Lacanian Psychoanalysis & Psychosis – 1. Schizophrenia

Helen Koumidi

Psychologist – Psychotherapist

www.elenikoumidi.gr

«Lacanian Psychoanalysis & Psychosis – 1. Schizophrenia»

«To be a psychoanalyst is simply to open your eyes to the evident fact that nothing malfunctions more than human reality. If you believe that you have a well-adapted, reasonable ego, which knows its way around, how to recognize what is to be done and not to be done, and how to take reality into account, then there is nothing left to do but send you packing» (Lacan J., 1956, p.82). 

1.Lacanian Diagnosis

In Lacan’s work a distinction is made between structure and symptoms. There are three clinical structures with different mechanism:

– Neurosis: The Neurotic Structure can be either Obsessive or Hysterical. The mechanism of neurotic structure is repression.

– Psychosis: The Psychotic Structure can be Schizophrenic, Paranoid or Manic- Depressive. The mechanism of Psychotic structure is foreclosure.

– Perversion: The mechanism of Perversion is disavowal.

«Structure»:

A subject cannot belong to two structures at the same time. It is either one structure or the other. Specifically, the term “structure” has the meaning of the internal representation of interpersonal relationships. What defines the subject is thus its position in relation to other subjects and signifiers. The first years of man’s life are the critical period in which his structure is determined. Then, the psychic structure does not change. For example, a psychotic person will not turn into a neurotic person. These structures constitute the three possible positions of the subject in relation to the Other. Let us also clarify that, for Lacan, there is no “normal” person, but every person has his symptom within a clinical structure.

«Symptom»:

Apart from the special importance of ‘structure’ in Lacanian diagnosis, the same applies to the concept of ‘symptom’. The concept of symptom in Lacanian theory differs from that of the medical approach. In the medical approach, the grouping of symptoms leads to the diagnosis of the disorder. In Lacanian psychoanalysis each symptom contains the unique ‘story’ of each subject. That is, the symptom itself does not refer either to a specific clinical structure or to a specific medical diagnosis. The symptom ‘dresses’, so to speak, the subject according to his particular fantasy. For example, the symptom of anorexia can appear in either a neurotic or a psychotic subject, but its interpretation differs. The same applies with the acts that a subject commits, such as for example a homicide or a suicide, which receive different meaning and interpretation depending on the clinical structure and history of each subject.

«Lacanian Diagnosis»:

Lacanian diagnosis thus has practical significance as the direction of treatment is different both according to the structure of the patient and according to the particular history within the structure of the patient. The psychoanalyst thus makes a diagnosis with the main aim of a correct handling of the transference. In other words, in what way will he approach the analysand and what tricks will he use. Thus, an analysis with a neurotic subject is not the same as that of a psychotic.

«The onset of psychosis»:

In the Lacanian theory of psychosis there is the following distinction:

• Psychosis: as a clinical structure.
• Psychotic phenomena: as the manifestations of psychosis, which can be delusions and/or hallucinations.

This distinction is made in order to clarify the fact that a person can have a psychotic structure but his psychosis has not been manifested. When we talk about “outbreak” of Psychosis we mean the “triggering” of psychotic phenomena.

«Two conditions for the ‘triggering’ of psychosis»:

According to Lacan, Psychosis can be triggered, which means the patient presents psychotic phenomena, if the following two conditions exist:

1. The person should have a psychotic structure. If there is no psychotic structure, then that person will never manifest psychotic phenomena.
2. When there is an event that will bring the person face to face with the lack within their psychotic structure. This means that, a real event in the person’s life can become the occasion for the manifestation of Psychosis.

«Contingency»:

If there is no such event, then the person will not manifest psychotic phenomena but his psychotic structure will remain latent. So this is where ‘random’ comes into play. No one knows which event and when, but also if there will be something that will become the occasion for the onset of psychosis.

2.Lacanian Structure of Psychosis

According to Lacanian theory, we could summarize the characteristics of the psychotic structure as follows:

«‘Foreclosure’ is the mental cause and mechanism of Psychosis»:

‘Foreclosure’ is considered the mental cause and main mechanism of psychosis. The psychotic mechanism of foreclosure refers to the rejection of a symbolic element from the person’s Symbolic order of reality. Briefly, for Lacan, there are three orders of psychic reality: The Symbolic (the order of language, society, the unconscious), the Imaginary (the order of the image) and the Real (the order of the non-symbolizable). These three orders are interconnected. But in the case of psychosis, these orders are disconnected due to precisely this mechanism of rejection, which excludes a symbolic element – ​​that is, causing a structural deficiency in the person’s Symbolic order of reality.

This symbolic element is the paternal signifier, and specifically it is the father’s No, the prohibition that enters as a barrier to the exclusive mother-child relationship so that the child stops being the extension of the mother’s desire. Specifically, the paternal signifier is the paternal function that has to do with the Symbolic Law, meaning the basic mental prohibition that needs to be given during the Oedipus Complex, which is none other than the prohibition of incest. The paternal function can also be passed in the absence of the natural father through the word of the mother. With this prohibition the castration and the first repulsion of the child is fulfilled by leading the child on the path of his own desire: So, quoting the words of Fink, the first repulsion, for both boys and girls, has to do with forgetting their desire to have certain forms of satisfaction with their mother. In psychosis, however, the paternal signifier is excluded, which traps the individual in a permanent imaginary dual relationship with the mother.

 

‘Foreclosure’ therefore means that the paternal signifier (the paternal function), or else the prohibition (the Law) did not pass, that the Oedipal passage to the Symbolic order failed, that the subject did not consent to his castration, that the first repulsion did not work with the consequence of the disconnection of the three orders of the individual’s psychic reality and his entry into the psychotic structure. Then, if at some point in time the psychotic person comes face to face with this excluded signifier, then psychosis is triggered, as this element comes “from outside”, that is, from the order of the Real in the form of an illusion or delusion.

3.The consequences of the disconnection of the individual’s three orders of reality form the characteristics of the psychotic structure:

a. Consequences in the Symbolic order of reality: Disorders of language

The Symbolic order of reality of the psychotic person involves a structural deficiency that disrupts the individual’s relationship with language. The psychotic subject thus has another relationship with language. As the Symbolic has been affected, which in fact concerns the order of language, this implies the existence of linguistic disorders, such as idioms, interrupted sentences, neologisms. In essence, the signifier is unleashed within the Real.

In the case of neologisms, the psychotic person cannot create a new meaning in a word or phrase and thus creates new terms with a new meaning. In the case where there are interrupted sentences we observe the “signifying chain” (the unconscious linguistic chain) “breaking” in the speech of the psychotic person. Lacan spoke in particular of the absence of several ‘points de capiton’ in the discourse of the psychotic person, which accounts for the slippage of meaning and the absence of fixed meaning.

Our unconscious is structured like language and language comes from the Symbolic place of the Other, that is, the mother or nurturer and the society where we live. While in the case of neurosis the person will be able to subjectivize a part of the speech and will “rent the language” in his own way, the psychotic person is unable to subjectivize his speech and consequently experiences that he is “possessed by the language”. That is, in psychosis, language – like psychotic phenomena – is experienced as coming “from outside” and not from within the subject. In essence, the psychotic learns to speak by copying other people’s way of speaking, i.e. imitating their speech, but without being able to use language metaphorically. The literal speech thus prevails.

Another main feature of psychosis is the certainty of the sense of experiencing a psychotic phenomenon. That is, the psychotic person is certain, not in doubt in the case of a hallucination (for example: «did I really see it or did I dream it? ») or a delusion (for example: «is he really watching me or am I imagining it? »). In addition, the psychotic person is certain that the meaning of this experience concerns him. The «psychotic knows» and no one can convince him of the opposite (as in the case of delusion: «surely the Government put a chip in me to monitor me and thus control me»).The same applies in the realm of the psychotic’s desire: there is no question about his desire, no questioning of his thoughts and experiences.

b. Consequences in the Imaginary Order of Reality: Preponderance of the Imaginary

The Symbolic order redefines the Imaginary order of the individual. This already happens during the Mirror Stage, where the infant (about 11 to 18 months) acquires the first sense of his Ego by identifying with his image in the mirror. The infant at that time does not experience his body as a unity but as a fragmented uncoordinated body in a chaotic universe of senses. This image of the self creates an image that brings order to this chaos by creating a sense of unity in both the sense of self and the experience of the body. This image needs to be validated symbolically, that is, with words from the parent: «Yes, it is you! ». The recognition of the image by the Other will mark the successful first transition into the Symbolic order of reality and the first sense of the ‘I’ identity. The individual then introjects the Ideals of his parents forming his Ego Ideal, which in turn further stabilizes his self-image. The Symbolic order is the means by which this can happen: the words – phrases of the parents, i.e. their language, will bring about this change in the Imaginary order of the child bringing the Symbolic order to the forefront of his reality. The Symbolic thus rewrites the Imaginary.

But, in psychosis this is not the case: « […] in psychosis the imaginary still predominates and that the symbolic, in so far as it has been assimilated, is ‘imagined’: it is assimilated not as a radically different order that reconstructs the original, but simply by imitating other people» (Fink B., 1997). The direct consequence of this predominance of the Imaginary is the absence of the Ego Ideal, which in turn brings about a weak self-image, that is, a weak sense of self, which can collapse in stressful moments. Here are the moments when the psychotic person feels like he’s ‘losing himself’. The individual is captured, fixed in the alienated ego of the Mirror Stage, and driven into imaginary relationships characterized by imaginary rivalry.

c. Consequences in the Real Order of Reality: The Invasion of the Libido-Jouissance

The body of the individual in neurosis passes through the Symbolic order. This means that the impulses of the neurotic individual are prioritized through socialization and the libido-jouissance is channeled only into the erogenous zones.The body thus no longer finds itself at the mercy of its impulses as it has been written with words, it follows the words: for example, in the case of sphincter control, the child learns to control its body after the parent’s verbal request.

In psychosis, however, this is not the case: the hierarchy of the psychotic’s impulses can collapse in the case of an unsupportive imaginary framework, since this hierarchy itself has been imagined rather than symbolically. The body here accepts the invasion of jouissance without being able to defend because of the chaotic situation of the Imaginary.

The disconnection of the three orders of reality in psychosis also has consequences for the fantasy of the psychotic subject. In neurosis, Fantasy (the relation of the subject to the libido, jouissance, object a) is essentially a defense against the Real of jouissance but also an answer, through the Symbolic, to the question of the difference of the sexes («am I a man?», «am I a woman?» «what should a man do?», «what should a woman do?») and to the question of the Other’s desire («what am I for the other?»). In the unconscious, there is no written answer of «what is a man», «what is a woman». However, an answer needs to be given by the subject himself with a story that will indicate to him how to stand in the world, otherwise he will be faced with the void of no answer to the question of the sexes and what he is towards the other. In psychosis, this fantasy is not formed and the subject’s relationship with jouissance, i.e. the objects and organs of the libido, is disrupted.

3.Lacanian Interpretation of Schizophrenia

Schizophrenia belongs to the Psychotic structure. In addition to the general psychotic features that also apply in the case of Schizophrenia, we would add the following special features:

→ Foreclosure – Generalized signification of the body – The subject without identity: The history of the schizophrenic starts from his very constitution as a subject. This means that the beginnings of the psychotic disorder of schizophrenia are placed at the beginnings of the causation of the subject. The subject, according to Lacan, is constituted through two processes: alienation and separation. In other words, the subject is the result of both the signifier and the pleasure. The process of separation concerns the separation of the subject from the libido, replacing it, through paternal transference and castration (under the status of the phallic signifier as signifier of lack) with the objects a. It is through this process of separation, acting with its lack, that the subject acquires identity. Specifically, the signifier gives us an identity. But the schizophrenic person cannot be represented by the signifier: Foreclosure causes dispersion and dispersal of the primary signifier. The emergence of a cluster of signifiers in dispersion thus leaves the schizophrenic person without an identity. It is the failure of the process of separation that emerges the schizophrenic subject leaving him in a state of split and in complete dysregulation both in the context of the signifier and in the context of libido-jouissance.

→ The schizophrenic person is the subject for whom all the Symbolic is Real: «[…] he is the only subject who does not defend himself against the Real by using the Symbolic, as we all do when we are not schizophrenic. He does not defend himself against the real of language, because for him the symbolic is real» (Miller J-A, 2008).

→ The schizophrenic person is the subject for whom the social Other does not exist: «[…] the subject whose distinguishing characteristic is not to be registered in any discourse, in any social bond» (Miller J-A, 2008).

→ The irony of the schizophrenic person: Irony is a special feature of the schizophrenic person that in essence reveals the absence of the social Other and the fact that every social bond is nothing more than a semblant.

→ Imaginary relationships: The relationship that the schizophrenic person has with the other person is based on the imaginary relationship. This means that he sees his imaginary self in the other. Through this relationship he can find the place where he will support his image. The other becomes the duplicate of his ego, i.e. his mirror. This point is important as it determines what image the schizophrenic has of himself and how this image may collapse the moment this other person changes position.

• Example: «Homicide – Suicide»

Imaginary identification with the other can have painful consequences. Specifically, if there is the accidental moment where a symbolic element intervenes between the two members of the fantasy relationship and the structural gap opens, then the fantasy dissolves, the fantasy identification that had a supporting function for the psychotic person no longer works, resulting in the release of psychosis that accompanied by elementary phenomena (delusions or hallucinations). These elementary phenomena can lead the schizophrenic person to extreme acts, to destructive «passage à l’ acte», such as in cases of homicide and suicide due to a command auditory hallucination: for example: «kill your wife and kill yourself to save yourself…». Here, the voice commands and the person is driven by this command. It is important to distinguish the mental context of a homicide or a suicide, whether it is a consequence of a psychotic situation or not [Note: According to researches about 10% of homicides are due to patients with schizophrenia and about 10% is the percentage of suicides with this disorder].

→The invasion of libido-jouissance and the disturbed relationship with the body:

•  Example: «Verbal Hallucination»

Lacan answering the question: Who speaks in the verbal hallucination? states: «The moment it appears in the real, i.e. accompanied by that feeling of reality which constitutes the basic feature of the elementary phenomena, the subject literally speaks with his ego, and it is as if a third person, the duplicate of the ego, were speaking and commenting his activity» (Lacan J., 1955).

• Example: «Self-mutilation»

The different relationship that the schizophrenic person has with his body is particularly evident in cases of self-mutilation. Major self-mutilation (MSM) is a rare but existent act that some psychotic patients may do during a psychotic episode. This act, according to research, mainly concerns psychotic patients with schizophrenia [Note: According to research about 75% of MSM cases involve a psychotic disorder, of which about 83% involve schizophrenia]. Specifically, major self-mutilation is defined as the destruction of a member or organ of the body or its function, by the individual himself without the intent of suicide. Self-mutilation mainly involves eye, genital or body parts [for example: self-enucleation (eye removal), genital self-mutilation, hand or foot mutilation].

The fact that the act of self-mutilation has not suicidal purpose leads us to think that the schizophrenic person not only does not experience it as a deadly act but instead as a viable solution for his body. Thus, the body part that is removed is experienced by the schizophrenic person as something “unreal”, as something unnecessary, as something foreign that causes confusion, as something that should be removed in order to balance the fantasy image he has of his body. Furthermore, the fact that this act usually occurs during the first psychotic episode leads us to think that the schizophrenic is reliving a mental disorganization, an experience of physical transformation, a change in his self and body image in the genesis of his psychosis. We perceive here that the organs of libido-jouissance, the objects a have been disconnected from the body of the schizophrenic person and that: «the so-called schizophrenic person will have to find a way of coexistence with all his organs beyond any reference to an established discourse» (Miller J-A, 2008). We would say that in this phase the schizophrenic person is as if experiencing the fragmentation of his body, reminding us the beginnings of the infant’s first bodily sensation of the mirror stage.

Therefore, despite the rarity of the phenomenon of self-mutilation, the reference to it helps us to understand the strongly disturbed relationship of the schizophrenic person with his body, which in turn reveals to us the more general subjective way of how each of us experiences his body and how it is disrupted in a mental disorder. But mostly, it makes us realize the seriousness of experiencing the relationship with the body that can lead to an involuntary death.

4.Techniques of Lacanian psychoanalysis for schizophrenia

In general, it is now universally accepted that a combination of medication and psychotherapy is the optimal therapeutic approach to psychosis. Lacanian psychoanalysis in combination with medication can also be such a solution for the psychotic subject.

According to Lacanian theory, the human structure does not change. Thus, the analyst does not aim to convert the psychotic patient into a neurotic one. The analyst works differently with a person suspected of having a psychotic structure or with a diagnosed psychotic patient receiving medication. In other words, the techniques used by the analyst need to be adjusted because there is a risk of causing a psychotic episode.

«The management of the transference and the position of the analyst»:

→ «We don’t ‘play’ with words»:

In particular, we do not ‘play’ with the ambiguity of words. The analyst’s position here is more of a “listener” position to the psychotic person’s thoughts. That is, the analyst does not interpret from the position of the social Other, does not rush to give meaning to the associations of the individual. Otherwise, an interpretation could trigger a psychotic episode, as it brings the subject face to face with the Symbolic. In essence, the relationship between the analyst and the patient is here on the imaginary level and there it needs to remain because if a gap arises in the Symbolic field of the individual, then psychotic phenomena will emerge in the place of this gap. The point is not to raise a question that might confuse the patient but to direct him to speak in his own way. The analyst therefore does not interpret but notes.

Lacan states: «One has to know what one’s saying. It isn’t sufficient to bring signifiers into play in this way – I tap you on the shoulder… You’re really a nice person… You had a bad daddy… Things will work out. One has to use them in full knowledge, make them resonate otherwise, and at least know how to employ certain of them. The negative indications concerning certain contents of interpretation are highlighted by such a point of view»  (Lacan J., 1955).

→«Delusional metaphor»:

Delusional activity can also lead to the construction of a delusional metaphor, with which the psychotic can attach a new meaning to the world. In essence, the delusional metaphor replaces the paternal metaphor to some extent.

→ «We support imaginary identifications»:

There needs to be a recovery of the Imaginary. The Imaginary order can to some extent replace the deficient Symbolic order of the individual. That is, the imaginary identifications, the imitation, so to speak, of other persons can sufficiently stabilize the psychotic patient. Specifically, in place of the deficit enters the self-image. So this means that the analyst should not shake these identifications, should not shake the ideas and beliefs of the patient as these are what support his mental reality.

According to Lacan, these imaginary identifications are the “imaginary crutches” of the subject. Therefore, the analyst becomes a “speaking place” for the subject with the main goal of recovering the Imaginary. The analyst can thus «help the patient to construct an understanding, to build a meaningful universe that will allow the person to live and find a place for himself. The meaning is imaginary […] and this is precisely the level at which the psychotic can successfully engage in therapy» (Fink B., 1997). The analyst therefore works with the imaginary Ego of the psychotic person: «the therapist should build in the psychotic person a sense of self that defines who he is and what his place is in the world» (Fink B., 1997).

In summary, the work of a Lacanian analyst with a psychotic patient concerns the recording of the individual’s experience, through a relationship of trust, with the aim of building his own meaning that will allow him to find his place in the world.

5.Lacanian Psychoanalysis for Schizophrenia… Why?

Sinthome is the purpose of Lacanian Psychoanalysis for Schizophrenia:

Psychosis has always been considered a complex issue both theoretically and practically for the entire field of mental health. The combination of medication and psychotherapy now aims to improve the quality of life of the mentally ill. Lacanian Psychoanalysis has contributed both on a theoretical level – with the study for the causes and interpretations of mental illness – and on a practical level – with its own direction of treatment.

The sinthome is, according to Lacan, the fourth term that can reconnect the disconnected three orders of psychic reality (Imaginary – Symbolic – Real). The analyst aims to construct a sinthome for the psychotic person that will give him a new name, a new identity. For example, writing can be a sinthome as it helps the patient to fix to some extent the meaning that is constantly slipping away by giving him the identity of the “writer”. Thus, the new identity “I am a writer” can provide a viable solution to the subject’s life.

Lacanian Psychoanalysis is primarily concerned with the transference relationship that develops between analyst and analysand. The schizophrenic person therefore, through his relationship with the analyst, will try to find his “own place of speech”.

In psychoanalysis, new thoughts will be developed with the aim of forming a sinthome, i.e. a viable identity and above all a new viable position in the world in an attempt to connect the image of the self and the body and to avoid destructive ” passage à l’ acte “.

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