There are no shortage of psychoanalytic theories of psychosis. The Lacanian account of psychosis that derives from the 1950s – and which we may think of as ‘classical’, in Lacanian psychoanalysis – can be found best expressed in Seminar 3, and the paper entitled ‘On a question prior to any possible treatment of psychosis’ in the Écrits. 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). It is as if a set of organising principles are lacking, at least, relative to those found in neurosis under repression.
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. A psychotic subject is always in some sense psychotic, and there is no shifting from psychosis to neurosis, or the converse. One can see how this theory of psychosis applies particularly well to paranoid psychosis, for instance, in which delusion (and foreclosure) is absolute and operates as the subject’s central organising principle. (And, conversely, one can see that it is somewhat less obvious how it might apply to autism, or to the fragmentation of schizophrenia). Expanding on Freud’s theorisation of the Schreber case, delusion is not merely an attempt at recovery, it is the attempt characteristic of classical paranoia.
In practice, this structural approach – three diagnoses – generally collapses into two (neurosis and psychosis), since perverse subjects supposedly seldom present for analysis. We are then left with a dichotomous clinic. We can contrast this with the many psychoanalytic approaches that argue for ‘borderline’ diagnoses and phenomena. The ‘borderline’ diagnosis now is practically a pejorative found in public mental health settings, but originally it was a psychoanalytic idea, specifying something between neurosis and psychosis. On the other hand, there are the approaches to psychosis that one finds in Peter Fonagy, or in the recent BPS report, or in the work of Melanie Klein. In these latter theorists, we find a relativisation of the notion of delusion, and of psychosis itself, which becomes a kind of ‘spectrum’ phenomenon. If psychosis is universal, then among other things, one is left with some difficult ethical questions as to where (and if) ‘intervention’ should occur. Then, there is also the risk of a complete collapse of diagnostic rigour, where ‘worry’ is conflated with persecutory delusion. I’ve touched on these issues elsewhere, and may expand on them further another time.
It is in this context that we can approach Miller’s intervention to the debate, which is to introduce ‘ordinary psychosis’ as a third term to a binary clinic (this was initially in 1998, I believe). The innovation is controversial for several reasons, not least of which is that its underpinnings are but slender in the work of Lacan, and ‘ordinary psychosis’ therefore risks resemblance to a third term from another tradition, namely purgatory. Secondly, ordinary psychosis tends to have a set of general coordinates as a concept rather than a definition as such, which means that different authors use it in different ways. In an attempt to clarify the concept, it is worth looking at what Miller himself has to say, in the paper ‘Ordinary psychosis revisited’.
Miller takes up the issue of a binary clinic – ‘if for years you have had reason to doubt the neurosis of the subject, you can bet he’s more like an ordinary psychotic. When it is neurosis, you have to know’. Neurosis ‘is not the wallpaper’, it is ‘a very definite structure’, and conversely, the analyst is obliged – for reasons of both prudence and epistemology – to presume psychosis in subjects until proven otherwise. When the analyst cannot diagnose neurosis, he is dealing with a veiled or dissimulated, psychosis, inferred from ‘very small clues’, and diagnosed more as an ‘epistemic category’ than an objective one.
From this, it seems that such a psychosis can occur without the precondition of symptoms typically regarded as ‘psychotic’, such as the delusions, hallucinations, ‘negative’ symptoms and so forth. Miller goes further – ‘perhaps what we call ordinary psychosis is a psychosis which is not evident until triggered’. To that the extent that there is a support for the concept of ordinary psychosis in the oeuvre of Lacan, it is to be found in the later work, or, at least, that which proceeds from the pluralisation of the Nom du père. As Miller puts it:
You may see, and we frequently see, with ordinary psychotics that for instance a loss of job triggers a psychosis because the job meant much more than a job or a way of living. Having a job was a Name-of-the-Father. Lacan says nowadays the Name-of-the-Father is the fact of being named, of being appointed to a function, of être nommé-à…We see that, in fact being part of an organisation, an administration, a club, may be the only principle of the world of an ordinary psychotic. For instance, having a job has an extreme symbolic value nowadays, an people are willing to take on badly paid jobs just to have the symbolic value of being at work, and governments are intelligent enough to understand this clearly and they offer them poorly-paid jobs.
This conception of things is less based on ‘classical’ Lacan than on the later, Borromean work, in which nomination is at the heart of psychoanalysis. So, how would one diagnose neurosis? For Miller:
You need some criteria to say ‘this is a neurosis’, you need a relationship to the Name-of-the-Father – not a Name-of-the-Father – you need some proof of minus phi, some proof of a relation to castration, impotence and impossibility, you need, to use the Freudian terms of the second topography, a clear-cut differentiation between ego and id, or between signifiers and drives, you need a clearly delineated superego, and if you don’t have this and other signs, well, you don’t have a neurosis, you have something else.
This is in keeping with the Lacan of Seminar 20, where it is a matter of la/le/the opposed to un/une/a. La femme, as definite article, or le Nom du père, for that matter, may not exist, yet there may nevertheless be une femme, or a Name-of-the-Father. Miller concedes that some may see ordinary psychosis as a third structure, and remarks that it constitutes a trinity. It is ternary insofar as it offers an alternative between n neurosis and psychosis’ binary insofar as it is subsumed within psychotic structure; and unitary, in that, in relativising delusion, everybody is a bit mad. (Pierre Skriabine also made this latter point, deducing it from Borromean theory). The diagnostic implications, however, are perhaps less significant than those for treatment, since in all psychosis, as Miller says, unless one is completely catatonic, one has something by which to survive. Putting together this ‘something’ then – constructing some form of locum or suppletion (suppléance) qua Name-of-the-Father – is one possible therapeutic goal for a psychotic subject in analysis.
If we are to compare ordinary psychosis to the ‘classical’ work of Lacan, it seems not so much a dissolution of differential clinical structure, as it is of a different notion of structure altogether. As Marie-Hélène Brousse put it in ‘Ordinary psychosis in the light of Lacan’s theory of discourse’, the structure underpinning ordinary psychosis is one where foreclosure need not necessarily be absolute, where foreclosure is not so much a case of yes/no as it is of not-all (pas-tout). There exists a plurality of psychoses, and of forms of organisation and of jouissance within the psychoses. As Miller quips, psychosis is a vast continent, and if there are to be treatments for psychotic subjects, presumably these, too, must be similarly, immensely diverse. There is much more to be said on this topic, but this sketch may serve as a start.
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