Review of Darian Leader’s What is Madness?

Published in Division 2014

What is Madness?
By Darien Leader
Penguin Press, 264pp .2013

To define true madness—what is’t but to be nothing else but mad—Polonius, Act II, Sc I, Hamlet

Polonius is a pedant whose chatty platitudes ironize the traditional role of the father as authority and advisor to his children. Hamlet, who he addresses, feigns madness to solve the mystery of his father’s murder only to find himself in a distinctly modern relation to madness—in thinking he controls madness, he becomes mad.
Shakespeare’s (1559) poetic reflections on madness—and practically every play contains a reference to it—are followed later in the 16th century by Pascal (1669), the greatest rationalist, who wrote in his Pensées, “not to grant a place to madness in the understanding of humanity would be madness itself.”
For the Romantic movement, this rationality risks the repression of the nature of humankind and madness becomes equated with forms of insight that contribute to works of genius in art and music. Some aspects of this romantic validation of madness reprise the role of the “daimonic” in classical civilization, as Nietzsche (1886) forcefully argued in the distinction he makes between the spirits of Apollo and Dionysus in The Birth of Tragedy.
With the exception of Pascal, most Christian theologians equated madness with possession by the devil, and while a place was made for the holy fool in medieval culture, with the Christian reformation came the attempt to defend the notion of a stable self—one that communes directly with God—and hence, madness, the de-stabilization of the self or ego, is equated with some form of satanism or punishment for sin.
Nineteenth century and some 20th century psychiatry has retained a complicity with this theological conception of madness. The resistance to the ideological notion of a stable self has marked both postmodern thinking as well as one of the inspirations for postmodernity—the anti-psychiatry movement of the 1960s and 1970s.
The leaders of that movement, R. D. Laing (1970), Donald Cooper (1978), and their philosophical allies, Michel Foucault, Gilles Deleuze (1968), and Félix Guattari (1968) (working at the La Borde clinic), saw the institutionalization of the schizophrenic as a repression of a creative potential in order to resist the increasingly mad demands of a highly regimented society. Largely unbeknownst to them, the Soviet psychiatric establishment was using and disseminating the practice of incarcerating under the label “mad” anyone who expressed ideological opposition to the soviet system.
The instability of the human subject’s relation to its body, and thus the psyche, is certainly rooted in the biological prematurity of the human infant, but madness is as rooted in the ideological operations of culture as it is in biological substrata.
As effective medication for psychosis began to empty into the great holding cells of the psychiatric asylum, a new form of ideology emerged based on the possibility, rather than the precise proof, that psychosis was rooted in genetic disorder. This conviction in a biological basis for psychosis would readily dismiss Polonius’ claim that to define madness would be a sign of it. At perhaps no other time in the history of madness has the equation of madness with “abnormality” been so great—even though it is relatively easy to show this idea of “normality” is based on a theological and ideological conviction that the self is essentially stable.
What then do we make of Hamlet: a manic depressive, a victim of bipolar disorder, an abnormal self whose struggle with his guilt and inability to avenge his father hold no other human significance than being a poetic representation of the symptoms of his biologically determined abnormality? Perhaps the answer to the enigma of the play is that Hamlet’s father or grandfather was also schizoid.
The contemporary conviction, expressed by eloquent advocates for the thoughtful treatment of the “mad,” such as K. Redfield Jamison (2000), is that only more research will relieve the suffering. Despite the fact that in her own memoir of going mad, Jamison reveals how important the love and patience of her husband, who is also a psychiatrist, was in her most severe psychotic episodes. Can we really be so blind to the obvious that madness can be worked with if there is a desire to care for the mad rather than a phobic classification of their instability as “abnormality”?
The return of the idea, via an ideological use of genetic research, that madness is a biological inheritance ignores the phenomenological observation of all the various theories of human development; that since the human infant takes so long to acquire even a modicum of agency and is dependent on the care and treatment of the Other for such a long period of time, it is not possible to rationally argue that the response to the helplessness of the infant and its introduction into the field of symbolic activity does not have a consequence on the creation of a subjectivity equal to any biological determinants.
As Leader points out in this eloquent and intelligent study, our contemporary society has condemned itself to a confusion about madness that impedes the actions that might ensure a place of safety for those among us who endure a form of psychic pain and illness that has been found constitutional to human subjectivity since the earliest studies of human psychology. This is not a reprise of anti-psychiatric radicalism. It is a brilliant critique of the nosological mania that ignores that psychotic symptoms are quite often readable so long as we acknowledge them when the individual subject is unable to gain access to a sufficient degree of symbolic activity—a consequence of a variety of forms of deprivation, trauma, and isolation. The subject will then have to foreclose the entry point into an engagement with the Other. This foreclosure is not biologically determined but is the consequence of the fact that to become human, a subject needs to be able to inscribe itself within signifying practices that enable it to speak and articulate its own desire.
As some of Freud’s (1911) earliest studies of the psychic apparatus revealed, we are all capable of hallucinations and our beloved ego is the seedbed of paranoia. Freud was also one of the first to point out, in his study of Daniel Schreber, in contradiction to the supposed primacy of reason, that it is the mad who frequently give us the best guidance to their condition. As Octave Mannoni (1968) remarked, “we are all in a sense partially cured psychotics” and as clinical practice frequently reveals, many of us may experience or be overwhelmed by an agonizing alienation.
Darian Leader, an English psychoanalyst and author of an excellent study of depression, melancholia, and loss, The New Black, has nuanced some of Freud’s research into psychosis by providing an unusually clear clinical exposition of the value of Jacques Lacan’s (1966) study of psychosis. Leader has incorporated in this highly readable book a remarkable survey of the post-Freudian literature on psychoanalysts penned by a generation of analysts who are largely forgotten. As this tradition has been largely discredited and dismissed since the 1980s, Leader’s book will be of particular interest to North American clinicians who may have come to believe that the era of the psychoanalyst contributing to the well-being of the psychotic is over. However, it should be said that a substantial portion of the book concerns itself with clinical vignettes—one of which reprises the story of Lacan’s famous patient Aimée; another of which introduces the history of Harold Shipman, an English doctor who killed a large number of his elderly patients. This case material may feel culturally unfamiliar to some readers and to some degree detracts, as does his revisiting of the case of Sergei Pankejeff—the famous patient of Freud who became known as, and preferred to be known as, the “Wolf Man.”
As a psychoanalyst rather than a psychiatrist, Leader always emphasizes the singularity of each patient’s history and the specific moment at which a psychotic episode has been triggered. No doubt there are many psychiatrists who do pay great attention to the life histories of their patients and the timing of a psychotic break, but any reader of DSM-5 or the Psychiatric Desk Reference will be unable to find any recommendation to the clinician that the degree of attention to the overall life history of the patient should approach the kind of detail shown by the founding figures of modern psychiatry such as Bleuler (1911) or Kraepelin (1913).
Leader’s psychoanalytic approach to the clinic of psychosis reminds us that these phenomenological studies of psychosis—Bleuler, Kraepelin, Jaspers, and others—not only took the time to provide detailed life histories of the patients, but they emphasized that the timing itself of a paranoia or breakdown was crucial to understanding what form and role the madness was playing in the subjectivity of the patient.
In Leader’s view, one of the things we fail to do, trusting so heavily in diagnostic criteria that are dictated by evaluations of current behavior, is to allow the history of the patient to provide a frame within which an evaluation can be made of a period of psychosis as possible to treat or possibly permanent and impervious to cure. In either case, such evaluation takes time and if that time is not taken, there is no possibility of recognizing that it is crucial to respect that where symptoms of paranoia, schizophrenia, or manic depression appear fixed, they are often the result of an attempt at self-cure and protection.
Leader is well versed in the history of anti-psychiatry but points out that its successes were often the result of simply taking a less authoritarian position toward the patient. He is certainly not naïve about the social treatment and conditions under which many patients were confined and treated during some of the more distinguished periods of psychiatric research. What he underlines is the seriousness and importance of these researchers and the relative ignorance of contemporary practitioners, who trained with a positivistic and neuropsychiatric approach, predominantly searching for a genetic and generic categorization.
Leader’s re-evaluation of clinicians, such as Freida Fromm-Reichmann (1955), points out that in working without the contemporary battery of psychopharmacology, they were more attentive to the kind of work the patient might subsequently be able to undertake after a period of treatment and enable the patient to stabilize and live with what Leader has called “quiet madness.”
Case after case from this period indicates patients, if treated with attention to the singularity of their madness, could find some kind of symbolic position that could enable them to stabilize—this might consist of writing, painting, caring for another person, being the object of a scientific study, whatever it might be to enable the subject to live with their madness. The examples he gives of his own clinical practice illustrate that this way of working is still possible in the analyst’s office. Moreover, as he also points out, listening of this quality can cushion the often traumatic effect that hospital and outpatient treatment may have on psychotics whose behavior is looked at through a cognitive or behavioral frame, which makes them victims of codes and orders of social normativity.
We come across these kinds of movements out of madness less frequently if, very early in the treatment, the patient is given so much medication that it is impossible to judge what actually might be a path toward their stabilization—other than a continuing, debilitating regime of medication. Which makes it very interesting to note, a genre of literary biography has emerged in which an author describes his or her own passage out of madness— although Leader mentions none of these works.
Leader is not in any way a naïve critic of the use of medication in working with psychotic patients, but he does point out that the life expectancy of people who are diagnosed as psychotic has declined significantly in the last 50 years as more and more empirical research forces us to recognize that the secondary effects of many of the medications can cause major disruptions of the endocrine system of the patient that can lead to obesity that in turn can lead to a variety of heart problems. He is certainly not asking for a return to the naïve application of Freudian dynamics that became dominant in American psychiatry from the late 1940s until the de-institutionalization of patients that began in the 1960s with the introduction of lithium among other drugs.
For Leader, the current excessive division between different categories of psychotic behavior and the ineffectiveness of empirical studies that create statistical models of subjective behavior or genetic predetermination means that many clinicians are only listening, if they are listening at all, to that part of the patient’s speech that indicates what psychiatric category they might best fit into and what form of treatment is predetermined for that category of patient.
He quotes a psychiatrist, “we don’t know what form of psychosis the patient is suffering from until we can see what medication is working.” Leader is proposing that we resist this regime of descriptive categorizing and attend to a different use of the concept of differential diagnosis that distinguishes between the experience of “going mad” and not actually “being mad.” Leader uses, in a highly effective manner, the dialectic between “being mad” and “going mad” as an anchoring point for his the whole of his book.
Leader questions the overemphasis on the “noisiness” of psychosis when an individual, evidently influenced by hallucinations or other attempts to fill their encounter with a void, are led to commit an act of great violence against themselves or others. There is no doubt that violence can be the outcome of a psychosis, but what Leader wants to draw our attention to is that it can be triggered when the patient is directed (sometimes by a well intentioned psychiatrist or clinician) to renounce certain actions or conform to others. This directive then triggers, within the patient, an encounter with what is missing or voided in their subjectivity to which they respond violently.
Leader carefully elaborates how frequently, not only in his own clinical practice, but also in the work of a very wide range of practitioners, what is really at stake in working with psychotics is not the existence of symptoms, but the way they are being used. He reminds us that experts in the history of psychiatric literature—late 19th century pioneers—were actually far more “empirical” in their approach than contemporary researchers (because they recognized the singularity of each psychotics experience). Even in the 1940s to 1950s, despite the inhuman practices of lobotomy and leucotomy, we find numerous researchers who are very attuned to the importance of stabilizing the psychotic patient and identifying those conditions and signifiers that triggered desperate moments when the patient was entering into an experience they were unable to symbolize or signify.
For Leader, this attention to the use of what is made of the symptom is completely congruent with the practice of psychoanalysis that Freud invented and Lacan inflected with the introduction of the “name of the father.”
Leader’s view is that psychoanalytic theory teaches us what not to do with psychotic patients rather than what to do with or for them. The accuracy of Leader’s idea of “quiet madness” is that when he traces the early lives of his patients he is able to identify a moment when something in the patient’s speech or account of their own actions indicates they have attempted to create something that substitutes a signifying substation that has not occurred in the psyche of the subject.
The symptom is not functioning in the same way that the symptom of a neurotic patient functions. It is not maintaining a certain form of alienation for the subject’s proper desire, hampering their capacity to invest drive and desire in their lives and work. Instead, this kind of symptom is holding the subject together, making it possible for the individual to go and survive with a potentially terrifying absence of meaning; a meaning that is not “intellectual” but includes the meaning of having a body, accepting sexuality, or tolerating moments of nonmeaning.
In his afterword to the book, he goes beyond his initial intention to provide a clear outline of the causes, the variants, and the possible ways of stabilizing and inventing with the psychotic. Here he points out how the eugenic plan to eliminate the mad was connected with the eugenic plan to eliminate “degenerate” races. The way in which a society responds to those within it who are “mad,” is no doubt a litmus test of its ethics. In this sense, Leader’s book goes beyond the question of the clinic of psychosis and is a testimony to what is at the heart of psychoanalysis—its ethics of difference and of the Other.

References

Bleuler, E. (1911)in English (1923). Demnetia praecox. New York. Macmillan

Cooper, D. G. (1978). The language of madness. London, RKPaul

Deleuze, G. (1968). Anti-Oedipus. London. Viking

Freud, S. (1911). From the history of an infantile neurosis (1917–1919) S. E. Vol 17.
Psychoanalytic notes on an autobiographical account of a case of paranoia (1911) S.E. Vol 12.

Fromm-Reichmann, F. (1955). Some aspects of psychoanalytic psychotherapy with schizophrenics. Chicago, International University Press

Guattari, F. (1968).in English(1970) Anti-Oedipus. London. Viking

Kraepelin, E. (1913).(in English(1924) General Psychopathology New York Macmilan

Lacan, J. (1966). Presentation on psychic causality (1946).Paris. Seuil

Laing, R. D. (1970). Sanity madness and the family. London, RK Paul

Mannoni, O. (1968). Clefs pour analyses. Paris, Seuil

Nietzsche, F. (1886). Birth of tragedy. New York Vintage

Pascal, P. (1669). Pensées. New York Penguin

Redfield, J. K. (2000). An unquiet mind. New York,Random House

Shakespeare, W. (1599). Hamlet. New York Penguin