On Psychosis

Dear Sirs,

I would like to offer a small contribution to the important discussion of the problem of psychosis, which appeared in the latest issue of the  Int. J. Psycho-Anal.  84(1):  3-15↗.

It seems to me that an essential point of the entire problem of psychosis concerns the patient's relationship to reality. In the case of acute psychosis, are we in the presence of a denial of reality (Verleugnung)—that is, of a flat refusal or scotomisation of reality? Or, on the other hand, are we in the presence of a withdrawal from reality, a loss of contact, as a result of which reality is not exactly denied but rather becomes something strange, new and unrecognisable?

I believe that the latter is the case. Although they do not overlap, I consider Bion's beta elements, Lacan's forclusion and Freud's rejection (Verwerfung) as concepts leading in a completely different direction. More specifically, they suggest a reality stripped of its usual meanings, removed from the context of symbolic meanings in which it was immersed under normal conditions, rather than a reality that is denied or scotomised.

The next question is whether this process of withdrawal from reality—which ranges from bland depersonalisation to an all-inclusive catastrophic collapse—is purely defensive (that is, the patient withdraws from reality in order not to feel painful emotions), or is it predominantly passive, suffered, to the point of seeming to come from the outside, and thus threatening and incomprehensible?

I believe that this basic question—the relationship of denial or rejection or loss of reality and the active or passive nature of the process—represents a critical problem that psychiatry, phenomenology, neuroscience and psychoanalysis can all help to elucidate, and whose solution leads to crucial differences in techniques.

It is one thing to consider withdrawal/detachment as a defence, and therefore to oppose it by all means, albeit delicately, through interpretations that re-present the denied reality to t