The treatment of psychotics in the Lacanian Orientation

I’m getting ready to (attempt to) teach students about the Lacanian orientation’s approach to treating patients with a psychotic structure. Most of these students have not had any exposure to Lacanian theory or practice.

Structures:

I plan to talk about the difference between psychotic and neurotic structures.

To start with psychosis is caused by foreclosure (foreclosure is not caused by psychosis, psychosis is caused by foreclosure). Foreclosure is not seeing, acknowledging, or experiencing the Law (i.e. Name-of-the-Father, castration, etc). I then plan to talk about how the neurosis is caused by repression (neurosis does not cause repression, repression causes neurosis).

To put it very simply, psychosis is conceived of as a structure, not a checklist of symptoms, or a particular phenomenological condition. Where neurosis is characterised by the fundamental operation of repression, and perversion by disavowal, in psychosis, foreclosure is paramount. To illustrate: in repression, signifiers and thoughts become unconscious. It is as if they were swept under a carpet; out of sight, but leaving a lump, nonetheless. In foreclosure, not only is the same material not swept under the carpet, but it is never admitted entry in the first place. This has ramifications for a subject’s entire place and function within the symbolic order (i.e. the order of discourse and law). … A psychosis is ‘triggered’, which is to say, becomes actively symptomatic (in the form of hallucinations, etc) when the subject is confronted with the foreclosed material, namely, the Nom du père (Name-of-the-father). However, the ‘triggering’ itself is of less importance than the structure, which never changes. ¹

Freud lived in a time that was stable in comparison to now. Due to the stability of Freud’s time/place more neurotic structures were produced than psychotic structures. Ergo, Freud’s psychoanalysis was built out of treating neurotic structures. (Freud even stated psychoanalysis was not an appropriate was to treat psychotic structures.)

Lacan extends psychoanalysis to the treatment of psychotic structures, and the Lacanian orientation (under the direction of Miller) has continued this work.

A Name-of-the-Father VS. The Name-of-the-Father:

Subjects who have accepted the tragic sense of life have a relationships with the Name-of-the-father, they are castrated but they repress the castration. Ergo, they are_neurotic_.

Subjects who have foreclosed castration do not accept the Name-of-the-Father, but they might accept a Name-of-the-Father. An example is a person who accepts the authority of a Guru.

It’s what gets people through life:

Regardless of if a person is a repressing neurotic with a neurotic symptom, or a forclosing psychotic with a delusion, both of these represent the structures an individual builds to keep themselves safe from the overwhelming power of the Real (i.e. the “tragic sense of life”).

This is important because it shows that in the treatment of neurotics you don’t want to take away (further repress) the symptom, rather you want to transform it into a sinthome. Likewise, in the treatment of a psychotic you don’t want to take away the delusion (prove the delusion to be false), rather you want to become support to the safety the psychotic structure provides.

Another way to think about this is that our structure (neurotic or psychotic) helps the subject of jouissance direct the flow of jouissance.

On the treatment of Psychosis:

I’m using an article by Susan Schwartz titled A Psychosis More Ordinary: A Lacanian Treatment of Paranoia² to introduce students to the ideas that inform the treatment of psychotic individuals for those operating from the Lacanian orientation.

One of the ways a clinician might go about determining that a patient is psychotic could be by paying attention to the ways the patient makes use of the symbolic / the ways the patient talks.

If some- thing is foreclosed it leaves a hole in the Symbolic, the effect of which will manifest in the subject’s speech (Lacan 19931955–56, p. 203)³. There will be a point, for the subject, where the rule that determines the connection between language and meaning fails: the psychotic may speak English but there will be certain words to which he attributes a meaning that is not shared by other people. He may even invent a word, a neologism that carries a meaning unique to his delusional framework.

Schwartz follow the section above up with the following sentence

Lacan will describe the psychotic as one who is within language but outside discourse because discourse depends on there being an accepted connection, decreed by convention, between a word and a meaning.

I think this is great! It shows how a psychotic subject can talk about the rules, but not have the rules integrated into their subjectivity as such.

So, how do we treat an ordinary psychotic patient?

Perhaps Lacan’s most radical direction to the psychoanalyst in relation to the treatment of the psychotic patient is to occupy the position of the ‘secretary’ (Lacan (19931955–56), p. 206). That, is the psychoanalyst occupies a place of active listening, of asking for clarification, of an acceptance of the psychotic’s view of things. Rather than offering interpretations — contra-indicated in the treatment of paranoia in particular, as the interpretation can produce persecutory effects — the analyst supports the delusional structure because it is the means through which the psychotic has found some stability. … Within the session the analyst will listen attentively to the psychotic’s speech for points where delusional elements appear and offer a symbolic support in a structural sense — that is, the analyst will offer words that function as does a third leg on a stool. … that is, aphorisms that he can have ready to put in place when the abyss of extreme anxiety suddenly opens before him.

The psychoanalyst/psychotherapist as secretary (as the person who helps keep everything organized, everything running smoothly enough) is an intervention I plan to stress with students.

The treatment of an ordinary psychotic:

Miller points out that there are many patients a clinician can’t easily recognize as psychotic or neurotic. One way to think about such patients is as ordinary psychotics.

For Miller, ordinary psychosis is a form of clinical practice that looks for small clues. Sometimes a psychosis is not clearly manifest but at the same time the subject does not present with the stability or consistency of a neurosis. … The category of ordinary psychosis is a way of introducing a point of inclusion for those who do not fit the determinants of neurosis or psychosis. It is not a new diagnostic category; rather, ordinary psychosis is a way of thinking about clinical phenomena.

Schwartz describes the way Millar’s articulates how the analyst/therapist as a secretary.

According to Miller, ordinary psychosis will be triggered by a sudden cut in the subject’s relation to the body, to the social or to his own subjectivity. For example, he might have an accident that affects his body in a significant way, or he could lose his job. If, in the latter case, the patient has lost his professional ‘name’, his title, he becomes nothing but an object to be persecuted by the Other. For example, a middle-aged man had a psychotic break after he lost his ‘name’ — ‘good husband’ — when he was sacked and could no longer provide for his family. Being a provider was the determinant, for him, of being a ‘good husband’. In the clinic of ordinary psychos is the function of the analyst is to locate the register of the disconnection and find a mode of reconnection or knotting that will work for the particular subject: as signifier, as image or in the real of the body. Where there is a foreclosure of an element in the Symbolic, the aim of the treatment of psychosis is to create a supplementary way of managing.