What Is Madness?

1. Madness Exists on a Spectrum, Blurring the Lines of Normality

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?

Quiet Madness. The book challenges the conventional view of madness as a clearly defined state, arguing that it exists on a spectrum and can be compatible with normal life. Many individuals may harbor delusional beliefs or exhibit psychotic symptoms without experiencing significant disruption or attracting attention. This "quiet madness" highlights the limitations of equating mental health with a lack of conflict with the surrounding world.

Visible vs. Invisible Psychosis. Traditional psychiatry often focuses on the most visible and disruptive symptoms of psychosis, such as hallucinations, delusions, and violent behavior. However, the book emphasizes the importance of recognizing and studying the more subtle and discreet forms of psychosis, which may never come to the attention of mental health professionals. These "white psychoses" or "everyday psychoses" can provide valuable insights into the mechanisms that allow individuals to remain stable and avoid the most shattering symptoms.

Destigmatizing Madness. By acknowledging the prevalence of quiet madness, the book aims to destigmatize psychosis and challenge the association with extravagant and dangerous behavior. It suggests that madness is not necessarily a sign of disintegration or dysfunction, but rather a unique way of responding to and elaborating on the difficulties of life. This perspective encourages a more nuanced and compassionate approach to understanding and treating psychosis.

2. Psychosis Involves a Breakdown in Fundamental Psychological Defenses

The ego rejects the incompatible idea together with its affect and behaves as if the idea had never occurred to the ego at all. But from the moment at which this has been successfully done the subject is in a psychosis.

Defense Mechanisms. The book introduces the psychoanalytic concept of defense mechanisms, which are strategies used to protect ourselves from disturbing thoughts or images. In neurosis, these defenses typically involve repression, where traumatic memories or unacceptable desires are pushed out of conscious awareness. However, in psychosis, a more radical defense mechanism called "foreclosure" is employed.

Foreclosure. Foreclosure involves the complete rejection of an idea or experience, as if it had never been registered in the mind. This rejected element does not simply become unconscious, but rather remains as a blank spot in the person's thought processes. It may then return from the outside in the form of hallucinations or delusions, with no sense that it belongs to the individual.

Neurosis vs. Psychosis. The key difference between neurosis and psychosis lies in the nature of the defense mechanism. In neurosis, the repressed material continues to exert an influence through symptoms, while in psychosis, the rejected element is completely disavowed and attributed to external sources. This distinction highlights the more fundamental disruption of reality that characterizes psychosis.

3. Language, Image, and the Body Form the Pillars of Reality

My eyes met a chair, then a table; they were alive too, asserting their presence.

Three Registers. The book introduces Lacan's concept of the three registers: the symbolic (language and law), the imaginary (body image), and the real (libidinal life of the body). These registers are interconnected and contribute to our sense of stability and reality. In psychosis, these registers become undone, leading to disruptions in language, body image, and the experience of the body.

Language and Meaning. Language can split off from conscious control or literally come apart, as it did for Renée. This shows how language can split off from our conscious control, or literally come apart, as it did for Renée. This suggests that what we tend to take for granted as reality is actually made up of different levels: bricks, newspapers, tables and chairs can all lose their everyday meaning and become enigmatic and threatening.

Body Image and the Real. The body image can separate off, as if the visual form of our bodies were not really a part of us. The body itself is not a given either. A patient complained repetitively that she didn’t have a body, and had to touch the interior of her mouth with her tongue all day to reassure herself of her existence.

4. The Oedipus Complex Shapes Our Understanding of the World

The symbolic clips the body, removing libido.

Oedipus Complex. The book explores the Oedipus complex, a psychoanalytic theory that describes the child's journey through early development. This process involves the child's initial attachment to the mother, the recognition of the father as a separate figure, and the eventual resolution of these desires through identification with the father.

Symbolic Order. The symbolic order, transmitted primarily through speech, gives us a place in the world, establishing coordinates and boundaries. It is not just language, but language plus law. This law is first and foremost the prohibition of incest, understood as not simply the internalized limit that separates mother and child, child and mother, but also the system of reciprocal renunciations that organizes each society.

Name-of-the-Father. The Name-of-the-Father is a privileged representative of this principle, what he called the ‘Name-of-the-Father’. Early-twentieth-century anthropologists at times showed bafflement at how ‘primitives’ attributed pregnancy to a woman’s encounter with a spirit at some sacred rock or spring rather than to the facts of coitus. If they had been having sex and babies for centuries, they asked, how could they have failed to notice the connection? Yet this ‘primitive’ lack of understanding in fact reveals for Lacan the true structure of paternity: that there is a difference between the real progenitor and the symbolic function of paternity that must frame reproduction.

5. Delusions Are Not Just Errors, But Attempts at Self-Cure

What we take to be the ‘pathological product is in reality an attempt at recovery, a process of reconstruction’.

Delusions as Solutions. The book challenges the traditional view of delusions as simply pathological symptoms, arguing that they are often attempts to make sense of a world that has become confusing or overwhelming. Delusions can provide a framework for understanding one's experiences, assigning meaning to events, and establishing a sense of order and control.

Restitution. Delusions 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.

Meaning-Making. Delusions are 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.

6. Paranoia, Schizophrenia, and Melancholia Represent Distinct Responses to Madness

In my world I am omnipotent, in yours I practise diplomacy.

Three Structures. The book outlines three main forms of psychosis: paranoia, schizophrenia, and melancholia. Each of these structures represents a distinct way of responding to the fundamental problems of meaning, libido, and one's place in relation to the Other.

Paranoia. In paranoia, a meaning crystallizes: the person knows what is wrong with the world. There is a plot against them, they have a mission to accomplish, a message to disseminate. Whatever the actual content of the delusion, there is a solidity to the meaning ascribed to their situation. Libido is localized outside: in the persecutor or in a fault in society or the order of the world.

Schizophrenia. In schizophrenia, meaning cannot be pinned down, and the subject remains at its mercy. The libido is not localized outside but returns to invade the person’s body. The distance from the Other is not easily maintained, and the Other may be present within their mind and body.

Melancholia. In melancholia, meaning is usually fixed: the person is the cause of every calamity and mistake. The libido here submerges their self-image, overwhelming their ego. The Other is included within the self, but without generating the terrible battles of inclusion–exclusion that we find in schizophrenia.

7. Triggers Detonate Underlying Psychotic Structures

The key for Freud lay not in the content of the disturbing idea, but in the mechanism of its rejection – ‘Verwerfung’, a term translated by Lacan as ‘foreclosure’.

Underlying Structure. The book emphasizes the distinction between the underlying psychotic structure and the specific events that trigger its manifestation. While the structure is established early in life, the triggering may occur much later, often in response to a stressful or destabilizing event.

Common Triggers. Common triggers include loss of social place, retirement, a change of milieu, marriage, divorce, or the loss of one's parents. These events share the characteristic of disrupting the individual's symbolic framework and forcing them to confront the fundamental questions of existence.

The Role of the Clinician. The book suggests that clinicians should be aware of these potential triggers and take steps to mitigate their impact. This may involve helping the individual to develop coping mechanisms, build social support networks, or find new sources of meaning and purpose.

8. Stabilization Involves Rebuilding a Personal Reality

In my world I am omnipotent, in yours I practise diplomacy.

Restitution Mechanisms. The book explores the various "restitution mechanisms" that individuals with psychosis may develop to stabilize their lives and find a new equilibrium. These mechanisms can include the construction of elaborate delusional systems, the adoption of specific rituals or routines, or the pursuit of creative or intellectual endeavors.

Individual Solutions. The book emphasizes the importance of recognizing the uniqueness of each individual's experience and avoiding the imposition of standardized treatments or expectations. The goal is to help the person find their own way of engaging with life, not to adapt them to a pre-defined notion of normality.

The Role of the Clinician. The clinician's role is to listen, support, and encourage the individual's efforts to create a meaningful and sustainable reality. This may involve helping them to identify their strengths, develop coping strategies, or find new sources of connection and purpose.

9. The Shipman Case Highlights the Disconnect Between Normality and Madness

He murdered more than 250 people, yet worked for years as a respected GP, earning the admiration of the community he served.

The Limits of Diagnosis. The case of Harold Shipman, a British doctor who murdered hundreds of his patients, illustrates the limitations of relying solely on external behavior and surface features to diagnose mental illness. Despite his horrific crimes, Shipman did not exhibit any of the visible symptoms of madness typically depicted in movies and psychiatric manuals.

The Logic of Psychosis. The book suggests that Shipman's actions can be better understood by exploring the logic of his psychosis, which may have involved a distorted sense of control, a need to alleviate suffering, or a desire to play God. This approach emphasizes the importance of listening to what psychotic subjects say about their experience and taking seriously the position they have in their own speech.

The Absurdity of DSM. The Shipman case highlights the absurdity of the DSM system of mental health diagnosis, which relies on a checklist of visible symptoms and fails to capture the complexity and nuance of individual experience. It underscores the need for a more nuanced and compassionate approach to understanding madness, one that goes beyond surface features and explores the underlying structures of thought and belief.

10. Working with Psychosis Requires Empathy, Respect, and a Rejection of Preconceived Notions

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.

Listening and Understanding. The book emphasizes the importance of listening to and understanding the individual's unique experience of madness. This involves taking seriously their beliefs, their fears, and their attempts to make sense of the world, even if they seem bizarre or irrational.

Avoiding Imposition. The book cautions against imposing one's own worldview or value system on the patient. This can be a form of violence, as it seeks to crush the patient's belief system and replace it with a new system of values and policies.

Collaboration and Respect. The book advocates for a collaborative approach to treatment, where each party has responsibilities and the patient's specificity and life story are valued. This approach recognizes that the psychotic subject is not simply an object to be treated, but rather a person to be listened to and understood.

Last updated: March 16, 2025