Psychoanalytic treatments of the psychoses

The title, "Psychoanalytic Treatments of the Psychoses" refers to the title chosen by Dr. Lacan for the rewriting of his seminar on the psychoses in 1958. Three years after his seminar, he transcribed the advances he had made into an article. He chose, as its title, "On a Question Preliminary to Any Possible Treatment of Psychosis". This text, which does not comprise the entire seminar, leaving aside the last trimester, clarifies a certain number of points. It is here that Lacan first proposes a matheme that has been extensively used to clarify his teaching, that of the paternal metaphor, and yet the lessons to be drawn from this article are marked with a certain ambiguity. I consider the difficult position the students of Lacan found themselves in after the publication of this article a sign of this ambiguity. I consider as an expression of their difficult position the fact that, before the publication of the article, the young psychiatrists who followed Lacan's teaching, people such as Leclaire, Oury, or Perrier, had all published articles on the possible treatment of the psychoses. Jean Oury had published regarding the institutional approach to the treatment of the psychoses; Serge Leclaire had produced an article based on the distinction between the imaginary and symbolic registers in Lacan's teaching. Leclaire indicated that in schizophrenia it was necessary to reinforce the deficient imaginary and that in paranoia it was necessary to perform a certain number of operations that would respond to the deficient symbolic. Francois Perrier emphasized the manipulation of the transference in psychosis. All of these articles were published at the same time or in the wake of Lacan's seminar, in the year that followed. Next, after 1958 and the publication of "On a Question Preliminary to Any Possible Treatment of Psychosis", there was a halt on the publication of articles and commentaries, as if the students found themselves hindered by the teaching that was being dispensed to them. The paths of practical application appeared less open than they had before. It must also be said that in 1958 the Lacanians were not alone in their attempts at treatment. When we talk about the "Preliminary Question" we are talking about a text that had the effect of a thunderbolt.

The 1950's were marked by the proliferation of psychoanalytic treatments of psychosis. The Kleinians were at work as early as 1949, publishing on the treatment of psychosis in children as well as in adults. It was the grand era of Bion and Rosenfeld. On the other hand, a number of "maternal", "mothering" therapists were publishing in conjunction with the Swiss school. Madame Sechehaye, a very sympathetic therapist who used to take her patients home with her and explain to them in a very touching way how to nourish the unloved psychotic child, is still remembered. There was Bruno Bettelheim, whose work, less well-known at the time in Europe, was beginning to be known in the United States. Finally, Mrs. Pankow was publishing a number of works as well. A proliferation! Lacan intervened by saying: be careful, preliminary question! He returned, in the middle of this modern expansion, to the memory of President Schreber and to a renewed analysis of the Freudian contribution, and this return was like a warning in the face of this expansion. This was the unchanging use of the "return to Freud" for Lacan: return to Freud before one got too lost reinterpreting him.

This preliminary question must be taken in the sense of the 1953 article "Function and Field of Speech and Language", in which Lacan warned the psychoanalysis of his era (the 1950's) against its own too-great success. Success in the extension of guidelines, in the extension of modes of treatment, in the lifting of all the prohibitions that Freud had set down. In the "Introductory Lectures on Psychoanalysis", the master had taken a certain number of precautions, warning psychoanalysts against the extension of the guidelines of psychoanalysis: not to be too occupied with psychosis, and, concerning the analysis of children, he expressed both positive assessments and warnings against what appeared to him to be the excesses of Kleinianism and other orientations. These warnings bore on the over-focalization or excess of interpretation on the mother or on birth, etc. All of these indications found themselves calmly brushed aside by the very success of the expansion of psychoanalysis. The two major fields of this expansion, psychosis and the treatment of children, brought to light the treasures of the imaginary. The interpretative emphasis was increasingly put on the imaginary, the body, or imaginary unity, working from the successes achieved in psychosis and in the treatment of children. The warning of the "Preliminary Question" signified: before going full speed ahead any farther in a direction that you yourself are unaware of, let's stop for a moment and reread Freud's approach with Schreber. In this sense, the warning shot and halt order of the "Preliminary Question" is coherent with the Lacanian orientation announced as early as 1953 in "Function and Field of Speech and Language". Extending this last text, it adds some new perspectives.

In this text, Lacan produces a close analysis of the language phenomena of the psychotic symptom inasmuch as they are exemplary of the spectral decomposition of the place of the Other. Next he gives an original version of the possibilities of treatment for psychosis. What was the consensus at the time? For the Kleinians, the Annafreudians, or the eclectic therapists, it was agreed that there was no possibility of establishing a paternal-type transference in psychosis. The same type of transference could not be established as in neurosis. The analysts of the time came to the conclusion that it was therefore necessary to play the role of the mother, following the different versions of the mother. The Kleinian mother is not the Annafreudian mother nor that of Sechehaye. She is not the good mother that nourishes, which is something else. Others suggested playing the role of the brother, i.e. making a fatherless society, the horizon of institutional psychotherapy. In such a system of equals, what is at stake is rather a sort of bureaucracy where anything resembling a paternal figure has disappeared. With modifications, with certain differences in emphasis, there was a certain consensus on this point: to make do without the father.

Lacan warned: the problem is nevertheless not to take ourselves for either mothers or brothers in the name of the fact that there is no paternal transfer. It consists in seeing that what is at stake is the subject's relationship with language itself. The "foreclosure of the Name-of-the-Father" denudes the relation with language as such. The horizon of possible treatment thus becomes the establishment of a new signification after the invasion of an unnameable jouissance, of a drive mechanism invading the body of the psychotic outside of the functioning of the erogenous zones. The "no possible interpretation in the name of the father" goes together with the bringing to light of the way in which the psychotic subject's language is inhabited by an effort to name the unnameable jouissance. The "fundamental language", as Schreber expresses himself, exposes a mechanism common to every psychosis: the establishment of a particular usage of language to hem in jouisssance. This is what is addressed in the Freudian clinic as the psychotic subject's reconstruction of the world. This language is addressed by Lacan in 1958, working from Jakobson, from Jakobson's reading of the work of Saussure and of the relation between code and message.

Jakobson complicates the model of the atom of Saussurean signification – signifier/signified – through the advances made in the years 1940-1950 on the code/message relationship. In doing so he extends the Saussurean conception of a "speech linguistics". The Saussurean algorithm of signifier/signified is an algorithm that does not intrinsically lend itself to lodging, to apprehending that which guarantees the unity of the sign. How does this unity stabilize itself? How does it establish itself? This is where Jakobson's contribution is crucial. The greatness of Jakobson's mind must here be appreciated. Heir to the Russian Formalist tradition, he refused a static model of language, a model of production along the lines of 'the code produces the message by simple rules of generation. Jakobson's point of departure was the study of language qua transformed, transformable living language, which would include phenomena such as literature – put otherwise, phenomena of creation, of what was not already there, of what permanently overflows any fixed conception of language. If one admits that the message includes literature, then the message returns in the code, ceaselessly enriches and transforms it.

The literary success par excellence is to introduce an invented word into the language. If Victor Hugo was "the greatest, alas", as Gide said, it is because we quote Victor Hugo in French without even realizing it. He gave his words and turns of phrase to the French language, and he inscribed them in our linguistic heritage. Likewise, if the Précieuse movement was so important for French civilization, it is that we still use a number of the metaphors that originally appeared in the Précieuse circle before passing into the French language. In contemporary literature, it is certainly Aragon who succeeded in introducing the largest number of of his constructions into contemporary usage, be it through his novels, his poems, or the songs based on them. There has been a contamination of modern language by the very expressions of Aragon. The Cereda comes from the poem that features the odor of the "reseda", the "true lying" (mentir vrai) has passed into the language of politics in the form of "straight talking" (parler vrai), etc. Here we see the way in which the message turns back on the code and subverts the very possibility of a code. We have always sought to know how literature was made and to fix the rules in such a way to reduce it to a code among others. The reduction to the simplest possible set of tropes has been a goal of grammarians looking to reduce the rhetorical operations of literary production. We have never gotten there, but we are still trying, and have been since the days of the Greek and Latin grammarians. Jakobson reduces this rhetoric to two, in a spirit that that does not consist of classification but of production. Meaning is produced either through metaphor or through metonymy.

Lacan took up this invention and transformed it immediately. He puts it together with the Freudian terms of displacement and condensation. This ad hoc psychoanalytic usage blurs Jakobson's categorization. For Lacan, the essential was not to faithfully reproduce Jakobson's categories, but to include in the place of the Other not only the reservoir of signifiers but the matrix of new productions. This is done based on the following: metaphor consists in the substitution of a signifier, whereas metonymy is approached as the contamination of the signifier by the drives. As Jacques-Alain Miller has established, Lacan grasped the importance for psychoanalysis of the operation metaphor/metonymy in the middle of his seminar on the psychoses. It was at that moment that he received an offprint from Jakobson regarding this article, and this inflected the seminar. Working from there, Lacan saw how he could establish the matheme of the place of the father as symbolic based on metaphor. In doing so, he specified how, from outside of the system of language, the Name-of-the-Father assures meaning-effects, guarantees the phallic effect, and stabilizes the sexual meaning (sens) that is marked by the small phi of the phallus. If the father is removed as guarantee, as that which assures the stabilization signifier/signified, phallic signification then disappears and the subject is invaded by the unnameable. He has to deal with a God who wants to feminize him; he has to deal with phenomena that invade him and which no longer have a name, ranging from manic excitation to waves of delocalized jouissance all the way to stupor. This is what happens when the Father disappears. What also happens is that codes and messages become mixed up; language begins to be invaded by new usages with "message codes" and "code messages". The voices announce that the word Luder, for example, means something else, a meaning which reveals itself through the experience of a hallucination. In this way, Schreber receives a certain quantity of information regarding the new usages of words, messages regarding the new code. Conversely, he receives message codes, uses, and message-phrases that impose themselves on him, that infect him, that parasitize the standard functions of language. These code/message relationships endlessly introduce new usages. Lacan illustrates this double aspect via the close analysis of Schreber's hallucinations. This had not been done by either Freud or any of the psychoanalysts that followed him other than William Niederland, a Viennese immigrant to the United States who had begun such a study from a certain perspective. Isolated in the United States, he had done some work showing to what extent Schreber's father's mistreatment, the "ideal" treatment at the hands of Schreber's father the educator, could be found in what Schreber named "miracles". He reduced the hallucinations to a sort of epiphany, to a return in the real of the crazy educational measures of the father, a well-known hygienist. Hallucination is for him a sort of post-traumatic syndrome. But outside of this partial approach, Schreber's hallucinations had not been studied as a system and Lacan showed that the apparent hallucinatory chaos ordered itself perfectly around an activity of renewed nomination thanks to those instruments for producing new meaning that are the categories of metonymy and metaphor. At this moment in the treatment of psychosis, it is a question of realizing a possible stabilization of the delusional metaphor without having recourse to the Name-of-the-Father. Since it is a question of phenomena linked to a dislocation of the code from the message, since there is no longer any guarantee on the side of the paternal metaphor, it is necessary to turn to a sort of neo-metaphor, a stabilization of the signifier/signified by an operation, by a phenomenon that would be a "non-standard" Name-of-the-Father, to borrow Jacques-Alain Miller's expression. Schreber's God functions, in his relation to Schreber, like a non-guaranteed Other. It is by assuring himself of the Other's jouissance that something is stabilized.

If I have permitted myself to use as a title “the psychoanalytic treatments”, in the plural, of psychosis, it is because Lacan's teaching displaced the question after his elaboration of this perspective. The Name-of-the-Father, which appeared in all of its Freudian singularity, was first pluralized in order next to find itself lodged in the set of names in language that take charge of the guarantee or the naming of jouissance. Lacan's path passed from the Name-of-the-Father to the Names-of-the-Father to end up at what Jacques-Alain Miller has named Lacan's "second paternal metaphor". The Other, language, takes charge of the wholesale naming of jouissance. The Other is fundamentally barred, fundamentally without guarantee. Jouissance, always in excess, is a place that has no name: the signifier of that which has no name is written S(A).

This perspective opens the way to all sorts of possible treatments for language troubles; the troubles can be treated differently according to the conception that one has of language. The language trouble approached by Saussure and modified by Jakobson has, as its remedy, the stabilization of the delusional metaphor. It is a question of finding or defining through different approaches the remedy brought to the absence of phallic signification, to the non-guarantee by the failed metaphoric effect. How could a practice seeking a new naming of this nameless object be established?

University linguistics departments are all currently fascinated by Chomsky's enterprise, begun in the 1960's. His big project was to describe language by working not from a descriptive, structural grammar system (for every language, a structural grammar that would already have a greater degree of formalization than the grammar used by academics) but by taking language as a universal and trying to describe every possible language through rule-rewriting systems that would be universally applicable. Chomsky thought that language was an organ, having no definition outside of the human species. His language definition enterprise has been a great success that has produced connections with the neurosciences and with all systems that process information by explicit rules. The evolution of the research program has given rise to a number of different conceptions that all claim this orientation. This approach corresponds with the contemporary concern over automatic translation systems for languages that would allow computers to be fed with programs permitting the recognition and transformation of the voice into written systems. It is a striking effort that attempts to reduce all of the equivocacies possible in natural languages and to obtain this same reduction by means distinct from those of artificial language. We can now consider that the program has run into failure. The notion of rule has been so rethought by Chomsky that it is becoming hardly operant. The current "Darwinian" approach of certain linguists like Steven Pinker or Daniel Dennett and echoed by the "functionalist" perspective of other linguists such as Fodor shows the difficulty in holding together the current explosion of different research orientations.

This is what allows a linguist like Jean-Claude Milner to say that he thinks the 20th century will have seen both the birth and the death of a linguistics centered on natural languages and their usage. What appears here no longer has anything to do with the program of linguistics. The accent placed by Saussure and Jakobson on the manner in which the production of equivocacies troubles or jostles code systems is incompatible with these systems of description by rules. What we can call Chomsky's scientific failure has not stopped him from developing theories concerning the politics of language. In the will of hemming in the fundamental absence of any guarantee for the system of rules, Chomsky has supported some very radical positions regarding American politics. Chomsky has deployed a characteristic Chomskyan extremism. He is very sensitive to the idea that as soon as we speak, it is the powerful who speak through us. Since the production of signification is impossible to stabilize, the meaning of words can only be established by power. It is power that fixes the meaning of words. Here he rejoins what was for a long time called the arbitrariness of the sign. Since the phenomenon of guaranteed meaning cannot be lodged within language, where there are nothing but rules that allow a certain number of things to be enunciated, meaning is nothing but an effect obtained by power. This is what leads Chomsky to a very wide interpretation of the First Amendment, the principle in the American constitution guaranteeing the freedom of speech. This is what allows you to make odious, racist remarks like those that can be heard constantly on American radio, for example. You might risk a trial but once you evoke the First Amendment it is the Supreme Court that must adjudicate. It is a very complicated system. Chomsky is for this system: one should be able to say everything because we must be careful that it is not power which establishes signification. For him the stabilization of the components signifier/signified is instituted by a non-standard Name-of-the-Father that would be power or the vigilant community of citizens. This is where Chomsky joins up with a sort of paranoid pragmatism. The conditions of enunciation fix the meaning of what is enounced in a general conversation. It is not possible to fix this meaning from the outside with the help of a dictionary, where only the seeming safeguard of meaning operates. One never knows what one says; one can only know it through a conversation.

This strange pragmatic perspective joins up with other philosophical approaches to linguistics, that of an author like the philosopher of science W.V.O. Quine, for example, who emphasizes what he calls indetermination in translation. This principle of indetermination proposes that for any given phenomenon, there will always be several theories to describe it and thus with which to say it. This goes farther than the opposition that Frege made between Sinn and Bedeutung. Frege's point of departure was the fact that "Venus is the morning star" as well as the evening star. The Bedeutung is the same and different Sinne can be used. Quine generalizes the system to natural languages, where it will always be impossible to designate, to unequivocally reconnect a word and the thing. There will always be distinct ways of speaking that aim at the same point. How then are we to agree on the meaning of one and the same expression? This can only be accomplished through a pragmatics that would emphasize the possibility of distinct usages and allow you to orient yourself to them. No one believes any longer that there are entities or rules that would function “downstream” from structure, outside of their usage, and that, for example, one should not interfere with the gender of words, with the family such as it is. New usages can be made: one can say "Madame la Ministre" [instead of le ministre] without being struck by lightning; PACS [civil union between homosexuals] can exist without there being any major trouble in the Republic. Beyond the realism of structures, no one believes that it is important to watch over the distribution of gender in language or the distribution of families and roles such as they are. We are in an era in which we have the feeling that we can tinker with usages. We are led to consider that the realism of structures, the fact that there exists a real of structures, in no case prevents the establishment of a conversation, of a group practice, of an adjustment of what things mean.

A sort of conversation about jouissance is fundamental in defining the treatments for psychosis. Working from the enigma of jouissance, which is always either lacking or excessive in the sea of proper names, possible treatments have always aimed at helping the subject to name the unnameable thing. It does not mean helping him in his delusional production; it means something else. It means choosing that which, in the delusional work, leads towards a possible naming. This naming is simultaneously an enterprise of constant translation of what happens to the psychotic: the code messages and message codes that traverse him. The analyst is there to uphold that it is possible to develop, to accompany, to foster this experience of translation. This is what Lacan distills into one point: it is a question of helping the subject, via this naming, to "make himself a name" (se faire un nom)¹. Through the endeavor of translation and nomination, the question becomes one of succeeding in having no other being than that of the translation itself. We had a somewhat mechanical first reading of "to make oneself a name". This reading consisted in accompanying the effort of the delusional subject towards an identity based on jouissance (une identite de jouissance) following the model of Schreber, who wanted to make himself "the wife of God", or that of the Douanier Rousseau, who once said to Picasso: "We are the two greatest painters of our time, I in the modern style and you in the pharaonic style!" - an obviously strange declaration that revealed that the Douanier Rousseau saw himself as the "modern painter" of his time! The mechanical usage of this process consists in retaining a neological usage of a name that the subject gives himself and in trying to fix him to it as to a master-signifier. We know that in psychosis, the more the delusion is systematized, the more the subject supports his effort to speak in the name of a mission, an ideal. The more systematized the delusion, the more solid the ideal: there you have the "name of the ideal" (nom d'idéal). "I do all this because I am the savior of the planet, because I am Christ the redeemer, because I must accept the obvious, that my mission lies there". The impassioned idealist is therefore a clinical category that can be more or less extended. To this category must be added the subject's fixation with "making himself a name", a more and more individualized ideal name adapted to our era in which the ideal is less and less collectivizing. A large number of modest ideals have been proposed: being "the best salesman", for example. Here we have a modest, adapted ideal with which one can identify: it's not the universal good, it's the good of the company or the community to which you belong. Being the best neighborhood resident, as well. It is more closely linked to the small communities that form our world. One can go through the list of those ideals that are so many possible ideal identifications.

More fundamentally, it is a question of accompanying the naming endeavor, all the while knowing that there is always a principle of indetermination in translation, that it is always possible to find another way to say something and to continue using another way of speaking. "To make oneself a name" is also to say that there is no other identification than the process of looking for the name that fixes itself "for a certain amount of time". When Lacan says: "Joyce the symptom", it is to say that, as sinthom, he is the person who manages to identify with his effort to produce a new language, in Finnegans Wake. The Joycean operation on language is extremely strange. It no longer has anything to do with the truth of the unconscious. Knowing what Joyce's life and infantile experiences were are of little importance for reading Finnegans Wake. It is not from this angle that we are going to figure things out. As Jacques-Alain Miller has noted, Joycean sublimation is entirely centered, not on truth, but on knowledge (savoir). The only way to read the book is to know all of Joyce's references, and if that provides work for academics, well, that's their area of expertise: one would have to spend one's time reading all of the books that Joyce read – and he read a lot of them.

How did Joyce use all of this to fabricate his own language based on knowledge? Joyce is not identifiable under the rubric of "I am he who...". It is much more a question of an identification with the Joycean process of transforming language. In this regard, the endeavor of the psychoanalytic treatment of psychosis consists in having the subject pursue his endeavor of translation through conversation, an endeavor that is always possible since jouissance is missing from the ocean of proper names. This is the fundamental logical structure behind "being the woman that all men are missing" that we see at work in Schreber. In our field, as soon as you say "all", there is a missing object, jouissance. As soon as you trace the circle that circumscribes the place of the Other, that which exceeds, that which has no name inside the circle itself, can be noted S(A), the siginifier that is on the outside, that is missing from the "all". It is the place of a jouissance that exceeds names: "being the woman that all men are missing" is to be the name of the jouissance that cannot be designated by "all men". This is Lacan's way of logifying Schreber's mission: "to become God's wife". "To make oneself a name" is not only to lodge oneself under an identifiable name in the register of the ideal but, more profoundly, to reconcile oneself to this endeavor of translating language. When the subject can attain that, find a certain peace in this constant translation, we have obtained a possible psychoanalytic treatment of this jouissance. One must not, however, see this in a fairy tale mode: "they began their endeavor of shared translation, had many delusional stabilizations, and lived happily ever after!"

What is bothersome here is that one of the fundamental modes of naming is the passage to the act. The subject's means of situating himself in the flight of meaning, the leak of meaning, is not only through the fleeing, leaky translation, but also through the short-circuit of the passage to the act. One can "make oneself a name" through the passage to the act: "I am he who struck the Other". This is what Aimee, Lacan's doctoral thesis case study, declared. The passage to the act is itself always possible, always present. The endeavor of shared translation must be mindful of the fact that short-circuits are possible. The strategy is thus to enable this endeavor to go on without too many short-circuits.  This depends on the case and on the precautionary, limiting measures that reveal themselves according to the knowledge you have of the subject. You learn little by little that there are some things that are very difficult for him to meet, to translate, to lodge. This is the moment at which he needs the help of a drug treatment, either ambulatory or in hospital. This is part of what is at stake in the endeavor of translation. When there are obstacles that you learn to recognize as being particularly painful for the subject, you can reconstruct what is traumatic for him. When this happens, you help ensure that the new encounter happens in such conditions that he may unsubscribe somewhat from his unconscious but, if I may say so, in such a way that he is made somewhat more aware of the major function of the drugs, which are anesthetic derivatives. When the pain is too strong, you have the right to anesthesia. There was, at a certain time, a grand refusal of anesthesia: "We don't want to be anesthetized, suffering is the being of man!" The trend has somewhat passed, from childbirth all the way to psychosis. Neither must we cede to the zeitgeist, that of general and generalized anesthetics! "We no longer want to suffer at all!" This is the version of contemporary hedonism whose mode is that of "we want to take as many antidepressants as we want!". We must therefore neither cede to the zeitgeist nor be obsessed by some ideal conception of human suffering. Here we have a register of de-idealization of what is at stake, to be pursued by the therapist.

The perspectives opened by Lacan in 1958 were followed, in his teaching, by developments that permit a rethinking of the psychoanalytic treatment of psychosis such as it is today exercised and executed. It is appropriate to resituate it within the perspectives on language and the subject's place in language, working from the pragmatic of the linguistics of our time. Taking Joyce as a place of an alternate reflection was for Lacan the moment of extending and rethinking the conception of literature issued from Jakobson's perspective. With Joyce, he opened up further for us the field of psychoanalytic sublimation in the sense that it can operate in the possible treatments of psychosis.

Translated by Timothy Lachin