Structure and The Epistemic Supposition of Clinical Categories: re-reading Jacques-Alain Miller’s Ordinary Psychosis Revisited

This text comes out of cartel work (a cartel is a kind of study group established by Lacan as a principle organ of his School). This cartel questions diagnostic structure, and this short paper responds to Jacques-Alain Miller's text Ordinary Psychosis Revisited, and framed by the cartel having looked over Miller's S'truc dure. Nonetheless I think the text to be of use even without those sources in front of you.

Structure and The Epistemic Supposition of Clinical Categories:  

re-reading Jacques-Alain Miller’s Ordinary Psychosis Revisited

I take as my starting point in looking at this presentation of Miller’s, firstly the question that comes from our work last time, that of the rigour of the question of what is structural in a structural diagnosis, as it corresponds to Lacan’s way of taking up a kind of structuralism. And to think about the paper at hand, Ordinary Psychosis Revisited through this. And Miller suggests in this text a renewed rigour in considering neurosis, and the list he makes, this list of clinical characteristics of a neurotic, which can be questioned as to their relation to the structural paradigm. 

I will start though with the question which has hung around for me since I first read this text. Miller describes Ordinary psychosis in this way: 

“It’s more of an epistemic category than an objective category. It concerns our way of knowing it.”

My question from the start about this corresponds to the structuralist paradigm – a Lacanian structural diagnosis is not like a psychiatric or medical diagnosis insofar as it does not follow from the assumption that the signifier of a diagnosis has an immediate correspondence to a thing in the world, the thing of a kind of illness. Just as through Lacan’s post-Saussurian lens, the word ‘cat’ does not correspond directly to that creature, but to a negative correlation to all the signifiers which are not ‘cat’ in ways which slide around a little, a category is not a kind of cat, and neither is a civet cat a cat. Lacan referred to this with regard to the elephant, which as soon as it takes being in being named, starts to be hunted towards inexistence, but more radically, that once we know the elephant through words, we cannot know the creature as such, without words, and thus ‘the word is the murder of the thing’.  And indeed in this paper Miller points out that the symbolic world is a construction, which is to say a delusion, and that a delusion is perfectly able to order the world. Indeed he proposes that the whole Freudian Field is a delusion, and we cannot be left without understanding that our diagnostic categories too, are delusions to be put to use. That is to say - epistemic suppositions.

So in what way is Ordinary Psychosis distinct as a kind of epistemic category from the general field of our structural diagnoses?

Firstly, perhaps in relation to the way the signifier, ordinary psychosis, came to be. There was not first a kind of theory of these kinds of cases which were difficult to classify in classical terms, into which the signifier was born, but rather an open question in relation to which the signifier was offered as a sort of lightning rod for theoretical elaboration to coalesce around. Whilst much has been said of ordinary psychosis, it retains something of this character of a signifier S1, in search of significations, S2. There are still some questions, between some of the S2s which have been produced, even if we can say that this text comes to make a few stable quilting points with regard to what we can make of the question. 

Secondly, what’s been constructed with ordinary psychosis is secondary to the clinical categories which already exist. If we can say we have here an ‘ordinary psychosis’, Miller proposes that we still need to know what it is in the categories Lacan developed from classical psychiatry, a paranoia or a schizophrenia, what kind of paranoia, is it for instance a sensitive paranoia in the terms described by Kretschmer? And so on. That is to say, that ordinary psychosis does not quite fit into the differential system of diagnosis, it lays over it to help facilitate it. And thus it is a distinct epistemic category with retards to our differential system of epistemic diagnostic categories.

Miller develops his text not quite by showing the ways in which a psychosis corresponds to a certain number of clearly demarcated observable phenomena, to make a sort of tick list analogous to those in contemporary diagnostic manuals (although it is not without indicative suggestions), but rather he talks about the way a linguistic function is taken up, that of naming, of accepting, saying yes to, a name, or more precisely a naming function, or not, with a range of implications following from this differential of accepting or not that naming function, called the Name-of-the-Father. It’s a kind of name function which acts like a common reference, a stopping point, which guarantees a particular relation to the commonality of the social bond. As opposed to those who refuse to be subject to this function, who must make for themselves their own stopping points, or guarantees of a relation to the social bond. The result may lead some to very strange and idiosyncratic kinds of private sense, private delusions (as opposed to what we might call common sense, or the common delusion), or to solutions which borrow from the common sense of how to relate to the social bond, and are difficult to distinguish from those given under the common guarantee.

Miller offers a list of three externalities as a device by which we can look for signs of a psychosis when the more obvious classical signs are not present. As Gil Caroz develops elsewhere in a paper titled Some Remarks on the Direction of the Treatment in Ordinary Psychosis, these externalities correlate to a borromean clinical distinction of knottings among the three registers RSI, a disconnect between real and symbolic, a disconnect between symbolic and imaginary, and a disconnect between real and imaginary. Again we’re working not with a differential clinic of the observable traits of a psychosis as such, but a differential clinic of the structural system which makes a kind of frame, and makes a kind of clinical world through this frame, and by which certain things become visible, and we may pick up these traits, these things which become visible, as visibilities only accorded by the common sense shared by the Freudian Field, distinguished by the knowledge of those who hold this sense, that it is also a common delusion, one ultimately not there to be believed in, but to be put to use, since it is indeed functional. Thus the status of the observable characteristics of an ordinary psychosis, is the status of an observation not so much of a fact of the natural world, but of a sign accorded by, created by, a signifying system, the thing having been murdered by the word in its apprehension.

The list of characteristics of a neurosis work in a similar manner. They’re not in fact very straightforward to read:

“You need some criteria to say 'this is a neurosis’, you need [1] a relationship to the Name-of-the-Father - not a Name-of-the-Father - you need [2] some proof of minus phi, some proof of a relation to castration, impotence and impossibility, you need, to use the Freudian terms of the second topography, [3] a clear-cut differentiation between ego and id, or between signifiers and drives, you need [4] a clearly delineated superego, and if you don’t have this and other signs, well, you don’t have a neurosis, you have something else.”

Whilst this is indeed a kind of tick list, it is not a tick list of signifiers to correspond to things in the world, but a tick list of structural distinctions which can only be read in relation to clinical observation via an apprehension of these structural distinctions.

We can note that there is a connection here between this most clinical concern, the system of diagnosis, and an analyst’s place in their own analysis, insofar as an analysis works towards a relation to the analysand’s semblants whereby they are not believed in so long as they may be put to use, a work that extends to the end of an analysis in its formal envelope.

In practice when colleagues in psychoanalysis discuss our work it’s not so uncommon to hear expressions which make the short cut of supposing that if a patient displays a particular trait, then this makes for a certainty that the diagnosis goes a particular way. Sometimes this is more contentious than at other times, and it’s at its most dangerous when it seems more natural. This is not how a Lacanian diagnosis works. It’s not via a given presentation, which surely indicates a given diagnostic result, as a sort of common sense unwritten Lacanian manual by which short cuts can be made, and X always means Y – it can amount to a common sense belief in the correlation of word and thing. But rather a given sign only comes to be read via the particularity of a case, when read through the lens of a structural system, in which we know that word and thing are not naively linked, but that nonetheless work can happen in a rigorous way between our words, and the inaccessible thing they occlude.