“What was foreclosed from the Symbolic returns in the Real” – Jacques Lacan

Last week I had the opportunity to attend the three-day “LACK Conference” hosted in the beautiful city of Burlington, Vermont. Over 100 of the world’s leading researchers, clinicians, and academics specializing in the field of Lacanian psychoanalysis gathered at the University of Vermont to present their current research. Based on the theories of the French psychoanalyst Jacques Lacan (1901-1981), Lacanian psychoanalysis is a clinical practice and theoretical framework that emphasizes the role of language, interpersonal dynamics, and social structures in shaping human subjectivity. Partly due to language barriers and Lacan’s obscure writing style (to put it lightly), this highly specialized and insular discipline has only recently become accessible to the mental health field in the Anglophone world. 

Lacan made some fundamental assertions about how humans make sense of our world. In our everyday experience, we assume that the language we speak refers to something substantial and objective that we call “reality.” For most people, language guarantees that our raw sensory experience, social conventions, and self-identity can be organized within a consistent system of meaning. The symbolic order of social life, along with its laws, expectations, demands, ideals, prohibitions, and identity positions—the sum of which Lacan called the “big Other”—are experienced as more or less self-evident and coherent. Lacan argued that language provides a guarantee of reality’s consistency and wholeness, but this functions only to guard us from confronting the unsettling and unfiltered “Real” of our immediate encounter with the world. Lacan’s fundamental wager was that this guarantee of meaning, coherence, and wholeness is a defensive adaptation in the human psyche that protects us from the chaos and heterogeneity of the Real, as that which “resists symbolization absolutely.” 

Lacan conceptualized psychosis as the lack of this symbolic guarantee. Without this guarantee, a person experiencing psychosis is confronted with an inconsistency in the symbolic order which they go to great lengths to explain and neutralize. Whereas a non-psychotic person has internalized the ideals, demands, and identity positions of their social environment, a person with psychosis is likely to experience these symbolic constructs as radically enigmatic, arbitrary, or even threatening. This perspective sheds light on several prominent features of psychosis such as delusions, hallucinations, and disorganized thought patterns, which arise due to the lack of a stable symbolic framework necessary to delineate between inside and outside, self and Other, reality and the Real. 

Building on the work of the pioneering psychiatrist Eugene Bleuler, Lacan identified two distinct moments in the experience of psychosis. The first, referred to as “primary phenomena,” is the initial trigger of psychosis and is experienced as a sudden eruption of meaning that cannot be associated with anything concrete in reality. Examples of primary phenomena could include hearing a voice or experiencing an inexplicable sensation in the body, which can be difficult to reconcile with one’s prior understanding of reality. On the other hand, “secondary phenomena” refers to the person’s attempts to interpret and make sense of the primary psychotic experience. For instance, someone who hears a threatening voice (primary phenomena) may develop a theory that their neighbors are conspiring against them (secondary phenomena). It is essential to note that secondary phenomena are not themselves psychotic processes but rather rational attempts to explain something that initially appears unintelligible. 

In this way, delusional beliefs (secondary phenomena) can be seen as efforts at self-cure, as they provide an explanation for an experience that was initially foreign and enigmatic. The work of the psychotic individual is thus to continuously try to make sense of primary phenomena in their experience, which leads them to beliefs and behaviors that may seem bizarre to others.

Lacan’s theory of psychosis has significant implications for treatment. By distinguishing between primary and secondary phenomena, a Lacanian approach to treatment focuses on helping a person with psychosis to rebuild their symbolic reality by constructing a meaningful explanation for their distressing experiences. This involves acknowledging that a psychotic person’s delusional beliefs are not merely random or irrational, but rather personal attempts to make sense of the world and their place within it. For individuals experiencing psychosis, an elaborate delusional belief may be the only way they can make sense of their experiences and give reality its stability. By providing a secure and accepting environment, the therapist can help a person with psychosis develop alternative interpretations of their experiences that are more consistent with their social environment. Furthermore, a Lacanian approach to treatment recognizes that the social environment itself can be a source of both support and stress for a person with psychosis. Therefore, this approach emphasizes the importance of working with the individual’s social network, including family members, friends, and healthcare providers, to promote understanding and acceptance of the person’s subjective experience. By doing so, the social network can provide a supportive environment where the person can continue to rebuild their symbolic reality and regain a sense of stability and coherence in their lives.