Romantic fantasies of madness and objections to psychotropic medication

Many patients object to, and often refuse, psychotropic medications. The exploration-a "defense analysis"-of their objections brings attention to ubiquitous fantasies of madness, which may be feared and concealed as a source of shame, destruction, and loss, and also cherished and revered as a source of power, inspiration, and mystery. They are commonly illuminated when the prospect of taking medication threatens to expose, confirm, and defuse the fantasized hidden or latent madness. Conscious or unconscious, fantasies of madness can be deeply, appealingly romantic in nature, providing valuable narcissistic supplies while defending against their more humiliating and terrifying aspects. Drawing on personal dynamics, experiences, and identifications, they are thus ultimately and intimately linked to representations of the self. Significant romantic texts illustrate how split-off conceptualizations of madness function as an organizing repository for unacceptable and intolerable emotions, wishes, and impulses. Psychoanalysts may also object to the introduction of medication into an analytic treatment. The analyst's own fantasies around madness and medication may in some cases motivate enactments in which the talking cure is privileged and medication excluded from analytic treatment or from analytic process.