A brief history of thinking ourselves insane

We think of madness as something that happens to people, either through biological insult or disease, or though traumatising and disorienting events. But could it also be that madness is something we are capable of doing to ourselves? Plug the phrase 'Is it possible to think yourself insane?' into Google and you'll get a rough glimpse of the uneasy preoccupation the question can inspire. People on message boards appear to seek reassurance; some respondents pour scorn on the idea, others seem to share the fear. Either way, the idea is not popular in the Western world. We are inclined, even encultured, to think of the origins of mental problems as outside the mind. Madness, we avow, is out of our control. And yet we don't (perhaps can't) live as though that were entirely true.

Recent research by psychologist Nev Jones and colleagues has focused attention on the fascinating possibility that agency could play a role in bringing about episodes of psychosis. Interviewing a sample of people with schizophrenia and other psychotic diagnoses, Jones and her colleagues have uncovered experiences that are at least suggestive of the possibility that people can bring on their experiences of madness, expand them in particular directions, or hold them back altogether. Interviewees had the sense that how they thought may have played a role in the development of psychosis, saying things like 'I got the idea that I might understand [a psychotic relative's experiences] a lot better if I actually made myself psychotic' (quoted in Jones et al., 2016, p.5).

Although Jones and colleagues' research does not claim to establish substantive mental causation of psychosis, it is part of a broader tradition in psychiatric and literary thinking on the role of top-down processes in the onset of madness. The idea crops up in some notable 20th-century literature. The protagonist in Robert Pirsig's 1974 Zen and the Art of Motorcycle Maintenance loses his grip on reality after single-mindedly ruminating on the concept of quality:
Obviously some things are better than others… but what's the 'betterness'? … So round and round you go, spinning mental wheels and nowhere finding anyplace to get traction. What the hell is Quality? What is it?

The sheer deranging obstinacy of the problem seems to tear his mental fabric asunder. Look up summaries of the book and it seems to be a semi-autobiographical account of developing schizophrenia. But if you actually read the narrative you have the sense that you are watching the operations of a mind that is coming apart under conceptual strain it can no longer bear.

If anyone else had asked, What is Quality? it would have been just another question. But when he asked it, because of his past, it spread out for him like waves in all directions simultaneously, not in a hierarchic structure, but in a concentric one. At the center, generating the waves, was Quality. As these waves of thought expanded for him I'm sure he fully expected each wave to reach some shore of existing patterns of thought so that he had a kind of unified relationship with these thought structures. But the shore was never reached until the end, if it appeared at all. For him there was nothing but ever expanding waves of crystallization.

Stefan Zweig's 1941 novella Chess Story also centres on what a mind can do to itself. In that little book, a political prisoner Dr. B. entertains himself by playing mental games of chess against himself. He internalises whole moves, then whole games, and then whole ranges of alternative possibilities, playing no longer with an improvised chess set and pieces, but simply letting the process unfold in his head. He plays faster and faster, impatient with himself. Eventually he breaks down. Here is how Dr. B. reflects on the experience:
Today of course, it's entirely clear to me that this state of mine was a thoroughly pathological form of mental overstimulation, for which I have found no other name than one heretofore unknown to medicines: chess sickness.

Are these scenarios realistic? There is some inclination to think not. When people go mad we seem to default to thinking about their experiences as the result of physical illness or trauma; an imbalance in a neurotransmitter system, a structural difference in a brain, a derangement of the HPA axis. Indeed, some philosophers and psychologists (e.g. Wegner, 2004) have even seen mental states as causally irrelevant, epiphenomenal add-ons to the substantive physical world. Why? Because the physical world is causally closed, distinct from the mental world in such a way that immaterial stuff like ideas and dreams cannot make events take place within it.

But take a moment to reflect on your own experience of thinking. Psychologists might be biased toward over-emphasising the impact of positive thinking or cognitive restructuring, but mental events have an undoubted impact on our mood, our ideas and our actions. When it feels so obvious that we could think ourselves into law school, rage or significant clinical depression, why are we reluctant to imagine we could think ourselves insane? There are pockets in the history of psychiatry that have seemed to allow space for the possibility. Some writers grappled with the problem in terms that now seem quaint. In an 1845 essay called 'On Man's Power Over Himself to Prevent or Control Insanity', the Revd Thomas Barlow broached the possibility that one could use cognitive processes to moderate and stave off insanity. Barlow made a distinction between 'the two great forces which manifest themselves in the phenomena of man's nature. The VITAL FORCE by virtue of which he is an animal-and the INTELLECTUAL force by virtue of which he is something more' (Barlow, 1845, p.292, capitals in original). Barlow takes it for granted that the intellectual force could bring on madness:
[W]e find paralysis, inflammation, or brain fever, and a variety other diseases of this kind, produced in many instances by causes purely mental – I need hardly give cases; they will occur readily to the recollection of every one. (Barlow, 1845, p. 294)

However, the main concern in his essay is the possibility that intellectual force could be used to prevent brief episodes of mental 'derangement' (a fleeting hallucination, for example) from developing into a full-blown madness. Barlow acknowledges that our brains deceive us all the time, but that it is possible for someone of sufficient mental calibre to rein themselves in through the exercise of judgement. Barlow's understanding of madness here then is still essentially as a bottom-up phenomenon, with the animal-like 'vital force' intruding into our psyche and competing with higher intellectual functions.

This bottom-up understanding of madness seems to have been widespread and influential. Here is a striking early psychiatric opinion, from medical testimony given at the trial of Charles Julius Guiteau (assassin of President James Garfield):
Those cases do occur in my experience, where persons are anxious and worried about their spiritual condition, and pray a great deal, and attend meetings, and by losing sleep, neglecting their food, and neglecting rest, they finally come into a condition of physical disturbance, which acts on the brain, and then they become insane. Then alone, and not through any religious feeling, insanity results. You can not work yourself into insanity through any state of feeling or think yourself into insanity. (Anonymous, 1882, p.438)

By 1911 Eugen Bleuler determined that his concept schizophrenia could probably be defined as essentially organic in origin, cleaving that most influential form of recognised madness away from mentally caused psychoses by writing: 'As yet we cannot answer the question whether there are psychic causes for schizophrenia. However, it is probably to be answered in the negative.'

The American psychoanalytic-psychiatric tradition initiated by Adolf Meyer (and enshrined in the first two editions of the DSM) did allow for a substantial psychological component to madness (schizophrenia, for example, was framed as a 'reaction' in those early DSMs), but this was reactive and the result of unconscious processes. The notion of agency in madness was absent.

One early theorist, influential primarily in Nordic countries but not very widely outside of them, was the Dutch psychiatrist August Wimmer. He developed the concept of psychogenic psychosis, a construct that was explicitly defined against the medical view of Emil Kraepelin and Benedict Morel (Castagnini, 2010). But an examination of Wimmer's concept reveals that the word 'psychogenic' may be misplaced. Though he does appear to invoke the mind's processing of emotional experiences as part of a causal chain, his is essentially a theory of 'reactive' psychosis, similar in kind to that inspired by Meyer in the US. If you leaf through the book Psychogenic Psychoses by one of Wimmer's followers (Færgeman, 1963), you find a series of case studies of people who have become psychotic as a reaction to some form of stress. This is a far more 'psychological' psychosis than the biologically based schizophrenia, but it still has its roots in events that occur in the external world.

Breakdown and breakthrough

The most famous psychogenic theory of psychosis is Laing's 'divided self' theory (Laing, 1960). In brief Laing's view was that a person susceptible to psychotic break was profoundly sensitive to the sense that they might not fully exist ('ontologically insecure' as Laing had it) and inclined to withdraw to a defensive 'false self' in order to shore up their place in the world. This 'false self' interacted with the external world, protecting the real inner self by acting as a kind of psychic veil. In the process, the person lost touch with the vitality and authenticity of their real self, with the false self becoming more brittle and further away from feelings of reality. When this process advanced far enough, a person's relationship with reality broke down altogether.

Laing's work developed over the course of the 1960s, absorbing and influencing a broader cultural taste for expanded states of consciousness. This era, described by Mo Costandi in these pages in September 2014, saw psychiatrists explore hallucinogens as a serious treatment option, while psychologist Timothy Leary extolled their mind-expanding virtues, and Ken Kesey's Merry Pranksters travelled across America handing them out at parties. By the time of his radical The Politics of Experience (1967), Laing was providing a guide to madness as something like a spiritual rebirth. He lionised madness and appeared to explicitly encourage it as an object of human agency. The most famous quote from that book almost eggs the reader on: 'Madness need not be all breakdown. It may also be breakthrough' (Laing, 1967, p.110). Indeed, Francis Gillet, a resident of Kingsley Hall (a therapeutic community opened and run by Laing) remembers being told by Laing to 'Go mad, young man'. 'I took him at his word, and I went as mad as I possibly could.'

We no longer seem to characterise insanity as something we are able to do deliberately. Nonetheless, working across various clinical settings, I doubt I have ever encountered a clinician who felt the purposive thoughts of a client were irrelevant to their mental health. Modern psychotherapeutic approaches to psychosis formally codify a role for such agency. Some ways of thinking ('jumping to conclusions', ruminating on voices) are widely held to contribute to the development of psychosis, and therapy engages people in deliberately trying to alter such patterns. No clinician would encourage the elaboration of a delusional system, or the active pursuit of ever more disorienting and distressing experiences. Without directly acknowledging it, we encourage clients to exercise mental agency all the time. How could it be otherwise?

- Huw Green is finishing a PhD in clinical psychology at the Graduate Center of the City University of New York. He is interested in the cognitive processes associated with psychosis, and in the philosophical issues raised by clinical work.

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Key sources

Anonymous (1882). The United States vs. Charles J. Guiteau. Indictment for murder of James A. Garfield, President of the United States. American Journal of Insanity, 38(1), 303–448.
Barlow, J. (1845). On man's power over himself to prevent or control insanity. American Journal of Insanity, 1(4), 289–319.
Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. New York: International Universities Press.
Castagnini, A.C. (2010). Wimmer's concept of psychogenic psychosis revisited. History of Psychiatry, 21(1), 54–66.
Færgeman, P.M. (1963). Psychogenic psychoses. London: Butterworth.
Jones, N., Shattell, M., Kelly, T. et al. (2016). 'Did I push myself over the edge?': Complications of agency in psychosis onset and development. Psychosis, 8(1), 1–12.
Laing, R.D. (1960). The divided self: An existential study in sanity and madness. London: Penguin.
Laing, R.D. (1967). The politics of experience. London: Routledge & Kegan Paul.
Wegner, D.M. (2004). Précis of the illusion of conscious will. Behavioral and Brain Sciences, 27, 649–659.