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Getting To The Triangle

Liam Hennessy

What is Madness? by Darian Leader, Hamish Hamilton, 359 pp, £20, ISBN: 978-0241144886

“It is a great time to be mad in Ireland,” said one contributor to a forum on mental health recently. The Taoiseach, Enda Kenny, in a by now infamous interview during the last World Economic Forum at Davos, suggested that “we all went mad borrowing” during Ireland’s understandably short-lived property-fuelled boom. Noel Whelan, a well-known commentator on Fianna Fáil affairs, has written in his Saturday column in The Irish Times while recounting that party’s descent into the political abyss: “If political parties can be said to have a personality, then, Fianna Fáil could be argued to suffer from narcissistic personality disorder given its infantilising and reckless behaviour.” A perfect illustration of that behaviour was Bertie Ahern’s self-characterisation as a socialist.

In the literary world, madness and related issues have featured in recent works by Sebastian Barry ‑ The Secret Scripture and Tales of Ballycumber ‑ and by Sebastian Faulks ‑ Human Traces, Enderby and A Week in December. Moreover, madness has always been a staple of the cinema. Consider, for example, Jack Nicholson as McMurphy and Louise Fletcher as Nurse Ratched in One Flew Over the Cuckoo’s Nest, itself based on Ken Kesey’s novel and Winona Ryder in the film version of Susanna Kaysen’s Girl Interrupted. Then there are the memoirs of those who experienced Churchill’s Black Dog and other mental illnesses. These range from William Styron’s classic Darkness Visible to poet Sylvia Plath’s prophetic The Bell Jar to clinician and Professor of Psychiatry at Johns Hopkins Kay Redfield Jamison’s informed and painful recounting of her bipolar illness in Unquiet Mind, to biologist Louis Wolpert’s Malignant Sadness (a very insightful metaphor for serious and recurring chronic depression) to journalist Sally Brampton’s Shoot the Damn Dog. Moreover,TV 3 is currently running a three part documentary series on depression in Ireland called significantly Depression the hidden epidemic. And this is before any mention is made of Freud’s case histories which, while undoubtedly focused on the clinical and therapeutic role of psychoanalysis , could also be conceived as literary in their own right, “Little Hans” and “The Wolf Man” being exemplars. So madness is out there in the personal, political, economic, social, literary and filmic discourses.

The comments of, and about senior Irish politicians, set out above are clearly fatuous when the realisation dawns that suicide ‑ particularly among young males – is a serious and growing problem in Ireland and one which does not get the attention it surely deserves. This is the case notwithstanding the fact that there is a seminal document on the future of mental health services in the country called A Vision for the Future. This exemplary policy was adopted by Government and published in 2006 and it sets out a very constructive roadmap for the future development of the mental health services. Possibly uniquely in recent civil service experience for an Irish Government-commissioned report, not only did the policy elicit unanimous agreement from all the members of chair Joyce O’Connor’s committee but its principles and recommendations have been adopted in full by all leading participants in the Irish mental health field.

On the face of it, this unanimity seems surprising given the often divisive nature of Irish health policy discourse. It can be attributed to the committee’s endorsement of the biopsychosocial model of mental health, that is an approach that sees mental health difficulties as arising because of any or all of biological, social and psychological causes. Biological causes might include a deficiency of the feelgood chemicals, dopamine and serotonin, in the brain. The depletion of such chemicals is characteristic of depression although, regrettably, there is no blood or other test that can establish such deficiencies. Social causes that can give rise to mental health problems are many and varied. Difficulties within families and financial crises – all too common with the collapse of the Irish economy – are obvious examples. Psychological causes would encompass cognitive, affective or emotional and personality disorders. As well as endorsing the biopsychosocial model, A Vision for the Future presents the case for the use of multidisciplinary teams, that is teams composed of personnel drawn from different disciplines ‑ from psychiatry to psychology, from nursing to occupational therapy ‑ to address the needs of people with mental health problems. Finally and most importantly, A Vision for the Future places a strong emphasis on the ethos of recovery and empowerment of the patient in relation to psychological problems, an ethos which many mental health representative groups have been arguing for for a long time and, indeed, continue to argue for. These three major elements of A Vision for the Future have a “tried and trusted” genesis in Canada, the Antipodes and, to a lesser extent, in the United Kingdom. Finally, there is the national anti-stigma campaign, See Change, which sadly because of its rather intermittent roll-out has not been as successful as some would have hoped.

All this is by way of contextual introduction to Darian Leader’s humane, challenging, provocative and, occasionally, tendentious study What is Madness? It is important here to define terms in order to establish the framework for Leader’s answer to the question he poses in the title of his book. His tentative prescription – for he is anxious to play down the role of the therapist as expert, rather he sees the therapist and patient as co-workers – derives from the Freudian and, more specifically, the Lacanian traditions (Jacques Lacan was the great early and mid-twentieth century French psychiatrist). In this context and citing mostly late nineteenth century and early/mid-twentieth century clinicians, he argues that there are only three mutually exclusive pathological mental structures: neurosis, psychosis and perversion. The difference between neurosis and psychosis lies in the degree of certainty with which beliefs are held by the patient. Neurotics tend to doubt, psychotics are more certain.

Thus, neurosis would include obsessive compulsive disorder (OCD), generalised anxiety disorder (GAD), panic attacks, phobias like agoraphobia, claustrophobia and the well known arachnophobia (fear of spiders) and other disorders on the anxiety and depression spectra where the characteristic, very broadly speaking, is that the sufferer is deeply fearful, unsure of him or herself and constantly questions their self esteem. While, for example, fear of spiders may seem like a trivial and largely avoidable complaint, some of the phobias can be deeply crippling. Agoraphobia (literally fear of the market place) can confine the sufferer to the four walls of his or her own home indefinitely, making normal life impossible. OCD too can be life-altering and confining as the sufferer has to check repeatedly and perform rituals in a futile effort to assuage his or her uncertainty. Shakespeare provides the classical example with Lady Macbeth’s compulsive handwashing – “All the perfumes of Arabia will not sweeten this little hand.” The reviewer knows of a case where the sufferer has literally washed his thumb to the bone with astringent cleaners as he is convinced that aeroplanes will fall out of the sky if he does not perform this ritual. In all other respects, he leads a perfectly normal life. And who can forget Leonardo DiCaprio’s playing of the obsessive, compulsive Howard Hughes in The Aviator? In one memorable scene from that film, the Hughes character cannot leave the bathroom of a restaurant until he has scrubbed himself virtually all over and, even then, he cannot make his exit until he is able to sidle out the door without touching the door handle as another customer entered. Howard Hughes had a lifelong fear of contamination and had the most rigorous instructions for his staff when serving meals or doing other domestic chores. Suffice to say that he spent most of his reclusive retirement in a futile effort to keep contamination away.

Are these neuroses madness? Leader would think not although they clearly have the ability to disable the sufferer severely from normal social intercourse. Psychosis, on the other hand, deals with certainty such as the creation of alternative worlds which the sufferer say believes in, inhabits or is threatened by and Leader gives some telling examples of this feature. Such worlds can give rise to delusions, such as hearing voices and hallucinations, for example, or believing with absolute conviction that one is being instructed to perform horrific acts by the television or the radio. These delusions and hallucinations are sometimes identified as the “positive” symptoms of psychosis; the “negative” symptoms are usually associated with the patient’s moods and are not “visible” in the way that hallucinations and delusions are. Within psychosis, Leader identifies a further three subcategories – paranoia, schizophrenia and melancholia. Finally, there are debates about how to characterise autism and manic depression (bipolar illness) in this schema. Leader, although he has identified it as one of the pathological mental structures, does not discuss perversion at all.

The parsimonious Lacanian tripartite division of mental structures contrasts sharply with the some three hundred and sixty diagnostic labels identified in the Diagnostic and Statistical Manual (DSM IV TR) of the American Psychiatric Association which is the diagnostic tool of choice in modern psychiatry (DSM V is in preparation!). According to Leader, the fault in the DSM classification lies in the fact that disorders are mostly defined in terms of visible behaviour and symptoms and that these aspects of life are used to define clinical categories. He takes the view that such classification has eliminated psychical causality or, even, the individual, interior life. It is worth stating here that, although Leader makes passing references to the neuroses in his book, these are included mostly by way of contrast with the psychoses, the elucidation of which, and therapeutic approaches to their “resolution”, are the main purposes of the work. It is clear that Leader takes the view that it is only the psychoses that can justify the label of madness.

Leader’s central thesis is that there is a difference between “ordinary madness”, which allows normal functioning and “triggered” or “detonated” madness. (The military metaphors are striking here). “Triggered” madness is where the attention-grabbing symptoms such as hallucinations and delusions are seen. In other words, there is a distinction between “being mad” and “going mad”. In his examination of various case studies, Leader illustrates this distinction with repeated descriptions of the ordinariness of lives led by many psychotic persons until events and circumstances triggered their psychoses. In such triggering not only could there be efflorescence of the kind of symptoms associated with psychosis – in the case of paranoia, a feeling of an inordinate, unbearable external challenge and, in the case of schizophrenia, the feeling that such a challenge comes from within – but also actual, physical violence tendered against some other, the Other in Lacanian terms, or the self. It should be made clear, however, as Leader states, that the chances of being assaulted by a psychosis sufferer are far less than with a drunken crowd outside a pub on a Saturday night. This point is one that needs to be emphasised, not least because of the tabloid tendency to report mental illness in often frenzied terms.

The concept of the Other or the Name-of-the-Father has its origins in Freud’s Oedipal theory and its refinement by Lacan. It would be foolish to suggest that this concept can be readily understood and there is no doubt that understanding Lacan presents great challenges to anyone not trained in his elaboration of Freudian psychology. It is not an understatement to say that the writer of this review struggled with those challenges. Moreover, at times, the density of Leader’s prose does a disservice to the clarity and strength of his arguments. Be that as it may, the concept of Lacan’s Name-of-the-Father lies at the centre of Leader’s perception of the origins of psychosis. The concept concerns the psychical migration of the child from dependence upon, and assimilation with, the mother to the acceptance of an externality which is reflected in the paternal metaphor (This need not be the actual, biological father but, in Lacanian terms, the symbolic father or Name-of-the-Father or accommodation with the Other). In psychosis this crucial migration has failed. The patient struggles with the question of meaning, localising the libido and creating a safe and workable distance from the threatening Other, what Leader labels “triangulation”. (This elaboration of the Oedipal theory can either be accepted or rejected ‑ it is impervious to evidence-based research and relies for its validation on case histories – but it is Leader’s fundamental postulate.)

Leader is systematic in the structuring of his book moving, as he does, from description of the basics, where he sets out his postulate, to the task of making a diagnosis and to an examination of the circumstances that trigger a psychosis or the move from ordinary madness to either paranoia or schizophrenia. Along the way, he looks at the language and logic of psychosis, for example, the fact that many psychotics construct neologisms to which they attribute particular and relevant (for them) meanings and at its causes. Finally and crucially, in the theoretical parts of his book he looks for the ability of psychosis to be both stabilised and creative. He concludes the book with three well-known case studies including, controversially, the notorious case of the mass murderer Harold Shipman. His material for these case studies is all drawn from published sources. He has been criticised for this, with the suggestion being made that he might have used more material from his own patients. There are confidentiality issues here, needless to say, but he does frequently throughout his book cite instances of things his patients have said to him. Of course as would be expected, he extracts material from cases which seem to bolster his central thesis.

It would be helpful to look at the different elements of Leader’s book to establish just how convincing his arguments are. However before doing so, it might be fruitful to examine his review in the early chapters of the historical development of psychiatry. In his review, Leader makes an important distinction between what he calls “classical psychiatry” (that is, psychiatry of the late nineteenth and early/mid twentieth centuries) and modern psychiatry (broadly speaking, psychiatry as practised from the 1950s onwards, where the biological or medical model of mental illness has held sway until relatively recently). This had come about following the introduction of the neuroleptic or anti psychotic chlorpromazine – still widely used in the treatment of psychosis and known to users in Ireland by its trade name, Largactil. It is interesting to note that the introduction of chlorpromazine is widely credited with “emptying” many asylums in the United States and elsewhere. It did so by making possible the “management” ‑ through the amelioration of some of the external symptoms of psychosis such as hallucinations and delusions – of illness outside the walls of those institutions. Regrettably, “management” included the tolerance of very unpleasant side effects from the drug’s usage. The most characteristic of these was the “chlorpromazine shuffle”, the slow, shambling gait experienced by many users. Leader also discusses what might be called intermediate treatments in the history of psychiatry from insulin coma to metrazol injections to (his term) “electroshock”. According to Leader, the aim of such intermediate treatments was to destroy or severely damage the executive functions of the brain/mind. While the first two of these treatments have been justly discredited, the latter, given its common name – electroconvulsive therapy or ECT ‑ is still used for therapeutic purposes in some countries though not in all. Its use, however, is usually as a treatment of last resort and, except in the case of incapacity and immediate danger to life, it is carried out with the consent of the patient to treat resistant or recurring severe depression which has not responded to other treatments. Leader’s suggestion that ECT may be destructive merits attention and very serious consideration, not least because of the controversies ‑ including debates about human rights and bodily integrity ‑ that have surrounded it. But it would be a step too far to regard it as barbaric, invasive and an abuse of human rights always. This is a very big issue with vociferous proponents on both sides of the debate. It will be returned to later.

Leader has very strong views on the use of drugs, antipsychotic and otherwise, arguing, not entirely convincingly, that such drugs are successful not because of their medical efficacy but because of the public relations successes of the companies that market them. Leader suggests that these drugs act on the visible, disruptive symptoms of psychosis (surely not a bad thing in itself) and that, over time, the actual illness that they were intended to treat becomes redefined in terms of the effects of the drugs. In a powerful, if mixed metaphor, he suggests that “(R)ather than seeing the drug as key to the lock of the illness, the illness was defined as whatever would fit the key, rather like Cinderella’s slipper”. This is a big statement and again some care needs to be taken with its promulgation. Nevertheless, there is considerable support for Leader’s position in Irving Kirsch’s The Emperor’s New Drugs. Kirsch’s book is essentially a metaanalysis of the individual research studies of the selective serotonin reuptake inhibitors or SSRIs. (One of these – Prozac – has entered the colloquial lexicon as a byword for inducing “better than well” states in depressives. Lauren Slater’s Prozac Diary, Elizabeth Wurtzel’s Prozac Nation and Peter Kramer’s Listening to Prozac are cases in point.) Kirsch seems to establish from his metaanalysis that, on first use, such drugs are only effective in one in three cases presenting with depression.

Reverting to the structure of What is Madness, Leader has interesting views on the making of a diagnosis and the circumstances that give rise to a triggering of a psychotic episode, to the migration from being mad to going mad.

In looking at the causes of psychosis, he argues the rather bleakly deterministic view that psychosis is a mental structure that will be established early in life, probably within the first few years. However, in keeping with his distinction between being psychotic and going psychotic, he suggests that this does not mean that the person in whom such a mental structure is laid down will ever go mad. He repeats here the importance of the “triangulation imperative or requirement”, that is, the journey from the close bond with the mother to acceptance and accommodation with the paternal metaphor which, as noted, need not be the biological father. It is the failure to negotiate this journey successfully that establishes the basis for a psychosis or being mad. The repeated recourse by Leader to the triangulation imperative has the feel of assertion but must needs be accepted if the Oedipal complex and its elaboration by Lacan are taken as a given. By its very nature the triangulation imperative cannot be corroborated by traditional scientific methodologies but must rest on case studies for its validation. In an ideal world it would be nice to have both and, although Leader rejects traditional science, he does provide tantalising, if not entirely convincing, fragments to support his theory from his own engagement with his patients and his elaboration (from published materials) of the famous cases studies of Freud’s Wolf Man, Lacan’s Aimée and of the formal official inquiry into the horrendous Shipman case. In all of these published cases, he argues for the failure of the eponymous patients to negotiate the triangulation imperative, to “integrate” (if that is an appropriate term in the context) the underlying questions of meaning, localisation of the libido and distance from the Other. As Leader puts it in his discussion of the Shipman “case”, “the registers of the real (the mother), the imagination (separation from the mother) and the symbolic (identification with the paternal)” failed. In particular, it is the failure of the third element of the triangulation which leads to the sense of internal and external persecution that schizophrenics and paranoiacs typically experience.

If the substructure for psychosis lies in the failure in early life of the integration of the real, the imaginary and the symbolic and if, as Leader argues, only “ordinary” madness or “white psychosis” results in most cases, what is it that leads to the fragmentation, dislocation and the sense of destruction characteristic of going mad, the eruption of psychosis often “in a terrifying and initially catastrophic way”? The temporal qualification is important here as it is central to the proposition of “self-cure” sought by psychotics through the allocation of meaning that they can attribute to such phenomena as delusions or hallucinations.

The precept of self-cure or stabilisation and creation, as Leader labels his penultimate therapeutic chapter, is something he sees as central to the psychotic experience and as having been largely ignored by post 1950s psychiatry. This contrasts sharply with the views and the case studies of the earlier clinicians working in the field. Leader suggests psychotic subjects often find a means to stabilise or make their suffering bearable after a triggering but also, in some instances, manage to avoid the triggering of psychosis altogether. (The choice of the noun “subjects” is peculiar given Leader’s very strong views on “colonialism” in psychiatry, that is, the imposition of the psychiatrist’s or psychotherapist’s Weltanschauung on patients/subjects).

There are a number of forms of stabilisation and Leader traces them is some detail. They include the construction of an ideal by the psychotic, that is, an image which acts as a kind of compass for the patient around which s/he can live their lives and the adoption of “as-if” (Leader’s terminology) or a mimicked character by the patient. They also encompass the creation of formulae or ideals to live by always involving a commitment to a role of some kind or another, say, that of mother in a mother/son dyad.

There are other mechanisms of restitution too. There is the creation of a prosthetic symbolic order designed to connect the psychotic to a symbolic system in the absence of success with the triangulation imperative. Such cases would include patients who develop attachments to mechanical devices. There is writing and language and Leader suggests that transformed languages are often found in cases of schizophrenia. He even goes so far as to claim Joyce in this regard. He notes that Lacan was particularly interested in Joyce and suggests that Joyce, rather than fleeing the fragmentary nature of language and speech, adopted a strategy to accentuate it. He even draws a parallel with Finnegans Wake and, just as it can baffle and intrigue readers, so the language sometimes created by schizophrenics can produce a similar result. This seems a bit reductive insofar as the works of Joyce are concerned but the creation of a metalanguage by psychotics to address and accommodate the omnipresence and intrusiveness of ordinary language is not uncommon in psychosis.

Perhaps, the most widely recognised method of stabilisation is the logic of exception, whereby the psychotic creates an exceptional persona for him/herself such as Christ or Napoleon. Recall the character played by Peter O’Toole in The Ruling Class and the character of Napoleon in John Katzenbach’s engaging thriller The Madman’s Tale, which has a schizophrenic as its unlikely hero. Curiously, Leader notes that patients with such delusions rarely have difficulty in carrying out menial tasks. What is important for them is the symbolic with which they identify not their day to day existence.

The last two forms of stabilisation that Leader identifies are limiting and naming, and the construction of a new way of dealing with the triangulation, of pulling the real, the imaginary and the symbolic together. Thus, the transformation of what affects the patient “into a way of living not by suppressing it but by exploiting it, by learning to use it” is the route to take, with Joyce again being cited as an exemplar. Leader argues that devaluing the work of nomination is both cruel and dangerous. This can be seen as a challenge to what he sees as the medical model prevalent in current psychiatry. He may be overstating his case here as it is arguable that the challenge has already been taken up with the elaboration of the medical model to include the psychological and social dimensions of presenting cases, as already noted, the so-called biopsychosocial model. There are other challenges too which Leader does not address such as the emergence of the wellness and recovery model in mental health. This model, as already discussed, is now central to mental health policy in many western countries, if not always practised. However, it is fair to say Leader would not have seen that as part of his function. Finally in his chapter “Stabilization and Creation”, Leader comments that is quite usual for a number of the mechanisms he has described to coexist for the psychotic patient.

Following his exegesis – incorporating his central triangulation predicate – of the published cases of Aimée, the Wolf Man and Harold Shipman, Leader moves to his final and, perhaps for clinicians, his most relevant chapter, “Working with Psychosis”. Leader’s role for the therapist in a very demanding one and, for practical purposes, it may actually be impossible. As has been seen, if psychosis can be triggered by a (failed) encounter with the paternal, then, the last thing the therapist needs to be is an authority or father figure. If this is correct, and it is the crux of Leader’s thesis, then, it poses obvious difficulties for psychiatrists who, in Ireland will have spent almost a dozen years in medical/psychiatric training and for psychotherapists and psychologists who would have had a minimum of eight years in training in most cases. Leader goes so far as to state explicitly “the more the analyst identifies with a place of knowledge, the more dangerous things are for the patients”. This seems to be a bridge too far and, in any event and to extend the metaphor, there may be other ways of making the crossing, some of which would be inimical to Leader. The spectre of what might be labelled “psychological sectarianism” (perhaps, it is time to coin a neologism, “psychsec”) raises its not so attractive head here. Leader cites a 1948 work by psychoanalytical psychotherapist Frieda Fromm-Reichman which merits quoting:

The therapist should feel that his role in treating schizophrenia is accomplished if these people are able to find for themselves, without injury to their neighbours, their own sources of satisfaction and security, irrespective of the approval of their neighbours, of their families and of public opinion.

The essence here is that any emphasis on normal social adjustment carries dangers as it risks neglecting the unique and idiosyncratic formulae for living that many psychotic patients have developed, in Leader’s terms, their methods of “self-cure”.

He makes further tough demands on therapists. Therapists undertaking psychotherapeutic work with psychotics must have no illusions about “helping” others and must be available almost constantly to their patients. He cites one of his own early teachers that therapy with a psychotic patient is for life. He identifies Lacan’s “secretary of the alienated subject” as the analyst’s locus. A secretary doesn’t try to impose a world view or tell the patient how s/he should behave. Above all and by definition, a secretary is not a boss, an authority figure.

It might be appropriate to conclude the outline of Leader’s book here but that outline does raise the question: what relevance does this extensive tour around Leader’s What is Madness have to the treatment of psychosis and, indeed, other mental health issues in Ireland? Certainly, it has relevance in that it addresses one, but for the most part only one, approach to therapeutic intervention in mental illness, specifically psychosis. In doing so it has laid down some challenges and provided some intriguing insights, although the cost to the patient of lifelong engagement with a therapist in Leader’s mode would be likely to be both emotionally and financially prohibitive. And the costs of the provision of good mental health services are an important issue. For example, the National Institute of Clinical Excellence (NICE) in the United Kingdom has supported relatively short sessions of cognitive behaviour therapy (CBT) as an evidence-based and both a cost- and an emotionally effective response to mild and moderate depression. Whatever views there might be on CBT, not least the perception that it is excessively mechanistic; it is arguably one cost-effective response to personal distress. And there are other responses too. The wellness and recovery model of mental health has gained considerable ground in recent years since its initial promulgation by American mental health pioneer Mary Ellen Copeland. It offers an eclectic approach to recovery from both depression and bipolar illness and suggests a suite of therapeutic possibilities that empower the patient and facilitate his/her recovery and maintenance in good health. The suite of possibilities extends from the use of appropriate medication, to counselling, to the ancient practice of meditation, to support groups, to name but a few. The practice of mindfulness meditation has become the “new kid on the mental health block” notwithstanding the fact that it is thousands of years old and derives from the Buddhist tradition in particular. It is worth repeating that the wellness and recovery model is now Irish Government policy as articulated in A Vision for the Future.

And then there is the contentious issue of ECT. It is a curious fact that ECT was demonstrated in two recent television series, White Heat and Homeland. In White Heat, the mother of the heroine, Charlie, suffers from bipolar depression and is treated with ECT. The actual ECT experience is very graphic and unpleasant as might be expected from a series partly set in the 1960s and 1970s. In sharp contrast in the contemporary Homeland, the heroine, Carrie, is bipolar and secretly takes the mood stabiliser lithium. In the final programme of that series, her existing treatments have failed and she agrees to have ECT. While her mentor, Sol, says “don’t do this Carrie”, her response is straightforward as she feels it is the only way to lift her intense depression and specifically tells Sol that “this is not One Flew Over the Cuckoo’s Nest”. In a sense, these two vignettes illustrate the development of ECT over the last fifty years or so. While it is the case that there is no exact understanding of how ECT works, nevertheless, it seems to have an ameliorative effect in relation to the feelgood neurotransmitter dopamine. (The SSRIs also act on the brain’s neurotransmitters.) Very strong opposing views are held about ECT but scientific evidence suggests that it can be effective in treating some seventy per cent of cases with severe depression. Moreover, its administration in