Mental 12 - Psychosis

Mental
ONLINE
INTERNATIONAL JOURNAL OF MENTAL HEALTH AND APPLIED PSYCHOANALYSIS
12
MAY 2003
The Future of Psychosis in Civilization

Contents
Editorial Marie-Hélène Brousse 3
Jacques-Alain Miller Milanese Intuitions [2] 5
Orientation
Pierre-Gilles Guéguen Symptomatic Homeostasis in Psychosis 17

Richard Klein Delusional Misidentification Syndromes 23
Marie-Hélène Doguet-Dziomba The French “Mental Health Plan” 31
Betting on Inventiveness in the Treatment of Psychosis
Jean-Louis Aucremanne,
Jean-Marc Josson, Nadine Page Thinking About Addiction with Reference to Psychosis 39
Roger Litten A Psychotic Invention: “Puffy Anorexia” 46
Carmelo Licitra Rosa Psychoanalysis and Psychosis: A Happy Couple 52
Ernesto Piechotka Interpretation or Invention 58
Vicente Palomera Orlando and Doctor Z’s Technique 62
Clinical Practice and its Concepts
Graciela Brodsky The Alchemy of Hysteria 71
The Subject Inside the Patient
Philippe Fouchet Epilepsy 79

Catherine Lacaze-Paule Pain and Dolor 92
Béatrice Serre A Case of Alopecia 101
Guy Briole Freedom of Information and Psychoanalysis 108
Marie-Hélène Brousse
Editorial
As you may have seen, the French edition of Mental has a new look. More elegant than before, it is now the
journal of applied psychoanalysis of the NLS, the New Lacanian School of the European School of
Psychoanalysis. These last two issues have been moving towards a reflection on new forms of social structure
within which applied psychoanalysis needs to find its place. The modifications of the discourse of the master,
the total hegemony of the capitalist discourse, makes of each subject no longer just a citizen but also a consumer
therefore creating a fundamental place for “gadgets” (as Lacan said) – that is, rubbish – with, in consequence, a
multiplication and triumph of modes of jouissance. This has visible consequences on politics as well as on daily
clinical practice.
It is precisely the empowerment of the object in its contingency, not linked to any expertise transmitted by
tradition, and with a very short life span, that motivates the theme of this issue. In one of his conferences Lacan
said that the psychotic has the object a in his pocket. In other words, his relation to the object does not pass
through fantasy, that organizer of a mix between the symbolic and the imaginary, which is the reality of the
neurotic subject. Does the modification of the category of object operated by the globalized capitalist discourse,
and the consequences on jouissance, push towards a subjective mode of organization for which psychosis would
be the laboratory? This is what is meant by the formula: the future of psychosis in civilization.
In this issue you will find several articles that illustrate the way the psychotic functions in this perspective. Faced
with psychosis, there is the hysteric’s act of defiance: he/she is a dialectician, adapting in order to respond to the
modifications of the discourse of the master and of the analyst. Gabriela Brodsky proposes one model.
The point of view defended by Lacanian psychoanalysis faced with organic disease can be found in the section
entitled “The subject within the patient.” And we open this issue with the second part of Jacques-Alain Miller’s
course, a political analysis that is a precondition for any applied psychoanalysis. Our wager, that psychoanalysis
will remain a symptom in the years to come, depends on this.
It is appropriate that the New Lacanian School should have a publication in English, the dominant language of
our times. Mental Online, now available on the Web, has been made possible thanks to the work and enthusiasm
of a team reunited around Francesca Pollock. It is a new “You can know” of contemporary Lacanian theory and
practice.
3
Jacques-Alain Miller
Milanese Intuitions [2]
We will devote this encounter to the political unconscious, a stone put in our path by the turns of history, causing
us to interrupt the laborious study we had undertaken on counter-transference*. I will pursue my reflections,
those I shared with you last time. The formula “The unconscious is political” that I used last time produced quite
a splash – that is to say, it propagated waves within practice as well as within theory, although here “theory” is
perhaps too big a word and must be put within quotation marks.
Reality staged by the structure
Theory, when we try to produce it – theory in the present – is nothing more, at least for psychoanalysis, than a
sinuous trail, a trail we blaze to try to catch up with what has already taken place and which is going forward on
its own. Theory and practice in psychoanalysis are not symmetrical or parallel. There is in psychoanalysis, it
cannot be ignored, a lagging of the theory that is not contingent, not accidental, but probably structural, at least
as far as its elaboration is concerned. And this elaboration is of course in tension with the very knowledge it is
supposed to elaborate. It would be fitting that this knowledge express the reality being accomplished according
to a necessary order, in conformity with the proposition 7 of book II of Spinoza’s Ethics: Ordo et conexio
idearum – the order and connection of ideas – idem est – are, is the same, since ordo et conexio are here reunited
– ac ordo et conexio rerum – the same as the order and connection of things.
This is an essential proposal, the very ideal which inspires Lacan’s structuralism, on condition that the order and
connection of signifiers replace the order and connection of ideas. This is what Lacan designated as the pure and
simple combinatory of the signifier. This combinatory was supposed to define relations of necessity meeting, the
same ones, in reality. That is the conception of knowledge we measure our efforts against, since it is the
conception of a kind of knowledge that is not a representation of reality, but that should be identical to the very
principle of the effective development of reality, identical to the principle of its production, of its Wirklichkeit.
According to this conception, the structure is neither an ordered description of reality, nor a theoretical model
elaborated apart from experience. With respect to this, see Lacan’s criticism of Lagache, page 649 of the Écrits,
a text that is for us a reference. Lacan claims to surmount the difference, the opposition, the contradiction he calls
the antinomy of these two conceptions of structure, as description and as model, by introducing a third mode for
structure by which it is produced within reality itself and determines its effects there. For Lacan, these effects
are effects of truth, effects of jouissance, effects of subject, and the truth itself is an effect, the jouissance also
and the subject as well.
It is in this direction that we must understand the proposal Lacan puts forth on this page, according to which the
structure operates within experience as – I have already quoted this formula, which was particularly forceful at
the time Lacan used it for the fantasy – “the original machine which puts the subject on the stage.” These terms
____________________
* “L’orientation lacanienne,” course given by Jacques-Alain Miller in the Department of Psychoanalysis at the University of Paris VIII,
May 22, 2002; text established by Marie-Hélène Doguet-Dziomba and Nathalie Georges, published with the authorization of J.-A. Miller.
Milanese Intuitions [2] 5

must be explained. Machine is a word that designates a signifying articulation, combinatory and determinist,
whose variations are strictly conditioned. Some years later, Lacan was to give an example that serves as a
reference in his four discourses. The staging of the subject means, in fact, that the combinatory machine is in the
wings, that it is not on display, that it is hidden, which makes us think it is at a distance. Its being hidden supposes
it escapes any descriptive phenomenology, that it is not sufficient to let things be in order to get to it. The
expression “staging the subject” carries an ambiguity that reflects the actual division of the subject. That is to
say, the subject is staged, is an actor, not the director, and at the same time the subject is a spectator, reality is
for him staged by the structure.
What does it add to qualify this machine as original? It is probable that Lacan means by this that it is not derived
from anything anterior to it, but in the specifically genetic sense, which he criticizes on this page, and not in the
combinatory sense. And original also means unique. This machine is specific to each subject, it must be
reconstituted in the analytic experience for each subject. But it would probably be abusive to limit its validity or
the inspiration of this proposal to the analytic experience stricto sensu, because the subject is not the individual.
Lacan also talks about the subject of science, for example, and we can perfectly well consider that the discontent
analyzed by Freud concerns the subject of civilization.
This is what we are confronted with when our attention is alerted as it recently was. We realize we are confronted
with the original machine that stages the subject of civilization at the present time, and that this also conditions
the analytic experience. And here we have what is mapped out, of an ambition constantly resumed, redrafted, to
recompose this original machine out of what we know of its effects.
The unconscious is connected to the social bond

I need to be more precise about a point I evoked last time when I quoted a remark of Lacan’s with reference to
a quotation that had been made of it: “I do not even say ‘politics is the unconscious’, but simply “the unconscious
is politics.” I had indicated that this remark was taken from “La logique du fantasme” and I had quoted it without
verifying the stenography of the seminar. Which I have since done. I wish now to add, before continuing, a few
considerations on this point. First, because we find in the stenography the formula “unconsciousness is politics.”
But I am in favor of correcting this stenography to read “the unconscious is politics.” The passage I had referred
to is found within a sentence that I wish to pass on to you more completely. This is what Lacan said: “If Freud
has written somewhere ‘anatomy is destiny’, there may come a moment, when we have come back to a healthy
perception of what Freud discovered for us, when we will say: I do not even say, etc.” This complement shows
that the matrix of Lacan’s words is clearly one of Freud’s formulas, and that Lacan opposes what Freud said in
echo to the emperor Napoleon, and what Freud discovered for us, that is to say, what Freud really said. What
Freud really said is not what Freud said. It is in fact the inspiration of all Lacan’s teaching which is concentrated
there. What Freud really did say is not that anatomy is destiny. It is not the anatomic body that Freud refers us
to in order to try to explain the subjective difference of sexuation. Moreover, anatomy does not even determine
hysteria, since, as Lacan points out in “Television,” hysterical conversion does not obey the anatomic partition.
Parallel to the anatomic body we could bring into question the living body and distinguish them. Of the living
body inasmuch as it speaks and as speech conditions its jouissance, we might say that it determines destiny. But
in this passage from his Seminar, Lacan operates a displacement from “anatomy is destiny” to the “unconscious
is politics.” And he explains this by saying “What bonds men together, what opposes them, must be motivated
by the logic we are trying to articulate” – and at that time, it was the logic of the fantasy. “The unconscious is
politics” is connected to what bonds and opposes “men” in relation to one another, that is to say, the unconscious
is connected to the social bond. It is this conception that, some years later in Lacan’s teaching, would be put into
a matheme by the cycle of discourses.
6 JACQUES-ALAIN MILLER
The unconscious is connected to the social bond – we introduce this gloss – precisely because there is no such
thing as a sexual relation. We could go so far as to say that where there is a sexual relation, where the sexual
bond is programmed, well then, there is no society.
Of course, we were enchanted to dream about the society of bees, or that of ants. Maeterlinck, when he did not
make us dream of Pelleas and Melisande, enchanted us, during our childhood, by describing those societies that
gave us a utopia, precisely because they were, because they are – what they were and what they are is precisely
the same thing – societies without politics. It is societies without politics that furnished us with utopias. We might
say that the theocracies tried to realize a society without politics, or else that ethnological structuralism presented
us with societies possessing elementary structures of family relationships, which were for this reason apolitical,
something that was contested later on.
Today it does not seem abusive to propose that there are no societies without politics, and that, correlatively, the
unconscious is political. This is what Lacan was elaborating during those years. After having shown that the
unconscious is produced within the relation of the subject to the Other, he continued by showing that it is
produced within the relation to the Other sex, coming up against, on precisely this path, the absence of sexual
relation and the interposition of the object a.
“The rejected being” and the political demand of the Other

This phrase of Lacan’s, – to be a bit more complete – is situated in this Seminar in the course of a reflection on
the formula “being rejected,” “being spurned,” provoked by considerations on masochism that he borrows from
Bergler’s work Basic Neurosis. Bergler introduces this status of the subject, “the spurned being,” with reference
to the oral stage and he founds the “being spurned” – the being spurned, which would be the principle of
behavior, of the attitude of certain subjects – on a “being spurned by the mother”; it would be the masochistic
desire that the subject would create, at the level of the oral drive, which would permit him to bewail this injustice
and find jouissance in it. “Being spurned,” which would constitute the motive for the complaint of the subject,
would find its motive in the desire to be saved from being swallowed up by the maternal partner. This is what
had held Lacan’s attention at the time, this finding jouissance in injustice which also discloses for Lacan
Bergler’s hostility towards his patients, whom he stigmatizes as collecting injustices in order to complain of them
– which is not absurd from the point of view of the phenomenology.
Lacan, in the very movement which produced the formula “the unconscious is politics,” makes a fundamental
objection to Bergler, which rather well situates Lacan’s political position, which he promoted and gave force to
in his teaching, and which was: but why then should one be accepted, rather than rejected? Why should one have
to do what must be done in order to be accepted? Is it the case, by chance, that the table at which one should
want to be accepted would always be benevolent? What is behind this is the metaphor of the Symposium and
those who are not admitted to the banquet. This clearly situates the position of subversion that was Lacan’s and
which, it must be recognized, is still today a current question.
At the time, the current question concerned what was taking place in a small region of South-east Asia, the
Vietnam War. Lacan commented on what was at stake in the following way – which resounds and can still
resound today when Asia has probably little by little fallen into step, but another zone of the planet, not yet! –
“It is a question of convincing them that they are wrong not to want to be admitted into the benefits of
capitalism.” At that time, what we found was that they preferred being rejected from it. It is with respect to this
that Lacan invites us to reflect on certain significations – especially on the signification of “being rejected” – and
it is in the midst of this that he introduces, without developing it, his “the unconscious is politics.”

What he adds, in its brevity, still susceptible to evoke an echo for us, is that one can only be rejected if one
proffers oneself. This leads him to remind us, as a key to the neurotic position, the close relation of the subject
to the demand of the Other. With respect to this demand, he says, we must suppose that there is for the neurotic,
“a necessity and perhaps a benefit in being rejected.” Later on, perhaps Lacan would have talked about the
jouissance of being rejected. This comports a very precise clinical indication, which is that you must think twice
before having the ambition to force a subject not to be rejected, before considering that being admitted to the
banquet of others is the best thing that can happen to him.
Lacan indicates that proceeding thus, having the prejudice that it is better to be admitted to what you consider
as a benefit, adjusting the analytic operation to that, can give the analyst a persecutive function. This puts an end
to what would consist in giving to what the analyst believes to be the principle of reality a primordial value,
rather than considering as valid in itself the desire to be rejected – that is to say not to be submitted to the demand
of the Other.
This is also indicative for the present moment of civilization where it is not the desire of the Other that is so
present but rather the insistence of his demand, of his political demand in the form of democracy and the market
considered as values that your welfare is dependent on. So that, what is presented as a preference, the preference
to be rejected from the order of these benefits, becomes incomprehensible, or even monstrous. This is, at any
rate, an indication of a position of reserve for the analyst, with respect to these master-signifiers of the
specifically political demand of the Other. That is what I wished to add, to modulate within what I had attributed
last time to Lacan’s remark, based on the quotation that I had gleaned in the work of an author.
The depreciation of psychoanalysis

I had gotten to my eighth reflection concerning the depreciation of psychoanalysis. I had announced the resource
that I had been able to find in The Future of Success, a book of Robert Reich’s, the political economist, who is
one of those essayists that have laid stress on social narcissism in the epoch of globalization – the first, in the
1980s, was Christopher Lasch and his Culture of Narcissism. His idea is that mass anonymity enters into
contradiction with the desire for celebrity induced by the object mass media – which leads to the major question
of how to attract attention. “How can I attract attention?” is a question which is present in the motivations that
we could recognize in the recent killer of Nanterre in France. He found in his act the occasion to realize Warhol’s
words, “being famous for a quarter of an hour” managing at least once to have his name on television and in the
newspapers.
Robert Reich’s idea is that there is an economy of attention, a demand for attention and an offer of attention, so
a market of artificial attention. It is within this register that he inscribes psychoanalysis, including what he tells
us about its increasing spread in the United States, because, from his position he does not need to make a
difference between psychoanalysis, psychotherapy and any other term beginning with “psy.” He thus delineates
the development of an entire sector of specialized activities in the service of attention. Which permits him to
create a category that includes both private gym teachers, “personal trainers,” “personal shoppers” – those who
do the shopping for you when you don’t have the time –, and the entire set of spiritual and psychological
counselors. He isolates the sector of attention givers, and includes within them domestic personnel, baby-sitters,
etc. It is as an economist that he creates this category, and he indicates that it is one of the two sectors that are
growing most quickly in today’s society, the other being creative workers. He prophesizes that, in the future, at
least in the United States – but for him the United States portends what less developed societies will become –
anyone who does not have what it takes to become a creative worker will probably find themselves working in
the sector of specialized attention givers. He says: Your children, if they are not creators, innovators, will find
themselves in this sector, which is promising but at the same time doomed to disqualification. If the economy is
growing within essentially two sectors, the creators and the attention givers, the attention givers are those who
do not manage to get into the other sector. It is also growing, but in the direction of an increasing disqualification.
We can however be reassured by the fact that he places psychoanalysts and psychologists among the highly
qualified workers, but he still includes them in the same category as butlers and baby-sitters.
This analysis is not ill-willed, its target is not essentially psychoanalysis. It is a study of the new working
conditions within the framework of the new economy – moreover it was followed in a few months by the burst
bubble of the new economy. It is more precious for not being polemical. It gives the impression of a depreciation
of psychoanalysis by the fact that psychoanalysis is not apprehended from the place of a desire for truth but from
that of a demand for personal attention. It is a depreciation, but at the same time we know that something was
modified within the classical dynamics of the analytic cure. It is this modification that Robert Reich
conceptualizes, in his own way. Certainly, it is not the ultimate truth of psychoanalysis, but it is useful for
relativizing the attention we give to the minute internal differentiations that fragment the analytic milieu but that
disappear before the eye of the economist. This is the sign under which we find the analytic act lodged. It is
blatant that, within this classification, the activity of the psychoanalyst, the psychotherapist or the psychologist
appears as being closer to baby-sitting than to medicine. There is, still and all, an effect of truth that surfaces
there despite the reservations we might have, of course, concerning the classification itself.
The machine of the not-all

Ninth reflection – I’ll name it thus: the bubbles of certainty. We must continue to look at ourselves in such a way
that we are exotic for ourselves. This probably belongs to social phenomenology, but it is really from such
elements that we have to try to reconstitute the original machine of today’s civilization.
The father. It is easy to see what still attaches psychoanalysis to the myth of the father, and to see that society,
in the process of modification at this epoch of globalization, has ceased to live under the reign of the father. Why
not say it in our own language, the structure of the all has given way to that of the not-all: the structure of the
not-all implies precisely that there be nothing left that serves as a barrier, that is in the position of what is
forbidden. The forbidden appears as contradictory with the movement of the not-all. The structure of the not-all
is what is described at the social and political level by Antonio Negri as impero, as the empire that develops
precisely without meeting up with a limit. This is what corresponds for us to the structure of the not-all, deported
to the level of what we can no longer call a social organization.
We should not be surprised to find here the not-all; this not-all was introduced by Lacan in his text “L’Étourdit,”
in which he responds precisely to Deleuze and Guattari’s L’Anti-œdipe – as indicated at the end of the text – by
reconceptualizing what the authors had tried to apprehend. The function of the father is in effect linked to the
structure that Lacan discovered in masculine sexuation. A structure that comprises an all with a supplementary
and antinomic element that poses a limit, and which allows the all to be constituted precisely as such, which
poses the limit and thus allows for organization and stability. This structure is the very matrix of the hierarchical
relation.
The not-all is not an all that includes a lack, but on the contrary a series in development without limit and without
totalization. This is why the term of globalization is a vacillating term for us, since it is precisely a question of
there being no longer any all and, in the current process, what constitutes the all, and what constitutes a limit is
threatened and staggers. What is called globalization is a process of detotalization that puts all the “totalitarian”
structures to the test. It is a process by which no element is provided with an attribute it can be assured of by

principle and forever. We do not have the security of the attribute, but its attributes, its properties, its
accomplishments are precarious. The not-all implies precariousness for the element.
We can see every day, in fact, what used to be respect for tradition giving way to the attraction of the new, and
this phenomenon, abundantly described, is staged for us by the machine of the not-all. To take an example that
is revealing, at least for those for whom it is familiar, the Catholic Church in the United States is undergoing a
veritable martyrdom. A cardinal, a prince of the Church, was summoned to the court to answer questions – the
kind of questions in American trials that you might have an idea of from Erle Stanley Gardner or Perry Mason
novels. You know how the questions are phrased. There must be no allusions; no speeches must be made, no
speeches are asked for. The questions asked are short and factual and follow one on the other. You must give a
yes or no answer just to the question that is asked, and then the lawyer will lead you by the nose. Well, the aptly
named Cardinal Law of Boston, two weeks ago, was called on to give answers to these questions. I found on
Internet the entire transcription of this interrogation, which was absolutely disconcerting for those who have
some attachment to tradition. And the pluck to require of the Catholic Church the transparency of its operations,
and the renewed distrust, including on the part of American Catholics, with respect to the role played by a
potentate living in a microscopic state near Italy. There we have a sign of the times when we see multi-secular
practices surrounded by a universal respect becoming today strictly undecipherable and thrust aside, rejected by
the spirit of the times.
This really gives us the feeling there is an original machine staging plays of an entirely unprecedented type such
as the one played by Cardinal Law humbly responding to the questions of the District Attorney: last name, first
name, explain what a cardinal is, explain what a diocese is, etc. We have not yet gone that far in the old Europe,
but we see in this what promises to be irresistible in this original machine.
By a certain short-circuit, admitting that the machine that is staging what we call globalization is the not-all,
signifies, for Lacan, who relates it to feminine sexuation, that we can refer to this structure what we observe of
the rise in society of values said to be feminine, those of compassion, of the promotion of listening practices, of
the politics of proximity, all of which must from now on affect political leaders. The spectacle of the world may
be becoming decipherable, more decipherable if we relate it to the machine of the not-all.
Obviously, we propose the practice of listening as political only in case of the absence of response. To listen
becomes itself the response within the silence of the master. This is the political usage of intersubjective
communication, namely that you will never receive a message other than the one you have sent. This is also why
we cry over the traditional element, which was already grasped half a century ago, namely that the virile is under
attack, and we observe, at least in the developed societies, a certain popularity problem for the war-mongers.
This is of course correlative to a call for authority, to the return of order, to a desperate appeal to the reign of the
master-signifier, which is in the process of being abolished. In any case, we can observe the tension between the
functioning of the machine of the not-all that exacerbates the nostalgia for the master-signifier and this appeal
to the master-signifier, all the more exacerbated as it appears as detached from the rest, and all the more insistent
as it appears clearly as supplementary.
Within the social not-all, on the contrary, the signifier does not come to us in organized blocks, it tends to be
presented in discontinuous fragments, for example under the form of instant information, so Americans study
information overload. What we call information is the way the signifier gets to us, no longer organized but
discontinuous, essentially fragmentary, with an effort to try to add to it an organization that is constantly in the
process of being undone. From this we have what even Robert Reich can spot as a pathology of disorientation.
The pluralized S1 and the subject without bearings
This is why sociologists have discerned, in face of the overdose of information, the subjective strategies that
consist in withdrawing within the limits of zones of certitude. Descriptively, this is quite strong – it was already
foreseen in the promotion of the postmodern by Lyotard, who generalized its concept. He had already
characterized it in the past by the destructuration of the great filters of knowledge, that is to say the traditions,
the consecrated authorities, what he called the meta-narratives, the stereotypes: these are the various
organizations of the signifier, which are the diverse forms of the discourse of the master, and which had the merit
of operating a simplification and a formalization of reality, of diffusing models of coherency, models of coherent
behaviors under the authority of jurisdictions recognized as competent.
One might wish that, in this period of the destructuration of the filters of knowledge, by some miracle, schools
be capable of operating this simplification and this formalization of reality, even though all the apparatus
supporting them have been fissured, stricken, besieged, or are at least declining. What the sociologists have
discerned is that globalization is accompanied by individuation. What is impaired is the mode of living together,
the social bond that exists under the form of unfixed, dispersed subjects, and which induces, for each one, both
a social duty and a subjective imperative to invent.
It’s the very effective formula “living my own life” – my own life precisely by its difference from the others –
that highlights the decadence, the decline of the collective organization of models, and places the subject in face
of a demand – that he takes as his own – to invent and enhance his own individual style of life. It is the epoch
we had called “of the Other who does not exist,” when what Bourdieu had tried to recompose as the mechanisms
of distinction already belonged to another epoch. Today the mechanisms of distinction he evokes are blurred; he
presents us a simplified world, almost the world of his childhood.
It is at this moment that we find in Lacan’s teaching, as he both defined and then questioned what he called the
S1, the central signifier of identification. He defined the master-signifier in his matheme for the discourse of the
master. This matheme comports as its central agent the master-signifier, which is pre-postmodern. It is the
discourse of the pre-postmodern master:
S1
____
→ ____
S2
S/ a
So, the first movement, isolating this central signifier. But as soon as he had isolated it, he pluralized it,
multiplied it, leading us to hear in the expression S1 the value essaim*, in order to say that there is not just one.
There are several, and nothing assures on the contrary that they are other than chaotic, even if the swarm travels
in a group. A constellation of signifiers rather than the unicity of the master-signifier.
And then, next to this matheme of the discourse of the master, he traced the first lines for the matheme of the
capitalist discourse, a modification of the discourse of the master, in which it is the barred subject that is put in
the place of this S1:
S/
______
S1
____________________
* [Translator’s note] “Swarm” in English. The prononciation of S1 and essaim are homophonic in French.

This is not so much a promotion of hysteria as it is the promotion of the subject without guidelines. It is in
function of this original machine that we can observe, as the sociologists do, the constitution of limited zones of
certainty that, on a small scale, give us these guidelines.
The bubbles of certainty

We can of course explain that the structure of the not-all is abstract and that, in fact, in reality, that is not the way
it happens, because, in effect, the machine of the not-all comports the ever more insistent constitution of micro-
totalities whose multiplication, and the investment of the subjects that are taken into it, translate the presence of
this machine. Micro-totalities that offer, within the not-all, pockets, shelters, a certain degree of systematicity,
stability, codification, and that permit the restitution of mastery, but at the cost of an extreme specialization. A
very restrained field of signifiers must be chosen, a very restrained field of knowledge in which mastery can be
restituted.
I found an example, which seems to me to be very indicative, in a study that was published two years ago
concerning a phenomenon observed in Japan and which is called there “the otaku effect.” It figures in an article
that I only know second hand, which is quite difficult to find and which is called “The Otaku Answer to Pressing
Problems of the Media Society.”
It recounts what was observed in Japan. These categories can of course be considered as suspect, but they are
not for as much less indicative. It concerns a certain aspect of the behavior of adolescents, or grown-up
adolescents – we no longer know where adolescence stops in fact – who become fanatics of a very limited zone
of the new technologies. They become complete specialists of what appears to be an entirely futile phenomenon
of the mediatic society or certain types of Mangas or comics, or else of an idol – an actor, a model, etc. – or of
some technology generally more or less linked to computers, or of video games, about which they accumulate
as complete a knowledge as possible, always abreast with the latest rage. Outside of this, the complete disinterest
they show in their contemporaries is remarkable, to the extent that it can be said that in Japan they no longer look
people in the face. “An otaku prefers to stay alone in order to pursue his hobby in peace. He devotes himself
obsessively to one unique sector of interest. The objects of his passion belong generally to pop culture.” We also
have military objects – this is Japan. “The essence,” says the sociologist in question, a certain Grassmuck, “the
essence of the otaku life-style has nothing to do with a specific argument, but is linked to his way of being in
relation with a theme.” The category that seems to be in use in Japan is not constructed with reference to the
theme of one’s interest, but to the manner of relation to this theme. “The otaku has a monomaniac personality.
His strategy is to gather information reserved to just one section of human knowledge and to push aside all the
rest. The otaku looks for a tiny zone of knowledge that he wishes to know everything about.”
This is generalized to all kinds of behaviors induced by the society of information, the media society, which
consist in wanting to know totally at each moment what is “in” and what is “out.” This has also spread to France
in magazines, which point out to you the “in” and the “out,” so that you know from one point to another how to
find your way through the crowd.
I cannot judge the pertinence of this description for Japan, and we can also consider that it is not necessarily well
constructed for the present state of civilization in France, but there is nonetheless something in psychoanalysis
that can be conceptualized as an otaku response. There is something of the otaku life style in the analytic
associations, in the Societies and Schools of psychoanalysis. We could even say that the analytic experience itself
is something of an otaku response – the analytic experience as a search for certainty, and also because the relation
in itself such as it is established within the analytic framework restitutes to the subject a zone of certainty.
Analysis puts uncertainty to work, but this is within the framework of a less hypothetical certainty – which gives
as a result the extreme valorization of the framework that we observe in the IPA, the extreme although
indefinable valorization of the framework. We can perhaps observe the same thing with Lacan in the definition
of the analytic discourse, which is presented as a transformation, a version* of the discourse of the master, that
is to say, as a bubble of certainty to which the subject is all the more attached for being plunged into the social
structure of the not-all.
We must undoubtedly add that if psychoanalysis is a bubble of certainty, at the same time it radiates through
society because it is put to work in advertising and it has taught politics how to manipulate the truth. It really did
teach politicians that truth is an effect, which gave birth to the “spin doctors,” to the experts in the manipulation
of the truth. We could moreover observe very recently in France the extraordinary promotion of a marketing
specialist, become Prime Minister – this is a first – , who was apparently chosen just for that. By the same token,
we must recognize that the extensive spread of listening practices, which submerges psychoanalysis, is the result
of the prolific radiation of psychoanalysis today.
Psychoanalysis in the epoch of globalization

Tenth reflection: psychoanalysis in the epoch of globalization. We shall attempt to look rapidly at how the
modifications of our clinical practice are related to the epoch of globalization and this machine of the not-all that
is behind it.
Classical clinical practice, such as we learned it and taught it, had as its pivot the Name-of-the-Father and was
directed with consideration for the positions of the subject with respect to the Name-of-the-Father. It is in this
practice that different modalities of desire were distinguished – the unsatisfied, impossible, anticipated desire,
etc. – or different modes of defense. Our classical clinical practice responded essentially to the structure of
masculine sexuation, to the structure of the all and of the antinomic element. This is what permitted us to have
these airtight, rigid, powerful classifications, which founded the notion of Lacanism for generations.
We might say that contemporary clinical practice, the practice we have been confronted with for years already,
balances to the other side, towards the side of the not-all. This clinical practice of the not-all is the one in which
we find flourishing the pathologies described as centered on the relation to the mother or on narcissism, but
which were attributed to the pre-Oedipal register when we disposed of the previous hierarchy, and which have
in a way taken their independence. To qualify this as pre-Oedipal is obviously too narrow.
When we show interest in everything that comes under the heading of addictions, we can clinically observe the
frenzy of the not-all, of the pathologies which highlight precisely the without-limits of the series. We can observe
at the same time the lesser effectiveness of the paternal metaphor and the pluralization of the S1s, even their
pulverization, so that, for some years already, we have recognized the crisis of our classifications. Let us just
consider the category of perversion, to which we are attached by the teaching we received and distributed, by
the very powerfulness of this category: we are forced to say it is a category that has undergone a massive social
rejection. It is assimilated to a stigma. We cannot extirpate from the category of perversion the fact that it refers
to a norm, that it belongs to a former regime where norms and ideals ruled the roost.
Of course, we object – Lacan says perversion is the norm of desire. But the very terms in which the diagnosis is
given, the category itself, have ceased to be operatory. And moreover, Lacan indicated other paths to us for
____________________
* TN:We must hear in “version” both the usual sense and the more unusual sense of “turning around” as for a fœtus. Reference to the
quarter of a turn in the passage from one discourse (of the Four) to the other.

approaching contemporary clinical practice as the practice of the not-all. He gave us the path of the knot. It is
not that the knot in itself is exalting, but the knot is effectively a means of responding to the structure of the not-
all, since this clinical practice gives us an indefinite series of arrangements beginning with three circles of string.
The ternary RSI can be distinguished and opposed to the former airtight, discontinuous repartition between
neurosis, perversion and psychosis.
Before, we had a combinatory clinical theory, centered on the Name-of-the-Father (to go a bit quickly), and
whose states were discontinuous, which gave us clearly distinct categories. It is obvious that – not that it is
invalid – referring clinical practice to the knot undoubtedly gives us arrangements that are different but in
continuity with one another. We have lost the security of the discontinuous and the clearly distinct, and the result
is that the symptom, rather than what we called the clinical structure, which was a class, has become the
elementary unit of clinical theory. The symptom has become the elementary unit of clinical theory and practice
and, after all, the symptom, what Lacan called the sinthome at the end of his teaching, is the Lacanian version
of the fragmentation of clinical entities that we find in the DSM. It is not the same fragmentation, but it is the
same movement of destructuration of the entities that can be observed in Lacan’s second clinical theory.
We first operated with a clinical theory centered on identification. Lacan’s first clinical theory was a theory of
identification: in analysis, I learn to tell my story truthfully, that is to say, I elaborate an identification that permits
me to be truthful. And the end of the analysis depends on the satisfying elaboration of a new identification, which
passes through a disidentification, etc –, but the central category is identification.
Lacan’s second clinical theory was centered on the fantasy, that is, once again, on a story, but this time a story
conceived as an unconscious scenario and centered on the relation of the subject to the stump of jouissance that
completes his constitutive lack.
Well, Lacan’s last clinical theory has as its pivot-term the symptom, and in this theory, the absolute, the
substance, is jouissance. To go back to the reference to Spinoza I had introduced in the beginning, it is really
Deus sive natura, sive jouissance. That is, there is jouissance, to the detriment of truth and meaning. At that
moment, it is no longer a question of there being a cure at the end of the analysis, nor is it a question of a
traversing, it is only a question of the passage from one regime of jouissance to another, from a regime of
suffering to a regime of pleasure.
What can be said of psychoanalysts in the epoch of globalization can be discovered through the pass. If it is clear
what the translation of this is in terms of what the machine of the not-all stages, the pass means that we are led
to suppose a disconnection between being an analyst and the practice of analysis. Those that Lacan wished to
consecrate as Analysts of the School, had necessarily to be of the School, since this was a definition of the analyst
independent of analytic practice, and which tries in this way to solve the problem of preserving the analytic core
of practice in a world where the analyst tends to be dissolved within attentional practice.
It is probably within this context that we must conceive analytic training. At the same time this training turns out
to be difficult to determine because we must, from now on, conceive it outside of any ideal to be attained, outside
of the very problematics of the ideal and the norm. This means that training tends to be understood as the
communication of a life-style rather than as an access to the realization of an ideal.
Translated by Thelma Sowley
Orientation
Pierre-Gilles Gueguen
Symptomatic Homeostasis in Psychosis*
No doubt in institutions these days it takes more than brandishing the psychoanalytical referent, albeit Lacanian,
in order to be heard. The transference required to establish the conditions of the psychoanalytical act requires
more than that. It requires, among other things, that the clinician make psychoanalysis desirable, and that he can,
therefore, attest to its efficiency, its pertinence and to the liveliness of the doctrine. As regards the treatment of
psychosis, we have a substantial corpus to rely on whenever required.
The title of this article joins the term “homeostasis” with the adjective “symptomatic.” This choice requires
clarification.
“Homeostasis” substitutes for the more familiar or more frequently-used nouns like “cure” or “suppletory
device” [to the foreclosed Name-of-the-Father] for example. It is closer to the term“ stabilization.” Commonly,
it is used to indicate the maintenance of a living organism's characteristics at a constant level. In applied
psychoanalysis, the term serves to indicate the fact that psychosis is not “cured” but rather contained, reduced –
that its disruptive manifestations are arrested by the treatment.
The adjective “symptomatic” adds something that the term “stabilization” does not render. That is, that
homeostasis results from the symptomatic formation. In this sense, the expression “symptomatic homeostasis”
replaces another frequently used, though poorly-put expression, that of “the delusional metaphor”.1 The idea that
it is the formation of a symptom that allows for a veritable stabilization modulates what the term “homeostasis”
would tend to evoke as a simple abrading of the painful and destructive effects of psychosis.
The research pursued for more than twenty years now by the School of the Freudian Cause, founded as it is on
a return to the clinical, has permitted great advancements in the clinical treatment of psychoses. We have gone
from a doubtful and experimental approach in dealing with psychotic subjects, often combined with a diagnosis
based only on language disorders or verbal hallucinations, to a keener and more pragmatic evaluation of
psychotic states and of their treatment. We can certainly consider these advancements to be the result of a
collective effort, one that has clearly demonstrated the necessity of a working School for psychoanalytical
research. The role of Jacques-Alain Miller’s course, with his deciphering of Lacan’s teachings, the importance
of his DEA [post-graduate] seminar, that of the Paris Clinical Section’s Evenings (IRMA), as well as the Study
Days of the Clinical Sections to which he has lent his impetus, belong at the forefront of these advancements.
The share of each has not been equal but on this theme, whose role is essential to mental health, a work
community has demonstrated its efficiency.
Our praxis for the treatment of psychoses has been marked by a certain number of scansions that I may resume
as chiefly the following:
____________________
* This text originally appeared in La Lettre mensuelle 211, September 2002.
1 Cf. “La psychose ordinaire,” Le Paon, Agalma, Paris, 1999, p. 290.
Symptomatic Homeostasis in Psychosis 17

—1986: The thesis of “generalized foreclosure” which establishes the passage from a theory of discontinuity in
the clinical treatment of psychoses to a psychosis-specific, continuous one.
—1993: Jacques-Alain Miller’s article entitled “La Clinique ironique”2, which asserts the thesis of “the universal
clinic of delusion” in these terms: “I assert that all of our discourses are only a defense against the real.” In this
article he also develops the basis for a Lacanian treatment of schizophrenia.
—1997-99: The collective works The Conversation of Arcachon and Ordinary Psychosis where the theory of
“ordinary psychosis,” deduced from the third period of Lacan’s teachings, is formulated for the first time.
Following this path, many consequences of Lacan’s teachings on the treatment of psychoses have been brought
to light and put into practice. In this manner we can positively state that we have gone from “On a Question
Preliminary to Any Possible Treatment of Psychosis” to a possible and logically-guided treatment of psychosis.
There still remains the task of giving detailed and classified accounts of these treatments in order to assert both
the validity of our concepts and the results they permitted. At present, the publications of the School of the
Freudian Cause and the Clinical Sections make available reports on a whole series of cases but which have not
yet been the object of a systematic listing.
I will insist strongly on two points concerning the therapeutic effects of the psychoanalytical treatment of
psychoses: the limit of therapeutic effects and the nature of the symptom elaborated in the treatment. I will
follow with three brief examples of therapeutic “successes.”
Therapeutic effects and their limit

The “Question Preliminary to…” introduces a radical difference between neurosis and psychosis in clinical
practice. Let us recall that this was not the position adopted in the 40s by the Kleinians for example, who were
also experimenting with the psychoanalytical treatment of psychoses.
By introducing the concept of foreclosure, forged from Freud’s work, which refers phallic signification in the
imaginary of the subject to the paternal metaphor as the quilting point of the signifying chain in the symbolic,
Lacan produces a theory on psychosis that replies to the language disorders cited in clinical experience.
When P0, the foreclosure of the Name-of-the-Father, is bared by the call to One father, who symbolically opposes
the subject in reality, it provokes a chain of reorganization of the imaginary and a collapse of the symbolic
register, accompanied by enunciation disorders: delusional phenomena, an intrusion of unveiled jouissance at the
heart of the signifying chain, hallucinations – particularly verbal-motor ones –, for which Lacan draws up the
full catalog in his re-reading of Schreber3.
The strength of this formula leads us to distinguish those cases where the quilting point of the signifying chain
ensures repression of the signification of the phallus, producing the automatism of repetition – as in neurosis –,
from those where the quilting point is absent – due to the foreclosure of the signifier of the Name-of-the-Father
– as a result of the “inadequacy of the metaphoric effect [which] will produce a corresponding hole at the place
of the phallic signification”4, along with the related injuries.
As Jacques-Alain Miller indicates, in Lacan’s work phallic signification accounts for both love and desire in
____________________
2 J.-A. Miller, “La Clinique ironique,” La Cause Freudienne 23, 1992.
3 J. Lacan, “On a Question Preliminary to Any Possible Treatment of Psychosis,” Écrits, A Selection, Trans. Alan Sheridan,
W. W. Norton, New York and London, 1977.
4 Ibid., p. 201.
18 PIERRE-GILLES GUEGUEN
terms of signifiers. Libido is therefore reduced to a phenomenon of signifiers. The concept of the phallus is
supposed to account for the libido and the symbolic at the same time. In neurosis, it does not allow to distinguish
between the sexes, except with reference to fantasy. In psychoses, it better accounts for paranoid psychosis where
jouissance is localized in the place of the Other, than it does for schizophrenic jouissance.
In a break with this conceptualization, and following the indications in Lacan’s third teaching, we find ourselves
today, as we have for the last fifteen years, with the scenario of a “continuous” clinic of psychoses. However, it
is important to avoid a relaxed use of this term and keep in mind that: without the backdrop of discontinuity
which determines whether or not the subject has access to the phallic signifier, no continuity can become
apparent.
To put it another way, we have not adopted the concept of “borderline.” Simply, there are cases, numerous
indeed, where the foreclosure of the Name-of-the-Father is not clinically observable because language disorders
are not present, or at least cannot be detected by an in-depth clinical examination. It may be in dealing with a
case where triggering has not occurred, or in one where the disorder that affects the subject is manifest, at least
at the time, on the level of jouissance rather than on that of the signifier.
The distinction between neurosis and psychosis – even ordinary psychosis – remains essential, as does the
training in differential diagnosis, which is one whole part of our formation, especially as it concerns the direction
of the treatment. On this point, pages 160 to 163 in the volume The Conversation of Arcachon are decisive: there
may be gradations in the obvious troubles of psychosis, it is nevertheless a “disorder caused at the most personal
juncture between the subject and his sense of being alive.”5
Jacques-Alain Miller proposes that for the cases discussed we use the term “disconnection” to designate the
phenomena that have as a primary feature a relocation of jouissance associated with disruptions in the sense of
time, even before they translate obvious enunciation disorders. Moreover, this phenomenon can remain as it is
and not “worsen”: in this case the first objective of the treatment will be to not hurt, in accordance with the
medical adage; primum non nocere.
Even so, there remains the problem of knowing whether, in cases of psychosis, diagnosed as ordinary or not, we
can come to a completely cured state. Medicine can make no better claim as we may note, since an illness – aside
from a few rare occurrences like chickenpox or a surgical operation like appendectomy – can always reoccur in
the patient’s lifetime. But more importantly, our concern to date is that of knowing if, in cases of either frankly
declared or ordinary psychosis, the subjects who have experienced psychoanalytical treatment can claim the
same guarantee as neurotics can with regard to the solidity of their riggings to the signifying chain.
The term “stabilization” indicates a temporary state; it suggests equilibrium as well as its fragility. It is the
appropriate term for the many cases where the psychotic rediscovers, for a time, a standard use of discourse and
seems to be in a state of remission. We might then believe them to be “cured.” Those who have cared over long
periods for subjects having, at times, experienced frankly triggered states, know that an unanticipated encounter
upsets the often hard won equilibrium that was hoped to be a definitive solution. In some cases, the vicinity of
the point where foreclosure will be bared can be localized, and the treatment directed so that this point is
endlessly carried asymptotically by the symptomatic signifying constructions elaborated in the treatment. In
other cases, the bad encounter to be avoided by the subject, the opening liable to undo the symptomatic
construction that produced homeostasis, is less evident. In these cases, the embryo of the symptomatic
construction falls apart like a house of cards, and is often accompanied with at least a minimal return of the
elementary phenomena for which the subject was the center.
____________________
5 J. Lacan, “On a Question Preliminary to any Treatment of Psychosis,” op. cit., p. 201.

Today there are two theses pertaining to prognosis in psychoses, even if they are not often clearly stated by their
authors.
The first, which Eric Laurent – for example – has asserted on many occasions, consists in conceiving the
treatment of psychoses as a tentative of constituting a new partner-symptom for the subject that will rig his
jouissance, but without supplementing the Name-of-the-Father. What must be understood here is that the
possibility of constructing an RSI knotting for the subject as solid as that of the neurotic is excluded. The
treatment would serve to indefinitely put off until later an encounter with the hole corresponding to the deficient
Name-of-the-Father. This view of psychosis takes symptomatic homeostasis into account, a perspective that
makes use of the requisite prudence and that has been exemplified by a certain number of cases followed over a
long period6.
This pragmatic thesis seems to us to be the most convincing: the reconstituted symptom makes use of certain
elements of the delusion. The fact is that this theory allows for contingency, and that in any case the therapeutic
result obtained remains precarious. Moreover, it corresponds to Freud’s observations on the question when, in
commenting the case of President Schreber, he indicated that the psychotic subject would have to make do with
the production of an asymptotic desire.
The other, more diffuse, thesis – which would need to be rigorously defended – is based on the idea that the
suppletory device obtained by the subject would have the same value as the neurotic’s partner-symptom. Lacan’s
choice of Joyce as an example has done much to spread this approach. It is based on well-founded
presuppositions which are, as Jacques-Alain Miller points out in his preface to Joyce avec Lacan, “that there is
not only signifier in a letter. A letter is a message that is also an object” and further on: “What is it we call a letter
as such? A sign, but that is defined, not by its effect of signified but by its nature as an object.” All the same, the
cases that would illustrate this do not seem to have clearly exposed their foundations.
The case of Joyce, chosen by Lacan, generated a great many therapeutic hopes. It does seem a particularly
appropriate example to account for an ordinary psychosis that is remarkably well compensated. First, by the fact
of making himself a name as an artist – despite the ever-growing obscurity of his work – and second, in the
coupling formed with a woman, Nora, who, despite his extreme singularity, accompanied Joyce throughout a
lifetime.
Still, should we think that all writing produced by a psychotic subject is susceptible of bringing a Joycian-type
of symptomatic resolution? We have offered up for discussion in our work community many cases where writing
under transference has brought sedation to certain patients. However, the example of Joyce, possibly only
partially understood, is by no means one that can be generalized and the function of the letter cannot be reduced
to written productions. The knotting of RSI specific to Joyce doubtlessly has to do with the status as an artist
conferred upon him even before he began to produce his most difficult works. Moreover, Finnegans Wake in all
likelihood marks a limit. Joyce became his own sinthome; he managed to make himself the equivalent of his ego,
whence Lacan’s title for his conference of June 16, 1975.
It would be interesting to take up once again the cases of stabilization which were proposed to the Paris Clinical
Section fifteen years ago, with so many years of added hindsight.
The symptomatic in homeostasis

____________________
6 Dominique Laurent has presented at least two cases to my knowledge. There are others that we have had the occasion to
examine in the cartels of the pass or elsewhere in the School's publications, cf. for example François Leguil's use of a case followed
by Michel Sylvestre.
When will we say that the homeostasis obtained in psychoses is symptomatic, even sinthomatic?
To begin with, it may be a good idea to distinguish the various cases in which the psychosis never breaks out
and never brings the patient to consult an analyst, the cases that produce one or more “brief delusional disorders”
that resorb themselves unaided (these two scenarios being quite frequent), and the cases where treatment under
transference has its effect on the psychosis, be it declared or not.
For these last cases there are also gradations. Certain types of psychoses, although clinically detectable, during
presentations of patients for example, are perfectly compatible with a normal daily life, with or without
medication. In these cases, delusions are confined to certain areas of social functioning. For example, let us take
the case of a subject suffering from a delusion of persecution which is limited to the theory of a restricted plot,
about a job promotion that never came to pass, and who otherwise suffers from a rigid personality, still
compatible with his social life, and from anxiety that medicine manages to suppress better than the alcohol he
so generously absorbed. There are certain cases, as the procedure of the pass has brought to light, that are held
in equilibrium by an analysis under transference following various modes, and that are not set off either by the
analysis or by the procedure of the pass.
In order to further our considerations we must yet give a more precise definition to the adjective “symptomatic,”
and link the operation that is carried out to the action of the transference.
The thesis of the universal clinic of delusion means just this: as regards the real, every subject, neurotic or
psychotic, is delusional. To say it another way: faced with the sexual non-relation, all subjects are delusional.
Freud, in his most explicit texts on psychotic mechanisms, insists more than once, especially in his
correspondence with Abraham [cf. letter of December 21, 1914], and in his 1915 text “The Unconscious,” on the
failure of the circuit of the drives in psychosis.
As Vicente Palomera’s remarkable, ongoing work demonstrates, Freud never stopped insisting on the disjunction
that exists in psychosis between the representation of things and the representation of words. The symptom is
then nothing other than a formation of the unconscious that reestablishes the union that paranoia undoes in favor
of the representation of words, and that schizophrenia undoes in favor of things. The delusion, linked to the
foreclosure of phallic signification, is an attempt at reestablishing this link when it is threatened. Whence the
characteristic, common to both delusion and symptom, is to be at the same time both decipherable and carrier of
jouissance. Lacan put it this way: “That the question of his existence bathes the subject, supports him, invades
him, tears him apart even, is shown in the tensions, the lapses, the fantasies that the analyst encounters; and, it
should be added, by means of elements of the particular discourse articulated in the Other. It is because these
phenomena are ordered in the figures of this discourse that they have the fixity of symptoms, are legible and can
be resolved when deciphered”7
In the expression “universal clinic of delusion” we must understand that the term “delusion” does not have the
same usage as the one psychiatry gives it. It is used to indicate that, faced with the real, or the sexual non-
relation, there are only specific cases, in which a fantasy gives access to “reality” and serves as matrix to a
symptom. The thesis of the universality of the “delusion” hides another, one that Lacan developed to a greater
extent in his last teaching; it is nothing other than the universality of the symptom.
This is exactly what Jacques-Alain Miller was developing in 1996 with his concept of the partner-symptom that
brought an essential complement to the theory of the universality of the delusion: “we don’t change on that level.
We don’t wake up,” he asserted. “We only manage to manipulate differently what does not change”8.
____________________
7 J. Lacan, “On a Question Preliminary to any Treatment of Psychosis,” op. cit., p.194.

The partner of love and of desire is no longer the phallus, signifier of jouissance in the Other. Nor is it the object
a – where the partner of the subject is its fantasy. The partner is instead the subject’s symptom in that the
symptom makes a social tie. Moreover, in his text entitled “Joyce the Symptom,” Lacan points out: “. . . [the]
symptom we call hysterical, we mean by that the last. Which means paradoxically that the only thing that
interests it is an other symptom: it only falls then in the next to last place and is not the privilege of a woman,
although we quite understand, in measuring the fate of LOM 9 as speech-being, what she is symptomatized by.”
In this way, analysis for the neurotic subject turns out to be a reduction of its symptom to that which cannot be
reduced because it finds there the reason for its jouissance, most often in its sexual partner, the Other’s symptom
becomes its own. For the psychotic, analysis allows for the bordering of the real of the drive with a symptom
established without the support of phallic signification. In both cases, it will be a matter of going to the limit
where the subject “will know how to do with the symptom.” Within this zone, the knowing-how-to-do-with is
not, as Jacques-Alain Miller notes, of the order of knowledge but rather that of an intuitive understanding. The
symptom comes in place of the rapport that does not exist. For all that, the symptom constructed in cases of
psychosis is not the equivalent of the one neurotics work to reduce by analyzing their relationship to the father.
Translated by Julia Richards
____________________
8 J.-A. Miller, “La Théorie du partenaire,” Quarto, N° 77, p.29.
9 [Editor’s note] LOM is a play on letters constructed by Lacan in “Joyce le Symptôme,” where he produces a long series of
such plays with reference to certain Joycian uses of the letter in Finnegans Wake. It is a reduction of the spelling of “L’HOMME”
(meaning MAN) and is found, for example, in the following phrase “LOM cahun corps et nan-na Kun” (something like “MAN
h’aza body and on-lyaz Wun”), which in ordinary spelling would be “L’homme qu’a un corps et n’en a qu’un,” and in English
“Man wh’as a body and only’as one,” the contractions marking elisions found in ordinary rapid speech. The syntactic relation
between the relative clause and “Man” here is more enigmatic than equivocal. The clause cannot be restrictive, despite the absence
of a comma, because the generic “Man” cannot be further defined. If we are to consider it as a non-restrictive clause, then we must
suppose that Lacan neglected to put in the comma. But the reading of the clause here suggests that the entire noun phrase, including
the relative clause, can be treated as a compound noun, which might have been written with hyphens (in English “Man-wh’as-a-
body-and-only’as-one”), thus explaining the absence of a comma. We refer the reader to “Joyce le symptôme” (Joyce avec Lacan,
pp. 31-36) to decide for himself.
Richard Klein
Delusional Misidentification Syndromes
My clinical contribution to the last Freudian Field Seminar of this year will consider three clinical syndromes
that in my opinion were never far from Lacan’s mind. In the 1930s they were collected under the heading of
L’illusion de fausse reconnaissance des aliénés which I will translate as psychotic false recognition syndromes
or as delusional false recognition syndromes. The first one was discovered by Capgras and Reboul-Lachaux in
19231. They called it l’illusion des sosies. L’illusion de Fregoli was discovered by Courbon and Fail in 19272.
Courbon and Tusques discovered the syndrome d’intermetamorphose in 19323. In English the “delusion of
doubles” or the “Syndrome of Capgras,” the “Fregoli syndrome” and the “intermetamorphosis syndrome”
respectively. They are not themselves nosographical entities or illusions but delusional phenomena that
uncommonly occur in the course of other psychoses, having been reported in paranoia, schizophrenia, manic
depressive psychosis and puerperal psychosis. These clinical syndromes provide the opportunity to review the
background to the concept of foreclosure of Lacan, which I will do under the notion of identification-cause.
There is no such signifier in the work of Lacan, and it is merely a device in this paper to make a point in
examining the structure of these psychoses, having to pass from identification-cause to object-cause in the
development of the logic of the perceived by Jacques-Alain Miller.
The systematic meconnaissance

Capgras, in 1924, called the mechanism he discovered in the delusion of doubles méconnaissance systématique4.
A British psychiatrist translates méconnaissance as misidentification5. In British psychiatry this group of three
syndromes has been collected under the heading of delusional misidentitification syndromes. It emphasizes an
aspect of their structure, which involves something like a disorder of identification. False recognition is a
phenomenon that occurs primarily in dementing disorders. Although British psychiatry would no doubt prefer to
consider it a neurological marker, the British translation makes false recognition secondary to a disorder of
identification.
The first occurrence of the term “systematic misidentification” that I can find in Lacan’s work is in “Propos sur
la causalité psychique”: “What is the phenomenon of delusional belief? I say that it is méconnaissance along
with the essential antinomy that the term contains. To méconnaître supposes a recognition, as is shown in
méconnaissance systématique which, it must be admitted, indicates a negation of something that has already
been recognized in some way”6. I think he asking what the mechanism of the phenomenon of delusional belief
is. The mechanism is systematic misidentification. He doesn’t mention false recognition because he is referring
____________________
1 J. Capgras and J. Reboul-Lachaux, “L’illusion des ‘Sosies’ dans un délire systématique chronique,” Bull. Soc.Clin. Med. Ment.,
11, 23.
2 P. Courbon and G. Fail, “Syndrome ‘d’illusion de Fregoli’ et schizophrénie,” Bull. Soc. Clin. Med. Ment., 15, 1927.
3 P. Courbon and J. Tusques, “Illusions d’intermétamorphose et de charme,” Ann. Med-Psych., April 1932.
4 J. Capgras and P. Carrette, “Illusion des Sosies et complexe d’Œdipe,” Ann. Med-Psych., 12th series, v.11, June 1924.
5 S. M Coleman, “Misindentification and non-recognition,” Journal of Mental Science, 79, 1933.
6 J. Lacan, “Propos sur la causalité psychique,” Écrits, Seuil, Paris, 1966, p. 165.
Delusional Misidentification Syndromes 23

to the one syndrome in which false recognition does not occur, namely, the delusion of doubles. On the contrary,
he says that what has been negated in the sense of misidentification has already been recognized. Negation in
the sense of systematic misidentification is something more radical than negation in the Freudian sense. My
contention is that Lacan is already using the concept of systematic misidentification of Capgras in the way he
will use his discovery of the concept of Verwerfung in Freud’s case of the “Wolfman,” that is as a disorder of
identification the result of which creates psychotic structure.
According to Lacan in 1946 his notion of the ego is derived from the work he had done on psychosis: “I have
myself demonstrated it in my study of the characteristic phenomena of what I have called the fertile moments of
the delusion. Pursued according to the phenomenological method that I commend to you, this study led me to
analyses from which I derived my concept of the ego . . .which I have left unpublished but which nevertheless
threw up the rather striking term connaissance paranoïaque7. The only concept he had to apply to it was the
mirror stage that starts out as a paranoiac theory of the ego, as Jacques-Alain Miller has already remarked. In
other words, he only has the imaginary to work with. Lacan describes the mirror stage in 1946 as ambivalent. It
is not an ambivalence involving fundamentally love and hate in the classical sense but in so far as the subject is
identified for its sense of self with the image of the little other and as that very image robs it of its sense of self 8.
That is, it is ambivalent by providing us with something neurotic, namely an identification, and with something
psychotic when that identification is undermined. The existence of an ego depends on this identification. When
there is a systematic misidentification, the ego becomes problematic. Systematic misidentification has effects at
the imaginary level only. A problematic ego creates the fertile moment of delusion.
Madame de Rio-Branco and the illusion of doubles

The case in which Capgras and his collaborator in 1923 discovered the new clinical phenomenon called the
delusion of doubles was diagnosed as a chronic, systematized, delusional state – in other words, paranoia. Mme
de Rio-Branco complained at a police station that people were being confined in subterranean Paris and that she
could hear their voices, especially the children, asking that someone come and look for them. This led to her
admission to Saint-Anne Hospital in 1918.
Her psychosis triggered after the death at a very early age of twin boys in 1906 when she became delusionally
jealous and grandiose. Her first child, also a boy, died very young too. Finally, she had twin girls of whom one
survived. In a delusional retrospective her children were poisoned or abducted and substituted for other children.
Mme de Rio-Branco herself was abducted from her parents and left with a Mr. M, substituted for his daughter.
She began life as a double. She must not be called Mme M but Louise C which is her husband’s name. Best of
all to call her Mathilde de Rio-Branco. Her own proper name was set adrift, and she invented princely names for
herself. The name de Rio-Branco was her invention, a royal name that gave her some rights over the Rio of
Brazil.
One of the principle themes of her psychosis was the delusion of doubles. She herself chose to name it the
illusion of sosies which she cobbled out of a play by Molière. She defined sosies as persons who look alike. A
sosie is substituted for the original person who disappears. She was the double of Mr. M’s daughter who
disappeared. Her surviving daughter had been replaced by sosies 2000 times and her husband 80 times. She
declared that her husband was not her husband. She complained that in the asylum she was taken for an other,
for an immoral woman who was discharged in her place. In other words, a sosie is a double at the level of the
image only and not at the level of moral actions.
____________________
7 Ibid., p.180.
8 Ibid., p.181.
24 RICHARD KLEIN
Her identity was under constant threat, and she took precautions against being substituted. She went to
extravagant lengths to provide a wealth of details to make her identity precise. She equipped herself with official
documents as to her identity: to make it impossible “To take me for an other that is a sosie.” The other here was
an expression in the patient’s discourse. The little other is in this case her double that she disowns. It is imposed
upon her from without. It is not that image of the little other that gives the subject its sense of self. It is,
nevertheless, an image, and if her daughter has been substituted 2000 times, it is indelible.
Once image and name are dissociated there is a theoretical possibility of countless substitutions by sosies. She
attempts to make a name for herself by collecting certified evidence as to who she is and by constructing a royal
family tree. Nevertheless, the function of the proper name seems to be still too much adrift, and it calls forth such
statements as: “I am a creature without doubt,” “I have never had any other color than that of virtue,” “The
woman without stain,” “My signature is valuable,” “My character is that of an honest woman,” “My good
antecedents are alluring for guilty people who wish to appropriate them by using all the papers that identify me.”
In the scopic field the patient of Capgras had undergone a number of transformations: she was blond and is now
brunette, she had bulging eyes which are now flat, she has no more bosom, just to cite a few of the changes. Her
self-image is not holding together because the image of the little other is a double from which she cannot
construct her body. The identity of Capgras’ patient is under constant threat. Her self-image is not holding
together. It is coming apart in the scopic field: being brunette instead of blond, flat-chested instead of full
chested, etc. The gaze as lost object, or, at least, as the most vanishing, is in play in the triumphant assumption
of the specular image, says Lacan on page70 of the Écrits 9. And more assertorically still on page 6 of the English
translation of Encore, the remainder holds the image together. Presumably then, the object is not lost since the
image is falling apart. If they were imaginary, they would remain in the visual field, but they are in the scopic
field. These objects are images that have lost their imaginary function. Such an object is a perceptum that is
gazing at her. Her hair, her breast, her eyes, are gaze objects. They are manifestly not lost, in fact, are phenomena.
Each is a perceptum.
In British psychiatry, presumably under the influence of Melanie Klein, ambivalence is the basis of the
psychopathology. One speaks about a long-standing love and an apparent new hatred to which the delusion of
doubles is the solution. The double is the bad object to which the subject reveals its hatred preserving the good
object10. Capgras himself points out that his patient dragged the concierge and tenants into her delusion. That is
to say, it wasn’t confined to her love objects. She does not have to preserve the concierge and tenants as love
objects. One evidently needs a love object to have ambivalence and therefore a hate object. What the good
professor of psychiatry here reveals in his analysis is the impossibility of being rid of an object. What he is
observing is that the object is always preserved in psychosis and not lost. For instance, it is preserved in the
indelibility of the image.
Capgras and his collaborator remark that the patient withdrew a feeling of familiarity from the image, which now
has become strange, foreign and believed to be other. It is not a question of the ambivalence of love and hate.
Love does not exist. The subject reduces the otherness of the image by loving it, by making it its own, by creating
from it a sense of self, of property, of intimacy. If this does not happen in identification, if the image does not
lend itself to it, the persecutory effect of being robbed of oneself is the result. The sense of property is destroyed.
When the other is not the self, it is the double. The double is, no doubt, a trauma and real. The image is
recognized but is affected by what has been called also in British psychiatry a delusional hypo-identification11.
For Capgras the basis of the psychopathology is what he called in 1923 agnosie d’identification and in 1924
____________________
9 J. Lacan, “De nos antécédents,” Écrits, op. cit., p. 70.
10 M. D. Enoch and W. H. Trethowan, Uncommom Psychiatric Syndromes, John Wright and Sons Ltd, Bristol, 1979, p. 88.

méconnaissance systématique. Agnosia is a neurological term indicating an incapacity to recognize objects,
which is not the problem in the delusion of doubles. The patient recognizes the image of her husband and her
daughter but believes that they have been replaced by exact replicas. The double could not establish itself if
recognition were not functioning. There is no identity between the double and the person who has disappeared.
One could translate this term “identification-agnosia” in the manner of DSM-IV-TR and call it a disorder of
identification. We already have the term “delusional hypo-identification” which implies a disorder of
identification.
In 1924 Capgras and another collaborator repeat that the problem is at the level of identification. The authors
now call the fundamental disorder méconnaissance systématique, systematic misidentification. Clérambault was
in the audience when Capgras and Carrette read their paper. He commended the isolating and use of the process
of systematic misidentification, considering that it can be found in melancholia and in mania as well as in
paranoia.
Jacques Lacan and méconnaissance

On page 165 of the Écrits, Lacan uses méconnaissance12 like Capgras uses it, that is, as a disorder of
identification, as a delusional hypo-identification such that the subject never acquires a sense of ownership of its
own representations, on the contrary, disowns them. In fact, it is difficult to say whether Capgras had such a
precise notion of identification as Lacan was already trying to develop in 1946. On page 179 he is using it like
Freud does by associating it with Verneinung13. Lacan calls it a formal negation which is, he says, a typical
phenomenon of méconnaissance. Used in this way negation is not, according to Lacan, a disavowal of the
subject’s own productions, not a disorder of identification. Using it like Capgras uses it, it is a psychotic
phenomenon, and like Freud it is a neurotic phenomenon. I think that Lacan is paying back his debt to the two
disciplines that begot him, psychiatry and psychoanalysis.
Identification is for Lacan at this time in 1946 associated with cause: “A form of causality founds it [the imago]
which is psychical causality itself: identification, which is an irreducible phenomenon, and the imago is that form
definable in the imaginary space-time complex whose function is to realize the identification that resolves the
previous psychical phase, that is, a transformation of the individual’s relations to its imaginary partner.14 It seems
that this identification-cause transforms the subject’s relations to the imaginary partner from a paranoiac relation
to a neurotic relation which does not occur in the face of a systematic misidentification.
One should not then be too surprised to find Lacan referring to this concept of Capgras as late as 1955 on page
416 of the Écrits.15 This is the year of his Seminar III, on psychosis, when he takes up the matter of foreclosure
in a more expanded way, having already discovered it in Freud’s texts. However, here we catch him applying it
to his American colleagues in an ironical way: “Its practice in the American sphere has been summarily reduced
to a means of obtaining ‘success’ and to a method of demand for ‘happiness’ that indicates a repudiation of
psychoanalysis which is the result amongst too many of its adherents by virtue of the pure and radical fact that
they have never wanted to know anything about the Freudian discovery, and they will never know anything about
it, even in the sense of repression: the effect is due to the mechanism of méconnaissance systématique which
simulates the delusion, even in its group forms.16 In the sense of repression they would, of course, know
____________________
11 G. N. Christodolou, “The Syndrome of Capgras,” Brit. .J. Psychiat, 1077, 130.
12 J. Lacan, “Propos sur la causalité psychique,” Écrits, op. cit., p. 165.
13 Ibid., p. 179.
14 Ibid., p. 188.
15 J. Lacan, “La chose Freudienne,” Écrits, op. cit., p. 416.
16 Ibid.
26 RICHARD KLEIN
something about it without knowing it. The repudiation is the effect of a systematic misidentification which
Lacan was already calling forclusion, and, in fact, he is using the two terms synonymously in this passage. Not
ever wanting to know anything about it is a foreclosure. The Freudian discovery is foreclosed in American
psychoanalysis. Only in 1955 he is recognizing that not only Freud but also Capgras is responsible for the
concept. Of course, neither Freud nor Capgras drew the consequences as Lacan did.
Courbon and Tusques, in by no means the last word on the matter, continue to consider the fundamental disorder
in all three syndromes as a problem at the level of identification.17 They classify identification into three
categories: hyberbolic, amnesic and delusional. In hyperbolic identification the patient expresses resemblance
perceived between people in an excess of language. This is the delusional hypo-identification in the delusion of
doubles. Amnesic identification produces the more typical false recognition of dementing patients in whom false
recognition is primary. Delusional identification in the case in which memory is intact is made responsible for
false recognition which is now secondary. The delusional identification of Courbon and Tusques is doing the
work of the systematic misidentification of Capgras. The interest of delusional identification is that it makes any
false recognition in these clinical structures secondary ensuring the functional status of psychoses.
Fregoli’s illusion
The psychopathology of the Fregoli syndrome and the intermetamorphosis syndrome is based on hyper-
identification and false recognition, false recognition being an effect of, secondary to, hyperidentification. The
Fregoli syndrome consists in the delusional belief that the persecutor is incarnated in one or more individuals.
Courbon and Fail describe a 27-year-old woman who is convinced that her persecutors, Sarah and Robine
Bernhardt, can inhabit other people in order to torture her, to look at her masturbating which they make her do,
and it is destroying her body. She experienced some sort of influence from an unknown woman passing by in
the street who became in that moment Robine. She assaulted the woman which led to her admission. The patient
herself, who spent all her free time at the theatre, called her persecutor a Fregoli who was an Italian actor able
to change his appearance several times in the same scene. The image of the person whom Robine is inhabiting
does not change but is, nevertheless, Robine. Robine is not a person who looks like Robine Bernhardt. It is a
false recognition which has to be taken, of course, as secondary to a delusional identification.
The delusion of intermetamorposis was discovered by Courbon and Tusques in a 49-year-old melancholic
woman with persecutory ideas. Neighbors became her husband who consequently became older or younger,
taller or shorter, depending on what neighbor. It had all the charm of being at the cinema according to his wife.
He retained certain features in the course of metamorphosis, for instance an amputated finger and his gray eyes.
The subject believes that persons in the environment change into each other which is also a false recognition.
Otherwise, it has been considered along with the Fregoli syndrome to be a delusional hyper-identification, a term
already used in the British Journal of Psychiatry.18
Identification, desire, recognition

Thibierge19, who has reminded us about these syndromes once again, has remarked upon the detachment of the
name from the image in the structure of the delusional misidentification syndromes. There are, according to him,
two functions in relation to the image, the function of the proper name and of recognition. He says that to pass
from recognition to identification, a symbolic operator called a proper name is required. If the function of the
proper name is foreclosed, no identification takes place. The subject remains at the level of recognition. He
____________________
17 P. Courbon and J. Tusques, “Identification délirante et fausse reconnaissance,” Ann. Med-Psych, 14th series, v. II, June 1923.
18 G. N Christodolou, “The Syndrome of Capgras,” op. cit.
19 S. Thiebierge, Pathologie de l’image du corps, PUF, Paris, 1999, p. 89.

doesn’t seem to mention that recognition is a function of desire in the early work of Lacan. To remain at the level
of recognition is not to remain at the level of desire in these clinical structures. It is recognition in some way, as
Lacan (1946) says. Thibierge is considering recognition as a function in the phenomenology of perception, not
as a function of desire. Regression to recognition is not regression to desire. In the delusion of doubles this
person looks like my daughter, but is not my daughter. She is an exact replica of my daughter but does not act
like my daughter. There is recognition but no identity, no accreditation, as it were. As for recognition, the author
just mentioned considers that it has a natural association with the image.
It is a fact that Lacan between 1946 and 1949 keeps recognition and identification distinct. In his 1949 paper in
the second paragraph the human subject recognizes its image in the mirror as indicated in mimicry.20 At this
time, the image has an inherent capacity to arouse recognition. The sort of image that does so is species specific.
The mirror image is species specific for the human subject. Recognition with respect to the human face begins
on the 10th day of life, says Lacan in 1946.21 There is no identification but there is recognition. The image in
1949 continues to have a natural association with recognition. In the third paragraph of that paper the image is
assumed which means identified with. Recognition is associated with the signs of mimicry and identification
with the triumphant assumption of the image. The type of recognition here is a function in the phenomenology
of perception. We now think of the gestures associated with mimicry and the assumption of the image as
belonging to the first paradigm of enjoyment, enjoyment circulating in the imaginary relation. If one could hold
Lacan to this distinction, recognition would be a form of identification that is less stable, that does not go beyond
the effects of mimicry, a non-symbolized identification. This kind of identification occurs, but it would be a form
of recognition close to the real and not one that has a natural association with the image in the phenomenology
of perception.
In 1948 recognition implies subjectivity and is demonstrable in the triumphant play of the infant with its specular
image, he says.22 If there is no identification in the structure till the sixth month of life or thereabouts, then there
is no ego to recognize an image. He, in fact, has to suppose a subject that recognizes the image since there is no
ego to recognize it. This is why Lacan does not center the ego on the system perception-conscience23 – because
there is only a subject who recognizes a signifier. This would be a subject of desire. With the advent of the
subject, desire is admixed with recognition. Recognition here is what is called Bejahung in Freud’s texts. In a
judgement of attribute the subject gives its consent to the signifier of the Other. It is a symbolic recognition.
Recognition associated with the image is then imaginary. Neither symbolic nor imaginary forms of recognition
happen in the delusional misidentification syndromes.
Take the patient of Courbon and Fail. She“ fregolizes” the world. To fregolize is her expression. In fregolizing
the world the symbolic becomes real. That really is a clinique ironique. It is an irony to contrast her position in
a confrontation with the real to something as symbolic as the theatre. She does not consent to the signifier of the
Other in a symbolic recognition. Robine is her persecutor who inhabits other people around. These other people
do not look like Robine, but they are called Robine. Phenomenologically that is a false recognition. The proper
name has become detached from the image of Robine. To call everyone by the same proper name is making
foreclosed use of the proper name. When she is delusionally convinced that Robine is inhabiting certain other
people, they become Robine, are called Robine. It is a delusional identification, according to Courbon and
Tusques, and a systematic misidentification, according to Capgras. The same disorder is at work in the Fregoli
syndrome as in the Capgras syndrome. Robine gazing at her masturbating recognizes the patient. It is the patient
____________________
20 J. Lacan, “Le stade du miroir. . .,” Écrits, op. cit., p. 93.
21 J. Lacan, “Propos sur la causalité psychique,” op. cit., p. 181.
22 J. Lacan, “L’agressivité en psychanalyse,” Écrits, op. cit., p. 112.
23 J. Lacan, “Le stade du miroir. . .,” Écrits, op. cit., p. 99.
28 RICHARD KLEIN
who is recognized in the real. The patient is gazed at by the Other and recognized but not in the visual field.
There is no natural association of recognition and image in any of these delusional syndromes. It isn’t a symbolic
recognition but one in the real.
The gaze is on the side of the Other

The Fregoli syndrome is an exquisite illustration that the gaze is on the side of the Other and not on the side of
the subject. The gaze of the subject is an occurrence in the phenomenology of perception. In the gaze of the Other
we pass from the phenomenology of perception to the logic of the perceived, following Jacques-Alain Miller’s
orientation24. Robine is gazing at the patient. She is not in the visual field when she is gazing at the patient
masturbating but in the scopic field which is the field of this logic of the perceived. It’s the patient who is
recognized and becomes an object of enjoyment under the gaze.
In Seminar XI Lacan is unraveling a gaze that occurs in neurotic structure. We have to do for the gaze in
psychosis what Jean-Pierre Klotz does for the voice in psychosis following Lacan’s paper on Schreber.
Phenomenologically, visual hallucinations do not commonly occur in the functional psychoses, usually in the
toxic psychoses only. The voice is associated with the verbal hallucination. The gaze in the psychotic
misidentification syndromes is associated with delusion and not hallucination. According to Jacques-Alain
Miller’s “Logic of the Perceived,” the field of perception is structured according to the sign. The gaze as
perceptum is a signifier that determines the subject at the level of the signified, determines what is called for this
purpose the percipiens. The percipiens is the material that is given-to-be-seen, says Jacques-Alain Miller. It is
not a given-to-be-gazed-at. The given-to-be-seen is material in the visual field in which field the subject is
located. The gaze, on the other hand, is outside this field and is an object a in the field of the Other. The subject
is gazed at from the field of the Other which is not the perceptual field but the scopic field. We would have to
write the scopic field above the bar of the sign and the visual field below the bar of the sign. What is given-to-
be-seen is below the bar.
There are varying effects at the level of the percipiens. That effects at the level of the signified always vary is a
principle of the sign, noted by Jacques-Alain Miller. This must also be the case when there is a special sort of
signified such as the percipiens. And, of course, that happens in Seminar XI. The subject at the level of the
percipiens is gazed at25, and this turns it into a picture.26 The picture is something that has attributes as well as
a hole in it.27 Lacan does not say it in Seminar XI, but that looks like the division of the subject to me, on the
one hand a hole, that is an emptiness, on the other an attribute. The subject is determined as picture, then, but
also as satisfaction. The percipiens can be determined, as satisfaction like for the woman who knows that she is
being looked at provided one does not let on that one knows that she knows.28 If in love, says Lacan, you never
look at me from the place from which I see you, it does not bring any satisfaction.29 The subject, not being under
the gaze, is not satisfied. Under the gaze the subject can be determined as shameful when caught red-handed
exercising his voyeurism. This is how he is determined in Lacan’s comment on Sartre’s passage from his famous
text, where the subject is a given-to-be-seen in the visual field and the gaze is “heard” outside in the scopic field.
He is occupied looking through a keyhole, hears a noise and supposes immediately that he is under a gaze from
____________________
24 J.-A. Miller, “The Logic of the Perceived,” Psychoanalytical Notebooks n°6, 2001.
25 J. Lacan, The Four Fundamental Concepts of Psycho-analysis, (The Seminar, Book XI, ed. J.-A. Miller), trans. Alan Sheridan,
The Hogarth Press, London, 1977, p. 72.
26 Ibid., p. 100, p. 106.
27 Ibid., p. 108.
28 Ibid., p. 75.
29 Ibid., p. 103.

outside in the field of the Other.30 That does not mean that there is anyone there. The gaze can absolutely be
absent in this situation and achieve the effect described. These effects generate representations. At the level of
the signified there are representations. The gaze itself is not a representation. It is rather symbolic of a lack that
constitutes castration-anxiety.31 This is the gaze in so far as it partakes in the symbolic, in so far as the hole in
the picture is constituting. The object gaze divides the subject.
There is no satisfaction for the patient of Courbon and Fail under the gaze. To conceive it, I’ll take up three
references to Jacques-Alain Miller. Firstly, the gaze is not a lost object. In psychotic structure the object is not
lost. We can connect that to Seminar XI by not making the gaze symbolic of a lack that constitutes castration-
anxiety. Secondly, in the dream of the neurotic the subject is entirely governed by the Other, the Other leads the
subject, Miller continues, one does not know where. The patient of Courbon and Fail is entirely commanded by
the Other on the street, not just in the dream. She experiences the influence of Robine from a woman who is
passing by in the street whom she assaults. This influence is enjoyment which she locates in the field of the
Other. The Other gazes at the subject who becomes an object of this gaze, of enjoyment as gaze. Thirdly, in “The
Logic of the Perceived” the given-to-be-seen is an offer by the subject. I myself would continue to say that the
subject is accepting the signifier of the Other. That the subject is offering itself as a given-to-be-seen is equivalent
to a Bejahung in the field of perception. This offer can be replaced with a force: to show, says Jacques-Alain
Miller. In psychotic structure the subject shows. Showing leads to the delusional belief of being under the gaze.
Is showing a disorder of the subject? I remind you again of Jean-Pierre Klotz’s paper in Psychoanalytical
Notebooks, no. 6. Is there one explanation based on a disorder of identification and now one based on a disorder
of the subject?
In the Apollonian effect of painting, as Lacan puts it32, the function of art is pacifying. It invites the spectator to
lay down his or her gaze. This function of painting is a taming of the gaze.33 What else is pacified and tamed but
enjoyment, jouissance? The Apollonian function of art is civilizing. The gaze being an object in the scopic field
must be a condenser of enjoyment. But the painting has no such Apollonian function in psychotic structure,
although I am told that painting and not the picture as such has a calming effect on some psychotics. Could we
call this, then, like Nietzsche in The Birth of Tragedy the Dionysiac function of art? It’s Nietzche who grasps the
history of art in these two dimensions: the Appoline and the Dionysiac. In the Dionysiac dimension the subject
shows herself masturbating. There is no taming of the gaze in this dimension. It becomes associated with the
delusional belief that someone with a superior soul is gazing at her, namely Robine. In the Dionysiac dimension
the painting has not got a hole in it. There is no constituting lack by castration of the subject. The subject cannot
approach its division.
The assault on the passer by is the passage to the act which led to her admission. It’s mainly women she has a
problem with, although the soul of women is superior to that of men, according to the patient. There could be an
erotomaniacal element which is also persecutory. That brings me to another problem whether the passage to the
act has the same structure in psychosis as in neurosis. In her passage to the act the young, homosexual woman
becomes an object that drops from the scene. Dora passes to the act when in the discourse of Mr. K she confronts
the possibility of being nothing which would also drop her out of the scene. The passage to the act in neurotic
structure involves the drop-function of the object. The patient of Courbon and Fail passes to the act when she is
forced into the picture. She is forced to live in a scene, masturbating.
____________________
30 Ibid., p. 84.
31 Ibid., p. 72-73
32 Ibid., p. 101.
33 Ibid., p. 109.
30 RICHARD KLEIN
Marie-Hélène Doguet-Dziomba
The French “Mental Health Plan”
How can we situate, at the beginning of the twenty-first century, the accelerated destruction of the field of
psychiatry, and the increasingly massive effects that have been evident for at least twenty years? This destruction
has been ratified by the substitution of the term “mental health.” for “psychiatry.” Before examining what new
field is covered by this invention of the modern master we should note the details of the announced death of
psychiatry. It is now clear that what we are seeing are the effects of the dissolution of the psychiatrist’s object,
and more precisely the effects of a denial, of a disavowal, even of a foreclosure that touches the relationship with
this object – the relationship with the insane, the psychotic.
Indeed the object of “mental health” is not the insane person, but the “user of the mental health system.” The
subtitle of the French “Mental Health Plan,” dated November 2001, is: “The user at the center of a system in
need of renovation.” It is striking that this document does not once mention the term “psychosis”; the term
“insane” is taken up in the first of the eight axes that constitute this plan, under the heading “Fighting against the
stigmatization attached to mental illnesses.” One can read there: “A recent survey, carried out by the
collaborating center of the WHO for research and training in mental health, reveals that the representation of the
insane and even more so of the mental patient entails a stigma due to the potential danger attributed to him or
her.”1 So it seems to be about “modifying the image of mental illness and the professionals who deal with the
patients” among “somatician care-givers” and the general public – we will see to what end.
The psychiatrist’s object

Shortly after the Second World War, Lacan praised the psychiatrist Henri Ey for obstinately maintaining the term
“madness” in the face of those who would have liked to reduce it to omnitudo realitatis. He thus situated Ey’s
“original and permanent problem” as that of “the limits of neurology and psychiatry – which certainly would not
have more significance than in the case of any other medical specialty if it did not engage the originality specific
to the object of our experience. I have named it madness.”2 The question he was dealing with at the time was:
“Is there nothing to distinguish the alienated from other patients, except the fact that one is put in an asylum and
the other in a hospital? (…) Does the originality of our object stem from a practice, that is, is it social – or from
reason, that is, is it scientific?” This brings to light, as if in a short-circuit, the radical change in mode of
psychiatry in the twenty-first century, explicit in the project of the modern master and his experts in “mental
health.”
To help us evaluate this change, I would like to extract four points from a conference given by Lacan in 1967,
entitled “A short talk to psychiatrists.” More than ever, these four points can be used as reference points and
confronted with what they anticipated, and is now visible in all the consequences which have amply developed
in over thirty-five years.
First point. In 1967, when addressing psychiatrists assumed to be in analysis, Lacan reaffirms that the heart of
____________________
1 Plan santé mentale “L’usager au centre d’un dispositif à rénover,” French Ministère de l’emploi et de la solidarité, Ministère
délégué à la santé, November 2001, p. 12.
2 J. Lacan, “Propos sur la causalité psychique,” Écrits, Seuil, Paris, 1966, p. 154.
The French “Mental Health Plan” 31

the psychiatrist’s field is the insane person. Admittedly, he adds, there are “a lot of other patients who come,
because the police is involved, within the same framework (…) the demented, the weak, the disintegrated, put –
momentarily – in a state of mental depreciation,” but “this is not, strictly speaking, the object of the
psychiatrist.”3
Michel Foucault, in his History of Insanity, showed that the position of the psychiatrist came into being with the
practice of isolating the insane – locking them up, that is to say, as Lacan specifies, treating them in a
“humanitarian” way. The idea of the symptom is related to this confinement. And the fact that we tend to isolate
them less and less, he notes, means that we put up other language walls: in particular, we regard them much more
as “study objects” than as “question marks” – concerning a certain rapport of the subject of the unconscious with
the signifier and jouissance.
The position of observer, who interposes protective barriers – a “hunch,” an “organo-dynamism,” a “labeling,”
a “scale” that separates one from the insane – obviates the “consideration of the subject”; the “position of
authority” of the psychiatrist, who is integrated in a hierarchy, is also an obstacle to this consideration. All this
converges towards an impossibility for the psychiatrist to approach the reality of the insane from a new point of
view.
Pharmaceutical dynamism and the followers of Kraepelin

Second point. Lacan states that in the area of this relation with the objet–fou – the insane person as object – not
the slightest clinical discovery has been made in thirty years. According to Lacan, in 1967, we were still left with
the beautiful nineteenth-century heritage whose most recent improvements were, in addition to Clérambault’s
clinical entities, his own Phd on paranoiac self-punishment. Lacan adds this: “Today, psychiatry is a part of
general medicine on this basis: that general medicine itself enters entirely into the pharmaceutical dynamic.
Obviously, new things happen: one blurs, one moderates, and one interferes or modifies. But one doesn’t have
any idea what one modifies, nor where these modifications will go, nor even the sense of them.”4 In short, there
are no new clinical discoveries apart from the clinic of drugs, and an absorption of psychiatry by medicine –
itself reabsorbed into the dynamics of pharmaceuticals.
About what we have inherited from the nineteenth-century, one could say it has been recycled, fragmented, and
transformed into criteria regrouped as syndromes in the DSM. As two American professors have shown, it is a
“college” of Kraepelin’s followers who imposed the DSM beginning in the 1980s, first in the USA and then
worldwide, in a truly forceful coup directed mainly against the American post-Freudian school. This coup was
based primarily on the transformation of the validity of a diagnosis into a technical problem of reliability.5
Third point. Lacan questions the “mass effects” of psychoanalysis. He only sees this in 1967, when the
psychiatrist pays less and less attention to the patient, and does not think about his position as psychiatrist,
because he is completely preoccupied with his psychoanalytical training. He comes to psychoanalysis in order
to “understand” his patients – a misconception stemming from the commonly-held notion that psychoanalysis is
in the register of sense. Quite to the contrary, Lacan finds the radical basis of “subjective facts” in non-sense.
What is crucial is locating the non-comprehension, the only possibility for “cleaning up the areas of false
comprehension.”
As a counterpoint to the practice of sense, a preconception that infiltrates common discourse, one should mention
____________________
3 J. Lacan, “Petit discours aux psychiatres de Sainte-Anne,” 10 November 1967 (unpublished), p. 2.
4 Ibid., p. 4.
5 Cf. S. Kirk, H. Kutchins, Aimez-vous le DSM?, Les empêcheurs de tourner en rond, Paris, 1998, p. 92.
32 M A R I E - H É L È N E D O G U E T- D Z I O M B A
the multiplication of psychotherapies. Marie-Hélène Brousse said that psychotherapies were described by Lacan,
in his preamble to the Founding Act, on the political, epistemological, and ethical levels, as a mixture of “a
conformity of objectives,” of “a barbarism [in the grammatical sense] of doctrines,” and of “a regression to
psychologism.”6
The truth of the effects of segregation

Fourth point. Psychiatrists, if psychoanalysis did not put them to sleep, might have something to say about the
true sense of the effects of segregation. Lacan predicted the generalization, on a planetary level, of the practice
of segregation, of which the Nazis were precursors. He considers that the price of the progress of the subject of
science. Science was born of a “first isolation of the pure subject, that does not exist anywhere except as the
subject of scientific knowledge.” The fundamental point is that one part of this subject is veiled, the part that
comprises half of the subject and his rapport with object a, that is to say which expresses itself in the structure
of the fantasy. Opposite this veiled part, which nevertheless underlies all social construction, what dominates is
the pure, universalized, subject of science, with its effects of radical reshaping of social hierarchies: borders,
hierarchies, degrees, royal functions disappear, Lacan said. The objects a, witnesses to the progress of science,
run around everywhere, isolated, all alone, “distracted glances,” “crazy voices,” only sustained by the subject of
science.
This effect is to be distinguished from the structure of the fantasy that sustains desire, insofar as desire is
dependent on the desire of the Other: a is always demanded from the Other. Here, we have an opposition between
a mode of enjoyment, universalizable, that is not dependent on the Other; and the particularity of the jouissance
as rapport that a subject establishes with his primal signifiers and the effect of the desire of the Other.
It is at this point of disjunction that Lacan situates the insane person together with the segregation that affects
him, as differentiated from the institution, as the supposed locus of segregation. The segregation of the insane
person has to do with his mode of jouissance: the psychotic subject “is not fastened to the locus of the Other
through object a,” there is no demand for an object a, he has his object a at his disposal, he has “his cause in his
pocket.”7 In that sense, he is a “free man.”
As Daniel Roy said, “it is about recognizing segregation where it is: where it is recognized, it is called fraternity;
where it is refused, it is the basis for concentration camps.”8 The challenges concerning the conditions of care
and admission of the psychotic – challenges that could have been put forth by the psychiatrist whom Lacan
interpellated in 1967, if he had been awakened by psychoanalysis – are summed up in this way by Roy: “an
institution that banks on the segregation that the subject’s mode of enjoyment operates – that is, the symptom –
and draws conclusions from this to guard against that other segregation operated by science, technology and the
law, in their universal versions.”
The social symptom

How, taking our bearings from there, can one consider the emergence of the signifier “mental health” with its
corollary “user of the mental health system”? We have described the conditions that have made this invention
possible: the decline of the psychiatrist’s position and dissolution of its corollary, his object; the death of clinical
practice and the absorption of psychiatry into medicine, to the benefit of pharmaceuticals; the multiplication of
____________________
6 M.-H. Brousse, “4 moins 1,” La lettre mensuelle, 211, p. 3.
7 J. Lacan, “Petit discours aux psychiatres. . .,” op. cit., p. 13.
8 D. Roy, “Relire l’allocution sur les psychoses de l’enfant,” ECF-débats 6 January 2003.

psychotherapies combined with the needs of social hygiene – to take up the terms used by Lacan in 1964; the
increasing power of segregative practices founded on the proliferation of objects a outside any social bond. Let
us note that these coordinates can be collected under the term used by Lacan in the 1970s, “social symptom,” a
synonym for the open crisis of the capitalist discourse.
In his conference “La troisième,” Lacan ironically defined the social symptom taking “the proletarian” as his
starting point: the individual has become the strict equivalent of no matter which surplus enjoyment produced
by our industry, what Lacan called a “sham surplus enjoyment”9 – all these transitory and volatile objects
proposed for our consumption, in which Lacan recognized Marx’s surplus value. He noted, in “Radiophonie,”
that “surplus value is the cause of desire that an economy takes as its principle: that of extensive production,
therefore insatiable, of want-to-enjoy (manque-à-jouir).”10
Lacan inscribed the capitalist discourse as a mutation of the master’s speech, by inverting the place of the master
signifier S1 and that of the divided subject, the barred S. Conversely, the proletarian individual is the subject of
science who has passed into position of master and who is completed in discourse by his “sham surplus
enjoyment.” Lacan specifies that he has nothing with which to establish a social bond. The capitalist discourse
includes the very ruin of discourse owing to the fact that the sham surplus enjoyment objects cut the subject away
from his bond to the Other – to knowledge and to truth.
Psychiatry’s change of system

The problems of “mental health” and its users are inseparable from this open crisis of capitalist discourse and
the resounding expressions of the proletarian symptom. Beyond the guise of “humanitarianism,” what the
“Mental Health Plan” is about is our future as a common market and our future in generalized segregation.
Health has become a market like any other, the patient a user, that is to say a consumer – himself, his health, the
psychotherapists increasingly more polyvalent and disqualified, or on the contrary hyper-specialized, the
“networking,” the training periods of all kinds, the sanitary, the medico-social, the social, today everything has
to do with surplus value and the economy of services. For many years now, the European capitalist master has
earmarked the psychiatric asylum structure for disappearance – that is the objective. The strategies remain to be
developed. Let us note that in France, the number of beds declined from 120,000 to approximately 50,000 in fifty
years (of which 16,000 have disappeared in the past six years). During this same period, the average length of
stay decreased from 300 days to 35.11 As for the number of psychiatrists, from 11,500 today, their number will
diminish to 7,500 in 2020.
Many experts12 have underlined a paradox qualified as “worrisome”: for about ten years there has been a
massive increase (more than 50%) in the number of admissions in urban areas – more precisely, of the number
of hospitalizations without consent (65,000 in 1999). These account for 13% of total hospitalizations. In services
where there remains only one 25-bed unit, on any given day approximately 40% of the patients have been
hospitalized under constraint.
In addition, experts note an evolution of the “clientele.” Let us note the surprising terminology used by one of
the members of the national Mission of support in mental health (MNASM Mission nationale d’appui en santé
mentale): “the proportion of young patients, in acute medico-psycho-social crisis with substance abuse,
____________________
9 J. Lacan, Le Séminaire Livre XVII, L’envers de la psychanalyse, Seuil, Paris, 1991, pp. 92-93.
10 J. Lacan, “Radiophonie,” Autres écrits, Seuil, Paris, 2001, p. 435.
11 S. Kannas, “L’offre de soins à l’hôpital,” La santé mentale des Français, Odile Jacob, Paris, 2002, p. 135.
12 See the “Rapport de mission Juillet 2001,” E. Piel and J.-L. Roelandt, “De la psychiatrie vers la santé mentale.”
increases, to the detriment of the traditional mental disorders: psychosis, anxiety-depression, mood swings (this
went, in a few years, from 60% to 40% of the total patients, for these latter.”13) Another member says: “Whereas
the sectorialized system is based on serious illnesses and in particular psychoses, forty years later psychiatry is
confronted with a whole series of new disorders: drug addiction, depression, victims of family violence, stress,
moral harassment, reactional states, passages to the act in adolescence. And with new populations: prisoners, the
excluded, adolescents, older children, and the aged”14. Moreover, faced with these “existential difficulties,” new
demands emanate from the somatic services and the medico-social and social sectors. In short, the field of
emergencies and “acuteness” is exploding. Putting these new categories – illustrations of the social symptoms
mentioned above – in the forefront testifies in a striking way to the dissolution of any clinical treatment of the
psychoses – clinical examination and thinking about contemporary forms of psychosis are never proposed.
An expert summarizes further the objective pursued: “only the reduction of beds that are extremely costly in
terms of care personnel, will make it possible to redeploy resources in the community, where these new forms
of suffering are emerging, permitting us not only to manage but also to prevent chronicity, thanks to relevant and
early action.”15 This early action is conceived overall on the model of the humanitarian interventions of
emergency NGOs. Mass psychotherapies also fall within this framework, as does analytical psychotherapy – if
it manages find its place on the market.
From this point of view we can situate one of the principal objectives of the French “Mental Health Plan” – that
of preparing to reform the law of June 27, 1990 by 2007. The action planned is the unification of the two current
modes of hospitalization without consent; it aims at “basing the indications for hospitalization without consent
on the indications of the European recommendations.”16 It is about setting up “short-term (less than 72 hours)
hospitalization without consent, near emergency services, within the framework of the organization of regional
schemes of health organization (SROS – schémas régionaux d’organisation sanitaire) and in partnership with
mental health teams in psychiatry sectors”17. In addition to a reduction in the number of beds, in addition to the
moratorium on investments in the specialized hospital complexes (CHS – centres hospitaliers spécialisés), here
is the strategy that seems to have been retained by the master to pass from psychiatry to “mental health.”
This has two consequences:
One of the master’s particular concerns is the increase in the number of prisoners suffering from mental
disorders, testifying to the increasing judiciarization of psychotic patients. It is, in particular, a question of
creating “protected hospital units” for the hospitalization of prisoners suffering from mental disorders.
Another concern relates to what the experts call the “inadequate” patient. According to these experts, all the
“inadequate” patients together would represent between 20 to 40% of full-time psychiatric hospitalization. For
the most part these are chronic cases of stabilized psychoses, or infantile psychotics grown into adulthood. For
these patients, “there does not seem to be a direct relationship between their incapacity to leave the hospital and
the manifestations of the symptoms they present.”18 The transfer recommended for these patients towards the
medico-social or social sector (MAS, FDT, FO etc.) is powerless to reabsorb the enigma of this “inadequacy.”
One could summarize as follows the regime change of contemporary psychiatry: if psychosis is no longer the
localized object of the psychiatrist, then psychosis is now everywhere, returning in the real of the social symptom
____________________
13 S. Kannas, “L’offre de soins à l’hôpital,” op. cit., p. 138.
14 Y. Bernard, “L’évolution de 1838 à aujourd’hui,” La santé mentale des Français, op. cit., pp. 55-56.
15 Ibid., p. 63.
16 Plan Santé mentale, p. 14.
17 Ibid., p. 13.
18 S. Kannas, op. cit., p. 156.

under the most diverse guises. As we have tried to show, this process is none other than an increasingly severe
extension of segregative practices. Today, only psychoanalysis is capable of countering this real – this is one of
the major issues for psychoanalysts of the twenty-first century, on the clinical level, as well as the epistemic and
the ethical levels. The consideration of the subject in psychosis, the reception and recognition of the segregation
of his particular mode of jouissance – beyond the analyst’s consulting room that psychotics frequent more and
more – pose the question of the institutions to be invented today whose logic will be that of analytical discourse.
Translated by Sylvia Winter
Betting on Inventivness
in the Treatment of Psychoses
Jean-Louis Aucremanne, Jean-Marc Josson, Nadine Page
Thinking About Addiction with Reference to Psychosis
Argument
It is clear: not all “drug addicts” are psychotic.
However, when the construction of a case permits us to spot or deduce the foreclosure of the Name-of-the-Father
or of phallic signification, why is it of interest to have recourse to the clinical theory of psychoses – elaborated
by Jacques Lacan and some others after him – for drug addiction?
Using the diagnosis of psychosis permits:
— To cast another light on certain clinical phenomena manifest in “drug addicts.” Someone’s lack of motivation,
for example, takes on another sense, another value, if it is situated within a subjective structure marked by the
absence of the very dimension of desire.
— The shifting of the definition of the function of the institution, where, for the process of admission, the stress
is less on the product – weaning, stabilization with a methadone treatment – than on the separation from a deadly
jouissance that submerges the subject, far beyond the use of a drug,
— The questioning of the place to be taken in the transference. A place must found next to the subject, in order
to accompany him in the elaboration of his solutions in face of the jouissance of the Other and its ravages.
— Finally, to question drug addiction – the functions of drugs and their ravages – in the relations of the subject
to an Other who persecutes him or who drops him, in his relations to a body invaded by jouissance, in his
relations to certain passages to the act.
I
Jean-Louis Aucremanne
It is clear, all the people we call drug addicts are not psychotic.
We are however often led to make this diagnosis. Is it a biased reading? Is it troubling, or even dangerous? We
can be criticized for it. Is the “good intention” of this criticism not linked to the pejorative value attributed to this
diagnosis in society as well as in the minds of those who are afraid of this diagnosis? In that case, the very idea
of “thinking psychosis” must be excluded as always being already a pejorative and segregating idea. It will no
longer even be sufficient to be “prudent” in making this diagnosis, we will have to eliminate it, proscribe the
name of psychosis itself…in order to attempt to escape from this pejorative definition.
An ethics of consequence
Lacan’s wager was different: it was “not to recoil in face of psychosis,” and to work at deciphering it and giving
it a non-pejorative definition. We can, with respect to this, recall the debate on psychic causality between Lacan
Thinking About Addiction with Reference to Psychosis 39

and Henry Ey in 1946. Where Ey considered that “mental illnesses are insults and obstacles to Freedom”1, Lacan
replies, concerning “madness,” “far from being an ‘insult’ to liberty, it is its most faithful companion, it follows
its movement like a shadow”2. A remark whose ethical bearing has perhaps never been sufficiently realized.
Rather than avoiding the diagnosis, Lacan indicates, from the point of view of psychoanalysis, the danger there
is in not recognizing a psychotic structure: it is the danger of making an erroneous maneuver in the handling of
transference and interpretation, and of effectively provoking a psychotic outbreak of even, we might add, not to
do what should be done, to leave him aside, which amounts in many cases to letting him drop.
The diagnosis then is of consequence as a clinical conclusion revealing a logical structure and it is of
consequence in as much as this structure brings light to practice. The interest of the diagnosis can be verified
finally in the “direction of the cure”: the diagnosis enlightens the modalities of transference and the modalities
of accompaniment of the subject.
As for our point – approaching drug addiction in the light of psychosis permits us to clarify the function and the
uses of drugs as a treatment by the real of the delocalized jouissance, but also for treating the Other as persecutor
or for keeping the sexual question at a distance.
Psychosis enlightened by drug addiction

But what is the problem of psychosis? As Alfredo Zenoni has reminded us, the foreclosure of the paternal
function is not a fact of direct observation and does not depend on an obvious psychiatric chart, but it is, on the
contrary, a fact of logic that can be deduced. It is the logic of existence itself that is concerned and we can observe
it in the clinical “details”: a non separated relation to the Other – since the paternal function is precisely an
operation of this separation – as well as a “non separated” relation to the drive – here it is not the lost object that
articulates the quest for desire, but the drive that “traverses” the body with an “impulsivity,” or else the drive that
“invades” the body. Drugs, in this respect, appear for some as a means of treating their Other, who is too close
or persecutor, while in other cases the consumption of drugs itself is taken in this state of “impulsivity.” We must
be attentive to these apparently anodyne words, which, among other signs, indicate this immediate relation to the
object – “if there are any drugs around, I take them,” that is to say drugs are imposed imperatively as
nourishment for certain psychotics.
This also concerns identifications, whether they be appendages by imaginary identifications, or alternative
identification to a problematic sexual identification – for example the well-known declaration “I’m a drug-
addict,” which must be examined case by case to know what it is an alternative to, how it constitutes an identity
and a defense for the subject.
In practice, it’s a matter of apprehending in a different way the special relation of these subjects to speech as well
as a certain number of phenomena. Especially when we sense the intrusive character of speech, which they
impart to us so readily and so simply by their reticence during “shrink interviews”: they have “nothing to say,”
they have already “said everything,” or else we come up against certain significations that are “unquestionable”
as such. These signs must be put into a series with others having to do with the family conjuncture, concerning
the “type of Other” they were up against, or their way of handling the other: for example, finding themselves
regularly in conflict, “going berserk,” because of a remark, which situates certain subjects much more on the side
of what is called “psychopathy,” close to the passage to the act, without a delusional construction.
____________________
1 J.Lacan, “Propos sur la causalité psychique”, Écrits, Seuil, Paris, 1966, p.157.
2 Ibid., p.176.
40 J E A N - L O U I S A U C R E M A N N E , J E A N - M A R C J O S S O N , N A D I N E PA G E
An enlightened support in face of the real…
All that indicates that it is not the position of interpreter, of supposed-to-know, or of enigma which is suitable,
but rather that of attendant, secretary, discreet counselor, sometimes something of a pedagogue, or a mediator
with respect to others.
As for this, I think that all institutional creations that are imposed by practice, without necessarily having
recourse to a diagnosis, which have consisted in introducing “low limits of exigency,” which have put aside the
ferocity of the ideals of abstinence, as well as the ferocity of therapeutic ideals, or else which have been
preoccupied by the “management of risks,” have been favorable to taking on these “psychotic” subjects, and
have constituted a first mode of appeasing treatment. A supplementary step can be taken when we work on the
“construction of the case,” which supposes not to recoil before the question of diagnosis, but fundamentally, in
order to help these subjects in face of the real they are at grips with, to support them, in a more enlightened, more
determined way, to find alternative solutions to the paternal function they have not found on their path – a
paternal function that also has its symptomatic scoria that neurotics can tell us about.
In addition, these “psychotic” subjects have met up with fathers on occasions, but fathers who are not themselves
“adjusted” and we could then see appear within the domain of “help for drug addicts” people who wanted to
“play the father,” play the father in an imaginary version, play at being “all powerful,” at being the saver –
assuredly charismatic personalities, but often little inclined to a clinical listening practice, because too
encumbered by their own narcissism.
…Or how to cope without the paternal function

The diagnosis of psychosis remains problematic: its pejorative value again! Suppose we were to put it into
perspective. Still, the true base of the question is logical: the formalization of the paternal function and its
avatars, including foreclosure.
Maybe we have not yet made so much progress that we can do without it. But if this operator is not conditioned
to function, the question is how do the subjects get along without it? What kinds of “normality,” what kinds of
inventions does that produce? What kind of symptoms? We could speak of the “other paths”: those that do not
go by the Name-of-the-Father. In that case, there would be need to consider the different symptomatic outfittings.
The most diverse: the classical – paranoia, schizophrenia, melancholia, and many others, which will take on the
form of “depression,” narcissistic troubles, anorexia, bulimia, psychopathies, all kinds of addictions, not to
mention the “pre-oedipal” structures of the “borderlines” and other “astructurations,” and of course the forms of
“normality” and exceptional destinies.
At any rate, what is important for us is how the subject defends himself in face of the real. More than ever,
clinical practitioners will have to learn from these symptomatic and creative paths “outside the Name-of-the-
Father,” because of the multiple configurations that the contemporary world produces and the “deregulations”
produced by the market economy.
But why then give so much importance to the Name-of-the-Father? Because it too is something we have learned
from clinical practice, a manner of “coping” with the real that counts. Which counts by all the positive stimuli
it carries for sustaining the social bond.

II
Jean-Marc Josson
In order to stress, within what permits the use of the diagnosis of psychosis, another way of looking at certain
phenomena concerning the clinical structure of “drug addicts,” and a shifting of the definition of the function of
the institution, I will present the case of a young woman.
She lives with her mother and takes heroin and methadone every day. She comes to the Enaden Medical Center
with a request to get off drugs.
A first reading would bring us to conclude that her problem is drugs, that what brings her to Enaden is a problem
of drug addiction and consequently that the function of the institution is to be a place for weaning as far as
Enaden’s Crisis Shelter is concerned, and a place to consolidate the weaning as far as Enaden’s Short-stay Shelter
is concerned. The fact that she comes to these two Enaden units for the second time in a year could be the sign
of an insufficient motivation.
Another reading
This first reading does not permit us to discern the real in play for this subject. It is a reading that scorns certain
clinical details, which would permit us to situate its problematic within a broader logic.
So this young woman lives with her mother. The day she has an appointment for the interview required for
acceptance in the Enaden Crisis Shelter, she overdoses on heroin. Later she says that she was unable to tell her
mother she was not well, that her mother was incapable of hearing this. Moreover – we had not spotted this at
the start – it is while she was considering a geographic separation from her mother that she passes on to the act.
An examination of her family constellation and her history – through which her subjective structure can be
mapped out – brings to light a ravaging relation with her mother. Her mother leaves her no place whatever and
bombards her with all sorts of things. Her mother, on the other hand, is afraid of her and of her reactions. This
relation is not mediated by the paternal metaphor. Her father, who is deceased, drank and would make licentious
sexual remarks to his daughter: these few traits evoke the figure of a father of jouissance.
Thus, this young woman is not separated from the Other, from her mother. She is both the object of jouissance
of the Other and a tyrannical master. There is no way out of the family sphere, no “post-oedipal” shift. Her entire
existence carries the mark of the foreclosure of phallic signification, of the absence of “operating instructions.”
Sheltering from ravage

The function of the institution is to shelter this young woman from this ravaging relationship. She is already
trying to get out of it, either by drug consumption or by passagse to the act, which are real and not symbolic
attempts to make a cut between the subject and the Other.
The institution creates a distance between this young woman and her mother, as well as between drug
consumption and passages to the act. In other words, the institution shelters this subject from a deadly jouissance
that, above and beyond the use of drugs, submerges her. This distance is of course quite relative. Being in the
institution does not prevent her from being in contact with her mother every day, or even several times a day on
the telephone, during visits or time outside. One fact of her structure is unavoidably there, “the point at which
she is persecuted is the point she cannot separate herself from,” to quote an indication given by Zenoni in
supervision. Nor does being in an institution prevent her from taking drugs.
It is however only on this condition – being in an institution – that this young woman can elaborate the question
of her place in life. Which she does through diverse uses of the institution – talks with a psychologist, painting,
proceedings to find another institution. But even then, the match has not been won!
III
Nadine Page
Making a diagnosis has consequences on the work with the patients.

The diagnosis inevitably comports an ethical dimension, even when it seems to stay completely out of it, under
purely technical aspects. It supposes a conception of the subject that shows its effects in the relationship with the
patient, notably in the objectives or the horizon that we give to this relationship.
If we postulate that the psychotic subject is characterized by a non-separation from the Other, and so from
jouissance – these two terms not being separated by the operation of the paternal metaphor – we can infer that
our work has as its objective to maintain, or to introduce in the more precarious moments, a distance between
the subject and this Other who has sometimes become ravaging.
In order to support this operation, we must situate the type of relation that the subject maintains with his Other,
and the function of the drug within this constellation.
These points will serve as guidelines to articulate this clinical vignette.
A “real-ization” of the separation

The following case involves a man who comes to the consultation at Enaden after a period of consumption of
cocaine that he describes as going beyond all the limits he had been able to give himself until then, and having
led him to a close encounter with death.
Two functions of drugs are progressively discerned during the work of elaboration he effectuates. The first seems
to have as its source an attempt at separation from the extremely intrusive Other, here the maternal Other. The
other consists rather in a form of cancellation of the subject when his attempts to have himself represented for
the Other, that is to treat this non-separation in another way, fail. In both cases, drugs appear as a real separation,
a “real-ization” of the separation, according to Zenoni’s expression, when this separation could not be introduced
by the paternal metaphor.
The mother of this subject – no longer that young – rules over many aspects of his daily life: his shopping, his
budget, his relations with neighbors, his medical treatments, the setup of his living quarters. . . All that is taken
within the field of the maternal logic as an attempt to put a stop to the devastating effects of his consumption.
These phenomenological aspects are however not sufficient to situate the “mode of being-object” of this subject
with respect to his Other, according to one of Zenoni’s indications. The place this maternal Other concedes him
is in fact extremely confined: none of his attempts to engage in a relationship with a woman were received
favorably by his mother, and were often actively put an end to, and he is accorded little credit as to his capacities
for professional achievement. Finally, as was made clear during a supervision session, the parental constraints
on the arrangement of his lodging – concretely, he can modify nothing in this environment, which contains all

his mother’s family souvenirs – appear to be perhaps the translation of an exigency: that he be the guardian of
this unalterable space, this mausoleum of maternal souvenirs.
When he correlates his unrestrained spending to a desire for vengeance with respect to his mother, when, in order
to finance this spending, he sells these sacred objects of memories, is he not operating a separation with this
omniscient Other, but at the price of a mortal risk?
“The taste of drugs in his mouth”

Another function of drugs was brought out more recently. There are zones of existence for this subject that are
kept a bit separate from the maternal omnipresence: his creative activities. He finds in them an interest, and the
occasion to establish social relations. He suffers a good deal from loneliness. However, when his projects for
achievement meet up with an obstacle, despite the relentlessness and the obstination he is capable of, when he
is confronted with a material impossibility, he has “the taste of drugs in his mouth.”
These achievements, whose originality, execution and the research they require are described in detail, have as
their function an attempt to represent the subject before the Other. He insists repeatedly on their unique, personal
character. The failure of this representation, that is to say the impossibility for him to occupy before the Other a
place that supposes a previous separation from this Other, a symbolization of this loss, would be the cause of this
appeal to drugs. To talk about an appeal is already going too far; this subject testifies to the immediacy of the
presence of this taste in his mouth.
Introducing a distance
With respect to this, what position can we occupy in this work?
The aim, it seems to me, is to introduce a distance through which the subject is not totally under the ascendancy
of this uncontrolled, mad, omniscient Other, at which he can elaborate responses that constitute a form of buttress
in face of this Other.
Thus, with respect the professional Other that he repeatedly suspected not to recognize him in his capacities, to
treat him as useless, it was a matter of proposing different hypotheses to him to explain the behavior of his boss
or his colleagues. Hypotheses that met several demands, exonerating the Other of a possible degrading intention
in his direction, but also situating this Other as being himself submitted to rules and constraints which are out of
his control. This has as effect to circumscribe his (this) Other, to reduce his possible persecutive or excluding
powers, while proposing to the subject a palette of explicative keys for the attitudes of this Other. This allows
him to keep his own attitude at a distance and even to control it, to trace for himself a margin from which to vary
his modes of being in relation.
The active support on this plane brought benefits: he could maintain his activity despite some very preoccupying
moments of relapse.
The distance with respect to the maternal Other is something quite different. If his invasion leaves this subject
with no other recourse except a “real-ization” of the separation in an attempt to effect it, at the risk of his life, it
is at the same time the space where he recognizes himself, where he has his marks, at the price of risking being
swallowed up by it.
The support of three different intervening institutions, the imminence of legal pursuits for his debts and finding
himself once again in jeopardy were all necessary before he would consent to having his finances administered
by a third party: a temporary asset administrator.
It is undoubtedly here that reside the difficulty and the ethical dimension for this subject, trapped within a double
impossibility as Zenoni underlined: that of being separated from the Other and that of not being separated from
it. The ethical dimension consists in wagering, in spite of everything, on the possibility of the production of a
subject, at the price of a mortal risk. When, really worried, I became more insistent by proposing a more drastic
therapeutic measure, a hospitalization, this patient immediately indicated what the price of our encounters were
for him: to leave him the choice, because if not, I was assimilated to the maternal Other, the one who knows what
is good for him.
Translated by Thelma Sowley

Roger Litten
A Psychotic Invention: “Puffy Anorexia”
It is not much more than half a century since Jacques Lacan felt impelled to hold up English psychiatry as an
example for the future of psychoanalysis. While the intervening years have seen profound advances in the
psychoanalytic orientation that he himself established, they have also left us with a psychiatric clinic stripped of
any structural points of reference by the development of the pharmacological treatments on which that clinic is
now exclusively reliant.
One may well question whether this pharmacological clinic still offers a space within which psychoanalytic work
would be possible. Which is not to suggest that psychiatry has nothing left to teach us. For the psychiatric clinic
still offers access to material not encountered in any other setting, even if it no longer knows what to do with
that material. And the very failures and impasses of psychiatric treatment remain most instructive, especially
when set against the structure clearly manifest in the material itself, if one only has the framework within which
to situate it.
This is the case of a lady who was born in Ghana, the fifth of seven children. Her father was a successful
businessman and hotelier in the capital. Her mother died when she was 16, apparently of complications
following diabetes. At about the same time she left school and came to London to study nursing. However she
was not accepted onto the training scheme and worked as a receptionist instead while studying at a secretarial
college at night. She graduated to work as a secretary at a solicitor’s firm in Oxford Street for some years. We
have no other information about this period, apart from her sister’s description of her as “energetic and
outgoing.”
Her father died in Ghana in 1981, when she was 31. She returned home for her father’s funeral and apparently
married a Ghanaian man while she was there. It is not clear what happened but when she returned to London
three months later it was without the husband. Her family report that she was rejected by her new husband and
never recovered from this loss. They trace all her subsequent difficulties to this episode. She appeared lifeless
and apathetic after her trip to Ghana and never seemed to recover. They feel that her failure to look after herself
or take responsibility for her life stems from this period. She did not return to work, but applied to study law at
a local college. She left this course before the end of the first year on account of what she called “moral
objections.” She does not appear to have worked or studied since.
This theme of being rejected or let down in the shadowy incident with the missing husband then plays a role in
her first contact with psychiatric service in England ten years later in 1991. By this time she was already 41 years
old. She was brought into hospital by her sister, who had become worried about her condition. She had been
living with the sister all this time, not working, but claiming state benefits. Her payments had been stopped the
previous year when she failed to attend job interviews at the benefits agency. Her sister had been supporting her
since then, but had obviously started to complain about her failure to make any attempts to sort out her own
situation or to do anything for herself.
The sister must have complained about the cost of keeping her, about the money being spent on food, because
this equation between food and money had apparently struck a chord in her. She had come up with the notion
that if she had no money then she would not eat. She had simply stopped eating, had taken no solid food for
46 ROGER LITTEN
almost a month and was starting to show alarming signs of weight loss. The sister obviously did not know what
to do with her and so brought her into hospital instead.
During this admission she was treated for depression, on the basis of the observed symptoms of lethargy, apathy,
and social withdrawal, although she herself always denied feeling depressed. In fact there was every sign that
she was simply furious with her sister, stating that she would never forgive her for bringing her into hospital. She
also repeatedly accused the sister of failing to look after her properly and not giving her enough food to eat.
She was in any case diagnosed with a “depressive illness accompanied by anhedonia and loss of appetite.” She
was commenced on antidepressants and in fact made a good recovery. Her appetite soon returned and she was
observed to be eating and drinking well. She spent a lot of time in bed during this admission, but claimed that
she was merely “getting her strength back.” Her benefit payments were sorted out by the hospital welfare worker
and she was discharged after one month.
We have little information about her whereabouts for most of the next decade. What we do know from her
contact with social services seems to turn around similar themes of money, board and lodging, marked by her
continuing failure to attend to the practical necessities of keeping her benefits up to date and getting her rent paid.
The recurring theme here is that this money is in fact hers by right and that she should not be expected to do
anything in return. She has in fact repeatedly given voice to suspicions that money to which she is entitled is in
fact being withheld or stolen from her.
This period is also marked by signs of progressive social decline and increased withdrawal from all social
contact. We next find her living in a homeless persons hostel, barricaded in her room for months on end and
refusing access to health and safety inspections and attempting to avoid any contact with staff. This situation
came to a head when she became aroused and threatening towards a member of staff who had been trying to
persuade her to complete a form to renew her housing benefits. She afterwards complained that the staff at the
hostel did not care about her but were only trying to steal money to which she was entitled.
She was assessed and brought into hospital under the Mental Health Act. Diagnosis was made difficult by her
refusal to co-operate in any way with the assessment process, choosing to remain largely mute during interviews.
She was commenced on anti-psychotic medication on the basis of signs of perplexity, suspiciousness and poverty
of thought. She refused to take this medication, stating that she would only take the anti-depressants given to her
during her previous stay in hospital. She claimed that there was in any case nothing wrong with her apart from
the fact that she was anorexic. She was more interested to know what kind of treatment she would receive for
her anorexia.
It must at this stage be pointed out that this patient is in fact a rather ample African woman and there is certainly
nothing wrong with her appetite. Yet despite all appearances she continued to claim that she was anorexic, that
she was only in hospital to receive treatment for anorexia, and that she was in fact so underweight that she should
be entitled to enhanced payments of incapacity benefit.
She was challenged about this belief that she was anorexic. How did she know this? She was adamant that her
psychiatrist had told her this during her previous stay in hospital. But this had been almost ten years previously.
Well yes, but she was a recovering anorexic, and everyone knows that recovering from anorexia is something
that takes time. You have to eat regularly and get plenty of rest in order to recover your strength. What else did
she know about the symptoms of anorexia? She knew that it gives you constipation and that you have no periods.
She also knew that it was a muscle-wasting disease, one that leaves you without any muscle-tone whatsoever.
Her own muscles have wasted way completely. They are not even attached to the bone any longer. In fact she
barely has any flesh at all.
A Psychotic Invention: “Puffy Anorexia” 47

At this stage it becomes difficult to resist the temptation of confronting her with the evidence of the senses. But
what about your own body, this ample frame we see before us? This is where she comes up with an ingenious
modification. On one hand, as I have mentioned, she is actually a recovering anorexic. And this process of
recovery takes time. In fact, one can never tell just how long that process of recovery might take. By implication,
one also never really knows at what point one is no longer anorexic, and should therefore keep on eating, just in
case.
On the other hand, and more significantly, she claims that what she is suffering from is a variety of anorexia
called “puffy anorexia.” Thus what appears to be flesh on her body is merely bloating. Her body is all bloated
and puffy, but underneath she has no flesh at all. In fact, if she could just be sent for an x-ray examination this
would show that she is rather “skeletal,” that she has no flesh at all on her body and that her muscles are not even
attached to the bone.
At this point a number of things might be said about the role of the body image in anorexia and psychosis. We
would want to look at the question of the relation between the image, the body and the drive. In this case we
might consider the role of the oral drive, which here appears to have developed an omnivorous capacity to
devour the body itself. This has certainly had some kind of devastating effect on the image, leading to what
appears to be a comprehensive failure of the imaginary register in its role of mediation between symbolic and
real, leaving our patient exposed to an overwhelming experience of jouissance.
The attempt to separate out the registers of imaginary, symbolic and real would then allow us more effectively
to start considering questions of structure and diagnosis. This in turn would allow us to enter into a discussion
of the difference between the psychoanalytic and psychiatric approaches to these questions, both at the level of
diagnosis and treatment. More specifically, it would allow us to decide whether we are to consider the
presentation of anorexia in this case merely as a delusional belief that is to be treated and removed or rather as
the subject’s own attempt to elaborate a symptom that might be supported and worked with.
The one thing that does appear clear is psychiatry’s complete lack of interest in any of these questions or in
anything that the patient herself might have to say about them. There is no attempt to follow up these indications
or to get the patient to elaborate what is at stake for her in these rather bizarre notions. The belief that she is
anorexic in flagrant contradiction to all physical evidence to the contrary merely serves to confirm the delusional
nature of the disorder that she is suffering from. This in itself is sufficient evidence to support a diagnosis of an
“unspecified psychotic illness with dysmorphia” and to set about trying to resolve the delusions that underlie it.
The patient is accordingly commenced on an anti-psychotic injection as the oral medication she has been
prescribed does not appear to have made any impact on her delusional beliefs. Unfortunately she does not react
well to this injection, which makes her feel dizzy, nauseous and weak, simply contributing to a sense of physical
malaise and lethargy. She thus spends even more time than before lying in her bed, coming out into communal
areas only at meal times. Fortunately it does not affect her appetite and she is able to treat herself by eating
copious amounts of whatever food is made available to her. This aspect of her recovery continues apace as she
begins to grow larger and larger before our eyes.
Nursing staff, in an attempt to introduce some movement into this picture, suggest that she be given some leave
off the ward, get some exercise, even be escorted back to visit her hostel to pick up a change of clothing. She,
however, is adamant that she was not going anywhere, least of all to her hostel. She had been brought into
hospital for treatment against her will. This treatment was obviously not finished, if anything she was feeling
worse than when she arrived. She was therefore not going anywhere until her course of treatment was complete.
She also added that she wasn’t prepared to go back to the hostel because staff there did not care about her. They
had been lying to her and were trying to steal her money. And she was also afraid of the mad woman who lived
48 ROGER LITTEN
upstairs and kept human bones in a bucket under her bed. Questioned about this detail she insisted that it was
the police who had told her about this woman. At the same time she was not too concerned as she knew that the
police had come to fetch this mad woman and taken her away to hospital.
The introduction of this new element provided a further indication that her condition was not improving. Yet this
theme was never further developed, but only introduced in passing in the context of her reluctance to leave
hospital. She was in any case to come up with a far more effective obstacle to going anywhere. She began to
speak for the first time about the experience of “retrieving” that she was undergoing. This process of retrieving
was making her far too weak to leave her bed and she would certainly not be able to leave hospital until the
retrieving was finished.
We would obviously like to know a little more about the nature of this process of retrieving. Yet it is difficult to
be precise, as she always remained extremely guarded when talking about any sort of delusional manifestation.
At the same time she gave a very strong impression that this was a process that was as mysterious and obscure
to her as it was to us. She was able only to describe some kind of massive process of flowing in her body, which
she described with vague gestures to indicate the direction of flows from her upper body towards the lower.
The most obvious analogy here would be that of menstrual flows, and she did at times refer to the sensation of
blood passing through her body. Yet she always insisted that this retrieving was not a physical process, that it
had nothing to do with her body, but was more of a “spiritual experience.” She was eager to keep the whole topic
separate from the realm of medical treatment. It had nothing to do with her illness or with the hospital, and
certainly had not been affected by the quantities of medication that she had been given.
This process appeared to cause her no obvious discomfort or distress. Its main effect seemed to be one of
exhaustion and weakness, which was only exacerbated by any attempts to question her about the process. She
could not explain when it had begun, whether it was periodic or constant, whether she felt it more in one part of
her body than another. She was merely subjected to an overwhelming physical experience about which she could
say very little, but which was her lot and had to be tolerated with patience and stoicism.
The one aspect of this process of retrieving that did seem more defined was its temporal dimension. It was
certainly introduced in the form of a limit or an obstacle. She could not think about leaving her bed or the hospital
until the process of retrieving had run its course. And how long did she think this would take? Oh, about three
weeks. How did she know this? Her father had told her. She gave the same answer when asked what she knew
about this process, how she even knew that it was called retrieving. She knew because her father had told her.
This reminds us of the shadowy role played by her father in her illness. Here he appears quite clearly in his role
as source of signifiers, as the source of any understanding she might have about this experience she was
undergoing. The figure of her father also appeared to serve as some sort of limit or goal to this process. She
would occasionally speak rather wistfully about a future when she had recovered from her illness, when the
retrieving had come to an end, she would go back to Ghana where father was waiting for her in a big house with
lots of children.
Sometimes this father merged with the figure of her husband, especially when she was pressed too closely about
the fact that her father had been dead for decades. Both her father and husband seemed to roam as shadowy
figures around the perimeter of the hospital. She claimed at times that her husband lived nearby. He was very
busy, too busy to visit her more often, but would occasionally visit at night. He would also send food to the
hospital for her. She had received a whole chicken from him for Christmas.
This sudden proliferation of delusional themes was a cause of some alarm. A woman who had come into hospital
with some kind of eating disorder was now being sent chickens by a dead husband in Ghana. The preferred

course of treatment was obviously not proving effective. If anything her condition appeared to be deteriorating.
Her psychiatrist was somewhat at a loss. He was even prepared to listen quite seriously to suggestions that she
be referred to an anthropological specialist in voodoo possession and traditional healing.
This resort to ritual, however open-minded, is a clear indication that the psychiatric treatment has lost its
bearings. We might contrast this with the patient’s own attempts to come to terms with her disorder by way of
the diagnosis of anorexia, something that she herself had fabricated out of her first contact with psychiatric
services and then attributed retrospectively to the doctor involved. Is this “auto-diagnosis” of anorexia merely
one more symptom of her illness or should we not rather consider it as the patient’s own attempt to construct a
signifier that would give a name to her condition and put a limit to her experience of jouissance?
Hence the importance of the question of diagnosis. We may recall her initial diagnosis of depression, in an
episode that appears to involve some sort of psychotic reaction to the withdrawal of nourishment. The fixed
equation that she had constructed between money and food suggests a relation to the oral drive that is not
particularly well mediated by any signifier. Money can only be stolen from her and food can only be withheld
from her. Here too we might consider her position as object of that drive. Her whole subsequent trajectory
confirms the importance for her of being looked after, cared for and fed. She goes to great lengths to situate
herself as the object of the care and affection of the Other.
This position as object in relation to the Other is clearly a somewhat precarious one. As object she runs the
constant risk of being devoured by the overwhelming jouissance of the Other. At some stage her body has in fact
been consumed by the oral drive, leaving her with a body without flesh and muscles no longer even attached to
the bone. Yet despite this experience we may note that the persecutory aspects of her relation to the Other are
never particularly well developed. The figure of the Other remains a shadowy one and the persecutory
phenomena appear transitory and ill defined, as if they were merely a secondary reaction to the collapse of her
position as object of the Other’s care.
Her disorder appears primarily to involve some kind of massive experience of jouissance in a body that has itself
become fragmented and dissolved. This suggests some kind of profound failure of the mirror stage to provide an
image that would give coherence to her body. Like her flesh and bones, the image and the body have come adrift.
She is left with a body without flesh, on the one hand, and a collection of bones kept in a bucket by the woman
upstairs, on the other. We would certainly want to know more about the conditions under which the paternal
metaphor has failed to provide her with the apparatus to articulate flesh and bones, imaginary and real, holding
her body together.
Without this apparatus she has been exposed to the unmediated jouissance of the living organism. She has been
forced instead to construct an alternative signifier to name the real of this experience and put a limit to it. The
signifier “anorexia,” a signifier provided by the Other to which she can attach herself, then serves as a point of
anchoring in relation to which she might attempt to manage her disorder, name her encounter and construct some
sort of link between imaginary and real. This signifier also creates for her the possibility of inscribing herself in
the social bond in the position of suffering subject, thus protecting her from the constant threat of disappearing
as the pure object of an omnivorous jouissance.
Yet the fragility of this enterprise is all too apparent. Not only does the signifier “anorexia” not appear to operate
particularly effectively as an S1, but it has also not allowed her to elaborate any significant links with an S2. In
fact we could say that it is precisely the poverty of delusional elaboration around this signifier, the failure to
elaborate any significant relation to the Other, even at the risk of succumbing to the persecutory aspects of that
relation, that leaves her exposed to the living necessities of jouissance.
The failure of her own efforts to elaborate a treatment for this jouissance are then merely exacerbated and
50 ROGER LITTEN
accentuated by the psychiatric treatment, which begins by immediately challenging the link that she has
attempted to construct between signifier and body. It attempts to remove the only useful symptom she has
managed to elaborate, proposing in its place a treatment aimed directly at the level of the body. This leaves her
without a signifier with which to present herself to others, reduced to presenting herself with her body via this
obscure process of retrieving, an experience of jouissance barely articulated as drive.
Even this brief sketch is thus sufficient to provide us with a framework that might allow us to account for the
vagaries of her treatment. Curiously enough, it is precisely her physical deterioration that leads to one of the main
turning points in this treatment. Prior to being commenced on an alternative neuropleptic medication, she is sent
for a full medical assessment. Almost by chance it is discovered that she has raised glucose levels and has
developed diabetes.
This is not a severe condition and can be maintained by oral medication as long as her diet is monitored. She is
accordingly referred to the diabetic nurse who gives her detailed instructions about what she can and cannot eat,
what foods she needs to avoid and what foods she can only eat in moderation. With this change of dietary regime
her physical condition improves rapidly. At the same time the change in neuroleptic medication seems to have
done the job, as any talk of anorexia or retrieving soon disappears. When questioned directly about it she simply
dismisses the whole question. Rather than anorexic, she is now a diabetic, as her mother was before her.

Carmelo Licitra Rosa
Psychoanalysis and Psychosis:

A Happy Couple
A journey
Because of a tedious concentration problem in her studies, Antonietta, at her family’s instigation, consults a
neurologist at the age of 17. She is prescribed a benzodiazepine-based treatment for a period of three months.
The length of treatment is not respected and she continues, uninterrupted, to take hypnotics at ever-increasing
doses. A depressive state ensues two and a half years later, complicated by the first signs of an eating disorder:
she ingurgitates great quantities of food that she regularly throws up in order to keep her figure.
Her parents then send her to a psychologist for a treatment that lasts for a year and a half. This treatment is
interrupted following a suicide attempt in which she swallowed an entire box of hypnotics on the day before
Christmas. Antonietta comments on this: “It was like a provocation. She didn’t believe that I would dare to
actually do what I was threatening to.” Being that the psychologist, frightened and irritated by what had
happened, refused to see her again, Antonietta goes to see another therapist, a doctor this time, who will care for
her for two years using both a drug-based treatment and psychotherapy. Of this therapist, Antonietta says: “She
was very interested in my weight, but not in my problems.” Moreover, when the pharmacological treatment
(Fluoxtine 40mg, every morning) starts to become ineffective, she proposes that her patient spend some time in
a Swiss clinic that specializes in cases of unusually resistant obesity and bulimia. Antonietta pushes off this trip
to the clinic, which terrorizes her. As the clinical picture is progressively deteriorating, with a problem of
overweight nearing 140 kilos, her father decides to stop the treatment and takes her to another specialist, a
neurologist with an excellent reputation, who practices in another town. For four months, once a week Antonietta
goes to this specialist accompanied by her father, but in vain. At this point she consults a famous university
authority who refers her to a no less famous colleague with whom she continues to meet for about three years.
She now weighs 180 kilos. Antonietta complains of the high price of this treatment. It is organized as follows:
three sessionseach week of psychotherapy, a monthly visit with another psychiatrist for the pharmacological
treatment, a couple therapy for the parents, and a weekly visit from a helper who, for a fee, takes her out.
It is at this point that she experiences a delusional episode – with the conviction of being the genuine
reincarnation of Cinderella, followed by a confusional episode in a train station restroom – during which she
cannot recognize where she is. After an umpteenth suicide attempt, and faced with her confusional state, she is
taken to a psychiatric hospital. At the time of discharge, the confusional state has resorbed itself, however the
symptoms persist with almost no change. It is a few months later that a thoughtful colleague refers her to me.
An artist of the law

I find myself faced with a young woman of 20 who weighs 165 kilos. She wants to leave the job in the public
services that she has only just begun and which, moreover, she had hoped her previous therapist would avoid the
trial for her. The clinical picture is characterized by frequent, quasi-daily and often nocturnal, bulimic binges,
followed by a strong feeling of guilt.
52 CARMELO LICITRA ROSA

When Antonietta was 18, she and Giulio fell in love. Giulio was a sensitive and romantic boy who liked art and
music, traits that gave Antonietta the solid conviction that she was bound to him by a profound affinity. There
was, however, never any physical contact between them. Antonietta only explained this vaguely as having to do
with a “lag” that she felt in relation to her own “woman’s image.” This obstacle was compounded by her moral
reservation about the illicit character of pre-marital sex. When Giulio breaks up with her, Antonietta who had
already experienced an anorexic episode with the idea of becoming more attractive to him, becomes fat, then
thin again and, finally and definitively, fat. She remains obese with her weight oscillating between 100 and 180
kilos. She has a certain compulsion to masturbate, accompanied by strong feelings of guilt.
Around the age of 13 or 14, there was an event that Antonietta qualifies as a “vision” and which is clearly a visual
hallucination. At the time of our first sessions, two paternal aunts had taken on the function of persecutors. They
were thought to have been the authors of a supposedly sexual aggression committed on her person when she was
around six years old. It is not unlikely that their role – although indirect – as the usurpers of the father, had
activated the associative chain that finally placed them in their present persecutory function. It would seem that
the paternal grandfather had disinherited the father, favoring the two sisters, her aunts. The grandfather probably
knew that this son was not his own, thereby confirming the local gossip repeated in the area. According to this,
he was the illegitimate son of a lawyer for whom the mother had worked in her youth. The father’s family was
in fact of very modest means and the father’s own social advancement was due only to his tenacity – via
identification to the professional signifiers of the presumed real father. He attained the distinguished grade of
magistrate. When he learned that he had been disinherited, the father reacted with violent behavior that disrupted
the family’s equilibrium. We note Antonietta’s strong paternal identification: her first name is a diminutive form
of her father’s, she also chose the same law studies, and idealized him as a person; she comments that “He knew
how to form judgements with a mastery, a competence and a special sensitivity; he was an artist of the law.”
The diagnosis
According to the criteria of the DSM IV, the diagnosis would first take into account the preponderance of the
bulimic symptom and secondarily that of the dissociative disorder. This corresponds to a nervous bulimia F 50.2.
In the Freudian Field, the psychoanalytical perspective that follows the teachings of Jacques Lacan, diagnosis is
founded on structural considerations that go beyond the strictly phenomenological appearance of symptoms. It
is for this reason that we can pose the diagnosis of psychosis despite the importance of bulimic symptoms present
in the clinical picture. It is not that we would deny the idea of the dignity of a bulimic-anorexic syndrome, but
rather that we prefer to give it the value of a manifestation caught up in an unconscious strategy for which the
logic can be explained. This is why a clinical picture such as this, defined as a psychosis from a structural point
of view, can be classified all the same as a bulimia according to the DSM IV. Quite to the contrary of the
diagnostic system sited above, our structural perspective excludes the possibility of a double diagnosis or co-
morbidity.
In psychosis, bulimic maneuvers are not oriented by the desire to recuperate a lost object. On the contrary, the
object is at the subject’s disposition. Still, this subject is looking to introduce in the real – through the alternation
+/- of binges and vomiting, up to the moment of the repeated act of attempted suicide – the function of castration
which, given the structure, does not reach the object. It would be a different case if the bulimic patient were
trying, as does the hysterical subject, to give consistency to the lost object in a dialectical relationship to the
Other. Moreover, if the psychotic subject is directly glued to the object, so is the Other: the one instance being
the logically reciprocal condition of the other. Whence the particular, tormented ambivalence typical in psychosis
and plainly evident in our case study.
Psychoanalysis and Psychosis: A Happy Couple 53

On the one hand, there is the enormous attempt to detach herself from the Other – but this is a false separation
because it is not upheld by the unique separating principle, the paternal metaphor. On the other hand, there is an
incessant searching out for this Other, the only presence that can guarantee her a subjective stability, albeit a
precarious one. It is within this framework that we must read the oscillations in her relationship with her mother,
at once sought after and rejected. This instability in the dialectic with the Other is the consequence, according to
the remarkable theory of Jacques Lacan, of the lack of a signifier that guarantees the series of signifiers, or the
stability of the Other: the Name-of-the-Father. The compensatory function falls, therefore, onto the imaginary;
in this case art, as the mediation between her relationship with Giulio and the bodily image as an ideal both
pursued and denied at the same time.
Antonietta has been in analysis with me for more than four years now. I will briefly describe a direction of the
cure as inspired by Lacan’s teaching, which has been crowned with a certain success.
The first phase: the letter

During our first encounters, Antonietta is skeptical about what she may hope to gain from this new experience
seen as just one more in an endless series. Her bulimia gives her no respite. On top of this, for a few months now
she has taken to drinking and she is tortured by moral scruples that allow her no escape. In the direction of the
cure, I held a firm and totally disinterested position regarding both the bulimia and dieting. It was as if to indicate
that that did not seem to me to be the main concern. This was not without producing the most energetic protests
on her part, being that weight and food completely polarized her preoccupations as well as those of the people
who gravitated around her. During one of our first sessions she tells me the following dream which I find most
eloquent: “I go into the house. I’m surprised to see that my mother has transformed it into a lovers’ meeting place
where people come to find pleasure. I look towards the table and I see you on little stuffed bread rolls. I feel
nauseous and disgusted. Who could they possibly be for? I am immediately sure that it’s my mother who has
prepared them for those who would come to flirt there.” The mother (who in the dream is the lascivious go-
between and prompt purveyor of food is, in reality, the one who forbids Antonietta the candy that her aunts are
always so prompt to offer her) illustrates well the solidarity, typical in psychosis, between jouissance and the
place of the Other that takes on a threatening signification for the subject, manifested in the feeling of disgust.
Antonietta does everything in her power to put a distance between herself and her mother. It is with this aim that
she decides to go and live alone in a small apartment belonging to the family. The situation then degenerates, as
she cannot manage to take care either of herself or of her environment.
The first year of analysis unfolds without any noteworthy results and even with some disquieting signs of a
worsened condition. During her sessions, she is seated facing me while I carefully transcribe – like a scribe – all
that she says. Carefully, but not passively, following Eric Laurent’s indication when he invites us to rectify the
classic position of the analyst as the secretary of the insane. This is of course the position of the analyst in the
direction of a cure with a psychotic, but understood in the same way as Hegel meant it when he defined the
philosopher as the secretary of History.
During this phase, the sessions were constant in length, but more than thirty minutes long. She always had more
or less something to say during sessions but demanded an answer at the end of each, which most often was not
forthcoming. At the outset, this greatly irritated her: “If I’m just coming here to talk to walls, I’m not coming
anymore.” I would answer: “Very good,” and end the session.
All throughout the year, these sessions were relatively turbulent. An answer to her energetic demand would have
been a matter of personal opinion, of practical advice or easy council. In other words, an answer would have
been of the same order as that which the mother so abundantly lavished on her, while Antonietta made her pay

for her role as persecutor in food. I saw that in this case counseling was to be absolutely avoided. My tactic was
to affront, impassively, her complaints, limiting myself to a few words of recognition of her suffering and to
uphold her enunciation with a “Yes, certainly,” or again to oppose myself to the invasive Other whenever the
occasion presented itself. As soon as she was out of my office, she would call me from a phone booth to ask if
she could come back, something I always accepted without hesitating. From time to time she would miss a
session or turn up with her mother who, feeling her to be a bit resistant to coming to a session, had offered to
accompany her. In the first instance, I would make her pay for her session, in the second, I would let her settle
and ask her, while noisily grumbling, what that bothersome mother could possibly be doing here. I took this
opportunity to inform her that it was her choice to come or not to her sessions, but that because of that damned
rule, I had to make her pay for the sessions she missed.
On the subject of this regulated Other that I tried to incarnate from the first session, I will relate only one
significant vignette. It began thus: “Doctor, I am a nervous eater. Up until now, I’ve taken Prozac. I still do take
it, but it doesn’t really have any effect anymore. Please, give me a different treatment. Doctor M. told me how
kind you are.” – “I’m not sure that I’m all that kind, nor am I sure to have a treatment adapted to your case. But,
if you want, I can listen to you.” “I do wonder what good it may do me, given that I’ve spent whole years talking
to psychologists – with the results that you can see, but if you say so. What’s more, I think that you could be the
kind of man I need – without your necessarily falling in love with me.” – “You see, I can’t allow myself
adventures with my patients, the deontological code forbids it and on top of that I’m married, as you can see by
my wedding ring; I promised to be faithful before both the civil code and the canon law. I can’t neglect my
engagements.” She threw me a perplexed expression and added, after a moment’s hesitation: “Yes, of course
there are the rules, and on the other hand there is what we do: there are so many married men who have a
mistress, without even talking about the number of doctors who sleep with their patient.” I answer her
emphatically; “Not I. I respect the law,” and end the session after more than fifteen minutes.
In the beginning I had thought about sending her to a colleague for a pharmacological treatment. Then I realized
that since this was a patient who had tried so many different products, and at massive doses, there was nothing
to be hoped for from molecules. It might be possible to obtain something more by managing to integrate the
prescription and the administration into the circuit if speech.
Antonietta is interested in painting and literature, and the mother, a retired art teacher, still paints and exhibits
her work. Other members of the maternal family are versed in the plastic arts, one of whom has had discrete
success. The father on the contrary, who is a man of the law, had aspired to become a writer or a director. From
the first sessions, Antonietta does not hide her aspiration to write; explicitly stating that she wants to accomplish
what her father had “to sacrifice in order to choose a more lucrative profession.” She tries to join up both sides,
painting on the maternal side and writing on the paternal side, thanks to her pronounced capacities as an art critic,
and especially as a critic of painting. She can also give accounts of films and literary texts, nevertheless without
ever managing to measure herself to the test of composition. She is writing a novel, a few brief reflections, and
numerous poems, many of which are dedicated to Giulio.
One day, she brings me a selection of her most significant writings, asking me if it would please me to read them.
I answer in the affirmative and she leaves them with me. Not only does she never ask for them back, but a few
weeks later she tells me that following that gesture, she stopped signing with her own name and adopted a
“masculine pseudonym,” possibly. . . and she pronounces the name of the father. “But a name written in another
language would be better.”
Around this time, near the end of the first year of analysis, the sessions become calmer. We clearly remark the
two phases of this subjective maneuver. In the first, Antonietta leaves me the letter – this symbolic element that

carries jouissance. She manages to partially disengage herself from a certain jouissance, the jouissance of the
Other – paternal and maternal, writing and painting – that had been causing interference. Thereafter she can
“make herself a name.” I think that the relative pacification that ends this period is to be equally accounted for
in the act of leaving the letter and in the encounter with a regulated Other. We will see how all of this could not
suffice to ensure a lasting stability.
The second phase: treatment of the Other

During the first months of the second year of analysis, after a brief period of relative pacification, we note a
worrying aggravation. The return of hallucinations coincides with a Sunday stroll in the father’s region, in the
company of one of her aunt’s friends who protects her when she is at her place of work. The motive of the walk
was to participate in a village celebration during which a pig was roasted and eaten on the public square.
Antonietta judged the celebration to be too wild. She remained impressed by this scene of public merriment,
reputed as unbridled and coarse. “It was practically a bacchanal.”
Quite surprisingly, this relapse only lasts for six months. Then the voices disappear, as does the delusional
surveillance and, above all, the nightmares about presumed sexual violence, the compulsion to throw herself on
children and the feelings of guilt surrounding religion. She asserts that she no longer wants to masturbate, no
longer believes in God, that she no longer even wants to hear tell of priests – from then on, she listens to Sunday
mass on the radio, alone – , that the episodes with her aunts and the priests seem so farfetched to her that they
might very well be a product of her fantasies. My position throughout this period having remained unchanged;
such an amelioration must be attributed entirely to the subject’s own work. In fact, she tells me a dream that she
had exactly one month before, at the same time the change took place, but that she had forgotten to tell me in
analysis. “I dreamt that my mother was getting smaller and smaller until she dissolved entirely, like a ghost. All
that was left was a piece as big as a walnut, that was going to end up in a bowl of soup, but I only noticed once
I had already swallowed her. I woke up with renewed serenity and not at all anxious: I wanted to laugh at the
idea that my mother had dissolved.”
At the approach of the Easter season, certain customs had a tendency to exacerbate her religious conflicts, and
her moral scruples would become more pronounced. Due to a lessening of her scruples, she does not go to Easter
confession. At the same time, she offers me an Easter egg, which I accept. I leave it on my desk throughout this
period, to materialize a place on which she is sure to be able to count.
The third phase: the diet, treatment of the object

At the end of the second year, she takes the initiative to see a dietician, whose address she found while reading
a health dossier in a daily paper. It is the first time that she follows the diet of a specialist of her own choosing.
It may be no coincidence that something starts to unblock. Antonietta succeeds at benefiting from this diet, which
specifies in detail the times and quantities of meals. For the first time, despite the strong neuroleptics she had
taken over the past ten years, her wake/sleep cycle becomes regular. She begins to really lose weight while
asserting that “It’s the first time that I recognize the difference between hunger and nervous eating.” Of course
things are not easy for that. From time to time her determination wavers. The diet does in fact include many
restrictions and much sacrifice. She asks me then for support and encouragement. I give these readily even if, as
I mentioned, I show a total lack of interest in the bulimic symptom and the dieting.
When, at a particular point, she suddenly interrupts her diet for a short period, telling me that she also wishes to
interrupt her sessions, I reply to her firmly; “What you do with your diet is up to you. What you do with your

sessions as well. But I am subject to a rule that obliges me, in spite of myself, to stop seeing a patient
immediately after she has purposely interrupted her sessions.” Not without with a certain rage, the perspective
of excluding herself from her meetings with me causes her to change her mind.
The fourth phase: a possible delusional stabilization

At the end of the third year of analysis, after a year of constant and scrupulously observed dieting, she shows
herself to be relatively satisfied, with her weight at 120 kilos. During the same period, the persistent amenorrhea
that had set in a year and a half before disappears. At first, the amenorrhea had bothered her greatly, then she
decided that maybe it was better that way after all. “It contributes to my feeling asexual, and that’s a benefit,
since sex causes me so many problems.”
I progressively reduced the duration of the sessions. They are presently almost always ten minutes long. I noticed
that little by little the delusion was diminishing, the material was becoming more precise and banal so to speak,
and she herself showed a certain impatience to end the session after that lapse of time. Parallel to this, I could
see a growing determination to not miss sessions.
The clinical picture appeared therefore to have improved: she was less asthenic and participated more actively
in the life around her. Indubitably, having turned away from delusion, her life had become less exciting and more
flat, as she herself admits. The proof of this is that she is no longer interested in art, and has stopped writing and
studying. But her depressive side is clearly resorbing itself. Doubtless, she is not satisfied with her secretarial
functions – her aspiration is to be a magistrate – even if she is slowly looking to adapt, with an admirable sense
of practicality.
She had always worked with a great fatigue and a less than optimal output until a few months ago when an
objective came to light. It is one that she now pursues and on which I greatly insisted, encouraging and
supporting her in this: an ideal of efficiency and transparency in public administration, which she declares she
has inherited from her father and grandfather. It is certain that the State needs competent employees and workers,
and that she can contribute in a determined way to this renewal. For the past few months she has been going to
the office with pleasure, no longer needing the tranquilizers that she had so long fallen back on from the first
light of day. Today she weighs 90 kilos.
Translated by Julia Richards

Ernesto Piechotka
Interpretation or Invention:
the Consequences of a Clinical Decision
Contemporary debates about sexual difference also pertain to the question of the therapy of psychosis. The
question of etiology articulates the question of sexual definition: sex or gender, inherited or acquired, gender or
role?
The old biological-hermeneutic dichotomy

The reference to the gene as real is also promoted by analysts who entrust the future of psychoanalysis to its
articulation to physiology and neuro-sciences: “the metapsychological considerations leave the advances of the
‘Project’ in the shadow,” we read in a recent article in the Journal of the American Psychoanalytical Association,
“recent discoveries about the cerebral bases of emotions at levels beyond conscience due to pre-frontal
regulation of the affections allows for a better understanding of the psychical structure described by the analytic
metapsychology. . . and this is of the utmost importance for future theoretical and clinical developments in
psychoanalysis”1.
Similar voices reduce the etiology of psychosis to genetics. Let us choose just one of the countless articles on
that subject published by the American Psychiatric Society: “The genes that are responsible for schizophrenia
appear at a very early stage in foetal life, acting on other neuronal areas. The masculine-feminine differences
result from a sexual malformation in the genes that determine schizophrenia. How do men and women differ
biologically? What are masculine and feminine brains?”2
Some authors criticize the psychoanalytical hermeneutic deviation, looking for something real beyond the
rhetoric, which leads them to confusion between science and psychoanalysis. John Gedo, in the above-
mentioned Journal, affirms: “since Freud was incapable of correlating the clinical data with the neurology of his
time, he tried to widen the field of psychoanalysis by means of a speculative metapsychology, thus abandoning
the field of science”; in a critique which can be qualified as quasi-Lacanian, he adds: “The hermeneutic is not
acquainted with important data such as the occurrence of the trauma... and promotes the theoretical fiction of
analysts having an intact ego”3.
The opposition to biologism takes the form of a reduction of psychoanalysis to the psychological experience.
Stoller and Melanie Klein meet on one issue. Stoller, defines gender as a feeling of being part of a specific sex
which goes back to the maternal world 4, and Melanie Klein, by links the cause of schizophrenia to the early
____________________
1 Allan N. Shore, “A Century after Freud’s project: is a rapprochement between psychoanalysis and neurobiology at hand?,”
Journal of the American Psychoanalytical Association, vol 45, no.3, 1997.
2 P. Seeman, “Brain development, X : pruning during development,” American Journal of Psychiatry, 1999.
3 J. Gedo, “Reflection on metapsychology, theoretical coherence, hermeneutics and biology,” Journal of the American
Psychoanalytical Association, vol. 45, no. 3, 1997.
4 R. J. Stoller, Sex and Gender, Science House, New York, 1968, chap. 9: “Mothers’ contribution to transsexualism.”
58 ERNESTO PIECHOTKA
relation of the child to his mother5, in such a way that the symbolic is reduced to a psycho-genetic product,
corollary to an emotional learning experience.
American relativism and economy are not absent from the debate: the International Organization for Gender
Rights fights for the de-pathologization of transsexualism6, trying to repeat the history of the homosexual lobby
and we are on the eve of the suppression of transsexualism as a Gender Identity Disorder in the DSM7.
Abandoning the psychiatric theory of gender for a biological theory would allow the medical insurances, which
do not cover plastic surgery for esthetical reasons, to do so for physiological reasons. Many scientific
publications argue for changes in language in order to create a Fair Gender Language that would not be sexist 8.
The logic of sexuation

The practice with psychotic patients requires the analyst to take a clear and firm position in this debate. Lacan’s
“not to retreat in the face of psychosis” consists, nowadays more than ever, in the adoption of the symptomatic
invention of the speaking being as a guide, for the etiological theory as well as for the intervention; making it
possible to go beyond the old biological-hermeneutic dichotomy which contributes to a false chemotherapy-
psychotherapy opposition, ignoring the issue of jouissance.
Lacan teaches us that the real of science is not the real of psychoanalysis. The real of psychoanalysis is the
impossibility to write the sexual relation and consists in the assertion that it is language, that marks the fate of
the jouissance of the subject. Freud already taught us in the Three Essays9 that the choice of object is not the
essence of sexuality, by emphasizing the contingency of the object where the satisfaction of the drive is
concerned and establishing one first identification, previous to any object relation, in his chapter on
“Identification”10. Where the theory of gender leads us to the question of identification, Freud brings us back to
the drive and its destinies. Paradoxically, Stoller remains attached to a biological concept of gender, by
conceiving of a third sex, transsexual, based upon the other two. The gender-sex differentiation merely creates
a binary that generates the delirium that supports the anatomic side of sex as real. The Anglo-Saxon confusion
between sexuation and gender repeats the mistake of Freud’s English translator: “instinct” for Trieb. To “mother
imprinting”11 we must oppose the Freudian “fixierung” and the corporeity of the signifier; to the “gender map”
(mental and cerebral codification of masculinity, femininity and androgyny) we oppose the Urvedrängung. With
Lacan, we opt for the first contingent incidence of the jouissance of the language in the body as the primary
etiological cause of psychosis, as well as of the sexual position.
Nevertheless, there is no signifier whatsoever in language that can relate a universal law between the sexes. For
Lacan, the clinical dogma of the subject leads to the clinical dogma of the sexuation of the speaking being,
beyond the Name-of-the-Father, which consists in locating, one by one, the solutions proposed by the subject in
his encounters with the radical otherness of the Other sex. The logic of sexuation developed by Lacan beginning
in the 70s does not elide the issue of psychosis12. Sexuation and etiology are linked in work with psychosis.
____________________
5 M. Klein, “The Importance of Symbol Formation in the Development of the Ego,” International Journal, 1930.
6 The International Bill of Gender Rights, 1995, Houston, Texas, USA.
7 “Challenging psychiatric stereotypes of gender diversity” in: GID reforming.org.
8 J. R. Redfern, The Writing Center.
9 S. Freud, Three Essays on the Theory of Sexuality, in The Standard Edition of the Complete Psychological Works of Sigmund
Freud (S.E.), Vol 7, Hogarth Press, London, 1962.
10 S. Freud, Group Psychology and the Analysis of the Ego, in S.E. (op.cit.), Vol 18, 1959.
11 Robert J. Stroller, “Mother imprinting, ” op. cit..
12 J.Lacan, “ L’Étourdit,” Autres écrits, Seuil, Paris, 2001.
Interpretation or Invention: the Consequences of a Clinical Decision 59

Sarit or the impasses of psychotherapy
Sarit’s case made us understand, during a patient presentation, the impasse that an interpretation in the name of
universal knowledge might produce since it does not take into account the singular invention of the subject.
Sarit was proposed for a patient presentation by her new therapist, to whom she had been sent after a crisis in
her previous treatment provoked by what we shall call a furor interpretandis (fury of interpretation) by her
psychologist. She had “pushed me to separate from my parents and look for men in order to engage with them
in a proper relationship.” Sarit adds: “even though it helped me to get out of my sexual abstinence, I felt very
threatened when she would say that it originated in my incestuous relationship with my father.” She told us that
her father would talk to her about his own sexual intimacy. He was committed to a psychiatric hospital after a
suicide attempt in which he had aimed at one of his eyes, and lost the sight in it. The father used to say he was
stupid and not clever enough to study. Her mother, on the other hand, a math teacher, was very ambitious to
succeed in her studies, “pillar of the family, source of security in my existence.” Sarit’s love life began with a
romance in high school, which she often refers to as a relationship with “an ordinary guy.” At University she met
and married a professor. The psychosis produced a unique invention: “the substitutes.” These “substitutes,”
suitors or lovers, or mythological figures of the entertainment world, replace her husband. Even her brother, a
biologist like her husband, can be a substitute. “Some day she will marry her brother,” she says. Referring to the
psychologist’s interpretation of the “contents” of her deliriums and to her supposedly defensive way of
functioning in the proximity of her husband, Sarit affirms emphatically that saying such things should not be the
therapist’s role.
In addition to this, there are deliriums that transform her into a famous person whose life is being recorded on
film, which gives her much pleasure and calms her anxiety. So her marital life goes on without any significant
incidents. Sarit and her husband spend many hours together. Only when sexual tension increases, excesses
appear that she deals with by using “the substitutes.” One substitution follows another incessantly. Sarit spends
each day with a different lover and affirms she never knows which man she will find each time she returns home;
“my husband comes back home every two weeks and the rest of the time he lives with another woman.” Slowly,
the formerly cacophonous chorus of lovers is reduced to delirious conversations with one or two simultaneous
interlocutors: the substitutions start to take place only within the circle of “the clever ones,” which “allows me
to live a different life.” The films produced about her are screened every night before the select public of “the
clever ones.” Even though there is some relation among them, she says it’s forbidden for her to know anything
about that relation. When the psychologist inquires about that prohibition, Sarit’s first reaction is perplexity; then
the unwise insistence receives a deservedly delirious answer: “because I am an extraterrestrial.” She adds: “the
psychologist used to say that I felt pleasure in showing my breasts and seducing men in order to later keep them
far away.” She then requested that the psychologist be replaced with a psychiatrist “to whom I could talk about
my lovers without being asked so many questions.” Between the night filming sessions and the lovers, the life
of the couple continues: “we have a great need to talk, my husband and I; we talk like broken records, we repeat
and repeat, we don’t listen to each other.”
How is Sarit’s love life organized? What is her choice in the field of sexuation? Sarit seems to imitate a hysterical
subject, and this misleads her psychologist. She shows us that the psychosis may well reject the phallus as a
referent but may retain imaginary phallic identifications, wear sexual clothing; her imaginary partners allow her
to remain in her marriage and act as a prosthesis in front of the abyss that the encounter with the Other sex
produces because of the lack of symbolic support. The imaginary staging she resorts to faced with the blind look
of the foreclosed father, who returns in reality, reminds us of what Jacques-Alain Miller had said in Arcachon:
“after all, the mirror stage. . . as the paternal metaphor. . .is also a symptomatic device”13. Sarit’s psychosis even
____________________
13 “L’appareil du symptôme,” La Conversation d’Archachon, Le Paon, Agalma, Paris, 1997.
60 ERNESTO PIECHOTKA
attempts a rudimentary binary by using a signifier in order to produce a pseudo imaginary classification without
turning to the father; that signifier is taken from the paternal language but it suffers from the mark of the
relentless maternal law; even though it exists in the common language, its use is neological and acquires the
dignity of the symptomatic localization of jouissance. Let us localize Sarit’s place of exception, not divided by
castration, as the one defined by the fixation to the image of The woman of “the clever ones.” Wisely, she doesn’t
know about the relationships among them, which allows her to keep the circle not hermetically closed, avoiding
thus to complete the Other, pursuer of jouissance.
Sarit shows us what position to take in the debate. Lacan already taught us (Seminar III) that the onset of a
psychosis is often produced by an obstinate interpretation14. If the analyst plays the role of the lack that prevents
the suture of the identification in neurosis, he will become the addressee of the attempts at restoration of
identification in the psychosis.
We then share the critique made of hermeneutics, by opposing the interpretation that tries to make sense, even
in practice with psychotic subjects, without resorting to the supposedly anatomic real as the etiology of the
illness or the sexuation; we do not strengthen our intervention with a univocal belief in the word, as
psychotherapy does, as does the psychology furnished exclusively with the Oedipus complex in order to deal
with the sexual position. We do not reduce sexuation to the symbolic as a theory of sexual identity; we also put
a stake in the sign. The universalizing fight for sexual equality does not make us neglect the singular real-
nonsense inventions, which the work of the psychosis produces, one by one, locating the auto-erotic jouissance
in a certain dimension of sexual otherness.
____________________
14 J. Lacan, The Seminar of Jacques Lacan (ed. J.-A. Miller). Book 1II, The Psychoses 1955-1956. Trans. Russell Grigg. W. W.
Norton, New York, 1993.
Interpretation or Invention: the Consequences of a Clinical Decision 61

Vicente Palomera
Orlando and Doctor Z.’s Technique
In La Formation de l’esprit scientifique, Gaston Bachelard cites the treatise of the Chevalier de la Perrière,
Mécanismes de l’électricité et de l’Univers, published in 1765. This treatise claims that all of the phenomena of
the Universe can be explained by the action of electrical fluids: “The empire of electricity is so vast that its limits
and its expanses belong to the Universe itself, which it includes: the suspension and the movement of the planets,
the breaking of celestial, earthly, and military storms, meteors, bodily sensations, the rising of liquids, refraction,
antipathies, sympathies, tastes, and natural repugnance; the musical healing of the tarantula’s bite and
melancholic illnesses, the vampirism and suction practiced reciprocally by people who sleep together are all
within its domain and under its control, as will be proven by the electrical mechanisms that we will give.”
Orlando, who did not know of the Chevalier de la Perrière’s treatise, made of the disconcerting inanity of such
a theorem the libidinal foundation in which all of his subjectivity was submerged. Thus, he came to see me one
day in order to recount the following: he functioned by remote control; his organs and limbs were controlled by
circuits that electricity passed through. Such was his delirious conviction.
To begin with it must be said that in 1962, when Orlando was still a small child, an exciting event occurred in
his native village. He was the exceptional witness of the simultaneous arrivals of electricity and of television. He
remembers in particular that the first images he saw were those of the enthronement of Pope John XXIII, as well
as that of his grandfather, seated in front of this new machine, the television set, saying that the newscaster was
speaking to him and to him alone.
When Orlando phoned me, I immediately recalled that we had known one another years earlier. He had attended
a Seminar on Lacanian theory of which I was one of the chairs in 1979 at the University of Barcelona. There,
Orlando had met a psychoanalyst, Dr. Z., who occasionally came to this seminar. Fifteen years had already
passed since then.
During our first meeting, Orlando pointed to his Adam’s apple and asked if I did not see something bizarre in
his neck. Did I notice anything bizarre in the movement of his Adam’s apple? he asked, raising his chin. Its
movement was beyond his control. He then added that he thought he was receiving messages transmitted by
Norman Foster’s Telecommunication Tower. This was because of “Dr. Z.’s technique,” which imposed messages
on him. He then explained that a year earlier, his analyst, Dr. Z., had left Barcelona and that he did not know
where he was now. Of course, the Doctor had informed him of his departure several months in advance. He had
begun the treatment in 1979 and left off in 1993 at the time of this departure. He wanted to know where Dr. Z.
was and asked, “Do you know?” I answered that I had not seen him for many years and asked him what Dr. Z.’s
technique was. He thus proceeded to explain it to me.
The triggering
He had consulted Dr. Z. in order to find out if he was homosexual or not. He was attracted to young, Adonis-like
men [jeunes hommes aux traits “d’éphèbes”]. When he was at University, he had been attracted to a male
62 V I C E N T E PA L O M E R A
classmate and told him so. The young man’s subsequent rejection of him as well as the snubbing he received
from their mutual friends deeply affected him. To Orlando’s question, Dr. Z asked him in turn, “What would you
do if you found out that you were homosexual?” To this Orlando answered, “Well, in that case I would have to
accept it!”
After two consultations, with the number of sessions, the fee, and the fundamental rule established, Orlando was
asked to take his place on the divan. He explained that “as soon as he was introduced into the great Other, into
the Apparatus,” he realized that the process involved something more than words. Following the analyst’s hand
movements, Orlando became convinced that Dr. Z. was operating an apparatus behind him and he began to feel
penetrated by “”he analyst’s technique.” In making use of his technique, Dr. Z. used an apparatus to make a hole
in the occipital zone and burned away, with an electrical current, traces of memory. The smell of something
burning left no room for doubt. In his sessions, Orlando was both the witness and the patient of this technique,
the effects of which were multiple:
1. It showed him images that he usually saw on a unique plane, which were either projected in the office itself
or projected outside and connected to electrical currents or, sometimes, to laser beams.
2. The apparatus produced in him and took away from him thoughts and feelings and this due to the electrical
currents and the rays associated with abrasive products, which gave him burns as well as skin irritation and
eczema.
3. The apparatus also induced motor actions in the body, in its limbs, as well as strange sensations described as
“electric meteors.”
For twelve years, with a patience bordering on complete docility, Orlando viewed what was happening to him
as a kind of “aversion therapy” or alternately as a “supportive therapy” where images and planes flew about.
Orlando was never able to discover all of the capabilities of the Apparatus.
After the triggering under transference, a relationship of complete delirium was established between Orlando and
the rest of the world.
This delirium was composed of certain consistent signs, but the fantastic character of the expression of his
delirium was also observed. As we shall see, the delirium took on the aspect of a multi-themed fantasy,
constantly renewed, and the central theme, “Dr. Z.’s technique,” did not prevent parallel themes from playing a
part. There was not the slightest attempt of construction or of a logical verisimilitude: everything yielded to an
unbridled fantasy, involving multiple personalities, where spatial boundaries were surpassed, and whose
fabulous and aesthetic character evoked movies based on fairy tales.
Perplexed, Orlando wondered if “Dr. Z.’s technique” was not a form of “hypnosis.” “What were those planes
that were spinning about? They spun about so that one could not tell the top from the bottom or the inside from
the outside.” Sometimes, Orlando saw himself speaking to himself as if he were outside of what was happening
to him, with sensations in his throat and on his skin caused by the electrical currents. These things that he saw
from the outside were distributed according to the space : there was “the analyst’s space, the analysand’s space,
and the object’s space.” Thus, in the session with Dr. Z., it was as if all of the space in the room was full of
currents which were sometimes words and sometimes objects. The words were so material that, as soon as they
were in the mechanism and addressed to Orlando, all of the space was filled with waves, with electrical currents
which, entering the analyst’s space, made the analyst speak. While all this was being filled with the analyst’s
words – which were not addressed directly to him – and reached Orlando in his space, “he felt strange things
happening.” There were moments when “neither the analyst nor the analysand was speaking, when it was being
which spoke.”
Orlando and Doctor Z.’s Technique 63

There were certain sessions where Orlando complained about Dr. Z. and the suffering that his technique obliged
him to endure: “Okay! Why am I hearing this now?.” Dr. Z. responded with something related to the situation,
but the question concerning “the analyst’s technique” remained unanswered. Orlando repeatedly complained of
having to deal with this Apparatus rather than being able to practice free association.
Just how the Apparatus worked never became clear to Orlando. He only deduced it from the effects of alienation
implied by “ Dr. Z.’s technique ” What effects? Starting with his first sessions, he had “horrible experiences”
when he looked in the mirror to verify the presence of the burns he felt on the skin of his face. At such moments,
he felt that certain objects appeared in the mirror and said to him: “We are Dr. Z.’s objects. We have come to
help you.” In other words, at the moment when his identity was the most fragmented, correlative to being
persecuted by voices – voices which both instilled fear and inspired imagination in him – he was anticipating a
an appeal to unity and to his integrity.
Another of these horrible moments occurred when, one night, Orlando had a vision that his entire body fell prey
to a complete transformation. He was in bed and was forced by invisible wires to turn onto his side, assisting at
the pumping or draining by the Apparatus of his bodily substances. What had happened during this kind of
corporal suction on the part of the Apparatus? Orlando called this a “metamorphosis” by wires and other
processes, a metamorphosis accompanied by great suffering. This transformation was often repeated.
Some of the functions of the powerful Apparatus were to program dreams, memories, and thoughts that took the
place of those traces of memory which had been burned away. Orlando thought that the Apparatus had
programmed, from the very beginning, the entire analysis. He felt “like an object penetrated by the technique of
an undetermined subject.”
From these feelings of influence and transformation, Orlando found himself attributing the effects of the
Apparatus to “the technique used by Dr. Z.” In the beginning, “the analyst’s technique” favored the symptom
that had prompted his analysis – expressed as the urge to frequent gay bars. However, Orlando attributed this
period of analysis to the intervention of an “aversive therapy” practiced in the analyst’s technique.
Among its other functions, “the technique,” whose object was the rememoration of the past and the continual
programmation of dreams and visions, caused the eventual disappearance of all of the images featuring the traits
of young, Adonis-like gay men, which at one time were very attractive to him, by way of an artificial erasing of
these images by the influence of the Apparatus. Orlando first begins to feel himself attracted to female friends
at the University and, then later, as a teacher, to his students.
In these cases, the Apparatus, in an imprecise way, projected images one by one, making women with
particularly white and shiny skin appear. When he found himself faced with those who attracted him, colors were
introduced into these projected images. For example, the lips would appear very red and remarkably full, a light
giving a spectacular brilliancy to the eyes – to the point that, sometimes, he felt frightened. In other words, the
function of the projections that “freeze the images”[sic] resulted in the foreclosure of castration. These moments
were opportune ones for the intervention of the voice. Thus, Orlando remarked, “the gaze speaks.” Once, for
example, when his eyes met those of a young woman, he heard: “perversions enchant me” as if “I had been
designated as a pervert.” This evokes the definition that Lacan gave to paranoia in his seminar, “RSI”: “Paranoia
is an imaginary bogging down; it is a voice that resonates the gaze that is prevalent in it; it is a freezing of
desire”1.
It was permanent. Going to one session, he felt that his body had been turned upside down. Going into the
analyst’s office was a form of torture. When the analyst opened the door, his eyes emanated a luminous ray that
____________________
1 J. Lacan, Le Séminaire, “RSI,” lesson from April 8, 1975.
was directed at Orlando’s brain. He lost consciousness and then regained it. Then he realized that it was not the
analyst that had opened the door, but the analytic objects. On the divan, he often experienced the sensation of
being upside down: he saw Dr. Z. approaching with his bright blue eyes, like those of his mother. He remembers
a dream where he is in his crib and “every time someone leaned over me, he would look at me and it was as if
he had taken away a piece of me.” Dr. Z.’s objects guillotined him, dismembered him.
Orlando as a “torn text”

Arriving at his sessions, Orlando consented to “this static electricity that traveled all through his body and that
was connected to the machine.” He felt that he was hooked up to the machine and he heard “That is me” (“that”
refers to the machine). When beginning to speak during the session, he heard: “him” “her” “me,” spiraling
endlessly; he also heard “masculine” “feminine.” In these sessions – that he called “princeps” – he entered the
divan and the machine made a strident noise. While entering the machine, he could not speak. The only time that
he wanted to speak while entering the Apparatus, he heard “Listen!” Very often, after having lay down on the
couch, Orlando saw that something physical prevented him from speaking and for five minutes he felt
frightening electrical currents like those one receives from an electric shock. “The right side became the left, my
entire system of reference changed; masculine became feminine.” At these moments, he heard Dr. Z. say in the
Apparatus: “And this, to begin with – and the current connected – “And then this. . .” (connection), “Good”
(connection), “We’ll stop there” (disconnection).
This “fundamental language” could be translated when it was discovered that all of these transformations, as well
as the fantastic characters of his hallucinations (characters in capes and tunics), were dependent on the
hallucination of one signifier: Leonardo de Vinci. Orlando had read Freud’s “Leonardo.” Orlando evokes that
Leonardo was ambidextrous and that he had a penchant for Adonis-like boys. This is why, when leaving the
office, he always went to the right instead of the left (where the exit was located). The currents almost always
came from the left side of the office. The electricity was matter, like static electricity; so that, when arriving at
his session, this apparatus that supported Orlando was connected to Dr. Z.’s apparatus. Then came the sensation
of oil seeping from his face – at night he soiled his pillow, his lips swelled up like those of a woman.
The jouissance that he obtained from this apparatus was thus reproduced in the automatism particular to
language, which is based on the difference between signifiers: in the alternations between connection/
disconnection, masculine/feminine, left/right, day/night, etc.
Within the Apparatus, each need had to be satisfied according to a system of closed/open [fermeture/ouverture],
anus/voice. A body without organs and without a soul, Orlando was fused with the signifier and when this fusion
reached its most intense, all sorts of strange phenomena were triggered, such as the necessity to evacuate the
excess of real: “When I spoke, something would slip in. It was my speaking that produced these phenomena.”
When they spoke to him, he listened without paying attention. He was only attentive to his anal sensations: “I
leave my anus open or closed. The other spoke and it was cl. . .” Then he goes further by saying, “it was gagged
dominated.”
He frequently suffered from eczema. Once, Dr. Z. said to him: “Maybe you should see if you have something
on your skin.” Hardly had Dr. Z. spoken before “he felt like a fire that was an unguent, covering his entire face
like a relieving coolness.” He was cured of the eczema.
Orlando turned to the task of explaining the Apparatus’s structure, its composition; “the objects,” for example.
They are an important part of the Apparatus, whose composition he enriches with psychoanalytical and electrical
concepts.

In the beginning, he remarks, there were few objects : the penis, the phallus, and excrement. As an illustration,
Orlando comments, for example, on “the excrement-object” which took the form of a pelican, whose pocket-like
beak served as a dump where one would dispose of garbage. The phallus-object was more difficult to locate. The
objects that surrounded Orlando were forty to fifty centimeters high and almost always appeared in
“programmed images” as mythical characters or as if part of anthropomorphic nature, like in cartoons where one
sees animals’ heads attached to human bodies.
All of the objects were linked together by a wire, which was itself connected to a machine, represented by a tall,
face-less woman. On this woman’s face images sometimes appeared and among these images was the analyst’s
face.
The analyst was fragmented into his objects as well. During the analysis, when Orlando took his place on the
divan, he was preoccupied with the body of a very beautiful woman – “Sleeping Beauty” – who was dead, as if
in a glass shrine. He entered the shrine. This could happen during the sessions but also when he was at home
where the Apparatus operated by means of the analyst’s technique. Orlando explained that over the years, this
experience had prompted two different feelings in him. On the one hand, he thought that these moments were
worth the trouble and compensated for all of the torments of the analysis. On the other hand, however, when he
entered the shrine, he was struck with fear, as if this woman would crumble into dust, fall apart, and disappear.
Over this period of years, Orlando had to be connected to the Apparatus in order to function and, despite the
wealth of imagination invested in his delirium, the relative preservation of all of his intellectual faculties outside
of this delirium was surprising. Orlando continued to be adapted to the world, holding onto his job as well as his
friends and family. Set into action by “Dr. Z.’s technique,” he was a robot, lifeless if he were switched off and
animated if switched on. He was thus a cog in the wheel of the Apparatus.
Transference and interpretation

Orlando came to see me for a period of four years. What kind of tie did he establish and why was it possible,
given that this was not a social tie within discourse, such as that defined by Lacan? What tie or ties could have
been involved in this case? Firstly, we know how Orlando situated himself in relation to his partner, the
Apparatus, which operated by means of the analyst’s technique. He clearly stated that the Apparatus – his partner
– was the Other of the signifier. He is involved in a very specific way: in the hallucinatory phenomena, the
Apparatus starts the electrical currents, the voices, the planes, the images – he then has to finish them and
contemplate them. It is thus that Orlando indicates his mode of inclusion in the Other, the place of the signifier.
This could materialize in a manner constantly described by Orlando: he was an object of jouissance for the
Apparatus.
What kind of relationship did he have to the exchange of words? First of all, he felt persecuted and he related
this sense of persecution to his perception of signs of the presence of the Apparatus (the Other). He perceived
this presence selectively as one of terror, provoked by two objects: the voice and the gaze. Besides this terror of
the voice and of the gaze, he had difficulty tolerating the unexpected as well as all sorts of change. At the
beginning of the treatment, Orlando had met in the Other something different from the demands which he was
used to.
Orlando conveys his illness very clearly as an illness of the narcissistic libido, which is compatible with Lacan’s
definition: “Language is an organ.” The libidinal mechanization of his body proves that the libido comes from
the Other (the Apparatus) towards the body, intruding into the organism. In fact, at the moment when he first
came to see me, Orlando complained of the long-distance action of “Dr. Z.’s technique”; the Apparatus continued
to speak to him and had not stopped sending him voices and messages. However, the fact that he was oblivious
as to its workings shows how abandoned Orlando felt as object and, thus, that part of the libido remains in the
Other. The situation is as follows: Orlando uses the Apparatus as an instrument and expects it to conclude his
bodily functions, but on the other hand when he loses the Other, he loses his libido-machine – which abandons
him. What could I do if the place already in position is precisely that of the demand of the Other, that of the
assignation of the Other?
Orlando repeated, during his sessions, his complaints of not having received an explanation concerning the
Apparatus and that ever since the interruption in his treatment, he had been awaiting this explanation. The
Apparatus is something that he has to put up with and “what he had to put up with was language, it was like
entering into the language organized by Dr. Z. and putting up with the effects.”
He asked if I could contact Dr. Z. so that I could question him “colleague to colleague” on his technique and
their effects, wherever he might be: “Send me a report. What do you have to say about what this analysand has
been telling me?” And “seeing that Dr. Z. doesn’t talk to me since I’m an analysand and doesn’t give me
explanations concerning what he was using with me, you could – like the doctors who use a method of
radiotherapy – question him on his technique.” “First of all,” I told him, “you know that psychoanalysis operates
according to a rule that was devised by Dr. Freud and there is no mystery about that as it is within the reach of
all who read his books. Secondly, what is happening to you is real, even if your explanation is completely crazy.
I have no way of knowing Dr. Z.’s address, so, consequently, I ask you to commit yourself to following Dr.
Freud’s technique uniquely and exclusively.” This seemed to interest him and encouraged him to continue seeing
me.
Orlando and Schreber: the double address

As for the place that Orlando set aside for me in transference, I will attempt a hypothesis. Remember that when
Schreber published his Memoirs, he included “An open letter to Professor Flechsig” as well as a preface. In the
first, Schreber addresses himself to Flechsig as the Other of jouissance demanding that he admit to being the
instigator of the destructions that he had suffered, that had been wrought in him “[...] I have no doubt at all that
your name has played the most important role in the development of the events in question [...] insofar as they
have gained access to a supernatural power, which permitted them for years to exert the same degrading
influence on me that they continue to exert. Presently, I still feel every day and at every hour that the destructive
miracles which are the fault of this ‘examined soul’ are at work in me. One hundred times a day, the voices that
speak to me invoke your name [...] I have not the slightest doubt that the central force in what has always been
considered by my doctors as banal ‘hallucinations’, consisted in an order exerted2 by your nervous system on
my nervous system. How can the thing be explained? I am tempted to consider the following possibility: could
you not have, you, in person, imposed on my nerves – and at first, I would really like to believe, with a
therapeutic objective – a hypnotic relationship, suggestive or otherwise, and this in spite of the distance which
separated us”3.
Consequently, just as Schreber expected a written response from Flechsig, Orlando expects an answer from Dr.
Z. relating to “the Technique,” which we may liken to the fear of being abandoned.
On the other hand, in the preface, which is a letter addressed to readers, Schreber turns to the realm of science:
____________________
2 Schreber wrote Einwirkung here, which has the connotation of command through use of a mechanism and which cannot be
translated by the word “influence” that dictionaries sometimes suggest.
3 D. P. Schreber, Mémoires d'un névropathe. Paris: Seuil, 1975, pp. 11-12.

“I firmly believe, however, that it would be useful to science and to the recognition of religious truths that in my
lifetime the competent authorities come to examine my body and note the trials and tribulations which I have
borne. [...] All of these difficulties have forced me to broaden substantially the scope of my personal
observations. As a consequence, a number of viewpoints expressed in the past must be altered; above all, there
can now be no doubt that the ‘mischievous forces’4 as they are called – actions controlled mechanically5 by way
of miracles – exert themselves exclusively on myself.”6 The letter’s mode of address, being directed toward
scientific discourse in order to render the singular aspects of his case (his transformation into a woman) a
universal one, seems essential in so far as, in Orlando’s case, it makes possible the analyst’s place in the
treatment.
Orlando had thus situated me in this place, sparing me from having to be identified to Dr. Z’s place which was
just as marked by the imaginary side of relationships of erotic aggression – “the analyst’s technique” – as by the
symbolic and the real side of the relationship to the Other of jouissance – the “Apparatus.” I think that the
reference to “Dr. Freud’s technique” helped to free a place from which I could begin to operate.
Although he continued to complain of “Dr. Z’s technique,” he let me know that from time to time, if he did not
think about it, he was calmer. It was when he spoke that the voices started and if he listened closely they stopped.
Later, he compared the voices to a radio whose volume had been lowered: one could not hear what was said but
it all stopped as soon as one listened closely.
During Orlando’s treatment, I intervened a second time. As I said, he taught at a private secondary school. His
relationships with students to whom he was attracted complicated a difficult work situation even further. What’s
more, his gentle and attentive personality made him attractive to certain of his female students. It is not
surprising, then, that when he approached certain of his students or went out with them, he had to submit to the
rigors of “Dr. Z.’s technique.” The problem for Orlando was that the voices were not always menacing. They
were often “kind, gentle and soft-spoken” (the voices could be masculine or feminine ones; that of a little boy
or of a little girl; that of a computer. . .).
Three years after Orlando had first come to see me, he told me that one of his students had showed an interest
in him. He was very attracted to her. He wanted to ask her to go out on a date with him. At this point, I intervened
by telling him: “It’s not in your interest to complicate your work situation! It would be better to wait until the
end of the year when she is no longer your student!” Having already been involved in an uncomfortable situation
of this order, he took my advice. He explained this to her and at the end of the year, the relationship materialized.
She was very much in love with Orlando. They had a sexual relationship from the very beginning and it was a
very satisfying one. When he was with her, Orlando was not subject to the effects that the eroticized word of
“Dr. Z.’s technique” had previously had on him. I continued to see him for another year. The sessions were more
spaced out and he came in order to tell me about his developing relationship with her. The theme of “Dr. Z.’s
technique” was little by little – and in a surprising manner – put to one side. He spoke to me only of his new
relationship and showed hardly any interest in “Dr. Z.’s technique.” She moved in with him and one day he came
to tell me that he no longer felt it was necessary for him to continue his analysis. That was three years ago now.
Translated by Kirsten Johnson
____________________
4 Menschenspielerei.
5 Einwirkung.
6 D. P. Schreber, Mémoires d'un névropathe, op. cit., p. 9.
Clinical Practice and its Concepts
Graciela Brodsky
The Alchemy of Hysteria
I begin with a statement*1. Like any statement in the field of psychoanalysis, it is not irrefutable and I present it
as a starting point: the psychoanalytic clinic of neurosis is basically the clinic of hysteria. This statement has
double grounds. On one hand, according to Freud and Lacan there is what we know as the hysteric core of
neurosis (in French, Noyau Hystérique des Névroses or NHN). On the other, there is what we know since Lacan
as the hysterization in the analytic setting
NHN Hysterization
I propose to write not only the initials of the hysteric core of neurosis but to write what constitutes a matheme
of this core. I propose to write it as:
S/
__
a
The matheme of the hysteric core

What I have called the matheme of the hysteric core of neurosis is really part of the writing of the discourse of
the hysteric but I do not write it as discourse. I propose that this matheme translate what is called since Freud
and Lacan, the splitting of the subject in the defense process. This expression is Lacanian but Lacan uses the
Freudian term Spaltung. Clivage in French and “splitting” in English translate this German word. I propose a
brief overview of the concept of defense in the perspective of splitting. I clarify this point, as there are other ways
of using the concept, as for instance in Anna Freud’s famous text The Ego and the Defense Mechanisms.
The first decisive text where Freud approaches this subject is precisely in “The Neuro-Psychoses of Defense” of
1894, contemporary with “Manuscript K,” but before The Interpretation of Dreams. The way Freud considers
the defense in this text is very useful to us. He says that the subject is going to treat the unacceptable sexual
representation as never having arrived, as if this representation had never existed. What is decisive is that for
Freud, this defense, this hysteric way of “saying no” produces a splitting that originates the difference between
conscious and unconscious. Hence the deduced solidarity for Freud between unconscious and hysteria.
In “A Project for a Scientific Psychology,” dating from the same period, Freud uses defense from another
perspective – defense in front of Fremde, which means the most alien thing. It is the answer of a subject who
says “no.” This defense also determines a splitting, occurring this time between the external reality and the body
itself. Lacan reviewed this approach in his Seminar The Ethics of Psychoanalysis.
The splitting between the inside and the outside is Freud’s first indication regarding the constitution of reality as
a consequence of a psychic act where the attribution judgment precedes the existence judgment.
____________________
1 Lecture given June 6, 2001 at the Clinical Institute of Buenos Aires, Argentina.
The Alchemy of Hysteria 71

After the “Project,” the use of the word defense disappears form Freud’s works, and is replaced by a variety of
mechanisms of which the best known and used is repression.
The astonishing thing is that after having been abandoned, the concept of defense reappears in Freud’s writings
in the 20s, in Inhibitions, Symptoms and Anxiety. Freud returns to his ideas of the “Project,” to show that in front
of the object that seems uncanny, there are two possibilities: if the object belongs to the external world, the
subject runs, but if what is assailing is the drive threat, how can he run away? One can run from the dangers of
every day life, but one cannot run away from the drive. It is in this perspective that the term of defense reappears,
as a solution to the drive from which the subject cannot escape.
Thus, we can understand defense as a radical no of the subject. It is necessary then to ask: a “no” to what? For
Freud, it is obvious that it is about a “no” to drive, a “no” to what is alien, threatening, that, as a result, leaves
the subject empty of jouissance. Whilst jouissance passes to another register, there is a jouissance that persists
separated from the subject and that Lacan writes with this small matheme:
S/
____
a
Is an empty subject that is constituted as such within the act of defense, barred S, and a jouissance, a, that subsists
separated from him by the bar. It is not really an eliminated jouissance, here is the paradox, as it acts, it is
effective, it has consequences. One can even say that the whole field of the neurosis is determined by the return
of this rejected jouissance.
From this primordial “no,” every signifier that evokes this rejected jouissance falls under the effects of
repression. The difference between defense and repression is thus well established: defense that is a barrier of
protection against this jouissance that cannot be signified, and the repression as a mechanism that always has to
do with signifiers. While defense takes place on the field of the emptied subject as a result from the “no” to the
real of jouissance, repression takes place in another domain, in the metaphoric substitution of one signifier by
another.
S S’
Defense _____ _____ Metaphoric substitution
a. . . . . .S
Metonymic connection
A signifier remains repressed under the bar while there is a metonymic connection between it and the real. There
is no other reason that justifies the repression of a signifier if this one does not evoke this radical core of defense.
A purification of defense
Once established what I call the matheme of the hysteric core, the analytic discourse is the one that goes exactly
in the opposite direction. I will only write the first level:
S/
___ a → S/
a
72 GRACIELA BRODSKY
They are the same terms as those of the previous matheme, except that the place of a has changed: it was what
the subject rejected and which produces an empty subject; becoming what the analytic discourse reintroduces.
The analytic discourse reintroduces the jouissance in the emptiness of the subject, thus upsetting defense.
Analysis is going against the subject that says “no” to jouissance and who consequently suffers from a “lack of
being,” subjective correlation of the empty subject.
The idea of upsetting defense, which has been abundantly developed by Jacques-Alain Miller in his course “The
experience of the real in the analytic treatment,” was already pointed out by Lacan in the Seminar “Crucial
problems for psychoanalysis,” in 1965. It was in that seminar that he said that the analyst has to lead the subject
to a ever-purer mode of defense, confronting him in transference to the impossible of the sexual relation. It is a
strategy, under transference, which is not interpretation and which aims to obtain a purification of defense.
In the oscillations of Lacan’s teachings there are two values that the subject seems to defend itself from. On the
one hand, the surplus jouissance of the drive, and in the other hand a non-existence, that of the sexual relation.
I use Lacan’s lozenge that implies inclusion and exclusion. Thus, it is about a surplus drive in its tight link with
the sexual non-relation.
Surplus jouissance ◊ Sexual non-relation
It is in this field, that of the non-existence of the sexual relation and of the surplus drive, that Lacan’s
considerations on defense are developed.
The two Freudian moments

On the contrary, for Freud it is not about the non-existence of the sexual relation, at least not directly. For him,
there is a first moment in the constitution of the subject, defined as traumatic irruption: it is the bad encounter
with something inscribed as a mark of displeasure. When we speak of displeasure we are referring to what
troubles the homeostasis, of something that interrupts a certain equilibrium, which we don’t know what to do
with. Freud considers that this first moment that I situate as the hysteric core of neurosis is the sexual trauma
experienced as displeasure. This is what is at the heart of every neurosis, even of obsession which, for Freud, is
nothing but a dialect, as he literally says it in the analysis of the “Rat Man”: The fundamental language is
hysteria, obsession is a dialect. Thus, moment one is the hysteric core of neurosis: the sexual trauma, the
irruption of jouissance registered as displeasure.
Second moment, is defense and splitting. The loss of jouissance produces the feeling of emptiness, of lack-of-
being, of which we know the clinical expressions – the typical phenomenon of the “leaf in the wind,” of not
having anchors, incredulity when faced with words, of meaninglessness, but also of disgust, which is a way of
saying “no” to jouissance. Disgust with sexuality, the male organ, odors, hair, meals, somebody’s proximity, etc.
The fact that the subject said “no” at the beginning is generally a clinical proof What does the hysteric’s
dissatisfaction denounce more than this gap between the excluded jouissance and all the signifiers that come to
fill that lack?
Lacan’s lever is to say that even desire is a barrier that doesn’t allow going beyond a certain limit. Lacan says
so in Seminar VII The Ethics of Psychoanalysis. Desire distracts, whirls in a circuit of something encysted,
“extime” something that is both interior and alien. Desire describes a significant path that always surrounds the
same point without ever going beyond the defense. When Lacan says for example, that the subject can heal from
anything except from hysteria, he refers to this core, which is not only at the base of hysteria but also of
obsession.

The neurotic unleashing
One must differentiate the hysteric core from what is the neurotic unleashing of hysteria. The neurotic unleashing
of hysteria is not equivalent to the clinic of unsatisfied desire, disgust, lack of being. The neurotic unleashing of
hysteria is something else. The hysteric lives with this neurotic core of neurosis, evidently he/she suffers but it
is not neurosis. Maybe it is due to the spreading of psychoanalysis that the hysteric consults more and more for
vague reasons, as if analysis could definitely solve that core – it cannot, but it is true that it can touch it.
I think that modern psychiatry has also contributed to flattening the treatment of unleashed hysteria – that is why
it is no longer in the DSM IV. Nevertheless, in psychoanalytical clinica practice, one must search for the “ripe
moment” of hysteria, meaning, the moment of breaking through of symptoms.
To further the distinction between the hysteric core of neurosis and the triggering of hysteria, the moment when
defense fails, I can refer to a paragraph of Seminar V: “I have reminded you how Dora lives until the moment
when her hysteric position decompensates”2. Lacan uses the terms of psychosis: decompensate. “She is very
much at ease, except for some small symptoms, which are precisely those that constitute her as hysteric, and
which are read in the Spaltung (…) What we demonstrated the other day is that Dora subsists as subject as long
as she demands love, as any good hysteric, but also as long as she supports the desire of the Other as such”.
Lacan remarks that everything goes well, everything evolves in the best possible way, “without anyone noticing
anything”. I want to underline that. Lacan describes that moment prior to unleashing very well.
At the moment when something fails, what irrupts are acting-out or body phenomena. When something that is
refused, unrecognized, not happening, bites into the body, this is the moment when hysteria is really constituted.
It is no longer the hysteric core common to every neurosis, but the symptomatic hysteria, unleashed.
Acting-out such as Lacan formulates it in Seminar X “Anxiety” is the irruption on the scene of the object a. The
body is itself the scenario of the hysteric symptom, to which Lacan refers in the 70s to distinguish hysteria from
obsession in which the question is located on the level of thought.
I consider that this is a precious indication: not to blind oneself in hysteria with dissatisfaction and lack of being,
but always to look to the body, the point where repression bites into the body.
It is at this moment of decompensation when an appeal to the Other can be made. That is why I underlined
Lacan’s expression: “without anyone noticing anything”: before, she managed by herself. One addresses the
Other in different ways: one can address him as witness, as judge, as magician, but one can take him also for
someone from whom one expects an answer which might be that of a psychoanalyst.
While contemporary clinical practice shows us the hysteric consulting before the moment of unleashing, it is not
certain that it is the good way to link the hysteric to analysis.
Let us consider for a moment what we call discourse. A discourse is always a social link, a link to the Other –
which is the reason why every discourse has four places, that of the agent, that of the Other, that of truth and that
of production.
agent
_____ Other
_____
truth production
____________________
2 J. Lacan, Le Séminaire Livre V, Les Formations de l’inconscient, Seuil, Paris 1988, p. 397.
74 GRACIELA BRODSKY
Hysterization
When we speak of hysterization in the setting, one means every symptom, hysteric or obsessional must be
addressed to the Other. It is easy to imagine for obsession, but more amusing, more astonishing is that one needs
to hystericize the hysteric. Why? Because we have to withdraw the hysteric from the hysteric core, so that
through the symptom that decompensated her, she goes towards the Other. This is not at all obvious.
In this third moment – which is not that of the hysteric core where there is no unleashing – we really are in the
direction of the Other, in the constitution of a discourse. To which Other does she address herself? Of which
discourse is the hysteric the agent? Lacan says that the Other sought by the hysteric is a master.
To summarize:
1) Sexual trauma: irruption of jouissance
2) Defense and splitting S/
__
a
3) Direction towards the Other S/ → S1

__
a
The hysteric addresses him- or herself to a master (S1) with his/her division, with that emptiness inhabited by
something, because the symptom indicates that in the emptiness something immixed, that the barred S is
inhabited by something else and that now it is not only suffering from the un-satisfaction of the lack-of-being or
even disgust. The symptom allows to see that in the emptiness something has sprang like a mushroom – in the
desert of jouissance, something emerged. The empty subject addresses its symptom to the Other as a question.
It is the first thing that Lacan indicates. That is why in Seminar III, there is the chapter called “The hysteric’s
question.”
The hysteric appeals to the master to produce knowledge (S2).
$ → S1
__ __
a S2
It is logical to imagine that if one asks a question, this question will find an answer. Insofar as the hysteric
addresses the Other, the Other can begin to produce a knowledge in answer to it. That is what Freud did with the
hysterics who consulted with him – elaborating knowledge to answer them, he invented psychoanalysis. This
knowledge comes in the place of the production in the hysteric discourse: if you want to produce knowledge do
not call upon the professors, call the hysteric! To produce knowledge, a hysteric must be in the place of the agent
saying: “And why?” “I do not understand,” “It is not what I said,” “It is not what Lacan says” etc.
The only problem is that this knowledge produced by the master is always going to be useless knowledge,
knowledge that does not touch what was originally rejected by the hysteric and that constitutes the truth of
his/her position, which he/she wants to know nothing about, and that we place under the bar to the left. Thus,
speak, speak! But be aware that we shall not touch the hysteric with knowledge. You understand why Lacan said
that interpretation must never be a transmission of knowledge. It is not modesty on the analyst’s part, it is
because it is useless, since the hysteric continues with his/her question.
“Very interesting, Dr. Freud, everything you say, but that doesn’t concern me.” Very interesting, insofar as he
does not get involved, the object a that is at the place of truth and not at the place of production. “That” is
precisely what the discourse of the analyst puts in the place of the agent.
a → S/

An alchemy that transforms emptiness into an object for the Other
One must see that the hysteric is someone privileged. One generally doesn’t do anything with a hole. The
hysteric is the subject capable of creating a world with a S/, with the hole of jouissance. It is remarkable. One can
say that it is a real alchemy. The alchemy of hysteria consists in transforming the hole into cause of desire for
the Other.
There is an entire clinic of everyday life that shows the privilege of the hysteric when she/he knows how to deal
with her own subjective division as well as with the Other placed in the master’s position. It is what we call in
psychoanalysis “the hysteric evasion” (la dérobade hystérique) – how never to be there for a rendezvous, how
never to be on time, always late, or to be in another place, meaning: knowing how to be not-there for the Other.
The first victim of the hysteric evasion was Freud, to whom Dora said, after a huge production of knowledge:
“I have to tell you that today is the last session.” Freud will say that she dismissed him as one dismisses a servant!
Transforming the hole into an object for the Other makes hysterics desirable, but pushes them to forced labor.
Nevertheless, being the object of desire for the Other does not touch in any way their own jouissance. This is the
point that hysterics keep as the most precious, they are experts at provoking desire, but do not want to know what
moves them, what tickles them.
Maybe you have read, in Seminar V, the chapter “The dreams of ‘l’eau qui dort’.” This chapter draws the portrait
of the hysteric: “what you give me is not what I search, I do not know it, I do not take it and I return with empty
hands.” There is nothing more satisfying for an hysteric than to return empty handed.
Translated by Maria-Cristina Aguirre
76 GRACIELA BRODSKY
The Subject Inside the Patient
Philippe Fouchet
Epilepsy
Epilepsy in the age of science

Although psychiatry was still interested in epilepsy at the beginning of the twentieth century, today epilepsy
seems to have been definitively placed in the field of neurology: medical follow-up, the classification of seizures
and syndromes, diagnosis and treatment are now organized almost exclusively along the axis of neurology1. This
observation, now unanimously acknowledged, can be associated with the preeminence of scientific discourse in
modern medicine. In this sense, the movement of epilepsy towards neurology was already beginning in the
second half of the nineteenth century.
In fact, it was around 1870 that John Hughling Jackson was able to formulate, based on an anatomo-pathological
method, the first and only definition of epilepsy and its elementary mechanisms. Epilepsy had been associated,
since Antiquity, with one of two causes: humoral (in official medicine), or divine (in magic or religious practice).
It was not until the end of the eighteenth century, and above all in the nineteenth, that the introduction of
scientific discourse into the field of medicine made possible, through anatomo-pathology, a radically different
approach to the illness.
This new theoretical framework permitted Jackson and a few other pioneers of modern neurology to abandon
questions of causality and to submit epilepsy to scientific examination. Today we can see two results of that
event:
1. The search for a cause for epilepsy has been abandoned in favor of a description of the organic substrate and
the mechanisms that disturb it. The definition proposed by Jackson, still in use, ignores the etiological question:
“A convulsion is but a symptom, and implies only that there is an occasional, an excessive, and a disorderly
discharge of nerve tissue on muscles.”2 This definition reduces the illness to nothing more than repetitive
seizures in a given patient.
2. At the same time, doing away with causality has been accompanied by a radical exclusion of the effects on
the human body, its immersion in social space, symbolic structures and, more generally, language. Paradoxically,
it is because the anatomo-pathothology operated a construction of the organism excluding from its domain the
dimension of the living, that it made possible Freud’s discovery of a dimension of the living inherent to his
structure of language. We will see that the impasses of current clinical practice in epilepsy can be a direct
consequence of the exclusion of that aspect of the drive that characterizes the body as specifically human.
____________________
1 This text is based on the major topics of a thesis for a doctorate in psychology (Université Libre de Bruxelles) presented in
September 2001. Its title was: “Le phénomène épileptique. Fonction et statut clinique des manifestations épileptiformes chez des
sujets présentant une épilepsie et/ou des troubles pseudo-épileptiques d’origine non organique.” (The phenomenon of epilepsy.
Function and clinical status of epileptic seizures in subjects with epilepsy or pseudo-epilepsy of organic origin). I would like to
thank Alfredo Zenoni, to whom this work owes a great deal.
2 Quoted by R. A. Gross, “A brief history of epilepsy and its therapy in the western hemisphere,” Epilepsy Research, 1992, pp.
65-74 (p. 72).
Epilepsy 79
Heterogeneous clinical practices
Analysis of clinical practice in terms of responses to pharmacological treatment
According to Thomas and Arzimanoglou3, in an approach examining medical treatment, it is possible today, by
looking at responses to anti-epileptic medication4, to divide clinical practice into four categories:
1. “Spontaneously benign epilepsies” (20 to 30% of all patients), with an “excellent” prognosis, slow evolution,
and spontaneous remission.
2. “Pharmaco-sensitive epilepsies” (30 to 40% of all patients), with a “good” prognosis, whose remission
permits, after a certain lapse of time, the end of medication.
3. “Pharmaco-dependent epilepsies” (10 to 20% of all patients), with a “more reserved” prognosis, which require
medication for at least several decades.
4. “Pharmaco-resistant epilepsies” (20 to 30% of all patients), with a “bad” prognosis because of the chronic
nature of the illness and a relative or absolute resistance to medication.
To simplify a little, these categories can be reduced to an opposition between non-evolutive epilepsies with a
good prognosis (70 to 80% of all cases), and severe pharmaco-resistant epilepsies with a reserved prognosis.
Jallon5 has pointed out that 20 to 30% of epilepsies still resist conventional treatment, in spite of the “enormous”
progress made since the 1980s in therapeutic strategies6.
So-called “rebel” or “pharmaco-resistant” epilepsies constitute an important clinical problem from both a
therapeutic and a diagnostic point of view in epileptology: on the one hand, the reasons for the persistence of the
seizures remain unelucidated; on the other, from the diagnostic point of view, these epilepsies raise the problem
of distinguishing between what neurologists consider “real” epileptic seizures and what they call “pseudo-
epileptic” seizures – and one and the same patient can have both kinds7. Paradoxically, so-called “rebel”
epilepsies are also the most malign, the most resistant to anti-epileptic treatments, and the distinction from
“pseudo-epilepsy” in those cases is the most difficult to establish: it is as if, when a certain level of exacerbation
is reached, epilepsy can no longer be distinguished from pseudo-epileptic phenomena.
Let us make it clear that pseudo-epileptic seizures are defined as seizures that mimic epilepsy, but that are not
accompanied by the abnormal electrical brain activity characteristic of epilepsy8. According to scientific
____________________
3 P. Thomas, A. Arzimanoglou, Epilepsie, Masson, Paris, 2000 (second edition, revised and corrected).
4 We should point out in passing that the introduction of anti-epileptic medication onto the marketplace happens in an essentially
empirical manner, without any detailed understanding of how they work. The different molecules now used are thought to act on
the neurophysiological and biochemical mechanisms involved in the seizures: stabilizing effects on cellular membranes, increasing
the inhibiting action of GABA – the principal inhibiting neurotransmitter – reducing the liberation of excitatory amino acids,
blocking certain receptors, etc. Therefore, no medication has an “anti-epileptic” effect as such. It is, rather, “anti-convulsive”
effects that act solely on the electro-clinical symptoms of epilepsy.
5 P. Jallon, “L’utilisation des anti-épileptiques en monothérapie et polythérapie. Evolution des idées,” Revue Neurologique, 1997,
153, 1, pp. 29-33.
6 Among children as well, at least 25% of epilepsies are resistant to medication. Cf. J. M. Pellock, R. Appleton, “Use of new
anti-epileptic drugs in the treatment of childhood epilepsy,” Epilepsia, 1999, 40, s6, pp. 29-38.
7 The incidence of pseudo-epileptic seizures among patients presenting a diagnosis of pharmaco-resistant epilepsy is estimated
at 40%. Cf. P. Francis, G. A. Baker, “Non-epileptic attack disorders (NEAD): A comprehensive review,” Seizure, 1999, 8, 1, pp.
53-61.
8 In Anglo-Saxon literature, the terminology used since the middle of the 1960s to identify this kind of seizure refers directly –
in the negative – to epilepsy: “non-epileptic attacks,” “non-epileptic attack disorders,” “non-epileptic seizures,” “psychogenic non-
epileptic seizures,” “pseudoseizures,” “pseudo-epileptic seizures,” “psychogenic pseudoseizures in non-epileptic patients,”
80 PHILIPPE FOUCHET
literature, today the pseudo-epilepsies constitute, in epileptology, a major preoccupation for neurologists9. As we
will see in detail, the criteria used to try to establish a differential diagnosis between epileptic and pseudo-
epileptic seizures do not hold up under clinical examination.
Definition and classification of epileptic seizures and of epilepsy
Following directly on Jackson’s research, the neurological definition of this pathology is in two parts:
1. A description of the electro-chemical characteristics of epileptic seizures, in which they are presented as the
association of two elements necessarily appearing simultaneously:
— First: clinical elements that can take different forms and for which it is not possible to find a common
denominator;
— Second: the appearance of brutal and excessive discharges of electric potential in the neuron population of
the brain.
2. A definition of epilepsy in terms of the repetitive character of the seizures: epilepsy is considered an illness
when seizures are recurrent in a given subject10.
Starting with that definition, the ILAE (International League against Epilepsy) has proposed a classification of
epileptic seizures: the most recent version is used today by the entire international scientific community11. The
seizures can be divided into three categories based on the location of the initial neuronal discharges:
1. Generalized seizures for which the paroxystic discharge is propagated immediately into two cerebral
hemispheres.
2. Partial or focal seizures in which the initial discharge is localized in a limited zone (called “epileptogenic
zone”) in one cerebral hemisphere.
3. “Unclassifiable” seizures, so called because of a lack of information or a puzzling semiology.
In this classificatory perspective, the accent is essentially on the anatomo-functional characteristics of the
different cerebral structures implicated in the path taken by the neuronal discharges.
Observation of clinical manifestations occurring during seizures contributes to the diagnosis insofar as it
provides information on the topographical localization of the initial discharges and on the anatomical paths taken
by these discharges during their propagation in the cerebral organ. But in the absence of sufficient
electroencephalographic elements, the neurologist must pay particular attention to the clinical logic of the
phenomenology of the seizures.
____________________
“psychogenic pseudoepileptic seizures,” etc. In a sense, this nomenclature takes the place of – without really covering the same
clinical reality – the classic opposition between hysteria and epilepsy.
9 Most studies estimate at about 20% the proportion of patients who come to a center or neurological service specializing in
epilepsy, with “pseudo-epileptic” seizures, associated (or not) with epilepsy.
10 The reproduction of seizures after the manifestation of the first epileptic phenomenon in a patient is not systematic. An
estimated 20% of tonico-clonic seizures are isolated and inexplicable events: J.-F. Chevalier, J. Plas, F. Fineyre, “Aspects
neurologiques de l’épilepsie,” Encyclopédie Médico-Chirurgicale (Paris), “Psychiatrie,” 1992, 37-219-N-10, 4p. The seizures are
indeed of an epileptic nature, and they appear independently of specific accidental circumstances, but they cannot be considered
as showing epilepsy since there is no repetition of the seizure.
11 Commission on Classification and Terminology of the International League Against Epilepsy, “Proposal for revised clinical
and electro-encephalographic classification of epileptic seizures,” Epilepsia, 1981, 22, pp. 489-501.
Epilepsy 81
The ILAE has also proposed, in addition to a classification of seizures, a classification of “epilepsies” and of
“epileptic syndromes”12 stemming from the interaction of two axes:
1. The “localization” (generalized or focal) of neuronal discharges during seizures. We have then:
— generalized epilepsies, in which all seizures are of the generalized type;
— partial epilepsies, in which the seizures begin in a specific area of one of the cerebral hemispheres (with the
possibility of a subsequent generalization);
— epilepsies in which the origin, focal or generalized, cannot be ascertained.
2. The axis called “etiopathogenic,” which tries to establish a distinction among epilepsies based on the presence
or absence of an organic etiology, objective or supposed. Generalized and partial epilepsies are then supposed to
be divided into three categories:
— idiopathic epilepsies (about 20% of all cases), independent of cerebral lesions, but for which a genetic
predisposition has been shown to – or is presumed to – exist;
— symptomatic epilepsies (about 40% of all cases), the consequence of a lesion in the central nervous system;
— cryptogenic epilepsies (about 40% of all cases), for which no etiological factor can be shown.
As shown by Loiseau and Duché13, in the end, all this is more like a descriptive inventory than a real
classification. The second axis, etiopathogenic, nevertheless takes into account the clinical difficulty of
identifying a factor other than a cerebral lesion – present in fewer than half of all cases: about 60% of epilepsies
are globally non-symptomatic. In that sense, it is important to note that genetic factors – that supposedly
intervene in idiopathic epilepsies, but that are also evoked for all epilepsies14 – are not considered to be
“predisposition” factors. One surprising element is that epilepsies in which the genetic factor seems predominant
are mostly benign15.
So, in spite of neurologists’ attempts at establishing a classification that would take into account etiological
organic factors, the question remains, in most cases, as to what causes the onset – and then the recurrence – of
the seizures that make up the clinical description of epilepsy.
What is most surprising is that the application of these diagnostic postulates in a clinical situation presents a
series of complications, or even contradictions, that seem to put into question the purely neurological status of
epilepsy.
Diagnostic paradoxes
In accordance with the logic of its scientific definition, the diagnosis of epilepsy depends on finding an abnormal
electrical discharge in the brain associated with clinical events. However, in practice it is not always possible to
____________________
12 Commission on Classification and Terminology of the International League Against Epilepsy, “Proposal for revised
classification of epilepsy and epileptic syndromes,” Epilepsia, 1989, 4, pp. 389-399.
13 P. Loiseau, B. Duché, “Classification et définition des syndromes épileptiques,” La Revue du Praticien, 1990, 40, 2, pp. 9-14.
14 Neurologists suggest that genetic factors intervene in all forms of epilepsy, most often “according to a multifactorial heredity
that entails the cooperation of several genes and environmental factors” (P. Thomas, A. Arzimanoglou, Epilepsie, op. cit., p. 15).
Together with other “predisposition” factors, genetic factors presumably play a role in the lowering of the “convulsion threshold”
– a threshold of neuronal “excitability” that depends on intrinsic properties of neuronal membranes. The interaction with
“precipitation” or “facilitation” factors of various kinds would take into account the onset of seizures. The model, called
plurifactorial, also includes factors of “aggravation” or “chronicity” linked to the neurobiological consequences of the seizures.
15 M. Boldy-Mouliner, Epilepsies en questions, Paris, John Libbey Eurotext, 1997, p. 63.
82 PHILIPPE FOUCHET
establish that link. In addition to the difficulties of gathering information from the electroencephalogram
(EEG)16, there are certain particularities involved in clinical practice with epilepsy that make diagnosis
problematic:
— for one thing, as Thomas and Arzimanoglou state, “the EEGs of many epileptic patients can be […]
completely devoid of all paroxystic activity”17 and “certain seizures are not accompanied by any perceptible
modification in the EEG;”18
— for another, “subjects who have never had epileptic seizures can occasionally show certain activities
typical of that illness”19 and “certain paroxystic discharges, wrongly called ‘electric seizures’ or ‘infraclinical
seizures’, remain – in appearance – without clinical translation”20.
Electroencephalographic information does not, therefore, make an unequivocal clinical evaluation possible,
either within any one group of patients or in one and the same patient. Epileptic patients, pseudo-epileptic
patients, and even subjects who have never had a seizure that even resembles epilepsy – all these groups may
present normal or abnormal EEGs21. Moreover, certain individual patients can have seizures that are sometimes
shown as anomalies on an EEG and sometimes not. In other words, the presence or absence of abnormal
epileptiform activity on an EEG does not necessarily indicate the epileptic or pseudo-epileptic character of the
seizure. The absence of that abnormal electroencephalographic activity typical of epilepsy, which constitutes the
main argument in favor of a diagnosis of pseudo-epilepsy, is not, in itself, enough to confirm that hypothesis or
to exclude the diagnosis of epilepsy. Conversely, the presence of the abnormal electric activity habitually
associated with epilepsy does not necessarily exclude the possibility of pseudo-epilepsy.
It should be noted that diagnostic difficulties are even greater when the phenomenology of the seizure can
suggest or resemble a psychiatric disorder. This is often the case with temporal lobe epilepsies in which the
clinical characteristics are often very similar to those habitually described (according to the DSM approach) in
various psychiatric pathologies22. In both situations (“epilepsies” or “psychiatric disorders”), the EEG patterns
may or may not show anomalies. For example, patients presenting “atypical panic attacks” (without temporal
lobe epilepsy) may present anomalies in their EEGs and may respond to certain anti-epileptic medication with a
diminishment or suppression of symptoms23. Conversely, certain epileptic patients may present partial simple
____________________
16 More often than not, the neurologist only has access to “intercritical” EEG results (EEGs made when the patient is not having
a seizure); the neurologist then must rely on a description of the symptoms given by the patient (or someone close to him or her)
after the fact. To compensate for this dearth of direct information, more and more patients are being offered extended EEG-video
monitoring (during a period of hospitalization in a neurology service) that would increase the possibility of observing seizures
during an EEG recording. This system aims at making possible the observation, recording, and measurement of electro-clinical
events (cerebral electric activity coupled with behavioral disorders) during seizures.
17 P. Thomas, A. Arzimanoglou, Epilepsie, op. cit., p. 36.
18 Ibid., p. 38.
19 Ibid., p. 36.
20 Ibid., p. 38.
21 Anomalies in EEGs (without associated problems) can be found in 10 to 15% of subjects in the general population (cf. H. I.
Kaplan, B. J. Sadock, Livre de poche de psychiatrie clinique, trans. S. Ivanov-Mazzucconi, Paris, Masson, 1998) and some patterns
absolutely typical of epilepsy (but not accompanied by seizures) are found in about 3% of the population (P. Francis, G. A. Baker,
“Non-epileptic attack disorders (NEAD): A comprehensive review,” op. cit.).
22 Cf. L. J. Puryear, M. E. Kunik, V. Molinari, R. H. Workman Jr., “Psychiatric manifestations of temporal lobe epilepsy in older
adults,” The Journal of Neuropsychiatry and Clinical Neurosciences, 1995, 7, pp. 235-237.
23 Cf. M. J. Edlund, A. C. Swann, J. Clothier, “Patients with panic attacks and abnormal EEG results,” American Journal of
Psychiatry, 1987, 144, pp. 508-509; M. E. McNamara, B. S. Fogel, “Anticonvulsant-responsive panic attacks with temporal lobe
EEG abnormalities,” The Journal of Neuropsychiatry and Clinical Neurosciences, 1990, 2, pp. 193-196.
Epilepsy 83
seizures in which the phenomenology evokes panic attacks, sometimes with a normal routine EEG and no
response to anti-epileptic medication24.
Finally, contrary to whatever precise criteria can evoke, diagnoses are more often made in terms of “a body of
more or less corroborating arguments” than according to strictly identical criteria25. The diagnostic approach
thus rests on the interpretation of various clinical elements; among them a neurological examination, a patient
history, familial and personal background, age of the first seizure, circumstances of its appearance, manner of
recurrence, sensitivity to therapy, etc.26 It is nevertheless clear that clinical studies show an absence of any
determining criteria for distinguishing between epileptic and pseudo-epileptic seizures.
Epilepsy versus pseudo-epilepsy: two distinct syndromes or two names for the same syndrome?
The increasingly common use of EEG-video monitoring in cases of difficult-to-diagnose epilepsy has drawn
neurologists’ attention to the frequency of pseudo-epileptic disorders (i.e., seizures that look like epilepsy but
that are not accompanied by disturbances in cerebral electric activity) and also to the difficulty of distinguishing
this disorder from epilepsy proper. As shown by Kuyk et al.27, diagnostic techniques and procedures are
essentially based on the idea that in cases where the probability of epilepsy is slim, the probability of pseudo-
epileptic seizures is great. Comparative studies have tried to evaluate the pertinence of different diagnostic
procedures.
To begin with, it has been shown through observation that clinical phenomena cannot be considered as sufficient
for diagnosis. Clinical indications traditionally seen as typical of epilepsy (like incontinence or tongue biting)
have also been described in scientific literature in pseudo-epileptic patients28; but according to some authors,
clinical phenomenology in pseudoseizures is rarely identical to that in real epileptic seizures29. Certain elements
supposedly characteristic of pseudoseizures are: longer, less stereotypical seizures than in epilepsy,
asynchronous movements of the extremities, atypical vocalization, particular movements of the head and pelvis,
etc.30 Nevertheless, the same authors also emphasize the fact that some epileptic patients have partial complex
seizures very similar to pseudoseizures, and also that in many pseudoseizures the phenomenology does not
correspond to the established clinical description. In the end, as Rowan states31, most authors agree on the fact
that, in general, one observes considerable variation in the phenomenology of pseudoseizures; some authors have
____________________
24 Cf. G. B. Young, P. C. Chandarana, W. T. Blume, R. S. McLachlan, D. G. Munoz, J. P. Girvin, “Mesial temporal lobe seizures
presenting as anxiety disorders,” The Journal of Neuropsychiatry and Clinical Neurosciences, 1995, 7, pp. 352-357.
25 P. Richard, “Crises épileptiques ou crises fonctionnelles? Quelques situations où les crises posent des problèmes de
diagnostic,” Perspectives Psychiatriques, 1996, 35, 3, pp. 184-192 (p. 185).
26 Cf. C. Dravet, “Les crises et les syndromes épileptiques,” Perspectives Psychiatriques, 1996, 35, 3, pp. 177-183.
27 J. Kuyk, F. Leijten, H. Meinardi, P. Spinhoven, R. van Dyck, “The diagnosis of psychogenic non-epileptic seizures: A review,”
Seizure, 1997, 6, pp. 243-253.
28 Cf. E. Peguero, B. Abou-Khalil, T. Fakhoury, G. Mathews, “Self-injury and incontinence in psychogenic seizures,” Epilepsia,
1995, 36, 6, pp. 586-591; J. Kuyk, F. Leijten, H. Meinardi, P. Spinhoven, R. van Dyck, “The diagnosis of psychogenic non-
epileptic seizures: A review, ” op. cit.
29 Cf. T. A. Gulick, I. P. Sprinks, D. W. King, “Pseudoseizures: ictal phenomena,” Neurology, 1982, 32, 1, pp. 24-30.
30 Cf. T. L. Riley, Brannon, “Recognition of pseudoseizures,” The Journal of Family Practice, 1980, 10, 2, pp. 213-220; J. R.
Gates, V. Ramani, S. Whalen, R. Loewenson, “Ictal characteristics of pseudoseizures,” Archives of Neurology, 1985, 42, 12, pp.
1183-1187; P. A. Boon, P. D. Williamson, “The diagnosis of pseudoseizures,” Clinical Neurology and Neurosurgery, 1993, 95, 1,
pp. 1-8.
31 A. J. Rowan, “An introduction to current practice in the diagnosis of non-epileptic seizures,” in Non-Epileptic Seizures, A. J.
Rowan, J. R. Gates, Boston, Butterworth-Heinemann, 1993, pp. 1-7.
84 PHILIPPE FOUCHET
even published studies stating an absence of characteristics permitting the distinction between the two kinds of
seizures32.
Other epileptologists have studied certain hormonal modifications related to neurophysiological mechanisms in
seizures. It has been shown, for instance, that the prolactin level goes up slightly during an epileptic seizure (an
increase related to neurotransmitter activity in the hypothalamus). In the first analysis, this measurement seems
to have an important predictive value in real epileptic seizures. But it is a bad predictive element for
pseudoseizures, and epilepsy cannot be excluded even if there is no such increase33. In addition, two other kinds
of information modify the hypothesis of prolactin’s discriminative value: first, the level can also be high after
pseudoseizures, and second, repeated measurements in epileptic patients show a wide variation is possible in the
post-seizure prolactin levels of one and the same patient34.
Some epileptologists have proposed using suggestion as a complementary diagnostic procedure. The main
technique used is that of suggestion-induced seizures, often accompanied by the injection of a placebo presented
to the patient as a product likely to induce an epileptic seizure35. Many authors seem to think that this kind of
technique is an efficient and safe means of distinguishing epileptic seizures from pseudoseizures36. But even if
we put aside the ethical questions involved, it appears that such practices are not conclusive: some pseudo-
epileptic patients remain impervious to suggestion and, on the contrary, some epileptic patients can have a
seizure in response to suggestion37.
In the same sense, as Rowan38 or Kuyk et al.39 report, attempts at distinguishing between the two groups based
on psychiatric or psychological criteria have not yielded convincing results40. On one hand, the studies have
____________________
32 Cf. B. Scheepers, S. Budd, S. Curry, S. Elson, “Non-epileptic attack disorders: A clinical audit,” Seizure, 1994, 3, 2, pp. 129-
134.
33 M. S. Yerby, G. van Belle, P. N. Friel, A. J. Wilensky, “Serum prolactins in the diagnosis of epilepsy: Sensitivity, specificity,
and predictive value,” Neurology, 1987, 37, 7, pp. 1224-1226; G. P. Anzola, “Predictivity of plasma prolactin levels in
differentiating epilepsy from pseudoseizures: A prospective study,” Epilepsia, 1993, 34, 6, pp. 1044-1048.
34 J. Alving, “Serum prolactin levels are elevated also after pseudo-epileptic seizures,” Seizure, 1998, 7, 2, pp. 85-89.
35 Different variants can circumvent the injection, for instance using an “intensive” psychiatric interview for provoking
pseudoseizures during an EEG-video recording (cf. L. M. Cohen, G. F. Howard, B. Bongar, “Provocation of pseudoseizures by
psychiatric interview during EEG and video monitoring,” International Journal of Psychiatry in Medicine, 1992, 22, 2, pp. 131-
140.). But whatever procedure is used, the main idea is the same: that the induction of seizures through suggestion constitutes proof
(when there is no abnormal electric activity shown on the EEG) of their “pseudo-epileptic” nature.
36 Cf. C. W. Bazil, M. Kothari, D. Luciano, J. Moroney, S. Song, B. Vasquez, H. J. Weinreb, O. Devinsky, “Provocation of
nonepileptic seizures by suggestion in a general seizure population,” Epilepsia, 1994, 35, 4, pp. 768-770; J. D. Slater, M. C. Brown,
W. Jacobs, R. E. Ramsay, “Induction of pseudoseizures with intravenous saline placebo,” Epilepsia, 1995, 36, 6, pp. 580-585;
M. Bhatia, P. K. Sinha, S. Jain, M. V. Padma, M. C. Maheshwari, “Usefulness of short-term video EEG recording with saline
induction in pseudoseizures,” Acta Neurologica Scandinavica, 1997, 95, 6, pp. 363-366.
37 Cf. M. E. Drake, “Saline activation of pseudoepileptic seizures: Clinical EEG and neuropsychiatric observations,” Clinical
EEG (Electroencephalography), 1985, 16, 3, pp. 171-176; J. A. French, “The use of suggestion as a provocative test in the
diagnosis of psychogenic non-epileptic event” in: Non-Epileptic Seizures, op. cit., pp. 101-109; J. Kuyk, F. Leijten, H. Meinardi,
P. Spinhoven, R. van Dyck, “The diagnosis of psychogenic non-epileptic seizures: A review,” op. cit.
38 A. J. Rowan, “Diagnosis and management of nonepileptic seizures,” in Comprehensive evaluation and treatment of epilepsy:
A practical guide, S. C. Schachter, D. L. Schomer, San Diego, Academic Press, 1997, pp. 173-183.
op. cit.
40 Stores was able to come to the same conclusion in clinical practice with children and adolescents (G. Stores, “Practitioner
review: Recognition of pseudoseizures in children and adolescents,” Journal of Child Psychology and Psychiatry, and Allied
Disciplines, 1999, 40, 6, pp. 851-857). In fact, he states that no criteria permit us to distinguish epileptic from pseudo-epileptic
episodes.
Epilepsy 85
shown that no psychological profile, no particular psychiatric or psychopathological category, can lead to the
possibility of distinguishing between an epileptic and a pseudo-epileptic patient; and on the other, psychiatric
evaluations of pseudo-epileptic patients show considerable variations among diagnoses and a combination of
psychiatric disorders for quite a few subjects41.
It is true that some studies would lead us to believe there must be a sub-group of pseudo-epileptic patients whose
seizures are more likely to be what is clinically considered as “hysterical convulsions”42. Still, most psychiatric
evaluations show, in variable proportions, almost all the possible DSM diagnoses. As Scheepers et al.43 report,
the phenomenon called pseudo-epilepsy (in which the diagnosis is made by excluding epilepsy) has undoubtedly
given the impression that it could be a clinical entity – but most studies contradict that hypothesis in the end.
With Kuyk et al.44, we can conclude that there are no distinctive criteria to be found among the psychiatric
illnesses, since the different pathologies evoked concerning pseudo-epileptic patients can also be found in
epileptic patients.
In the end it is so difficult to establish the distinction between epileptic and pseudo-epileptic seizures that one
could simply say “epileptic” and “pseudo-epileptic” seem to be two names for the same clinical phenomenon
that is sometimes accompanied by abnormal electrical brain activity and sometimes not (whether in one and the
same patient or many patients). In fact, Wyler et al.45 have clearly shown that, apart from the EEG (whose limits
we have pointed out), none of the tools generally used for diagnosing the epileptic or pseudo-epileptic nature of
the seizure offers sufficiently clear criteria. Their research, based on a “deep” EEG (so as to establish the
diagnosis with as much certainty as possible), indicates that none of the elements under consideration make
possible a distinction between the two: neither a precise description of the seizures, nor the neurological
examination, nor the patient history, nor the psychiatric or neuropsychological evaluation scales. In short, we
have no way of tracing a clear frontier between the two supposed classes of patient: even factors called
____________________
41 Cf. R. S. Stewart, R. Lovitt, R. M. Stewart, “Are hysterical seizures more than hysteria? A research diagnostic criteria, DSM-
III, and psychometric analysis,” American Journal of Psychiatry, 1982, 139, pp. 926-929; C. W. Vanderzant, B. Giordani,
S. Berent, F. E. Dreiffus, J. C Sackellares, “Personality of patient with pseudoseizures,” Neurology, 1986, 36, 5, pp. 664-668;
M. E. Drake, A. Pakalnis, B. B. Phillips, “Neuropsychological and psychiatric correlates of intractable pseudoseizures,” Seizure,
1992, 1, 1, pp. 11-13; C. B. Dodrill, A. J. Wilensky, “Neuropsychological abilities before and after 5 years of stable antiepileptic
drug therapy,” Epilepsia, 1992, 33, 2, pp. 327-334; E. S. Bowman, O. N. Markand, “Psychodynamics and psychiatric diagnoses
of pseudoseizures subjects,” American Journal of Psychiatry, 1996, 153, 1, pp. 57-63 ; P. M. Moore, G. A. Baker, “Non-epileptic
attack disorder: A psychological perspective,” Seizure, 1997, 6, 6, pp. 429-434; D. Kalogjera-Sackelleres, J. C. Sackellares,
“Analysis of MMPI patterns in patients with psychogenic pseudoseizures,” Seizure, 1997, 6, 6, pp. 419-427 ; A. M. Kanner,
J. Parra, M. Frey, G. Stebbin, S. Pierre-Louis, J. Iriarte, “Psychiatric and neurologic predictors of psychogenic pseudoseizures
outcome,” Neurology, 1999, 53, 5, pp. 933-938.
42 Some authors believe that there exists a sub-group of pseudo-epileptic patients whose seizures, presented as symptoms of the
“conversion” type, resemble a dissociative state (according to the DSM description). These seizures would be a kind of “somatic
communication” symbolizing some sexual abuse or physical violence suffered by the patient at an earlier time. The accent is on
the frequency and the supposed etiological importance of the sexual traumatisms and physical violence (these latter have become
an etiological explanation for many functional problems and various clinical syndromes). Yet the statistics reported by the majority
of authors (10 to 15% of antecedents of sexual abuse and physical violence among pseudo-epileptic patients) hardly differ, for
example, from those evoked by Greig and Betts concerning the proportion of antecedents of sexual abuse, estimated at 10 to 20%,
for the entire female population of Great Britain (E. Greig, T. Betts, “Epileptic seizures induced by sexual abuse. Pathogenic and
pathoplastic factors,” Seizure, 1992, 1, 4, pp. 269-274).
43 B. Scheepers, S. Budd, S. Curry, S. Elson, “Non-epileptic attack disorders: A clinical audit,” op. cit.
op. cit.
45 A. R. Wyler, B. P. Hermann, D. Blumer, E. T. Richey, “Pseudo-pseudoepileptic seizures,” in Non-Epileptic Seizures, op. cit.,
pp. 73-84.
86 PHILIPPE FOUCHET
“emotional” or “stress,” as described in the literature46, can precipitate or exaggerate epilepsy and pseudo-
epilepsy in the same way47.
To sum up, everything leads us to believe that there are no diagnostic criteria permitting the tracing of a clear
boundary between the two groups. In that case, would it not be more in keeping with all the results from these
studies to entertain the hypothesis that – with the exception of post-traumatic epilepsies linked to a cerebral
lesion – no such boundary exists and that these are indeed one and the same phenomenon that is sometimes
accompanied by abnormal electrical activity in the brain and sometimes not?
We will see that this question can be approached more precisely if we consider another clinical observation, that
of the frequency of the association between epilepsy and certain psychiatric disorders. The coexistence of
epilepsy and various psychiatric syndromes is not exceptional: the prevalence of major psychiatric disorders
among epileptic patients can be estimated at between 20 and 30%48, in spite of occasionally important variations
in these figures. Depression and psychosis are often cited as the most common psychiatric pathologies associated
with epilepsy.
Psychiatric disorders associated with epilepsy
Epilepsy and depression
We will not discuss here the very problematic nature of the supposed nosographic entity, “depression,” since its
clinical pertinence and etiological status are constantly being put into question.
It is nevertheless interesting to look at the clinical and theoretical observations proposed in neurological
literature concerning the frequency of the association between epilepsy and “depression.” It appears that the
presence of “depressive symptoms” among epileptics is correlated the resistance of epilepsy to anti-convulsive
medication. According to Lambert and Robertson49, psychiatric research conducted on patients with pharmaco-
resistant epilepsy indicates that two-thirds of these patients seem to have depressive symptoms or seem to have
had depressive episodes in the past. Thus, for Lambert and Robertson, epileptic depressions should be classed
with endogenous depressions, since the very high frequency of the association of pharmaco-resistant epilepsy
____________________
46 In a cognitive-behavioral approach, “stress” or “tension,” “conflicts,” a “feeling of being neglected,” “deceptions,” “pressure
to perform,” “depressive episodes,” “ange,r” “overexcitement,” “boredom,” “ menstrual periods,” “hunger,” “sexual stimulation,”
“happy events,” etc., are considered to be principal factors is the triggering of epileptic seizures (cf. L. Miller, “Psychotherapy of
epilepsy: Seizure control and psychosocial adjustment,” Journal of Cognitive Rehabilitation, 1994, 12, 1, pp.1 4-30 ; C. Schmid-
Schönbein, “Improvement of seizure control by psychological methods in patients with intractable epilepsy,” Seizure, 1998, 7, pp.
261-270). Note that the data presented in this type of study sometimes goes counter to the theoretical presuppositions of
researchers, who generally define “stress” as a factor, both psychological and biological, that tends to augment the frequency of
seizures. In fact, contrary to what psychologists expected to see, it is remarkable to note that, for certain patients, “disagreeable”
events do augment the frequency of seizures, but for others, such events provoke, on the contrary, their diminishment. (cf. R.
Neugebauer, M. Paik, W. A. Hauser, E. Nadel, I. Leppik, M. Susser, “Stressful life events and seizure frequency in patients with
epilepsy,” Epilepsia, 1994, 35, 2, pp. 336-343.).
47 Cf. H. McConnell, J. Veleriano, J. Brillman, “Prenuptial seizures: A report of five cases,” The Journal of Neuropsychiatry and
Clinical Neurosciences, 1995, 7, pp. 72-75.
48 Cf. P. Vuilleumier, P. Jallon, “Epilepsie et troubles psychiatriques: Données épidémiologiques,” Revue Neurologique, 1998,
154, 4, pp. 305-317. It is important to note, so these figures can carry their real weight, that the advent of seizures in relation to
taking psychotropic drugs seems extremely rare, in spite of the variations in the epileptogenic threshold (lower or higher depending
on the medication) provoked by certain molecules (cf. A. P. Popli, J. C. Kando, S. S. Pillay, M. Tohen, J. O. Cole, “Occurrence of
seizures related to psychotropic medication among psychiatric inpatients,” Psychiatric Services, 1995, 46, 5, pp. 486-488).
49 M. V. Lambert, M. M. Robertson, “Depression in epilepsy: Etiology, phenomenology, and treatment,” Epilepsia, 1999, 40, s10,
pp. 21-47.
Epilepsy 87
with depression makes a good argument in favor of the presence of genetic, endocrinological, and metabolic
etiological factors common to both pathologies (depression itself is considered, medically, as an illness).
Even more surprising, these authors suggest that the same genetic, endocrinological, and metabolic factors could
explain the frequency of “neurotic characteristics” or “psychotic symptoms” in this type of patient (the psychotic
or neurotic “characteristics” and “symptoms” being then considered as the consequences of an organic
dysfunction just like the so-called depression and thus also epilepsy) – as if the relation between certain
“psychiatric illnesses” and epilepsy constituted in itself a proof of the presence of a common biological factor.
This explanation is a good illustration of the bias of many studies in this area: clinical manifestations of so-called
depression or other psychiatric disorders among epileptic patients supposedly translate the presence of
neurobiochemical or genetic etiological processes at the origin of both the psychiatric illness and the resistance
to anti-epileptic medication – to such an extent that the “psychiatric” medication itself does not constitute a
treatment adequate to that resistance.
Yet one has only to abandon this prejudice to see another set of hypotheses appear, simpler and more in keeping
with clinical data: why not invert the terms of the question and consider pharmaco-resistance of epilepsy and the
frequency of the association of epilepsy with diverse psychiatric disorders as a sign that epilepsy is not a clinical
entity in itself, but rather a phenomenon whose appearance can accompany – or not – the symptomatology
(“depression” among others) of the more fundamental psychiatric clinical entities like neuroses and psychoses?
Psychosis and epilepsy

The association between psychosis and epilepsy has been the subject of much discussion. In spite of widely
divergent interpretations of results, a double assessment can be made:
1. Epilepsy is apparently seven times more frequent among psychotic patients than in the general population50.
Even more striking is the fact that, among autistic patients, Deykin and MacMahon51 have found an incidence
of epilepsy three to 28 times more elevated than in the general population (incidence is strongly age-related).
2. The incidence of transitory psychotic episodes or persistent psychotic states appearing among epileptic
patients is significantly higher than in the general population52. As an example, Bredkjaer et al.53 have shown,
based on an epidemiological study of more than 65,000 patients diagnosed as epileptic, that the frequency of
non-affective psychoses and schizophrenia was much greater among epileptic patients (men and women alike)
than in the general population54.
As Hyde and Weinberger state55, most studies show results leading to the conclusion that there is a relatively
____________________
50 H. I. Kaplan, B. J. Sadock, Livre de poche de psychiatrie clinique, op. cit.
51 E. Y. Deykin, B. MacMahon, “The incidence of seizures among children with autistic symptoms,” The American Journal of
Psychiatry, 1979, 136, pp. 1310-1312.
52 P. J. McKenna, J. M. Kane, K. Parrish, “Psychotic syndromes in epilepsy,” The American Journal of Psychiatry, 1985, 142,
pp. 895-904.
53 S. R. Bredkjaer, P. B. Mortensen, J. Parnas, “Epilepsy and schizophrenia,” Schizophrenia Research, 1996, 18, 2-3, p. 112;
S. R. Bredkjaer, P. B. Mortensen, J. Parnas, “Epilepsy and non-organic non-affective psychosis. National epidemiologic study,”
British Journal of Psychiatry, 1998, 172, 3, pp. 235-238.
54 It is worth noting that patients presenting a recalcitrant temporal epilepsy are considered more vulnerable to psychiatric
disorders and particularly psychosis. Of course, this observation has stimulated the search for neurobiological mechanisms – or
even genetic predisposition – common to epilepsy and psychoses. Nevertheless, as of today no consistant discovery has come to
light in this direction.
55 T. M. Hyde, D. R. Weinberger, “Seizures and schizophrenia,” Schizophrenia Bulletin, 1997, 23, 4, pp. 611-622.
88 PHILIPPE FOUCHET
frequent association between epilepsy and psychosis: on the one hand, the rate of epileptic patients with
psychosis is higher than what would be expected if these two clinical entities were totally independent; on the
other, there are more epileptic seizures among psychotic patients than among the general population. In addition,
although no statistics can be produced in this area, professionals practicing in psychiatric institutions have often
observed the frequency of epilepsy in adult and infant psychoses
But the most startling, as summed up by Vuilleumier and Jallon56, is that the appearance of psychotic events
among epileptic patients is often negatively correlated with the frequency of seizures. In fact, one can often
observe an alternance between psychotic states and periods of epileptic seizures. It has even been possible to find
a particular phenomenon called “forced normalization,” in the course of which seizures and psychotic disorders
are in an “antithetical” relation: the psychotic symptoms appear precisely when the seizures disappear, the EEG
becomes more normal, even altogether normal, as compared to the EEG during the seizure57. Thus, not only are
epilepsy and psychosis associated more frequently than if there were no link between these two pathologies, but
their respective symptomologies are quite often in a relation of alternance that makes it possible to consider the
epileptic phenomenon as a kind of alternative to classical clinical manifestations of psychosis.
All these elements inevitably lead us to rethink epilepsy’s position in the framework of neurology and to
reconsider the relation of epilepsy and psychopathology.
Towards a psychoanalytical approach to epilepsy

The results of much of the research we have covered converge towards the hypothesis of a clinical continuity
between epileptic and pseudo-epileptic phenomena. Indeed, as we have seen, the distinction between these two
types of seizure is extremely problematic. Even EEG data – which remains essential for pharmacological
treatment – is not decisive for diagnosis, since identical crises can be accompanied, or not, by abnormal electrical
activity in the brain, even in the same patient. An attentive reading of the neurological and psychiatric literature
invites us, rather, to entertain a different clinical distinction, one that opposes a sub-group of pseudo-epileptic
seizures having to do with hysteria (as suggested by a series of studies that points out the existence of a sub-
group of pseudo-epileptic patients whose seizures seem to resemble a symptom of the “conversive” type58) and
the pseudo-epileptic or epileptic seizures that fit into fundamental psychopathological structures other than
hysteria, and most particularly in diverse forms of psychosis.
Yet, in a certain sense, this distinction as it appears in the neurological literature had already been suggested by
Freud, and then slightly developed by Ferenczi. Freud looked at epilepsy from the point of view of a double
clinical distinction:
On one hand, he insisted on the distinction between epilepsy and the hysterical symptom. According to the
observation already made by Charcot, Freud indicated that certain convulsive seizures, whose clinical
phenomenology evoked epilepsy, presented themselves in fact as the symptom of a neurosis and turned out to
be “grave hysteria”59. Under the term “epileptoid convulsions,” Freud reassembled those clinical manifestations
that were part of the symptoms typical of hysteria (with some neuralgias, different anesthesias, contractions, and
____________________
56 P. Vuilleumier, P. Jallon, “Epilepsie et troubles psychiatriques: Données épidémiologiques,” op. cit.
57 Cf. D. Ranoux, “Les psychoses épileptiques,” Synapse, 1998, 149, pp. 21-22; E. S. Krishnamoorthy, M. R. Trimble, “Forced
normalization: Clinical and therapeutic relevance,” Epilepsia, 1999, 40, s10, pp. 57-64.
58 Cf. note 43.
59 S. Freud (1928), “Dostoevsky and Parricide,” in The Pelican Freud Library, v. 14, Art and Literature, trans. J. Strachey.
Penguin, Harmondsworth, G. B., 1985, pp. 441-460 (p. 444).
Epilepsy 89
paralyses, various vision problems, visual hallucinations, tics, or vomiting of a functional nature, etc.) and that
could not be confused with “true epilepsy”60. And in his text “Dostoevsky and Parricide,” Freud seemed to feel
that the author of The Brothers Karamazov had seizures related to hysterical symptoms, not without saying that,
in the biographical information he had access to “our information about the relations between [the attacks] and
Dostoevsky’s experiences are defective and often contradictory”61. In the absence of any account, discourse, or
chain of thought from Dostoevsky, Freud admitted the fragility of his hypothesis. When he tackled neurosis,
Freud did put the accent on the articulation of the symptom with unconscious desire as it emerges in the
transference. As opposed to the hysterical symptom, epilepsy belongs to a different logic.
From another point of view, Freud envisaged a second opposition, this time within epilepsy itself, that is between
epilepsies in which “mental life is subjected to an alien disturbance from without,” and those in which “the
disturbance is an expression of psychic life itself.”62 In the first case, according to Freud, the seizures seem to
have a strictly organic origin: they appear to be “exterior” to mental life even though disrupting it (post-traumatic
epilepsies linked to a cerebral lesion, as we would say today). As for the second type of epilepsy, Freud proposed
the hypothesis of a possible intervention of the dimension of the drive in the onset of the seizures: the “amounts
of excitation” which it cannot deal with psychically would be liquidated “by somatic means.”63 Thus, even if
one has to admit that Freud did not manage to clear up certain ambiguities concerning the clinical distinctions
he tried to introduce64, the context of the article “Dostoevsky and Parricide”65 leads us to believe that the
liquidation “by somatic means” in question in this category of epilepsies seems to designate a different destiny
for the drive than hysterical conversion (in which the “amounts of excitation” are, on the contrary, psychically
linked to unconscious representations). Freud seems to consider that, in both cases, the epileptic seizure cannot
be confused with the hysterical symptom: either it is an epilepsy of organic origin that can have repercussions
on psychic life, or it is a manifestation of the drive that comes to disrupt the functioning of the organism in a
manner that appears to takes paths other than the “return of the repressed.”
It is important to note that these developments concerning epilepsy are situated in the prolongation of a remark,
made several years earlier, in which Freud underlined “the preponderant place taken by the death wish” in the
mechanisms of drive discharge involved in the epileptic attack66. And Ferenczi was to use these indications when
he proposed considering that “the epileptic seizure could be described as an attempt at suicide [...], only
symbolically suggested in benign cases, but really accomplished in extreme cases.”67 He thus suggests that the
epileptic seizure presents itself as the equivalent of a passage to the act qualified by the author as “suicidal.” He
also stresses the momentary absence of defenses in epileptic seizures: the defenses, he says “periodically, at a
____________________
60 S. Freud, J. Breuer, “Studies on Hysteria,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud
(S.E.), Vol 2, Hogarth Press, London, 1956.
61 S. Freud (1928), “Dostoevsky and Parricide,” op. cit., p. 446.
62 Ibid., p. 466.
63 Ibid., p. 445.
64 These ambiguities in Freud’s text seem to have led some authors “of psychoanalytic inspiration” to envisage the epileptic
seizure as a neurotic symptom and to favor the imaginary or fantasy content over a structural study of the defense mechanisms:
repression, denial, forclosure.
65 “Dostoevsky and Parricide” is the only text of Freud’s to give epilepsy a relatively central position (but still along with other
questions not directly related). Apart from this text, epilepsy is barely mentioned, and only in a few rare cases. However precious
they may be, Freud’s indications leave this clinical area more or less a wasteland.
66 S. Freud (1923), “The Ego and the Id,” in S.E. (op. cit.) , Vol 19, Hogarth Press, London, 1962..
67 S. Ferenczi (1921), “A propos de la crise épileptique. Observations et réflexions,” in Psychanalyse III. Œuvres complètes
(1919-1926), tr. J. Dupont & M. Viliker, Payot, Paris, 1974, pp. 143-149 (p. 148).
90 PHILIPPE FOUCHET
certain moment, liberate these drives and let them go wild.”68 So it is by leaning on the concept of the death wish
that Ferenczi brings together a series of somatic manifestations (where epilepsy is then brought closer to certain
respiratory disorders, in particular bronchial asthma) that have in common the fact of being what he calls
“instinctual unleashing.”69 No doubt one should see in this image of outbursts (as opposed to enchaînement
through unconscious representations) the outline of a notion of “organ neurosis” through which it will end up by
differentiating the hysterical symptom from other syndromes today brought together as “psychosomatic
phenomena.” Although only slightly elaborated, the notion of “instinctual unleashing” seems to go in the
direction of the designation of a new category of clinical phenomena (distinct from conversion phenomena), in
which the instinctual dimension seems to manifest itself in a mark on the organism itself.
The frequency of the association with psychiatric disorders and the analogy with psychosomatic phenomena (an
analogy that suggests Freud’s and Ferenczi’s indications, but also the work of other psychoanalysts who later
became interested in epilepsy) will lead us to take up – in a future article– the phenomenon of epilepsy in the
area of a clinical theory of the drive. We will try to formulate in greater detail what Ferenczi was suggesting in
his idea of “instinctual unleashing.” In particular, we will try to make a distinction between the convulsive
seizure that stems from “hysterical conversion” and seizures (accompanied or not by abnormal electrical activity
in the brain) in which the logic of the drive appears to approach that of the psychosomatic phenomenon. Finally,
we will come to see that the epileptic phenomenon can serve in the context of a psychosis: it can function as the
localization of the “return in the real” of jouissance, offering an alternative to the passage to the act or other
classic manifestations of psychosis (like voice hallucinations, the feeling of being watched, paranoid
interpretation, etc.). We will see that locating this function is absolutely essential to the accompaniment of the
subject.
To put it in another way, we will try to specify the different kinds of clinical practice with a subject that
reintroduce the dimension of the drive foreclosed from the scientific approach to epilepsy. That is to say, paths
that allow for the possibility of introducing, implicitly, into the classical schemes of institutional medical
responsibility, an orientation of therapeutic accompaniment that will take into account, beyond the effects one
can see in the organism, the other real that causes them.
____________________
68 Ibid., p.148. Ferenczi returned to this hypothesis in 1929 in an article having to do with, as he said, “manifestations of the death
wish” that can be seen in this kind of organic disorder (S. Ferenczi (1929), “L’enfant mal accueilli et sa pulsion de mort,” in
Psychanalyse IV. Œuvres complètes (1927-1933), trans. J. Dupont et al., Paris, Payot, 1982, pp. 76-81. (p. 77)) and that is based
even more directly on the theoretical advances introduced by Freud in 1920 in Beyond the Pleasure Principle – where Freud lays
down the clinical foundation for the “death wish.”
69 S. Ferenczi (1929), “L’enfant mal accueilli et sa pulsion de mort,” op. cit. pp. 76-81; S. Ferenczi (1933), “Présentation abrégée
de la psychanalyse,” in Psychanalyse IV, op. cit., pp. 148-194.
Epilepsy 91
Catherine Lacaze-Paule
Pain and Dolor
In 1895, Freud asked himself, in “Studies on Hysteria,”1 concerning the case of Elisabeth von R., why and how
“instead of, and in the place of, psychological pain that has been avoided, physical pain appears.” But as early
as 1884, in his first research projects on anesthesia as a young doctor, he was interested in the mechanism and
treatment of pain. As a scientist and a doctor, he used contemporary research, in particular concerning a
substance American Indians chewed: Coca. In keeping with the procedures of that time he experimented on
himself and published an article in which he outlined a certain number of therapeutic indications. When he left
to join his fiancée Martha, his notes on possible applications of Coca went to his young colleagues. It was Koller
who got the benefits – and the recognition – Koller is credited with the discovery of the applications of Coca to
local anesthesia in ophthalmology.
After meeting hysterics, Freud informed Fliess, in a letter dated April 2, 1896: “I am about to carry out the
philosophical wish to pass from medicine to psychology.”2 However in 1926, he would ask “the reader’s
indulgence” for his “timid remarks”3 on this question of pain: his wish was not to be fulfilled. However,
concerning the mechanisms of pain, his approach would thereafter always be scientific and organic rather than
psychological.
The two faces of Freudian pain

The paradox is that pain, this motor for cure, is also its impediment. It can present itself as moral anguish and
mental pain or as bodily suffering and physical pain. It is constantly included in the symptoms. Freud always
regarded it as a “real fact,”4 and never stopped considering it as such. He maintained two axes of research: that
of determination in language, first mentioned in “Studies on Hysteria” in the symptoms of hysterical conversion,
and that of jouissance, indicated by auto-eroticism, linked to narcissism and the body itself. This side of
jouissance is revealed in hypochondria or in conjunction with mourning and anxiety in Inhibitions Symptoms and
Anxiety in 1926.
To describe and treat the question of pain, Freud always stressed the ambiguity of language, that does not make
a distinction between physical and mental pain. He considered, in accordance with the characteristic of primitive
words, as he develops it in “The Antithetical Meaning of Primal Words,”5 that one and the same word could
translate the effect or the cause. Inflicted pain can be a pain that is suffered by the subject.
An etymological study of the words dolor and pain, “looking for the significance that evolution of the language
has deposited in a word”6, shows the value, the stakes involved, and opens on the question of its complexity,
even of its aporia. The history of language how bodily and mental pain are intricately linked, and also linked
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1 S. Freud, J. Breuer, “Studies on Hysteria,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud (S.E.),
vol. 2, Hogarth Press, London, 1956.
2 S. Freud, “The Origins of Psycho-Analysis,” S.E. (op. cit.) vol. 1, Hogarth Press, London, 1954.
3 S. Freud, Inhibitions, Symptoms and Anxiety, S.E. (op. cit.) vol. 20. Hogarth Press, London, 1960.
4 S. Freud, “Studies on Hysteria,” op. cit.
5 S. Freud, “The ‘Uncanny’,” S.E. (op. cit.) vol. 11, Hogarth Press, London, 1957.
6 S. Freud, “The Antithetical Meaning of Primal Words,” S.E. (op. cit.) vol. 17, Hogarth Press, London, 1955.
92 C AT H E R I N E L A C A Z E - PA U L E
with the positions of the subject. The multiple Greek roots of pain – pathos, algos, etc. – are not articulated
around the opposition of the physical and moral, but according to the degree of the subject’s implication in the
pain and modes of perception7. Temporality and source of the pain are what define the quality of feeling: pain
and sorrow are thus intimately related. The Latin root of the word dolor – dol – as early as the eleventh century,
also put the accent on the homology between pain and suffering, sorrow, and mourning. Mourning (deuil in
French) and pain or dolor (douleur in French) have the same root, their effects merge with the cause through
metonymy. The colloquial French expression la douloureuse means a bill to be paid. . .
The mask of pain

We can also note the other senses that register pain according to the position of the subject between passivity and
activity – to be beaten, dolenté, to receive blows but also the axe, the adze (doloire in French) of the wet cooper
or the mason. Lastly, the idea attached to the bond between complaint and pain, not without ruse and trickery, is
included in the semantic field of pain or dolor. Dolus8, in 1248, indicates ruse, the fraudulent maneuvers used to
get people to bind themselves legally so as to bring a complaint against them. Dol refers, earlier still, to the
theatrical means of carrying out a ruse9. In pain, part of the complaint is unrolled and unfolded, consists and
exists, but not without ruse or displacement. There is a mask of pain that shows and that hides.
Medicine, first related to Judeo-Christian concepts and then abandoning them, would separate physical from
moral pain. We will briefly recall the various contributions to the comprehension of the most modern
significance and use of pain.
The Christian doctrine of sin long allotted to pain a redeeming grace and a significance, a use and a function of
redemption, which influenced the medical approach to pain.
Pain as signal
In the seventeenth century, the sensation of pain was a means for Descartes to see the union of the soul and the
body. In his Principes de la philosophie, he was interested in the pain of a phantom limb, based on the case of a
girl whose hand and forearm had been amputated. In line with his idea of the body-machine, he writes: “The pain
in the hand is felt by the soul not because it is in the hand but because it is in the brain.”10 Pain is not felt at the
painful point, but in the brain, site of the soul. Thus, pain becomes a danger signal, a protection for the organism.
This idea is a step in the elaboration and integration of the treatment of pain by medicine. Descartes opens the
way to research on the localization of cerebral functions. This localization will make possible materialist
interpretations of pain.
Up until the middle of the nineteenth century, pain was seen as a necessary and useful evil. It was regarded as a
sign of vitality. The medical profession was relatively indifferent to pain. So the surgeon Velpeau, who took part
in the great debates on anesthesia, could say – in connection with the utilization of ether: “Is the fact that a patient
suffers less or more of any interest to the Academy of Sciences?”11 Marc-Antoine Petit, at the beginning of the
nineteenth century, said about pain: “This bitter fruit of nature hides the seed of great good, it is a salutary effort,
a cry of sensitivity that informs our intelligence of the danger that threatens us, it is the thunder before the
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7 R. Rey, L’histoire de la douleur, La Découverte, Paris, 1993, p. 19.
8 Ibid..
9 Cf. The Gaffiot Latin-French dictionary.
10 R. Descartes, Principes de la philosophie, IV° partie, Gallimard, La Pléiade, Paris, p. 659.
11 Cf. R. Rey, L’histoire de la douleur, op. cit.
Pain and Dolor 93

lightening.”12 Pain continued to be regarded as beneficial and salutary. It should be preserved, and even sought
after in certain circumstances, because it is a favorable impetus, vital, and also a signal – pain is a guide. The
pain of gangrene, for example, invites sacrificing a part for the whole.13
Abandoning sense
Nevertheless, the most eminent scientific and medical discoveries would permit the nineteenth century to
become the century of anesthesia for pain.14 Scientific progress and laicized medical ideas detached pain from
the idea of utility. Scientific advances took the Judeo-Christian sense out of pain, and therapeutic progress made
it an interesting subject for research. The turning point was in 1847, a year of great medical innovations in the
field of anesthesia. Morphine, ether, and chloroform were used experimentally for anesthesia during surgery,
then extended to other indications, in chronic diseases. Many debates were held at the Academy of Sciences, trial
and error in dosages did not retard the use of these processes or the development of drugs, surgeries, and
techniques increasingly effective for any type of pain. New questions remained unanswered. How could we
understand that pain can persist after the initial lesion has been healed? Why are some lesions unaccompanied
by pain?
It was almost a century later, in 1937, that Rene Leriche, a great pain surgeon, came up with the modern idea of
pain. His insight was to disengage pain from its association with utility or as a vital signal or safeguard: “The
number of illnesses revealed by pain is negligible, and generally, when pain accompanies them, it only serves to
mislead us.”15 For Leriche, pain did not have much value, either for diagnostic purposes, or for prognoses; on
the other hand, it could, itself, be a disease that had to be treated. Thanks to Leriche, the saving value of pain
was radically contested, then abandoned. It lost, in medicine, its sense; it became useless and harmful. Moreover,
Leriche made pain a disease in itself, he paved the way for a distinction between acute and chronic pain, he
connected subjectivity to this reality: “Man creates his own pain, like he creates an illness or his mourning, more
than he receives or is subjected to it.”16
At the end of the twentieth century, pain is not well thought of, its presence is stalked, it has to be chased away.
For more than ten years, in France, a governmental program has made it an obligation for hospital care-givers,
to carry around an instrument that measures pain visually and registers, for each patient, an evaluation of the pain
he or she feels on a scale from one to ten. One is the minimum pain threshold it registers, ten the maximum
supportable. The slogan that accompanies this prerogative is “Pain is no longer a fatality. Let us refuse it!”
Physical and moral pain increasingly lead to continually changing protocols. However, in spite of the means set
up to fight it, far from being eliminated, pain is back in our midst.
The paradoxical return of pain

Paradoxically, today’s body is characterized as a body saved from suffering. The twentieth century is marked by
the diminishment and even the disappearance of pain. Banished from educational systems, treated by medicine,
pain is less and less a part of the landscape. In the Western World, the body is a body dedicated to the pleasure
principle. Food is no longer lacking, but is rather in excess. We no longer know how rough it can be to adapt to
the weather. Never too hot, never too cold, the body moves about in a temperate climate. Work no longer requires
____________________
12 Ibid., p. 110: citing M.-.A. Petit “Discours sur la douleur,” spoken 28 Brumaire year VII.
13 R. Rey, L’histoire de la douleur, op. cit., p. 110.
14 Ibid.
15 R. Leriche, La chirurgie de la douleur, Masson, Paris, 1937, p. 31.
16 Cf. G. Canguilhem citing Leriche, Le Normal et le pathologique, PUF, Paris, p. 56.
the great physical effort it once did. Even if scientifically organized work can create excess through the repetition
of gestures that generate other kinds of suffering, this tendency too is lessening. The body is anaesthetized,
locally or completely, for each painful medical act. Physical suffering fades or subsides, just like chemically
treated mental pain, which is psychologically cared for more frequently and earlier.
However, some practices seem to seek out and defy this diminished status of pain. In high-level sports, pain is
not considered to be negligible or derisory, or seen as inevitable – and even desirable. In body-marking practices,
pain, far from being avoided, can be desired for itself. Certain artists make the body a work of art; the skin is
painted and decorated, the hypodermis worked and carved. Certain practices are becoming fashionable: in
”body-sculpting,” implants can transform the body. The most extreme practices are becoming commonplace:
branding (applying a design to the skin with a red-hot iron), burning (burns highlighted with inks), cutting
(inscribing figures or drawings with a scalpel), peeling (taking away the skin’s surface), implants of metal balls
or various coins under the skin, etc. Piercing of the tongue and the genitals are, according to some, marks which
intensify erotic feelings.17 Pain, far from being an impediment, is sought after in these practices as satisfaction.
This growing attraction responds to a feeling of the incompleteness of a body that must be completed, improved,
finished, and tested through pain. All these representations and practices of the body-in-pieces, transformed and
mutilated, testify to a kind of a muddled idea of the body. What is one to do with one’s body?18 That is the
question today.
The negative therapeutic reaction

In medicine, acute pain is generally better controlled, or avoided, or even treated preventively, before it appears.
However pain returns in an incurable form as chronic pain. Pain, with or without an organic substrate, is the
object of care protocols that institute pain as a reason for consultation. In the very definition of pain, the organic
substrate is not necessary anymore since now pain can be perceived without an organic lesion. A request for help
and psychological accompaniment is made according to established protocols. Generally, the ambiguity of the
request is related to the cause of the pain. Is the pain the cause of the suffering or is the suffering the cause of
the pain? For doctors, the dividing line is pragmatic; it rests not on the organic substrate but on resistance, the
negative reaction to treatment. A pain that does not go away is itself a pain whose psychogenic resonances are
an obstacle to medical treatment. It is then necessary for a psychiatrist or a psychologist to intervene.
Among chronic pains, back pains – the second cause for sick leave globally – is a real public health problem,
and shows itself to be resistant to the most elaborate treatments. The bio-psycho-social dimension of this
pathology is evoked as an explanation. Psychological accompaniment, for this reason, is requested because the
psychic dimension of the pain is recognized as an obstacle to the recovery.
A series of questions is then posed. Is pain a real accessible through words? Can it be regarded as a symptom,
and if so, under which conditions? In which cases is pain a conversion, a psychosomatic phenomenon or a body
event that affects the being-of-speech? Which can we learn from ideas about pain in psychoanalysis?
Pain is a problem connected to several disciplines. It is often presented as a limit or frontier of these disciplines
– those of medicine, religion, and philosophy, but also of sociology, ethnology, and anthropology. Even if it is
not a Freudian concept, it is present as a clinical fact and questions psychoanalysis. Present in bodily or mental
symptoms, it can also, as physical suffering, generate modifications in the life of the subject. So: is pain located
at the borders of psychoanalysis or at its heart?
____________________
17 Cf. D. Le Breton, Signes d’identité : tatouages, piercing et autres marques corporelles, Métaillié, Paris, 2002.
18 J.-A. Miller, “Biologie lacanienne et événement de corps,” La Cause freudienne 44, p. 48.
Pain and Dolor 95

The affinity of pain and desire
Neither Freud nor Lacan side stepped the issue, quite the contrary. In their work, they both considered pain to
be real;19 as their theories advanced, they each proposed an approach to this question. Moreover, they altered
their theories in the light of this question. The anchoring of pain in the body makes pain the bodily organic
substrate of psychic facts. In that respect, Freud and Lacan found in pain the possibility of developing their
materialist line to deploy the causality of psychic phenomena. The painful body can be the material substrate of
psychic symptoms.
In 1895, Freud had already seen pain as “a striking and even a comic example of the genesis of hysterical
symptoms through symbolization by means of a verbal expression”2.0 “Studies on Hysteria” swarms with
examples of hysteria expressed in language, allowing Freud to say, of conversion symptoms: “I have had the
most tangled threads to unravel.”21 The signifying side is there as an induction of the conversion symptom linked
to unsatisfied desire. Lacan takes this up in his comments on the case Elisabeth von R.22 He proposes “not an
explanation but a positioning of the problem.”23 He sees the pain in the patient’s thigh as identical to desire. After
Freud, Lacan reiterates the function of pain as a compass. But he then proposes to mark “the eccentricity of
desire in relation to any satisfaction,”24 which indicates the alliance point where “desire verges on the pain of
existing.”25 Lacan insists on the deep affinity of pain and desire – last term and wellspring of existence where
desire and pain are joined in the pain of existing.
Pain as sudden appearance of jouissance

Pain makes it possible to account for the imaginary and symbolic functions explored in this first direction, but
also for what the real inscribes in the body “the organism as being.”26 Useless, harmful, pain is a sudden
appearance of jouissance. That is the definition of jouissance given by Lacan, in Seminar XX, Encore, in 1972:
“What is jouissance? Here it amounts to no more than a negative instance. Jouissance is what serves no
purpose.”27
From a different point of view, we see pain as sudden jouissance when it is bonded to the organism in “somatic
compliance” and gets fixed there by eroticization. It can then constitute a psychosomatic phenomenon. Short-
circuits of the symbolic and of language structures28, these psychosomatic phenomena relate to “relational”
organs. So we are dealing with the organ in its function and not in its representation any more, as in the symptom
of hysterical conversion. It is in this double light of desire and jouissance that we will present the problems of
chronic lumbago.
Back pain is at the origin, in French and in English, of many expressions that have to do with the position of the
____________________
19 S. Freud, Studies on Hysteria, op. cit., p. 247.
20 Ibid., p. 253.
21 Ibid., p. 248.
22 J. Lacan, Le Séminaire Livre V, Les formations de l’inconscient, Seuil, Paris, 1998, p. 327.
23 Ibid.
24 Ibid., p. 328.
25 Ibid.
26 J. Lacan, “La psychanalyse et son enseignement,” Écrits, Seuil, Paris, 1966, p. 287.
27 J. Lacan, The Seminar of Jacques Lacan (ed. J.-A. Miller). Book XX, Encore 1972-1973. Tr. Bruce Fink. Norton, New York, 1998.
p. 3.
28 Cf. Greps, Le phénomène psychosomatique et la psychanalyse, Navarin, Analytica, n°48.
subject and its affects29. The back escapes the mirror; it cannot be seen or imagined. Like all organs, it is felt
only through pain. This pain leads to immobility, it can solidify a person in petrifaction – here we can see the
truth of the legend of Daphne petrified, evoked by Lacan.
These two aspects of pain, signifying determination and jouissance, can be body events. Sensitive to words, these
events can either be symptoms of hysterical conversion, or psychosomatic phenomena. We will approach two
cases of neurosis here30 that refer to psychosomatic phenomena. These two cases together will make it possible
to show different facets of the subjective function of pain. They show in particular that pain, a body event, can
be related to statements of the subject, and how these subjects can – or not – constitute them as symptom.
Pain and petrifaction

This patient presents an obsessional neurosis and suffers from back pain. The case illustrates how thought
intrudes into the psyche and the body. This forty-five year old patient suffers from back pains related to a
kyphosis. This malformation did not make her suffer until her father died brutally of a heart attack eight years
before. In the year that followed, she gave up her professional activity “on a whim”; she had a responsible
position in a company that functioned well, but she explained that “just when something is about to work, I
sabotage myself each time.” Since then, she has not been able to take up a regular occupation. She stays out of
financial difficulty by reducing her expenditures a little more each year. She adjusts her standard of living
according to whatever is available in allowances for job hunting or training. Recently, since the pain had reduced
her activity severely, she started worrying about this situation: “I watch my life go by,” she says. When the pain
became more intense, she had herself hospitalized in physical therapy, and that is when a doctor sent her to me.
She finds herself without desire, is passionate about nothing, the intensity of the pain worsens with time: “my
body hurts me too much, my body shouts too much,” she concludes when speaking about the back pains and also
about the migraines. She says: “I do not dwell on it. Either I take out my eraser and wipe out the problems or I
put them in the closet, in a drawer. But I don’t have the key anymore. Then my body reminds me with its
presence, it’s heavy to carry, it’s as if I had put them in a backpack that I have carried ever since. It’s a family
trait, we are all stooped and twisted. In the family, one doesn’t hope to benefit from our inheritance, we transmit
it, that’s all. Only death allows us to benefit from it.”
She asks herself about her attachment to this paternal heritage that she feels is made up of “stones, of ruins,
pebbles and thorns. . . and of family discord.” She asks herself about all these objects she accumulates without
being able to part from them. “I collect objects, furniture, and knowledge. I collect and I don’t know what to do
with it.” She collects furniture, books and decorative objects she finds in fleamarkets, in junkheaps. All this piles
up, reducing considerably her companion’s “life space” – and also her own. The various artistic creations she
makes and sells since she stopped working are for her only copies, imitations, recycling. She also complains of
being unable to create. Creation for her is always a failure, it is “a block.” Her production without creativity is
something controlled, a mastery she carries around like a too-heavy backpack. She links this production with a
backpack that makes the whole family stooped, a paving stone that marks. She is literally welded to the past.
A recurring dream clarifies the function of pain for this subject. “Behind my parents’ house, there is a path with
a stone marker. I see my father dead, behind this marker.” With the account of this dream, she is astonished to
____________________
29 In French: submission (courber le dos), contempt (tourner le dos), flattery (faire le dos rond), excess (en avoir plein le dos), fright
(faire froid dans le dos), deadlock (être dos au mur) etc. In English: to turn one’s back on someone; to get one’s back up; to make one’s
spine tingle; to have one’s back against the wall; to back down, etc.
30 These two patients participated in a presentation of patients at the Section Clinique in Bordeaux. Several of my remarks, readings,
and comments issue from the exchange that followed. Our thanks to C. Dewambrechies-La Sagna et A. Merlet.
Pain and Dolor 97

see that it prefigured, years in advance, what indeed happened. Her father did die in his vineyard, behind the
house, working the earth, after two heart attacks he had ignored. The marker in the dream, the stone, incarnates
the petrifaction of the subject. Any life, any desire, would fade and disappear faced with this mortification. But
this petrifaction, this marker, covers it and leaves a hole. It appears, for this subject, that any subjective division
is stopped at once by the pain of the body. This pain evokes what the father neglected, and returns to haunt her.
We can ask ourselves to what point pain replaces these thoughts. In any case, this subject refuses any division.
This pain does not have the characteristics of a conversion.
Does that make it a psychosomatic phenomenon? Note the holophrastic value here, the way the recurrent dream
short-circuited the symbolic of the father’s death well before he died. If this dream keeps her near the marker,
the real death of the father petrifies her just as much. This marker symbolizes the “reign of the stone.”31 Stone,
like the patch of soil to which she remains attached, soldered, incarnates the impossibility of movement. She is
petrified and welded, as she says herself about the vertebrae of her back. The back pain is the very incarnation
of this mortification imaginarily anticipated in the dream. The psychosomatic phenomenon carries out, writes
this mortification, at the junction of the imaginary and the real. The patient is the sterile petrifaction of the father.
Under the influence of the gaze, she cannot escape this mortification. She is a marker that shows the limit where
there is no more possibility of movement32, between life and death. Pain appears here as a limit, it is the occasion
to point out the intrinsic “homology of the motor reaction and pain”33 that Lacan with Freud saw. Let us note
here the investment of the “libido inside the organism,”34 indicating this singular relation, narcissistic, “auto-
erotic,”35 with the body itself – a phenomenon in which the object and the source merge.
Will words, for this subject, be able to constitute a movement and to arrange some “permanent desire to live”36?
Double story of voice and pain

Another case illustrates a facet of the pain problem related to object a as Lacan saw it. It concerns the object
“voice.” This case shows how painfully a link between the object cause of desire, the voice, and the living,
suffering body can be articulated for a subject. This patient, more than forty years old, was seen in the framework
of a functional rehabilitation for back pains, when I met her as a psychologist. She had been operated for a
slipped disc two years before and, after a remission, she began to suffer again from sciatica. Her sciatica
problems started when she was very young, leading to a femoral neuritis, and ceased when she was eighteen, just
after the baccalaureate, when she started to sing.
She had shared her grandmother’s and her mother’s passion for the opera from an early age. At seventeen, she
decided to consult a singing teacher, who confirmed that she “had a voice.” Within four years she had learned to
sing, gotten a first prize, and begun, at the age of twenty-four, a professional career. For fifteen years she sang
regularly. She met her husband and sang a little less, refusing some concerts to spend time with him. A pregnancy
set off sciatica attacks. She stopped giving concerts and decided to raise the child. The few concerts she did give,
“stuck in the hollow of the piano,” made her realize that using her body and her voice together in an opera was
what gave her incomparable satisfaction. She even concluded one day that her pains, that her “back is bound” to
____________________
31 J.-A. Miller, “Biologie lacanienne et événement de corps,” op. cit.
32 J. Lacan, The Seminar of Jacques Lacan (ed. J.-A. Miller). Book VII, The Ethics of Psychoanalysis 1959-1960. Tr. Dennis Porter.
Norton, New York, 1992. p. 60.
33 Ibid.
34 J. Lacan, The Seminar of Jacques Lacan (ed. J.-A. Miller). Book II, The Ego in Freud’s Theory and in the Technique of
Psychoanalysis. Tr. Sylvana Tomaselli. Cambridge University Press, Cambridge, 1998. p. 95.
35 Ibid.
36 J. Lacan, Seminar “Le désir et son interprétation,” Lesson of 12-12-1958, (unpublished).
the stage. The pains only appeared when she was not on stage. She remembered the different circumstances of
her life when she was on her “bed of pain,” as she called it, unable to move. “The more I sing, the less back pain
I have” she said.
The patient’s mother had been separated from her father when pregnant, but the father recognized the child. She
retained a very early memory, from when she was one year old, the deep voice of her father leaning over the
cradle to offer her a present. At the age of two, ill with a primary infection, she was sent to a sanatorium for
several months. The relations with the father would have been interrupted at that time. She had never wanted to
know what had become of him until her own child was born. She found him. She now knew he was alive but
did not wish to meet him. When she was six, her mother remarried; this new husband raised her and she adored
him. He died one year after she had started to sing. She started singing under his name, out of love for him. Then,
for the sake of her career, she was asked to find a stage name. She created one made up of her father’s name and
that of the main character in La Traviata for whom she had a real passion and with whom she identified. When
she was seventeen, on a trip to Italy, she visited La Scala and forged the dream of singing La Traviata there. It
appears stupid and absurd to her, because she did not have the right voice for that. She defends herself against
the idea, but never forgot it.
A recurring dream, typical of singers (as she said), nevertheless showed her as believing in the possibility of
having that deep voice she lacked. “Someone asks me to sing, I do not know what to sing. When I open my
mouth, I do not know this repertory. Then I sing, and I hear myself with a deep voice.” This dream oppressed
her, she recognized there the deep voice she had developed over the years. It was her husband, her “ear,” who
first heard it. It seemed that this new tonality of voice had appeared when she gave birth to her son and her
husband said it was heard at once. That frightened and surprised her. Nevertheless, since then she had worked to
find and develop this new register, a deeper voice. This voice she acquired is a voice that “dopes” her: she can
sing without tiring, as if in a “trance.” She can now say that she always dreamt of that.
This subject thus alternated between two positions: on stage and off. The phallic identification with the father
incarnated by the object “voice” and condensed on the three levels of the imaginary, the real and the symbolic,
sustained the subject’s desire and jouissance. The appearing of the body on stage provoked by the gaze and the
voice is tied to the subject's invented stage name. But the off-stage part – pregnancy, illness, the organic thorn
of back pain, or even of her “condition” as wife and woman – caused a shunt in the circuit of the subject’s
jouissance. The pain appeared in this context as something helpful and as a recourse that the subject throws
herself into, which is what the back pain incarnates and condenses.
Like the Lady of the Camellias, she finds herself alone and abandoned in illness. The illness is what returns her
to her existential pain; it is a repetition of the abandonment she felt when she was sent to the sanatorium. Not
giving up singing, making that the cause of her desire, is the solution she consented to. What remains in question,
starting from this specific jouissance, body jouissance and body phenomenon, is this jouissance of the being not
situated in a relationship with the Other, but beyond identifications. For that, she must accept making a detour
via the register of the Other scene.
It is by linking the body to the subject’s utterances, in the relationship the subject maintains with what he/she
says, that a subject’s positions of jouissance are singularly determined. Between body and speech, there is life.
The living body can be precisely what the painful body incarnates. Still, it is necessary to see the imaginary,
specular body that doubles that of the organism; then the symbolic, where the signifying chain is articulated; and
finally the living body “life, which is a condition of jouissance.”37 Pain can be a factor in this sudden appearance
of paradoxical jouissance.
____________________
37 J.-A. Miller, “Biologie lacanienne et événement de corps,” op. cit.
Pain and Dolor 99

We will conclude with the following comment from Jacques-Alain Miller’s introductory text to Lacan's Autres
écrits: “The Autres écrits teach, about jouissance, that it concerns the signifier, but at its juncture with the living;
that it derives from ‘manipulations’, not genetic but linguistic, affecting the living speaking being, traumatized
by language.”38 From the point of view of this comment, pain can form itself as an analytical symptom.
____________________
38 J.-A. Miller, “Présentation des Autres écrits,” Autres écrits, Seuil, Paris, 2001.
Béatrice Serre
A Case of Alopecia
In my dermatological consultations, I encourage certain patients to tell me more about what has happened to
them, depending upon whether or not I think they might wish to express themselves at further length.*
In this article, I will be relating interviews I had with a woman who had suffered from alopecia for many years;
moreover, I will try to point out, based on her conversations with me, significant scansions occurring during the
course of our interviews regarding triggering, remissions, and even aggravations. Thus, ideas concerning the
demand or the wish of the Other, summoning up in particular the figure of Dominique’s mother or that of her
sister, would seem a necessary focus in this attempt to elucidate the case. It is crucial here that we do not delve
into what such a wish or need would objectify. Indeed this is the way Dominique subjectified such a desire or
such a wish, and therefore it seems essential that we conclude, on the basis of her interviews, that such had been
her subjectification of the Other in question.
The first incident

Dominique was 35 years old when she came for a clinical consultation for her beauty marks. She was afraid of
having contracted skin cancer due to the numerous times she had been treated for alopecia with ultraviolet rays.
Her fears proved to be unfounded and initiated the interviews regarding her alopecia. These interviews started
five years ago and evolved from the recounting of her background to an account of daily events which, though
perhaps less interesting, seemed to hold much importance for the patient.
Dominique was 21 years old when she lost her hair for the first time, when her only sister Christiane, her elder
by six years, returned to the family home. Christiane had disappeared eight years prior to this after her mother
threw her out of the house. Their father had said nothing. Dominique, who was then twelve years old, hearing
nothing from her sister, feared that she was dead. She was relieved, however, when her parents received a letter
from the police informing them that Christiane was being prosecuted for engaging in illicit behavior in a public
place.
Dominique had admired her sister. She had defended her at school when the other children called her a tease.
She also defended her when their mother attacked her with hateful words. Christiane returned to beg her parents
to take her back because she did not have any money left. The mother immediately threw her out again, violently
reprimanding the father for the few signs of attention he had shown towards their eldest child. During
Christiane’s absence, the mother forbade the others to mention her name.
Christiane secretly got back into contact with her sister and one day they returned to the house together. The
parents took her in again, as if nothing had happened, no doubt because she no longer asked for money. In the
meantime, Christiane had married her pimp.
Within a few weeks of Christiane’s return to the family home, Dominique’s hair fell out. After a consultation
with a dermatologist and a routine treatment using ultraviolet rays, half of the hair grew back. However, her hair
did not and has never grown back entirely.
__________________________
* Thanks to Guy Trobas for his precious assistance.
A Case of Alopecia 101

Shortly before her expulsion from the family, Christiane was smacked in the face by her employer for having
stolen money from the cash register. Following this scene, the employer turned up at the parents’ apartment;
Christiane opened the seventh-story window in order to throw herself out and was held back by her father.
Again, before the expulsion, Christiane often went out with her sister, especially when their mother asked
Christiane to go look for a job. Instead, they walked around Paris. Dominique was asked to keep quiet about
these wanderings. She remembers that Christiane introduced her to a prostitute, who was very enthusiastic about
what she did.
Christiane is the only person to whom Dominique cannot really talk to. When she was young, she suffered from
mutism and only began expressing herself in sixth grade when her sister was thrown out of the house. She
explained to me that she was afraid of contradicting her sister because she might start shouting.
Shortly after the sisters’ reunion, Christiane’s husband made advances toward Dominique. Dominique’s long-
held idea of Christiane as an ideal, as a desired woman, thus fell apart. Doubtless, there was another factor at
work here as well. In fact, Dominique, after having told Christiane once their contact was renewed, that she loved
someone, was extremely disappointed by her sister’s negative attitude: “He’s only a mechanic,” Christiane had
retorted.
An elision of being
Long before Dominique learned to talk, at the age of nine months, an important event occurred which caused a
rupture in the care she received: her mother contracted poliomyelitis and remained bedridden for a period of
somewhere between six months to one year. Dominique was often accused by her mother of being the cause of
her illness. It was thus her sister who took care of her, though she had never been known to be affectionate with
children. In fact, she had always refused to play with Dominique. The mother had also spent time in an asylum
when Dominique was nine years old. She often threatened to kill herself and Dominique was very afraid she
would die.
The mother made it clear that she did not want children – above all, not a girl – and that she had only married
in order to escape her own family. She did not love her husband. These were words that Dominique heard very
early on. She did not remember her mother ever smiling or ever showing her any affection. Instead, she showed
only signs of hostility and hatred as evidenced in the refrain, “you’ll end up a whore like your sister!”
Dominique, if we go back a bit further, cannot remember anything about her early childhood. However, she did
hear her mother tell her father to watch out by saying, “I feel like strangling Dominique!” Dominique thus
remembers being very afraid when returning home after school. Moreover, in the same vein, her mother
confused Dominique’s date of birth, February 1963, with that of the death of her mother in February 1962.
This young woman, confronted with the evidence of her mother’s rejection, rarely reacted to it. However, she
remembers it in a particular and probably unique manner: she recounts that when she had appendicitis, when she
was about twenty years old, she did not want to be operated on because of the anesthesia and, upon waking up,
she slapped her mother in the face.
Dominique loves her father and it is important to say that he is bald. She hopes that her mother will die before
he does so that she can see him again. In fact, for about three years now, Dominique has not seen her parents.
This rupture came about because of a letter Dominique wrote them. This letter was motivated by the anger and
distress of her sister, who Dominique had seen crying because of all that her mother had made her suffer.
Some years after Christiane’s return, one of Dominique’s very close friends tried to commit suicide several
102 B É AT R I C E S E R R E
times. The number of alopecia patches augmented. This was the second incident of hair loss. Did this period echo
the fear she had experienced upon the disappearance of her sister – a disappearance which had not, in fact,
provoked her hair loss in the first place?
The third serious incident of alopecia occurred when she was 29 years old, eight years after it had first occurred.
The context is as follows: the two sisters were no longer speaking since Dominique had, for the first time, refused
to go with Christiane by car to visit their parents, though she had not yet broken off with them. This “no” was
in response to Christiane’s repeated refusal to do her a favor despite the fact that she, Dominique, had always
done what her sister had asked of her. Through the parents, Christiane asks to take back a painting that she had
given Dominique and which had been given to her as a gift on the occasion of her son’s birth. Dominique
answered her parents: “she can come and get it,” but then took it to her parents’ home herself and without seeing
Christiane. It was at this point that the third incident of hair loss occurred. She pulled out the little hair remaining,
explaining that the hair actually falling out was worse than the alopecia itself. After this third serious incident,
Dominique bought a wig that she only kept for a few weeks. Dominique was convinced that everyone knew it
was a wig.
Dominique divorced her first husband, the mechanic, after the third incident of hair loss. Annoyed, she
reproached him for being too kind, for doing everything she wanted him to. She was bored with him. The divorce
did not aggravate the hair loss. A few patches of hair remained.
The bald woman

Some years later, Dominique found herself unfairly fired from her job. The reason seems to be that the director
of the cosmetic company where she worked could not abide couples and he was convinced that Dominique was
living with a sales director. This was not true at the time, but became true since this man was eventually to
become her second husband. Dominique did not immediately notice an aggravation of her alopecia and even
thought there had been a partial re-growth. She was sure she would find another job right away. She had always
worked in the cosmetics industry.
The fourth serious incident of alopecia occurred when Dominique found herself repeatedly refused jobs because
of her physical appearance. She was convinced that this was the reason. At first, she wore a wig to the interviews,
but arranged it so that the potential employer knew that she had bald patches. Then, in the following weeks, she
went to interviews without the wig. She was refused very interesting jobs and always for the same reason.
She says she did not recognize herself when wearing a wig: “it’s not me.” In the bus, she tried to spot women
wearing wigs and then imagined herself tearing them off so as to expose the fact. When she decided that she
would no longer wear a wig, she wore dark glasses so she could, she says, hide from the gaze of others. Behind
these glasses, she had tears in her eyes.
She finally found another job – it was some time after finding a position that she came to see me – where a
colleague told her, “if you don’t wear a wig, it’s because you’re trying to stand out.” This made her furious.
There is then a period where her hair begins to grow again. She asked her sister to be the witness in her second
marriage. She figured that this second husband, thirteen years her senior, would be more “presentable” in her
sister’s eyes. Her sister said yes, in theory, but wanted to give her final decision when she knew the date of her
son’s screen test. For Dominique, this waiting period was difficult and she found another witness. Very
distressed, she rehearsed for three days, with the help of her future husband, what she should say to her sister so
that she would not come to the ceremony: “you’ll be bored, it’s not worth coming.” This is in the end what she
did say to her on the telephone and her sister did not respond. A patch of three centimeters in diameter then grew
back within a week.

Dominique then decided that she should find out what her sister had done during the eight years of absence from
the family. She questioned one of Christiane’s former employers. This is the response she was given: “I didn’t
know that she had a sister.” The hair fell out again within three days. This was a new crisis – the fifth one – the
subject’s expression via the phenomenon of alopecia.
The idea of having a child distressed this young woman. She had refused to have one with her first husband, who
wanted one. However, she was having a lot of difficulty convincing the second, who no longer saw his children.
She feared having a child because she was afraid to subject him or her to the hell that she had gone through when
she was young. The picture of laughing infants in school playgrounds made her cry. She was also afraid of the
deformation of her body, of tearing during the birth. She had done two years of gymnastics and had wanted to
become a dancer. Having a child was for her the one irreversible situation. Moreover, she did not want to
breastfeed.
When she stopped using contraception, the hair started to grow back. According to her, it was because of the
irregular way that it grew back that she had to shave her scalp daily. She then remembered that during the first
incident of alopecia, on her doctor’s advice, she had also stopped using contraception, though without the
intention of becoming pregnant.
Recently, she offered to do her husband a favor and call the company where they first met because he wanted to
get back into contact with a woman who had worked for him. As soon as the receptionist answered, Dominique
could not speak, started trembling, and hung up without saying anything. The result of this was that the little hair
that had grown back fell out again and cast doubt on the idea that her being fired had had nothing to do with the
triggering of the fourth serious incident of alopecia. This was, thus, the sixth episode of alopecia.
Dominique, in the meantime, did not wish to see her sister again and said that this was a relief to her. She forgot
the name of the town where her sister lived as well as her telephone number. She threw out the trinkets that
Christiane had given her.
It is important to note that this young woman adores photographs and mirrors; accordingly, her house is filled
with them. For her, the gaze is what is most important: she does not like gazes that are “blank, without
expression.” She spoke on several occasions of her mother’s black and cruel gaze.
At this point, Dominique now has a very unusual style: she is always dressed very elegantly, holds herself very
upright, and walks as if she were modeling for a top fashion designer. However, the way she expresses herself
is typical of the very economically and socially depressed areas where she grew up. She rarely speaks and what
she says is unimaginative – bereft of allegory, of metaphor, of humor: her discourse is without sensuality. We
could speak here of Dominique’s language as an imaginary desert which disincarnates Dominique’s speech. In
other words, this subject’s discourse presented an elision of the dialectic of speech and a cushioning of the
invoquing drive. Let us not forget that Dominique suffered from mutism when her sister was around. Little
happened, on the level of language, in this family.
A loss inscribed on the body

The aim here is not to decide what meaning to give to alopecia – which remains for the subject itself an enigma
insofar as it is the effect of a subjective cause, which is far from being clear. Rather, it is to expose the relation
between the loss inscribed on the body, signified by the alopecia, and the problem of the non-existence of the
subject’s being. To this end, we shall first look at the six incidents of hair loss.
First of all, what is happening during the first triggering of alopecia? Dominique witnesses the confrontation
between her mother and her elder sister, Christiane. After those eight years of absence, nothing was said, nothing
was symbolized in the parents discourse, just as if their elder daughter had never existed: neither as a subject,
nor even as a being. By not giving any consistency to this absence, the parents were sending a message which
could be likened to a cancellation of Christiane’s existence: whether she was there or not was of no importance.
We are confronted here with the total cancellation of a being on the levels of the symbolic, the imaginary, and
the real which cause one to exist for the Other. Is this not what was being represented when the hair fell out?
After some of the hair had grown back, the second incident of alopecia occurred when a friend, who Dominique
had treated maternally, made attempts to take her own life. This could not help but bring back the memory of the
failure in the maternal role not only of her mother but also of her substitute, Christiane. The care Dominique gave
her friend appears to have been a retroactive attempt – through a specular identification to the friend – to sustain
herself in her sister’s desire. But what is reactivated is the situation in which she did not count as the love-object
for her mother and her sister. Do we not find ourselves confronted here with the problem of the elision of the
subject’s being?
A third incident of alopecia happened when Christiane asked to take back the painting that she had given
Dominique – a painting that had been given to Christiane when her son was born. This painting had represented
a giving of maternal love on the part of her elder sister. When she decided to take it back, she erased the value
formerly placed in the gift and at the same time took away the symbolic support it had represented.
A fourth incident of hair loss occurred when Dominique was repeatedly refused jobs. While she was trying to
find a certain consistency of being in presenting herself as a bald woman, what she understands the Other to say
is that she is not desirable as such. She is sent yet again the message signaling her non-existence in the desire of
the Other – a non-existence that is signaled in the register of the gaze. We should note that, on the other hand,
the unfair dismissal from her job did not result in the aggravation of hair loss – certainly because it showed that
she was inscribed in the desire of the Other: she was thought to be desired by the man who later would become
her husband and this had not failed to incite the jealousy of their employer.
The fifth incident of alopecia coincided with the moment when she was told: “I didn’t know Christiane had a
sister.” Her own being was put into question when met by her sister’s silence regarding her existence. She
retroactively sees her non-existence as a being of the drive, as subject of demand, in the desire of the Other to
whom she had addressed her demand for love.
A sign of the subject in the real

We may suppose that this new incident of hair loss is inscribed in a real which is not drive-motivated because
not linked to the demand. Alopecia is definitely a phenomenon that inscribes itself directly in the real. The hair
loss really embodies, in Dominique’s case, the falling of her being into the void of the Other’s demand in her
regard. There is a hole in place of her existence in the Other of love. In this hole where her being disappears from
the symbolic and imaginary registers, alopecia is the only sign of the subject in the real. Dominique could have
asked herself questions, become angry, complained, but she never reacted. She has no words, images or allegory
for what happened to her. The symbolic and the imaginary failed.
The sixth incident occurred when, telephoning for her husband, she is loses her voice. This incident would not
seem to align itself easily with those that preceded it. We may, however, venture the hypothesis that here, she is
incapable of making herself known – her mutism in this incident echoes what she exhibited when young and
living with her sister.
Creating a certain consistency of being for oneself

What can we observe concerning the re-growth of Dominique’s hair? First of all, there is the circumstance of her

asking her sister not to be the bridesmaid at her wedding. Her hair starts to grow back. Dominique had asked her
sister to be her witness because she wanted her to testify that this wedding was also inscribed in her desire.
Confronted with her sister’s stalling, she faces the following alternative: accepting this message as a new signal
of her non-existence in the desire of the Other or else deciding that she can forego this demand and that she can
signify something for the Other – that she allow herself to demonstrate her desire to exist in this marriage. It is
this second option that she chooses. She creates for herself a certain consistency of being in separating herself
from her sister’s desire – more specifically from that which, in this desire, operates in the field of the gaze.
Dominique was successful in her attempt at an elaboration of the symbolic that permitted her to separate from
the alienation that she experienced living as her sister’s non-desire. In order to achieve this, she had to confront,
accept, and overcome her anguish.
There is a second occurrence of re-growth when Dominique stops taking contraceptives and accepts her desire
to have a child, separating herself here from alienation in the desire of her husband who did not want one. Her
desire was thus very strong and the re-growth very active. However, this re-growth stopped after six months. We
learn that her husband has become impotent. It is probably the continuation of her desire, despite the obstacle
presented by the husband, that keeps the hair from falling out again and only stops the re-growth. Dominique is
very suspicious of her husband’s explanation that his sexual impotence is due to polyneuritis. She instead
recognizes the sign which tells her that she is no longer inscribed in the desire of the Other as a mother being.
She feels she was dropped. However, her husband then buys Viagra and his potency is restored along with his
ability to become a father. Thus her possible mother being becomes once again inscribed in the desire of the
Other.
Moving from the writing in the real to “style”: a transformation of the subject
What status should we give Dominique’s alopecia? Could it be said that her baldness is the inscription in the real
that signals the precariousness of her being as subject? A transformation in the subject indicates that Dominique
puts an emphasis on, and gives a face to, her alopecia – separate from its original meaning – starting from the
moment that she decides to stop wearing a wig. She seems here to be “reclaiming” in no uncertain terms her
alopecia in order to situate herself as one who exists in the Other’s gaze. She regards this “reclaiming” as a
challenge. Equally, and on the same level, she wants to unmask the imposture of other women, reinforcing her
own existence as one who does not hide herself: “I, for one, accept myself,” she might have said. Dominique
attempts a demonstration which is contrary to that of the non-existence of her being as subject. She creates, by
way of this real, a mode of seduction, a relationship of rivalry with other women: she creates a style.
Before deciding to stop wearing it, her non-existence had been hidden by the wig. After getting rid of the wig,
the manner in which the world viewed her subsumed her thoughts. The alopecia became the image of her
existence: we could refer to this as an imaginarization or specularization of the real.
Within this transformation, the register of the gaze is prevalent. However, insofar as this psychosomatic
phenomenon itself appears in the field of the gaze, what she reveals here is something which is falling from her
being, which is falling into the real. She reveals a mutilation of her being. Something in the register of the scopic
drive may have more or less structured itself in a prevalent way in the relationship with the Other. Here, the
question becomes whether what she was able to understand concerning the existence of her being does not fall
entirely into the sphere of the gaze. Within this desire of the mortifying Other, because Dominique does not lean
on her own demand, she leans on the register of the scopic drive in order to support her existence.
What this loss of hair shows is that she has found her substance and her subsistence in her relationship to the
Other in the register of the gaze, where something of her desire is structured and preserved. This hypothesis finds
its support in the secondary usage Dominique makes of her baldness, a usage that presents itself in the
appearance of hysterical desire – a style that combines seduction and a sense of challenge.
Following this logic regarding the scopic drive, why was psoriasis not triggered in Dominique’s case? This is
obviously an abstract question, removed from the present case, but let us not forget that, contrary to subjects
suffering from psoriasis who create “too much,” patients with alopecia create a “lack.” Subjects with psoriasis
probably exist too much in the demand of the Other. There we would find a context, in terms of the subject’s
relationship to the eroticization of the being in the demand, which is the opposite of that of subjects affected by
alopecia.
The clinical observations in Dominique’s case seem to correspond to a logical temporality which, following the
cue of the subject within the desire of the Other, causes the hair to fall out or to grow back. When, in the register
of alienation, this desire is absent and when its being is no longer supported, the hair falls out. When the subject
finds its existence confirmed in the desire of the Other or, through its own desire, he/she takes a step regarding
this desire of the Other, the hair grows back. Here, where the subject could react to its elision through fantasy,
through a symptom, through anguish, through aggressiveness, she reacts with an alteration of the real of her
body, where she is not represented symbolically but offers herself up nevertheless in order to represent
something for an other in the field of the gaze. If the subject is not represented in its psychosomatic phenomenon,
it still manages to signify something for the Other. Could this be the mark, in Dominique’s case, of that which
is maintained of her desire even though she is no longer subject in it?
Translated by Kirstin Johnson

Guy Briole
Freedom of Information and Psychoanalysis
The right of patients to information – in medicine, through external forces – increases to the extent that one
considers them to be a subject in their own right, as responsible and as having a right to know what their health
professionals know about them. Following the example of information in other areas of their lives – professional,
banking, citizenship, etc. – those concerning their state of health also belong to them by right, as stipulated in
the French Code of Public Health decree dated 29 April 2002.1
As far as psychoanalysis is concerned, an initial question arises: are we dealing with the ill? What can the nature
of this information in psychoanalysis be? Is the medical model transposable into the analytic situation? Is the
model of medical or surgical services transposable as such into psychiatric services, and, a fortiori, to an
institution conceivable on the basis of psychoanalysis?
Not all psychoanalysts are doctors or psychologists and, even for those who are, while they practice
psychoanalysis they do not do so in the name of anything that could include them in this professional field. Can
they practice in these institutions, on the basis of what guarantee and how are they to respond to the legal
requirements, for example in the matter of information?
Seeing an analyst and commencing an analysis arises from a personal decision and a dyadic commitment that
implicates the analyst and whoever asks to be taken into analysis. Anyone who chooses to do an analysis does
not define him or herself as ill, even if it is psychical or physical suffering that has led him or her to take this
step. A psychoanalyst will not call this type of demand into question, even though, in his practice, his focus is
beyond the alleviation of symptoms. Instead of the term “patient,” inherited from the beginnings of
psychoanalysis, we prefer the term “analysand,” which Jacques Lacan proposed.
This approach can take a different form when psychoanalysts practice outside the strict framework of the analytic
consulting room – in an institution, for instance. In this practice of “applied psychoanalysis,” the psychoanalyst’s
interest also includes the reasons for the patient’s presence in the place in which he is intervening. A
psychoanalyst is implicated in this institutional context in just the same way as everyone else is. More broadly,
whatever the context might be in which psychoanalysts intervene, “being implicated” does not derive from the
law, but arises from the ethics of their position in their practice.
Information and unconscious knowledge

The introduction to the “Charter for hospitalized patients” stipulates that over and above the health regulations
practitioners must take care not to discriminate, but to respect persons, their individual freedom, private life, and
autonomy.2 These questions are at the heart of the analytic undertaking, even though it seems they are being
discovered today in the medical field. Psychoanalysis has always considered the patient to be a responsible
_____________________
1 Decree no. 2002-737, 29 April 2002, relative to access to personal information held by health professionals in application of articles
L. 1111-7 and L. 1112-1 of the French Code of Public Health. JORF. no. 101, 30 April 2002, p. 7790.
2 “Charter for hospitalized patients”. Appendix to the French Ministerial Circular no. 95-22, 6 May 1995, relative to the rights of
hospitalised patients.
108 GUY BRIOLE

subject. Lacan even made it into a fundamental ethical position for every subject.3 Medicine, because of its ever-
increasing scientific reference point, has come to forget the subject whose psychical and existential dimension
increasingly appears as an artifact. Modern medicine has in this way extended the anatomical, historical and
biochemical fragmentation of the body more and more, each part finding itself increasingly separated from the
field of speech, which is alone capable of giving unity to the body, the subject. Thus, knowledge was confined
to the side of the doctors, even as the patient was maintained in a state of ignorance.
Approaching the subject of patients’ right to information leads us first to enquire into this term “right.” Let us
say that anyone who chooses to see a psychoanalyst places him or herself in a different ethical perspective: that
of the saying-it-well. What they must hold to in analysis is to work at saying well what they feel, what they recall
by avoiding none of the corridors of thought down which their associations have led them. It is not being
informed by their analyst that analysands are concerned about during their sessions!
The analytic situation produces an inversion of the position of knowledge in relation to medical practice.
In medicine the university confers knowledge. Doctors have an obligation to place this knowledge at the patient’s
disposal. A scientific knowledge is transferred to the patient whose right it is to receive something in return and
to obtain the doctor’s knowledge concerning what he has elaborated on the basis of the patient’s complaints.
In the analytic arrangement knowledge is supposed in the analyst. But this knowledge – unconscious, therefore
not known – is to be produced by the analysand, session after session. It is therefore the analysand who informs
the analyst about the progress of the knowledge acquired by the analyst, the knowledge that comes from the
analysand’s associations, from their formations of the unconscious.
This knowledge is eminently transitory. As it is being completed it is being modified, sometimes over the course
of the entire analysis. The analysand’s trajectory is rich in these discoveries that give a character of lability,
which makes truth precarious, to the information that he or she delivers up at the start of the analysis.
Privacy and confidentiality

A relationship of confidentiality lies at the foundation of the analytic relationship. Confidence in analysis
proceeds under a fundamental rule: the analyst must not tell what he hears.
Psychoanalysis is this process that unfolds, in camera, in the analyst’s consulting room. Between the analyst and
the analysand there is no regulatory third party, in the institutional sense. In its place there is the ethics of the
analyst’s act.
The analyst’s consulting room is a privileged site, one in which a subject is able to come and speak without
anyone having access to what he says there. Nothing is more intimate than what is said in analysis. It is also a
site in which one says more than one thinks of saying, and even where one says more than one thought or meant
(to say), on the basis of one of the fundamental rules of psychoanalysis: free association.
Singularity
The relationship with a psychoanalyst rests on a verbal contract between two people, the analyst and the patient
who has requested an analysis. This is not just an easy thing to say, but arises from the very complex and subtle
establishment of the analytic arrangement. It is the analyst’s act that, through the transference, makes it possible
in the preliminary interviews to uncover that area that the psychoanalysis is going to focus on. That is to say,
well before an analysis commences, the patient has already provided the analyst with a lot of information about
_____________________
3 J. Lacan, “La science et la vérité,” Écrits, Paris: Seuil, 1966, p. 858.
Freedom of Information and Psychoanalysis 109

himself. It is also to say that the analytic process does not focus on a diagnosis and prognosis in which the analyst
engages. An approach like this differs from the doctor’s who has an undertaking – through his own knowledge
and the social place that this confers on him – towards the patient he agrees to receive, in an approach that
encompasses diagnosis, prognosis and treatment.
The psychoanalyst attaches himself to the singularity of each subject. He considers subjects one by one, in a
trajectory specific to each, and without reference to one group or another of patients.
Neutrality and act

The new decree relative to access to information concerning people’s health states that, for patients, access to
information is direct – it is no longer necessary for them to proceed via a doctor of their choice.4 For patients in
analysis, what could they think of having access to, except what they themselves have confided to their analyst?
The question can present itself differently when it involves information relative to the gravity of the analysand’s
state or of the risks he or she may be running in a given situation. In the medical situation patients must be
informed of those risks “susceptible of having an influence on their free and informed choice.”
There are indeed situations in which an analysand can place him or herself in danger – affectively, professionally,
physically, socially. Must the analyst bring it to his or her attention? Must the analyst abandon his or her
neutrality and enter, to a greater or less extent, into the orientation of the subject’s life?
One of the fundamental rules for analysts is not to intervene in the reality of their analysands’ lives. Nevertheless,
should analysts remain inert and limit themselves to observing their analysands? In relation to what the analyst
perceives as inadequate in the analysand’s conduct – and which escapes the analysand – the ways he or she can
intervene covers the full range of his or her means of acting: scansion, emphasizing a point, astonishment,
seeking clarification, asking for something to be repeated, etc. Nevertheless, however tactful these interventions,
the analyst risks finding himself in a false position in his practice, rejected, de-jected, towards a knowledge that
can be experienced by the subject as intrusive, even persecutory.
I will illustrate this point with an example taken from practice. An analysand has been complaining for a long time
about her relationships with her partner. She insists upon a recent incident, she even mentions the fact that she is
in the process of “leaving her life there.” The analysand who makes this remark does not clearly understand its
import. Its significance will only take on its true consistency from the analyst’s simple punctuation, “That’s it!”
At this moment when the analysand could have grasped the consequences of her remark about her relationship,
the “That’s it!” assumes, for her, the value of adopting a position, on the part of the analyst, towards her partner.
On the basis of what knowledge? What does the analyst want for her? The question is displaced onto the analyst
and occults what could be opened up concerning an impasse in her life. It could be thought that interrupting the
session on this remark could have just as well led to this effect of understanding without inducing this reaction,
caught up in the transference and prejudicial to the progress of the analysis.
On the basis of this example, paradigmatic in its simplicity, one can see that it is always very complex for the
analyst to intervene, even in situations in which the analysand acts against herself.
Interventions “outside the framework”

However, faced with a serious situation, one that could put the analysand’s life at risk, the analyst will make a
_____________________
4 Decree no. 2002-737, 29 April 2002, relative to access to personal information held by health professionals in application of articles
L. 1111-7 and L. 1112-1 of the French Code of Public Health, op. cit.
110 GUY BRIOLE

judgement about the appropriateness of an intervention – “outside the framework,” as it were – that can extend
from giving encouragement to consult a psychiatrist, to making contact with the relevant services for the sake of
hospitalization: for example, in the case of a risk of suicide in a state of melancholia.
On this point, we must make special place for psychotic subjects for whom analysis presents a different situation,
where certain situations require the analyst’s concrete intervention – to help the psychotic in terms of personal
choices, professional orientations, and sometimes to oppose him, or even, at other times, to accompany him for
hospitalization or, again, to endorse the taking of medication. In all these situations not only does the analyst
inform the subject, but he also takes a position on the basis of what he knows about the person who has confided
in him.
The analyst’s notes

One of the common images of the analytic situation has the analysand lying on the couch and the analyst
comfortably seated behind him, in his armchair, taking notes. Some imagine that that evening the analyst
carefully goes over the notes and adds his personal reflections, with the aim, like Freud, of writing up the history
of the case – that of the analysand, to be sure. This is to say, the analyst’s personal notes are often the object of
ambivalent attitudes on the part of the analysand. The analysand knows that he is the true composer of the notes,
but he may also be tempted to discover whether the analyst might have added something of his own making. In
other words, the analysand would like to assure himself of the place he occupies for the analyst. The analyst’s
notes are caught up in the transference.
According to the decree of 29 April 2002, of all the documents in the medical file that the patient may have
access to, only “the personal notes of the doctor do not appear in this list.” To my mind, the analyst’s notes can
only ever be “personal.” They are part of the analytic relationship and, by virtue of this, any request referring to
them can only be treated within this framework, through the transference work.
The same goes for documents that the patient entrusts to the analyst – personal writing, letters, projects, etc. –
that are to be considered on a case by case basis, in terms of the place they may occupy at a particular moment
of the analysis.
The same comment could be made concerning letters or other documents received by the analyst, coming from
someone close to the analysand.
Freedom and information: a tension

Concerning third parties, the decree of 29 April 2002 foresees restrictions in the case of patients opposed to
psychiatric hospitalization and of minors who may refuse permission for their parents to be informed about their
state. Relative to confidentiality, can one not consider that coming to speak to an analyst has the value of a
declaration of “opposition” to any third party being informed of what it involved for a subject in his or her life?
Even if this is valid for all subjects, one has to be more careful in the case of minors whose parents will attempt,
through various means, to circumvent the strictly personal nature of the relationship with the analyst – in order
to get access to information or to provide information, under the pretext that they are the parents, that they are
the ones who are paying, etc.
The notion of confidentiality and that of keeping the family informed are rather contradictory notions. A certain
tension is introduced between, on the one hand, the ever-increasing need for freedom and autonomy of the
subject, correlative to the extension of the notion of personal confidentiality, and on the other the requirement
for knowledge, for a right to knowledge about a person, under the pretext that this person is someone close!

The analytic situation exemplifies this tension, particularly where a psychotic subject is involved. Even today
the question arises – and this includes some health professionals – of what the value of taking on a psychotic
subjects’ commitment can be. Is he a responsible person? Does one have to make an exception in his/her case if
a family seeks access to information? There are psychotic patients for whom freedom, the margin of
maneuvering in their life, presupposes this passage through speech in the work of analysis. Today, many
psychotic subjects themselves ask the question of their freedom and of an ethical choice that takes into account
what engages them as a subject responsible for their acts and statements.
An increasing number of psychotic patients seek out an analyst. There would thus seem to be no reason to treat
information concerning the families of psychotics any differently to that for any other subject.
Practice with children

Psychoanalytic practice with children, whether in the consulting room or in an institution, has the particularity
of including, or even requiring, the participation or at least the agreement of the parents. The ways of working
vary according to the psychoanalyst and the situation: initial interview with the parents and child, with the child
on its own, the parents on their own – both parents, one parent, etc. Whatever the case with the multiplicity and
particularities of these meetings with the family, personal information concerning the parents and the child will
be exchanged in the presence of the analyst. Two brief remarks are called for. Children are subjects in their own
right and it is essential to consider that, for them too, privacy exists. One will take care on this point to maintain
strict confidentiality. As for the parents, it is important to respect their wishes and not to disclose personal or
intimate matters in the presence of the child. They may ask to speak to the analyst alone and, secondly, approach
another analyst.
Objects of value
Depositing objects of value with the analyst is mentioned here less for its frequency than for the particularity that
it introduces into the practice of the psychoanalyst, both in private practice and in institutions. It is very rare,
perhaps exceptional even, that a psychoanalyst will agree to be a depositary of these objects of value. Very
special circumstances must arise. Most often, these are situations in which the patient performs this gesture as a
last resort to protect a good that he feels is in danger from an imminent passage to the act that he believes he can
no longer control.
This step can also be inscribed in a delusional context dominated by an experience of menace, the fear of
spoliation, or by the seizure of goods – not always wrongly, moreover! For other patients it may be part of a
favorable development as in the case recounted by a patient who deposited her most precious jewels with her
analyst and attributing to them, in the time of the session, an ordering that re-established a semblance of
coherence, of symbolic order in her life.5
If the analyst is able to agree to receiving, under very special conditions, the deposit of objects of value, this can
only be temporarily. He is not their owner. These object, when necessary, re-enter the legal field that regulates
them. This even becomes an imperative in an institution.
The death of an analysand
In the case of the death of a patient, the next of kin can have access to the medical files – unless the deceased
opposed this during his or her own lifetime – in order to ascertain the causes of death, preserve the memory of
_____________________
5 O. Ventura, “Une femme prodigue”, L’amour dans les psychoses, Institut du Champ freudien, Journées des Sections cliniques,
XIIèmes Rencontres internationales du Champ freudien, Paris, 20-21 July 2002, pp. 49-62.
112 GUY BRIOLE

the deceased, or to claim his rights. This is a situation that a psychoanalyst may encounter and to which he is
obliged to find, with tact and discretion, a response appropriate for each case. In these particular circumstances,
receiving his family and listening to them is different from releasing information about the analysand’s private
life. This person may wish to speak to the person in whom his loved one had chosen to confide. It is a step that
is not only to be understood as an attempt at intruding into the analysand’s personal privacy, but rather as one of
the elements that will enable family and friends to carry out the work of mourning. Here, too, the response to
give depends on the analyst’s judgement on a case by case basis.
Information and legal obligations

Medical doctors are excluded from the offence of not informing as stated in the article 434-3 of the French Penal
Code when they learn in their practice that a subject is committing an offence. Could this also apply to the
analytical situation? Legal obligations do not fend well in the case of psychoanalysis, where the range of
situations and answers varies considerably.
Let us consider the specific situation where we learn in a session that a subject is committing an offense. Broadly,
three situations arise, even if each situation is to be considered unique:
— One is dealing with a perverse subject who uses the analytic situation so as to continue, with impunity, to
satisfy his or her perverse jouissance. The question thus arises of breaking off the analytic relationship as the sole
ethical response.
— The moment of the offence is the moment of the onset of a psychosis and, thus, measures appropriate to the
situation will have to be taken.
— With the neurotic subject marked by guilt, the conduct of the treatment will lead him to consider responsibility
for his acts and to adopt an appropriate legal attitude towards his conduct.
Consent and commitment

Information about the ill is thus regulated. It is included in legislation that embraces the “citizen as ill.” Whereas
medicine involves a person who is ill, in psychoanalysis the analysand is a subject, who may also be ill. In fact,
it is not this statute of being ill that is central to the analytic process. With the ill, it is question of obtaining their
consent, whereas with the analysand, as from the preliminary interviews, it is question of verifying his or her
engagement in the analysis.
The place of knowledge in the analytic arrangement is diametrically opposed to that of medical practice. In this
sense the question of providing information to analysands runs against the singularity of the relationship with
the psychoanalyst.
Information is owed to an “enlightened user,” as the text of the law puts it. A person who goes to see an analyst
is not in this position. On the contrary, he is making this choice of an analysis so that something about his life
can be clarified, on the basis of what he is able to put to work in his treatment. The question arises less from the
side of information to give the analysand than of what his ethical position implies.
Translated by Russell Grigg

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Mental

The Future of Psychosis in Civilization

Editorial Marie-Hélène Brousse 3

Jacques-Alain Miller Milanese Intuitions [2] 5

Pierre-Gilles Guéguen Symptomatic Homeostasis in Psychosis 17

Betting on Inventiveness in the Treatment of Psychosis

Clinical Practice and its Concepts

Graciela Brodsky The Alchemy of Hysteria 71

The Subject Inside the Patient

Philippe Fouchet Epilepsy 79

Milanese Intuitions [2]

Milanese Intuitions [2] 5

The unconscious is connected to the social bond

“The rejected being” and the political demand of the Other

Milanese Intuitions [2] 7

The depreciation of psychoanalysis

The machine of the not-all

Milanese Intuitions [2] 9

Milanese Intuitions [2] 11

The bubbles of certainty

Psychoanalysis in the epoch of globalization

Milanese Intuitions [2] 13

Translated by Thelma Sowley

Symptomatic Homeostasis in Psychosis*

Symptomatic Homeostasis in Psychosis 17

Therapeutic effects and their limit

Symptomatic Homeostasis in Psychosis 19

The symptomatic in homeostasis

Symptomatic Homeostasis in Psychosis 21

Translated by Julia Richards

Delusional Misidentification Syndromes

The systematic meconnaissance

Delusional Misidentification Syndromes 23

Madame de Rio-Branco and the illusion of doubles

Delusional Misidentification Syndromes 25

Jacques Lacan and méconnaissance

Identification, desire, recognition

Delusional Misidentification Syndromes 27

The gaze is on the side of the Other

Delusional Misidentification Syndromes 29

The French “Mental Health Plan”

The psychiatrist’s object

The French “Mental Health Plan” 31

Pharmaceutical dynamism and the followers of Kraepelin

The truth of the effects of segregation

The social symptom

The French “Mental Health Plan” 33

Psychiatry’s change of system

The French “Mental Health Plan” 35

Translated by Sylvia Winter

Thinking About Addiction with Reference to Psychosis

Thinking About Addiction with Reference to Psychosis 39

Psychosis enlightened by drug addiction

…Or how to cope without the paternal function

Thinking About Addiction with Reference to Psychosis 41

Sheltering from ravage

Making a diagnosis has consequences on the work with the patients.

A “real-ization” of the separation

Thinking About Addiction with Reference to Psychosis 43

“The taste of drugs in his mouth”

Translated by Thelma Sowley

Thinking About Addiction with Reference to Psychosis 45

A Psychotic Invention: “Puffy Anorexia”

A Psychotic Invention: “Puffy Anorexia” 47