What is psychosis?

The term ‘psychosis’ has a number of connotations, all of them negative. It’s often used in place of the word ‘madness’. It is also used as a term for schizophrenia, bi-polar disorder (manic depression), and paranoia. There is also a fairly widely held, though mistaken, view that psychotic individuals cannot be treated by psychoanalysis or psychotherapy, and therefore have to be treated with medication.   From this perspective, psychosis is seen as being on the ‘hard’ or ‘severe’ end of the ‘spectrum’ of mental health problems, and all that can be done is to ‘contain’ and ‘manage’ the problem.

The case of Anders Breivik is a good example of how negatively the term ‘psychosis’ is viewed.  In July 2011 Breivik bombed a government building in Oslo and then proceeded to murder 69 young people on the island of Utoeya.  Breivik was originally diagnosed as having a psychotic illness, but later on another team of psychiatrists challenged this view, and in August the following year a court decided that he was sane.  In other words, he was responsible for his actions.

The key point here is that this is exactly what Breivik wanted. He viewed (and presumably still views) himself as a political prisoner who is engaged in a war again Islam and ‘cultural Marxism’. Many of his political views are, in fact, shared by a large number of far-right groups spread across the globe. The last thing Breivik wanted was to be declared insane, because then his beliefs and actions could be dismissed as those of a crazed madman.

There are a number of key issues here: one being that the terms ‘sanity’ and ‘insanity’, ‘sane’ and ‘insane’ are legal not clinical terms. It is my view, which was shared by the psychiatrists who originally interviewed Breivik, that he is indeed psychotic – in the clinical sense. Many psychotic people, especially those who have the form of psychosis called paranoia, are perfectly able to plan, organise and execute the kind of atrocity that Breivik carried out. They are also well aware of what they are doing. Therefore it is simply untrue to equate, as the legal definition of insanity does, psychosis with a lack of understanding of right and wrong; or, as some psychiatrists appear to think, with not being able to think and act rationally. If anything, some psychotic individuals are too rational.

It is also not the case that psychotic individuals are unable to function in life, to hold down good (or any) jobs, have meaningful relationships with others, and so on. In fact, it’s quite likely that many psychotic individuals are running large and successful corporations, are in key government posts, and are important establishment figures. Furthermore, they are making a very good job of what they do.

The important point here is not to confuse some of the more bizarre and destructive behaviours that characterise some psychotic individuals at particular moments in their lives, with psychosis as a clinical structure – or, to use a more popular term, with the psychotic personality.1 Most psychotic individuals live perfectly normal and uneventful lives – at least in terms of how they might be viewed by others.

When it comes to how psychotic individuals experience the world, themselves, and their relationship with others, things get more complicated. Psychotic people often have a very fragile, precarious sense of self; of who they are and their position in the world. Because of this, meaning and certainty of meaning are critical for them. Being sure that things are what they are, and not something else, or do not have double or multiple meanings, is crucial.

Many psychotic individuals either construct or are drawn to very elaborate structures of meaning, sprawling political ideologies (in the case of Breivik), complex religious and metaphysical belief systems. However, the key point here is how they relate to such structures, to such ideologies and belief systems. Basically, they become cast in stone, beyond question or criticism. They are what they are, this is what the world is like.

All the time that such structures of meaning ‘work’ for the individual, allow them to function, to relate to other people, then there is no real problem. The problems start when either such structures start to break down, or they result in actions which are damaging either to the psychotic individual him or herself or to others. This was, of course, what happened in the case of Breivik. The moment he decided to ‘enact’ his ideology, catastrophe followed.

From a psychoanalytic point of view, the idea is not to try and ‘rid’ a psychotic client of his or her belief systems – which are effectively keeping him or her afloat in the world. Rather it is to see how these views can be restructured and rechannelled in less destructive ways. For some individuals, however, the problem is they have no meaning system at all, they whole world has effectively collapsed in on them. In this case, the focus of analysis is to support the individual in constructing a structure of meaning which works for them – and, hopefully, is not detrimental to other people.

  1. Though this has a different meaning clinically []