Book Review Essay: Ethics without Ethics: A Review “Psychosis and Extreme States: An Ethic for Treatment” by Bret Fimiani

Review of Psychosis and Extreme States: An Ethic for Treatment by Bret Fimiani, Palgrave Macmillan, 2021, 249 pp.

Bret Fimiani’s (2021) Psychosis and Extreme States: An Ethic for Treatment, the product of decades of research and clinical experience in the psychoanalytic treatment of the psychoses, is published at a particularly kairotic[1] moment, addressing itself more broadly to the contemporary crisis of psychoanalysis. The plague Freud called forth meeting our plagued world. If only poison can cure our poisoned lands, as Freud wagered, we must ask if contemporary psychoanalysis can invent new poisons that might touch the soft spot in the wasteland of our times, not T.S. Eliot but billy woods:

On the TV, I see fire in their eyes

Fire in the streets from the firescape

I watch it eat, I watch its teeth

Dream fire could burn it clean (Moor Mother & billy woods, 2020)

There is a gentleness in Fimiani’s style, a welcoming of all and sundry somewhat unusual for Lacanian theorists, but, I will argue, the greatest gifts of his text are its teeth, not immediately evident in the generosity of his prose.

Fimiani’s most basic project is to develop a theory of transference-in-psychosis, the function of ethics in the installation of transference, and what psychotic transference has to teach us about the Law and ethics more generally. His argument is subtle and warrants careful study, and I will only erect a few cairns to indicate his itinerary here. Drawing from a number of often contestatory voices — Freud, Lacan, Deleuze and Guattari, Apollon and the Gifric group, Davoine and Gaudilliere, and, most importantly, the voices of psychotic subjects themselves — Fimiani posits that the body of the psychotic is a primary site of social contestation.

It is the subject’s first “choice” of foreclosure of the primary signifier (the nom-du-pere or Name-of-the-Father) that structures the body of the psychotic.

I am suggesting that psychoanalysis is in search of a body that is in between the organism and representation, a body that is no longer of the organism, however a body that remains without recourse to representation.  Eventually, following Lacan, we will locate this body that is stranded between, and that is literally in pieces, as the body of the letter. The psychotic knows the body of the letter very well. (Fimiani, 2021, p. 19)

Suspended and torn between the biological organism that is the object of medicine and psychiatry and the neurotic’s body image, the body of the psychotic refuses and suffers.

Foregrounding ethics and following Freud’s enigmatic proposal of the “choice of neurosis” (Freud, 1950, p. 271), Fimiani posits foreclosure as a “first choice” that produces both disastrous consequences and a particular savoir (knowledge) for the psychotic subject. While for the neurotic subject in the experience of Oedipus and the encounter with castration, the object is represented and lost thereby programming the subject’s desirous itinerary, the psychotic subject’s foreclosure of the Name-of-the-Father and the Law lodges the object in the subject’s body (as with Lacan: “… Let’s say he has his cause in his pocket, that why he’s a madman,” [1967, p. 12]). Without the question of desire (the desire of the Other) as a protection against total jouissance, the psychotic subject constructs the delusion which “functions as a totalizing knowledge and provides the psychotic subject with a fixed place/role that in turn bypasses the question of desire: ‘what does the Other want?’” (Fimiani, 2021, p. 70). The psychotic subject retreats and is stranded in the closed world of delusion and the persecutory voices of the object lodged in him.

While acknowledging the painful and socially alienating effects of the choice of foreclosure, Fimiani insists that it also results in a savoir that is specific to the psychotic subject. In foreclosing the Name-of-the-Father, the psychotic subject has refused the credibility of any a priori universal that might serve as the basis for the Law, Aristotle’s Good or Kant’s respect for the moral Law within. This has significant consequences for transference and the direction of the psychoanalytic treatment. Unlike the neurotic subject whose transference situates the analyst as the subject supposed to know, inaugurating and serving as an engine for the treatment, for the psychotic subject, there is no such supposition (as Freud and Lacan well recognized and was the source of their circumspection about the possibility of psychoanalysis with psychotic subjects). Fimiani proposes a transferential inversion: it is the analyst’s desire to know and the psychotic subject’s savoir of the absent foundation of the Law that is the initial transferential knot of the analysis. This is the only condition upon which a psychoanalytic treatment of a psychotic subject might begin. It is not, however, the end of the story.

Following Apollon and the Gifric group with whom he trained (Apollon, Bergeron, & Cantin, 2002), Fimiani places great weight upon the emergence of the dream in the analysis of the psychotic subject. The navel of the dream, with its radical undermining of the closed wish of the dream (“A wishis always a wish to do away with desire (lack) altogether” [Fimiani, 2021, p. 71]), can serve to rupture the closed certainty of the delusion. With the emergence of the dream and the (potential) rupture of delusion, the psychotic subject might begin to formulate a question. The rupture offers the opportunity for a second choice and the emergence of a new transferential form as a desire to know on the part of the psychotic subject. The emergence of the dream brings with it only possibility and for an analysis to proceed further makes particular demands of the psychotic analysand and of the psychoanalyst both. The analyst’s desire must serve as a support for the psychotic subject, who now must confront the defect in language and the Law without the delusion but also without the Name-of-the-Father, offering herself as “a temporary barrier between the subject and the horror of the Void” (p. 81). With the support of the analyst’s desire, the psychotic subject might make a second choice and create a new ethic.

Yet we must insist upon a distinction here; the ethical act itself is constituted by morethan the simple emergence of an opposition and potential rupture [dream].  What is required on the patient’s side is a ‘choice’ that affirms the rupture as such, i.e., the rupture is pure potential that represents the possibility for a reconfiguration of the subject’s relation to death drive, and thus another way to be in the world. (Fimiani, 2021, p. 128)

This concludes the first section of Fimiani’s text outlining a new theory of transference-in-psychosis and the direction of the treatment. The centrality of terror for both the psychotic subject and analyst is clear, and the second section of the book is primarily concerned with the fear of psychosis. It transcribes a series of interviews accompanied by Fimiani’s notes on the discussions. The first interview is with Cindy Marty-Hadge, an individual with lived experience of psychosis and peer specialist in the Hearing Voices Network (HVN). Fimiani argues for a continuity between the methods of HVN and his psychoanalytic approach, the role both have to teach us about ethics, and the fundamental importance of dignifying the experience of psychosis against the medical reductionist conceptualization of psychosis as illness. Fimiani then interviews Dr. Annie Rogers, a scholar and psychoanalyst with lived experience of psychosis. The two explore, among many other topics, “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 far-horizon’” (Fimiani, 2021, p. 11). And finally, he interviews psychiatrist and psychoanalyst Dr. Barri Belnap, focusing on the violence and impulse to control psychotic subjects that so often emerges as an effect of this fear.

The final section of the book serves as a critique of the concept of analytic neutrality in the treatment of psychosis, focusing on the work of Francoise Davoine and Jean-Max Gaudilliere (Davoine & Gaudilliere, 2004). Employing Davoine and Gaudilliere’s conception of “zones of non-existence,” Fimiani argues that there may be moments in the treatment of psychotic subjects in which it is imperative for the analyst to disclose a shared truth of groundlessness so that analysand and analyst can co-construct a groundless ground and credible site of address for the psychotic subject.

 

***

Fimiani has produced a rich, heterodox account of psychosis and a psychoanalytic approach to working with psychotic subjects. His arguments are subtle and theoretically sophisticated, but his prose is remarkably accessible, even for readers who are visitors rather than permanent residents of the Lacanian field. Moreover, his exploration opens up the question of ethics with ramifications that extend far beyond the often specialized fields of psychoanalysis and the study of psychotic experience and extreme states. The one somewhat glaring omission in the text is the absence of any discussion of the role of an institutional apparatus in the treatment of psychotic subjects. Although their emphases and theorization were often radically divergent, the discourses of antipsychiatry, the therapeutic community movements of various theoretical stripes, institutional psychotherapy (Tosquelles, Oury, Guattari, Fanon, etc), and even Gifric, where Fimiani himself trained, all consider some form of institutional structure or milieu essential in the treatment of psychosis. While it is not, of course, Fimiani’s responsibility to theorize all aspects of the psychoanalytic treatment of psychosis in a single text, I was left hungry for his thoughts on this issue. This was heightened by his deployment of critiques by Deleuze and Gauttari, who, along with the other institutional psychotherapists, similarly re-imagined and expanded the concept of transference-in-psychosis (burst transference, dissociated transference, transversality), the absence of a gathering up of a subject supposed to know in the figure of the analyst, and who proposed the use of the institutional apparatus and the collective or constellation in inaugurating the transference in the psychotic subject as well as a grid for its interpretation.

The structure and style of Fimiani’s book deserve closer attention. What I have called the first section of the book — the first six chapters — to which I devoted the vast majority of my summary, is a systematic argument about the nature of transference-in-psychosis and the role of ethics in the treatment of psychotic subjects. However, the expectation of a systematic treatise is ruptured by the opening onto interviews in chapters seven and eight and the shift of emphasis from the fundamental concept of transference to the technical concept of neutrality in the final chapter. This rupturing movement is mirrored in Fimiani’s style. His careful explication of Lacanian concepts for consumption by the uninitiated initially gave the impression of so much of the secondary Lacanian literature, what Lacan himself referred to as the university discourse (Lacan, 1969-70/2007). In the university discourse, it is the master (S1) that is the truth that propels the discourse, instituting knowledge (S2) in the position of agent.

In fidelity to the “ethics without ethics” to which his psychotic analysands have guided him, Fimiani’s text is without a master, and there is no system to be had.

 In order to include the psychotic’s particular dilemma in the face of the Law, we might say that both analysand and analyst have a duty to the subject in order to oppose the commands of the superego (neurosis) and delusional certainty (psychosis). Thus we have an initial sense of an ethics (a new responsibility) that becomes necessary in a field that is beyond neurotic Ideals and psychotic certainty – beyond any command. (Fimiani, 2021, p. 120)

This movement is apparent in the contestatory voices through which Fimiani weaves his chorus: Freud, Lacan, Deleuze and Guattari, Apollon, Bergeron, and Cantin, Aristotle, Kant, Sade, Marty-Hadge, Rogers, Belnap, Davoine and Gaudilliere, and his fictitious psychotic analysand to whom he returns throughout the book. There is implicit in this movement a critique of Lacanian orthodoxy/ideology and groups such as Jacques Alain Miller’s World Association of Psychoanalysis (WAP) as well as that of Fimiani’s former masters, Apollon, Bergeron, and Cantin and their Gifric group, our great systematizers and bastions of theoretical rigor, which so often create closed and internally referential communities committed to the preservation of a doctrine and that lose all porousness to an outside and elsewhere. It is a lesson that if unheeded by all of us within the international psychoanalytic community will bring ruin upon our institutions. For many, it already has[2].

In what proved to be a synchronicity of sorts, I happened to read Fimiani’s book at the same time as Gabriel Tupinambá’s (2021) The Desire of Psychoanalysis: Exercises in Lacanian Thinking. On the surface, these books have little to do with one another, outside of their basic Lacanian orientation. Tupinambá’s book is not concerned in any way with psychosis, and Fimiani’s makes no explicit critique of the institutional vertex of psychoanalysis. Whatever synchronicity there is to be had here, I expect it is quite personal and should be acknowledged as such. I am a co-director at the Greene Clinic[3], a sliding scale psychotherapy practice in Brooklyn, New York committed to increasing the accessibility of psychoanalytic psychotherapy and providing training in socially informed psychoanalysis to students and postgraduate trainees. In addition, I have joined the board of a newly formed non-profit, The Community Psychoanalysis Project[4], dedicated to making psychoanalytic treatment accessible for all, through funding low cost psychoanalytic treatment, funding supervision and training, providing consultation to developing practices that plan to offer low fee treatment, and developing public programs related to socially-informed psychoanalysis. With my colleagues, I have been trying to think together community psychoanalysis, the treatment of psychosis and the building of an institutional treatment apparatus, and psychoanalytic training outside of formal institutions. While all three threads are very important to me, it has felt impossible to think them together in any meaningful way. Reading these two texts more or less simultaneously has proved very generative in that effort[5].

Fimiani proposes that the question of psychosis serves as the “Body without Organs” (Deleuze & Guattari, 1983) for psychoanalysis itself. To understand what he means by this, we must return to the circumspection with which Freud and Lacan approached the question of the psychoanalytic treatment of psychosis.

What does the field of psychosis present to psychoanalysis that, for Lacan, rendered any attempt at treatment ‘premature’ and, in addition, indicative of going “beyond Freud”?  In light of Lacan’s positing of the treatment of psychosis as “beyond Freud”, I would add the following question: Does the treatment of psychosis require a mutation of psychoanalysis itself – perhaps a reorganization of the fundamental precepts of psychoanalysis in order to properly receive the discourse of the psychotic?  (Fimiani, 2021, p. 56)

As the Body without Organs for psychoanalysis, the discourse of the psychotic can serve as either a destructive or productive limit. With Freud and Lacan, Fimiani is adamant that the transference-in-psychosis functions fundamentally differently than the transference-in-neurosis. And with Deleuze and Guattari, he insists that if psychoanalysis is to properly receive the discourse of the psychotic, it cannot attempt to Oedipalize the psychotic subject. We are working here with a radical difference in kind.

In his efforts to think the relationship of the discourses of psychoanalysis and politics, Tupinambá offers us a conceptual tool as well as a warning for where psychoanalysis has so often gone wrong historically. He proposes four modes by which psychoanalysis can relate itself to other discourses: unilateral contribution, correlation, separation, and compossibility. While it is through unilateral contribution that psychoanalysis has most frequently related to other discourses, imagining itself the master interpretive grid through which it diagnoses their strayings, it is the final mode of compossibility that is of interest to us. In compossibility, one accepts the radically extrinsic nature of the two discourses (psychoanalysis and politics for Tupinambá, psychoanalysis with the neurotic subject and psychoanalysis with the psychotic subject for Fimiani), and asks, “What must psychoanalysis be if I affirm that X or Y is possible for politics?” (Tupinambá, 2021, p. 21). The very question Fimiani poses for psychoanalysis confronted with the psychotic subject’s discourse. We can see a very similar ethical commitment to that demonstrated through the structure and style of Fimiani’s book: against the preservation and systematization of the master’s doctrine and the policing of its borders against corruption by the stranger from outside.

With this in mind, Tupinambá returns to Lacan’s theorization of the passe and critiques the procedure in its triple role of 1.) authorizing the psychoanalyst, 2.) bringing to a conclusion the analysis, and 3.) providing institutional support and recognition for the newly formed psychoanalyst. Instead of the identification of a new psychoanalyst, Tupinambá argues, the passe — a new testimony of what is possible as passage or traversal — should serve to challenge the knowledge and identifications of all analysts (p. 213). Moreover, he writes:

If psychoanalysis can only treat people of a certain social class, or of a certain culture [or, we might add, of a particular psychic structure], then we are abdicating from the examination of cases, passes, and clinical examples which might come to contradict aspects of our clinical listening which we currently consider as invariant parts of the backdrop of free association – contradictions which could thereby enrich and transform the limits of clinical listening. The generic perspective – in psychoanalysis, as much as in politics – is always the one which asks who is allowed to participate in the infinite process of reinventing what it means to be human. (Tupinambá, 2021, p. 98)

We have arrived again at the ethics of the rupture, “ethics without ethics,” and of a new responsibility and choice, without any recourse to the Good, to choose the Evil that transgresses and even destroys, that which is to open instead onto the unknown and the new. I am grateful for the support Fimiani and Tupinambá have offered me in confronting this terrifying decision, never made once and for all. It is an infinite responsibility: to “dream fire could burn it clean” (Moor Mother and billy woods, 2020), again and again to co-construct with the other the groundless ground that is not, but only will have been, the new.

Bibliography:

Apollon, W., Bergeron, D., & Cantin, L. (2002). After Lacan: Clinical practice and the subject of the unconscious. State University of New York Press.

 

Davoine, F. & Gaudillière, J.M. (2004). History beyond trauma (S. Fairchild, Trans.). Other Press.

 

Deleuze, G. & Guattari, F. (1983). Anti-Oedipus: Capitalism and schizophrenia (R. Hurley, M. Seem, & H.R. Lane, Trans.). Penguin Books.

 

Fimiani, B. (2021). Psychosis and extreme states: An ethic for treatment. Palgrave Macmillan.

 

Freud, S. (1950). The complete letters of Sigmund Freud and Wilhelm Fliess 1887-1904. (J.M. Masson, Ed.) Belnap Press.

 

Lacan, J. (1967). Intervention of November 10, 1967. Untranslated lecture to psychiatry trainees at Saint Anne.

 

Lacan, J. (1969-70/2007). The other side of psychoanalysis. In J.A. Miller (Ed.) & R. Grig (Trans.) The seminar of Jacques Lacan, Book XVII. W.W. Norton & Company.

 

Moor Mother & billy woods. (2020). Guinness. On Brass. Backwoodz Studios.

 

Oyer, M.  (2019). Notes on kairos and the psychoanalytic act.  In V. Sinclair (Ed.), Rendering unconscious: Psychoanalytic perspectives, politics, and poetry (pp. 348-354). Trapart Books.

 

Tupinambá, G. (2021). The desire of psychoanalysis: Exercises in Lacanian thinking. Northwestern University Press.

Notes:

[1] Unlike the temporality of chronos, the linear unfolding of past, present, and future, kairos is the temporality of the act, the opportune moment, the lethal point, opening momentarily and then gone again, the seizing of which will lead to a radical change. See Oyer (2019) for an exploration of kairos in relation to the psychoanalytic act.

 

[2] See, for example, the recent events involving the American Psychoanalytic Association (APsaA) and Dr. Lara Sheehi. While detailing all of the events in this disturbing affair would require a paper in its own right, it is difficult to ignore in the context of our discussion of Fimiani’s centering of his text on ethics and the psychotic subject’s knowledge of the void at the center of the Law. To briefly summarize, the Executive Committee of APsaA overruled, in an unprecedented fiat, the decision of the Program Committee to invite Dr. Sheehi, an Arab woman and long-time APsaA member and committee position-holder, to participate in a panel at the June 2023 meeting on “Psychotherapy Under Wartime Conditions” based on a Title VI complaint filed against her with the US Department of Education by the right wing Pro-Israel group StandWithUs. In response to the unprecedented intrusion of the Executive Committee, 13 members of the Program Committee and all of its members of color resigned in protest. Following the mass resignation, the remaining members of the Program Committee refused to mount the meeting entirely, and the Executive Committee then disbanded the Program Committee in toto. APsaA’s President, Dr. Kerry Sulkowicz, and Vice-President, Dr. Dan Prezant, sent a letter to the APsaA membership announcing the decision of the Executive Committee, while glaringly leaving Dr. Sheehi unnamed, seemingly erased, denying that racism or misogyny, structural or otherwise, had contributed in any way to the unprecedented action, and justifying the decision based on concerns about “containment.” This was followed by open letters from Dr. Sheehi announcing her resignation from APsaA and all of her committee positions and roles, from the remaining members of the Program Committee, and from the group of members who had resigned. In the meantime, Dr. Sheehi’s academic institution, George Washington University, which had elicited an independent investigation of the complaint (in itself, a remarkable departure from the typical internal investigation of such complaints), made public the findings of this investigation which found no evidence substantiating any allegations of discriminatory or retaliatory conduct on Dr. Sheehi’s part. The backlash from APsaA’s membership was swift (if also conflictual), and has resulted in some form of public apology from the Executive Committee and retraction of the decision to refuse Dr. Sheehi invitation and dissolve the Program Committee, the resignation of APsaA President, Dr. Sulkowicz, and calls for a vote of no confidence for the entire Executive Committee. It appears that the effects of this event are far from resolved and there can be little doubt that its reverberations will be felt within and beyond APsaA for years to come. It seems clear to me that this is very much an example of an organization that would seek to police its borders and protect itself and the psychoanalytic doctrine of which it is the steward from contamination by the stranger from without. In the public discussions that have followed, a common critique leveled by members of the Executive Committee and those who defend their actions has been to claim that the “illiberal and extreme left” is only interested in the destruction of what has been and the silencing of dissenting opinions and has proposed no positive agenda for governance. It must be acknowledged that this is not without some truth. Returning to Fimiani’s ethical (and clinical) proposition, it is noteworthy that he provides no indication of what the “reconfiguration of the subject’s relation to death drive” might be. It cannot be otherwise: there can be no neurotic Ideal or psychotic certainty that might predetermine this next step. It can only be a step into the unknown. Fimiani cites Zupancic: “It is a matter of acknowledging that any ethical act, precisely insofar as it is an act, is necessarily ‘evil.’ This is the evil that belongs to the very structure of the act, to the fact that the latter always implies a ‘transgression’, a change in ‘what is’” (p. 129). As to the question of silencing, however, the shift into counter-authoritarianism has been the fatal trap of revolutionary movements throughout history, and our present times are certainly no exception. This is a collapse of the ethical leap that Fimiani is proposing, a lapse back into the familiarity of the command, and it must be guarded against vigilantly.

 

[3] My fellow co-directors at the Greene Clinic include its founder Cassie Kaufmann, Sophia Frydman, Jenny Marion, and Loren Dent. For more information, see https://www.greeneclinic.com/

 

[4] Although still in the very early stages, the volunteer board of directors of the Community Psychoanalysis Project include Chris Hughes, Jamieson Webster, Ben Kafka, June Lee Kwon, Cassie Kaufmann, and Loren Dent. Jenny Marion serves as operations officer for the project.

 

[5] While I suspect the effort to think these three threads together is particular, the topics of community psychoanalysis and of the migration of psychoanalysis outside of traditional institutions appears to be a significant if minor aspect of the current zeitgeist. See the recent launch of Parapraxis magazine (https://www.parapraxismagazine.com/), and the special issue of Division / Review, 28 (https://div39members.wildapricot.org/DR-Home/) devoted to the topic of community psychoanalysis, and “Not Your Daddy’s Freud” in the New York Times, March 26, 2023 (https://www.nytimes.com/2023/03/22/style/freud-psychoanalysis.html).

Bio:

Matthew Oyer is a licensed psychologist and psychoanalyst.  He is a Co-Director at the Greene Clinic, Assistant Clinical Professor at the Icahn School of Medicine, and Adjunct Supervising Faculty in the clinical psychology doctoral program at City College.  He completed his doctoral training at the City University of New York and his doctoral internship at New York Psychoanalytic Society and Institute (NYPSI) and Mount Sinai Medical Center.  With a small group of others, Dr. Oyer created and implemented a program of independent psychoanalytic training through which he continues to pursue lifelong formation.

Publication Date:

June 1, 2023

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