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More simply human: on the Universality of

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Nancy McWilliams

To cite this article: Nancy McWilliams (2015) More simply human: on the Universality of
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 Psychosis, 2015
Vol. 7, No. 1, 63–71, http://dx.doi.org/10.1080/17522439.2014.885557

More simply human: on the Universality of Madness

Nancy McWilliams*

Graduate School of Applied & Professional Psychology, Rutgers University, Flemington, NJ,
USA
(Received 8 January 2014; accepted 16 January 2014)

A dimensional conceptualization of psychosis that evolved from clinical

experience has been replaced in recent decades by a categorical model useful for
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certain kinds of research. Although both dimensional and categorical paradigms

have been valuable ways of viewing “madness,” the loss of a dimensional sensi-
bility is arguably retarding our progress in developing therapies for psychotic
suffering.
Keywords: diagnosis; treatment planning; schizophrenia; delusions;
hallucinations

Underlying models and metaphors inevitably frame the terms of professional

discourse. Throughout history, “madness” has been conceptualized in two somewhat
incompatible ways: categorically, as a discrete phenomenon, and dimensionally, as
an extreme manifestation of universal vulnerabilities. Each implicit paradigm is
defensible; each offers something valuable for therapists trying to help our most
anguished patients. But in recent decades, the ascendance of the categorical model
at the expense of dimensional considerations may have diminished our capacity to
think usefully about psychotic suffering and its amelioration.
Categorical notions of psychosis imply that some of us are essentially sane while
others are afflicted with madness; dimensional assumptions suggest that we are all
both sane and potentially crazy, with different degrees of sanity and madness at
different times. The categorical metaphor intimates that one either “has” or “is free
from” psychotic illness, whereas dimensional representations imply that with suffi-
cient adversity, anyone could go mad. Both conceptualizations capture elements of
the lived experience of extreme mental suffering, and both have been valuable
heuristics for understanding the phenomena we view as “psychotic.” But because
they have profoundly different ramifications, it is worrisome when one or the other
assumptive bias defines our terms and silences reflection from the other perspective.
Categorical paradigms, whether the ancient idea of demon-possession or contem-
porary references to the “disease of schizophrenia,” have been recurrently attractive,
both to professionals and to those suffering from their own or others’ madness. The
idea of psychosis as a blameless disease process has lifted shame and guilt from
countless families. If your daughter is felled by a brain disease, she does not have a
more diffuse sickness of the soul, and you are not a soul murderer. Categorical ways

*Email: nancymcw@aol.com

© 2014 Taylor & Francis

 64 N. McWilliams

of framing schizophrenia have permitted useful research into the etiologies of

psychotic suffering and have facilitated the development of pharmacological treat-
ments that have made lives outside institutions possible for many who would once
have been candidates for physical restraint, life-long hospitalization, or lobotomy.
But they have also constricted our therapeutic imaginations. In Mackler’s (2008)
documentary, “Take These Broken Wings,” virtually every interviewee opines that
schizophrenia is a brain disease, a neurotransmitter defect, a chemical imbalance cor-
rectable only by proper medications. I remember how, shortly after the discovery
that chlorpromazine could mute many psychotic symptoms; we began to descend a
slippery slope in talking with patients diagnosed with schizophrenia. To promote
compliance with the new drugs, which offered great hope, we compared schizo-
phrenic suffering to chronic illnesses like diabetes, implying that a lifetime of insulin
equivalents was required. Not surprisingly, as Orwell said of recurrently repeated
falsehoods, this account has, with help from pharmaceutical and insurance compa-
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nies, become the conventional wisdom about the essential nature of madness.
A defect in the brain has no special meaning, can respond to no psychological
intervention, involves only deficit, and offers nothing elevating or informative from
which the patient and the rest of us can learn. It leaves no space for therapeutic iden-
tification and empathy, explorations of subjectivity, or the sense of competence that
issues from a suffering person’s intimate acquaintance with, and mastery over, his or
her internal psychological saboteurs. I worry that in these technocratic times we are
losing a vital piece of ancient wisdom, Terence’s “Nothing human is alien to me.”
I argue here for restoring a dimensional sense of human suffering and the
compassion it breeds toward fellow sufferers. When colonizers subdue conquered
populations, they begin – without malevolent intent – by destroying indigenous lan-
guages (Phillipson, 1992). The language that has evolved from clinical experience is
currently being replaced by that of corporate bureaucrats, pharmaceutical marketers,
and policy experts eager to reference only the “evidence” provided by academic
researchers, many of whom have little experience in the clinical trenches and insuffi-
cient grant money for the long-term follow-ups necessary to evaluate therapies for
the seriously mentally ill.
I am not championing an exclusively dimensional view. Appreciation of qualita-
tive difference permits the potentially life-saving awareness that “something here is
way out of kilter.” Feeling something alien in psychosis can protect us from failures
like those of some early psychoanalysts who concluded that because we are all on
the human continuum, one therapeutic technique should apply to everyone. A cate-
gorical sensibility can foster curiosity about what we cannot understand by identifi-
cation. It highlights our need for our patients to teach us, and it can inspire
psychosis-specific treatments.
Every age and every known society has had to deal with those we currently
describe as mentally ill. In other eras and cultures, responses to madness have been
remarkable for their diversity – everything from torture and death to idealization and
sainthood (Read, 2013). A central challenge for our era involves addressing the mul-
tifarious consequences of accepting a categorical model in the absence of any
dimensional sensibility. Embedded in phrases like “the psychotic,” “the schizo-
phrenic,” “the disease of schizophrenia,” or “those who have schizophrenia” is the
assumption that the best way to depict madness is as a condition in which one is
taken over by an invading otherness or deforming calamity. While it is intuitively
resonant that losing one’s sanity involves a qualitative distortion of the mind that
 Psychosis 65

categorical formulations capture nicely, the current tendency to see madness only via
categorical metaphors unnecessarily constricts our vision.
The disquieting idea that we all have the potential for madness can correct an
over-reified conception of extreme mental states and offer realistic hope for reducing
psychotic anguish. I am not saying we are all potential candidates for the specific
diagnosis of schizophrenia; ample research (e.g., Tienari et al., 2004) suggests that
some of us lack the constitutional prerequisites for developing that version of psy-
chotic psychology. But I am saying that any of us could go mad in the ancient sense
of losing contact with consensual reality, that we could lose our moorings so drasti-
cally that our lives are overcome by our craziest self-state.

Historical Background
Every age tends to overcorrect for excesses of the previous era. The tired “nature-
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nurture” polarity permeating discussions of psychosis tends, despite our knowledge

that epigenesis is vastly more complicated, to accompany the categorical-versus-
dimensional tension. Here the alternation of oversimplified emphasis on one, cor-
rected by oversimplified emphasis on the other, is apparent. In the mid-twentieth
century, psychological ills were often attributed primarily to nurture; currently, they
may be ascribed primarily to nature, as NIMH’s Thomas Insel implied (2013) in
construing all psychopathologies as “biological disorders involving brain circuits.”
The dimensional sensibility of many twentieth-century thinkers was a corrective –
sometimes an overcorrective – to nineteenth-century Kraepelinian diagnosis in which
neurosis and psychosis were sharply differentiated on the basis of a patient’s apprecia-
tion of consensual reality. Even severe psychopathologies – e.g., those of Freud’s and
Breuer’s “hysterics” – were seen as neurosis rather than psychosis. Although “Anna
O.” entered self-states in which she hallucinated and could not speak her native
language, her capacity to reflect realistically on such experiences qualified her as
“neurotic.”
Professional challenges to such dichotomies, culminating in a consensus about a
range of severity of psychological suffering that makes “carving nature at the joints”
difficult, grew out of a long, nuanced clinical conversation. First, therapists differen-
tiated individuals with neurotic characters from those with simpler “neuroses” trig-
gered by outer stress and inner conflict. “Character neurosis” (later, “personality
disorder”) became a middle ground between neurotic and psychotic psychology.
Soon, articles appeared on patients whose intense, irrational, or maladaptive
thoughts, feelings, and behaviors were ego-syntonic: the “as-if personality,” “psy-
chotic character,” “ambulatory schizophrenic,” “pseudoneurotic schizophrenic”;
“borderline” states, syndromes, and personality organization. Lacking first-rank
Schneiderian symptoms, patients of these descriptions were not considered psy-
chotic, but they were clearly more troubled than those whose symptoms felt like
exceptions to their usual mental state. Eventually, a borderline area between neurosis
and psychosis was hypothesized (e.g., Grinker, Werble & Drye, 1968; McWilliams,
2011).
Later, clinicians working with higher-functioning individuals posited a “psy-
chotic core” (Eigen, 1986) within the relatively healthy. We were learning that under
enough stress, even paragons of sanity may go temporarily out of their minds.
Conversely, therapists of diagnosed psychotic patients observed that within every
manifestly crazy person were areas of realistic – even remarkable – perceptiveness
 66 N. McWilliams

and adaptation (Sullivan, 1973). We now know that many who hear voices or nurse
ideas that others consider deluded are, by every common-sense definition, highly
attuned to consensual reality (see Williams, 2012).
The idea that psychosis reduces to a categorical loss of contact with reality,
exemplified by hallucinations and delusions, seemed oversimplified as therapists for-
mulated a spectrum of difficulty reflecting a complex interaction among constitution,
maturation, and experience. A dimensional sense of pathology and personality
structure gradually became normative (e.g., Garrett, Stone & Turkington, 2006;
Kernberg, 1984). Effective therapeutic styles were found to differ substantially
depending on where someone was on the health-to-illness continuum. The idea that
under adverse circumstances anyone can experience psychotic ways of thinking and
feeling was an article of faith for several decades among experienced therapists,
especially those who worked with the most troubled clients.
But accreted wisdom changed with the 1980 decision, intended to facilitate cer-
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tain kinds of research, to describe psychopathology in the DSM and ICD systems in
neo-Kraepelinian categories. In a dismissal of therapists’ long-evolving dimensional
sensibilities, reified diagnoses replaced the continuum concept that had long been
considered the best interpretation of the complex clinical data. The clearest exemplar
of the U-turn toward categorical classification was the depiction of “Borderline
Personality Disorder” as a type rather than a level of personality organization. There
are research-based reasons to frame borderline psychologies categorically, but for
purposes of clinical understanding and treatment, many seasoned therapists lament
this choice (e.g., Klerman, Vaillant, Spitzer & Michels, 1984; PDM Task Force,
2006). As for psychotic conditions, by eschewing dimensionality, contemporary
taxonomies have effectively isolated them as qualitatively different from other men-
tal suffering.

Aspects of Psychotic Experience

Post 1980 psychiatric taxonomies have in effect resurrected the Enlightenment-era
idealization of reason in assuming that what is qualitatively pathognomonic of psy-
chosis is loss of contact with what “rational” people agree is reality. But going mad
consists of more than a “break with reality” (McCarthy, Marriott, Knowles, Rowse,
& Thompson, 2013). Irrational beliefs are a key part of the story, one that has
prompted therapists from several theoretical orientations to develop ways of tapping
the capacities of diagnosed psychotic patients to rethink their most cherished but
self-damaging beliefs (e.g., Garrett & Turkington, 2011). Without minimizing the
importance of the cognitive aspect of going crazy, let me note other elements of psy-
chotic experience.
From a psychoanalytic developmental standpoint, the hallmark of psychotic
experience is an inability to discriminate inside from outside. Merger with others
dominates experience, and because an ongoing sense of separate selfhood has not
been fully achieved, annihilation anxiety is pervasive. Developmentally archaic
defense mechanisms (projective identification, denial, dissociation, withdrawal,
omnipotent control, extreme idealization and devaluation) deploy automatically and
to the detriment of the patient and others.
From an emotion-focused perspective, the inability to tolerate and regulate over-
whelming affect is centrally implicated in psychotic decompensation. The interper-
sonal withdrawal and affective flatness of some diagnosed schizophrenic patients
 Psychosis 67

may be a defense against being inundated with unendurable feelings. Patients

subject to the catatonic states common before the antipsychotic drugs arrived tended
to describe their experience afterward as an unbearable excess of affect, not its
absence. The terror in psychotic suffering, the non-stop activation of Panksepp’s
FEAR system (Panksepp & Biven, 2012), is excruciating.
From a phenomenological perspective, what distinguishes psychotic-level misery
from less grave problems is the elevation of one uncontainable preoccupation over
everything else. Garrett (personal communication, March 30, 2013) compares the
functioning of those in psychotic states to a “recurrent opera with only two or three
characters” – their lives have been reduced to one story that eventually exhausts and
destroys the social fabric that could support them. When this happens, the self-con-
ceptualization of “mental patient” overrides all prior identities, forever trapping the
patient in a dead zone, the ghost of a person who might have been.
In terms of their subjective experience, people in psychotic states feel assaulted
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by stimuli that penetrate their consciousness against their will, making it impossible
for them to discriminate self from other, figure from ground. They suffer from intol-
erable impingement by sense impressions they cannot sort out. They become fright-
eningly stimulus-bound (Piaget, 1954) and hyper-reflexive (Sass, 1992) as they try
to escape unrelenting sensory overload. As patients describe it, improvement from
medication involves a deadening of the intensity of those stimuli, not their disap-
pearance (Mizrahi, Bagby, Zapursky & Kapur, 2005).

Dimensionality in Psychopathology
One casualty of the descriptive, non-inferential, categorical classifications that cur-
rently drive mental health policy is the time-honored assumption that there is a psy-
chotic level or version of most clinical syndromes. We seem to have decided that
“schizophrenia” and psychotic mood disorders exhaust the functional ways to go
crazy. Yet there are many conditions that could be considered just as insane as those
diagnoses.
Obsessions, for example, can border on delusions. Some individuals do not sim-
ply worry that some disaster will occur if they fail to conduct their rituals, they know
it. They cannot interrupt their compulsions to test their convictions, because even
thinking about doing so invites annihilation anxiety (Hurvich, 2003). A patient of
mine who has never had a “break” accounted for her tardiness one day by explain-
ing she had gotten a late start boiling her sheets and towels. “You boil your sheets
and towels?” I asked. She responded crossly that of course she did, daily, to protect
her family’s health. In response to my intimation that her fastidiousness was exces-
sive, she could not reconsider her belief; instead, she seemed to conclude she could
not trust a therapist so naïve about germs. Notwithstanding years of warm collabora-
tion, she began treating me warily, as if I were now a contaminating object. This felt
pretty crazy, at least to me.
One of my hypochondriacal clients oscillates between intense worries about her
health and somatic delusions. When she is most upset, she talks about her body as if
it were a tormenting persecutor, and she has strange ideas about her own anatomy
that could have come out of a medieval treatise on the physiognomy of witches. She
does not sound irrational unless she is talking about her body, but when that is the
topic, she sounds utterly deluded.
 68 N. McWilliams

A client of mine who has never had a psychotic episode suffers periods of devas-
tating, anxious sleeplessness. When he does drop off, he startles awake in a panic
that he is in mortal danger. His dreams are full of humiliation and attack; the conse-
quences of his having presumed to take up space or embrace hope or accomplish
something. Conversely, one man I treated, who had during college come to believe
voices calling him the resurrected Jesus, recovered fully with extensive support –
most notably from a psychiatrist who persuaded his family to keep him out of the
hospital and who saw him every day for weeks. He has lived a generative, rich life.
I regard the second man as better off psychologically than the first, and yet it is the
second who has carried the psychotic label.
What about anorexic patients who believe they are grotesquely fat yet weigh so
little that their lives are jeopardized? Surely they are as irrational and self-destructive
as many who hear voices. What impels us to posit a qualitative difference between
the delusion of a starving woman that she is overweight and the delusion of the
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pained sinner that she is the Virgin Mary?

There is a small group of paraphilic men who have healthy limbs amputated and
then circulate photos of their maimed bodies on the Internet, seeking lovers attracted
to such mutilation. Individuals with Munchausen’s syndrome deliberately harm
themselves or others, evidently out of some delusion that the enactment of life-and-
death dramas is the best route to connection and meaning. More prosaically, an agor-
aphobic neighbor of mine has not left her house for 20 years. Despite lip-service to
the unreasonableness of her behavior, she remains too terrified to venture out her
front door.
Some survivors of trauma experience flashback-like states in which others,
including therapists, are felt as dangerous persecutors like their earlier tormenters.
They feel not as if a clinician has become like the abuser; they believe “it is all hap-
pening again.” Trauma can precipitate psychosis, and even the stress of trying to
trust a therapist can provoke a severe traumatic transference (Kluft, 1992). How are
such experiences not psychotic phenomena?
Some antisocial individuals seem to live in a similar assumptive world as the rest
of us, even if they believe the rules shouldn’t apply to them. Others, the ones
Henderson (1939) called aggressive/violent psychopaths, may plot serial murders in
a driven, sexualized effort to feel powerful and alive, often targeting victims (per-
haps representing an internal object) of a particular physical appearance or socioeco-
nomic status. Forensic realities prevent legal arguments that such individuals are
insane – many court decisions hinge on the question of whether a perpetrator is psy-
chotic or psychopathic – but surely in every ordinary meaning of the terms, some
sadistic murders are both.
Conversely, Eric Marcus (2003) writes about “near-psychosis” in people other-
wise free of mental illness, like a friend of mine who opened the refrigerator on the
anniversary of her grandmother’s death and, in a transient hallucinatory state, saw
the grandmother inside. The practice of checking off DSM or ICD criteria for psy-
chosis when a person “endorses” hearing voices is often executed irrespective of
whether the voices are telling the patient to kill her daughter or reminding her to
take her vitamins. Many therapists are currently not trained to ask about the content
and context of answers to diagnostic queries.
Most of my colleagues have treated people they believe would have had a psy-
chotic break without therapy. Unfortunately, like politicians who cannot prove that
their pet policy has averted some evil, we cannot demonstrate prevention empirically.
 Psychosis 69

(Even cure is hard to demonstrate when the response to the dramatic improvement of
someone diagnosed with schizophrenia, especially if it occurred without medication,
is the conclusion that the person was not schizophrenic to begin with.)
My colleague Richard Reichbart (2012) recently disclosed that as a young
man he had had a psychosis that was healed by intensive work with a devoted
analyst. No one who has known him over his distinguished professional career
suspected this; he has been free of psychotic symptoms for over 30 years. Simi-
larly, although Elyn Saks (2008) takes medication to quiet her voices, she surely
is a poster child for a kind of wellness. As is Joanne Greenberg (Green, 1964),
who trusted in Frieda Fromm-Reichmann’s big heart. And Arnhild Lauveng
(2012), Debra Lampshire (2009), Daniel Fisher (2006), and countless other
recovered individuals who seem saner by any conventional definition of sanity
than many non-psychotic people.
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Implications of Restoring a Dimensional Sensibility

If psychotherapy is a useful response to the suffering of the deludedly anorexic, the
deludedly obsessional, the deludedly phobic, and others, why have we minimized its
value to individuals diagnosed with schizophrenia and psychotic mood disorders?
Not because therapy is qualitatively harder; it can be just as difficult with individuals
of other descriptions. And not even entirely because of contemporary cost-contain-
ment strategies, which cripple therapeutic efforts despite increasing documentation
of the longer-term evidence that, in Susan Lazar’s (2010) words, psychotherapy is
“worth it.”
Part of the answer may be that to get our communities to support the treatment
to which psychotic patients are entitled as fellow human animals would require a
paradigm shift in our habits of thought. And that shift depends on challenging sys-
tematic denial about the nature of the human condition. Central to the “othering” of
people with categorical psychotic diagnoses is our reluctance to acknowledge our
own vulnerability. Accordingly, Karon (1996) writes that “understanding schizo-
phrenic persons means facing facts about ourselves, our families, and our society
that we do not want to know, or to know again” (p. 191).
George Atwood (2011) offers the following “definitive theory of depression”: “It
is caused by the depressing things that happen to us” (p. 162–163). Or as my col-
league Tom Tudor memorably put it, “Bad things happen and they screw you up.”
To believe that life could make any of us crazy with grief or terror or confusion or
emotional exhaustion is not incompatible with acknowledging that we as individuals
are differently subject to depressive reactions, have different biologically based
vulnerabilities, and differ widely in what kinds of experience set off pathological
reactions.
Western literature is replete with portraits of individuals driven mad by the sheer
unbearableness of their lives. Nonprofessional readers have for generations identified
more compassionately with that fate as a universal peril than most twenty-first-cen-
tury scientists are willing to do. One thinks of Lady McBeth, hallucinating in her
agonizing guilt; Dickens’s Estelle Haversham, traumatized by disappointment and
delusionally fixated on her wedding day; Hemingway’s “A Way You’ll Never Be,”
recounting a soldier’s hallucinations and delusions in the aftermath of battlefield ter-
ror. Great writers capture something that goes way beyond dopamine malfunction to
the psychological perils we all face as we suffer, love, strive, and fear.
 70 N. McWilliams

Challenging conventional wisdom and the perquisites of the powerful inevitably

risks the fate of Cassandra, who was cursed with the gift of prophecy and doomed
not to be believed. Robert Whitaker (2002, 2010) may be a contemporary Cassan-
dra. A colleague who works with hospitalized psychotic patients recently asked an
eminent biological psychiatrist to address his medical residents. On learning that
Whitaker had been invited previously, the guest launched a tirade, framing him as
beyond the pale of mainstream psychiatry, which understands that treating people’s
potential psychiatric conditions with even earlier drug interventions is our best
hope. Minutes later, this critic was acknowledging that a down-side of medicating
inconvenient behavior might be the overprescription of psychoactive drugs for chil-
dren – one of Whitaker’s main points. Evidently when trying to speak truth to
power, we have to tolerate being the target of dripping contempt, and worse, the
likelihood that we will never be publicly vindicated, even if – perhaps especially if
– our message actually gets through.
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The categorical-dimensional paradox

Holding both dimensional and categorical perspectives honors the fact that there
may be many routes to becoming diagnosably psychotic, some involving more
genetic tilt and some involving more disabling experience. Biology and psychology
are inseparable and mutually interactive. Pharmaceutical intervention can reduce
psychotic misery; psychotherapy changes the brain (Viamontes & Beitman, 2008).
Everything in the body, including the brain, can break. Yet even people with broken
brains have psyches or, in an older language, souls. If our language tends to reduce
a psychotic person to a malfunctioning brain, we have killed the psyche and are
engaged in soul murder on a monumental scale.

Acknowledgements
The author thanks Michael Garrett, Kerry Gordon, Judith Logue, Henry Seiden, Mark Sieg-
ert, and Janna Smith for their contributions.

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