The goal of this project is to move towards a theory of transference-in-psychosis that will provoke a change in the way the experience of psychosis is understood and, thus, clinically treated. My specific question is with regard to the function of ‘ethics’Footnote 1 in the ‘installation’ of transference in the treatment of psychosis. In my approach, the problem of the installation of transference raises the question of ethics because, I contend, the aim of the psychoanalytic experience is the creation of a new ethic for the analysand. I see the psychotic’s ‘choice’ to enter transference (redefined as a ‘desire to know’) as linked to the creation of a new ethic—in which ‘ethics’ concerns the emergence of a new ‘responsibility’ on the part of the psychotic. Furthermore, I suggest that it is through an account of the specific knowledge (savoir ) implicit in the psychotic experience that psychoanalysis can maintain its bearings as an ‘ethical praxis’.

Basing my approach on the work of psychoanalyst Jacques Lacan and philosopher Gilles Deleuze (regarding the body in particular), I begin with the premise that the body of the psychotic is a site of social contestation. In this framework, the ‘organism’ is defined as the object of medical science, and biological psychiatry, while the ‘body’, eroticized by language, is the primary concern of psychoanalysis. This body is the result of a radical disruption (by language and cultural demands) of the original instinctual functioning of the organism. Beginning with this premise, I then suggest that we will be better positioned to guide the psychotic towards a psychoanalytic cure if we first formulate the psychotic’s condition as a failed attempt to resist (contest) capture by the demands of social–symbolic exchange and libidinal–economic imperatives.

Drawing upon the work of Freud, Lacan, Deleuze and Guattari, and Apollon et al., this book reframes the problem of the ‘body’ (as an effect of language) and its relation to transference, and ethics, in treating psychosis. In the course of my research I have found no studies conducted in the North American context that specifically address the problem of the ‘body’ and transference in psychosis from the perspectives of Freud, Lacan, Deleuze, and Guattari.

It is important for my readers to understand that I distinguish the ‘structure’ of the psychotic experience from the ‘phenomenology’ (symptoms) of psychosis. Now, the dominant approaches to treating psychosis in North America derive from the medical/psychiatric model that defines psychosis by reference to a biologically driven understanding of the phenomenology of psychosis. Likewise, contemporary American psychoanalytic approaches have little to say regarding the structure versus the phenomenology of psychosis. The consequence of their common failure to account for structure is that the psychotic experience has continued to be understood as a malfunction of the biological organism and/or a deviation from neurotic-level psychical functioning. In either case, the psychotic experience is reduced to a problem internal to the individual (organism or psyche).

To avoid falling into the trap of the ‘nature/culture’ binarism (“organism/psyche”) therefore requires an epistemological critique that undermines the nature/culture binarism itself. Such a critique is implicit in my approach to the theorization of the psychotic experience. For if, as I suggest, the ‘body of the psychotic’ is a contestation of the fundament of the symbolic universe, then the structure of knowledge itself is called into question, including the knowledge(s), or discourses, that have attempted historically to take the psychotic experience as their ‘object’ (e.g., medical science/psychiatry, and psychoanalysis). To suppose a ‘subject’ of the psychotic experience is to suppose a specific knowledge of the psychotic that calls all general and expert knowledge(s) into question.

1.1 From the Body to Ethics

My hypothesis is that the phenomenon of contestation manifest in psychosis is key to the development of an ethics in the analytic experience—the ethics of both the analyst and analysand. ‘Ethics’ is here understood as situating the psychotic subject in relation to a failed Law and to death drive.

In this book, I am not using the term ethics in the sense understood by North American practitioners in psychology or psychiatry as the ‘code of professional ethics’. Rather, I theorize the question of ‘ethics’ by extracting the true stakes of Kant’s moral Law (categorical imperative) by reading Kant after Lacan and in light of the psychotic’s savoir . The problem is that of constructing an ‘ethics without ethics’—in other words, an ethics without the guarantee of Aristotle’s Good or Kant’s “moral law within”. Ultimately, this way of understanding ethics directly affects the clinic and potentially bears consequences for our conception of ethics in the social sphere as well.

Positing the body of the psychotic as a site of social contestation further requires a re-theorization of the body itself. One theoretical concern of this study is to challenge biological determinist readings of Freud’s drive theory.Footnote 2 Maintenance of the distinction between ‘drive’ and ‘instinct’ allows for an understanding of a second body—the body of drive (versus instinct). I contend that the re-theorization of the body requires a return to Freud in order to articulate a drive theory of psychosis which, however, necessitates a passage through the re-readings of Freud by Lacan and Deleuze and Guattari . They offer a novel way to read Freud and to understand the true status of drive (versus instinct), i.e., to consider drive as the effect of language. More precisely, as in Chap. 1 where I discuss the ‘body’ as an effect of the trauma of Language on the ‘organism’: drive is to the ‘body’ as instinct is to the ‘organism’. The crucial point is that the psychotic’s unique relation to Language is fundamentally ‘traumatic’.

In psychosis, we have a specific type of social contestation that is the result of a forced choice and therefore a choice prior to the entrance into the transference, and thus prior to the creation of an ethic. In Seminar III, The Psychoses (1992), Lacan theorized that the psychotic psychical structure is determined by a radical exclusion (“foreclosure”) of the primary word or “signifier” that, for neurotic subjects, comes to provide a first link in the subject’s effort to make sense of experience. Thus the psychotic is without the primary, or fundamental, (symbolic) link to anchor the structure of psychical reality: and the ‘body’, as defined in this book, is a ‘psychical reality’.

I argue that “foreclosure” is the result of the psychotic’s (first) ‘choice’ in life: a choice deployed at the moment of the ‘advent of the subject’. The psychotic’s ‘first choice’ is to radically exclude (“foreclose”) the symbolic anchoring point for Sense and meaning. I argue that situating the psychotic’s “foreclosure” as a ‘choice’ is in fact the precondition for psychoanalysis and, by extension, the precondition for a new ‘freedom’ for the psychotic subject. However, this first ‘choice’ bears certain disastrous consequences for the psychotic: without the anchoring point for Sense, she retreats into the closed universe of delusion and the ‘violence’ of the persecutory voices.

Yet it is of particular importance here to note that the psychotic’s ‘choice’ of foreclosure also yields a specific ‘knowledge’ (savoir ) regarding the foundation of the ‘Law’ and the Ideals that support the rules of social coexistence. It is the psychotic’s savoir of the Law that guides us in defining and theorizing an ethics and, furthermore, in formulating the aim of analysis as creating the conditions for a ‘second’ (ethical) choice in the face of the effects of the Law that return when the delusion is ruptured. I argue that the psychotic’s entrance into transference, defined as a desire to know, constitutes a ‘second’ choice to enter the field of ethics and thus to assume a new ‘responsibility for death drive’.

Thus to make contact with the ‘subject of psychosis’ we must begin with the body of the drive, where the psychotic (in her disorganized body) finds herself stranded without speech and without the fundamental word necessary to begin the articulation of her experience. The psychotic, if given the place to speak, will reveal her subjective truth as well as the truth of the Law itself.

My thesis, then, is that there is a correspondence between the psychotic’s savoir and the truth (or ‘principle’) behind the moral Law. The psychotic’s savoir of the Law will take us further than even Lacan’s powerful critique of Kantian ethics. The objective here is twofold: we aim to gain a clarified understanding of the moral Law itself, which, in turn, allows the analyst to better understand the symbolic (i.e., ethical) position required to invite the psychotic into the transference defined as a desire-to-know. The psychotic will not respond, except with “indifference” or paranoia, to anything other than the analyst’s genuine desire ‘to know’ the truth of the psychotic’s experience. Whereas Lacan based his interrogation of traditional ethics upon the neurotic’s libidinal ‘tie’, we will allow the psychotic to lead the inquiry. An understanding of the psychotic’s experience, and specific knowledge, of the moral Law is fundamental to an effective treatment of psychosis.

1.2 Ethics and the Clinic

The aim of the psychoanalytic experience is the construction of a new ethic for the subject. I deploy the term ‘ethics’ to capture and explain the subjective shift that may occur in the course of treatment wherein the subject of psychosis assumes a level of responsibility for her experience—hence my question regarding the function of ‘choice’ in the experience, and in the treatment of psychosis. The said ‘shift’ implies that the psychotic (in the course of treatment) moves from the position of ‘object’ to that of the ‘subject’.

In addition, my usage of the term ‘ethics’ regards the nature of the subject’s position in relation to the failure of the pleasure principle (Biology) and to the unfoundedness of symbolic castration (or Law). The term ‘ethics’ therefore refers to a particular subject’s specific way of facing death drive , insofar as death drive (or “jouissance”)Footnote 3 is that which is ‘beyond the pleasure principle’ and in ‘excess’ of any symbolic limit. Psychoanalyst Willy Apollon (2002) writes :

The Lacanian clinic favors an ethics where savoir [specific knowledge] is substituted for a jouissance that the treatment experience reveals as lapsed and thus impossible. (After Lacan, p. 140)

Apollon’s remark implies that, through the analytic experience, the analysand constructs a new knowledge (savoir ) that creates the conditions for an ethical choice: the subject can choose the symptom (addiction, obsession, delusion) or face what Apollon calls the necessary “failure of jouissance” (p. 140). Apollon’s reference to “failure” speaks to the interface between Language and the organism, and between the Law, castration, and drive, a linkage elaborated throughout this book. It will suffice here to remark that the “failure of jouissance” is a requirement for the subject of desire to emerge, and to construct an ethics based upon the stakes of desire and lack, insofar as desire is a ‘failure’ or a lack introduced into the fullness of an imagined satisfaction (jouissance). However, I argue that, given the psychotic’s “foreclosure” of the Name-of-the-Father and its consequences, the installation of transference in the field of psychosis marks the introduction of ‘desire itself’: thus the stakes for the psychotic (versus the neurotic) are necessarily higher.

With respect to the clinic, the problem of ethics is particularly relevant to my question regarding the problematic of the psychotic’s entrance into transference: a question that stems from the linkage between ‘contestation, ethics and the transference’. This question is ‘what precisely causes the psychotic to enter the transference?’ My hypothesis is that the ‘cause’ is itself dialectical in nature insofar as the “desire of the analyst” (as both ‘cause’ and ‘support’) is in play in the provocation of the transference. Is the movement into the transference (for the psychotic) a choice based upon a new ethics vis-à-vis the ‘trauma of language’? A ‘second’ choice, and an ethics, after the ‘trauma’?

The following questions guide the discussion of clinical material in Chap. 6, and hopefully provide the reader with a sense of the stakes of this project:

  1. 1.

    What is the ethic of the analyst: on what does the analyst base their action and ‘justify’ their offering to the psychotic?

  2. 2.

    How can we locate the dream as a “psychoanalytic dream” that, by definition, calls the certainty of delusion into question?

  3. 3.

    Where, in treatment, does the subject of the unconscious appear in the dream-work to challenge/contest the certainty of delusion and the command of the Voice?

  4. 4.

    How does the patient respond to the contestation of delusion by the work of the dream, and the appearance of the subject?

  5. 5.

    Did a new ethic emerge on the side of the patient? In other words, did the patient choose to put a new savoir (a lacking knowledge) in place of certainty?

  6. 6.

    Finally, how do we theorize the presence or absence of a shift towards an ethical position for the subject of psychosis?

The theoretical inquiry into the questions of the body, transference, the dream, and ethics is fundamental to our effort to answer these questions.

1.3 The Fear of Psychosis

The latter chapters of this book will address the topic of the ‘fear of psychosis’ based upon a set of diverse perspectives. I contend that there is a powerful fear of psychosis (and of “madness”) that pervades our healthcare system, including within the disciplines of psychology, psychiatry, and psychoanalysis. The fear of psychosis leads to treatment approaches that are reductive, sometimes harsh, and stigmatizing. First, I will explore the topic of fear via the perspective of people with lived experience of psychosis. People with lived experience of psychosis offer new insights into (1) the experience of being the object of fear-based approaches to treatment and, by contrast, (2) the healing experience of encountering a respectful and curious listener. Furthermore, in contrast to fear-based clinical approaches, I will explore the vital importance of a peer-driven approach to psychosis, namely the Hearing Voices Network (HVN). HVN is a peer-facilitated group-based approach to living with psychosis that was founded by people with lived experience of psychosis. Towards the goal of learning from people with lived experience of psychosis, I have included an interview with a member and educator within the HVN. In my assessment, HVN has spontaneously discovered methods to “treat”Footnote 4 the experience of distress that can so often accompany voice hearing and distressing beliefs (i.e., delusions). Furthermore, HVN’s perspective and practices have much to teach clinicians regarding how best to position oneself ethically in order to connect with people experiencing psychosis.

Second, I will explore the topic of ‘fear’ from a clinical perspective via interviews with practitioners of psychoanalysis and psychiatry. The insights that follow from these interviews, in addition to my analysis of the theoretical and clinical work of psychoanalysts Françoise Davione and Jean-Max Gaudilliere, will illuminate how the fear of psychosis can lead to transference impasses.

This book is divided into nine chapters: (1) “Introduction: The Psychotic as Guide”, (2) “The Body of the Psychotic”, (3) “The Impasse of Transference in Psychosis”, (4) “The Dream-work Versus Delusion”, (5) “The Utility of Gilles Deleuze’s Critique of Psychoanalysis”, (6) “Towards a New Ethics”, (7) “The Fear of psychosis: Part I”, (8) “The Fear of psychosis: Part II”, and (9) “Bridging the Gap Between Psychotic and Non-Psychotic Experience”.

In Chap. 1, I provide the rationale for the book and an overview of the structure of the book, including chapter summaries. In brief, I articulate how my reformulations of the body of psychosis, transference, dream-work, and ethics are key for a psychoanalytic approach in the clinic of psychosis. In addition I summarize my argument for an inclusion, within psychoanalysis, of the perspectives of people with lived experience of psychosis and, in particular, the importance of the Hearing Voices Network/Movement for both psychosis and psychoanalysis. Finally, I present my assessment of the shortcomings of the orthodox Lacanian notion of analytic neutrality when working clinically with psychosis.

In Chap. 2, I present my theorization of the ‘body of the psychotic’ from a Freudian–Lacanian psychoanalytic (versus medical) perspective. I offer a reading of Freud’s Project for a Scientific Psychology (1895), Three Essays on Sexuality (1905), Instincts and their Vicissitudes (1915), and Beyond the Pleasure Principle (1920) to render what in his text problematizes biological determinist interpretations of his theory of the ‘instincts’. In the Project, a “pre-psychoanalytic” text, Freud is on his way to discovering the true stakes, for the subject, of the primary loss of the ‘object’ of satisfaction, and the way in which the “first registration” (a Niederschriften or “writing down”) of the ‘first loss’ in turn creates the ‘body’. We will follow Freud and Lacan in order to locate the contours of the psychotic’s first encounter with Language and to begin to theorize the psychotic’s experience of the “first registration” of loss. I argue that what is at stake for the psychotic is the lack of any ‘justification’ for loss, insofar as the Name-of the-Father (or primary representation) functions for the neurotic to repress the ‘unjustifiable’ status of loss itself.

In Chap. 3, I suggest a way to re-conceptualize the transference that follows from the new understanding of the body of the psychotic, as well as from the consequences of the psychotic’s “foreclosure.” The main task of Chap. 3 is to isolate the stakes of the ‘transference-impasse’ reached by both Freud and Lacan and, thus, to open the way for a redefinition of transference that will serve the psychotic.

In Chap. 4, I theorize the structural difference between the dream and delusion, and suggest a way to ‘treat’ delusion via the symbolic work of the dream. Here, I redefine transference strictly in terms of ‘knowledge’: transference defined as a ‘desire for unconscious knowledge’. Ultimately, I argue that for the analyst to enter the psychotic experience requires a “reversal” of transference, thus modifying the usual analytic positions. In this chapter I also use clinical examples to ground the theorization of the function of the dream versus delusion.

Chapter 5 serves as a preliminary to the discussion of ‘ethics’, which is the substance of Chap. 6. In this chapter I address Deleuze’s claim that psychoanalysis “botches the encounter with the psychotic”, and then demonstrate that Deleuze’s concept of the “Body without Organs” is key to understanding what is at stake in the psychotic’s experience.

In Chap. 6, I show that the “reversal”, and therefore the installation, of transference depends upon the isolation of the field of ethics: an ‘ethics derived from the psychotic’s singular knowledge (savoir ) of the moral Law’. Under transference, defined as a ‘desire to know’, the psychotic’s delusion (as solution and defence) will ‘fall’ and thus expose the psychotic to the Void of both language and the moral Law. By what means, or ‘term’, can the psychotic bear the Law and its Void? This book proposes that the fall (‘rupture’ ) of delusion opens the ‘field’ of ethics, and thus marks the threshold the psychotic must cross to inaugurate her journey towards becoming a desiring subject. I argue that the task is to locate the field and function of ethics in the context of the experience and treatment of psychosis.

In Chap. 7, I address the topic of the ‘fear of psychosis’. In doing so, I expand the scope of approaches to psychosis to include the perspective of people with lived experience of psychosis and I explore the importance of a peer-driven model, namely the Hearing Voices Network (HVN). Ultimately, I argue that the HVN and my psychoanalytic model share a ‘common ethical stance’ and both approaches understand delusions and the content of voices as forms of knowledge. My interview with peer-specialist and educator Cindy Marty Hadge, as well as my conceptual discussion that follows the interview, will illuminate the stakes and consequences of the ‘common ethic’.

In Chap. 8, I extend the discussion of the ‘fear of psychosis’. The discussion, both clinical and conceptual, again revolves around interviews with people particularly well suited to provide new insights into the problem of fear. From the dual perspective of a person with lived experience of psychosis and that of psychoanalyst and scholar, Dr. Annie Rogers helps us understand how the curiosity (versus fearfulness) of the analyst creates a space for the person with psychosis to speak openly while also feeling safe from judgement, misunderstanding, and stigma. My discussion with Dr. Rogers also opens up an important discussion of the various versions of the ‘Other’ that can populate the experience of psychosis, e.g., the Other as destroyed, capricious, or enigmatic, or the “Other as a far-horizon”. My discussion with psychiatrist and psychoanalyst Dr. Barri Belnap illuminates how affording psychotic experience a certain “dignity” in the process of mutual understanding can effectively combat the corrosive effect of fear and the impulse to ‘control’ that so often follows from fearfulness. Dr. Belnap also provides important insights into the precarious nature and status of ‘authority’ for, in particular, someone living with psychosis.

In Chap. 9, I revisit the problematic of transference, and traditional Lacanian notions of the analytic relation, with regard to psychosis. More specifically, I explore the possibility of a “shared truth” between the analyst and the person experiencing psychosis. Are there moments with particular patients when the analyst may be called upon to reveal their own relation to the failure of words to account for loss and trauma? This question sets up a confrontation between the well-known dictate, and position, of analytic neutrality and an alternative position where the analyst may be called upon to explicitly acknowledge how trauma is created via the “annulment” of loss. ‘Annulment’ renders loss non-existent, thus creating a hole or “zone of death” in one’s experience. I understand zones of death, or zones of “non-existence”, to be common to the human experience (i.e., universal). Thus, I suggest, in revealing his or her encounter with ‘annulment’ and erasure, the analyst is speaking about (and to) the universal strangeness of encountering loss-without-words. As noted earlier, the theoretical and clinical work of Françoise Davoine and Jean-Max Gaudilliere will serve as a guide in understanding how we can traverse such “zones of death/non-existence” in order to bridge the gap between psychotic and non-psychotic experience. My discussion of how to enter and inhabit shared zones of non-existence will open the way to approach the challenge of “co-creating a credible address” for the treatment of psychosis.