For many people with serious mental illnesses, the reality they experience has not been passed on to them by other people. The reality they experience is not one that they find easy or straightforward to pass onto someone else, either. It is a reality nonetheless. Naïve positivist researchers may have felt that they had made a breakthrough in understanding psychosis when they found people's experiences of auditory hallucinations to ‘light up' parts of their brains on PET scans, but people with psychosis had been telling us that they actually heard the voices for hundreds of years. The experiences occur and are real. This fact challenges the person with the illness in numerous and serious ways; we are familiar with the nature of some of these challenges from our clinical work. But my interest here is instead in the fact that this fact challenges us as well, and in no fewer or less serious ways. That is because the existence of these experiences should call into question our own ready to wear sense of reality as well as that of the person who is hallucinating. We may not like it when it happens, but if we fail to recognize it, then our science and our clinical practice will remain extremely limited and of very little use to our clients.

I think I can explain this most readily through the example of what we describe as delusions. Another characteristic symptom of psychosis, delusions are firmly held, false beliefs; false being defined as contrary to a given consensual (i.e., ready to wear) reality. In my experience, delusions almost always emerge out of hallucinations, as ways to make sense either of the hallucinatory experiences themselves or of other anomalous experiences that may be indirectly related to the hallucinations (e.g., why people shun me or think I am weird). Regardless of the particular experience the person is trying to make sense of, it is pretty clear that delusions represent active attempts to make sense of something-something that presumably could not easily be made sense of in other, less alien and alienating ways. What this suggests is that a delusion is not simply a false, firmly-held belief that is, as it were, added onto a pre-existing (ready to wear) sense of reality. It is not that simple. Rather, the delusion is most likely playing a key role in holding together whatever sense of reality the person has at the time. Taking away the delusion, if you could, would leave a large hole in the tapestry. And this is a whole that is much too big and important to be filled by the vague and sketchy idea that the person has a mental illness. If it is "just" a mental illness that is playing tricks on my brain, then why are the experiences, whether voices or thoughts, so compelling? A "brain disease" is as inadequate an explanation of my reality as is the explanation that Shakespeare's works could have been produced by a chimpanzee randomly pecking at the keys on a typewriter. To use a radio metaphor, what I hear isn't white noise, static, or interference, but rather a fully articulated conversation. Explain that.

What Amy, a friend of mine who has schizophrenia, has explained to me is that some people with serious mental illnesses do not necessarily share our ready to wear sense of reality to begin with, only to add on top of that their few, select, anomalous experiences or symptoms. Rather, they are trying-often valiantly and with tremendous courage and resilience in the face of repeated failures-to construct a reality that makes sense of their experiences-all of their experiences. They seldom have the luxury of simply leaving some experiences out of the equation, as better-resourced or less challenged people might do at times as a matter of convenience. The stereotypic "lack of insight" thought to accompany schizophrenia may, when it occurs at all, be one such attempt on the person's part to deny some of his or her own experiences, but this unfortunately does not work. Rather, he or she is left with the challenge of accounting for these experiences somehow, and usually has only his or her own devices to fall back on. The rote answer of "I have a biochemical imbalance" may satisfy some people some of the time (e.g., mental health practitioners and family members), but it does little to actually help the person understand and incorporate such experiences into his or her sense of reality. And, regrettably, they often have the detrimental effect of convincing the person that he or she is fundamentally flawed and deficient, and therefore unsuitable for a normal life.

In reality, though, it is not the person who is flawed or deficient, but it is our ready to wear sense of reality that does not allow room for such anomalous experiences to occur. These experiences occur, and they occur to human beings; therefore, they are human experiences. They can be distressing, but they also are real. We need a sense of reality which acknowledges that they occur, that they are part of human experience, and which then offers us a more constructive way of making sense of them than either the person's denial or the mental health system's (dis)regarding them as alien have made possible in the past.