Why Psychosis Is Not So Crazy

An expert’s guide to humanizing psychosis through communication offers key insights for family and friends to support loved ones during mental health crises.

Are we all a little crazy? Roughly 15 percent of the population will have a psychotic experience, in which they lose contact with reality. Yet we often struggle to understand and talk about psychosis. Interactions between people build on the stories they tell each other—stories about the past, about who they are or what they want. In psychosis we can no longer rely on these stories, this shared language. So how should we communicate with someone experiencing reality in a radically different way than we are? 

Drawing on his work in psychoanalysis, Stijn Vanheule seeks to answer this question, which carries significant implications for mental health as a whole. With a combination of theory from Freud to Lacan, present-day research, and compelling examples from his own patients and well-known figures such as director David Lynch and artist Yayoi Kusama, he explores psychosis in an engaging way that can benefit those suffering from it as well as the people who care for and interact with them.“Vanheule…combines a long history of treatment of patients suffering from psychosis with a firm grasp of the current research on the subject…he provides useful information for sufferers and those who care for them, laid out in an articulate, sympathetic manner.” —Kirkus Reviews

“This superb and highly accessible book shows how psychosis should be seen less as an illness than as a way of responding to difficulties and trauma in our early lives. It offers a destigmatizing and profoundly humane approach both to thinking about and working with psychosis, reminding us how so much of what tends to be seen as negative and incorrect behavior is in fact a creative solution that the psychotic subject has developed in order to find safety. Vanheule’s book will be an invaluable resource for anyone touched by psychosis, whether they are a patient, a family member, or a clinician.” —Darian Leader, author of Introducing Lacan

“Shaking up conventional ideas, Stijn Vanheule makes us understand what being psychotic is like, and thus discloses a logic of insanity. This accessible, fast-moving survey, written with clarity and verve, offers a fresh take on psychosis. A must-read for anyone curious about the method in madness.” —Patricia Gherovici, author of The Puerto Rican Syndrome

“Why Psychosis Is Not So Crazy makes a vital contribution for readers who have experienced psychosis, their friends and family, as well as professionals. Stijn Vanheule elucidates experiences of psychotic crises eloquently, including what kind of life events may trigger a crisis, how such a crisis manifests and can be recognized, and crucially, the presence of someone able to listen to a person who has lost their bearings in language. Vanheule follows Freud and Lacan into a deep respect for the subject of psychosis; he speaks to the work of delusion as a work of repair, to kernels of truth in psychosis, and to the difficult work of listening, all with a minimum of psychoanalytic theorizing. Perhaps the strongest contributions in this book are Vanheule’s explanations of the ways that language can fall apart and the resulting effects on experience; and his showcasing the capacity of those who have experienced psychosis to navigate primary process fragments alongside lucidity through original creative projects sustained over time.” —Annie G. Rogers, author of Incandescent Alphabets: Psychosis and the Enigma of Language

“Stijn Vanheule offers psychological insight into what occurs when someone starts to feel a rupture with their context. It is not a question of illness but a meaningful response to chaos. The book is recommended for all those involved, especially for professionals looking to turn the page and engage in more humanistic approaches.” —Jaakko Seikkula, Professor of Psychotherapy, University of Jyväskylä

“Vanheule…is known for his constructive, in-depth research on the DSM and psychosis…With his familiar clear style, he succeeds in [comprehensively explaining psychosis to a wide audience].” —Tijdschrift voor Psychiatrie
 
“[Vanheule] dispels the myth that psychosis is best viewed through a purely biological lens.” —Sociaal.NetStijn Vanheule, PhD, is a clinical psychologist, professor at Ghent University, Belgium, and psychoanalyst in private practice (New Lacanian School for Psychoanalysis and World Association of Psychoanalysis). He is the author of the books The Subject of Psychosis: A Lacanian Perspective, Diagnosis and the DSM: A Critical Review, and Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation, as well as multiple papers on Lacanian and Freudian psychoanalysis, psychoanalytic research into psychopathology, and clinical diagnosis.PROLOGUE

During psychosis, the world is turned upside down. Voices that no one else can hear whisper confusing messages, other people look as if they might harbor dark intentions, and reality is behaving strangely. Difficult times, not only for those who experience an episode of psychosis but also for those around them. But what exactly is psychosis? Can you really understand what someone is going through at such moments? Or is their head simply full of madness? And how is it even possible that delusions, hallucinations, and other alienating experiences can take over someone’s thoughts and make them do and say strange things?
To get in touch with the world of a person experiencing psychosis, the first thing we need to do is to look beyond the simple conclusion that psychosis is strange. The strangeness of a psychotic experience is self-evident. Someone who has never heard secret messages transmitted in the radio news or has never suddenly discovered that words no longer have meaning will inevitably think it strange that someone else can experience these things. To bridge the gulf of incomprehension this observation entails, it is better to regard psychosis as a deep crisis experience. A psychotic episode is a crisis in which the very nature of reality becomes unreal. Words no longer guarantee certainty of thought, and familiar stories lose their supportive power, resulting in all different kinds of alienating experiences.
The fact that something like this is possible can cause astonishment. Using words and telling stories are things that we all do. Does this mean we can all be affected by psychosis? At the very least, it shows that language and stories are crucial for giving meaning to what we experience, because our reality is never as straightforward as it might seem. We give expression to this reality by verbalizing. That is, we combine words and events to create thoughts, which we use in turn as building blocks for stories. Stories that we first tell ourselves and then tell aloud to others, or sometimes the other way around.
Stories smooth over troublesome cracks. With words and thoughts we seek truth and meaning, freedom and connectedness. At best, these stories help us to make events comprehensible and reality acceptable. Not fully, of course, but enough so that we do not despair. Enough to share with others the things that touch and concern us, which in turn creates connectedness.
Sharing words and thoughts is powerful because language and patterns of social interaction are linked in ways that are not always visible. The stories we take for granted help us to make choices about who we are and how we should act. However, as we make these choices, our perception of reality becomes selective. Narratives shape our perspective, and they also create blind spots that inevitably determine how we approach the world. As a psychoanalyst, I refer to these blind spots in consciousness as “the unconscious”— an endless collection of messy and usually invisible stories that also pass through our minds and shape us in ways we may not be aware of.
However, organizing reality in such a narrative way is not always possible. Sometimes our stories are too insubstantial, or events are too devastating for words. That is when we say: “This is inconceivable.” Incapable of being expressed in terms of normal conceptions. Too overwhelming and too incomprehensible to be forged with mere words into ordered thoughts. When that happens, the storyteller cracks. And if the storyteller cracks, your experiences crack as well. This tips your consciousness into confusion, and a strongly associative way of thinking starts to take over. The consequences of this are not inconsiderable. Reality becomes sinister and unpredictable, and everything you knew and in which you trusted, including yourself, is disrupted and thrown off balance. Until you almost go mad. Or go mad completely.
Without a cohesive narrative, our minds lack a framework to rely on and have no messy subplots to distract us. This leads to a highly distressing experience where reality itself becomes messy, with fragments of unconscious horror, resulting in the severe mental crisis known as psychosis.
That kind of crisis experience is the subject of this book. A colleague once told me that “wei jie,” Chinese for “crisis,” also points to the ideas of opportunity and challenge. I found this thought so inspiring that I was unable to get it out of my head, because a psychotic experience is also an opportunity and a challenge to deal with stories, ideas, and others in a different way. An opportunity to provide the madness of life with its own space.
In this book I examine in detail how different kinds of discrete and manifest psychotic experiences can be understood. I also explain how hallucinations and delusions attempt to create order in a world of thoughts that no longer have a story to tell, and I discuss the challenges to which a psychotic crisis serves as a response. In the final chapter, I investigate the ways in which connective dialogue and creativity can offer a way out of the madness that psychosis brings.
The latter statement may surprise some readers. Nowadays, many people tend to believe that psychosis is primarily a genetically determined brain disorder that should be treated with medication. So, why is it meaningful to invest in engaging in conversations with individuals experiencing psychosis?
The reason is that understanding the causes of psychosis is not as straightforward as is often thought, especially in terms of biology. For example, when we compare patients with non-patients, genetics accounts for only about 7 percent of the risk for psychosis. This is surprising, and it suggests that the environment plays a much bigger role in the overall heritability of psychosis than previously thought. For example, among other social factors, early-life adversities such as sexual abuse, emotional abuse, emotional neglect, and bullying have a significant causal impact. Such events can have a detrimental effect on a person’s self-perception and understanding of the world. They erode trust and disrupt a person’s sense of narrative coherence, potentially exacerbating psychosis. After all, how can one meaningfully express oneself in a world that actively contributes to the horror that one is experiencing?
Discrimination based on minority group membership and social alienation and isolation in big cities are also causally related to psychosis. This may be because the more people are treated as outsiders, the more unfamiliar the world becomes for them, making it difficult to articulate coherent ideas that connect them to the world. Again, this highlights that psychosis is not only a biological issue but also a social and a subjective event. A person’s entire sense of self in the world is involved.
This has clear implications for therapy and counseling. Assuming that antipsychotic medication alone will solve the problem is overly simplistic. These drugs may help, but they do not cure underlying disease mechanisms. If the medication is effective, it can suppress psychotic thought processes to some extent. But to truly help people recover from psychosis, we have to provide them an appreciative and supportive environment that helps to address the unconscious challenges they are facing, such that they can reintegrate into their lives and develop hope for the future.
It suggests that we need to view psychotic symptoms such as hallucinations and delusions in a different light. They should not be seen as mere signs of an illness, but rather as meaningful expressions and attempts to survive in a chaotic world. We should strive to understand these experiences in relation to the challenges an individual is confronted with. This is something I have learned to do during the past twenty-five years.
I obtained my degree in clinical psychology in the late 1990s. At the time, there was a strong belief in the power of biological psychiatry. In the 1970s American psychiatry held the belief that restructuring an individual’s ego through intensive inpatient psychotherapy was the most effective treatment for psychosis. However, by the 1990s, this notion had been discredited and a promising biomedical approach seemed to emerge. At least, that was the perception or understanding that was conveyed to me as a student. Currently, it is acknowledged that this promise was not fulfilled, and that today, more individuals than ever before are suffering from severe mental illness.
However, thanks to my training in Europe, I was meanwhile also exposed to other perspectives on psychopathology, such as those of Jacques Lacan, Michel Foucault, and Gilles Deleuze. These helped me understand that psychosis is not just a mental disorder but rather, or also, the subjective manifestation of a struggle that touches upon the fundamental aspects of human existence. The suffering caused by this is not limited to just the biomedical aspect. Practically, it stimulated me to start talking with patients and fostered curiosity about the structure and meaning of psychotic experiences.
How such curiosity translates into practice is something I learned to understand through working with cases such as Mario, a young man with Down syndrome whom I met at the start of my career as a clinical psychologist. I will share more about that in the next chapter, arguing that creating genuine encounters and paying detailed attention to what individuals experience are key to overcoming episodes of psychotic crisis.