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CLINICAL NOTES
Bruce Fink (2007). ‘Treating Psychosis,’ Fundamentals of Psychoanalytic Technique: A
Lacanian Approach for Practitioners (New York and London: W. W. & Company), pp.
231-272.
These clinical notes have called attention to a number of analytic techniques for
practitioners.
These techniques however are meant to be used for the treatment of the
psychoneuroses and not for the psychoses.
The psychoneuroses in contention in the Lacanian clinic are hysteria, obsessional
neurosis, and phobia.
The main reason for this analytic distinction is that neurotics have an unconscious
that uses repression as the main causative mechanism whereas psychotics do not
have an unconscious that ‘functions.’
The main causative mechanism in psychosis is foreclosure of the name-of-the-father.
This analytic distinction, needless to say, is not widely known.
Attacks on psychoanalysis proceed on the assumption that a large number of
psychotics consult with analysts and that the basic assumptions of Freudian meta-
psychology apply directly to both neurotics and psychotics.
Freud however points out quite categorically that in order to treat psychotics, it will
be necessary to change certain aspects of the analytic method.
In Lacanian analysis, neuroses and psychoses are not the same and borderline
categories do not exist in analysis like they do in some approaches to analysis which
work with overlapping categories or mental structures.
The specific form of psychosis that Fink analyses here is paranoia; it is not his
intention to explain all the psychoses though he enumerates the different types of

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psychoses including ‘paranoia, schizophrenia, erotomania, melancholia, mania, and
so on.’
The point of entry into the analytic distinction between neurosis and psychosis is not
so much how the patient relates to reality (given that there is always a withdrawal from
reality in all mental disorders), but in terms of how they relate to language.
So, for instance, Fink makes the claim that psychotics are less likely to make slips (i.e.
performative errors) in everyday life since they do not have much to hide (given the
absence of repression).
Neurotics however are full of slips and performative errors. Unlike, neurotics,
psychotics also do not editorialize what they say in acts of free-association.
Psychotics prefer concrete utterances to the neurotic fondness for fluidity in
discourse and are not secretive about anything.
Psychotics are also less bothered by the gap in the chain of signification between the
signifier and the signified or the words in a sentence.
Neurotics however cannot bear the emergence of the gap in the chain of
signification; that is why Lacan identifies the unconscious precisely in the locus of
this gap.
Since psychotics are less acquainted with the gap in the chain of signification, they
cannot appreciate or understand the difference between ‘what is said’ and ‘what is
meant’ (i.e. the literary trope of irony).
Analysts also differentiate between psychosis and neurosis at the level of the
transference; psychotics are not responsive to the knowledge contained in the
symbolic Other – that makes them less or not at all responsive to the transference.
Neurotics however are full of fantasies about the locus of the sujet supposé savior.
They respond readily with a range of responses from the positive transference, the
negative transference, and the full transference.
This is of great help in making a differential diagnosis.
Treating neurotics is a lot easier in the clinic because it is possible to convert their
neurosis into a transference neurosis and work with that in lieu of whatever might
constitute their mental structure or form of psycho-pathology
Furthermore, the transferential dimensions for the psychosis involve only the real
and the imaginary, but for a neurosis all the Lacanian dimensions (the real, the
imaginary, and the symbolic) are involved.

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What are transferred in the psychoses are more like erotic passions, but what is at
stake in a neurosis is the extent to which knowledge is contained in the symbolic
Other and the relationship between Eros and knowledge.
That is why erotomania and persecutory delusions constitute an important symptom
in the psychoses unlike the neuroses.
The neurotic, to simplify a bit, is preoccupied with the ‘Other of Desire’ whereas the
psychotic is preoccupied with the ‘Other of Jouissance.’
The neurotic’s ego is too strong; the psychotic’s ego is too weak.
It is precisely the strength of the neurotic ego that leads to a form of repression that
is more severe than required to fend off a thought incompatible with the ego.
The psychotic ego is however fragile; it has a hole in it that becomes obvious during
a psychotic break.
The main form of explanation that neurotics use for why they find themselves in the
world is missing as far as psychotics are concerned.
Neurotics may not be happy with their lot in life, but they at least have a fantasy to
cling on to as why to why their parents gave birth to them.
Psychotics however try to live without seeking recourse to such an explanatory
schema.
That is why psychotics seek recourse to delusions; these delusions do not sever them
from the world – they are instead attempts on the part of psychotics to reintegrate
into the world albeit with an explanatory schema that was previously lacking.
The main assumption in delusions is that the psychotic is less likely to break down if
he has a delusion than if he did not. Unlike neurotics who may not believe in their
fantasies and know them to be precisely that, psychotics believe in their delusions.
Freud’s analysis of the Paul Schreber case is really an analysis of the various
delusions that Schreber suffered from as recounted by Schreber himself in his
‘memoirs of his nervous illness.’
These delusions included the possibility that Schreber would become a woman,
copulate with God, and the off-spring of this union would save the world.
The delusion however is not the illness itself; it is instead the attempt on the part of
the psychotic to cure himself without seeking recourse to a psychiatrist.

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To conclude, then, Bruce Fink cites Jacques-Alain Miller who points out that ‘when
faced with someone who is insane and delusional, do not forget that you too are or
were once an analysand and that you too spoke about what does not exist.’
SHIVA KUMAR SRINIVASAN