The Embodiment of Madness, Wilhelm Reich Center, 17.05.2025

Madness

Though I am aware that many people today self-define as mad, and that the term is widely used, madness is not a word or category I much care for as a clinician. I don’t, in general, find the distinction between sane and mad or the category “madness” to be helpful. That said, in preparing for this conversation, I reflected over the fact that I work with many people who experience phenomena such as hearing voices, seeing figures, loss of an agentic relationship to the body, an altered experience of the world, delusions about the body etc.. Further that discussions within the hospital where I work around whether these experiences are best understood as psychosis or dissociation are often unhelpful to the person in question and of limited use to the therapist. In this context, “madness,” is perhaps a useful word, providing as it does an umbrella term that allows us to sidestep such discussions.

I hope it is uncontroversial to define madness as a break with, or retreat from reality. In The Interpretation of Dreams, Freud makes a comparison between the unconscious mind and the external world, writing that both are equally mysterious and unknown to us. What we know of the outside world we can only know through our sense organs (Freud, 2010 p.607). Reality outside of the nervous system is a pure abstraction. Our experience of the world, and of important others within it, begins in a multi-modal, primal density of undifferentiated experience (Winnicott 1954, Loewald 1960, Mitchel 2000). We gradually structure this primal density through language, cognition, relationships and through our implicit understanding of our body in relation to the world. What we understand as reality is whatever consensus we can manage to come to, based on our embodied and relational organization of our sensory impressions, both conscious and unconscious.

If we are not afforded sufficient opportunity to organize and integrate our sensory and embodied experience, or when contact with the world (usually meaning key others that represent the world) is too traumatic, disorganized or overwhelming, it has consequences for this process of organization and integration (Sletvold &Brothers 2021). Our sense of the world and reality might collapse or may never have felt coherent. In my work with survivors of severe abuse or neglect in childhood, I find that lived experience is fragmented or remains undifferentiated. To experience the body is to experience the world, and this must be avoided for survival. Experience of the body can therefore be diffuse, broken up, deadened, numbed, rigid or any shifting combination of these, often interspersed with moments total overwhelm.

Here there are some serious issues with the contemporary paradigm and practice of trauma-oriented therapy with its focus on stabilization and grounding. Stabilization assumes a lost level of coherence and functioning which may never have been present. Many grounding techniques focus on the body in an overly simple way. We cannot, for example, assume that sensing our feet on the ground is helpful. Contact with the body is contact with the world, and the world is terrifying. The body, and especially the body below the waist, often houses memories that are not part of the conscious autobiographical story known to the linguistic self. Contact with these memories can feel like a new trauma.

Within the therapy room

In a conversation with the therapist, different parts of the body may be simultaneously  reexperiencing, enacting or communicating about different experiences that are not present in conscious awareness or even in autobiographical memory. As an example: the hand might say one thing, the face another, the legs meanwhile are dissociated, and the verbal conversation taking place is referencing none of these experiences. After the session the therapist may be overwhelmed by experiences that were not part of the conscious experience of the verbal exchange.

Proprioception relies on our experience our body parts in relation to each other as well as their movement through space. It underlies our experience of time. When this is disrupted, time can become stretched or it can disappear – either in the sense that time goes by quickly unnoticed or in the sense of a timeless experience of infinite limbo.

A paradox: In retreating from the world through retreat from the body, we experience reduced contact with the boundaries between body and world, inside and outside. What occurs outside can be experienced as inside and that which occurs inside can be experienced as outside. This has implications also for experience of self and other. Some examples: Affect can feel like part of the external world. Sounds or images out in the world can become an intolerable inner experience.

Language

Donnel Stern (2019) argues for a distinction between a categorical, descriptive speech and a kind of speech that is more creative, spontaneous and authentic. In therapy we often aspire to this second category of language as formative of insight and growth. This requires that language is spontaneously produced in connection with embodied experience. Fonagy (1995) observes “pretend mode,” a way of communicating in which language, cut off from authentic embodied experience, apparently produces meaning and insight that the person cannot use or integrate, a kind of pseudo-insight. In more extreme states, language takes on other functions. It can at times be experienced as a barrier to contact, a kind of wall, almost a violence. In other cases, it is as if dissociated speech continues to strive after understanding on its own, generating sentences, clauses and theories that do not connect to one another and that confuse not only the listener but also the speaker. We make a mistake if we focus too much on linguistic content, trying to interpret or decipher specific words or phrases. We might instead observe the functions and qualities of speech, its embodied effects, qualities and uses.

The Therapist

One of the questions initiating this conversation regarded the adaptation of psychoanalytic technique. I believe the therapist’s role is to observe and respond to the patient – both verbally and non-verbally – over a range of modalities. One example with which I have been experimenting in more recent times is verbally mirroring movements and stances that appear unconscious or dissociated, at times sharing my own associations to these. “It is as if your left arm protects your stomach no matter what the rest of your body is doing.” “It’s like something heavy is weighing upon you.” Another strategy is to tag or verbalize affect that is in the room, without insisting upon whose affect this is. “There is a sadness.” In such ways we might begin to help the patient organize their experience through their opportunity to recognize or – importantly – to disagree with our observations and associations.

Further, I believe that the therapist must sink into the landscape that the patient inhabits (Stephen 2025). For the patient, both the body and the world as known are too frightening or chaotic to allow direct contact. Over time the therapist can come to represent something else that is neither the body nor the world – a kind of anchor around which the multimodal confusion of lived experience can be structured. There is a paradox here in as much as the therapist too comes to the patient through the body. This is one of many reasons why the relationship is so fraught. We might think, however, of Ogden’s (2007) suggestion that we must make ourselves available for our patients to dream us. The therapist consists half of the world and of half fantasy. In order to hold this position in the patient’s landscape we need to be as reliable as possible – for example becoming a kind of clock, with sessions at the same time and in the same place. If we are to remain useful, we also need to cultivate curiosity and tolerance for intense embodied countertransference experiences that initially seem intolerable. As Ogden (1979) suggests, much of this work is done between sessions, when painful, confusing and horrifying experience is integrated into the therapist’s very different personality structure, such that the therapist again can be available in the way the patient needs. For this to be successful, supervision needs to include an embodied component.

Finally, I draw attention to the work of Dhwani Shah, who writes extremely well on the topic of intolerable states in countertransference. Amongst other insights, he makes a distinction between anxiety and dread (in Freud often referred to as “Schreck”). Unlike anxiety, dread is the experience of something coming too close (Shah, 2023 p.50). It is my experience that such countertransferential dread is a major challenge of therapeutic work, not only with the chronically suicidal people about whom Shah writes, but also in working with many others experiencing alien and terrifying psychological states, or (re)discovering a history of sadistic abuse. It is intrinsically extremely difficult to acknowledge, let alone to tolerate, integrate or become curious about our own dread. As clinicians, however, we must endeavor to do so if we hope to be successful.

Sources

Fonagy, P. (1995). Playing with reality: The development of psychic reality and its malfunction in borderline personalities. International Journal of Psychoanalysis, 76, 39-39.

Freud, S. (2010). The interpretation of dreams. New York: Basic Books.

Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Psychology Press.

Ogden, T. H. (1979). On projective identification. The International Journal of Psychoanalysis, 60(3), 357–373.

Ogden, T.H. (2007), On talking-as-dreaming. The International Journal of Psychoanalysis, 88: 575-589. https://doi.org/10.1516/PU23-5627-04K0-7502

Seltvold, J. & Brothers D (2021) A new language for traumatic experience: From dissociation-enactment to the fracturing of embodied wholeness, International Forum of Psychoanalysis, 30:3, 149-155, DOI: 10.1080/0803706X.2021.1953707

Shah, D. (2023). The Analyst’s Torment: Unbearable mental states in Countertransference. Phoenix Publishing House.

Stephen, V (2025). Emily’s Ghosts: Invitation and Embodiment in the clinical situation. In press.

Stern, D. B. (2019). The Infinity of The Unsaid: Unformulated Experience, Language, and the Nonverbal. Abingdon, Oxon: Routledge.