soul died and emptiness came, loneliness before the whole world. How hard it must be! There must be many thoughts in the soul... It seems to me that we have learnt about secret schizophrenic experiences here at the Museum. We have not seen this either at the lectures nor even at the meetings with schizophrenic patients.
Student G. There is more to it. Perhaps we have received something more important. Do you agree that such soul elevation like this at this Museum takes place seldom. Besides, I believe open dialogue mobilizes our own thinking.
Teacher. I'd like to add that open dialogue gives us an opportunity to look into our own souls and make reassessment of values by means of thinking and emotional perception.