A Psychiatrist and a Paranoiac

Francesco — one of my patients in the Mental Health Service of Naples, Italy, where I work as a psychiatrist — was born in 1953, the son of a poor hod carrier and a very rich young girl, disinherited by her father because of this marriage. He is the oldest of three brothers. He is cripples as a reuslt of poliomyelitis, which he contracted at two years of age. When he was six, his mother suffered a violent psychotic episode and was admitted to a psychiatric hospital. Francesco remembers visiting her there: he is in his father’s arms, watching from a distance his mother, who is agitated as though possessed; an asylum attendant orders the child taken away; his father says: “She’s his mother”; his mother shouts: “A child doesn’t want me, doesn’t help me”, and cries; little Francesco turns away.

His mother, hospitalized for a long period as a chronic schizophrenic but without any improvement, finally returned home when Francesco was six. He once described to me a “dream”, which later became a “childhood memory”: “When I was eight, I returned home from school; my mother made me… how do you say? incest? no, ejaculation! however, she made me come.” Because of his mother’s illness, Francesco and his brothers were sent to a Catholic boarding-school, where Francesco stayed until he was twelve; he continued his studies upon returning home, and became an electrotechnician at eighteen.

“Once I came back home,” Francesco says “me and my father, we didn’t understand each other any more.” His father, opposed to his attendance at Catholic clubs and church, increasingly reduced his allowance, belittling him and praising his brothers. Francesco felt deprived of his primogeniture, in the line of transmission of the Name of the Father. Discussions, quarrels and punishments followed. His father sometimes locked him out of the house if he came home late. Listening to him reminded me of Franz Kafka’s Letter to the Father.

When he was twenty-two, Francesco had his first love affair with the mother of a friend. He mentioned that as a result of having had anal intercourse with this woman, an abscess formed on his penis, which necessitated a small surgical incision done at an emergency room. There were two stretchers divided by a screen: Francesco lay on one, a woman on the other; he could hear her voice, but could not see her. A male nurse passed from one stretcher to the other, speaking mostly to the woman, although Francesco’s impression was that he was speaking of him. “He’s dying”, Francesco heard him say. “That’s your baby”, the attendant said to the woman. Then he turned to Francesco, holding a needle with which to prick the genital abscess: at first, a succession of light and rapid strokes, then a stronger stroke that pierced deeply. Francesco, later, felt guilty for not having reacted to what was happening: “Perhaps everything would have been different if he had cut, rather than pierced with the needle.” In fact, at tht moment, the Neapolitan word “ricchione” (queer), which he would not forget for years to come, emerged audibly in the real.

A month later, he was admitted for the first time to a psychiatric hospital with a diagnosis of “depression”. Three years later, his father died, and Francesco’s state worsened; over the next ten years he would be admitted, approximately 90 times, to psychiatric hospitals. His two brothers eventually married, and Francesco went to live with his schizophrenic mother. A year after his father’s death, Francesco repeated in the real his traumatic scene: he cut the veins of his arm with a razor-blade, and — although the physical wound is completely healed — he still blames this for his incapacity to do anything.

When I met Francesco in the summer of 1985, he was wearing a long, heavy overcoat, convinced that his limping was a sign of his homosexuality, which he sought to hide from the others’ gaze. Francesco felt he was to be transformed into a woman: sometimes, looking at his breasts in the mirror, he felt a sort of female pleasure. Like Justice Daniel Paul Schreber (1), he had “the impression of a pretty, well-developed female bosom.” Francesco was also tortured by anal excitations that were true somatic hallucinations, which anguished him: “The sensation,” he said, “is like a penis penetrating my anus. It does not last long, a second or so, and I move my pelvis.” I started off seeing him twice a week in my Mental Health Service: for five years I listened to him, and let him speak. The underlying question in all his wanderings from doctor to doctor — from one psychiatric admission to another — was: “What am I?”, to which a voice replied: “Ricchione” (“queer”). But this voice came from the real, not from the paternal place, from the symbolic authorities that he questioned. I never ventured to interpret his delusions, or to persuade him that he was wrong, as all the psychiatrists who had previously treated him did. Francesco’s overt psychosis diminished: in 1988, he no longer required psychiatric admissions or drugs. The idea of “queer,” however, persisted, but he was able to live well with it — or, better still, on it.

But never fear, this is not a happy ending. As I had mentioned, Francesco went to live with his schizophrenic mother; but in 1991, his two brothers, fearing for her health, decided to admit her to a nursing-home. It was a disaster. Francesco remained alone at home, confused, without that point of reference. He began consuming increasing amounts of drugs and alcohol, crying for that mother he had once considered an obstacle to his life. Once, two years ago, he came looking for me, demanding watching a piece of paper which he had given me some months later, on which he had written “nevrotico, psicotico, sociopatico” (“neurotic, psychotic, sociopathic”). I was sure to have returned it to him, and told him so, but he did not believe me and continued to demand that piece of paper which he referred to as “my documents.” I wrote on my letterhead his name followed by the word “paranoia”, which I signed and gave to him. This set his mind at rest.

* * *

I am very interested in paranoia, not only for psychoanalytical reasons, but because it is the most “philosophical” psychiatric disorder, facing head the great problem of truth. The ancient Greek term paranoia (used by Aeschylus, Euripides, Hippocrates and Plato) simply meant “madness, folly”, and its modern meaning as “partial delirium” was included in the great constellation of melancholy for a very long time. Emile Kraepelin, in the VIth edition of his Lehrbuch der Psychiatrie, made the important distinction between paranoia — a chronic systematic delusion without hallucinations — and the paranoid form of dementia praecox, a distinction lost in English-speaking countries, where the ubiquitous “paranoid” wins out over the adjective “paranoiac” (as DSM III authoritatively shows). Kraepelin’s definition of paranoia is rightly famous: “insidious development, depending on internal causes and with a continuous evolution, of a lasting and unmodifiable systematic delusion, associated with a complete maintenance of lucidity and order of thought, will and action.” As Jacques Lacan would notice 50 years later — in a way typical of the French psychiatric tradition, never well-disposed to Kraepelin — that definition by a so eminent clinician, is important simply because it contradicts, point by point, all clinical data…

Let us consider Francesco as a “clinical datum”. In psychotic development, the child remains in a dual, symbiotic union with his mother, identifying with her, being her desire’s object. According to Lacan, the signifier of the mother’s desire is the phallus. Thus, in attempting to be the imaginary phallus of his mother, the child rejects the limits implied by castration. These limits are the constraints invoked by the Law of the symbolic Father, who intervenes in this dual relation, establishes primal repression (Verdrängung) by structuring desire according to the laws of language, and makes it possible for the child to have a place in a signifying network of kinship relations, sex roles, sanctions, and discourse. When the mother fails to affirm the law of the father, by not allowing the symbolic father an intervening role, the name of the father is rejected, foreclosed (2), as is foreclosed, consequently, also the symbolic castration involved in giving up the position of the phallus and becoming subject to the Law. The outbreak of the actual psychosis which occurs in later life is triggered by a transference-like encounter with what Lacan terms “Un-père” (“One-Father” but also impair, “Odd”), a father figure in a special relationship to the subject (3).

One must not consider the presence or absence of the father as something which concerns reality. For psychoanalysis, Francesco’s first psychotic episode (hearing “ricchione” for the first time), in spite of what he thought, was not a matter of pricking, but, at the symbolic level — in Freud’s terms, at the Oedipal complex level — a question of the subjects’ altered relation to the signifier. This encounter with the question of generation, and of paternity, of the sexual difference between the two sides of the screen, invokes the fundamental signifier of the father, but since it has been foreclosed, there is only a gap (béance), a hole in the symbolic order where this signifier should be. Thus, paradoxically, although the mentally ill person in his family was the mother, Francesco pays the consequences for the failure of the paternal metaphor.

We can also consider the genesis of paranoia — as Rosolato (4) calls it — through the fantasy of the primal scene, where a phallic mother (the parasitic and symbiotic mother, who does not convey the law of the father) encounters a symbolic void on the father’s side. One of Francesco’s dreams relates to the trauma of the primal scene, another dream relates to the symbolic void on the father side: “I was sleeping in a meadow where a mare was grazing. The meadow was surrounded by a fence. A horse jumped this fence and mounted the mare. About ten persons, sitting around a table, watched this scene; I made myself into a ball near the fence. A man and a woman of that group began to kiss each other. I woke up troubled and frightened.” The other dream: “I’m in Heaven, and I continue quarrelling with my father, just as I did on earth. My father’s back is turned to me, or his face is covered with his hair. In any case, he has no face.”

On the imaginary level, an ideal father, who shelters from persecutory fantasies, corresponds to this symbolic void as a compensation. Francesco dreamed of having political discussions with Senator Kennedy, of being a member of his clan, of being in the Vatican with the Pope, etc. For a man, dependence on the ideal father is expressed as a fantasy of being penetrated and fecundated by his father. It is not a question of a narcissistic choice of object, but of the relation of the son, as a woman, to the father; were the paranoiac a woman, she would try to find her way back to the childish feminine attitude towards the father. The delusional sublimation of homosexuality is the key to paranoia, its central idealization, the contestation of which is necessarily destructive. The paradigmatic example of the relation between paranoia and homosexuality is, of course, the case of Justice Schreber. Until Jacques Lacan first mentioned “transexualism” in this Freudian case, psychoanalists had spoken of “homosexuality” to define the sexual identity of that great paranoiac — Freud himself made the rejection of homosexuality the basis of his theory of paranoia. The grammatical machinery which generates the various forms of paranoia –“I [a man] love him,” the originally rejected phrase that justified paranoid delusion — can be grammatically transformed in four different ways:

  • it can be denied in the verb, transformed into its opposite, and projected out, becoming “I hate him”, then “he hates me”, giving birth to persecutory delusion;
  • it can be denied in the object and then projected out, becoming “I love her,” then “she loves me,”, giving birth to erotomanic delusion;
  • it can be denied in the subject — a grammatical mechanism that distinguishes the subject of the énoncé (utterance) from that of the enunciation, so that it needs no projection — becoming “she loves him,” giving birth to jealousy delusion; or
  • it can be totally denied, becoming “I don’t love anything or anybody,” then “only I am worthy of love,” giving birth to grandiose delusion.

All this is beautiful, simple and elegant, but also questionable. Lacan has spoken of an authentic error by Freud, who was unable to make the fundamental distinction, for Lacan, between having the phallus and being the phallus. But it is not true that Freud failed to distinguish between to have/to be. Lacan simply developed theoretically, and applied to clinical practice, one of the least Freudian intuitions scrabble down on little scraps of paper collected under the title Findings, ideas, problems. To quote:

“Having” and “being” in children. Children like expressing an object-relation by identification: “I am the object.” “Having” comes later, after loss of the object it relapses into “being.” Example: the breast. “The breast is a part of me, I am the breast.” Only later: “I have it” — that is, “I am not it”… (5)

Lacan, however, added abstraction and generalization to this intuition: the breast became just one example of the larger set of Freudian objects, characterized by that salience, pregnance and prominence that find their best representative in the phallus.

“To have” and “to be,” we said. The first verb — in its two possible values, “to have” or “to have not” the phallus — distinguishes secondary sexual identification, defining two positions, “to be man” and “to be woman”; the second verb — “to be” or “not to be” — is peculiar to a more original identification, termed “primary identification.” In this case, what is at stake is not a subject qualified by “having,” or “having not,” by his/her relation to an object (in a grammatical sense, as we are obviously speaking of signifiers), but an object (in the same grammatical sense) placed there where it can choose to become a subject. “To be or not to be mother’s phallus?” By answering yes, I assure my identity — but as the object of another subject — by answering no, and separating myself from the other, I can have my subjectivity, but at the risk of total annihilation. Schreber’s transexual jouissance (6) is the delirious consequence of the answering positively that question. “I am the woman whom God lacks,” as Justice Schreber says, is just another way to say “I am the phallus that the mother lacks.”

There is a female jouissance extorted from Francesco too: the impression of a female bosom on his image in the mirror, the anal excitations, the sensation of a penis in his anus. Thus jouissance in the place of the Other wears its victim out beyond all legitimacy, having the same rhythm and the same insistence as that voice — “queer” — which confuses him and condemns him to fragmentation. It is an Other’s jouissance, foreclosed in the symbolic, coming back into the real, and not sexual in itself. Only delusion can tie it to the sex signifier. This imposed jouissance, dangerous to the boundaries of the body, is tied to “emasculation” (Entmannung), which is not castration but its lack, that is, a signification of a non-phallic jouissance. This “homosexuality”, directly dependent on the relation with the ideal father nd on his imaginary power, is thus clearly a virtual one, the opposite of the realization of sexual pleasure in perversion. And in paranoia, as in Francesco’s case, the perversion is considered disgusting behaviour when confronted with the supernatural relation with the ideal father. Francesco said: “I can’t accept it. I would rather kill myself.” Francesco told me he wanted to sleep “like a son” at night, but his mother forced him to get into her double-bed, to take “the place of my father,” as he said. But obviously, he can’t take that place. And he could do nothing more because he had “wounded himself.” Unable to take his father’s place and to possess of the phallus, Francesco identified with and assumed his mother’s desire for the phallus. As Lacan says of Schreber, as he is incapable of being the phallus that the mother lacks, he is left with being the woman that men lack.

A hole in the symbolic order appears as a hallucination, such as voices, in the real order. Auditive hallucination has a special value in paranoia because it is an expression in the real of the father’s voice. But in Francesco’s case there are other hallucinations. One of his dreams reminds me of the Wolf-Man’s hallucination about his cut finger (7): “I’m in a butcher shop. It’s all red from the blood of the meat cut by the butchers. I cut the meat, too. A friend of mine tells me: ‘Be careful.’ I reassure him, but soon afterwards I cut my finger. I wake up anguished.” The psychotic imaginary is always, averywhere, the same: the cut finger, the butcher (think of Lacan’s case “I’ve just been to the pork-butcher’s”) (8). Like all of Francesco’s dreams, it is a sort of hallucination, the cut finger being not a metaphor of symbolic castration, but a mirror reflex of Francesco’s lifelong many real wounds: on his legs from polio; on his penis from pricking; on his arms from his suicide attempt; in his head from nervous illness; etc. In attempting to be the phallus, the psychotic typically struggles with having or not having it. Thus, Francesco’s phenomena centered in the imaginary/real loss of his penis implied by his becoming a woman, by his not having the phallus in order to be his mother’s phallus. With the failure of an adequate symbolic mediation, the destructive forces of the death drive are unleashed on the level of the real, aiming at a kind of self-mutilation on the real. As in Freud’s Wolf-Man case, Francesco experiences of bodily violation as a consequence of the foreclosure of the symbolic law. Following the rejection of castration, there is a return from the real of what is foreclosed in the symbolic: the cut, the loss — for the Wolf-Man a hallucination, and for Francesco in the form of delusions, somatic phenomena and acts. In the absence of the Name of the Father, the symbolic wound is reduced to the horror of the unspeakable real, where the lack appears as a true absence of somethin — an organ, a function.

As for the temporary end of the story, I am reminded of a few lines in Lacan’s Four Fundamental Concepts of Psychoanalysis (9):

At the basis of paranoia itself, which nevertheless seems to us to be animated by belief, there reigns the phenomenon of the Unglauben. This is not the not believing in it, but the absence of one of the terms of belief, of the term in which is designated the division of the subject. If, indeed, there is no belief that is full and entire, it is because there is no belief that does not presuppose in its basis that the ultimate dimension it has to reveal is strictly correlative with the moment when its meaning is about to fade away.

Francesco did not believe me because he wanted from me his diagnosis, that is, the mark of his own subjective division (“neurotic, psychotic, sociopathic” — almost precisely the three possible subjective positions according to Lacan!).
The paranoiac’s ever present communication problems are expressed in his delusions: thought insertion, thought broadcasting, thought withdrawal, God’s rays, voices, etc. It is a communication problem between, on the one hand, a central point from which a metaphor is possible — something in the real that can anchor his subjective signification — and, on the other, the organized knowledge in the symbolic order. How is it possible to organize a knowledge around a point that is in the real? This is what is at stake in the construction of a delusion: a paternal function that comes back into the real. Through his/her delusion the psychotic subject him/herself tries to construct a signification, not guaranteed by a symbolic filiation. He tries to construct a pseudo “paternal metaphor.” When Francesco came to me demanding that piece of paper with the words “nevrotico, psicotico, sociopatico,” he was in a crucial, fecund moment. I was summoned by his transference in the place of the paternal metaphor in the real: the place of the father who gives a name, at the same time giving the subject a place into the symbolic structure. Therefore I could act, binding together the symbolic (his name, my signature), the imaginary (paranoia diagnosis, a better answer to his question “What am I?”), and the real (that stupid scrap of paper he asked to me to give him back).

Psychoanalysts generally think that only one thing is possible with a psychotic: let him speak, in a symbolic space and with a fixed rhythm, because it is only the circulation alone –socialisation, so to speak — of the patient’s delusional metaphor, that prevents him from the passage à l’acte, passing to action. Lacan did not believe so. We can do something, by trying to compensate for the gap in the symbolic order by a word, by an act, or by something that can provide a support to the signifying chain, a fixed point of orientation. That is what I have attempted to do.


(1) President Schreber, too, was placed in a feminine position in his delusional system: having been turned into a woman, Schreber submitted his body to the voluptuosness of God’s rays for the benefit of a new human race to be procreated through his woman’s body. See Sigmund Freud, “Psychoanalytical notes on an autobiographical account of a case of paranoia (Dementia Paranoides), S.E., Vol. XII, pp. 1-82. See also Zvi Lothane, In Defense of Schreber: Soul Murder and Psychiatry (Hillsdale, NJ and London: The Analytic Press, 1992).

(2) Lacan discussed the Freudian notion of Verwerfung (foreclosure), the mechanism he held to be at the origin of psychotic phenomena, in his essay “Réponse au commentaire de Jean Hyppolite sur la Verneinung de Freud” [in Ecrits (Paris: Seuil, 1966) pp. 381-400], based on Freud’s “Wolf-Man case.” Foreclosure is a complete failure to recognize symbolic castration and the Name of the Father, which results in profound disturbances in the symbolic order. See also Bice Benvenuto & Roger Kennedy, The Works of Jacques Lacan. An Introduction (London: Free Association Books, 1986).

(3) John P. Muller, “Language, Psychosis and the Subject in Lacan” in Joseph H. Smith & William Kerrigan (eds.), Interpreting Lacan (New Haven and London: Yale University Press, 1983).

(4) Guy Rosolato, “Il padre nel sistema generativo della paranoia”, Gli Argonauti, 6, 1980.

(5) Sigmund Freud, S.E. XXIII, p. 299.

(6) Jouissance has no simple English equivalent. As Alan Sheridan, the English translator of Lacan’s Ecrits, notes: “‘Enjoyment’ conveys the sense, contained in jouissance, of enjoyment of rights, of property, etc. Unfortunately, in modern English, the word has lost the sexual connotations it still retains in French. (Jouir is slang for “to come”.) “Pleasure”, on the other hand, is pre-empted by “plaisir”–and Lacan uses the two terms quite differently. “Pleasure” obeys the law of homeostasis that Freud evokes in “Beyond the Pleasure Principle,” whereby, through discharge, the psyche seeks the lowest level of tension. “Jouissance” transgresses this law and, in that respect, it is beyond the pleasure principle.” See Jacques Lacan, Ecrits: A Selection, transl. by Alan Sheridan (New York: W.W. Norton & Co., 1977).

(7) “I was playing in the garden near my nurse, and was carving in the bark of one of the walnut-trees with my pocket-knife … Suddenly, to my unspeakable terror, I noticed that I had cut through the little finger of my… hand, so that it was only hanging on by its skin. I felt no pain, but great fear… At last I calmed down, took a look at the finger, and saw that it was entirely uninjured.” See Sigmund Freud, “From the gistory of an infantile neurosis,”, S.E. XVII, pp. 1-122.
(8) This is a clinical example of a young psychotic woman interviewed by Lacan. She described one incident that involved the lover of one of her neighbours: “This man… had apparently called her, as he passed her in the corridor of the block of flats in which they lived, by the offensive word: ‘Sow’… she conceded that, on seeing the man, she had murmured the apparently harmless enough word: ‘I’ve just been to the pork-butcher’.” The word “sow” was an hallucination whose meaning was: “I am like a sow who should be cut in pieces like a piece of meat in a pork-butcher’s, as I fear my family-in-law would do.” See Jacques Lacan, Ecrits: A Selection (New York: W.W. Norton & Co., 1977), p. 179-225.

(9) Jacques Lacan, The Four Fundamental Concepts of Psycho-Analysis (Penguin Books, 1979), p. 238.

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