Clinical Psychiatry Open Access

Keywords

Schizophrenia; Father; Mother; Metaphor; Development; Child; Medication; Treatment; Schreber; Lacan; Paternal; Schiller; Aulagnier; Vergote

Introduction

Child development: The crucial role of the mother
figure

When a child is born it is totally dependent upon another, upon a mother figure. A human baby could not even survive without the care and support of a mother figure. But total dependency is not acceptable for a consciousness. Hence the child must find a solution for this unacceptable situation. What do human beings do when they are faced with unacceptable situations, like having barely prepared for an exam and having received a bad grade. Human beings can, in such cases use their imagination. They can imagine and tell themselves that they will, next time, study hard and not just pass but get an A.

What can we suppose the child will start to imagine in order to deal with its unacceptable dependency. We propose that there is evidence that the child starts to imagine two things.

First, the child imagines that its mother or mother figure is omnipotent and perfect [1]. If the mother is not omnipotent and perfect the child does not feel save because the mother might not be powerful enough to protect it in danger. That human beings, as children, create something like the image of a powerful, perfect mother can be observed in their teenage years. All teenagers criticize their parents, including their mother. However, when such teenagers are with a group of friends and a friend openly criticizes their mother for the same reason that they themselves criticize their mother, such teenagers become upset and even angry. When asked how they would feel and react when a friend would criticize their mother openly for the same points, by which they internally criticize their mother, one teenager expressed herself metaphorically and said: “they would be dead.” Thus, even during the teenage years, when they criticize themselves their mother, they cannot tolerate that others criticize their mother. Thus, in the unconscious, there is a need to keep alive the idea of a powerful and perfect mother.

But the child needs to create a second fantasy to feel save even if it is totally dependent upon another. The reason is that the mother could be powerful and perfect but why should the mother always care for it, the child. To this uncertainty the child reacts by creating a second fantasy. They imagine that they are everything that a parent, a mother, would want. Winnicott says it even stronger. He argues that children who are healthy create the illusion that they possess the mother’s breast. The healthy child does not feel that it is given the breast from the outside. No, it feels that it itself possesses the breast which is available to the child anytime it wants it [2]. Again, we can find proof for this supposition.

An American family went to Germany for a year. When they had returned back to the US, the following scene occurred. On the breakfast table, the wife was looking at the newspaper and told her partner that there was an article which said that there were now few children in Germany. One of the children reacted to that piece of information by asking with some astonishment: “why are there so few children in Germany?” The mother answered with, what one can consider to be, a commonsense answer. She said: “I think those German parents must feel that having children is too much work.” To this information the four/ five-year-old child provided an answer which proves the second fantasy we have hypothesized. The child said: “Do those German parents not know that it are the children who do all the work?” To this answer the oldest child responded with aggressive conviction: “This is the dummest thing I have ever heard. It is only in this family that the children do everything.” In her answer the oldest child achieved several things. She could satisfy her sibling rivalry while also politely accusing the parents. But one thing was also clear from the oldest child’s response. She too believed that she was indispensable for her parents, since as child she did all the work that needed to be done in the family.

When children are able to develop those two fantasies they flourish. However, if those children would maintain those two fantasies, as adults, they would not be attractive choices to have as friends or as future partners. So, the internal psychic life of children must radically change for them to become acceptable mature adults. How does this change occur?

A first important step occurs during the no-saying period of about fifteen months [3-6]. No-saying is done more often to the mother figure than to any other figure. The result is that the no- saying period creates some distance between the child and its mother. Still that distance is relative. Thus, when a mother and a child are walking in the halls of a building, and the child is quibbling with the mother, it is enough that anyone approaches the couple and asks the child any question and the child immediately changes its position from quibbling child to a child that now holds on tightly to the legs of its mother. Thus, the quibbling between a young child and its mother goes together with giving the mother a privileged position. Still some distance is created between mother and child.

The distance created between the child and the mother, allows the young child to discover other people, most importantly the mother’s partner who is mostly the father. Having developed the ability to distinguish different persons the child is now in a position to discover that the mother has a relationship with her partner, which I will now, for simplicity’s sake, refer to as the father. If the mother does not show a relationship to the father figure, i.e., if the mother does not introduce a third in her relationship with the child, Lacan argues that we have the conditions for a psychotic structure in the child. This is the case because a crucial signifier “the Name-of- the-Father” is absent in the unconscious. This was the case with the famous German poet, Holderlin [7].

But discovering that the mother has a relationship with the father destroys the child’s two fantasies. First, the child figures out that if the mother has a relationship with the father, then the mother must be missing something. The mother therefore must not have it all. But second, if the mother is missing something, why is it the child not enough to give the mother what she misses [8]

If the discovery that the mother has a relationship with the father is so disturbing to the child we can now ask ourselves as to how the child reacts to this discovery. There are many examples showing that a first reaction of the child is to deny the fact that there is a such a relationship. There are even examples which show that children, even older children, try to disrupt the threatening discovery of a relationship between mother and father.

A friend reported that one of her children was about three or four years old when she let him go to a child care center in the morning. The mother picked him up at lunch time. At that time, the father was working at home. When the mother and son arrived home, the mother would ask the son to go upstairs to the father and ask him to come down for lunch.

The friend reported that when walking home from the child care center her son would say to her: “I am not going to tell. I am not going to tell”. When they came home the friend asked her son to call his father. He ran up the stairs and shouted that he, the father, needed to come down for lunch. Then her son ran back to the lunch table and said to his mom: “Dad is not coming.” Then the father came down and all three had lunch. This scene happened every day until a radical change occurred. After having called his father and after lunch had started, the son said that he would become a professor, the profession of his father. Later he stated that he would become a bicyclist. We have not yet the theory necessary to explain and fully understand the radical change at our lunch table but we have here a clear example that one reaction by the child to the discovery of his mother’s interest in the father is to try to deny that relationship as long as possible until the reality of the relationship sinks in.

There is a less civilized example that is even a clearer example of the child’s attempt to refuse the realization of the relationship of the mother with another. This was the case with a friend who had hired a baby sitter. The baby sitter had a one-year old child and had asked if she could bring her with. The friend agreed. Most often it was the wife who interacted with the babysitter. But one day the husband was the one who needed to give instructions to the babysitter. The baby sitter had her baby in her arms when the husband started to give the instructions. Presumably the baby experienced the man talking to her mother as a threat and flapped the man in the face. The mother was horrified and excused herself profusely. But this scene again demonstrates that a child must feel threatened by seeing that another than herself is important to the mother.

A last example comes from a student who reported that her mother was dating a new guy. She and her sister could not stand the idea that their mother was courting this guy. The student reported that she and her sister created a plot. They threw dirty stuff in the mother’s car and went to their mother and asked her to look at the dirty stuff in her car which they claimed that guy had left. They then asked their mother if she would still continue the relationship with that guy. The student reported that she and her sister were successful and their mother did not continue the new relationship. This example shows that the demand for exclusive attention by the mother continues even in later years.

Child development: The crucial role of the third, normally the father

We have already seen that the introduction of a third, most often that of the father in the life of the child, is a radical challenge for the child. We have seen that a first reaction is that of the attempted refusal of this third. Still if the mother continues to show respect and interest in that third, then the child has to accept the existence of such a third.

Children are resilient. Having to accept the reality of the third they readjust. Instead of concentrating themselves upon their mother they start taking a look at what it is in the father that is of such interest to the mother [5]. They then make that mark the basis of their identity [1]. But they know that they are not yet like the father but they will have to work to reach the mark they identified in the father as the reason for their mother’s interest in the father. If the child guesses that it is the father’s medical profession that is of such interest to the mother the child can make the goal of becoming an MD, but the child realizes that it is not yet an MD. The child then develops the ability to make the future the essence of its own identity. Such a child acquires the willingness to work, acquires the ability to accept that it is not yet what it wants to be and acquires the ability to have patience [1].

Lacan refers to this process of radical change as the consequence of incorporating the paternal metaphor [5]. By referring to this period in the life of the child, not just by the word “father” but rather by the expression “paternal metaphor”, Lacan implies that the introduction of a father in the life of the child has linguistic consequences. The introduction of the father invites the psychic changes which allow the child to possess the psychic characteristics to later understand metaphors [1]. Let us try to understand this claim of Lacan.

A metaphor, like somebody saying that you are a chicken, is a curious linguistic phenomenon. If someone says you are a chicken, that person does not mean to say that you are a chicken, that you have a beck, that you have feathers, etc.

Now the introduction of the father in the psychic life of the child makes that the child is invited to change. Originally the child was attached to the mother and created the necessary fantasies to accept that dependence. Later that same child attached itself to the father and developed a totally different personality. The child now learns patience and has less tantrums. The child has changed but is the same child. To be at the same time, the same child but also a changed child is psychologically the same as being a metaphor. That change in the same child is introduced by the incorporation of the figure of the father. Lacan refers to that consequence of the introduction of the father by calling the Oedipus complex the introduction of the paternal metaphor [6].

An example might illustrate the connection referred to by Lacan. A lady came to a therapist and said that she had no hands. The therapist asked how she knew. The patient said that her father had told her so. What your father told you, the therapist asked. The patient said that her father had told her that she was “handicapped”. She was only able to hear the literal meaning of the word “handicap” i.e., my hand is cut of [7]. Thus, for Lacan, being mentally ill is to have a defective relationship to language.

This Lacanian idea has far reaching consequences. Suppose that a student applies to many law schools and is rejected by all. Suppose that he applies again to law schools the next year and is again rejected. Such a young person can continue to apply for ever to law schools and become a failure in life. Or that person might make what we like to call a metaphoric move. He can ask himself: Why do I want to go to law school? He might discover that he wants to go to law school to earn a lot of money. He can then say to himself, but if I want to earn a lot of money and I am not accepted in law schools, I can become an old car salesman. He sees the possibility to replace something he cannot become (lawyer) by something else (salesperson) which he, from an essential point of view (earning a lot of money), he considers the same. He can be said to have made a metaphoric move in his life. Persons without metaphoric capabilities will therefore be stuck in life, whenever they cannot reach a goal because they do not have the psychic capabilities to look for an alternative that is acceptable: Something that is different but felt to be the same. They lack the ability to create metaphoric moves.

The Structure of Mental Illness: Absence of the Paternal Restructuring

In studying the case of Judge Schreber Lacan corrected Freud. Freud argued that the symptoms of Judge Schreber could be explained by the fact that Judge Schreber could not accept his homosexual feelings [8]. Instead, Lacan argued that Judge Schreber had not yet internalized the idea of sexual difference. Indeed, at the end of his life, he believed in his delusions that he was both a man and a woman having intercourse with himself [9].

Lacan then explained the symptoms of Judge Schreber as being the result of him not having incorporated psychically the role of the father [5]. Hence Judge Schreber’s illness could be explained by the fact that he still maintained the fantasies of a child where the role of the father had not been introduced.

Hence, Schreber felt that he was everything for an omnipotent other. Indeed, an essential figure in the hallucinations of Schreber was the omnipotent God. Furthermore, in his hallucinations Schreber was the crucial figure needed by God. Schreber hallucinated that he needed to become a woman in order to marry God in order to create a new mankind for God. For that new mankind Schreber would become the patron saint [9].

For Lacan, Judge Schreber showed through the features of his illness, that he had returned to the psychic structure of a baby relating to his or her mother. Judge Schreber fantasized to be the all-important person (child) for an omnipotent God (mother).

In reality, Scheber had become a successful lawyer and had been appointed president of the second highest court in Bismarck’s Germany [10]. Still there was one reason for deep unhappiness in the life of Schreber. He wanted to have children, but his wife had had five or six miscarriages [9]. Thus, Schreber was forced to accept that he might not have children.

Schreber dealt with his unfulfilled wish to have children by falling back on his psychic structure of a child. He imagined being a unique person for an almighty person. He hoped and expected that such an almighty person would, as his mother did, satisfy his wishes, in particular his wishes for a child. As we just mentioned, Judge Schreber hallucinated that he was becoming a woman to marry God in order to create a new mankind [9]. His wish to have children would be over satisfied.

A student of Lacan, Laplanche, described a concrete case of a schizophrenic breakdown: The case of the famous German poet Hölderlin. Hölderlin was a precocious genial poet. The recognized great poet Schiller discovered his work and promoted him [11]. He even introduced the young Hölderlin to Goethe (Ibid). So, Schiller played a maternal protective role for the young Hölderlin.

However, there emerged the tragic moment in the relationship between Hölderlin and Schiller. Hölderlin dreamt of creating a new journal and he expected that Schiller, whom he related to as his mother, would pay for the new journal. The report is that Schiller declined [11]. This refusal by Schiller destroyed for Hölderlin the image of Schiller as his good mother. Given that Hölderlin had not undergone a paternal restructuring, he was not able to relate to Schiller except as a mother figure. But he had related to Schiller as a mother. Hence, for Hölderlin the ability to relate to others was destroyed. That is when Hölderlin had his psychotic breakdown. He then was moved to an asylum in Southern Germany for one year. Thereafter, he was put in the care of a well-to-do and cultivated carpenter in Tübingen, where he stayed the rest of his life visited from time to time by dignitaries [11].

Beyon d Lacan

The theory of Lacan about schizophrenia explains the difficulties with language experienced by the patient. It does not explain well the difficulty that such patients have with their body. Vergote and Aulagnier introduce the idea that the mother of a person afflicted by schizophrenia was a defective mother as well. They explain the deficient relationship of persons afflicted by schizophrenia by referring to the deficiencies in the mothers of these patients.

Aulangier treated psychotic children. Aulagnier observed that there were no differences in the birth process of psychotic children and normal children. In both case there were both easy and difficult births. Aulagnier did discover a difference in the pregnancy experience of mothers of normal children and mothers of psychotic children. Mothers of future normal children go through the physical work of pregnancy. But they also do psychic work. Even when the future baby is only a fetus with a couple of cells, the mothers of future normal children start imagining the future child after birth. They imagine how the child will look. They imagine how they will deal with the child. They even start imagining what the future child will become.

A woman friend reported that when she became pregnant she gave her unborn child a name, because, she said, she wanted to be able to talk to future child in her.

Another illustration of the work of imagination that takes place during pregnancy is the testimony of the wife of another friend. To the question on what her reaction was when she saw her child after birth, this mother replied that she was amazed that her child did not look more after his father. This mother too had done psychic work during her physical pregnancy.

Aulagnier reports further that the presence of the labor of imagination has an impact on the experience of giving birth. Giving birth is experiencing that part of the own body is leaving the body. Giving birth is thus experiencing a loss. This loss creates what is known as the postpartum depression. Even mothers who did the labor of imagination during pregnancy are reported to have a feeling of depression. But mothers who did the work of imagination during pregnancy experience giving birth also as the realization of the expected child. Seeing their child lets a mother who did the work of imagination experience giving birth as a gift of what was expected. That aspect of the experience of giving birth let such a mother to overcome the postpartum depression, mostly, rather quickly.

Aulagnier reports that she discovered that mothers of future psychotic children did not do the labor of imagination she had observed in mothers of future normal children [6]. They do not do so because they do not accept the contribution of the father in the creation of their baby [6,12]. Thus, one mother reported that she felt that the contribution of the father to her baby was that his semen excited, tickled her egg [12]. Aulagnier reported further that such mother then relates to the newborn child as an extension of their body. They treat the new baby as a mouth to be fed, a bottom to be cleaned. Such mothers do not have the psychic power to project onto their new born baby the feeling that it is a new human being, not just a mouth to be fed and a bottom to be cleaned [12]. Such children lack the love of themselves by their mothers which must allow these children to love their own body in the mirror stage (Ibid).

Thus, we find in the theory of Aulagnier an argument to show that a defective mother can explain the defective relationship of a child and thus of a future adult to their own body. This is one of the characteristics of persons afflicted by schizophrenia, not explained fully by Lacan’s theory.

Vergote starts by pointing out that persons afflicted by schizophrenia do not use metaphors. Vergote then provides a deeper explanation for the absence of metaphors in the language of persons afflicted by schizophrenia than Lacan and his followers.

Lacan’s theory argues that the child changed its psychic structure by moving away from an identification with the mother to an identification with the father. Lacan theory sees that the same child has become different. To be different and also the same is the definition of a metaphor. Lacan even labels the move from mother to the father a linguistic move because it allows the child to incorporate a new signifier, i.e., the Name-of- the-Father in the psychic structure of the child. Hence Lacan relabels the Oedipoes complex the incorporation of the paternal metaphor. Lacanians then argue that this psychic move which incorporates the paternal metaphor makes such a child and such a person psychologically capable of using and understanding metaphors. Persons who have not incorporated psychically the paternal metaphor lack the psychological ability to understand linguistic metaphors. This was the case with a psychotic patient who interpreted the statement of her father that she was “handicap” as meaning that she had no hands.

Vergote sees another deficient structure in the psychotic person responsible for the deficient relations towards metaphors. Vergote also sees a different deficiency. Instead of misusing metaphors, Vergote points out that psychotic persons do not use metaphors. Vergote refers to Schreber’s Memoirs where we find no metaphors.

The argument of Vergote is as follows. In order to be able to use metaphors a person needs to have access to two substantially different kinds of signifiers. If I say to somebody that he is a chicken, I talk about a concrete visible animal in order to point to an abstract vice: Weakness. The two kinds of signifiers are on the one hand a signifier for an abstract idea and on the other hand a signifier for a concrete object representing the abstract idea.

Vergote then points out that a psychotic person constructs an ego where the pleasure-body is excluded. As a consequence, the psychotic person is deprived of a second series of signifiers substantially different from the abstract intellectual signifiers. The absence of this second and substantially different series of signifiers deprives the psychotic person of the tools to create and understand metaphors.

A More Complete Picture of the Symptoms of Persons Afflicted by Schizophrenia

DSM-V-TR gives five symptoms by which schizophrenia can be diagnosed. DSM-V-TR makes a difference between the first three and the two last symptoms. The first three symptoms are:

• Delusions.

• Hallucinations.

• Disorganized speech (e.g. frequent derailment or incoherence).

Of the two symptoms needed for a diagnosis of schizophrenia we need to observe at least one of these three symptoms.

The second group of symptoms contains the two following one

• Grossly disorganized or catatonic behavior.

• Negative symptoms (i.e., diminished emotional expression or
abolition).

Of those five symptoms, Lacan concentrates on the third symptom. The first two are understood as being methods to deal with a crucial but unsatisfied desire. The fourth symptom: i.e., grossly disorganized or catatonic behavior can be explained within the Lacanian theory by the fact that the psychic possession of the body is a precondition for proper bodily behavior. That coordinated behavior can be or become deficient when the psychic structuring connected with the mirror stage is defective. We indicated that such psychic structuring requires maternal love for the baby’s body. Indeed, Lacan later stressed that the child is not only looking at its own body in the mirror, the child looks and enjoys the pride of the mother seeing that her child is discovering its own self in the mirror. Such an interpretation of the mirror stage allows us to conclude that the baby uses the love of its mother to love its own body. Spitz reported on the consequences of such motherly love lacking. Such children are lacking in bodily development. As already reported, they walk later, they are toilet trained later and they talk later. Even more dramatically, 29.6% died the first year and another 7.7% in the second year. So, the absence of a loving mother does not just lead to retardation in bodily skills, it even leads to a greater % of dead [2].

Whereas Lacan concentrated his explanation of the symptoms of patients afflicted by schizophrenia on the deficiency of the paternal figure, with the help of Aulagnier and Vergote we have pointed out that the lack of a sufficiently caring mother has also negative consequences for the development and the experience of the own body for a human being.

In our explanation of schizophrenia, we have relied upon psychological causes with a bodily consequence. If my arguments are correct then it would follow that treatment of persons afflicted by schizophrenia should give preference to a psychological treatment. This theoretical conclusion finds statistical evidence in the success reported by the psychological treatment given to persons afflicted by schizophrenia. Karon and VandenBos devote a whole chapter in their book “Psychotherapy of Schizophrenia. The treatment of Choice” on outcomes of psychotherapy with schizophrenic patients. The authors conclude: “Medication seems more helpful than no treatment at all; psychotherapy for schizophrenic patients by “average” inexperienced (but medically qualified) therapists is not of much help. If careful quality control of what it is that is called psychotherapy is maintained, psychotherapy is helpful for schizophrenic patients”. In Finland where the “Open Dialogue” method is used the report is that “86% had returned to their studies or full-time job and that only 17% had relapsed during the first two years and 19% during the next three years”. The authors explain their method and their success as follows: “The focus [of the therapy] is primarily on promoting dialogue and secondarily on promoting change in the patient or in the family. In dialogue patients and families increase their sense of agency in their own lives by discussing the patient’s difficulties and problems” (Ibid). The ego-structuring method developed by Palle Villemoes too reports good success in healing patients afflicted by schizophrenia and psychosis [1]. One study described the results of the use of ego-structuring therapy on borderline and psychotic patients who were chronically ill and could not be helped by other methods. They had between 30 and 100 hours of therapy for a period lasting between six months and two years. The result measured by several different tests, reports and interviews were as follows: Clear improvement (35.1%); improvement but less (38%) and no change (27%) [1]. One of the unique aspects of ego-structuring is that the therapist cannot ask questions to the patient afflicted by schizophrenia. The argument is that such patients have not developed the ability to speak for themselves. Thus, Judge Schreber reported that he heard voices which told him part of a sentence and he had to complete the sentence according to the wishes of the voices even if the sentences were a self-description contrary to the opinion Judge Schreber had himself. Thus, Judge Schreber felt insulted when his doctor Flechsig told him that he was the “greatest seer of all centuries.” Schreber objected and said that it should have been at least the “greatest seer of spirits of all millennia” [9]. Patients suffering from schizophrenia do not define themselves. They feel defined by others.

Discussion

An American study reports on the positive effects of metacognitive reflection and insight therapy (MERIT) for patients suffering from schizophrenia. “Metacognitive reflection and insight therapy (MERIT) helped the client to move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and that of others. He then could use these representations to understand and effectively respond to life challenges” [13].

In France Cognitive Remediation (CR) was used to treat persons afflicted by schizophrenia. “Cognitive Remediation (CR) is a psychosocial therapy that seeks to restore patients’ cognitive abilities by providing strategies to improve functioning in cognitive domains and helping them transfer acquired capabilities to everyday life” [14].

The cognitive remediation therapy was found to be so successful that since 2008, CR programs have been introduced in several regional health ministry areas in France (Ibid).

Given the psychological interpretation of schizophrenia argued for in the beginning of this article, one should conclude that primary help for patients suffering from schizophrenia should be psychological which is provided by appropriate talk therapy. Several regional ministries in France have supported the “cognitive remediation” therapy for patients suffering from schizophrenia.

The psychological approach to the treatment of patients suffering from schizophrenia there is place for the use of medication. Some of the psychotherapists mentioned above explicitly recommend medication in the following conditions.

Vergote argues that medication is recommended if the patient cannot sleep because without sleep such a patient does not have the energy and concentration required to do psychoanalytic work. Karon too recommends that patients be given medication. He recommends in particular that patients be encouraged to keep medication on themselves in case they experience a sudden crisis.

But both Vergote and Karon consider medication a secondary help, since it does not address the cause of schizophrenia. Medication is helpful because it diminishes the impact of some symptoms.

If we look at the recommendations for different medications for schizophrenia we indeed find that the recommendations stress the help provided by the medication for some symptoms. They do not claim the ability to cure schizophrenia.

“Aplyta” is a new medication for the treatment of schizophrenia. The use of “aplyta” is recommended because of its efficacy with regards to the “Positive and Negative Syndrome Scale (PANSS) total score.”

The PANSS is a 30-item scale used to measure symptoms of schizophrenia. Compared to the placebo group, patients randomized to CAPLYTA 42 mg showed a statistically significant reduction from baseline to Day 28 in the PANSS total score. The treatment effect in the CAPLYTA 84 mg group (vs. placebo) was not statistically significant. The treatment effect in the CAPLYTA 28 mg group (vs. placebo) was not statistically significant [15].

Another new medication for persons afflicted by schizophrenia is Fanapt produced by Vanda. Vanda reports that taking Fanapt (24 mg/day) reduces the PANNS shore by 12 points whereas a placebo diminished it by 7.1 points. This medication is helping to reduce the severity of the symptoms. It is not aiming at a cure.

Parnas and Zandersen defend my position when they write: “That the essential feature of schizophrenic spectrum disorder is a disturbance of the core of the self in its immediate relation to the world” [16]. In a more recent article they refer to schizophrenia as a “self-disorder” and refer to and reflect upon the psychological treatment of schizophrenic patients when they write:

“Self-disorders research has important theoretical and therapeutic consequences. Schizophrenia spectrum is not seen as a contingent mixture and meaningless collection of positive and negative symptoms but as an expression of profound structural changes of subjective life that often cause suffering, other pathological phenomena, and varieties of dysfunctions. A familiarity with self-disorders enables the clinician to understand certain meaningful patterns of psychopathology and re- humanizes the patient-clinician relationship. Furthermore, such familiarity improves differential diagnosis, especially in the early stages of the illness and opens up novel psychotherapeutic approaches. Finally, a pathogenetic focus on a core phenotype may be more useful and fruitful than the study of causally distant symptoms such as delusions and hallucinations in Schizophrenia” [15].

Parnas and Zandersen and the people connected with “Self- disorders” stress, as I do, the psycho-social dimension of schizophrenia. The publications about medications, helpful for the patients suffering from schizophrenia, describe their medications only as helpful, not as a cure.

An example of a successful treatment of patients suffering from schizophrenia

In the practice we have treated patients sent to us with a diagnosis of schizophrenia. We concentrated on two such patients. The first patient was dismissed from a top university with a diagnosis of schizoaffective disorder. The second patient was sent to me with the diagnosis of schizophrenia. We used Lacan’s approach for diagnosing patient and use only three categories: neurotic illnesses, perversions (aggression and masochism) and psychosis. A nice method to make a tentative diagnosis of a new patient is to ask: “What brought you here?” When the patient answers by saying: A taxi, a bus or my car, then we have an indication that the patient is likely psychotic. They interpret language concretely.

Once a therapist has established that the patient is psychotic then a special form of treatment needs to be used. The treatment methods are dictated by the fact that the psychotic persons have no agency. They are not able to speak in their own name, as we illustrated with the case of Judge Schreber, who felt that he had to describe himself as the voices wanted it. Interpreting the symptoms of psychotic patients is therefore counterproductive.

Psychotic persons need help with their use of language. The goal of the treatment of such patients is for them to learn the implications of language. Thus, if psychotic patients want to have and want to keep a job, they have to accept that they need to go to work every day and that they need to arrive at work on time. To tell this to a psychotic patient has no permanent impact.

To improve the relationship to language for psychotic patients we started by describing in details the objects in the consulting room. We pointed to and name the door, the window, the book case and its books, the rug and its colors and figures. We went into so much detail that used a whole session of 45 minutes to describe the colors and figures of the rug in the room. In doing so the therapist provides a service to the psychotic patient. The therapist shows the patient that, even if one loses details in the description, (One patient explained his difficulties as follows. He said “If I look with my senses to the world, it is infinitely rich. If I describe it in language, I lose the infinite richness of the sensual world. What am I supposed to do?” By themselves, such patients cannot deal with the unavoidable loss involved in using language to speak about the sensual world. That same patient told me that he wants to know everything. However, he now realizes he cannot know everything. Again, this patient asked me: “What am I supposed to do?” In my opinion, such patients have not been able to introduce in their psychic structure the idea of loss that is connected by giving up the symbiotic unity with their mother as a child. Hence, no loss is psychically acceptable). One successfully communicates about what one sees. Hence, the patients feel that they live in the same world as the therapist. Hence, their loneliness diminishes.

Next one helps the patient describe their own room. Again, the therapist cannot ask questions. The therapist says something like: “People live either in a house or in an apartment”. If the patients say: “A house”, then the therapist can say: “Some houses stand alone or some house is connected with other houses”. If the patient states: “My house stands alone”, the therapist can then say: “Most houses have a door and one or two windows”. As this kind of talk therapy describes the patients’ own places, this part of the therapy satisfies the narcissism of the patients. This promotes identification with the therapist. When such an identification has taken place, it is time to move to the second phase of the therapy: The working phase.

In the working phase, the therapist helps the patients describe objects in earliest memory of the patient, by saying something like: “Many children go to Kindergarten. For some children, it is the mother who brings the child to school. For other children, it is the father”. The patient might say: “I walked with my siblings to school”. The therapist can then say: “I wonder if the siblings walked a bit fast”. The patient may then say: “Yes they pulled me along.” The therapist can then say: “The school building could be big or small.” The patients can then say: “It was big.” The therapist can then say: “When you arrived at school there must have been a play area. I wonder what you were playing?” The patient may say: “We played with a soccer ball.” The therapist may then ask: “I wonder if you made friends playing with the soccer ball?” The patient might say: “Yes, I liked two other students.” The next move of the therapist might be to say: “I wonder if you are still friends with them today.” The patient might answer: “I lost contact with one, but I am still in touch once a year with the other friend.” The therapist might then wonder what the patient and his old friend are doing together? This allows the patient to discover a continuation in his/her life. (As one can see from the above paragraph, the task of the therapist, treating psychotic patients, is to provide the language that the patients can use to describe their own situation).

The therapist can then let the patient describe what happened in the class. Again, the therapist helps the patients describe objects. The therapist can say: “I wonder if you were seated on a desk by yourself or with another student.” Next the therapist can say: “I wonder whether your desk was in front or in the back of the class”.

One invites the patient to describe then the first-grade class, then the second-grade class and so on. At one point, one of the patients was describing his place in second grade and suddenly added: “I was a trouble maker.” That patient went a step further and said: “I needed attention. At home I did not get attention by neither my mother nor my stepfather. So, I played the trouble maker in school”.

Having discovered the need to get attention, then made my therapeutic intervention and stated: I wonder how you can satisfy now your desire for attention”. The patient stated that he can aim for attention by working hard to get good grades. Having found a way to satisfy, in a constructive way, his desire for attention and for recognition the patient decided to stop the therapy. At this point we started the third phase of the therapy: ending therapy without the patient feeling a kind of permanent longing for the therapist. One way to do this, is by asking the patients what they have learned in the therapy.

The purpose of this kind of therapy is to invite the patients to describe objects in their memory. Normally patients start to connect the description of the remembered objects with people with whom they interacted. When one comes to the patients’ current age, they have discovered who they have become. They are able to take charge of their lives. After eight months of treatment, my first patient went back to his university and finished his college degree.

The second patient, early in the treatment, got a one day-a- week job at Walmart, from which he resigned soon. A bit later, he walked into a wine store and asked if they could use him. They said that they could use him a couple of days a week. He accepted the job. This job allowed my patient to interact impersonally with people. Six months later, the patient added, for one month, another part time job with the census bureau. He continued to apply for fulltime jobs and was successful in starting a fulltime job after 13 months of therapy.

In describing, early in the treatment, the objects of the kitchen, this patient agreed to clean the kitchen. This was the first active contribution to the duties around the apartment. Four months after the therapy had begun, the wife of the patient reported that the patient had made great dinners, including eggrolls. Talking about the objects in the environment of this patient, particularly the objects in the kitchen, became for this patient an invitation to take initiative. He started to cook for himself and his wife.

The patient’s wife often comes with to therapy. During the therapy, the quality of the marriage has substantially improved. The couple, including the schizophrenic patient, learned to communicate their desires and expectations.

Several patients confess that articulating their desires is very difficult. We let such patients describe what the advantages are of communicating their desires. By putting in words the advantages of communicating with their partners, such patients provide for themselves reasons to do the hard work of improving their communication. I do not give the reasons. We invite the patients to explore the reasons for working on their communication skills.

The goal of the therapy, however, is for the patients to report on the interactions with other people, so that the patients can discover who they have become who they are.

Conclusion

For Lacan schizophrenia is to be explained by the fact that the person did not benefit in his development, from the introduction in his psychic life of a father figure. Such a person has not been able to introduce the future as a time dimension by which one can deal with current deprivation. The other is for such figures like a mother figure that needs to provide all what the child wants. When such a figure does not provide such satisfaction then a breakdown occurs.

Lacan’s theory did not provide an explanation for some symptoms of psychotic persons, like their defective relationship to their body. From Vergote we learned that schizophrenic persons exclude in their ego construction signifiers for the pleasure-body. From Aulagnier we learned that psychotic children are deprived of the maternal imaginary support to experience their body. We learned from Spitz that absence of mothering care diminishes the child’s development in many domains and even leads to increased death ratio.

We also looked at the claims made about medications for the persons suffering from schizophrenia and discovered that medications are recommended for persons suffering from schizophrenia not for curing the illness but for ameliorating its symptoms. Medication can thus be an auxiliary method for treating persons suffering from schizophrenia supplementing a psychological treatment.

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