LEARNING OBJECTIVES
After reading this article you will be able to:
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• understand the origins and significance of psychiatric poetics
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• understand a range of clinically relevant poetic concepts
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• recognise and utilise images therapeutically as they emerge during the consultation.
Evolved historically and for more than a century, contemporary psychiatric practice depends crucially on history taking, mental state examination and descriptive psychopathology. The aim remains to reach a diagnosis (definitive, provisional or differential) to guide further investigations and treatment. The therapeutic alliance and case formulation remain essential, although concern has been expressed in recent years about the waning of the latter (Stanghellini Reference Stanghellini and Mancini2017). Checklists, standardised interviews and diagnostic systems such as the DSM and ICD, helpful and necessary though they may be for clinical practice, research and administration, have contributed to these concerns, as have digitisation and intensification of work routines in the service of current political economy (Ikkos Reference Ikkos and Bouras2024a). Nevertheless, the epistemic, affective and ethical power of images in psychiatric care (Stanghellini Reference Stanghellini2026), and the importance of metaphor, have long been recognised in psychotherapy (Cox Reference Cox and Theilgard1987) and together with the poetics of the illness experience have impressively been underlined recently (Kirmayer Reference Kirmayer2025).
This article directly extends our previous contributions to the field, in which we examined the structural pressures of modern clinical economies (Ikkos Reference Ikkos and Bouras2024b) and championed the reclaiming of the lived, visual and embodied dimensions of patient suffering (Stanghellini Reference Stanghellini2023a). Moving on from this established foundation, we seek to translate these theoretical insights into an actionable clinical framework. Some of the terms we use, although straightforward in some respects, may not be familiar to some readers and are explained in Box 1.
Glossary of terms
Anamnesis A chronologically ordered clinical narrative designed to trace the aetiology and pathogenesis of a symptom or syndrome, largely indifferent to the patient’s subjective experience.
Collective effervescence The intense, shared feeling and energy that emerges naturally when people come together in groups.
Condensation Witnessing the merging of disparate events, sensations, thoughts and memories into a single word, image or scene.
Constellations A cluster of interrelated phenomena – including ideas, affects and lived moments – arranged non-sequentially rather than chronologically.
Dialectical image An image composed in text that holds opposing truths in tension, often revealing historical connections hidden by linear thinking (in German, Denkbild – thought-image).
Displacement The redirection of images, thoughts, feelings, etc. from a conflicted object to another, less immediately anxiety-provoking one.
Existential knot A contradiction at the heart of the patient’s being – a fundamental tangle that they are living with but cannot unravel through logic alone.
Mana The sacred power attributed to phenomena by communities, binding them together through shared religious beliefs.
Parataxis The side-by-side placement of contradictory elements, ideas or experiences without forcing a logical resolution or hierarchical order.
Introducing psychiatric poetics
Inspired by pioneering cultural critic Walter Benjamin, we have previously emphasised that, tracking back before cognitive representation, psychiatric poetics mandates attention to elementary embodied experiences and syntactical forms (Ikkos Reference Ikkos2022, Reference Ikkos2022c). Grounding clinical practice in Benjamin’s philosophy – particularly his ideas on the Denkbild (German, thought-image), the dialectical image and the rejection of linear history in favour of constellations – provides a rich alternative to the experientially flattening effect of diagnostic checklists. In Benjaminian terms, concepts categorise, but images awaken. In psychiatric practice, a concept (such as ‘psychomotor retardation’ or ‘trauma response’) organises symptoms clinically from the outside, whereas an image arising between the patient and the clinician acts as a threshold, condensing the entire history and emotional reality of the patient’s suffering into a vivid snapshot. In that shared space of imagination, psychiatry becomes a poetics of recognition – a practice of seeing that allows life to find its form again.
Respectful attention to fragments helps understand patients’ narratives not as broken stories to be fixed but as ‘existential knots’ (Stanghellini Reference Stanghellini2025). We have argued that images help us move beyond concepts to the vivid phenomena that emerge directly, live, during the consultation (Stanghellini Reference Stanghellini2026). And openness to parataxis, i.e. acceptance of side-by-side contradictions, without forcing logical conclusions, enhances the creative potential of the clinical encounter (Stanghellini Reference Stanghellini2023b, Reference Stanghellini2024a, Reference Stanghellini2024b). In the following fictitious case vignettes, we illustrate the application of our approach in practice.
Case vignette 1: Working within the stagnant image
A 47-year-old man presents with a major depressive episode, exhibiting psychomotor retardation, poverty of speech and experiencing manifest anhedonia. Stalled by a standard chronological history taking, the clinician asks him to describe his experience. The patient responds with delay: ‘Like a rusted anchor… [silence] Stuck at the bottom of the lake… [longer silence] in the silt’.
Rather than checking off diagnostic criteria, or challenging this hopelessness with cognitive restructuring, the clinician steps directly into the image: ‘I want to sit here at the bottom of the lake with you for a moment. Don’t try to pull yourself up to the surface right now. Tell me about the weight of that silt pulling on you. How does it feel in your body right now?’
Patient: (He shifts slightly, presses a hand to his chest) ‘Huge weight on my chest… suffocated’.
Clinician: ‘Let’s just notice that weight on your chest. It makes sense that you can’t move. And what about that rusted anchor? What does the rust do?’
Patient: ‘I’ve been flaking away for years… it’s frozen stiff…’
The clinician honours the patient’s immediate spatial and embodied reality by validating the anchor instead of trying to ‘fix’ it. Working inside the image allows the patient to articulate an otherwise inaccessible experience – revealing that his depression is a corrosive process (‘rusted for years’). The alliance is instantly strengthened. Eye contact is established and the pace of dialogue quickens.
Case vignette 2: Holding the paratactic fragment
A 26-year-old woman with a history of early and recurrent relational trauma meets diagnostic criteria for borderline personality disorder. Tearing apart logical sequence, her narrative is highly paratactic, jumping from intense idealisation of her partner to overwhelming terror. In a state of high emotional arousal, she describes her relationship with him in the following way.
Patient: (Speaking rapidly, then stopping abruptly, then starting again from a different angle) ‘When he looks at me – it’s like lightning. A mirror. I’m beautiful, completely… and then it’s… the glass is everywhere. I’m standing in it. I can’t… I’m still looking [alarmed], I’m bleeding and I’m still looking at it…’
A standard response might label this as ‘splitting’, attempting to ground the patient or teach emotion regulation. Instead, the clinician accepts the side-by-side contradiction: ‘That is a terrifying place to stand. You are bleeding from the shards, yet you cannot look away because that reflection is where you feel beautiful. I can see both things happening right now in your eyes – the beauty of being seen and the absolute terror of being cut’.
Patient: (Crying, rocking slightly, the words arriving with sudden clarity in the midst of her despair): ‘Yes. If I leave the room of glass, I disappear. If I stay, I die’.
Clinician: ‘We are not going to clean up the glass right this second, and I am not going to ask you to step out of the room until you are ready. I am just going to stay here in the room of broken glass with you, watching both the reflection and the wounds’.
Patient: (visibly relaxes, moves back in her seat).
By explicitly acknowledging the coexistence of the desperate need for connection and the somatic experience of destruction, the clinician holds the existential knot. This paratactic acceptance creates a safe container, bypassing a lecture on emotion regulation and allowing the patient’s live, chaotic trauma history to be safely witnessed in the room.
Discussion
We do not claim absolute historical originality regarding our general concepts, but rather an original emphasis on their direct application in contemporary clinical practice. The effort to capture unmediated human experience and behaviour has a rich intellectual lineage, Walter Benjamin’s work only representing a key achievement. Straddling the late-19th and early-20th centuries, Émile Durkheim wrote about the collective effervescence produced by the mana of unmediated group exposure (Ikkos Reference Ikkos and McQueen2019). Around the same time, Sigmund Freud identified the puzzling, non-linear mechanisms of condensation and displacement to decode the unconscious and founded psychoanalysis (Freud Reference Freud1976). Eschewing the constraints of psychoanalytic metapsychology, phenomenologists like Maurice Merleau-Ponty have championed the primacy of the lived, embodied experience (Merleau-Ponty Reference Merleau-Ponty1962), paving the way for 21st-century integrations of phenomenology, cognitive science and neuroscience (Varela Reference Varela, Thompson and Rosch1991). Building on these traditions, we suggest that a psychiatric poetics offers an indispensable corrective to standard, checklist-bound and purely anamnesis-based psychiatric practice.
If Emil Kraepelin (Ikkos Reference Ikkos, Becker and Stanghellini2026a) sought to categorise the finished ‘compound’ (the nosological entity), a poetic approach identifies the elemental, atomic components of the human encounter. We thus propose expanding psychiatry’s ‘periodic table’ of ‘elements’ – which currently relies on concepts, medical history, descriptive psychopathology and biomarkers – to include the distinct resources of psychiatric poetics (Ikkos Reference Ikkos and Morgan2026b). As a starting point, we propose the following clinical vectors.
Image: Moving beyond literal description or clinical summary to hold the vivid, fragile and alive images (the Denkbild) that arise dynamically between clinician and patient (Stanghellini Reference Stanghellini2026).
Condensation: Witnessing the merging of disparate events, sensations, thoughts and memories into a single image, word or scene. This expresses the stratification or ‘folding’ of apparently unrelated fragments into an affective aggregate saturated with tension (Kirmayer Reference Kirmayer2025).
Metonymy: Tracking the sliding of meaning through the changing, associative affinities of words and somatic complaints, where the true locus of distress shifts from one representation to another (Lacan Reference Lacan1966; Ritunnano Reference Ritunnano, Littlemore and Nelson2026).
Fragment: Approaching the patient’s fractured narrative not as a broken story to be ‘fixed’, but as a series of ‘existential knots’ containing compressed, dialectical clinical truths (Stanghellini Reference Stanghellini2025).
Parataxis: Recognising the profound meaning in side-by-side contradictions and emotional ‘shocks’ (Benjamin Reference Benjamin2006) without rushing to force a logical resolution; this includes attending to the creative anomalies of a patient’s narrative ‘montage’ (Stanghellini Reference Stanghellini2023b).
Rhapsody: Engaging with the irregular collection of apparently unrelated narratives or scenes. This poetic structure expresses a waning of chronological links, allowing memories and affects to appear as discrete, highly charged fragments rather than a smooth, linear timeline.
Conclusion
A psychiatric poetics does not seek to dismantle the necessary frameworks of contemporary diagnostic psychiatry; rather, it offers an indispensable, creative architecture to supplement them – a makeshift bridge over the widening precipice of diagnostic reductionism and administrative efficiency. Crucially, this approach should not be deemed ‘psychotherapy’ in the sense of a specialised, distinct subdiscipline detached from general clinical practice. It is, instead, intrinsically and fundamentally psychiatric. By recovering the subjective dimension of suffering, it delivers the necessary psychotherapeutic component that should inherently belong to all psychiatric care.
When clinical practice relies exclusively on the flattening taxonomies of standardised checklists, it risks pathologising the symptom while entirely missing the person. By shifting our therapeutic gaze from the finished ‘compound’ of nosological categorisation to the elementality of the fragment, the thought-image and paratactic montage, we expand the descriptive periodic table of mental healthcare.
Stepping into the patient’s space-time and immediate imagery redefines the therapeutic alliance. It transforms the psychiatric encounter from an external act of diagnostic classification into a collaborative space of recognition. By holding side-by-side contradictions without rushing to enforce a linear, rational resolution, the clinician honours the patient’s immediate embodied, spatial and temporal reality.
In the era of artificial intelligence, when technology risks pushing the development of empathetic skills down the training and continuing professional development rank, the importance of humanities in psychiatric training and continuing development has increased. Ultimately, attending to the poetics of illness experience and recovery allows an authentic voice to emerge from beneath the weight of clinical concepts. It reclaims the fractured, rhapsodic narrative not as a broken history to be mechanically repaired, but as a site of profound existential truth. It ensures that even when a patient’s life feels utterly senseless, the deep resonance of their core humanity is heard, preserved and safely witnessed within the clinical encounter.
MCQs
Select the single best option for each question stem
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1 Psychiatric poetics is:
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a a clinical tool
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b a form of literary criticism
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c an alternative to mental state examination
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d poetry written by psychiatrists
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e poetry written by patients.
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2 Walter Benjamin was:
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a a transcultural psychiatrist
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b a neuroscientist
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c an abstract painter
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d a cultural critic
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e a German poet.
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3 Dialectical images are:
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a digital images
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b photographs
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c hand-painted
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d memories
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e experiential.
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4 Which of the following is not a concept in psychiatric poetics?
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a condensation
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b metonymy
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c fragment
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d parataxis
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e narrative.
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5 Psychiatric poetics:
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a aims to abstract from lived experience
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b can enhance the therapeutic alliance
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c is a specialist psychological therapy
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d is irrelevant to working with psychosis
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e will be included in next version of the DSM.
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MCQ answers
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1 a
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2 d
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3 e
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4 e
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5 b
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this work.
Acknowledgement
The authors made use of the Claude Sonnet 5 (https://platform.claude.com/docs/en/models/sonnet-5/overview) to assist with language editing in preparing this article.
Funding
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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