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

Structure and The Epistemic Supposition of Clinical Categories:  

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

This paper comes from the midst of a cartel (a cartel is a kind of study group established by Lacan as a principle organ of his School) on clinical structures, with Jacques-Alain Miller’s S’truc dure in mind, and in a discussion of his Ordinary Psychosis Revisited amongst other papers. I presented this paper at a cartel day of the Irish Circle of the Lacanian Orientation. I don't mention Ordinary Psychosis Revisited because of its subject matter, psychosis, so much as that it comes to hand as a way to think about the way clinical categories respond to a Lacanian orientation.

A question from Ordinary Psychosis Revisited.

Miller proposes that with ordinary psychosis:

“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. Dismissing the assumption that a diagnostic signifier has an immediate correspondence to a thing in the world, the thing of a kind of illness. Roughly put, through Lacan’s post-Saussurian lens, the word ‘cat’ doesn’t correspond directly to that creature, but to a negative correlation to those signifiers which are not ‘cat’ in ways which slide around a bit: a category is not a kind of cat, and neither is a civet cat a cat. Lacan referred to this kind of correlation with regard to the elephant, which as soon as it takes being in being named, starts to be hunted towards inexistence, and that in knowing the elephant through words, we cannot know the creature as such without words. Thus ‘the word is the murder of the thing’.  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—they’re all epistemic suppositions.

So why is ordinary psychosis distinct as an epistemic supposition?

We might think it relation to the way this signifier 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 knowledge, 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. Although it’s uncertain that this argument excludes any diagnostic category.

Rather we might say that 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, melancholia, or schizophrenia, what kind of paranoia. Perhaps a sensitive paranoia in the terms described by Kretschmer? And so on. That’s to say that ordinary psychosis doesn’t 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 regards to our differential system of epistemic diagnostic categories.

Maybe.

Externalities.

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,  accorded by a sense only barely common to 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.

A list relating to neurosis.

Sometimes we do find little lists of clinical criteria. We find it in Ordinary Psychosis Revisited for example in the tricky list of criteria for a neurosis:

“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, [3] to use the Freudian terms of the second topography, 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 observable traits, but of structural distinctions which can only be read in relation to clinical observation via an apprehension of these structural distinctions.

***

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 no longer 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.

What is opaque in what is most intimate.

At the start of Miller’s paper Extimité he talks about the medieval division of a lesson into littera, at the grammatical level, of the construction of a text; sensus, the level of the meaning (sens), of the signified; and sententia - at a ‘deeper understanding’, and that a commentary can only be justified at the level of sentantia.

We can say that if sentantia is distinct from the surface meaning of a text, what we suppose things look like, and imaginary in this regard, then it is because sentantia responds to what does not seem self evident, what is opaque, from the perspective of sensus. Additionally, Miller tells us, Sentantiae means “commonplace”. Perhaps, I’d say, what is opaque in what is commonplace. From this Miller proposes that Lacan’s familiar aphorisms, such as “desire is the desire of the Other” “The signifier represents a subject for another signifier” and so on, are Lacan’s sentantiae. They examine what is opaque in the familiar, but without refuting that opacity as such, that opacity proper to what is most intimate. It’s an approach to structure we find repeated with Freud (familiar, for instance, if you’ve read his paper on the Uncanny), and throughout Lacan’s structuralism, the very reason for it.

Miller proposes that Lacan being a teacher and not an author in the medieval sense (that being the one who knows what he says), works through the way that sentantiae make “[…] contradictions, […] antimonies, […] deadlocks, [… or] difficulties” apparent. This makes for a teaching on the analytic experience in the manner of a “work in progress”.  It seems to me that in this sense, diagnostic categories function as sentantia, with which we are taught, with which we learn, about the clinical aspect of the work, always a “work in progress” with “a back-and-forth motion between text and experience”.

From this point of view the logic of the structure of diagnosis is one quite true to the Copernican revolution which Freud initiates, and which Lacan develops, of displacement of what we suppose we know about ourselves. Of a sustained attention to what happens in those modes of opacity most intimate to each, to make it usable without making of it too much of a new common sense, a new sensus.