The Lacanian approach to diagnosis is bound to seem strange to those schooled in the DSM-III or DSM-IV; it is in some ways far simpler, yet in other ways more discriminating, than what passes for diagnosis in much of the contemporary psychological and psychiatric world. Lacanian diagnostic criteria are based primarily on Freud’s work—a certain reading of and extension of notions found in Freud’s work—and on work done by a handful of French and German psychiatrists (most notably Emil Kraepelin and Georges Gatian de Clérambault). Rather than tending to multiply ever further the number of diagnostic categories, such that every new clinically observable symptom or set of symptoms is taken to constitute a separate “disorder,” Lacan’s diagnostic schema is remarkably simple, including only three main categories: neurosis, psychosis, and perversion. And unlike the categories developed in the DSM-IV, which provide little concrete direction for the psychotherapist regarding how to proceed with different categories of patients, Lacanian diagnoses find immediate application in guiding the practitioner’s aims and in indicating the position the therapist must adopt in the transference.
At the most basic level, Lacanian theory demonstrates that certain aims and techniques used with neurotics are inapplicable with psychotics. And not only are such techniques inapplicable—they may even prove dangerous, triggering a psychotic break.1
Diagnosis, from a Lacanian standpoint, is not merely a matter of performing perfunctory paperwork required by institutions and insurance companies; it is crucial in determining the therapist’s general approach to treating an individual patient, in correctly situating him- or herself in the transference, and in making specific kinds of interventions.
This should not be taken to imply that Lacanians are always able to make a precise diagnosis immediately. As many clinicians are aware, it can sometimes take quite a long time before one manages to discern the most basic mechanisms
in a person’s psychical economy. Nevertheless, a preliminary situating of the patient as most likely neurotic or psychotic is quite important, and the clinician’s very inability
to situate a patient at this level must incline him or her to tread lightly during the preliminary meetings.
Lacan attempts to systematize Freud’s work on diagnostic categories, extending certain of Freud’s terminological distinctions. Freud himself separates neurosis from perversion by theorizing that whereas repression (Verdrängung
) is characteristic of neurosis,2
the primary mechanism characteristic of perversion is disavowal (Verleugnung
Lacan points out that Freud employs another term—Verwerfung
—to talk about a still more radical mechanism (though not in theoretical detail). This term is found in a number of contexts in Freud’s work,4
and Lacan suggests (especially through a close reading of Freud’s 1925 paper “Negation”)5
that we understand it as the primary mechanism characteristic of psychosis; he translates it first as “rejection” and later as “foreclosure.”6
I will discuss this term at some length in Chapter 7
. Suffice it to say here that Freud uses it to describe not simply a rejection of something from or by the ego (repression might be talked about in some such way), or the refusal to admit something that was nevertheless seen and stored in memory (disavowal might be talked about in this way), but an ejection from oneself—not simply from the ego—of some part of “reality.”
Thus, the three main diagnostic categories adopted by Lacan are structural categories based on three fundamentally different mechanisms, or what we might call three fundamentally different forms of negation (Verneinung):
Regardless of whether one accepts these mechanisms as fundamentally different and as defining three radically different categories, it should be clear that Lacan’s project here is essentially Freudian in inspiration
, and in direct continuity with Freud’s efforts to discern the most basic differences among psychical structures. (In Chapter 8
, we shall consider Freud’s attempt to distinguish between obsession and hysteria—an attempt that is perhaps more familiar to the reader.)
It will, I hope, be immediately clear that the possibility of distinguishing among patients on the basis of such a fundamental mechanism—the way in which they negate something—would constitute a diagnostic contribution of
major proportions. It would allow the practitioner to go beyond weighing the relative importance of certain clinical characteristics, comparing them with lists of features in manuals such as the DSM-IV, and to focus instead on a defining
mechanism—that is, a single determinant characteristic. For, as Freud was wont to say, repression is the cause
of neurosis. In other words, repression is not simply associated with neurosis; it is constitutive of neurosis. One becomes neurotic due to repression. Similarly, Lacan puts forward a causal argument: foreclosure is the cause of psychosis. It is not simply associated with psychosis; it is constitutive of psychosis.
An important consequence of this structural approach is that there are three and only three principal structures. (There are, of course, various subcategories. For example, the subcategories of neurosis are hysteria, obsession, and phobia—these are the three neuroses.) People referred to in common parlance as “normal” do not have some special structure of their own; they are generally neurotic, clinically speaking—that is, their basic mechanism is repression. As Freud himself said, “If you take up a theoretical point of view and disregard the matter of quantity, you may quite well say that we are all
ill—that is, neurotic—since the preconditions for the formation of symptoms [that is, repression] can also be observed in normal people.”7
Obviously, it is conceivable that other forms of negation could be found, leading to four or more principal structures; but on the basis of current research and theory, these three seem to cover the entire field of psychological phenomena. Thus, “borderline” does not constitute a genuine diagnostic category in Lacanian psychoanalysis, as no specific mechanism corresponds to it
This does not mean that Lacanians never hesitate in making a diagnosis; for example, they may note certain psychotic traits in patients, though they are not convinced of the existence of a true psychotic structure. They may, in other words, wonder whether the patient is neurotic or indeed psychotic; but they view this ambiguity as resulting from their own inability to make a convincing diagnosis. The patient is not on the border between two clinical structures; it is the clinician who is hesitating at the border in his or her diagnostic ponderings.8
The defining mechanisms of the three major clinical structures will be discussed in detail in subsequent chapters. Here I shall merely point out that, however sophisticated our theoretical understanding of these structures may be, determining which mechanism is at work in the case of an individual patient is still a matter which requires a great deal of clinical experience and expertise. Foreclosure, like repression, is not something that the clinician can “see” directly; it is not perceptually available. It has to be inferred from the clinical material with which analysts are presented and which they are able to
elicit. Lacan was a highly experienced clinician by the time he gave Seminar III, The Psychoses
(he was fifty-four and had been working with psychotics for at least twenty-five years), but in this seminar he attests to how difficult it can be—even in a case in which psychosis seems more than likely—to elicit the “signature” of psychosis,9
the feature which makes it absolutely clear that the patient is psychotic.
Fine theoretical distinctions between neurosis, psychosis, and perversion do not eliminate clinical difficulties, but it seems to me that Lacan also details the essential clinical features associated with, say, foreclosure which allow the analyst to diagnose psychosis with a great deal of confidence. Some of these essential clinical features may be immediately manifested by a particular patient, whereas others may require a good deal of questioning and probing on the clinician’s part. The more familiar the analyst becomes with them, however, the easier they are to discern.
Foreclosure and the Paternal Function
Foreclosure involves the radical rejection of a particular element from the symbolic order (that is, from language), and not just any element: it involves the element that in some sense grounds or anchors the symbolic order as a whole. When this element is foreclosed, the entire symbolic order is affected; as has been noted in a great deal of the literature on schizophrenia, for example, language operates very differently in psychosis from the way it does in neurosis. According to Lacan, the element that is foreclosed in psychosis intimately concerns the father. He refers to it as the “Name-of-the-Father” (as we shall see, the French, Nom-du-Père
, is far more instructive). For my present purposes, I will refer to the “father function” or “paternal function,” since they cover more or less the same ground. The latter term can occasionally be found in Freud’s work, but it is Lacan who rigorously formulates it.1
The absence of the paternal function is the single most important criterion to consider in diagnosing an individual as psychotic, yet it is by no means immediately visible in the majority of cases. The paternal function is not the function played by the individual’s father, regardless of his particular style and personality, the role he plays in the family circle, and so on. A flesh-and-blood father does not immediately and automatically fulfill the paternal function, nor does the absence of a real, live father in any way automatically ensure the nonexistence of the paternal function. This function may be fulfilled despite the early death or disappearance of the father due to war or divorce; it may be fulfilled by another man who becomes a “father figure”; and it may be fulfilled in other ways as well.
A complete understanding of the paternal function requires knowledge of a good deal of Lacan’s work on language and metaphor. For our purposes
here, let it suffice to say that the father who embodies the paternal function in a nuclear family generally comes between mother and child, stopping the child from being drawn altogether to or into the mother and stopping the mother from engulfing her child. Lacan does not claim that all
mothers have a tendency to smother or devour their children (though some do); rather, he says that children “perceive” their mOther’s desire as dangerous or threatening. This “perception” reflects in some cases the child’s wish for the mother to take her child as her be-all and end-all (which would ultimately annihilate the child as a being separate from its mother), and in other cases a reaction to a genuine tendency on the mother’s part to obtain a kind of satisfaction with her child that she has not been able to obtain elsewhere.
In either case, the result is the same: the father keeps the child at a certain distance from its mother, thwarting the child’s attempt to become one or remain forever one with the mother, or forbidding the mother from achieving certain satisfactions with her child, or both. Stated differently, the father protects the child from le désir de la mère (which means both the child’s desire for the mother and the mother’s desire)—that is, from a potential danger. The father protects the child from the mother as desire (as desiring or as desired), setting himself up as the one who prohibits, forbids, thwarts, and protects—in a word, as the one who lays down the law at home, telling both mother and child what is allowed and what is not.
The father I have been describing thus far is a stereotypical figure seen less and less frequently in our times (at least according to sociologists): the “head of the household” who is the authority at home, the master in his own castle who has no need to justify his orders. Even if he generally does provide reasons for his commands, he can always put an end to any controversy by saying, “Because I said so.”
We are familiar with this rhetorical strategy, since it is adopted in a great many contexts. In a leftist study of political economy, a particular line of reasoning may be merely suggested, not proven, and then followed by the fateful words, “As Marx says in volume 3 of Capital . . .” This is known as the “argument from authority,” and is as prevalent in psychoanalysis as it is in politics, philosophy, and virtually every other field. In my own writing, I do not appeal to “Freud” and “Lacan” as living, breathing individuals; I appeal to their names. Their names lend the weight of authority (only, of course, to those who accept them as authorities).
In the same way, when a father says, “You’ll do it because I
said so,” there is often an implicit “I am the father here, and the father is always to be obeyed.” In modern Western society, many contest the principle that “the father is always to be obeyed,” but it seems to have been widely accepted for
centuries and is still commonly appealed to. The point is that in many families the father is granted a position of authority not so much because he is a “true master”—a truly authoritative, brilliant, or inspiring figure who commands total respect—but simply because he is the father and is expected to take on the functions associated (in many people’s minds) with “father.”
The paternal function is a symbolic function, and can be just as effective when the father is temporarily absent as when he is present. Mothers appeal to the father as judge and castigator when they say to their children, “You’ll be punished for that when your father gets home!” But they appeal to the father as a more abstract function when they ask a child to consider what its father would do or say if he found out that the child had done such and such. They appeal, in such cases, to the father as a name, as a word or signifier associated with certain ideas. Consider the case of a woman whose husband has died; she can keep him alive in her children’s minds by asking them, “What would your father have thought about that?” or by saying, “Your father wouldn...