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CLINICAL NOTES
Jacques-Alain Miller, ‘An Introduction to Lacan’s Clinical Perspectives,’ Reading
Seminars I and II: Lacan’s Return to Freud (Albany: SUNY Press, 1996), edited by
Richard Feldstein, Bruce Fink, and Maire Jaanus, The Paris Seminars in English,
SUNY Series in Psychoanalysis and Culture, pp. 241-247.
Jacques-Alain Miller’s analysis of Lacan’s clinical perspectives was delivered in 1996
at the Sainte-Anne Hospital in Paris.
Sainte-Anne has for long been the main psychiatric hospital in Paris and Jacques
Lacan himself had worked there during the early part of his career when he began as
a psychiatrist influenced by Henry Ey and Karl Jaspers.
So it is only appropriate that Miller should relate how Lacan’s early research and
work in psychiatry relates to his later work in psychoanalysis; and how thanks to
Lacan there was an enormous emphasis on integrating the work of leading French
psychiatrists like Henry Ey into the clinical work of the Lacanian school.
Miller starts his intervention by pointing out an important difference between
French and American psychiatry.
The French believe that mental structures are discrete entities; they work with the
diagnostic schema of ‘neurosis, psychosis, and perversion’ that constitutes the
Lacanian approach to psychiatry and psychoanalysis.
In other words, the French do not invoke ‘borderline’ clinical phenomena that are
becoming increasingly common in the Anglo-American world of psychiatry.
They look upon the mental structures in their classificatory schema as self-contained
discrete entities.
This fact is however commonly overlooked because it is a part of the ‘general
background’ in French psychiatry; it is only when a comparative perspective is
introduced that the differences between the Lacanian and other approaches become
obvious to those who are not well-acquainted with clinical phenomena.

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What are the implications of invoking discrete entities in a classificatory schema of
mental structures or illness?
The main implication is that there is no direct correlation between a symptom and the
underlying mental structure of the patient in analysis.
Each of these mental structures or forms of illness is understood as being animated
by an existential question in the Lacanian approach to clinical diagnosis.
So, for instance, the hysteric is situated as a subject who is asking herself: ‘Am I a
Man or a Woman?’; the obsessional subject is situated as asking himself: ‘Am I Alive
or Dead?’
Identifying the existential question that animates an illness is more important in the
French approach than classifying symptoms or clustering them into syndromes as is
the case with the methodology deployed in the Diagnostic and Statistical Manual.
So it is quite possible that a hysteric and an obsessive will use the same symptom,
but wind up asking different questions.
It is therefore important for the analyst to not fall prey to interpreting the symptom
merely through a frequency analysis or by calculating probabilities of where they are
most likely to occur.
While such an exercise may make sense in terms of macro clinical phenomena, it will
not tell the analyst whether the specific patient that is free-associating on the couch is a
hysteric or an obsessive.
The meaning of a symptom is not internal to the symptom but is related to what the
patient is ‘doing’ with the symptom; the only way to find out the meaning of a
symptom is to get the patient to free-associate around the symptom.
The ‘existential and phenomenological’ horizons of analysis must never be forgotten;
otherwise the clinical intervention becomes meaningless and the uniqueness of the
suffering subject is lost.

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When it was not clear which category a patient fell under, Lacan would prefer ‘to
wait for further indications before offering up a diagnosis’ rather than seek recourse
to borderline descriptions.
The best known example of this was the question of whether homosexuality should
be treated as a symptom.
If yes, does homosexuality mean the same in paranoia as in the perversions? The
answer to this question would depend on the context of a particular analysis.
Another example pertains to hallucinations.
How should the clinician differentiate between auditory and visual hallucinations?
Miller points out that not all instances of hallucinations can be related directly to the
psychoses.
Why does Lacan insist on classifying mental structures as discrete entities?
Miller argues that it could well be a result of the Cartesian approach to philosophy
and psychoanalysis in France. That is probably why the causative mechanism for
each of these mental structures is also neatly differentiated with a separate name.
The causative mechanism in neuroses is repression; in psychoses, it is foreclosure;
and in the perversions, it is disavowal.
These then are the three modes of negation in psychoanalysis.
In the neuroses, it is the subject that is negated; in the psychoses, it is the name-of-
the-father that is negated; and in the perversions, it is the symbolic phallus which is
negated.
Lacan also considers the spread of patients in a typical clinic in terms of which of
these mental structures is most likely to occur in the male or female subject.

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While the male propensity to obsessions and the female propensity to hysteria is
well-known, Lacan points out that this is not always the case.
It is important not to essentialize the sexual or gender basis to mental structure. This
point becomes obvious in Lacanian discourse theory which accommodates male
hysteria and female psychosis.
This anti-essentialist approach to classification also gives Lacan an opportunity to
invoke his concept of ‘pousse à la femme’ in the context of how femininity is
implicated in the psychoses.
However the prototypes of mental structures for Lacan described in the the classic
Freudian case histories comprise Dora for hysteria, the Rat Man for obsessional
neurosis, Little Hans for phobia, and Schreber for psychosis.
These are the representative cases in the Freudian canon for Lacanian analysts.
In all these cases there is a problem not only with the subject’s approach to the name-
of-the-father, but also a predominance of the imaginary (as opposed to the symbolic)
and a negation of the importance of the father in the locus of the Other.
That is why Lacan was interested in the representations of the ‘humiliated father’ in
the work of the French writer, Paul Claudel.
That is also why it is important to refer these mental structures to not only the
oedipal matrix, but to the forms of symbolic deficit that the subject experiences in the
context of the symbolic father who is absent, indifferent, dead, or himself the cause
of trauma for the subject.
In all these instances, the subject is not able to come to terms with the lack in the
symbolic Other. In extreme cases, like the psychoses, this lack may repeatedly
emerge in the form of hallucinations.
Miller also differentiates between the roles played by hallucinations in hysteria as
opposed to the psychoses; he delineates the clinical conditions in which it is possible
to make progress towards a cure.

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Whether a cure is possible or not depends on whether the form of negation deployed
by the patient is dialectical or non-dialectical.
That is the sum of what Jacques-Alain Miller had to say at Sainte-Anne Hospital.
These clinical notes should help workers in the Freudian field to get a better
understanding of the different forms of classification and why Lacanians work with
discrete entities rather than with borderline categories in the context of a clinical
diagnosis.
It will also help them to relate symptoms with mental structures.
SHIVA KUMAR SRINIVASAN