On being mad

The recent court ruling on Anders Breivik1 highlights a number of important issues relating to the nature of madness.  The judges found that he was sane at the time he carried out the bombing of the government buildings in Olso and the subsequent shootings on Utoeya island.  In other words he was responsible, and therefore accountable, for his actions.

One the ironies of this case is that this is precisely the verdict Breivik was hoping for; the last thing he wanted was to be found insane, which would imply that not only did he not know right from wrong (the legal definition of insanity), but also that his whole political ideology, which he claimed motivated his actions, was nothing more than the delusions of a mad man.  As far as Breivik is concerned, to be found sane is to vindicate his actions as a political terrorist; in other words he can now claim he is a political prisoner – and there is also the outside possibility that he could be released in ten years time, when he will still be relatively young and. presumably, be free to continue to espouse his ideology.

One of the key points here is that ‘sanity’ and ‘insanity’ are not psychiatric or clinical terms; rather they are legal definitions.  In other words, it is still quite possible to argue that Breivik is clinically mad, i.e. psychotic, and yet legally sane.  Furthermore, it is quite possible for someone to construct an elaborate and totally rational belief system and yet be totally psychotic.  In fact, this is precisely what paranoid (in the clinical sense) individuals excel at.

Although the term ‘madness’ is not (officially) used nowadays in psychiatry and clinical psychology, the idea of madness still permeates our culture.  Most people would prefer to be diagnosed with a physical problem rather than with a mental health problem, which carries all kinds of negative connotations.  To be mad, i.e. mentally ill, is to be an outcast – both metaphorically and (often) literally.  As I have written previously, in many environments, and especially in ‘macho’, corporate ones such as the City, to be diagnosed with a mental health problem is effectively to have a death sentence passed on one’s career prospects, and on the lifestyle that often accompanies such a career.

Furthermore, in spite of the many campaigns that have run over the years to try and combat the stigma of mental illness by organisations such as Mind and Rethink, there is still a great deal of ignorance and prejudice in the wider culture regarding the nature of madness.  And I use the word ‘madness’ deliberately here; in my view using terms such as ‘mental illness’ or referring to specific psychiatric diagnoses such as schizophrenia or bi-polar disorder, or even anxiety or depression, whilst being psychiatrically more accurate, simply clouds the issue.  Although such terminology is often used to de-stigmatise madness, by showing that it’s ‘just like any other (treatable) illness’, most people, and especially those who have received such diagnoses, are fully aware of the wider social connotations.

This might help explain why so many people are reluctant to admit to psychological problems (another euphemism for madness perhaps?), or to present them to their GP.  Most GPs will tell you that a significant proportion of their consultations relate to some form of psychological problem, and yet this is rarely the presenting issue.  And then there are the whole array of symptoms which people present to their GP which have no apparent physical basis (‘medically unexplained symptoms’).   Such individuals can get very upset with their GP if he or she suggests that perhaps their chronic fatigue or irritable bowl syndrome might be psychological in origin.  To suggest that a condition might be ‘psychological’ or ‘psychosomatic’ seems to imply to a lot of people that this is not a ‘genuine’ illness and, to add insult to injury, that the individual is suffering from some kind of mental health problem, and is therefore not of sound mind – and is therefore mad.

So there are good reasons not to be mad.  But, actually, do we have any choice?    Many psychoanalysts would argue that we do not.  Although strictly speaking ‘madness’ equates with psychosis, in the wider sense of the word, many analysts would argue that we are all, in fact, mad – although, to paraphrase Orwell’s Animal Farm, some people are madder than others.  Freud famously wrote of the ‘psychopathology of everyday life’ and as well as being the title of an important book of his, it is also a useful metaphor for madness in this wider sense of the word.  In other words, from a clinical (psychoanalytic) point of view there is no such thing as ‘mental health’.  Rather, there are certain states of mind, certain behaviours, certain ways of relating to others, which are socially more acceptable than others, and which are more or less troublesome for the individual in question.

From a psychoanalytic position, the key question is not whether a person is or is not mad (mentally ill, psychologically disturbed, if you like), but the nature of such madness.  From a clinical perspective, what matters is how an individual constructs their sense of reality, and how they relate to it.  This is not so much about the meanings that people construct for themselves, which is more in the realm of cognitive behavioural psychology and some forms of person centred and existential therapy.  Rather, it is about the actual process of constructing such meaning systems in the first place, and how stable they are.

Generally speaking, psychotic individuals have serious problems in constructing and maintaining their meaning systems, whereas neurotics tend to be deeply troubled by the ones they already have.   So although, loosely speaking, both neurotic and psychotic individuals could be said to be ‘mad’, there are serious differences regarding the nature of such madness.   This does not necessarily mean that neurosis is less ‘serious’ than psychosis; in some ways the neurotic individual suffers more, because neurosis is characterised by doubt and uncertainty, whereas psychosis is characterised by absolute certainty – hence the attraction for many neurotics of a psychotic leader.   The real problem for the psychotic is that his or her sense of  reality, i.e. structure of meaning, is extremely fragile and is in perpetual danger of collapse, which leads to intense anxiety and all kinds of strange phenomena, e.g. hallucinations, somatic disorders, distorted perceptions.

The role of psychoanalysis in relation to madness also depends on its nature.  With the neurotic individual the focus of the treatment is on deconstructing their system of meaning in order to ascertain where it came from and why it is so troubling for the individual, i.e. in the sense of their symptoms.  With the psychotic individual, on the other hand, the focus is more on supporting them to construct and sustain a system of meaning in the first place, one that can help them live in a more bearable way.

  1. http://www.guardian.co.uk/world/2012/aug/24/breivik-verdict-sane-21-years?newsfeed=true []

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