368 pp., £15.74 (cloth), £6.99 (paper)
Ernst Wagner was a respected school master in Stuttgart, cultivated and intelligent, a husband and a father of four. Until 1913 he had never attracted the attention of psychiatrists. The night of September 4 of the same year, aged 39, he cut his wife and children’s carotid arteries. He then caught a train to the small village of Mülhausen, where he started firing on whomever crossed his path; he killed eight men and a young girl and wounded another twelve people before being disarmed.
Psychiatrist Robert Gaupp and his students at Tübingen discovered that the serial killer was a paranoiac who had felt persecuted for twenty years, ever since, at the age of eighteen, he began to masturbate. He was convinced that everyone became aware of his ‘sin’ just by looking at him, and that people made continuous allusions to it in his presence. It was found that he had also had sexual contact with animals in Mülhausen, and was also convinced that every man in the village knew about it. He had killed his wife and children to end a degenerate lineage, his own.
This is one of the many cases of psychosis evoked by Darian Leader in his What is Madness? The Wagner case effectively illustrates one of the book’s essential assumptions: proving that it is possible to be psychotic even in the absence of psychotic behaviors. In other words, one thing is ‘being mad’, another is ‘going nuts’. In fact, we know about that school master’s psychosis only because at one point he committed fatal actions; but if he hadn’t, for whatever reason, taken any action, probably no one would ever have noticed his delusions, not even his wife.
But Leader raises the ante. He dedicates a whole chapter to the case of Harold Shipman, the English doctor who killed at least 250 people between the mid-seventies and late nineties. His victims were elderly men and women, either suffering from chronic illnesses or in bereavement, widows in particular; he killed them by administering ‘medicines’. He was discovered and arrested in 1998 and hanged himself in prison in 2004.
The challenge taken up by Leader in the Shipman case is twofold:
- All psychiatric examinations agree that no traces of mental illness were to be found in Shipman.
- He was an extremely respected general practitioner in his region, completely devoted to his mission as a doctor, which in a way he continued to practice even in prison. ‘He was a saint’, one patient had said of him.
Leader’s conclusion on the Shipman case is that the doctor was a psychotic even though he had never manifested any delusions: his being a serial killer shows his psychosis. In short, Leader states that it was not the act of killing in itself, but the sense it had for Shipman that was psychotic.
So, as a psychosis can remain ‘private’ (or ‘silent’ or ‘white’ or ‘ordinary’) for a lifetime, unless a particular event hastens the subject into a psychotic state, a suspicion seizes us: what if we all have a psychotic ‘gap’ somewhere that can be reopened by particular events—specific to each one of us?
Leader is an analyst, leader—excuse the obvious pun—of the Lacanian movement in Great Britain. He is President of the College of Psychoanalysts and cofounder of the Centre for Freudian Analysis and Research (CFAR). He is the author of several works, one of which explains Lacanian thinking in comic book form, Lacan for Beginners (Cambridge: Icon, 1995. Republished as Introducing Lacan in 2000 and 2005); another is entitled Why do Women Write More Letters than They Post? (London: Faber & Faber, 1996). His other books include Freud’s Footnotes (London: Faber & Faber, 2000) and The New Black. Mourning, Melancholia and Depression (London: Hamish Hamilton, 2008), while 2013 saw the publication of his Strictly Bipolar (London: Penguin). He is also very active as an art critic. The strength of his books is that they are written in English and not Lacanish.
Leader is not an exegetic Lacanian, in that he is not dedicated to a devout exegesis of Lacan’s writings and seminars. Leader is instead a missionary Lacanian, and his mission is to explain Lacanian clinical thinking to Britons, whether psychoanalysts or not, in a suggestive and convincing way. He is a secular, not an ecclesiastic Lacanian. So he draws his examples not only from Lacanian literature or his own clinical experience, but also from authors from the most diverse schools, including the classics of psychiatry (Kraepelin, Kretschmer, Sechehaye, etc). The ambitious project behind this abrégé of his is for it to be an encyclopedic summa of psychosis in a Lacanian key.
Now, Lacanian theory on psychosis is based on the premise that it is not a set of particular acts and speeches, but a subjective structure. In other words, a subject can be psychotically structured even without giving rise to a socially recognized clinical psychosis.
Indeed, Lacan dedicated a seminar (XXIII, 1975–76) to James Joyce, proving how Joyce’s structure was psychotic, even though the writer never went nuts (though in actual fact he did hear voices, which he would ‘transcribe’ in his novels). According to Lacan, what prevented him from ever falling into a full-blown psychosis was his writing, which he used as a solution to his psychotic ‘deficit’. His writing was a prosthesis—which Lacan calls sinthome, modifying the spelling of symptôme, symptom, in French —compensating for a lack. In fact, as we shall see, for Lacanians psychosis is always related to a specific lack.
The belief that there is an amount of madness in many who do not manifest clinical psychotic symptoms immediately opposes the Lacanian approach to two modes of thinking, which are actually opposites of each other.
First, Lacanian theory is the opposite of the anti-psychiatric movement of the 1960s and 1970s (Szasz, Laing, Esterson, Cooper, etc.), according to which psychosis does not exist as such, but is only a social judgment that changes according to the culture. Ronald Laing often said that if a woman swoons during a mystical crisis in a church, she is an exemplary worshipper; if she has the same mystical crisis a hundred yards from a church, she ends up in a psychiatric hospital. Leader, instead, would say that a lady can develop a ‘silent’ mystical delusion, without displaying its marks to the outside world, neither in a church nor anywhere else.
Secondly, Leader opposes the Lacanian approach to the constituent criteria of DSM. DSM-5 treats the 360 nosographic categories it isolates as a cluster of behaviors, verbal ones too, without any sort of structural criterion. It suffices that these behaviors cause the subject distress. In fact—I would add—it is quite amazing how this Manual can have such a hegemonical role in psychiatry although it gives no justification for its ‘choices’, i.e. for its classing of certain symptoms in a given category, if they persist for at least six months (why not only four? Why not eight?). Basically, those who have not contributed to drawing up DSM have to accept it without argument, taking for granted that its authors—mainly American—are endowed with a supreme psychiatric knowledge that requires no explanation.
But what does it mean that psychosis, before being a pathology, is a subjective structure?
For Lacan every human subject belongs to one of three structures: neurosis, perversion, psychosis. The so-called ‘normal’ person is therefore in most cases a neurotic with no neurotic symptoms. The problem is how to also fit into these three structures—a Procrustean bed?—other psychopathologies accepted by Lacanians, such as eating disorders, drug addiction, autism and so on. On the other hand, Lacanians reject the category of borderline, which they consider a form of hysteria (and significantly about 75% of those diagnosed as borderline are women). Indeed, hysteria, rejected as a category by DSM, is at the heart of Lacanian nosography. In any case, Leader admits that categories such as manic-depressive psychosis and autism pose problems to this tripartition. Though he quotes the case of the autistic boy Joey, described by Bruno Bettelheim (1967), he seems to doubt that autism is a psychosis (and I also believe myself that considering autism a psychosis is a mistake).
For Lacan, the three structures—neurosis, perversion, psychosis—correspond to three fundamental negations that constitute subjectivity. Lacan was originally a psychiatrist, he never abandoned the treatment of psychotics and he gave an original contribution to the theory of psychosis: the psychotic structure is the effect of a specific negation which he called forclusion (foreclosure), using a legal term. Psychosis in the clinical sense is triggered when subjects are confronted, during their lifetime, with something that reactivates a very special foreclosure: that of the signifier Name-of-the-Father. For this reason a Lacanian will never talk about someone’s ‘psychotic nuclei’, because a subject either is psychotic (since childhood) or is not; subjects cannot have psychotic parts.
In what sense is paternity a focal signifier? Lacanians point out that for all cultures in all epochs the existence of a male parent, ‘efficient cause’, who fecundates a woman is not enough. For a parent to become a ‘father’ a sort of symbolic transubstantiation is required, and each culture elaborates this in its own way. Indeed, in many primitive societies the belief is that a woman becomes pregnant because she has met a spirit, or a particular rock or spring. But these ‘savages’ are neither stupid nor ignorant, they are quite aware that the cause of pregnancy is sperm, but this does not take away the fact that they also need a ‘symbolic cause’, so to speak, that gives a core of untranslatability to paternity. In our supposedly rationalistic society too we use patronymics, which are symbolic marks, making it necessary for a father to recognize someone as a daughter or son, even when (as in adoptions) he is not the material parent.
In my opinion, Lacan’s choice of the term Name-of-the-Father was an unfortunate one, as it ties this signifier too closely to the concrete figure of the father in Western families. Wanting to keep the reference to the Christian Trinity, he could have called it ‘Name of the Holy Spirit’, the actual impregnator of the Virgin Mary. The Holy Spirit goes beyond the father-son relation, setting itself as a ‘third party’, an absolute senseless signifier. A father becomes Father in virtue of the Holy Spirit.
Leader offers us a series of clinical vignettes to help us see more vividly the significance of this foreclosure or exclusion that constitutes psychosis. In this way he tries to systemize the tapestry of psychosis, which Lacan had really only sketched out. For example, Lacan didn’t seem to know where to place ‘schizophrenia’ (in Bleuler’s sense), which he always referred to using a prefix, ‘so-called schizophrenia’. When presenting cases at the Hôpital Saint-Anne, where he faced various psychotic patients presented by various psychiatrists, he would only rarely diagnose schizophrenia. Leader, on the other hand, does try to describe the three great psychotic structures—paranoia, schizophrenia and melancholia—through a rigorous game of permutations. Exactly what it consists of, we shall see later.
What makes us qualify someone as ‘mad’ is the fact that someone reads an excess of signification in the world. In psychosis ‘the world means too much’, ‘the world speaks’. Paranoiacs read persecutory intentions in, for example, gestures and words that we find insignificant; schizophrenics hear voices that are insulting them or ordering them to do something, they perceive, in other words, a language in addition to the language we recognize. As for melancholics, they read the things that happen around them as signifying an irredeemable guilt of theirs. In short, psychosis means giving the world a hyper-signification. But then, ‘and for reality to be able to do this, doesn’t it suggest that it is made, in part, from language?’ (p. 43), Leader writes. In other words, psychosis exposes what according to Lacan is the very essence of human beings: the fact that our relationship with reality—intersubjective and material—is imbued with language. Psychosis reflects the fact that reality itself, insofar as it makes sense to us, is structured symbolically. This talking and signifying world the psychotic lives in is the revelation of the fact that all subjects and their worlds are structured like a language. Lacan calls this language that structures us the Other. An Other that, however, always ‘incarnates’ itself in concrete ‘others’ who for us have the power of giving a sense to the world: first of all our mother, then our father and the Mentor, if we find one; and the person we love, and our analyst…
Significantly, psychotics often talk about a ‘system’ that is encapsulating or persecuting them. Where does this theme of system or influencing machine in psychotic experience come from? According to Lacan ‘the system’ or ‘the machine’ is language itself, which was described as a system by linguistic structuralism. Ferdinand de Saussure compared all languages to a game of chess. Non-psychotics don’t realize they are trapped in the language ‘system’ because they find it adequate for giving them sense to the world. Psychosis therefore signals a fatal check mate of the system, hence the collapse of sense for the subject.
Lacan identifies language in the Other, insofar as language is also always an interjection, there’s always a self and an Other. Leader quotes C.S. Peirce: thinking is always a dialogue. The self and the Other are always respectively in the position of speaker and receiver or vice versa. Leader, for example, stresses the fact that the erotomanic subject does not believe so much in the other’s love, but in the fact that this love is communicated to him, signified to him. A paranoiac feels that certain events or objects are addressed to him, even if he doesn’t know who from. Hence his perplexity, which in most cases dissolves itself in a delirious certainty. The ‘normal’ correspondence between speaker and receiver is disrupted.
Leader takes Freud’s basic thesis on paranoia very seriously: that delusion is not the illness itself, but an attempt at recovery. And what is the true ‘illness’ that the delirious psychotic tries to heal? Primary experiences of terror, fragmentation and invasiveness, a life experience of radical annihilation, of which the catatonic stupor is only the exterior manifestation. Delirium, especially if systematized, ultimately gives order and sense to an unbearable experience of chaos. Leader thinks, in Lacan’s wake, that this reaction occurs when subjects find themselves before an event or situation where they can no longer ignore the ‘gap’, that excluded signifier. A signifier—paternity—which has no corresponding signified. Now, this confrontation with the ‘gap’ can produce the complete breakup of the subject’s sense structure, in other words, it can produce schizophrenia. According to Leader, a psychotic is someone who struggles first and foremost with questions of senses to give to himself and to the world. Hence psychosis cannot be reduced to certain behaviours, but it is a certain sense that certain things have for a certain subject.
To distinguish the three main forms of psychosis, Leader evokes the three fundamental ‘problems’ he thinks every human subjects needs to solve, which are:
- How can a sense be given to my reality?
- How can my bodily libido be tied down? It can be invested in the world or retreatinto my body (note that Leader reinstates the original Freudian term ‘libido’ and neglects the term that translates it by the Lacanian revision, ‘desire’, probably wanting to minimize the ‘Hegelian’ and idealist implications of the Lacanian term désir);
- How can a safe distance be created between myself and the Other? That is, how to situate myself in relation to an instance that distinguishes itself from me insofar as it is so radically other from me?
In paranoia, sense is produced through a delusion, which supplies a description of the world and of everything that is wrong with it. Libido is localized in the Other, in the sense that he or she who loves and hates is always an other outside myself. In fact, I, the paranoiac, always use libido passively. It is either: ‘I am persecuted by the Other’, or ‘I have been betrayed by the Other, because the latter loves another’ (jealousy delusion), or ‘I am loved by the Other’ (erotomania), or ‘I am admired and glorified by the Other’ (megalomania). Insofar as paranoiacs always rigidly separate themselves from the Other, the Other always acts on subjects from the outside (Kraepelin  noted that in paranoia we never find the idea of the abolition of one’s will.)
In schizophrenia, instead, sense cannot be fixed, hence subjects are at its mercy. The ‘fugue of ideas’ expresses this rush by subjects towards a sense that always escapes them. The schizophrenic’s libido is not located outside the subject, as in paranoia, but it rebounds, so to speak, in order to invade the person’s body. The distance from the Other is not assured, so that the Other can install itself in the subject’s body and mind. Leader quotes one of his woman patients: ‘I look at my arms and they aren’t mine. They move without my direction. Somebody else moves them. All my limbs and my thoughts are attacked to strings and these strings are pulled by others’ (p. 98).
Finally, in melancholia, sense is fixed (as in paranoia): the subject is the cause of any calamity and error. Here libido overwhelms the image-of-the-self and overpowers the Ego in the Freudian sense (as the instance of the second topic). The Other is included in the subject, but without generating the monstrous battles of inclusion-exclusion that we find in schizophrenia.
We notice that the elements Leader considers crucial—sense of the self and of reality, investments of libido, distance between the self and the Other—do not entirely coincide with the three registers Lacan focused on (Imaginary, Symbolic, Real). We find a shift with respect to Lacanian orthodoxy.
Leader opposes neuroses and psychoses specifically in relation to libido: whilst in the former the subject always complains of a libidinal lack, a ‘minus’ that inhibits or distresses him, in psychoses libido is ‘extra’. Psychotic libido is always positive, in excess. In schizophrenia this libidinal surplus brews in the very body of the subject. In paranoia the excess characterizes the Other, making it either a persecutor, a lover or a cheater. In melancholia libido is not situated in the Other (as in paranoia), nor in one’s own body (as in schizophrenia), but in the subject’s image of the self as scum, irrelevance, waste of space (p. 91).
Basically, Leader attempts a global theoretical systematization of psychosis. But does he really succeed—without forced interpretations—in leading the variegated psychotic phenomenology, of which the book offers us so many examples, back to such a simple, yet so elusive, key, as the exclusion of the paternal metaphor? Does the key—powerful because too flexible—that Lacan suggests manage to account for all the forms of raving that psychosis offers us? It’s not a rhetorical question. It’s a question I ask myself too.
For example, Leader notices that the psychotic subject nearly always feels in a unique, exceptional position, irreducible to any other networkof places. The psychotic feels unique in the universe. This ‘uniqueness’ of the psychotic is usually associated with megalomania. Instead, Leader leads this position of the psychotic back to that unique ‘gap’—the paternal metaphor—within which psychotics position themselves to fill it with sense. Yet, in his book Leader himself tones down this uniqueness of the Name-of-the-Father, stressing that the late Lacan talks about ‘names of the father’ (p. 63); in other words, it is not evident whether the signifying foreclosure at the heart of psychosis is unique and exclusive.
With regard to the treatment of psychotics, Leader confirms Lacan’s indications. The latter believed that psychoanalytic technique, developed for neurotics, should not be applied to psychotics, but that the psychoanalyst should meet the psychotic as analyst and not only ‘as a person’(as psychologists say today). Not a psychoanalysis for psychotics, but a relationship between a psychoanalyst and a psychotic. In particular, the analyst should avoid the interpretation of dreams or actions, as she does in analysis; because the psychotic tends to read the interpreting metaphor (all interpretations are metaphors) as a statement on reality, taking it ‘literally’, and could receive the interpretations as persecutory. Lacan recommends the opposite of the interpretative stream that so many analysts used to flood psychotics with. The analyst, Lacan quoted by Leader says, should be ‘the psychotic’s scribe’, registering everything the psychotic says, acknowledging it, without ever occupying a superior hierarchical position as ‘the one who knows’, ‘the one who interprets’. With the psychotic the analyst should instead come forward as a pupil, as ‘one who does not know’. Fully aware that treating psychosis is a question of caring rather than of curing. A care that usually lasts a lifetime, the psychotic’s or the analyst’s.
Bettelheim B. (1967) The Empty Fortress (Berkeley, CA: Free Press).
Guapp R. (1914) Zur Psychologie des Massenmords: Hauptlehrer Wagner von Degerloch (Berlin: Springer).
Kraepelin E. (1896) Psychiatrie. Ein Lehrbuch für Studierende und Ärtzte. 5 (Leipzig: Johann Ambrosius Barth).
Lacan J. :
- (1955–56) Le Séminaire, livre III. Les Psychoses, 1955–1956 (Paris: Seuil, 1981). Eng. Tr. The Seminar of Jacques Lacan, Book III / 1955–1956: The Psychoses, ed. Jacques-Alain Miller, trans. by Russell Grigg (New York: Norton, 1993).
- (1957–58) ‘D’une question préliminaire à tout traitement possible de la psychose’, écrits (Paris: Seuil, 1966) pp. 531–583. Eng tr.‘On a Question Preliminary to Any Possible Treatment of Psychosis’, in Ecrits: The First Complete Edition in English, trans. by Bruce Fink (New York: Norton, 2006) pp. 445–488.
- (1975–76) Le séminaire de Jacques Lacan: Livre XXIII. Le sinthome (Paris: Seuil, 2005) Eng. trans., http://www.lacanonline.com/index/links/
Peters C. (2005) Harold Shipman: Mind Set on Murder (London: Carlton).