Four Preliminary Questions To A Renewal Of The Clinic 

Serge Cottet

From Psychoanalytical Notebooks, Issue 4, Psychiatry and Psychoanalysis, Spring 2000.

I shall first raise a question concerning the relations between psychoanalysis and psychiatry. Then I shall focus on what one can expect from the classical opposition neurosis/psychosis. We shall raise the question of new types of symptoms. Finally, I will speak of passages-to-the-act [passages à l'acte] and of the position of the psychoanalyst in relation to the act in psychosis. A lot of things to pin down since they are questions that one is often led to ask oneself in practice.

1. Relation between psychoanalyst and psychiatrist

First, a point about the relations between psychoanalyst and psychiatrist, or more broadly, the relations between the practice of psychoanalysis and the psychiatric clinic. Basically, there is an historical problem. Has the teaching of Lacan led to a dissolution of psychiatric signs and symptoms, or, on the contrary, does it still make use of it without its concepts ever managing a new distribution of clinical types or to constitute new clinical entities? What point have we reached here? Has a symptom for psychiatry the same nature as a symptom constituted in the analytic discourse? Perhaps, one could go back to the years 1975-76, to the birth of the Clinical Section of Paris that Lacan wanted. I remember at that time anti-psychiatry was the rage - a critique of psychiatry under the post-1968 rush (Laing, Cooper, Mannoni). At that time, de Clérambault was considered as a kind of magister in the chair of forensic of psychiatry. And also the question of locking up patients was raised politically, of universal imprisonment - Foucault's work was much read. It was also the era in which the dissolution of psychiatry ended up in the Basaglia laws in Italy which destroyed the hospital institution. In this context, the Clinical Section threw up problems both institutional and theoretical in its relation to psychiatry. Is psychoanalysis all about giving Lacanian names to entities which already exist, which have been established since the 19th century? For each schizophrenic statement can the Bleulerian say 'weakening of the chain of association, ambivalence, negativism' and can the Lacanian displace it and say 'S1,S2, a, A'? To be clear, the problem is historically resolved. Lacan in his case presentations was extremely classical. He did not hesitate to use Bleulerian categories without speaking of de Clérambault. He gave the impression of looking for the erotomanical symptom of de Clérambault or the flat affect of the schizophrenic. And at the same time in his seminar he carried on about knots, mathemes, etc. whose application to the clinic one did not see immediately. In his practice he gave one the feeling of investing his own doctrinal position in his case presentations. In his manner of questioning patients, his extremely lively side, his use of paradox, of jokes, one saw that he was not questioning the patient as if he were the incarnation of an already constituted psychiatric entity. He had his own approach to the classical trilogy of diagnosis, prognosis, treatment. Lacan unlike classical psychiatry made paradoxical diagnoses. When everyone saw a dangerous madman, Lacan said 'not at all, he is normal'. Of a so-called compensated psychotic, Lacan said: "he's not a psychotic, he is not at all compensated, he is a dangerous obsessional neurotic." Rather a bizarre display for the young psychiatrists who were there. The tendency wasn't at all to favour a diagnosis of neuroses in order to acclimatise the patient to Freudian concepts - to make an hysteric or an obsessional out of him. When the registrar considered the patient an obsessional, Lacan might say 'Not at all, he's a paranoiac', and inversely, when a woman patient considered that her pillow was speaking to her, that she heard voices from her pillow, Lacan considered that she was an hysteric. Eric Laurent had to demonstrate with the help of Schema Z that she could not have been an hysteric for Dr. Lacan finally to agree with him. Nothing at all systematic. Recourse to listening, clearly, to cutting up of language, an interest on the subject's enunciation which was quite striking for everyone, all the more since within the framework of the period one was not in the habit of listening to people for a very long time. The practice of presentation of patients had something shocking about it, out of date for the people of my generation. At this time psychiatric authority was shaken for political reasons and to a certain degree because of Lacan. The ambiance was favourable to a dissolution of psychiatric certainties, but, nevertheless, the clinic resisted it. Today, a fortiori, the psychiatric clinic has scuttled itself - it has even self-dissolved and no longer exists except in the aberrant forms of DSM III or IV actually. It's an enciphered code, a clinic of the continuum, of the syndrome from which are swept such entities as chronic delusion or paranoia. At the same time hysteria is considered as insulting, prejudicial to the dignity of the woman. These references are all the more necessary in this context there where one reads with nostalgia Seglas, the classical studies of Henri Ey on schizophrenia and, of course, de Clérambault - never forgotten. Psychiatry having today fallen under American influence and abandoned signs based on a discourse, knowingly or not, founded on a certain usage of the signifier, the psychoanalytical clinic is paradoxically the sole defender of such observations as de Clérambault's ideoverbal hallucinations, etc. Defending the interest there is in distinguishing, according to the French tradition, on the one hand, the chronic delusional states and, on the other, schizophrenia, and introducing between them Kraepelin's paraphrenias as so many entities which, as Freud demonstrated, are justified in the real - they are not arbitrary constructions - by a certain regime of the libido, by certain vicissitudes of the sexual drive and by the radical opposition of repression and foreclosure. Psychoanalysis has a new adversary, a new SAMCDA, as Lacan said of psychoanalytical societies under American influence, or Mutual Aid Societies Against the Analytic Discourse, a society animated by the dissolution of classical psychiatry, not against pharmacology but against the psychiatric clinic of signs where the names of Kraepelin, Bleuler, Jaspers, de Clérambault can be found. The psychoanalytical clinic is a clinic of the symptom and does not confuse symptom and syndrome; it's a clinic of delusion, of its process, and beyond, of its function, of its cause, of its structure, indeed of its sense. A clinic hostile to theses of deficit, of degeneration dear to the 19th century, rehabilitated again today. Psychosis is not a deficit state, up for discussion again concerning autism, the most disintegrated forms of schizophrenia, catatonia, or what the clinic describes with a German term as Verblödung, 'intellectual deterioration'. These entities were established on the basis of a preoccupation with the final state: is there a deterioration, does it end up in a dementia? Does the subject preserve an unchanged conviction, without alteration of intellectual functions? And how does the psychiatrist intervene in this: prognosis, treatment? This question is operative amongst us displaced to the level of psychoanalytic practice. Can one break up a delusion, should it be suppressed, used for other purposes, stopped, or, on the contrary, transformed into a symptom? So, against quantitative and syndromic scales one opposes preoccupations with the sense of the symptom and, as you know, one confirms positions which are characterised by a hostility to the theses concerning biological causality in considering at a minimum psychical causality that Lacan reclaimed in the 1950's. One must say that there is a hiatus between psychiatry and psychoanalysis, psychiatry stumbling over questions relative to causality. The latter has in preference occupied itself with forms, categories, genuses, species. One sees in Henri Ey preoccupations with taxonomy, classifications: is schizophrenia paranoid or not? Is it a pleonasm, what is the role of the paranoid sign in schizophrenia and what is not? Far reaching questions constituting a zoology, a garden of species, considerably blown up with research on intermediary forms; these very numerous studies date from the 1930s to the 1950s. One sees how they elicit the question of borderline and intermediary forms between neurosis and psychosis. Blown up in the direction of taxonomies, an obsession with classification is to the detriment of a clinic of the subject, of a clinic of the particular, on top of which there are a number of monographs of which we ourselves have no more use. Indeed, psychiatry has stumbled over the opposition: environmental causality (familial or social) or biological causality in despair of finding an unconscious causality for the delusional phenomenon and for the stumbling stone that the act constitutes - the act without motive, the crime without motive to which Henri Ey alludes. In the 1980's psychiatrists who were truly interested in the question of motives, in causality, remained silent before a certain number of crimes which were not premeditated or which appeared without motive. This hiatus, this gap between psychological motive and the act led them to think that there was no psychological causality at all. So, if it's not psychological, one opts for a biological causality: since the family, the brothers, the sisters, are all good people, if one of them upsets everything, why? since one cannot explain it by the family context? Psychoanalysis is under an obligation to make precise what it exactly means by psychical causality, to pass beyond psychological motivation, unconscious motivation in order to make precise the use we make of signifying causality. I was speaking of the blown up tendency that one also finds in DSM III: to create an entity for every hurt, symptom, one is multiplying the garden of species; psychoanalysis has finally been content - in the wake of Freud, and Lacan added nothing to it which is very satisfying - with the distinction between schizophrenia and paranoia in respect of the function of the subject's relation to the Other. Lacan allowed us to tighten up in psychoanalytical terms this opposition based on the concept of jouissance: cutting up into pieces of jouissance and of the signifier, body-in-pieces in schizophrenia, jouissance of the Other in paranoia. There remains the problem of melancholia, extremely controversial today, since this entity is a neighbour of depression and nourishes all the fantasies of contiguity, of depressive syndromes up to melancholia. Of course, it's not for the pleasure of introducing large or small differences with psychiatric taxonomies or for the taste for polemics, that there is room to refine the psychoanalytical clinic, but there are practical questions which are raised, and it is absolutely necessary to know of what use an analysis is for a subject who presents symptoms of this type. It is worthwhile knowing what one is doing. And to know better what one is doing, it is worthwhile knowing what the risks are when one does nothing. There are questions here concerning the development of a delusion, what its structure is, etc. One cannot oppose a psychoanalytical clinic to a psychiatric clinic; what is to be opposed is an act, a practice, an ethics, the responsibility of the practitioner, the limits of his responsibility, etc.

2. The neurosis-psychosis relations

I will take a little detour by way of the history of psychoanalysis. It's a fact that Freud began with neurosis. In any case, on advancing into the domain of the clinic of psychosis, he allowed himself to be guided by the concepts discovered in neurosis: conflict, intrapsychic conflict, the relations of ego and drive, the vicissitudes of this conflict. Even the concept of Verwerfung is thought on the basis of a stumbling point in repression. Freud treated psychosis within the framework of neurosis and of the Oedipus. President Schreber of 1911, is perfectly well derived from this framework, and there is, perhaps, a good reason to explain, if not a blind spot of analysts in relation to psychosis - because, as I have been saying to you, there is a question of training in the matter - there is even a natural enough tendency amongst analysts to move a clinical case towards neurosis: towards hysteria, obsessional neurosis or phobia - if one wishes to make the latter a neurosis. And I have often noted - I cannot consider it a reticence but rather an habitus - a natural enough inclination amongst psychoanalysts which is basically the inclination towards understanding, going not without reason to the very end of the possibilities of understanding like in Jaspers. As long as the case is within the limits of understanding, it favours rather neurosis. And then, suddenly, there is a hiatus, there is no longer any psychical motivation, one no longer understands. It is like Guiraud with his motiveless crime, the structure resists any Oedipal motivation, one is not within the framework of an infantile neurosis or of a repression or of a displacement. It is always in the last instance, in despair of the cause, of a causality in the order of understanding, that one opts for a psychosis. As much as one might have a dogmatic attitude towards Lacanian diagnostic criteria in opposition to those that one believes to belong to the psychiatric clinic: as long as there are no disorders of language, one will not opt for psychosis. From the perspective of Seminar III in the 1960's, one was content with this criterion, although one was hesitant nevertheless about a certain number of facts classically shown to belong to psychosis or states of mood which are not necessarily accompanied by hallucinations, neologisms nor disorders of language and still indisputably psychoses. In his Preliminary Question of 1957, Lacan remarked on this history of psychoanalysis which had difficulties in disentangling itself from the framework of neurosis in order to think about psychotic structure. Lacan remarked that Freud contradicted himself in his President Schreber of 1911, concerning for instance the question of homosexuality, and was reproached by the post-Freudians, notably the Kleinians. The well known syntagma - defence against homosexuality - is not very coherent. To make paranoia a defence against homosexuality lacks precision to say the least, for there are psychotics who are declared homosexuals, and there are declared homosexuals who are not psychotic. With their good clinical sense, the English, particularly Rosenfeld, were constantly denouncing this dogma with no relation to empirical reality. But Lacan reproached Freud for contradicting himself on what concerned, you know, the course and outcome of President Schreber in the direction of transsexualism and of the Push-to-the-Woman. Firstly, why call it homosexuality? What relation does it have with, on the one hand, perversion, and, with homosexuality, on the other? But, contrary to the English who say 'it conforms to empirical reality', Lacan explains it according to a genesis of Freudian concepts. In 1911 one is not in 1914! In 1911 Freud had not yet discovered the structure of narcissism. And, when he discovers the structure of narcissism in 1914, he has not yet discovered the death drive. Whilst for us, let's put ourselves in the situation of 1955, when Lacan is rereading President Schreber with the tool of the death drive, of the cadeverisation of the subject given over to its singular narcissistic jouissance, he is able to bring together two concepts in psychosis, that is, the stagnation of Ichlibido, the withdrawal, as one says today, of jouissance into the body with all the effects of mortification linked to the death drive. So, one has no need for aggressivity, for projective identification that the Kleinians are going to add to all of that, because they do not see the logic of the concepts put into place by Freud, which are firstly neurotic concepts applied to psychotic concepts, then to discover another libido, the Ichlibido: what is a libido that does not have a sexual objective, which takes one's own body as object? As for the death drive which is not aggressivity but self-destruction, or finally the self-destructive jouissance of the subject imprisoned by his own image, here one has something to account for the celebrated passage of Schreber's sacred time from the leprous cadaver. One has here a very precise use of concepts in order to think about an enigmatic clinical moment in the tale of President Schreber, and these two articulations, narcissism and death drive, will be brought together by Lacan in what he calls his 'broom' of the mirror stage. One has to think the mirror stage as the function of the death drive and even of what is the subject's master-signifier. (Cf. this topic to Jacques-Alain Miller's analysis on The Mirror Stage, Lettre mensuelle de ECF, No 50, 1986) Armed with well understood concepts, one can clean up an entire clinical field, clarify it, considering that Freud did not have all the keys in the same pocket at the same time, that art is difficult. And we can say the same thing today about Lacan who had not said his last word in 1955. Has anyone spoken better than Freud about psychosis? In the 1950s Lacan read the post-Freudians, the Kleinians, especially the Americans of the era. At that time, there was much produced on President Schreber. A translated anthology of these articles exists called The Schreber Case (PUF). You have about fifteen articles one after the next in the period 1949-60, two categories of article: those about the onset of psychosis with the thesis that he had not assumed the paternal position and those that deny it because when one goes into it in detail, one sees that he did assume the paternal position. After a first episode, he would not have been named president of the senate or of the court of Dresden if he had not been in a position to assume a certain number of laws, and if he progressed in the hierarchy, he had assumed something. The psychological explanation - no assumption of the paternal function - is relevant to neurosis. One brings into it, one translates, the phenomena of foreclosure in the framework of neurotic phenomena. For instance, Katan - who comes in for a severe criticism by Lacan because he did not put the homosexual drive into question - does not question the thesis of defence against the homosexual drive, although he was in a position to take into account On Narcissism: An Introduction. So, this is the way Lacan thinks the theory of the clinic! One has to make the effort to begin at the end in order to read the beginning. It's not like the poetry of Mallarmé where there is some meaning which is self content, containing itself in the enunciation. It's not like that in psychoanalysis. In order to understand a dream one has to wait a few sessions for it to clarify; in order to understand the Freudian concept of homosexuality, one has to wait for several things: transformation into a woman - which is transsexualism - must not be confused with paedophilia, which have nothing to do with each other. These are very simple notions. Freud considered it but not in the same moment. So for this reason Lacan is hard on Katan who is a Freudian of the International, of the IPA. But he reads Freud by the letter, not knowing how to interpret it. There is fundamentally quite a homogeneity between knowing how to interpret a psychoanalytical text and interpreting a discourse. Lacan considers that what he says must be referred to Freud himself, the Freud of interpretation of dreams or of interpretation of the symptom, that is, be attentive to the signifiers, to the punctuation, to the denials, to the contradictions. Curiously, Lacan takes up the position of dissident with respect to the psychoanalytical mainstream. Lacan always loved dissidents, being one himself. Those who do not join the chorus in the group or who introduce a hiccough in the concert. There was an Ida Macalpine, and it's true that certain ladies in the Anglo-Saxon school could be breezy and cheeky, go further than Rosenfeld. For her Freud did not understand anything about psychosis, there is no homosexuality in the affair, there is a feminine fantasy, and the first signs of transformation are signs of hypochondriasis. Freud neglected hypochondriasis. One does not know how one gets from hypochondriasis to the delusion of pregnancy but, basically, these are premonitory, preliminary signs of transformation into a woman. And instead of boring us with the inverse Oedipus, it's not at all an inverse complex, not at all the Oedipus! It's a feminine identification, there is no man! - everything is reinterpreted in this way: the sun... It's also a little Jungian at the same time, serving archetypes, seeking in ethnology encoded meanings like the femininity of the sun. She rejects the equation sun = father. Not at all! To a certain extent Lacan agrees with her. Not entirely, because, evidently, for the English psychoanalysts what is not Oedipal is pre-Oedipal. She might have taken one step further and completely shaken up the ant-hill by associating herself with concepts outside the Oedipus, post-Oedipal. But one cannot do everything in one day. She thought that one had to squeeze President Schreber like a lemon to get him to fit within the Oedipal framework, but she thought he was more suitable for a pre-Oedipal framework. Nevertheless, one sees that Lacan is forcibly trying to defend the Oedipal schema by displacing it in order to introduce another treble, the treble, real, symbolic, imaginary. But it is still in a Freudian spirit since the pre-eminence of the symbolic is asserted. One has to distinguish 'After Freud' and then 'With Freud'. After Freud one betrayed Freud, or one bastardised Freud. And then with the chapter With Freud, it is, evidently, nevertheless Freud who is correct. One has to rethink the schema with other concepts than those of Freud. One cannot remain at the level of the Oedipal complex. In this somewhat anti-Oedipal operation, Lacan is making for a respectful meeting with Freud because there is a political combat to be led. Therefore, in the Freudian analysis of 1955, Lacan nevertheless retains the concepts of Freud even though he criticises them. In any case, one cannot consider that the rupture with the concepts used in neurosis is radical. From 1975, the year in which the Clinical Section opened, will be the years in which Lacan is going to work with his own concepts, and not those of Freud, in order to articulate - I was going to say decipher the discourse of President Schreber, it's not quite that - in order to give to those who want to do this work the occasion to do it and the green light to do it. To explain myself: in 1975 the question was raised in the Clinical Section of Paris about taking a little distance from Freudian concepts. Twenty years later Lacan is not the same as in 1955. He brought new concepts, passed to topology, discovered the object (a) as object separated from the signifier. If Lacan rewrote his article on President Schreber, how would he do it? Lacan did not do it but gave the green light to the teachers of the Clinical Section to do it. And, indeed, in 1977, twenty years ago, under the impetus of Jacques-Alain Miller, the teachers of the Clinical Section reread line by line the Memoires of President Schreber, with the new keys given by Lacan, on his invitation, since Jacques-Alain Miller asked him the question (Cf. Ornicar?, No 9, p.12): "What can one do with your four discourses, with your four little letters, S1, S2, a, $? For neurosis it works very well, but do you really think that one can apply it to deciphering psychosis?" One has to verify the solidity of these concepts by using them in the domain of psychosis. You have the traces of this work in No 17 of Lettres de l'Ecole freudienne, defunct today. There are elements which are familiar to us, namely the dismantling of Schema I in function of this new strategy: to rethink the position of President Schreber in relation to his Other, in relation to God, in function of the category of jouissance, for instance. In Lacan's article the category of jouissance is practically an imaginary one which is basically the result of Schreber's own confusion of God's jouissance with his own. On the contrary, and this is already present in a note of 1966 Lacan suggest that his new topology can produce effects of a rereading of the Memoires - I remember that this was put to work by Jacque-Alain Miller based on Schreber's position as object of God's fantasy. This does not come back to inquiring, as one has a tendency to do sometimes, what Schreber's fantasy is. What is the object (a) of Schreber? What are the drives of President Schreber? What becomes of the drives in psychosis? Once again, one raises these questions within the framework of neurosis. But, on the other hand, of one arms oneself with these new titbits, one sees that Schreber has rather the position of the object (a) in the universe and that one has to put God on the side of $ - the fading of God in place of the fading of the subject. And in the moment when you formulate the fantasy to put God on the side of the divided subject, you see how President Schreber feeds the jouissance of the Other, how he is its prey. He no longer has the status of this narcissistic swelling which is at work in Lacan's article in which at certain moments Schreber swells up narcissistically but, on the contrary, there are passages in the Memoires which are not explainable by this imaginary structure, notably the point which has nothing exceptional about it, nothing antinomic between the cadence of the voices and the fact that the rays acquire more and more taste for his body. Hence an antinomic structure between jouissance and signifier which is very marked there. Citing p.249 of the Memoires: "the more soul-voluptuousness is aroused in me…", the more the libido of the Other is aroused, "the more one is constrained to draw out at length the voices". Hence, a concentration of jouissance of the Other in opposition to the meaning of the voices - voices which are noise, a pure signifier without meaning. He does not even hear insults any longer. There is there a very clear divergent regime - one has divergent and convergent words in the article. One can take up again Lacan's Schema I, and rethink it in the light of this distortion between jouissance and signifier. Exemplified by the text one has the chance to verify the solidity of the opposition or of the tension which risks becoming otherwise a rigid syntagma: jouissance opposed to signifier. There are other examples that I have not got the time to relate to you. You see the method: in the same way that Lacan reread the Freud of 1911 with the Freud of 1924, it's possible to reread Lacan's major article on President Schreber, 1955, with the new mathemes. In that moment one sees where the displacement is: one is no longer within the framework of neurosis, one has the same schema that one can use with simple letters, but not concepts, letters which are distributed in another way - that's structuralism, the letters occupy other places. For instance, the object (a) is not the imaginary object, exponent of the subject's desire like in neurosis, it's the subject itself who is identified with such an object! That's a structural position, and I think that we have there a precious methodology on which diagnosis can be oriented.

3. Are there new symptoms?

I just criticised the tendency that there is to establish a new psychopathology, a new garden of species, based on a single symptom, for example, alcoholism. Then, one shall say, based on this, is there a psychoanalysis of the alcoholic or of the drug addict? Should one take a perverse subject into analysis? Based on a perversion, can one say that the subject is perverse, etc. These questions are not the appropriate ones because psychoanalysis - in fact, Lacan - changed its definition of the symptom as a function of that radicality that I have been evoking, and which consists in not being prisoner of Freudian definitions of the symptom as conflict. One often lives on the certainty that the symptom is the sign of a conflict, that it has to be deciphered because it is a message. It's not entirely false, the symptom means something, it has a meaning. Lacan does not reject the category of meaning in order to speak about the symptom, it's even a definition from 1975. The category of meaning is not to be spat upon, to be pulled to the side of the function. It is besides the analysis which sets the example: the analysis delivers to the analysand the sense of his or her symptom, if it does not do it, it is, perhaps, that he or she has not finished - that's not a reason to communicate it to him or her. Nevertheless, you see that by extracting the meaning of the symptom from the side of its function - which is what it serves - one is already leaving the framework of expression or of the sign of a conflict! In other words, the 'message' dimension, the unconscious meaning of the symptom was finally buried by the real function of the symptom, by the new social bond that a symptom can introduce. The first article in La Lettre mensuelle de ECF, No 157, entitled Nouveaux symptômes pour la psychoanalyse, takes up this thread which describes the symptom more like a solution than a problem or an enigma, admitting that we take up the symptom more as a construction in the real, not limiting it to the symbolic. Why can one do that? The whole question of psychosis is there. I am presenting the matter in an absolutely reversed way. Can one not take advantage of the Lacanian description of the symptom in psychosis - let's say of the last version of the Lacanian symptom, the real of Joyce as it appears in Joyce le sinthome? Can one extract an emphasis from it to think the neurotic symptom? You see that one is in an inverse situation from the preceding one. Now, it's psychosis that can give us a glimpse of neurosis, whilst Freudianism pressed for the opposite attitude for an entire era. Basically, at Vincennes in 1968 Lacan already provided some curious formulae, "everyone is deluded!" Jacques-Alain Miller gave a paper in Buenos Aires, which is published, on generalised foreclosure, that one can extract from schizophrenic irony, which also translates this foreclosure by the imposture of the Name-of-the-Father. And, straight away, one can completely change the view on neurosis and question it. There is a positive aspect to the symptom which is in any case irreducible to a symbolic conflict. It has to be precisely demonstrated since there are opposite formulas in the Ecrits to what I am putting forward: the double meaning of symptoms, overdetermination. One cannot say that it's wrong. The old definitions have to be integrated with the new and one has to see in which case a symptom as message can also be a prosthetic device [suppléance]. In the end one has to be guided as to what use a delusion can be put to. In what way can a delusion succeed in certain cases in pacifying the patient, and up to what point has a neurotic symptom also the function of filling in a hole, of resolving the enigma of femininity, of the sexual relation? Just some suggestions raised by this reversal: to take the point of view of rejection of the unconscious, not to imagine that everything the neurotic does or says has an unconscious meaning. One might even consider the end of analysis as giving up one's subscription to the unconscious, a formula Lacan used for Joyce. Of course, clearly it could be dangerous to present things like this because, evidently, it could feed the thesis or give those who think that a continuity exists between neurosis-psychosis something to chew on, and that the end of an analysis would consist in passing through a psychotic moment. Even in Lacan's School the pass was sometimes given such a doctrine: one has to pass through a psychotic moment. Without providing an example psychosis reveals manifestations of a rejection of the unconscious. Well, Lacan has given formulas rather critical of analytical interpretations which make the unconscious proliferate. The unconscious is produced by the analytic procedure and is under the responsibility of the analyst. And it is not necessarily a 'thing' in the subject ("I have my unconscious, I am going to express it, cross it or make symptoms out of it…"). The unconscious under transference, the unconscious under the analytic procedure, is also under the responsibility of analytic interpretation. That's the reversal made by Radiophonie which is made more precise in Television where Lacan says: Does the unconscious depend on someone listening to it, did it exist before psychoanalysis? That's not certain: yes, it existed beforehand, there were unconscious manifestations but not as the Freudian unconscious. It didn't exist as transference-love, which gives it a creationist aspect creating unconscious structure by the very fact of transference and of analysis, and doesn't the psychoanalyst have to rely heavily on it or not? Or do not the breaks favour a separation from that fascination that the neurotic has for the unconscious…? It is not absolutely obligatory to love one's unconscious like oneself! Some people do without it very well. There is then a reversal of perspective which allows a rethinking of the hysterical symptom, the clinic of hysteria without the classical symptom of hysteria. The Americans don't see that anymore. There is no opisthotonus, exaggerated hysterical mutism, for there are no more grand attacks according to Charcot. Whereupon they consider that it is a misogynistic concept; basically, Lacan got us used to thinking about hysteria as a discourse and not as a drama. Such in any case are new ways of thinking about the clinic. There are hysterics without hysterical symptoms that we have to keep in mind. But even Freud said that there were obsessionals without guilt, and perhaps a tendency is reinforced from the sheer fact of social discourse which favours perversion more than before. Can one say that homosexuality is still a perversion? It is not well thought of in the media or on the West coast of the USA! Do psychoanalysts consider that homosexuality is a perversion? That's up for discussion, and one can take neurotic subjects as perverse whilst really neurotic, and likewise there are perverse subjects who are psychotic which is immediately obvious. Finally, the question is always raised in our field about intermediate structures (Lacan was always clear on this, no borderline, no intermediate entities between neurosis and psychosis) or at least about legal cases which could become paradigms. And what about the unclassable, taking on difficult cases, working essentially with the unclassable? On this subject there will be the conference of next July in the Clinical Section about 'rare cases' or difficult cases. Shouldn't a clinic of the subject, of the particular, give the prerogative to rare cases? As in mathematics the exception provides the concept; the exceptional, singular case can become paradigmatic. President Schreber is very particular which does not stop it from becoming paradigmatic. Anyhow, one cannot say that all psychotics are Schreberian. On the contrary, what is interesting is to see just to what point a psychotic measures up to the Lacanian paradigm, just to what point a psychotic is Lacanian. Lacan used to say to us: "That's a Lacanian psychosis!" That's why one is obliged to rehabilitate autism or to work with it; as with schizophrenics there are subjects who are not at all Schreberian. Basically, they're not capable of transforming anything, and above all not their body! And even less to transform themselves into a woman! You are not going to force psychotics to be Schreberian, you'll not manage it, not even by interpretation, and one has to count on the inertia of the symptom and on the individual modes of jouissance. Not all forms of jouissance are transsexual even if it's always the paradigm thanks to which one grasps the function of the Other, of the jouissance of the Other, etc. Why force a search of what cannot be found in such and such a patient? Why break one's head on how to transform a case of literature, of theatre, into a clinical case, for instance, was Medea psychotic or hysteric? This is not interesting. One should not force her to enter this zoological garden but take her as she is - she is neither hysterical nor psychotic but a true woman, as one says today, which is the diagnosis! Why? Because she demonstrates that a woman might not want to be a mother. She illustrates the gap that exists between the signifier woman and the signifier mother. It's a paradigm in the conceptual sense, but it is not a model to imitate! It's better to ask oneself to what point a woman blocked in her maternity is a Medea or not. It's a good, clinical question: to see if a feminine subject has such a vocation, to let her child drop, or to refuse neurotically or psychotically the Freudian equation: woman = mother. Likewise, why would you want every obsessional neurotic absolutely identified with the Rat Man? There are very gentle obsessional neurotics who are not at all obsessed with Turkish torture, who have a sleep ritual, etc. They would be absolutely horrified reading the Rat Man. It is not worthwhile forcing them into such a clinic. There are hysterics who are not Dora, hysterics who make love, who are mothers of families, and their father is absolutely not impotent. One has to see exactly in what a case is paradigmatic. It's about practising a clinic of the symptom in so far as it is quite particular, seeing how it has been made rather than crushing it, hiding it, not by a diagnosis; we must hold on to diagnoses, well-founded ones: a true woman, that's a diagnosis, no question of refusing such labels, but they have to be adjusted to what Lacan calls the formal envelope of the symptom instead of crushing it with a frozen syntagma.

4. Anticipating the act?

I shall perhaps have no time to speak about the fourth point. I was inspired by anticipation about a conference to be held tomorrow on the theme of passage to the act1 in psychosis and the means of anticipating it. How can psychoanalysis become an alternative to such acts in psychosis in the two most well-known registers of suicide and murder - suicide by self-mutilation and murderous violence. I will account for this from my reading of some classical papers on the question, notably, from the English, who do not back down from psychosis, not for a long time, because they don't make any difference in their structure between neurosis and psychosis. But, then, psychosis under transference ends up in impulsive acting out [passage à l'acte], and one might ask if they are accelerated by the transference or even produced by interpretation of transference. Hence our first observation: the question is not quite on the mark. One has to reply to it theoretically. One can reply to it with concepts, certainly, but there are in the history of psychoanalysis empirical traces of what analysis induces, produces, and what it doesn't. One of the references is Rosenfeld who considers that transference activates acting out. He doesn't make any difference between acting out and passage to the act. By acting out he understands a certain number of dangerous forms of behaviour for the subject that have not been interpreted by him, which are directly linked to the treatment, to the transference. One of his patients made the rounds of the most sordid pubs in London, got herself raped, run over one night, with the explanation that she was looking for a husband. Translation of Rosenfeld: in fact her ideal husband is me! But as she is psychotic, Rosenfeld's explanation is that love in psychosis leads to a confusional state, to paranoid anxieties, to a maximum of anxiety. The passage to the act consists in defending oneself against primary anxieties of fusion, fragmenting to the Other. It's true in one sense, one sees a whole lot of lovers who are so many souls examined à la Schreber, bodies examined in a series, according to an infinite process. This infinite fragmentation is made in order to avoid the encounter with Mr Rosenfeld's jouissance who considers that he has entered - although he doesn't say the word - an erotomaniacal relation. The person defends herself from erotomania by multiplying her relations with men whom she whips through chaotically. What he doesn't see exactly is that a transference-interpretation nevertheless stirred up the anxiety. It stirred it up by interpreting the transference with his concepts of splitting. The subject cannot be split in that moment she enters a fusional relation with the jouissance of the Other. In other words, his thesis is exactly contrary to that of Lacan for whom the subject is provided with an unconscious. Rosenfeld interprets the transference as being outside the unconscious - for Lacan it's the putting into play of the unconscious - whereupon the fact of multiplying the encounters and of taking the blows is a sort of wild putting into play of the unconscious and all of that is interpreted. There are other examples constructed like that on the concept of defence - the subject defends itself from the transference - and not at all from the key concept of jouissance. The analyst does not see his responsibility in these passages to the act - rather then acting out - in other words it doesn't call for interpretation. Anxiety leads the subject directly to seek the most abject jouissance, the most corrupted, in order to remake her body. I was looking forward to speaking of a second clinical vignette borrowed from de Clérambault. He studied with a fine brush altruistic homicide amongst melancholics, what he called a folie a double form: a very mixed, polymorphous case with ideas of persecution. The subject is persecuted by a neighbour, hears voices, wants to kill her husband, and at the same time she wants to commit suicide, saying that she is neurasthenic. She is called to a mission in the beyond. And especially - here de Clérambault makes his diagnosis of melancholia - she considers that she is an admirable mother and is therefore very anxious about her children and asks herself what will become of them after her suicide: they have to be killed out of love. Altruistic homicide, finely drawn by de Clérambault, who indexed on it formulas of the type: "what is pathological is the delusion, the voices, the melancholia, but what is normal is the murder", "as soon as a delusional suffers from altruistic anxiety, one is correct to consider altruistic homicide. It's a law that has already been demonstrated that fear of death generates a suicidal impulse", a law, you already know de Clérambault's taste for axioms: "The first known law would make it a serious error for a psychiatrist not to section a patient suffering from thanatophobia. . .", the second law is "whoever is anxious about others can kill and logically must kill". This is a type of saying based on a certain normalisation of psychosis. As Lacan emphasised on numerous occasions, logical processes are psychotic, and the danger of altruistic anxiety for whomsoever is its object is proportional to the degree of affection from which it proceeds. I appreciate these clinical notions which go against good sense, against prejudices, for instance: "It seems moreover that the child exercises a therapeutic role for the mother because it keeps her busy. In fact, it's the opposite: the child is under a greater threat than others, and its presence can only increase her anxiety. There is a prejudice about which this truth is a paradoxical reigning amongst families, non-specialist doctors and the police." For us who are not police, the indication to be followed: do not back off from psychosis but with all the means of a psychiatric team.

Translated by Richard Klein

1. The signifier passage à l'acte can be translated, but the closest one can come to the signified is in the rather loose concept of 'impulsive acting out'. However, in Seminar X Lacan made a structural distinction between passage to the act and acting out [Transl. Note].

This text was originally published in Filum No 11, 1997.

Copyright © Serge Cottet 2003. This text from the website of the London Society of the NLS, at http://www.londonsociety-nls.org.uk. Permission to use material from this site must be sought from the LS-NLS. All rights reserved. Please include this portion of the text in any printed version of this paper.

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