The mind in pieces

PSYCHOANALYSIS: CARLO GÉBLERreviews What Is Madness?By Darian Leader Penguin, 359pp. £20

DARIAN LEADER is a psychoanalyst whose practice, judging by his new book, observes many of the principles established by Freud and the early psychoanalytical pioneers. In essence, the patient talks (often at incredible length) and Leader listens, very carefully.

In the last century this technique, sometimes known as the talking cure, was popular, but in the early 21st century the psychoanalyst who wants to be of use to patients using this system finds himself in competition and conflict with many other types of practitioner, including behavioural geneticists, cognitive neuroscientists, psychiatrists, psychologists and psychopharmacologists.

Healers with different beliefs have always been fractious and disputatious, but whereas in the past this was usually (or so they claimed) because they believed their system alone was the right one, and therefore the one that served the poor old patient best, today, more often than not, these quarrels are about achieving dominance in order then to secure lucrative contracts, in the UK, from the National Health Service and others to provide therapy.

As an old-style psychoanalyst Leader is hostile to these new procedures: as he has it, they’re glib and superficial; they deal only with the surface symptoms and not with the deep causes of psychosis; and their aim isn’t (as it ought to be) to repair the patient profoundly, permanently and ethically but to get the patient back to being a productive member of society who’ll pay their taxes as quickly and as cheaply as possible.

Leader isn't the first (and nor will he be the last) classical psychoanalyst to reject much modern therapeutic practice on these grounds. And his book contains some nice polemical swipes at the new orthodoxies. As Leader knows, however, it isn't enough. To win this war a practitioner must present an original exposition of his practice that demonstrates how superior it is to its competitors. Most of What Is Madness?is devoted to doing just this. The thesis goes like this: the traditional view of the fantasies, delusions and hallucinations that the paranoiac, the schizophrenic and the depressive present is that they are symptoms, indicators of the illness, and that their removal is the best indicator the patient is cured.

Yes, they’re indicators, Leader agrees, but, he says, fantasies, hallucinations and delusions are also wonderful strategies devised by the damaged psyche: they have purpose, meaning and function.

The best analogy to explain Leader’s view (and its implications) is probably the medical one. When a person gets an infection their immune system works to get them better, and medical science (when it’s working properly) works in tandem with that immune system.

Similarly, when a paranoiac, a schizophrenic or a manic depressive gets sick, their psyche’s equivalent of the immune system (which uses fantasies, delusions and hallucinations instead of white blood cells) throws out materials that are intended to get them better, and psychoanalysts (in Leader’s view) rather than treating these as symptoms to be oppressed or obliterated, should instead seek to incorporate those psychic materials into the patient’s recovery programme. In short, there is nothing wrong with being nourished by a fantasy, sustained by a delusion or living with a voice (or voices) so long as no harm is involved, and many of us do all of the above without knowing it, or with its being problematic

Leader's hypothesis draws heavily on and is deeply indebted to ideas of the French psychoanalyst Jacques Lacan. I wasn't really familiar with Lacan's ideas before I started What Is Madness?and, having finished, I can't say I have progressed. Some of Lacan's ideas are difficult, and I found his expression of psychological concepts with algebraic formulae particularly truculent.

On the other hand, large tracts of Leader’s book are riveting. I was hugely engaged by the three long case histories in the second half of the book. These concern Marguerite Anzieu (“Aimée”), the main subject of Lacan’s doctoral thesis; Sergei Pankejeff (“the Wolf Man”), a patient of Freud and numerous other early psychoanalysts; and Harold Shipman, the English GP who murdered at least 200 elderly patients – as well as by the case histories Leader presents from his own practice (though I’d have liked much more of this material).

These show he’s not only a wise but also a marvellously practical doctor who has devised all sorts of novel ways to help his patients. For example, to reduce inner turmoil he will let delusional patients text him key words during their psychotic episodes, which can sometimes lead to his receiving dozens or even hundreds of “abusive” texts a day. It’s hard not to like an analyst who makes himself available like this.

What Is Madness?may not be a completely successful book, but I still closed it feeling it was good to have read it and that it said something that very much needs to be said.

Western psychiatric practice is fixated on low costs and guaranteed, measurable outcomes. In Leader’s view, this is bad because it stops doctors listening until they can “unearth the logic” in what their patients say and then act with, rather than against, what they have understood.

This going with rather than against the grain has an attractive, commonsense quality, and makes sense. But this book isn’t only about improving practice: it’s also an argument for a model that puts patients back where latterly, because contemporary therapeutic practices have been so concerned with costs, efficiency and their own processes, they haven’t always been, which is at the centre of therapeutic practice. And isn’t that where patients belong? I’d have thought so.

One final quibble: why has this book no index?

Carlo Gébler is a writer and prison teacher. He is completing a memoir, Autobiographies of a Catastrophist, for Lagan Press