In his haunting “Shelter from the Storm”, Bob Dylan sings of the notion of asylum, from the classical Greek word for “sanctuary”. Asylums became the standard place of treatment for people of “unsound mind” from the 19th century until the 1960s, and some remain today. Deriving from the principles behind “The Retreat”, founded by the Quakers in 1796 to rescue the “shattered bark” of troubled brothers who had developed psychiatric problems, asylum care originally ensured removal from the hurly-burly of the world, and offered fresh air, pleasant surroundings and moral therapy. Even today’s busy, and often chaotic, acute psychiatric wards try to provide something of this sort, with cognitive, behavioural and occupational therapies substituting for the “moral” bit.

Mr A required asylum when he had a fit and became confused in his late thirties but he responded to treatment with antipsychotics. A further admission occurred four years later when he started hearing voices and became delusional. He was given a standard antipsychotic (Trifluoperazine), which he gradually cut down over the next three years, at which point the voices started to reoccur. In his view, they belonged to angels, and he developed a firm belief that he was Jesus. In other respects he felt fine.

Mr A was brought to our unit by the police because of a contretemps outside the local mosque. He had decided, in his role as Messiah, to preach to the world and explain who he was. This was met with disbelief, abuse and threats. On admission he was distressed, but nicely turned out, and willing to describe his experiences. He had tried to downplay the Messiah message, working quietly as an accountant, but he still heard regular angelic voices. He showed no other abnormality of mind, was polite and thoughtful, and agreed to take medication and remove the Messiah letterhead from his work correspondence.

We discussed with him in outpatients how he was coping, and, while he understood other people’s disbelief, he still felt he should await advice from God as to what he should do. He was not depressed or agitated, but described occasional experiences of the angels still talking to him, mainly at night. These met the criteria of hypnagogic hallucinations or the experience of hearing/seeing/feeling something that seems absolutely real, in the context of falling asleep. Up to 30 per cent of people experience such phenomena, which are often seen as ghosts or experienced as waking dreams, and they are not especially indicative of mental illness.

The “Messiah delusion” had been a common condition in 19th-century asylums, as reported in an 1890s British Medical Journal leader. One approach was to put such patients together and see how they got on. Would this help them develop insight into their illness? When questioned after such meetings, the standard response from each and every patient would be, “I’m the Messiah, and they’re all mad.”

Mr A has remained stable, has not caused a disturbance in his neighbourhood and has not required any further treatment. He has a formal psychiatric diagnosis of a persistent delusional disorder, something regularly seen in adult psychiatry practice. Every month or so we come across people believing they are Michael Jackson, Madonna or even an animal. I have seen two other Saviour/Messiahs, but they are less common in this ungodly age.

Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity

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