What Is Madness?
Hamish Hamilton, 368pp, £20
As a student, his head full of theories, Darian Leader worked in a therapeutic community. He was interested in psychosis, but none of the wild behaviour, hallucinations and delusions he expected of the "mad" was on display. Instead, patients worn down by medication quietly attended to their private routines. A lone man wanted to talk, and he did so with such lucid intelligence that Leader wondered why he was an inmate. Only months later did the reason become clear: the man informed him that they were living not in England, but in Zamara, a land of strange gods, with its own intricate history and laws.
In this fascinating book, Leader forces us to rethink our assumptions about that illusory gift called "mental health". He does so with a formidable grasp of psychiatric history and a storyteller's flair for detail. Leader shows that altogether ordinary people can have long-lived forms of quiet madness - delusional beliefs or symptoms that cause no conflict in their lives, and thus call no attention to themselves. Underlying psychotic structures can coexist more or less happily with daily life. Being mad is not the same as going mad.
Before he tipped into flamboyant madness, Sigmund Freud's case study Daniel Paul Schreber was for many years a high-ranking judge, his powers of logical deduction more acute than most. And no one - not his wife, not his colleagues, not even his patients - could fault Harold Shipman's doctorly "normality", until it was discovered that he was a mass murderer. In 1913, Ernst Wagner, a respected German schoolteacher living in the suburbs of Stuttgart, murdered his entire family; he then travelled on to the next small town and killed or wounded anyone within shooting range. His diaries showed that, over the preceeding 20 years, he had harboured paranoid delusions about all and sundry, whom he suspected of knowing his big secret: in 1901, he had had sex with an animal. Yet, for all this time, Wagner had led an ordinary life, and might have continued to do so, had something not made him crack.
Such cases don't prompt Leader to champion early preventive diagnosis of potentially "dangerous" psychotics, who could well include leading scientists or politicians. Rather, it is the measuring of human worth in terms of normative social utility that he considers dangerous.
Leader is sceptical of the medical classifications codified in the bible of the psychiatric professions, the Diagnostic and Statistical Manual of Mental Disorders, which is so preoccupied with visible behaviour that it forgets that human beings have inner lives. Using it, doctors can too often diagnose problems by the drugs that seem to work on them. In the process, they lose sight of how the "mad", like the "sane", attribute meaning not only to their experiences, but also to the drugs and treatments that psychiatrists give them. The violence of electroconvulsive therapy can work very well with a patient who somehow feels she needs punishment for her acts. It may have a completely destructive effect on another who does not.
In drawing attention to the prevalence of “ordinary psychosis", Leader is going back to an older tradition in psychiatry, one sidelined from the 1950s onwards by a tendency to diagnose an amorphous "schizophrenia" and to define ills by visible symptoms and brain chemistry only. This development went hand in hand with the introduction of drugs that mask symptoms and sedate feelings, and which confine rather than cure. The individual is lost in the process. But what Leader does so effectively is to give us a sense of what it might be like to live inside the mind of a psychotic.
The absolute certainty of the psychotic is what distinguishes him from the neurotic, who is full of inner doubt. Where the neurotic, as Freud showed, represses incompatible ideas and their accompanying emotions, the psychotic rejects them as unthinkable. He cannot integrate them, and so projects them outwards. Paranoid delusions are the result. Yet these also provide the psychotic with an account of the world and what is wrong with it. Leader teases out ways for the analyst to stay attentive to this inner world and to stabilise it.
Reminiscent of R D Laing in its passion, What Is Madness? is a humane and timely book.
Lisa Appignanesi's latest book is “All About Love: Anatomy of an Unruly Emotion" (Virago, £20)