It was 3am when the soldiers came.  She was woken up by the sound of shots being fired somewhere down the hill.  Her father shouted at her to get dressed.  ‘We must run into the woods, now, before they get here.’   The next moment, there was a thump at the door. It crashed open and four, five, six of them surged in.  She remembered how young they looked, little more than boys, but they were drunk and excited, out of control.  Her father tried to hit one of them with a stick, but they seized him and  dragged him  out into the yard where they shot him both in the head. They did the same to her brother.  Her mother screamed, and managed to stab one of them with a kitchen knife, but he threw her off, grabbed the knife and slashed her throat.  Then they turned to Nabalungi, who was cowering in the corner of the hut.  It took three of them to hold her down while rest take it in turns to rape her.  When they had finished, they tossed her aside like a rag doll and left.   


How in the bowels of the living Christ, can anyone survive an experience like that?  Nothing had prepared Nabalungi for it.  She was cheerful, intelligent girl with a loving family,  she was going to be a nurse, her boy friend a teacher.  She had just celebrated her first communion.  Suddenly, within the time it took to wait for the bus into Masaka,  her family had been killed, her village burnt and reduced to rubble and she had been violated, injured, and possibly infected with AIDs.  At the 15, her life as she knew it, was over. 


The nurses from the mission found her where the soldiers had discarded her,  half dressed and whimpering in the corner of what was once the veranda with the decomposing remains of her family, chewed by dogs, scattered in the yard in front of her.  They led her gently away from the horror to a safe house in the town. 


Three months later, she still hadn’t said anything.  She sat for most of the day, gently rocking and staring at the wall.  She was like an infant. She could not look after herself.  She allowed the nurses to wash and dress her.  She ate when they fed her.  They took her by the hand and led her into the garden, but she walked like somebody asleep, unaware.  That was before the screaming started.


At first a low moan deep in the back of her throat, it built to a crescendo while she tore at her clothes and hit herself with her fists or any object that was close at hand.     Any attempts at restraint made her worse.  The only thing that would calm her was  singing.  They would take her to the church and she would sit rocking in time to the music, sucking her thumb.   


Nabalungi was paralysed by her ordeal. She had gone into emotional hibernation. Brain scans of people in such dissociated states show minimal levels of activity throughout the cortex.  But as the memories returned, she was traumatised all over again.  The singing not only calmed her, it gave her a  meaning for her life.  She came to believe that Jesus had saved her and asked her to marry him. She never left the mission.  How could she?  It was an alternative world for her, a refuge from an intolerable reality, and she seemed happy helping the sisters and looking after the children.  She never talked about what happened to her. 


It might be said that what had happened to Nabalungi had driven her mad.  If to be sane, means the ability to live independently and congruently in the society of others, then she wouldn’t qualify.  She would not survive in the society outside the mission.  She has to be looked after.  She is lucky to have an existence where she is sustained and doesn’t seem out of place. 


Madness is a social construct.  A mad person is somebody who does not conform to the accepted conventions and mores of the society in which they live.  But this tells us as much about the society as it does about the individual.  Is it the society that is mad or the individual? 


In the repressive environment of the Soviet Union, free-thinkers, intellectuals were considered to be deluded, and were sent away to live in asylums.  In Port-au-Prince, beliefs in spirits, the evil eye, witches and demons is quite usual, but they would get you locked up in Dorking.     


But when reality has become intolerable, when something so traumatic, so devastating that it defies reason and any attempt to make sense of it, happens, then the only way a person can survive is to take refuge in a different reality.  This may seem mad, but in the context of what has happened, it is perfectly sane.  It is just doing what many of us do when we have a crisis in our lives – move to a new environment, make new friends, establish new interests, use these to find new meaning in life – to remodel an identity.  The only difference is that people, whose life has been devastated by dreadful experience have to move much further out.  Traumatised people don’t just need to start again elsewhere.  They have to construct their own alternative world and go and live in it.    


Psychiatrists tend to regard schizophrenia as a genetic disease. It isn’t.  It may not even be a disease.  It does not have a distinct pathology.  It is perhaps best described as an abnormal behaviour, in which people inhabit a different reality. 


There are few disorders where genes provide the only explanation and Schizophrenia is not one of them.  So while there may be genes that might predispose to an escape into psychosis perhaps by encoding for specific chemicals that induce an abnormal reactivity to stimuli,  the social environment and the way an infant was entrained is  hugely important, and adverse life events, abuse and trauma, can render individuals more susceptible to psychotic breakdown.  One man may be born mad, another may acquire madness though the way he was brought up and a third may have it shocked into him by the vicissitudes of life.      


Psychosis is a spectrum.  We all have a tendency to delusion.  King Christian X of Denmark, who was a potent symbol of passive resistance against the Nazis, once said ‘We console ourselves with our imaginings and delusions’.  We create a make believe of our lives to make it tolerable.  This isn’t madness, but it is easy to see that if reality was intolerable, the only recourse would be live the make believe, to escape into a alternative reality that looked to the outside world like madness. 


It’s always important to listen to people with psychosis.  There is method in their madness and a meaning and memory that underlies it.  When I was a medical student, I was impressed by the understanding compassion of the Scottish psychiatrist R.D.Laing.  He understood the communications of his psychotic patients as valid descriptions of their reality rather than symptoms of some distinct disease,  and would listen to their stories, engage with the delusions and with calm reassurance and a safe environment, help them make sense of them.  This would connect them with reality and provide a route to rehabilitation.  It is not necessary to talk about the traumatic experience. Many people who have been severely traumatised do not wish to talk about it.  Why should they?  It will only re-traumatise them. Their survival depends on the new identity they have created.  Therapists of the Laingian persuasion would work in the present, engaging with the delusions, understanding them, questioning them and trying to alleviate tension by bringing them into line with the rest of society. Although drugs might need to be given to reduce the disturbance of delusional patients, they can also tend to alienate them and make them less accessible.          


Nabalungi has escaped, not into madness, but into religion, a kind of institutionalised delusion that helps people cope with the uncertainties and insecurities of their real lives.  This refuge has equipped her with the make believe she needed to survive