Darian Leader,
What is Madness? 2011


'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.'