Confusing Psychosis with Imagination

Psychiatric TimesVol 34 No 12
Volume 34
Issue 12

Imagination and psychosis are different categories of experience, and should not be confused or conflated.

In 1934, the writer James Joyce sought treatment for his severely disturbed daughter, Lucia, and brought her to Dr. Carl Jung for an analysis. (Soon after, Lucia received a diagnosis of schizophrenia at the Burghölzli psychiatric clinic in Zurich.) James Joyce saw a direct connection between his own creative genius and his daughter’s illness. “Whatever spark or gift I possess has been transmitted to Lucia,” Joyce told Jung, “and it has kindled a fire in [Lucia’s] brain.”1 But Jung perceived an important distinction between father and daughter. He described them as “two people going to the bottom of a river, one falling and the other diving.”1 I believe Jung was getting at a crucial distinction: that between the involuntary nature of psychosis (“falling”) and the voluntary act of the creative imagination (“diving”).

All this comes to mind in light of an op-ed by Mark Lukach that recently appeared in the New York Times.2 Lukach gives a poignant account of his wife’s multiple episodes of psychosis, which-eerily enough-tend to recur on or about Halloween. Lukach describes his wife’s first psychotic episode as follows:

It came out of nowhere. She got nervous about her new job; she lost her appetite; she stopped sleeping; she began having delusions. The first delusions were encouraging. She said she spoke to God, who told her that she was going to be fine. Giulia had never been very religious, so I was alarmed, but at least she was hearing things that were comforting. But then, the delusions turned on her. The voices said she wasn’t going to make it, there was no point in even trying, she was better off not being here. That’s how she ended up in the hospital the first time. They gave her medication. The delusions eventually went away. She was depressed for a long time afterward. They gave her more medication and then she got better.2

When his wife’s second hospitalization for psychosis occurred, Mr. Lukach began to reflect on some supposed connections-or perhaps analogies-between her delusions and the imaginative activities he and his son enjoy. He writes that:

. . . as a parent, I love imagination. I constantly make believe with my son [Jonas], to make the world more exciting and interesting. There’s Fred the Friendly Coyote, whom we sometimes hear at night in the hills nearby; the monster broom in our closet to sweep the scary monsters out of the house. . . Maybe just as the make-believe world is a place of delight and refuge for Jonas, there’s something profound or even helpful in what Giulia envisions. Maybe.2

It would be a hard-hearted reader indeed who did not feel sympathy for Mr. Lukach, his wife, and son. And those of us who have dealt with the scourge of mental illness in our families-this writer included-will naturally respond with empathy to Mr. Lukach’s “look on the bright side” re-frame of his wife’s psychosis. But I think there is a serious error in this view of psychosis. As Jung understood in his encounter with Lucia Joyce, there is a world of difference between the voluntary, playful engagement of the imagination, and the involuntary descent into psychosis.

Mr. Lukach’s wife apparently received a diagnosis of bipolar disorder. Re-framing her psychosis as “something profound or even helpful” is an understandable but misguided romanticizing of mental illness. It is a reflection of a larger pattern of rationalization that presents serious mental illness as merely an alternative way of seeing the world-or even as a profoundly creative encounter with the universe. As my colleague, Joseph Pierre, MD, has pointed out in his critique of a report from the British Psychological Society (BPS):

. . . the BPS report goes beyond its well-intended attempt to destigmatize psychosis, treading into the territory of romanticizing it. It talks of the positive aspects of psychosis, the historical reverence of psychotic symptoms in shamanistic cultures, and a potential link between psychosis and creativity. Again, that sounds good, but to one experiencing a psychotic disorder, there are few upsides. Psychotic disorders are by definition associated with impairment, not benefits. And sadly, while there is a link between creativity and bipolar disorder, the creative spark is all too often destroyed among those with schizophrenia.3

It is also tempting-even for clinicians-to read “creativity” and artistry into what are essentially psychotic thought processes.4 We see an example of this in the writing of the French dramatist and poet, Antonin Artaud (1896-1948). Artaud suffered from serious psychiatric problems for much of his life and appears to have been frankly psychotic at times.5 In one of his letters, Artaud writes, “My mind is open through the belly and from below it piles up dark, inexpressible knowledge full of subterranean tides, concave blocks and frozen turbulence.”6 Crucially, he then adds, “Do not mistake this for imagery.” I believe Artaud was putting into words his direct experience of psychosis-not engaging in an imaginative act by invoking vivid metaphors.4 As psychiatrist Dr. Albert Rothenberg has noted:

In a technical sense, direct outpouring of unconscious processes is the sine qua non of schizophrenia because persons suffering from this condition are unable to marshal the defenses and other adaptive forms of mastery which keep these processes under wraps for most of us. If poetry were really the result of a direct outpouring of unconscious processes, schizophrenia and poetic creativity would be equivalent.7

Of course, they are far from equivalent. Nor is the psychotic state one of playful and imaginative creativity, of the sort engaged in by Mark Lukach and his son. To be clear: many people with psychotic illnesses can be immensely creative and “imaginative” in the way Mark Lukach describes, sometimes drawing inspiration from their periods of psychosis. But these creative acts usually occur during periods of remission or recovery. As Dr. Rothenberg concludes in his important book on creativity, “. . . full psychological health and lucidity would be optimal for all types of creativity.”8

In short, imagination and psychosis are different categories of experience and should not be confused or conflated. Indeed, I believe the most helpful part of Mr. Lukach’s article comes near the end, when he writes: “We hope that psychosis never returns for Giulia. It’s a terrible, disorienting experience, and I’m relieved that we know which medications help her weather that storm.”2


This article was posted 11/3/17 and has since been updated.


1. Acocella J. A fire in the brain. The difficulties of being James Joyce’s daughter. The New Yorker. December 9, 2003. Accessed November 3, 2017.

2. Lukach M. When the make-believe world is all too real. New York Times. October 27, 2017. Accessed November 3, 2017.

3. Pierre J. Psychosis sucks! Antipsychiatry and the romanticization of mental illness. Psychology Today. March 5, 2015. Accessed November 3, 2017.

4. Pies RW. Poetry and schizophrenia. In: Psychiatry and Literature. Baltimore, MD: Johns Hopkins University Press; 1985:13-23. Literature and Medicine; vol 4.

5. Antonin Artaud. New World Encyclopedia. Accessed November 3, 2017.

6. Artaud A. Further letter about myself. In: Corti V, trans. Antonin Artaud: Collected Works. Vol 1. London, UK: Calder & Boyars; 1968:187.

7. Rothenberg A. Psychosis and the creation of poetry. Psychology Today. October 22, 2016. Accessed November 3, 2017.

8. Pies RW. Scientific creativity in psychiatry. Psychiatric Times. January 26, 2015. Accessed November 3, 2017.

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