I’ve just finished reading Darian Leader’s latest book, What is Madness? It’s an absorbing read – sometimes difficult – but ultimately, fascinating and humane. Leader explains the roots of psychosis using the psychoanalytic theories of Jacques Lacan and at times the explanations seem rather more complex that the phenomena being explained. The discussion of Lacan’s client, “Aimee”, for example, is labyrinthine in its use of competing psychoanalytic explanations for her psychosis and behaviour. That's why I appreciated Leader's comment that, "A psychoanalytic theory of psychosis does not imply a psychoanalysis of psychotic subjects" (294). Indeed Leader points out that individuals experiencing psychosis are suffering from too much meaning and do not benefit from the interpretations of therapists.
The book opens with a chapter entitled, “Quiet Madness” in which Leader draws our attention to a mistake commonly made in conversations about psychosis. According to Leader it is wrongly assumed that madness and the visible symptoms of madness are the same thing. For Leader the symptoms of madness - hallucinations, paranoia, delusions - are the individual’s attempt to make sense of the horror that has befallen him or her: ‘responses to madness, attempts at self-cure’ (17). This is a fascinating insight and extends my own belief that emotional disorders such as depression or anxiety are perfectly functional when seen in the context of the individual's history and current experience. This realisation ought to guide the therapists approach. Attempts to remove the symptoms of psychosis without helping the patient to explore their condition may well interfere in the process of self-healing. As Leader says, medication is useful because it tempers the intensity of psychotic symptoms but should also serve as a 'platform for dialogue'.
Leader emphasises the importance of symbolism and language when explaining madness. He sees madness as a breakdown in these structures, resulting in a terrifying loss of meaning and a disconnection from reality. In response to this the individual cobbles together what he can to make sense of his experience. This may show itself as paranoia or other delusions. The individual may believe he or she has been abducted by aliens if this restores meaning and makes sense of a catastrophic event. Psychotic individuals (and psychoanalysts?) cling to the most unlikely ideas in their attempt to make sense of the world.
In what Leader calls, “Quiet Madness”, the individual may appear balanced, keeping his delusional world under wraps and thereby achieving the semblance of normality. In an interesting chapter, Leader suggests that the serial killer, Harold Shipman, is an example of “Quiet Madness”. To his patients and colleagues he appeared to be a professional, kind and diligent doctor; but it was this role that enabled Shipman to stabilise his madness, part of which involved the murder of hundreds of patients.
Leader argues that quiet madness can erupt into full blown psychosis through various trigger events, often associated with rites of passage. Marriage, divorce or having a book published, all have the potential to trigger psychosis: moving the individual from ‘being mad’ to ‘going mad’. Events have this potential because they require from the individual a new set of symbols, and if the individual cannot symbolise this transformation they are at risk of becoming psychotic. Leader spends several chapters exploring this process so my summary here is incredibly superficial.
The final chapter of this complex book suggests ways of working with psychosis. Following his hero, Jacques Lacan, the author uses the metaphor of the secretary - to quote Lacan, the therapist ought to be, “the secretary of the alienated subject” (305). Leader likes this description, likening the therapist to a secretary who faithfully records, asks for clarifications and doesn’t intrude too much (305). The therapist as secretary helps the client to build a personal history, helps the individual to explore their own frame of reference and thereby helps in the work of self-healing. Leader is honest about the amount of time, hard work and commitment required to work with clients experiencing psychosis. He is hostile to therapies that seek to return clients to “normal” and measure success by how far their clients have adapted to social and community norms. Instead Leader suggests that an “investment in dialogue and a curiosity about the logic of that person’s world can open up new therapeutic directions and offer the possibility of change. Therapy can do no more and no less here than to help the psychotic subject do what they have been trying to do all their lives: create a safe space in which to live” (330).