HAMISH HAMILTON
an imprint of
PENGUIN BOOKS
HAMISH HAMILTON
Published by the Penguin Group
Penguin Books Ltd, 80 Strand, London WC2R 0RL, England
Penguin Group (USA) Inc., 375 Hudson Street, New York, New York 10014, USA
Penguin Group (Canada), 90 Eglinton Avenue East, Suite 700, Toronto, Ontario, Canada M4P 2Y3
(a division of Pearson Penguin Canada Inc.)
Penguin Ireland, 25 St Stephen’s Green, Dublin 2, Ireland
(a division of Penguin Books Ltd)
Penguin Group (Australia), 250 Camberwell Road, Camberwell, Victoria 3124, Australia
(a division of Pearson Australia Group Pty Ltd)
Penguin Books India Pvt Ltd, 11 Community Centre, Panchsheel Park, New Delhi – 110 017, India
Penguin Group (NZ), 67 Apollo Drive, Rosedale, Auckland 0632, New Zealand
(a division of Pearson New Zealand Ltd)
Penguin Books (South Africa) (Pty) Ltd, 24 Sturdee Avenue, Rosebank, Johannesburg 2196, South Africa
Penguin Books Ltd, Registered Offices: 80 Strand, London WC2R 0RL, England
www.penguin.com
First published 2011
Copyright © Darian Leader, 2011
The moral right of the author has been asserted
All rights reserved
Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the above publisher of this book
ISBN: 978-0-14-195578-0
Introduction
1. Quiet Madness
2. The Basics
3. Psychosis
4. Language and Logic
5. Making a Diagnosis
6. Causes of Psychosis
7. Triggering
8. Stabilization and Creation
9. Aimée
10. The Wolf Man
11. Shipman
12. Working with Psychosis
Afterword
Notes
By the same author
Introducing Lacan (with Judy Groves)
Why Do Women Write More Letters Than They Post?
Promises Lovers Make When It Gets Late
Freud’s Footnotes
Stealing the Mona Lisa: What Art Stops Us from Seeing
Why Do People Get Ill? (with David Corfield)
The New Black: Mourning, Melancholia and Depression
For M again
Many years ago, when I was still a student, I started weekly voluntary work in a therapeutic community. I had my head full of psychoanalysis, and wanted to understand more about the strange phenomena of psychosis: the hallucinations, delusions and language disturbances that I had read about yet never experienced at first hand. Most of the people I met were rather calm and showed few signs of being ‘crazy’. Long-term medication had worn them down, and they had settled into their own quiet routines. One man, however, was eager to talk, and we would spend many hours discussing philosophy, politics and current affairs. He was articulate, lucid and extremely intelligent, and it mystified me to learn that he had spent the last few years in psychiatric hospitals. Chatting with him, he seemed no more or less disturbed than the student friends I would meet with after work at the community.
As our conversations continued, I asked a couple of the staff members why he was living in a therapeutic community and why he was medicated. The wry smiles I received in reply suggested that there was something obvious I had missed, some glaring fact that had not registered on my youthful radar. And indeed, it was true. Several months later, during the course of one of our chats, he referred to a country I had not heard of. His surprise at my ignorance was followed by enlightenment: he explained that he lived not in England but in Xamara, a place populated by wild animals and a legion of exotic gods. He described its geography, its history and its infrastructure. Everything had been named and classified, like the kingdoms of Angria and Gondal invented by the Brontë sisters during their childhood.
For him, there was no incompatibility between his role as a protagonist in the saga of Xamara and his everyday life and chores at the community. Describing it, there was no excitement in his voice, no accent of emotion, no change of tone, as if it were simply one further fact of his existence. It was this continuity in his voice that really struck me: there was no sign or marker in his speech that we were leaving the territory of some shared reality to enter a private world. It was as if everything were the same, and our subsequent conversations bore no trace of a secret initiation or inclusion into his confidence. Life just continued as before.
How could it be, I wondered, that delusion and everyday life could be so seamlessly woven together? How could one inhabit two apparently different places at the same time as if there were no barrier between them? And even if living in Xamara seemed crazy, why should it require a medical regime or a hospitalization? It hurt no one, and caused no turbulence in that person’s life. These are questions that I still ask, and in this book I have tried to explore some of the links between madness and normal life. Are delusion and sanity to be rigidly separated or, on the contrary, could the former be not only consistent with but even a condition of the latter?
These are not abstract, intellectual questions, and they have a real bearing on the way in which psychosis is treated in society today. Our attitudes to madness will shape our response to it, in terms of both our everyday interactions and in the choice of therapies that are available. Yet there has been a marked absence of dialogue between traditions here. There are theories and therapies of madness that have been developed around the world for at least half a century, yet which are more or less unknown outside a very narrow professional field. They provide fascinating and powerful tools for understanding the experience of madness and explaining why and how it can come about. They also offer a rich set of possibilities for therapy and for thinking about how a psychosis can stabilize. Although we may like to think that knowledge is cumulative and unified, especially in the age of the Internet, this is far from the case. There is a superficial and troubling confidence in what advertises itself as ‘up to date’ research, as if an article published in a fancy journal in 2010 were more valuable than one written in a now-forgotten medical review a hundred years earlier that we can access only in some dusty archive.
The work that I am going to focus on comes out of the Continental tradition in psychiatry. Late-nineteenth- and early-twentieth-century psychiatrists have been much maligned for their prejudices on issues such as hereditary, constitution and mental degeneracy, yet many of them took the time to listen to their patients and developed theories of madness that were faithful to what they learned from their clinic. The absence of long-term drug treatments made it possible to study how a person whose life had been torn apart by psychosis could find a new equilibrium over time. Exploring what psychiatrists called these ‘restitution mechanisms’, the pathways back into life, formed a central part of this research, and we have much to learn from it today.
When the young medical student Jacques Lacan began his psychiatric training in the Paris of the 1920s, this is the culture in which his own ideas began to grow. Today, Lacanian clinical work with psychosis takes place around the world, especially in France, Belgium, Spain, Italy and the Latin American countries, and, increasingly, in the UK. There is a flourishing culture of journals, books, newsletters, conferences, courses and lectures all devoted to exploring different aspects of madness. To date, several thousand case histories of work with psychotic subjects have been published by Lacanian clinicians. Yet sadly, outside of the field itself, most psychiatrists, psychologists and mental health workers will never have come across any of this research.
There are many reasons for this. It is often assumed that psychoanalytic work with madness means classical psychoanalysis: the patient lies on the couch and free associates and the analyst makes interpretations about their childhood. Aside from the fact that most psychoanalysis isn’t like that anyway, the real confusion is about the difference between theories and techniques. A psychoanalytic theory of psychosis doesn’t mean that psychoanalysis will – or even should – take place. Rather, it means that analytic ideas can be used to inspire other kinds of work, other treatments that are tailored to the singularity of each individual patient. This fact has been clear to clinicians for the last hundred years, yet it continues to generate misunderstandings and confusions, perhaps due to the deep-rooted prejudices against – and within – psychoanalysis itself.
The attention to the uniqueness of each patient that the psychoanalytic approach involves is all the more important now, as we live in a society that has less and less space for the detail and value of individual lives. Despite the ubiquitous lip service to respecting difference and diversity, people today are coerced more than ever to think in uniform ways, from the nursery to the corridors of professional life. We see this reflected in the mental health world, where treatment is often considered an almost mechanized technique to be applied to a passive patient, rather than as a joint collaborative work, where each party has responsibilities. There is increasing pressure today to see mental health services as a kind of garage, where people are rehabilitated and sent back to their jobs – and perhaps to their families – as soon as possible.
The psychotic subject has become less a person to be listened to than an object to be treated. The patient’s specificity and life story are often just airbrushed away. Where old psychiatry books were once filled with the reported speech of patients, today all one sees are statistics and pseudo-mathematical diagrams. Studies hardly ever mention what happens in unique cases, but present figures where the cases have been aggregated together. We never find out, for example, why one individual responded to some treatment and what exactly their response was; instead we get the statistics of what percentage of participants responded or failed to respond. The individual has vanished.
These are facts of contemporary discourse, and not just of psychiatry, yet one might have hoped that it would be precisely psychiatry that would have offered something different here. Despite the warnings of progressive psychiatrists over the years and the anti-psychiatry movements of the 1960s and 1970s, psychosis is still too often equated with the ways in which some people fail to fit the norms of society. As the pioneering clinician Marguerite Sechehaye pointed out many years ago, ‘When we try to build a bridge between the schizophrenic and ourselves, it is often with the idea of leading him back to reality – our own – and to our own norm. He feels it and naturally turns away from this intrusion.’ Today’s premium is set on conventional adjustment to social norms, even if this means that things will not go well in the long run for the individual.
We can see this at the most basic level of our culture, in primary- and secondary-school education, where the formula of multiple choice has been replacing that of the child’s original response. Rather than encouraging children to think for themselves and elaborate an answer, multiple choice simply proposes two or three answers that the child must then choose between. This means, of course, that children learn that there is a ‘right answer’ that someone else knows, and that their own constructions are discouraged. The key to success is figuring out what someone else wants to hear, rather than attempting an authentic solution oneself. No wonder that social commentators describe our times as an era of the ‘false self’.
We have moved so far away in the last fifty or sixty years from a culture of inquiry, open-mindedness and tolerance that comparing the texts of the clinicians who worked with psychosis in the 1950s and 1960s with those of today is astonishing. Many contemporary authors write as if the problems of madness have just been solved by genetic or neurological research: psychosis is a brain disease and drugs will cure it. There are of course notable exceptions – and in particular the work of many psychiatrists and mental health workers in the Scandinavian countries – yet the general situation is quite miserable. A pseudo-scientific emphasis on measurable outcomes and visible ‘results’ has replaced careful, long-term work that gives a dignity to each individual patient.
Two American psychologists who have continued the old tradition of psychotherapy of psychosis compare their efforts with Dr Seuss’s Horton. This sympathetic elephant can hear the inhabitants of a microscopic world contained on a speck of dust, yet no one else in the jungle believes him. He knows about their plight and the impending disaster that they face, yet cannot make anyone else listen. Horton’s endeavour to save them is solitary and made even more difficult by the lack of support from his macroscopic friends, who do their best to hamper his efforts. Anyone working in the mental health field who favours the psychotherapeutic approach will recognize the analogy immediately: the obsession with predetermined outcomes, surface behaviour and ‘normalization’ makes alternative views seem far-fetched and implausible.
I hope that the ideas set out in this book will generate some dialogue around a set of questions that, after all, concern all of us. Different traditions need to listen to each other, in the same way that Phillippe Pinel, often praised with humanizing psychiatry in the eighteenth and early nineteenth century, listened not only to his patients and his Continental colleagues, but also to William Tuke and his co-workers at the York Retreat in England. These Quakers favoured humane treatment, with small institutions and an emphasis on relations between people as opposed to medicalizing interventions. They urged a tempering of the passion to ‘cure’ and a critique of the ‘cult of curability’. Tuke was opposed to the use of restraints and punishments, and his work, taken up by Pinel and others, would lead eventually to the demise of the most barbarous techniques in psychiatry in many countries.
Although this cruelty perhaps seems absent today, violence towards psychotic subjects has taken a different form. Later historians of psychiatry have been critical of Pinel and Tuke, arguing that restraint simply moved from the outside to the inside, in the form of techniques of moral management and suggestion. If the use of external force and restraint was diminished, violence was still present in the imposition of a worldview. The clinician who attempts to graft his own value system and view of normality on to the patient becomes like the colonizer who seeks to educate the natives, no doubt for their own good. Whether the system is secular and educative or religious, it still bulldozes away the culture and history of the person it purports to help.
Not long ago one of my patients was hospitalized during a manic episode. When I arrived at the ward, a large security guard was sitting on top of her, while a nurse attempted to administer an injection. Since being forcibly restrained was one of the most devastating aspects of her childhood history, this situation was not a happy one for her and she resisted most vigorously. This led to even greater physical pressure, yet the brutality of the scene continued after her sedation in a distinct but no less significant way.
The checklist and interviews she had to go through after sedation gave her little room to speak about what had happened. There was no interest in the detail of what had precipitated her episode. Instead, she described how she was forced into a set of concepts and categories that were alien to her, like the protagonist in Sarah Kane’s 4:48 Psychosis, whose fury grows as her doctor refuses to go beyond the question of whether her act of self-harm provided relief or not. My patient was told how her behaviour was incorrect, and how she needed to learn to think differently and to see herself as a person with an illness requiring chemical treatment so she could be ‘normal’ again. And she had to have a diagnostic label, a stamp on her that would remain inscribed not only in her medical records but also in her mind for the rest of her life.
However valid we might believe such conceptions of illness and health to be, we must surely take seriously the inner life and beliefs of each person, and avoid imposing our worldview on them. This is the difference between mental hygiene – in which we know what is best in advance for the patient – and psychotherapy – in which we don’t. It is easy to miss the violence at play here, yet it is present each time we try to crush a patient’s belief system by imposing a new system of values and policies on them. We could contrast this with an approach that looks not for the errors but for the truth in each person’s relation to the world, and the effort to mobilize what is particular to each person’s story to help them to engage once again with life: not to adapt them to our reality, but to learn what their own reality consists of, and how this can be of use to them.
A word on vocabulary and concepts. I refer to ‘madness’ and ‘psychosis’ throughout this book, using the terms interchangeably. I don’t hold a relativist view – that madness is just what doesn’t fit social norms – for reasons that will become clear in later chapters. Recognizing that there is such a thing as psychosis, however, does not mean that we need to buy into the discourse of mental health and illness. Although many people experience unbearable levels of suffering, this does not make them ‘mentally ill’, as there is simply no such thing as mental health. The more we explore each individual case, the more we find that the seemingly ‘healthy’ person may have delusional beliefs or symptoms that generate no conflict in their lives and hence attract no attention. Each of us faces problems that we tackle in our own unique ways, and what is labelled mental illness may in fact, as we shall see, be an effort to respond to and elaborate these difficulties. Using such labels not only entrenches the false dichotomy of health and illness, but also eclipses the creative, positive aspect of psychotic phenomena.
I would like to thank several friends and colleagues for their kind and various contributions to this book: Josh Appignanesi, Chloe Aridjis, Devorah Baum, Sadie Coles, John Forrester, Anouchka Grose, Andrew Hodgkiss, Richard House, Ruiz Karu, Peter Owen, Colette Sepel, Christos Tombras and Lindsay Watson. In Paris, I learned about psychosis from Éric Laurent and Colette Soler, and their psychoanalytic approaches have informed much of this book. As ever, Geneviève Morel’s work has inspired me to question received wisdom and to link theoretical and clinical questions as closely as possible. Jay Watts was indefatigable in her endeavours to balance and critique my Lacanian views, and to broaden my horizons. Astrid Gessert, Sophie Pathan and Pat Blackett gave me invaluable help with research, and everyone at Hamish Hamilton has made the publication process a smooth one: thanks especially to Sarah Coward, Anna Kelly and Anna Ridley. Simon Prosser was once again a perfect editor, both critical and supportive, and I am especially grateful to him for his insights and suggestions. My agent, Tracy Bohan at Wylie, has also helped me consistently with her encouragement and advice. Last but never least, thanks to my psychotic patients for everything they have taught me. I hope that the book remains faithful to their experience, and that they can hear their voices within it.
Whether it’s One Flew Over the Cuckoo’s Nest, Girl Interrupted or A Beautiful Mind, why is madness always made so visible, so tangible, so audible? People talk to imaginary companions, they foam at the mouth, they have terrifying hallucinations, they blabber incessantly, they rant and rave about a plot against them. Generally, they are depicted either as incredibly clever or incredibly stupid, as genius or brute, yet with little in between. There is no doubt that madness is sometimes accompanied by striking symptomology, but what about the case of the man who calmly goes about his business and family life, one day goes to work, does his job impeccably, then goes to a public place, pulls out a gun and shoots some public figure? There is nothing noticeably abnormal about their behaviour until that moment. They may in fact have been a model citizen, responsible, respectable and even-tempered. But, in the time preceding their homicidal act, could we really say that they were not mad? Surely it invites us to think about those instances of madness that are compatible with normal life. This is a quiet, contained madness, until the moment it erupts in the act of violence.
But what if the act of violence never came? What if, in our example, the man just carried on with his daily life? If there was madness before the act, what if it just continued in its quiet way, bothering no one, drawing no attention to itself. If madness and normality are indeed compatible, would that person be any more mad whether they had pulled the trigger or not? What if nothing of any note had occurred, and they had just pursued their daily routines and activities. Perhaps they might have taken up some hobby at retirement – a piece of historical research, a genealogical investigation, the study of a science – or started writing – letters, notebooks, a novel. This would be a normal life by all accounts, yet would it be any less mad than its more visible, spectacular shadow?
The fact that newspaper reports of ‘mental illness’ so often associate it with violent crime mean that dramatic outbursts become almost what we expect madness to be about. Mental health campaigners have worked long and hard to challenge such associations, yet they continue to shape popular perceptions of psychosis. Although the chances of being randomly attacked by a so-called ‘paranoid schizophrenic’ are infinitely less than those of being set upon by a gang of young white males at pub closing time, it is the former stories and not the latter that make the news. Perhaps, at some level, we not only expect this from madness but actually want it, as if to externalize the latent feelings of violence we all harbour within ourselves.
When the great nineteenth- and early-twentieth-century psychiatrists began their explorations of madness, they focused first of all on the visible, attention-grabbing symptoms. They studied the acts of violence, the hallucinations, the delusions, mood swings and extreme, acute passions that could convulse a human life. They tried to classify these phenomena, dividing up disorders, creating new diagnostic entities, searching for the details that would allow a taxonomy. But soon enough, they found that the most obvious, socially disruptive symptoms could not be used exclusively to define the forms that madness could take.
Almost every major author in this period who made claims about the defining course of their favourite diagnoses – dementia praecox, schizophrenia, chronic hallucinatory psychosis – would then gradually admit that they had been hasty and that not all cases fitted the pattern. Progressively, they found that the initial features used to make the diagnosis and which attracted attention could mutate, transform or even disappear. A bizarre thought disorder, for example, might settle into a picture of social integration and cohesion. Terrifying hallucinations might, over time, fade away, and a rhythm of normality be established. Someone might complain of persecutors, yet later on would barely mention them. An acute feeling of internal deadness could coexist with an uneventful working life and a position of social responsibility within one’s community.
An even greater number of cases would simply never come to the attention of psychiatrists. These were the discreet psychoses that had always managed to fit in well with society, never exploding into spectacular symptomology, never disintegrating into breakdown or crisis. Being psychotic would not mean that one’s psychosis would actually trigger, in the sense of a sudden detonation apparent to both the person and those around them. A popular pre-war psychiatric textbook could state categorically that: ‘Most paranoiacs will go through life without ever developing psychosis.’ And Eugen Bleuler, often credited with first theorizing and popularizing the diagnostic category of schizophrenia, could conclude after many years of research that the most common form of schizophrenia was in fact the latent variety, the kind that never became visible as madness. He added that there was ultimately no clinical sign that could exclude the diagnosis of schizophrenia, a suggestion that shocked many of his readers and would no doubt shock many today.
Bleuler’s view, as one psychiatrist put it, broke ‘the equilibrium and harmony of psychiatric concepts’. It meant that there was no test that could prove that someone was not schizophrenic: not the kind of schizophrenic whose actions and speech attract attention, but the quiet, discreet kind that Bleuler and many of his colleagues would study. As the schizophrenia researcher Silvano Arieti could conclude, reviewing studies in his field after more than three decades, ‘Typical psychotics who are not under treatment do not seem to know that there is anything wrong with them.’ This subtle, reserved madness has been called ‘white psychosis’, ‘normal psychosis’, ‘lucid psychosis’, ‘everyday psychosis’, ‘private psychosis’ and ‘ordinary psychosis’.
Recognizing the prevalence of this kind of psychosis and studying its structure is especially important today, for a number of reasons. It can not only help in the effort to destigmatize madness, by weakening the equation with extravagant and dangerous behaviour, but, once we realize that people can be mad without going mad, and live perfectly normal lives, this will have significant consequences when it comes to helping those whose madness has indeed detonated. If we can understand what has allowed someone to remain stable and avoid the most shattering and painful symptoms of psychosis, we can use what we learn to think about directions for work with those whose madness has, in fact, triggered.
Early in the twentieth century, the French psychiatrists Paul Sérieux and Joseph Capgras reviewed the massive literature on quiet madness. The psychotic subject could be well adapted to their milieu, showing no confusion or intellectual impairment, no hallucinations, no euphorias, no depressions. Their emotional lives could seem normal and their language clear, precise and logical. These cases showed ‘the strange association of reason and madness’, with a central delusional idea that might not seem extravagant or even unrealistic. The person would not display any manifest oddities, yet certain categories of thought would be ruled out. There would be blank spots in that person’s consciousness, areas where information could not be assimilated.
Such psychotic subjects were like ‘specialists’, who saw the world in terms of their primary preoccupation. They could function perfectly well in everyday life, and those around them might never suspect that anything were remotely out of the ordinary. Indeed, Sérieux and Capgras even ask, at one point in their study, if the kind of delusions they were studying should be classified as ‘mental illness’. The person might complain of some injustice from their superiors, someone of humble birth might try to prove their connection to a titled family, or one partner might accuse their spouse of immoral behaviour. Generally, everything could be made to fit one fixed idea, based on a false premise. But, after this, the person’s reasoning was watertight. There would never be any appeal to supernatural powers, just good arguments using what was not inherently impossible.
The psychoanalyst Piera Aulagnier discusses the case of a patient who was by all accounts a ‘normal’ member of society, married with children, keeping a shop, conversing with her customers and who sought help only when a phobia intruded into her life. Before long, Aulagnier learned that she had a peculiar theory of how children were born: the man’s sperm played no part, except to excite the woman’s ‘procreative apparatus’, and the vagina would be forced to insert the male substance into that apparatus. Hence men died younger and lost their hair. These delusional ideas had never attracted any attention, since no one had ever asked her to expound her view of conception, and when other people did raise such themes, ‘Either I go out, or I don’t hear,’ she said.
To take another example, one of my patients complained of a diffuse feeling of anxiety, and spent many months telling me about his history and his childhood. He had never seen an analyst or therapist before, and was troubled by the recent encroachment of anxiety into his life. His career in the legal profession had been successful, never hampered by any manifest symptoms or inhibitions. After some time, the cause of his apprehension became clear, and he was able to find what seemed like a workable solution to attenuate it. With this, he left the treatment. In one of the last sessions, however, he mentioned something peculiar: the belief that anyone who shared his first name must also share some common quality with him. The name itself was not unusual, and it meant that whenever he encountered a namesake, he would gravitate towards them, inquisitive to learn more.
When I probed further, he was uneasy, understanding that his belief would seem odd. Yet beyond it was an absolute certainty: the name was only applied if the people in question possessed an inner essence, immutable and invariant. He took care not to broadcast this delusional thought, and it had never caused him any problems. Indeed, we could suspect that it helped him maintain an identity, as he believed also that those sharing the name must have had a common ancestor. As with Aulagnier’s patient, there was no reason for the belief to become problematic or cause conflict, and it could remain hidden in the course of his everyday life.
If Aulagnier’s patient had not developed her phobia and had not visited an analyst, the delusional ideas would perhaps never have become apparent. She might have continued with her life and kept quiet about her beliefs. If there were no major frictions with her environment, there would have been no suspicion of a psychosis, as was the case with my patient, whose delusional thought was highly encapsulated. Yet it is exactly these forms of psychosis that we can learn from: through studying them, we can try to understand the mechanisms that have allowed the person to be mad – quietly – without going mad. Since today mental health is so often defined as a lack of conflict with the world around us, this kind of psychosis simply goes off radar: it vanishes.
This disappearance of what earlier clinicians took to be the most common form of psychosis is reinforced by the fact that delusional thoughts are generally kept secret. As one of Manfred Bleuler’s patients put it, ‘In my world I am omnipotent, in yours I practise diplomacy.’ Today, few clinicians will have studied the old psychiatric category of ‘reticence’, which described the ways in which topics may be avoided and kept silent. Yet long-term work with a psychotic subject always shows that there is a lot that does not get revealed immediately, if at all. De Clérambault could speak of ‘those silences that are the hallmark of delusion’, and the psychiatrists of the early twentieth century warned against confusing remission and reticence. Bleuler spoke of the psychotic subject’s ‘double book-keeping’: he knows that most people won’t understand his thoughts and beliefs so hides them carefully, even when in a confidential and benevolent setting.
In the case we will discuss in Chapter 9, it took more than 300 sessions for the patient to reveal to her curious and dedicated young psychiatrist what was really on her mind. Imagine how little one could find with a questionnaire-style interview for an hour with a patient today. Indeed, the success of many contemporary treatments is measured in terms of how well a psychotic subject can hide their psychosis, how well they can conform and comply with the expectations of others. We lose out here on what can be learned from long-term conversations: not an hour every month but, often, a conversation that runs over years, and, indeed, decades. It is telling that since the end of the nineteenth century, the psychiatric literature on reticence has been almost non-existent, as if we want to know less and less about what matters to our patients.
Historically, the movement to follow visible madness to quiet, invisible madness began through critiques of the principal diagnostic entities. Emil Kraepelin and many other late-nineteenth- and early-twentieth-century psychiatrists gave a special place to the evolution of psychosis: the course of the illness would determine how it was classified. Dementia praecox, for example, would move towards cognitive and affective impoverishment. The term ‘dementia’ implied a decomposition, the morbid intrusion of an organic process into the psyche that followed its own irreversible laws. If it didn’t, then it wasn’t dementia praecox.
This progressive movement towards dementia was the defining characteristic, which differentiated it from manic-depressive psychosis. The idea that it was thus more or less incurable and doomed to a bleak outcome played its part in forming popular conceptions of madness. It meant despair for both patients and their families. This emphasis on poor prognosis and breakdown worked powerfully to shape expectations: if the patient seemed to be doing well, they couldn’t be psychotic. As one psychiatrist told the American anthropologist Tanya Luhrmann about a patient diagnosed with schizophrenia: ‘She’s had a partner, she’s actually got this guy interested in marrying her and he’s apparently perfectly reasonable, she’s managed without meds. I just don’t think the label makes sense.’ She couldn’t be psychotic because her life wasn’t falling apart in the expected way. The diagnostic preconception was thus a vehicle of prejudice: to be schizophrenic one would have to be visibly disintegrating and unable to attract a mate.
Such rigid ideas about psychosis are present also within the world of psychoanalysis. The Russian aristocrat Sergei Pankejeff first visited Freud in 1910, and, after a four-year treatment, Freud wrote up the case of this patient who became known as the ‘Wolf Man’ after a key dream in which a group of wolves gazes terrifyingly at him. He returned to see Freud for another brief period of analysis, and then continued with Ruth Mack Brunswick, who diagnosed him as paranoiac. Despite good clinical evidence, this diagnosis was unpalatable to future generations. The American analyst Muriel Gardiner, who knew Pankejeff well, contested it on the grounds that ‘He made a most orderly and reliable impression, was always appropriately and carefully dressed, was very polite and considerate of others.’ This attitude is just as prejudiced as that of Luhrmann’s interviewee, as if psychotic people have to stay psychotic in a visible, noisy way, and ultimately don’t have the right to live fruitful, bearable and orderly lives, or even dress carefully.
If these prejudices seem to stem from an adoption of the Kraepelinian view of a chronic, downward spiral in psychosis, defined by its terminal state, we should remember that both Kraepelin himself and his contemporaries would question these very views. Some Anglophone psychiatrists did not read Kraepelin’s original German texts, and assumed that dementia praecox was what the name implied: a disorder starting in adolescence (the praecox) that got worse (the dementia). Yet Kraepelin would acknowledge in the 8th edition of his textbook that the term was ill chosen, and both he and Bleuler would relativize their initial prognostic pessimism, admitting the possibility of positive evolution and change.
Kraepelin acknowledged that the ‘disease’ could be arrested or, indeed, in some cases, ‘cured’, with ‘a complete and lasting recovery’. Emmanuel Régis spoke of a ‘dementia praecox without dementia’, adding that the pessimism attributed to Kraepelin may have been due to its hospital-based framework rather than the city practices of other physicians. Many of Kraepelin’s colleagues, likewise, criticized the use of the term ‘dementia’, with its implications of long-term destruction of mental faculties and psychical decay.
In France, Philippe Chaslin wrote a brilliant and neglected critique of the notion of dementia praecox, proposing instead the concept of ‘discordant madness’, with an emphasis on the curability or improvement that was clinically possible. The term ‘dementia’ suggested a morbid organic process, yet he pointed out that if some cases were triggered in the teens or early adulthood and worsened rapidly, others didn’t, despite the same initial symptom picture. Like many other psychiatrists, Chaslin insisted on how the psychotic subject may retain all their mental faculties, again questioning the implications of Kraepelin’s initial formulation. The problem was less in the faculties – like memory or will – than in the relation between them: in other words, in their discordance.
Symptoms of discordancy could of course get worse, but they could just as well improve or vanish entirely. Perhaps surprisingly, despite the hundreds of critiques of the simplistic understanding of Kraepelin’s concept, and the efforts of epidemiologists and of ‘survivor’ organizations to emphasize positive outcomes, a diagnostic pessimism is still with us today in both consulting rooms and hospital wards. Although we ought to know better, today’s risk society reinforces these prejudices. In both public and private health services, the possibility of litigation looms so large that clinicians are often obliged to present worst-case-scenario pictures to patients and their families. Their alibi is the language of ‘science’, the clinical trials and studies that generate the statistics that we set so much store by today. Bleak outcomes are conveyed as humane candour, without the realization that the very fact of making the prognosis may have significant effects for the sufferer. What impact might it have on the manic-depressive patient who, stable for two years, is told that the statistics indicate that they are likely to relapse within the next six to twelve months?
In contrast to the image of decay suggested by the term ‘dementia’, many of the early-twentieth-century psychiatrists developed their observations of a kind of madness in which all the psychotic subject’s faculties were intact. Thought disorders would only become apparent, if at all, when areas of particular sensitivity were approached. Thus Daniel Paul Schreber, a German judge whose memoirs of his ‘nervous illness’ were first published in 1903, and who believed he was being transformed into the begetter of a new race, inhabiting a bizarre universe of divine rays and filaments, could still deliver acute legal arguments and expertise, not least concerning his own tutelage. He was able to convince the courts, using both legal argument and personal narrative, that he was fit to be released from his incarceration in an asylum and to take charge of his affairs.
Discussing the Schreber case, Freud observed that what we take to be the defining features of madness – delusions, hallucinations, etc. – are in fact not primary but secondary symptoms. They are less constitutive of madness than responses to madness, attempts at self-cure, as Bleuler, Jung, Lacan and Winnicott would also argue. What would happen, for example, if people around you started to whisper, spreading malicious gossip about your lack of morals and sexual behaviour, for no apparent reason? You would have to invent a reason. As one woman explained, how could one make sense of all the horrible gossip about her if not by realizing that a double with loose morals was dressing in her clothes and pretending to be her. This was less a bizarre efflorescence of madness than a hypothesis with explanatory power, less insanity than a response of reason to insanity. It was, perhaps, good thinking. Madness and reason were thus not opposed but identical, as Erasmus and Pascal had famously argued
But why the whispering and gossip in the first place? As this process of logical reasoning continues, a delusional system can be constructed. The double was put there to damage one’s reputation, to then ensure one missed out on an inheritance, for example. If the TV or radio started to speak, it was to alert one to something, or perhaps to antagonize. The engineers responsible, in turn, may be mere agents for some other power. Thinking here is not really disordered, just more ordered than everyday thinking: if someone else heard a voice, they might just dismiss it as an effect of fatigue and continue with their life. But the psychotic person takes things seriously. For psychiatrists like Charles Lasègue and De Clérambault, the psychotic can be a master of rational deduction. First he hears voices, and then he makes sense of them, using powers of reasoning that are absolutely intact.
A delusion can thus be a way of trying to understand one’s experiences, drawing on all the faculties of inference and deduction at one’s disposal to find an answer. In the words of G. K. Chesterton, the madman has lost everything except his reason. Such thought processes are usually pursued with some privacy, and would only rarely be broadcast. Many other cases discussed by the early psychiatrists showed highly capable, intelligent and articulate subjects who discreetly held to mystical, sexual, religious or persecutory belief systems. These ‘contained’ cases challenged the view of madness as an organic and psychological decomposition, yet over the course of the twentieth century they received less and less attention. Their study moved from mainstream psychiatry to Existential, Phenomenological and Lacanian psychoanalysis and psychiatry. Given the early focus on such forms of psychosis, how could one explain this gravitation of interest?
There are three main answers to this question: first of all, the fate of the diagnostic category of paranoia, which is the clearest example of quiet madness; secondly, the effect of pharmacology on the landscape of mental health; and thirdly, the radical revision in diagnostic procedures that characterized the biological psychiatry of the 1980s, which effectively removed the problem of meaning from the study of psychosis. These three factors would lead to the eclipse of the study of the everyday psychoses that had once seemed so evident to early-twentieth-century psychiatry. Although recent studies that examine psychotic phenomena – such as hearing voices – in the general population have helped to counter this trend, their statistics, which hover anywhere between a prevalence rate of 2 per cent and 30 per cent, underestimate both the frequency and the discretion of quiet madness.
The question of paranoia had once polarized this debate on the coexistence of madness and normality. When Kraepelin described ‘true paranoia’, the two defining characteristics were delusional thought and a striking conservation of all mental capacities and intelligence. Delusions, often with ideas of grandeur or persecution, would be combined with an unimpaired clarity of thought and action. Although he at one time believed it to be chronic and irreversible, he would admit, after many critiques, that there were other forms of paranoia, and, indeed, in one of his later texts, he described paranoia as less a ‘disease process’ than a ‘mental torsion’ or ‘malformation’. But how could it be that one’s faculties were so preserved?
The answers to this question were progressively clouded by the assimilation of paranoia into the heterogeneous group of schizophrenias. Where paranoia had once accounted for a large part of hospital diagnoses, the popularization of the diagnosis of schizophrenia would quite swiftly absorb it. Psychiatrists like Henri Claude had warned against the confusion of paranoia and paranoid states, yet the distinction would become weakened and often lost sight of. We can see this reflected in translations of the title of Lacan’s thesis De la psychose paranoïaque dans ses rapports avec la personnalité: the first phrase is usually rendered as ‘paranoid psychosis’, although, at the time of writing, there was already a psychiatric distinction between ‘paranoid psychosis’ and ‘paranoiac psychosis’ that Lacan was well aware of. Paranoid states can occur in almost any type of mental disturbance, yet paranoia as such was a distinct diagnostic category involving the construction of a stable system of beliefs with a named persecutor. Yet, all too swiftly, paranoia lost its diagnostic dignity.
The case of Ernst Wagner, studied by the psychiatrist Robert Gaupp and his students at Tübingen, was of particular significance here. Wagner was a highly respected schoolteacher, an educated, intelligent man who led an orderly life and had never attracted medical or psychiatric attention. But, on the night of 4 September 1913, he calmly slit the carotid arteries of his wife and four children, then travelled by train from Stuttgart to the village of Mülhausen where, after starting a series of fires, he shot all the men he could see, killing nine and wounding twelve others with the guns he had strapped to his hands.
This spectacular outbreak of violence naturally made the front pages, fuelling a litany of hatred against the ‘mentally unwell’. Wagner, it was said, carried out his killing spree during an acute attack of insanity, yet, as Gaupp bravely and persistently demonstrated, the murders had in fact been planned years previously by a man who felt unbearably persecuted, as his notebooks and diaries confirmed. The wealth of written evidence that Gaupp now examined was an invaluable resource, tracing the mental development over several years of a man who would eventually feel compelled to realize his homicidal projects. The psychiatrist did his best to challenge the demonization of Wagner, and bring out the fact that he was, like his detractors, a human being whose actions could be explained without appeal to notions like ‘evil’.
For Gaupp, the conceptual interest of the case lay in the light it shed on paranoia, which was clearly compatible with a normal life in the community. Wagner, after all, had delusions for at least twenty years, yet could function as a good citizen and family man with no visible signs of madness. This ran against the simple Kraepelinian view that paranoia followed an insidious course, unaffected by life events. Until 4 September 1913, no one had guessed that anything was wrong. He killed his whole family that night, yet the evening before he was his usual polite self, exchanging pleasantries with another teacher’s wife and her daughter, and fulfilling his duties with commitment and competence.
The written texts, together with his interviews with Gaupp, brought out the logic of the homicides. At eighteen Wagner had started to masturbate, which heralded a catastrophe of self-torment. He was certain that others could tell his guilty secret from his appearance, and interpreted the remarks of those around him as allusions to it. In 1901 he obtained a teaching post in Mülhausen, where, despite various heterosexual relationships, he continued to masturbate. One evening, on the way home from a local inn, he had some kind of sexual contact with animals: no details of what exactly he did were ever fully explained, despite years of questioning by Gaupp. No one had seen Wagner’s act, but he felt he had sinned against the whole of mankind. After that night, he wandered about in an agony of persecution, interpreting conversations he overheard as alluding to his act and sensing the laughter and jeering of the local population. He had become an object of mirth.
Wagner knew that if he retaliated he would lose his job, less because of any aggression than because his crime would become known. He began to carry a loaded gun in case the police came for him, even concealing it under his jacket at his own wedding. His marriage was not enough to temper his despair, and Wagner realized that he would have to kill his family as his children might carry the germ of his sexual anomalies. As his feeling that he was an object of scorn and mockery for the men of Mülhausen spread to encompass the neighbouring villages, he bought more guns, practised and planned his revenge. As his sense of persecution increased, Wagner eventually asked for a transfer and was moved to Stuttgart, yet even there he came to believe that his sin was known and laughed at. He had to kill the men of Mülhausen, he said, to stop the gossip.