School of Counseling, Australian College of Applied Psychology, Melbourne, VIC, Australia
In contemporary Lacanian psychoanalysis, Verhaeghe’s theory of actualpathology / psychopathology in psychosis and the Millerian idea of “ordinary psychosis” provide diverging conceptual approaches to psychosis. I am sympathetic to Miller’s reading of Lacan and find his idea of “ordinary psychosis” useful for thinking about the complexity of psychosis and its treatment possibilities in talk therapy. Although ordinary psychosis requires further development it promises greater utility than Verhaeghe’s model, which is restricted by the “schizophrenia / paranoia dichotomy”, as it provides a broader and more nuanced approach to the complex vicissitudes of triggering and stabilisation in psychosis.
Lacanian clinicians use psychosis to refer to a variant of subjectivity (i.e. a psychotic structure) that may or may not exhibit symptoms. Psychosis is not viewed as a medical illness with a biological pathogenic basis (psychotic phenomena with a clear biological basis designate a neurological problem). While Lacanian clinicians recognise that psychosis is often linked to the most painful, extreme and terrifying aspects of human experience they maintain that psychosis can also be mild and banal Ordinary psychosis does not designate a new nosological category but refers to milder instances of psychosis that are not characterised by positive and negative symptoms such as hallucinations, delusions and grossly disorganised behaviour. In psychosis, a “disturbance to the inmost juncture of the subject’s sense of life” may find subtle expression via personal identity, body integrity, social relations and the individual’s integration with social structures. In one sense, it is close to Bleuler’s idea of latent schizophrenia. Ordinary psychosis is useful as it builds on Lacan’s theory of psychosis and returns to his influences in European psychiatric tradition (Kraepelin, Bleuler, Jaspers, de Clérambault) in an attempt to broaden the current understanding of psychosis to include milder variants.
The idea of ordinary psychosis also emphasises three clinically important features of psychosis: the initial onset of psychosis, subsequent triggering events, and the stabilisation of symptoms (i.e. residual phase). Crucially, it does so while maintaining an emphasis on the client’s subjectivity. As a clinician, being attuned to the vicissitudes of psychotic phenomena and subjectivity is a necessary condition for effective treatment. How many clinicians have had the experience of working with an individual who seems relatively “together” only to find that they become psychotic subsequent to a “benign stressor”? The idea of ordinary psychosis provides a framework for thinking about such cases and provides a theoretical model for conceptualising onset, triggering events, and the stabilisation of symptoms. This has a direct bearing on treatment possibilities.
Moreover, my research is critical of contemporary psychiatric nosology for using a reductive view of psychosis with questionable clinical utility and validity. The recent backlash against the publication of the DSM-V demonstrates that both the public and professional bodies are no longer going to accept the idea that a small panel of experts will have the “final word” on mental health. It is not surprising that consumer driven organisations, such as the Hearing Voices Network, who are profoundly critical of the medicalisation of psychosis, aim to de-pathologise and normalise psychotic states in an attempt to reclaim the “right” to be psychotic without stigma and pathologisation. Lacanian ideas on psychosis, while derived from classical psychiatric knowledge and Freudian theory, also present a non-medicalised view of psychotic subjectivity. What ordinary psychosis adds is greater sensitivity to psychosis in its multitude of milder forms and to the factors leading to the onset, triggering and stabilisation of psychosis. By building on Freud’s views that certain symptoms in psychosis constitute an attempt at recovery, further research will undoubtedly show that certain psychotic phenomena are not symptoms to be eradicated but can be part of how an individual effectively engages in the world.