Why Psychosis Is Not So Crazy: A Conversation with Stijn Vanheule

Stijn Vanheule is a clinical psychologist, psychoanalyst, and professor of psychology at Ghent University. Trained in the Lacanian tradition, he has written widely on the structure of psychosis, the limits of psychiatric diagnosis, and the importance of attending to the subjective logic of mental distress.

His books include The Subject of Psychosis: A Lacanian Perspective, Diagnosis and the DSM: A Critical Review, and most recently, Why Psychosis is Not So Crazy, which offers a reorientation of how clinicians, families, and broader society might understand and engage with psychotic experience.

Drawing on psychoanalytic theory, case studies, and contemporary cultural examples, Vanheule treats hallucinations and delusions as creative responses to existential disruptions. He emphasizes the importance of listening—clinically and socially—for the structure and logic within a person’s seemingly incoherent world. His approach challenges dominant psychiatric models that prioritize symptom suppression, calling instead for a therapeutic attitude grounded in humility and collaboration.

In this interview, Vanheule discusses the role of hallucinations in restoring a shattered sense of meaning, the necessity of admitting one’s limitations as a clinician, and the importance of everyday practices—gardening, conversation, shared meals—in building connections that can anchor recovery.

The transcript below has been edited for length and clarity.

Ayurdhi Dhar: From your experience of working with patients and your background in Lacanian theory, could you tell us what you think psychosis is, and why, as the title of your book says, “it’s not so crazy”?

Stijn Vanheule: I don’t think of psychosis in terms of a disease. For me, it’s a kind of human experience. If people are confronted with difficult challenges in our lives, in our contexts, our families, our jobs, then we tend to respond in a certain way. Some of these responses are more standard responses, more attuned to what the collective way of reacting to events is, but all of us have reactions that are a bit off standard.

People who have psychotic experiences are struggling with human situations, situations any of us might be confronted with. They have non-standard reactions, which are psychotic reactions, which tend to make us think that it’s not understandable, that it’s so strange, so different, that there is no connection with the common way of experiencing reality.

For me, as a psychoanalyst, these experiences are bridgeable, something we can connect with. The main challenge is how to translate what happens in a psychotic experience into something that can be communicated.

Ayurdhi Dhar: You talk about hallucinations and delusions as a response to alienation, especially a disruption in one’s sense of self. You use the example of Schreber from Memoirs of a Mental Illness, where he wrote about his own experience with psychosis. You beautifully wrote that when he lost everything, his sense of reality, time, self, and body, at least delusions and hallucinations were still there to “breathe vestiges of new life into his thought world. These images gave him something to think about.” Could you tell us a little bit about the purpose of hallucinations and delusions if we were to not think of them as nonsense?

Stijn Vanheule: I was informed by Freud and by Jung, who both articulated the point that hallucinations and delusions are survival reactions – they’re not the problem, but a way of coping with something difficult people are struggling with.

For Schreber, before he starts having hallucinations, he experiences something of a collapse. The world is collapsing. It is as if he’s dying. Nothing is to be trusted anymore, and reality is like a show that is going on. Nothing is stable anymore, and he thinks that he’s losing members of his body. He’s experiencing disintegration.

It is in the context of that disintegration that suddenly he hears something. He hears words, and he believes it’s God who is speaking to him. At that point, that’s something to hold on to, something being communicated to him. We should think of hallucinations as spontaneous coping in the experience of the world and of oneself. There is at least a new element, and it’s difficult to make sense of that new element, but at least there is something. We should take it as an act of creation, not as a random or damaging thing.

Ayurdhi Dhar: What happens if we consider it random and damaging? In other words, how can we undermine recovery if we were to use a simple biomedical model that either shuns these experiences or considers them nonsense?

Stijn Vanheule: On one hand, these experiences have something disruptive, and we have to acknowledge that sometimes it’s very difficult to have delusional experiences that there is a conspiracy, or hearing voices that are communicating confusing things. We have to help people soften that disruptive experience. The biomedical tools might help at that level. But we have to use them wisely, not to sedate people so they cannot think anymore, but to soften something from the experience.

But on the other hand, the topics that people are concerned about, or the things communicated through a hallucination, are not purely random. It is a mind that is reacting to something. It’s not a narrative response to an event; there is an associative link between what is being experienced and the threat.

If we say that it is random, or that it doesn’t matter what you hallucinate, then you potentially lose something. We erase something of the human experience. It’s wiser to try to listen.

Ayurdhi Dhar: Can you give us an example of finding subjective truth in a hallucination or a delusion with a patient? Then we can talk about how we can listen differently to realize these subjective truths.

Stijn Vanheule: One of the cases I discuss in the book is a patient of mine, Mario. Mario was a young man, 18 years old, who was having psychotic experiences; he was sensing as if a female person was next to him, and she was whispering words to him. You have to know that Mario had Down syndrome, so he had a relatively low IQ. This female voice was saying dirty things to him, things with a double meaning and a sexual connotation. For me, it was not random that he was hearing a female person saying things with sexual meaning.

He was still living with his parents. It became clear that in that family, the transition for Mario from the position of a child who obeys the parents to living in an adult body was difficult. Sexuality had no explicit place in their lives as a family. It was not that surprising that he was hearing a female voice who was whispering sexual content. It was coherent with the challenges of his life. I could observe that there was a link between existential social life challenges and what was occurring in the hallucination.

My role as a therapist consisted of trying to translate all of that into something of a conversation and helping him, but also helping his parents to see him as an adult person. That led to changes, such as him stopping going to school and switching to working in a guided workplace. He was addressed in a different way, and that had an impact on what he experienced.

Ayurdhi Dhar: I remember my clinical internship in a psychiatric hospital. This was in India, and a young woman from a very low socioeconomic background was admitted. Her main hallucination was that a camera in front of her face would follow her everywhere. While it seemed nonsensical to people, it made perfect sense for a young woman to feel she was constantly under surveillance. Her body and her being were the carriers of her family and society’s honor, which is a common pressure in India. No wonder she thought there was a camera following her around constantly.

Let’s talk about your “fall” in front of Mario and how Mario needed to see that his analyst was fallible, limited, and not perfect. In Lacanian terms, that he lacked something. Could you tell us a little bit about the story of this fall and what a good therapeutic attitude is to have towards a psychotic patient? How do you listen differently?

Stijn Vanheule: Clinicians often start working with psychotic patients during a crisis. People want a solution and they look for an expert who can provide it, who can provide security, safety – big expectations! As a young clinical psychologist, when I started working with Mario, I really felt that need from his family. While his parents were very open and talkative, Mario himself kept a little distance. It was more difficult to have a connection with him.

Then one day, I arrived at his house because it was a treatment at home. It was raining and I was hurrying out of my car. I slipped and I fell, and I was cursing to myself. Mario had seen that as he was sitting in an old room in the attic. It was a room where he used to hide. He had observed me falling down.

He came down, opened the front door, and shouted, “Stijn, you’ve fallen!” Then he went to the bathroom, came back with the handkerchief, and gave it to me. I was surprised to see Mario in that active role of the one who was doing something. It was an interesting shift in position because I was there as “the expert”. I was the one who knew what to do, so to speak, and he was the patient who was having a crisis. He was the problem! Then, with the fall, there was an interesting shift in positions because suddenly I was the one with the problem. I was the one who didn’t really know what to do in that specific situation, and Mario could do something for me. That created a shift in the power balance, which was very important.

When we want to do psychotherapy with someone who is having psychotic experiences, we have to start from, in Lacanian jargon, our lack of being, not from what we are, or our expertise, or from the ego.

Ayurdhi Dhar: Connection is from both sides – we have responsibility as family, friends, and clinicians to connect with the person going through psychosis, for the person to survive or even thrive or flourish. Could you tell us what we, as acquaintances, friends, or family, can do to build that connection with someone? You wrote about the example of Sven and his garden — maybe you could give that example.

Stijn Vanheule: Connection is created often by doing ordinary things together with people, but when people start having psychotic experiences, a distancing process takes place. People start to be afraid of someone who has psychotic experiences, or the person feels estranged from others. It becomes difficult to communicate with one another. These are sensitive topics that are difficult to talk about, and when this happens, people tend to isolate themselves. Connecting in a relaxed way becomes difficult. Therefore, when we want to offer a therapeutic context, human connection should be to the fore.

Human connection starts with welcoming people, looking at people, addressing people, drinking coffee together, sitting together — an invitation to have a meal, play ping pong, watch the news on television, tell a joke together, and do the common human things.

Stigma is like that — people have prejudice, and they don’t interact anymore. Doing the everyday things we do in relation to one another goes against that. In an institution, someone who does the housekeeping is often very good at connecting, maybe better than the psychiatrist.

Also, we have to look at people’s talents, something they have an interest in, or had an interest in the past, and reconnect with that. There is a possibility of dialoging or connecting with people through what is fascinating to them.

Here, I can indeed give the example of Sven, who is a Belgian conceptual artist who struggled with psychosis for many years and was hospitalized for it. He describes that for him, the way out of psychosis started when his psychiatrist/psychoanalyst invited him to something with his training as a landscape architect. The analyst said, “We are here in an institution, and there is a little garden, but the garden is nothing right now. Why don’t you design something of a plan for that garden?” That made Sven think about the fact that he was in his mind struggling with darkness and with brightness, maybe also a psychotic preoccupation with darkness and with brightness.

He started designing a garden with darker zones and brighter zones, which could be translated into darker and brighter flowers. That was taken seriously by those in authority. For him, it was a bridge to talking with people about normal things, but not just things like a cup of coffee, but things that were in line with his interests.

It’s also about how what’s there in the psychosis is allowed in that creative process. Something so strange can be used as material for sharing things, looking for new solutions, and creating.

Ayurdhi Dhar: You write that the experience of psychosis is in many ways a creative one. Many theorists have talked about this relationship between psychosis and creativity. You said that narratives, these big and small stories of our lives, help us make sense of our world, our place in the world. Sometimes, for certain people, they begin to question these narratives that are given to us by the world, and they question them more than others. You write that psychosis is usually related to creative and deeply inquiring minds, and that they are more susceptible to psychosis.

Stijn Vanheule: As people, we are very aware of our own existence. We don’t just live. We know that we live and we think about living — why we live and how we should live. How to relate to our parents, deal with sexuality, relate to a partner, and make sense of life. These are typical human questions.

Human beings make use of the narratives around them, like religion and science, to make sense of these questions. We read books, watch TV series, and talk with friends. These are all ways of trying to make sense of the things we are struggling with. We try to deal with the challenges with words.

In psychosis, something of the story that has been told is not working anymore. For me, psychosis means that someone is being confronted with a typical human dilemma, but the stories around them are not functioning anymore to deal with it. At that point, an effort of out-of-the-box thinking takes place, whilst most people think in the box, within the narrative constraints within which we are educated, psychotic experiences are out-of-the-box thinking.

It’s a way of being creative, but in such a way that maybe you lose yourself, you’re too creative in a certain sense. There is a strength in there, because it’s starting from something when there is nothing of an answer, there is a lack, and then you start doing something in response to that. That’s already a very creative act.

You could say that hallucinations and delusions are creative actions, but maybe too wild, in the sense that they overwhelm everything. This creative potential manifested in a psychotic experience could be cultivated in different ways, in ways that are not so devastating for a person.

Ayurdhi Dhar:  We have been talking about the nightmarish world of psychosis, which is important because we don’t want to romanticize it. But there is significant anthropological research coming from Tanya Luhrmann, my own work, that hallucinations are not necessarily terrifying for everyone, and you write about that. A lot of people are okay with hearing voices.

When I give talks, students come up to me and say, “Hey, I hear this voice, but I just haven’t told anyone about it”. You write that voices don’t always have to be disruptive; even Freud thought they’re only a problem if there is distress. How common is it for people to have these experiences without it turning into a full-blown schizophrenic break? What do you think protects some against the distress?

Stijn Vanheule: Most people with these experiences do not feel distressed and do not require clinical treatment, as these experiences do not interfere with their lives or sense of self. Epidemiological research suggests that about 10 to 15% of the general population has, at some point, encountered phenomena such as hearing voices, seeing ghosts, or experiencing other paranormal events like communicating with the dead.

Only 3% of the people have a clinical problem with psychotic experiences. That means that there is a substantial group of people who are not suffering. That’s hope. That means that even when some of the voices stay in your head, you can find a different relation with these, because there are people who never have clinical support needs.

Freud’s idea is that we all have pathological traits, neurotic traits, or tendencies towards psychosis, but as long as there is a balance and it doesn’t make you suffer, it is okay. We don’t have to intervene in everything that is a bit weird. In the book, I make a comparison between living with the voice and working with a colleague you share an office with. At certain points, you don’t really listen to them because you’re working. You listen with just one ear.

We can have this towards a psychotic voice. Some people who hear voices know how to live with them; they negotiate with their voices, or learn when to deny what they’re saying.

Ayurdhi Dhar: You wrote about James Joyce and said that analysis and therapy are one way to give some sense, language, and meaning to psychotic experience, but there are other ways to do this, too. What have you seen? What are these other avenues apart from therapy that can help a person with psychosis navigate that world?

Stijn Vanheule: The James Joyce example really comes straight from the work of Jacques Lacan. His point was that therapy is not always needed, and he used Joyce as an example. He said Joyce did all the work that you can do in psychoanalysis by himself. It was writing for him. It was his artistic practice. It was his way of dealing with language; from a clinical view, you could say what Joyce is doing with language is a bit strange. It reminds us of what is called schizophrenic language, like jumbling, decomposing words, and seemingly nonsensical sentences.

You could pathologize it, but that’s not what Lacan would do. He would say that Joyce had a peculiar relation to language because he used language in a very non-conventional way. That’s similar to psychosis. In psychosis, conventions don’t guide you in how you interact. Convention was not guiding Joyce in how he interacted with language, and that made him creative. But Joyce didn’t need clinical help because he cultivated it in the context of being a writer. That was the identity that he cultivated, that of an artist.

That was Lacan’s idea that even if there is something peculiar to reality or a very non-conventional way of relating to something, that shouldn’t be a clinical problem because you can develop a known practice around it. The challenge is creating a way of practicing while still making a connection with others. There is also a responsibility of those around you who have to be open to what you are creating.

At the same time, there is a challenge for the person not to get overwhelmed with their experience, to try to contain it, and to be creative with it. You don’t need a clinical psychologist, a psychiatrist, or a psychoanalyst to support you in finding your way. But it’s not a shame if you need one.

Ayurdhi Dhar: There are multiple paths towards recovery, however one envisions recovery. Towards the end of the book, you talk about vulnerability to psychosis and write about ‘tipping points’. Tell us more.

Stijn Vanheule: The idea that for everybody, there is a groundlessness in life is what makes a human being vulnerable. When all of us are confronted with big disasters, we have the potential of losing our minds. There is potential that what overcomes us is so impactful and traumatic that the words and the narratives that we have at our disposal are not functioning anymore. There is something of a basic human frailty there. For me, vulnerability is that, first of all.

Then I think there is variation in how we tend to express that vulnerability. Some people might become rigid when they’re confronted with disaster. Others will go mute. Still others will start with really wild, out-of-the-box thinking, which we call psychosis. The tipping point is like these existential challenges that we are confronted with. At certain points in our lives, we are obliged to rethink ourselves.

There is an example from Elyn Saks’ book when she describes having sex with her boyfriend for the first time. It opened something, produced something in her body that was very overwhelming, and she couldn’t situate it at first. That was a trigger for her psychotic experience because when you have this sensation in and with your body, and when you haven’t had intimate contact with another body before, it obliges you to have a different relation to your body. We have to think about it, and we might lose, at that point, coherence in what we think.

I always listen for the tipping point that people have been confronted with. It’s about existential questions, about the groundlessness of existence. But it’s also very specific. It will be anchored biographically, like in the case of Elyn Saks, her particular way of having intimate contact. We have to be very attentive.

Ayurdhi Dhar: My last question is if we were to ask people with psychotic experiences, what has helped you? What was the source of support? What do you think people would say?

Stijn Vanheule: For many people, there is a lot of suffering when psychosis is made into an identity and not taken as an experience. When people tend to reduce everything that you are to psychosis, that is painful. We should approach psychosis as a process, as an event that goes on in your mind, in your life. It should be respected. When it’s taken as the only quality of who people are, that is very stigmatizing. It’s reducing the humanity of people.

On the other hand, it’s also very difficult for people when this experience is completely denied, as if it cannot have a place in their lives. It is important to accept the complexity that such an experience can be part of who you are and what you’re living through.

So, when others approach you either in a way that stigmatizes you or avoid what you experience, people lose perspective and hope because they feel alone, isolated, and locked up in the experience.

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Photo by Patrick Cohen

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