Reality, if you think about it, is a kind of social contract. You and I might be strangers, but we agree, at least at a really basic level, on what is real.
So when you talk to someone who isn't signed onto that same contract, it's kind of unsettling.
"What do the gloves do?"
I'm asking a guy named George about the thin plastic hospital gloves he was wearing when we met. "It's so the cosmic dust doesn't get on my hands," is his reply.
I met George at the Citywide Mental Health Center in San Francisco's tenderloin district. It's the type of place where men wearing unseasonable winter parkas loiter around the entrance smoking cigarettes.
The clinic let me come in and talk to its clients on the condition that I won't use their last names. Staff there says that part of looking out for their patients' best interests is protecting their privacy – something that's also required under the Health Insurance Portability and Accountability Act - HIPAA.
George was upstairs, in a computer room. He's in his 50s, with neatly combed hair and faded tattoos on his forearms.
And when I spoke to him, he told me he saw flashes of light coming from my mouth.
"It looks like yellow, with light pinkish color."
When I asked him if he's always seen colors when people speak, he told me he has, and that seeing the colors helps him understand life and makes him feel superior.
I'm not proud of it, but this conversation made me uncomfortable.
It was something about the particular way that George drifted back and forth between delusions and reality that was unsettling.
And that's partly why when antipsychotic drugs were invented in the 1960s, they seemed revolutionary.
Up until that point, the treatments for schizophrenia were pretty draconian, says Dr. Sophia Vinogradov, a psychiatrist and researcher at the San Francisco VA Medical Center.
"Wrapping them in wet towels, locking them in a padded cell, frontal lobotomies if the behavior was really out of control," she says.
"So when anti-psychotic medications did evolve and they did reduce psychotic symptoms, it was like the heavens had opened."
Pat Deegan advocates for people who have been diagnosed with mental illness — people like herself. She has been diagnosed with schizophrenia. Degan collaborated with others to create an audio simulation, inspired by the voices that they themselves hear. It's intended to give insight to therapists and others who work in mental health. Sometimes the voices are distressing and intrusive, they say, but not always. Visit Deegan's website to hear the audio simulation.
Antipsychotic drugs are good at tamping down the kinds of symptoms that scare people — those strange beliefs and visions. And to be clear, for a lot of people this is a lifesaver.
But for others, the drugs don't work that well. They can have bad side effects, make people gain weight, have tremors or get slow and sleepy. Some people with schizophrenia say they don't want to get rid of their hallucinations because they are a part of who they are.
And for Vinogradov and other researchers who study the disease, the antipsychotics aren't really getting at the disease itself. They are just treating one symptom of it.
"We haven't been addressing these underlying cognitive dysfunctions, which are really at the heart of what impede people's ability to have a fulfilling and successful life," says Vinogradov.
This is important, but it's a little bit complicated. So let's back up.
Schizophrenia, the word, means literally "split mind." And that's how people usually think of schizophrenia, as a disease defined by weird ideas, like believing in cosmic dust. Or that the FBI is following you.
But this public perception of schizophrenia hasn't kept up with the science. When you talk to scientists today who study the disease, these weird beliefs are not what they emphasize.
If you want to really understand schizophrenia, look instead to how the disease begins, says Dr. Daniel Mathalon, a neuroscientist at the University of California, San Francisco.
"Kids seem to be growing up OK. But somewhere, typically in the teenage years, you start to see a decline in their functioning," he says. "They were doing better in school, now they're doing worse. They may have they had friends when they're younger, but they're starting to be more socially isolated."
This stage in life is supposed to be a time when the intellect flourishes. But for teenagers who go on to develop schizophrenia, the opposite can happen. They start to lose focus. Some say they used to be able to read books and now they can't. They used to be able to play the guitar well and now they can't.
At its core, schizophrenia is a decline in basic brain functioning, says Mathalon and others. Abilities like memory and basic motor skills start to falter. It's almost like a dementia that hits young people.
Someone without schizophrenia can hear a car alarm go off in the distance and barely register it. The brain instantly knows that the car alarm isn't salient. You can ignore it.
But for some people with schizophrenia, says Vinogradov, it's as if the filter is broken.
"They are walking down the street trying to have a conversation and their brain is being flooded with the sound of the door slamming, the airplane going overhead."
The brain of someone with schizophrenia tries to process all that information as though it has meaning, says Vinogradov. And maybe, though this is just a theory, this onslaught of extra stuff, extra data —that is what gives rise to hallucinations.
"It tries to make sense of it so that the person can go about with their life," says Vinogradov. "And there's some evidence to suggest that that's what gives rise to delusional ideas, to paranoia, to hallucinatory activity."
Considered this way, schizophrenia is a disease in which the stream of consciousness has swollen into a tsunami.
This seems to be the case with Paul, another guy I met at the clinic. Paul is an Asian man in his 50s whose conversation is hard to follow.
"Punjab, Punjab, Punjab," Paul keeps repeating. Then: "I've never been to India, but I saw pictures of it, books. You go places you never been like books." Pretty soon he's talking about his brother Kenny, Chuck Norris, Stanley tools, Battlestar Galactica, and on and on.
Everything I say to Paul, or he says to me, triggers a jumble of tangentially related ideas. It's like playing pinball with a machine where the ball never comes back down the chute. It just keeps bouncing around.
So what if you could teach someone like Paul to tune out the distractions in his head, to have a real conversation?
This is what researchers in schizophrenia want to achieve these days. They're less focused on making delusions go away. They want to help people with schizophrenia simply think more clearly.
One way to do this might be with a drug designed to improve memory and basic brain performance. Pharmaceutical companies have been working on this, but without much success, so clinicians are prescribing things that seem to be good for the brain like fish oil pills and exercise.
And at the mental health clinic where I met Paul and George, Vinogradov is conducting a study to see whether the brain can be, essentially, retaught. It uses computer games designed to train people with schizophrenia to tune out distractions and focus on simple instructions.
The idea isn't that video games would replace antipsychotic drugs, at least not for everyone. Vinogradov says there are many people whose voices or delusions are so destructive, so violent, that they need to be turned off. Medication is still the best way to do that.
But for another group of people, these kinds of approaches might let doctors focus on a different set of questions, says Vinogradov. "Is this person able to have the kind of life they want? Are they able to have friends, people they love who can love them back? Are they able to keep food and shelter?"
Voices and beliefs may not be what are getting in the way of that. Simpler problems like memory and focus may be the bigger obstacles to a good quality of life.
Addressing those questions may be a lot more important than whether someone hears voices or not.