In 1899, Kraepelin identified schizophrenia as early dementia. The precocity of the onset of schizophrenia may be verified in psychotic episodes in the clinic of adolescence, which this article explores both from the point of view of psychoanalytic theory, and from the point of view of its clinic, in particular regarding the transference of the psychotic adolescent. It departs from the importance of differential diagnosis in relation to neurosis, using the guidelines of Freud about the loss of reality, then studies the contributions of Lacan in relation to that which returns from the real when not included in the symbolic. Final l y, it articulates the drive theory to identify the issue of jouissance in transference.
“[...] it would be a mistake to ignore more integrated approaches for understanding the mysteries of schizophrenia or other psychiatric disorders. The complexity of the biopsychosocial paradigm should not lead to ignoring its potential value for understanding these disorders. The role of subjective data other than those identified as ‘symptoms’ is also likely to be crucial” (John Strauss, 2013) [
The study of schizophrenia in adolescence is, more than anything, a study of the onset of schizophrenia. It is also the study of the first vicissitudes that result from this onset, or how the subject tries to deal with attempts to cure him, on the one hand, and autism—in Bleuler’s point of view [
There is a very good reason why Kraepelin referred to schizophrenia as premature dementia. It is actually the psychosis that is more likely to emerge in adolescence, where its precocity distinguishes such a form of dementia from the senile form. Usually it is the parents themselves who can no longer stand their child’s state and seek the help of an analyst.
By the time the adolescent gets to an analyst he is already experiencing an episode. And even if the analyst is able to see the subject immediately, he also usually has to provide close support to the parents. The level at which they have been mentally affected will also determine how much they will be able to assist in the adolescent’s treatment. Cases where the analyst cannot count on minimal assistance from the parents during the beginning of treatment will be the most serious, because initially the adolescent is at the greatest risk: at risk of suicide, homicide, committing violent acts, etc.
It is common, after the initial evaluations, for the parents to seek out the analyst very often. The diagnosis will guide the course of treatment and it is the analyst who diagnoses the subject, with transference, as schizophrenic. Though parents would never suspect this disease in their children, providing them the diagnosis is not of great importance in our clinic. We reveal the seriousness of the situation to the parents very gradually, in meetings and in the many phone calls that the analyst receives from the parents once he agrees to treat a schizophrenic teenager. The parents will also very gradually begin to remember some of the bizarre childhood incidences that have occurred with their child. Schizophrenia in adolescence points to previous episodes that were not appropriately identified by the parents. There should be significant support for such parents whose narcissism is injured and who are now trying to support their child in finding a solution.
It is also very common that during the first episode, the analyst will decide on a referral to a psychiatrist who can support the therapy. This does not mean that the psychiatrist and the analyst need to share exactly the same diagnostic orientation on the case. Sometimes they are theoretically oriented in a different way, often they have different observations on the same case. It is also not overly important to share diagnoses with psychiatrists since medication necessarily treats different phenomena than therapy. I am thinking of the case of a subject diagnosed in his first episode by an analyst whose assessment was that the subject’s life was in danger, referring him to a psychiatrist. The analyst and the psychiatrist worked together, even agreeing that the subject had to be admitted to a clinic. Back at home, the subject would spend most of his time in bed so the psychiatrist diagnosed depression and decided to get him out of the depression. Except that the subject had told the analyst in their sessions that he remained in bed because that was how he contained his delusional activities, which he did not know how to fight otherwise. The psychiatrist medicated for depression, while with the analyst the adolescent discussed those delusional activities...
In the beginning of the 20th century, psychiatry and psychoanalysis joined forces to discover the fundamental basis of schizophrenia. I am referring here to the relationship between Freud and the Burghölzli. Nowadays psychiatric and psychoanalytical treatments seem to be moving further and further apart, which certainly has to do with the different clinical orientations. This article joins the theory of Freud and Lacan.
A divided mind is not specific to a psychotic subject. As a matter of fact, wherever we look, adolescence is marked by σχίζειν [schizein], to split, or as Freud [
Adolescence is the clinic in which this is most evident; it is “the opening of a tunnel on both ends” [
Two years later, Lacan returns to the idea of Versagung, this time based on obsessive neurosis: its symptom, that of asking the Other for permission, implies an extreme dependency on the Other who refuses this permission. That is the Freudian concept of Versagung. “The pact is refused on grounds of a promise, which is better than speaking about frustration” [
With Lacan, we need to introduce a difference between Versagung in psychosis and Versagung in neurosis, as in terms of the former there is a lack of primordial Bejahung (affirmation or acceptance). Versagung on the background of Verneinung implies the impossibility of reuniting the object of the split (Spaltung), for the single reason that there never was a separation from this object to constitute a subject of desire.
In addition to the loss of parental authority and life drive, adolescence is predominantly a time of fantasies. At the place where the subject cannot meet the Other sex —where there is Versagung in reality—he fantasies about finding it. In the fantasy the subject will carry out everything that he has not been able to do in reality. If the subject is neurotic, he will carry this out in his fantasy because he is incapable of carrying it out in reality. He will fantasize while he is unable to “act, with the specific purpose of changing the outside world to make it more effective for him” [
In many of his passages Freud suggests that both neurosis and psychosis imply a regression. In 1926, he demonstrates this on the basis of an obsessive symptom: faced with the Versagung of reality, the subject, unable to deal with the situation, regresses to the anal-sadistic phase to seek his satisfaction there [
The subject of desire is formed through the paternal metaphor and the subject relies on this metaphor when he enters adolescence. Freud [
Every loss of parental authority requires the subject to use the structural reference of the Name-of-the-Father which, as we have learned from Lacan, is foreclosed in psychosis, so that the psychotic subject is unable to use it. Hence the risk that a subject structured this way will develop a psychosis—or more particularly schizophrenia— during adolescence.
Each time that the subject deals with the loss of parental authority and does not find the Name-of-the-Father, the psychotic episode is the effect, on the subject, of exposing the lack of anchorage between the Real, Symbolic and Imaginary, in other words it is the imaginary deterioration itself [
Prevented from resorting to the Name-of-the-Father in a phase as decisive as adolescence, the subject tries to reconstitute the imaginary consistency of parental authority. That is the reason why, in treating adolescent schizophrenia, we observe that the subject will very easily subject himself to parental authority—or whoever takes its place—when he no longer knows what to do.
The problem is that subjecting himself to it leads the subject to submitting once again to an absolute Other that does not allow a place for his desire; an Other which speaks in the subject who will rather be inhabited by language than inhabiting it. This Other is the body, his own body—that no longer is—the Other body that infiltrates in that which is his own and the Other that creates a body presenting an otherness that the subject cannot doubt because of this embodiment.
A Spaltung is that of an ethical subject, in which he sees himself either as a subject of desire or not. In the first case, it derives from a bet on the Name-of-the-Father as an exception. A second Spaltung is that of the drive, in which the subject is at the same time the object of eroticization. The drive involves the subject’s relationships with his demands, in which the Other is merely implied as a code, a determinant of alienation. Here we are talking about neurosis.
In psychosis, Spaltung brings out the absence of a bet on the Name-of-the-Father as a symptom, and brings out the terrible truth that the fundamental helplessness (Hilflosigkeit) of the human being means that the subject can only rely on the father in the symbolic sense. Psychosis also exposes the fact that drives are completely determined by the Other, but in this case, the subject does not receive back his own message in an inverted way. First, because the Other misleads, lies—the person cannot claim the message as his own—and second, because there is no speech between, at least, the two different people—for the subject to receive his own inverted message from the Other requires speech [4,15]. In commenting on one of his patient presentations, Lacan concludes that in hearing “Pig!” the actual subject emits a message: “I come from the sausage maker”, it is the other side of the same coin. The subject identifies one speech as coming from inside of him, the other from outside. That is how the two lines of Spaltung are represented in psychosis.
Freud [
In “The Loss of Reality in Neurosis and Psychosis” Freud [
On one hand, in schizophrenia there is a loss of the regulation of the energy level in the psyche that corresponds, on the other hand, to the extinction of the libido because the libido is the psychic energy relating to the phallus, and therefore to the imaginary consistency of the subject and his world, references that, as we have seen earlier, have been abolished. Finally, a third approach raises the issue about the life drive in a schizophrenic episode beyond the extinction of libido. In his Seminar on the object relations, in a passage already noted above, Lacan does not translate the term Befriedigung—the goal of the drive—as satisfaction, as we normally would, but as “appeasement” [
Every drive is a death drive because the drive involves the relationship with the Other that kills the being, creating the Spaltung [
This does not occur in schizophrenia, where the organ jouissance, Organlust [
The world falls apart, breaking the ego. Before megalomania takes hold, in a rescue attempt, the subject is dominated by elementary phenomena and mental automatisms. The family environment becomes restless, and the family wants to limit his dispersal; he seeks to rid himself of this movement, he wants to limit the Other, return to his autonomy. But as he is unable to do so, he fights against the environment, against the disease, risks his life by even undertaking actions out of a need for autonomy and often, reaching the point when hospitalization is inevitable. Slowly, little by little, the analyst guides the subject in reclaiming his responsibility as subject, by working on the definitive loss of a part of himself that no proof of reality can recover, learning to live with the limitations of the disease.
This is where there may be a risk of autism—the main characteristic of the drive [
In research, I discovered a significant amount of testimonials about transference in schizophrenia. In the eyes of the schizophrenic adolescent the analyst knows about that which is real. Therefore he does not place the analyst in an assumption of knowledge the way a neurotic subject would—who believes that the analyst knows what determines him—but the analyst represents the actual knowledge of the real. In the case of neurosis, the subject sees his analyst as the ideal, implying not only imagining him at the place of the ideal, but also identification. In the case of the schizophrenic adolescent there is no identification with the analyst, let alone idealization. They are radically different, or rather, the analyst is so similar to others and to those who the adolescents interacts with— for example his parents—and he is the only different one, subject of and to experiences that others do not have. So also in the realm of transference the schizophrenic subject reveals the truth that neurotic subjects try so hard to mask: there is no intersubjectivity in the psychoanalytical relationship. But even though his analyst is like all the others, he serves as an analyst—occupying an exceptional position for the subject—as the analyst intervenes in the subject’s jouissance. The schizophrenic adolescent asks the analyst to say and intervene in that which he, the subject, knows about his jouissance. A neurotic subject would arrive at his analysis with a question about his symptom, whereas a psychotic subject would have an answer about his jouissance.
“What will I do when I come here?” “Why am I here?”
“When you come here, you tell me the things you think, I listen to you, you tell me your experiences, right? And when you tell me about it, as you have said to me before, it allows you to maintain a certain distance from it, remember?”
“Yes, but I think this is very slow. I don’t see any progress. I don’t see what it is for. You know what, I had a great idea when I was thinking about coming here today!”
“Really?! What?”
“I could bring a disc or a tape. Do you have a recorder? A disc player?”
Silence.
“I would give you the disc and you would play it while I lay down and relax. So in the middle of the music you would interrupt the sound and my relaxation and say something for me to associate and I would have to associate it with something.”
Silence.
“What do you think? There is the possibility for us to work here. I don’t have anything else to say to you. I have already said everything I wanted to say.”
“Well, there are things that you don’t want to say.”
“Yes. Not now. So shall we try this next time?! (starts to get up from the chair to leave).
“Wait a minute, hold on! Let’s talk a little bit about it!! Tell me a little about how you got this idea?”
This was certainly a difficult session in terms of dealing with transference. Of course the analyst will not collaborate with the subject’s attempt to put the analyst in the place of the Other that makes the subject his own puppet. Certainly the subject’s “indecent proposal”, that the analyst takes him out of his tranquility and interrupts his desire for pleasure and relaxation, reflects a demand that will not be answered, just as any demand in an analysis should not be answered. As much as we ask ourselves how an analyst could deal with this psychosis, this is certainly not the way to a viable treatment in analytical transference. The analyst is warned about this: in his role he needs to say no, to all imperative attempts. In this specific case, the subject was also looking for a course for his therapy in the light of the model imposed by his mother—who was also in therapy—instructing him how to use that space the same way she used hers. In an attempt to find his own way, the patient proposes this strategy to the analyst who, in accepting it not only gives up that position but would also impede the subject from continuing his search for a possible separation. This subject taught the analyst that it is not enough to be a secretary of the alienated, as Lacan [
Transference is justified as the cause for treatment in the following three registers: at the symbolic level, the schizophrenic adolescent speaks and, when he speaks, the subject is formed. The caution with words is extreme, which supports Lacan’s [
As secretary of the alienated, the analyst cannot interfere in the work of the subject but needs to be unequivocal and say no to any passage to the act that brings jouissance. The neurotic believes in the subject’s supposed knowledge that masks what Lacan already pointed out in his published first Seminar, in the year of 1953- 1954, the presence of the analyst [
As the imaginary is impoverished by the profusion of the unknotted real, the imaginary transference in schizophrenia has a small chance of being constituted in one-on-one sessions and for short periods of time. But this is where great caution is required, when a gesture, a glance, far from constituting a gestalt, lead again to the real and to the horror that the adolescent is so familiar with because there is no intersubjectivity. Surprisingly it is through the aesthetic sense that something happens in the gestaltisation of transference. “You have very good taste”, said the subject of the indecent proposal on a different occasion. “Your foot is beautiful!” said another subject, scaring his analyst.
If the strategy of an analyst in treating a neurotic subject implies that he can increasingly position him in the place of object a, so that the real transference allows the subject to face the obstacle of castration, the strategy of an analyst who works with a schizophrenic subject aims to avoid the real transference, to allow the subject to use some of his signifiers to shield his relationship with the real.