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In his talk today, ‘What is madness?’Darian Leader presented us with three old ideas from European psychiatry, which he believes should be revitalised. In Darian’s view, these ideas are crucial to better understanding and responding to madness. Firstly, there is an important difference between symptom and structure. For example, people who suffer from extreme shyness, sweating and shaking when faced with unfamiliar company may receive a diagnosis of social phobia. Talking to two patients who both present with this symptom, however, may reveal that the first has these symptoms because they put a high value on avoiding making a fool of themselves, whereas the second may be convinced that other people can read their thoughts. Although the symptom – shyness – is the same, the underlying structure is very different, and it makes little sense to treat the patients as though they have the same condition.

Secondly, there is an important difference between being mad and going mad. Modern, Western culture associates psychosis with visible, noisy outbursts, in which the sufferer causes some kind of commotion and has to be restrained. Early psychiatrists had the idea that the most common forms of psychosis were actually the discreet ones. Darian stressed that instead of looking for the resources and strategies which may have kept a person stable for all the years before their psychosis ‘detonates’, modern psychiatry places emphasis on what has gone wrong. If you can have an idea of what kept someone stable before their psychosis triggers, then you may be well on the way to understanding the kinds of restitution measures which might help them find stability again.

Thirdly, there is an important distinction between primary and secondary symptoms of psychosis. When someone experiences psychosis, there is the initial phenomenon of disintegration, but there is also the easily forgotten response, and associated personal strategies of recovery.  Darian pointed out that it is irrational to try to work against people’s natural efforts at recovery, but contemporary mental health services are not structured to take these into account. Sometimes this might be about assigning oneself a role in the face of the confusion psychosis brings, which may manifest as a different set of delusions. The fact that it is common for clinicians to impose their view of what form ‘normal’ life should take on their patients gets in the way of allowing the patient to make their own efforts to recover through trying to better understand what reality is for them.

It’s seems crazy that psychiatric practice overlooks these important ideas, and obvious that if clinicians took more care to understand the ‘why’ as well as the ‘what’, found out more about what stopped people from going mad before the onset of madness and took care to understand people’s natural approaches to recovery that their jobs would be easier.

One point from the discussion emerged for me as particularly striking. In response to a question as to whether it is legitimate for sufferers of mental illness to say ‘my brain made me do it’, Darian commented that sometimes people see their brains as being external to themselves. For those on the receiving end of psychiatric diagnosis, this can be a helpful way of maintaining a sense of oneself. Darian was clear that he believes this is a dubious and ultimately unhelpful way of thinking. The argument goes that while it might appear a kind of salvation to say ‘you are not psychosis, you have psychosis’, this kind of externalising in fact leads to greater stigma. Darian explained by talking about non-western cultures whose ritual treatments of psychosis give a social place to marginal behaviour without marginalising the person. So, madness is you, at the moment you are mad, but it doesn’t define you forever, or prevent you from having a social place. I think I agree with Darian’s assessment about the stigmatising effect of externalising, but not without a degree of hesitancy.

Under the biomedical perspective, life experiences become ‘symptoms of illness’, decoupled from who we are and the social world in which we live. This transforms our day to day life into decontextualised indicators of illness, which is brutally depersonalising. Being told that the uncontrollable tears you cried for three hours this morning are a symptom of your depressive illness invalidates that experience and stops it belonging to you. This can result in a lessening of the search for meaning of one’s life, as one begins to feel completely at the whim of the next symptom. This may in turn create a situation whereby the mentally ill person regards him or herself as having a mind, or indeed a life, which is ‘diseased’ and of less value to others. Embracing madness, then, is perhaps a deeper and more authentic liberation than fighting to make it external. But, in order for going mad gracefully to be a real possibility, the way in which madness is made sense of in our culture certainly needs to shift. Engaging with the three ideas Darian put forward today may help us on the way.

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