More on psychosis: Subjective structure and incompleteness

 

AS

I am not going to be exhaustive here. The aim is to present a little exegesis and a little analogy.The above chart – taken from Lacan’s Seminar X, on anxiety – may help to illustrate a couple of things at the very least, concerning the entry into subjecthood, and the separation of neurosis and psychosis.

To begin with the top left-hand side, we have the Other(A for Autre) , the capital Other, as the symbolic register that precedes the subject’s arrival (and which will persist beyond the subject’s demise), and into which the subject is born. The subject, here, is marked as S, and is subsequent to the Other. One is dealing with alienation from the outset.

The entry into subjecthood proper is marked by the barred S, which is to say, the divided Subject, the subject of lack. Subjective division – and we can take this as correlated with a series of somewhat overlapping but not totally coextensive terms, such as repression, desire, lack and law – has its counterpart in a corresponding division in the Other. The Other, and not just the Subject, is lacking, incomplete. The small a below is objet petit a, the remainder of this process of division.

This is how things stand with neurosis, at least. In psychosis, in psychoanalytic terms, there has to be some problem in this process of division, and several such problems are possible. For instance, the subject could be excluded from the outset somehow, without any place in the symbolic configuration. Every clinician must have encountered melancholics (subjects with psychotic depression), for example, whose very being does not seem to correspond with any associated parental desire; who function as unwanted, entirely surplus to parental lack. Likewise, the child who fits all too perfectly with maternal lack (for instance), may be apt to lapse into a folie à deux. Alternatively, there could be a lack in the Other which is inadequately marked or symbolised. The nature of the marking may have subjective repercussions for years, perhaps even generations. To use a Winnicottian term, it must be ‘good enough’. I don’t believe that one should be too schematic about the aetiology of psychosis, given the vast multitude of different pathways, but we have here a very basic sketch.

With this in mind, we should have pause for reconsidering the so-called ‘negative’ symptoms of psychosis, since it is actually the neurotic who ends up in a position of deficit. (Some phenomenological psychiatrists – Josef Parnas and Julie Nordgard – seem to have some similar scepticism regarding psychotic ‘negativity. I may have occasion to discuss them at some other time).

We are left with two positions, then, that approximately resemble Gödel’s two theorems. In response to the philosophical project to establish rigorous, logical principles to undergird mathematical truth, Gödel demonstrated that no such system could be found. One is left with an incomplete set of axioms (such as in neurosis, where the inconsistent axioms/signifiers/desires are unconscious), or an inconsistent set of axioms (as in psychosis, in which the operation of repression has not functioned in a comprehensive manner).

There are at least two reasonably obvious implications for the treatment of psychosis that might follow from this analogy. First, a goal of treatment in psychosis, if we presume that the Other for a psychotic subject is unbarred, is to decomplete the Other, to show that the Other is lacking in some way. This can, in fortuitous circumstances, happen to some extent. A paranoid delusion may lose some of its rigid, brittle character, and permit of some flexibility and amendment to changing circumstances. This may not be a ‘cure’, precisely, but it may nonetheless be better than a subject clinging to a paranoid construction at the expense of all else. Second, if the aim is decompletion, then the clinician would entirely undermine his position by too earnestly playing the role of expert, of authority, of the one who issues imperatives (or homework), the one who surveys and disciplines, however subtly, or who denies his or her own lack, or who exhibits too keen an inquisitiveness, or who unwittingly enacts some form of exclusion. Such positions in treatment, irrespective of one’s precise disciplinary orientations, are likely to foster greater paranoia, and reinforce the notion of an Other without limits. This is one of the reasons for nomination to be given primacy over interpretation, since the introduction of new meanings could be one of many inadvertent causes of destabilisation. Here, more than ever, one must be very precise in handling any notion of ‘resistance’, and, to follow Lacan, situate this resistance strictly on the side of the analyst, not the analysand.

 

 

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8 thoughts on “More on psychosis: Subjective structure and incompleteness

  1. Very astute exegesis in my opinion. I was curious about something you touched on and whether you had any opinions on the following.

    Where you write: ‘A paranoid delusion may lose some of its rigid, brittle character, and permit of some flexibility and amendment to changing circumstances’, such an approach would seem – for lack of a better term – beneficial in relation to paranoid psychosis; I was wondering what approach you think applicable to a schizophrenic subject (as distinct from the paranoiac and following the analytic perspective rather than a psychiatric perspective), given that this ‘looseness’ or ‘flexability’ of delusion (non-systematised) can actially be present in schizophrenia. How might the approach differ?

    Simon

    • It’s a good question, and upon reflection, I might have worded things slightly differently on the topic of paranoid delusion. (A reasonable, if cursory summary on paranoia can be found in a short paper by Charles Melman, somewhere on Cormac Gallagher’s Lacan in Ireland website).
      The way that I understand things is to situate paranoia primarily as a problem in the symbolic register, and schizophrenia as a problem at the level of the imaginary. In paranoia, the subject has some fundamental exclusion from some aspect of the symbolic order, and delusions (often very detailed and elaborate) come to fill this void.
      In schizophrenia, I find that the delusions are much less elaborate, and may be very fleeting. The relation to the Other in these delusions can also be very tenuous. This is a contrast to paranoia, where a relation to the Other is very clearly present, but of a persecutory nature.
      To give an example, last year I wrote a short blog on the ABC’s Changing Minds doco, and made reference to a man on the show who believed his body to be broken. My remarks here are speculative, since viewers only have limited access to this man’s discourse, but he appears to be someone who fits the diagnosis of schizophrenia in a psychoanalytic sense. His delusion – concerning his body – does not appear very elaborate, and has no explicit relation to the Other at all. It’s a narcissistic delusion in the sense that it concerns his relation to his own body and bodily image. In schizophrenia, there is very often a great impoverishment of fantasy life, constriction of affect, and limited social relations. The schizophrenic can be much more solitary than other psychotic subjects. At the level of the mirror stage (in Lacanian language) or the ego (in Freudan language) there is often a gross lack of synthesis and consistency. One direction of the treatment, in my opinion, might be to assist a schizophrenic subject in doing some work to shore up this precarious imaginary relation. For instance, with the man in the doco, we might speculate that the activity of sculpture, for instance, might allow him to construct a stable, consistent bodily synthesis wherein the components are not broken, and may theoretically, at least, serve as a supplement or double for problems at the mirror stage. Now, obviously, one cannot go around prescribing the plastic arts to every schizophrenic subject, but this sort of activity strikes as the sort of thing that might be relatively beneficial.

      • Thanks for your reply, the approach you’ve outlined seems to fit other views I’ve been exposed to, particulary the primacy of the imaginary as distinct from the symbolic; though, I also understand that the relation, in schizophrenia, to the other – as per delusional constructions – can be similar to, say, persecutory constructions, albeit much more haphazard and unfixed, if not fleeting – e.g., it may appear paranoic but in content but unstable so as to be easily discarded or changed easily. I will bring some references to this in another comment if it’s of interest.

        That said, in a related way, it seems that the analytic view is far better equipped to posit an ‘understanding’ of what is fundamental to schizophrenia precisely due to the basic elaboration you gave above. The focus on language disturbance, so-called, that is rife in contemporary psychiatric discourse on the subject seems to often efface a very fundamental concern with the body, to put it simply. I am speaking here of the difference in literature that brings this to bear but also of very limited experience with others and the discipline, etc. Do you have any thoughts on this matter?

        Thanks for your reply.
        Simon

      • A couple of brief points:
        I think that psychotic diagnoses are often non-discrete entities, and also that multiple diagnoses may be valid for a person over different periods of time. Thus, whilst there are some ‘classic’ schizophrenics and ‘classic’ paranoid psychotic subjects, many subjective constellations are possible.
        Second, I know that a certain Lacanian school in Melbourne teaches the notion that, broadly speaking, psychosis is like a spectrum, where you have autism at one extreme, schizophrenia in the middle, and paranoia (and perhaps mania) at the other extreme, in terms of level of dysfunction (and corresponding type of foreclosure). In fact, since diagnoses can change over time, I think such conceptions are a bit redundant. Also, they can be misleading in some respects. If we take social life as an example, some schizophrenic people may be perceived as ‘odd’ by others, but may be pretty good at getting along with people. In contrast, some supposedly ‘high-functioning’ paranoid psychotics are mired in endless imaginary idealisation/hostility power struggles, etc. More depends on the specific details than on the general diagnosis.
        The theme of the sinthome appears in Lacan’s 23rd Seminar, and it continues to inspire much debate on the conception and treatment of psychoses. For there to be a viable sinthome, it would have to knot all three registers, and would therefore need to have some relation to consistency in the imaginary, and jouissance in the real, both of which pertain to different aspects of the body. So, it would certainly be a mistake to focus only on the symbolic, or to construe psychosis (as some have) as some sort of cognitive ‘impairment’.

      • Thanks for the response. I just have a brief comment/question in reply.

        When you speak of diagnoses changing over time – is this not the position of the analyst changing, a reflection of the analyst, rather than a reflection of the analysand? (Speaking strictly of an analytic situation, obviously.) Or is something more being said?, i.e., the often dubbed ‘later Lacan’ ushers in a ‘relativism’ (I use the word cautiously… this is probably not the best choice of words but I hope you get my meaning here)?

        I understand this very loose conception of a ‘spectrum,’ which only reflects a certain theoretical positioning in relation to conceptualising the psychoses (i.e., it doesn’t necessarily entail that individuals fit neatly into discreet, strictly demarcated positions), though perhaps what you are referring to is a little more hazardous; and I understand the significance of the ‘sinthome’ and the developments of Lacan in the later Seminars. I don’t, however, think that this ‘later Lacan’ supersedes (for lack of a better term) his prior work, as people at times seem to think – would this be a point of disagreement?

        The point I was making regarding focus on the symbolic was to do not so much with psychoanalysis as with the determination of S2s derived from phenomenological, behaviorist, and biomedical models of approaching and conceptualising schizophrenia. Psychoanalysis is able to approach things differently… What I am trying to say in this regard is probably not entirely clear, but I hope to explicate my meaning on this point in an other writing.

        On the last point, is this ‘cognitive impairment’ notion coupled with the notion of ‘degenerative disease’ and a neurological notion of brain impairment? Because it seems like CBT-style approaches to treatment of schizophrenia qua ‘cognitive impairment’ (which is becoming more and more the norm from what I’ve noticed) would be incompatible with such a view…

        But yes, I don’t think one should conflate or render equivalent social conditions with conceptualisations of subject positions.

      • I think that the sinthome definitely introduces a relativisation with respect to the neurosis/psychosis dichotomy. Lorenza Chieza is his book, ‘Subjectivity and Otherness’, argues that this relativisation was there in Lacan’s early work also. In any case, I don’t take it to overturn the neurosis-psychosis binary as to suggest that this distinction, by itself, is insufficient.
        Within a broad diagnosis of neurosis, and especially within psychosis, I think it is entirely possible for a subject to change symptoms or sub-diagnosis, and for that this change does not necessarily imply a vacillation on the part of the analyst. I think that one can affirm that a subject is in a position of foreclosure in terms of the Name-of-the-Father, and nevertheless not particularly obliged to be conceptually encapsulated within the classical categories of mania, melancholia, paranoia, etc.
        I’m not so familiar with the broader literature on schizophrenia, but from what I can tell, the cognitivists do not seem much concerned with etiology. I’m not sure that they would invoke biological notions of schizophrenia as ‘degenerative illness’. A lot of the strongest advocates for CBT for psychosis are in fact British psychologists who identify as left-wing, and who would prefer to argue for psychosis as an ‘understandable response’ to trauma, social inequality, etc. To some extent, this is a function of the NHS which is extremely bureaucratic and biologist, and which has historically forbidden any talking therapy at all for psychosis (on the curious notion that speaking of delusions would somehow strengthen them). All the same, there are a bunch of people holding a set of paradoxical positions, namely that psychosis (and all phenomena of mental distress) arise from environmental factors and, above all, injustice; that the biological psychiatrists are ethically wrong; but that the role of the talking therapist is to affirm the existence of these environmental problems and to nonetheless use CBT to persuade the subject to undertake ‘pleasant activities’, challenge delusions, etc.

      • Interesting points, thanks for the clarification (I’ve nothing against relativism, by the way). I agree with your understanding here, I think the clarification is important – there is a very good piece in *Lacan on Madness*, ‘”You cannot choose to go crazy”‘ by Nestor Braunstein, which you may find interesting. In any case, I think Chieza’s point at the end of Subjectivity and Otherness (from memory) is largely correct. I would say, this relativism that is supposedly introduced by the ‘later Lacan’ of the sinthome, greater focus on the Real, etc., introduces something, yes, but it is not a break with Lacan’s preceding work; rather, it is in a certain sense continuous with it. Perhaps expressed as: it is an extension that is not contiguous.

        I think one can overemphasise the later Lacan as completely changing the entire field. But that’s just my opinion.

        It is interesting that you point out the left-wing view of ‘mental illness’, I’m actually writing a critique of this view, of how the left conceive of ‘mental illness’- both in the guise of ‘social-environmental causation’ (entailing a different sort of relativism, one which doesn’t make sense) as well as the somewhat dated view of ‘madness is liberation’ (e.g. some of those who were part of the anti-psychiatry movement, as well as the ‘anti-Oedipus’ stuff). (As someone on the left, I feel like this stuff needs to be criticised.) It might be interesting to see what you think once I’ve completed it.

        And, since you mentioned it, it does seem like ‘trauma’ has become a generalised category of experience almost void of meaning, much like ‘anxiety’, though this might be a different discussion. In any case, CBT, aside from everything else wrong with it, in encouraging one to ‘challenge delusions’ is committing a not insignificant error; it is essentially removing the the development of a stabilisation and subjective solution to psychosis – kind of like how neoconservatives like to remove the infrastructure of a country when they invade it. The idea of *working with* psychosis is, from my experience, completely unavailable to most in psy-disciplines.

      • In general, the left is not very good on mental health. I would be interested to see your critique. The analogy with ‘humanitarian’ regime change is a very suggestive one.

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