Some effects of subjective elaborations in child psychosis: The clinical interest of a Lacanian approachAbstract
The article examines the relevance of a Lacanian approach in treating children with psychosis, emphasizing the continuity between childhood and adult psychoses. Through a literature review and clinical examples, the authors demonstrate that psychosis should not be seen solely as pathological, but rather as a subjective structure that can be compensated. This compensation allows psychotic children to achieve social integration by using specific mechanisms to cope with their symptoms. Clinical cases, such as those of Maxime and Paul, illustrate how interventions based on Lacan’s theory assist in the children’s social and subjective recovery. The Lacanian approach is valued for respecting the singularity of the subject and avoiding pathological labels, creating space for creative and therapeutic solutions. It provides a framework that allows the therapist to welcome symptoms and guide treatment in an individualized, non-predictive manner
Keywords:
Childhood psychosis; psychoanalysis; subjectivity; recovery; ordinary psychosis
Resumo
O artigo examina a relevância de uma abordagem lacaniana no tratamento de crianças com psicose, destacando a continuidade entre as psicoses infantis e adultas. Através de uma revisão da literatura e de exemplos clínicos, os autores demonstram que a psicose não deve ser considerada exclusivamente patológica, mas uma estrutura subjetiva que pode ser compensada. Essa compensação permite que crianças psicóticas alcancem integração social, utilizando mecanismos singulares para lidar com os sintomas. Casos clínicos, como os de Maxime e Paul, ilustram como intervenções baseadas na teoria de Lacan ajudam na recuperação social e subjetiva das crianças. A abordagem lacaniana é valorizada por respeitar a singularidade do sujeito e evitar rótulos patológicos, abrindo espaço para soluções criativas e terapêuticas. Ela fornece uma estrutura que permite ao terapeuta acolher os sintomas e guiar o tratamento de forma individualizada e não preditiva.
Palavras-chave:
Psicose infantil; psicanálise; subjetividade; recuperação; psicose ordinária
Abstract
L’article examine la pertinence d’une approche lacanienne dans le traitement des enfants atteints de psychose, en soulignant la continuité entre les psychoses de l’enfant et celles de l’adulte. À travers une revue de la littérature et des exemples cliniques, les auteurs démontrent que la psychose ne doit pas être considérée comme exclusivement pathologique, mais plutôt comme une structure subjective qui peut être compensée. Cette compensation permet aux enfants psychotiques de s’intégrer socialement en utilisant des mécanismes spécifiques pour faire face à leurs symptômes. Des cas cliniques, comme ceux de Maxime et de Paul, illustrent comment les interventions basées sur la théorie de Lacan aident les enfants à se rétablir socialement et subjectivement. L’approche lacanienne est appréciée parce qu’elle respecte la singularité du sujet et évite les étiquettes pathologiques, laissant place à des solutions créatives et thérapeutiques. Elle fournit un cadre qui permet au thérapeute d’accueillir les symptômes et d’orienter le traitement de manière individualisée et non prédictive.
Mots-clés:
Psychose infantile; psychanalyse; subjectivité; rétablissement; psychos ordinaire
Resumen
El artículo examina la relevancia de un enfoque lacaniano en el tratamiento de niños con psicosis, destacando la continuidad entre las psicosis infantiles y adultas. A través de una revisión de la literatura y ejemplos clínicos, los autores demuestran que la psicosis no debe considerarse únicamente patológica, sino como una estructura subjetiva que puede ser compensada. Esta compensación permite que los niños psicóticos logren una integración social, utilizando mecanismos singulares para lidiar con sus síntomas. Casos clínicos, como los de Maxime y Paul, ilustran cómo las intervenciones basadas en la teoría de Lacan ayudan en la recuperación social y subjetiva de los niños. El enfoque lacaniano es valorado por respetar la singularidad del sujeto y evitar etiquetas patológicas, abriendo espacio para soluciones creativas y terapéuticas. Proporciona, así, un marco que permite al terapeuta acoger los síntomas y guiar el tratamiento de manera individualizada y no predictiva.
Palabras clave:
Psicosis infantil; psicoanálisis; subjectividad; recupración; psicosis ordinaria
Introduction
While the recovery hypothesis has been fairly widely exemplified in the adult clinic, it still seems insufficiently explicit on the philosophical level that underpins it (Wannberg, 2022) particularly given the widespread dissemination of degenerative theories. In fact, it is even rarer to read about it in relation to infantile psychoses, which are undoubtedly suspected of being more serious when they appear at an early age, despite the statistical evidence that infantile psychoses do not necessarily have a pejorative course (Eggers et al., 1999; Eggers & Bunk, 1997). It should also be noted that, while the term “infantile psychosis” persists in the French CFTMEA (Misès, 2020) this diagnosis is considered extremely rare. Autism spectrum disorder, developmental disharmonies and neurodevelopmental disorders seem to be preferred by the new classifications, which are now based at least as much on public health needs (health economics - particularly important when it comes to financial compensation for a handicap), on associative or lobbyist pressures, as on heuristic considerations. According to de Becker, the notion of psychosis is now used only by psychodynamic approaches (De Becker, 2014).
Despite these new classifications, and the fact that autism and schizophrenia are now addressed as spectrums by some classifications, a number of clinicians refer in their practice to the Lacanian notion of subjective structure (Lima, 2001; Brémaud, 2017, 2020; Leduc & Roy, 2019; Lucchelli, 2018; Tyszler, 2024). And Benoist has shown that there is not only Lacan’s teaching on infantile psychosis, but also a contribution by the French psychoanalyst to the international debate (Benoist, 2007) in particular with Melanie Klein. While both referred to Freud, Lacan’s orientation was resolutely structural in the early years, while Klein studied object relations. In fact, from the outset, psychoanalysis was based on the idea that the symptoms presented by patients were responses to an unconscious conflict they were experiencing. The initial hypothesis, based on encounters with hysterical patients, was extrapolated to psychosis - the Freudian idea of delirium as an attempt at healing was widely exploited and demonstrated its relevance - but also very quickly to treatment with children: we were interested in their drawings, the games they invented (Winnicott, Klein, Anna Freud etc.), i.e., their productions as being equivalent to the subjective elaborations of adult patients. Vanier indicates that the object a that Lacan invents borrows from the notion of the transitional object, which Winnicott discovered in the infantile clinic (Vanier, 2009), and with which he also corresponds (Lacan, 1985). Subsequent developments led him to move away from Winnicott’s concept. Indeed, Lacan subsequently draws on the model of the child completed by the maternal breast to develop this concept. He is also interested in the game of Fort Da. Although he makes the object a a key operator for formalising the logic of desire, which is far from being limited to psychoanalysis with children, this connection is yet another indication of Lacan’s interest in psychoanalytic work with children. However, it should be noted that during seminars X and XI, Lacan constructed the object a to designate that part of the real which cannot be symbolised. It designates this residue, lost in the operation of castration. Unlike Winnicott’s transitional object, Lacan’s object is not a physical object, but represents precisely the missing object.
In the early years of his teaching, Lacan was interested in developing a structural clinic and isolating the signifiant of the Name-of-the-Father, as well as its function in the production of phallic meaning. After focusing on distinguishing between the symbolic, the imaginary and the real, Lacan gradually abandoned the idea of the supremacy of the symbolic in favour of a topological logic. However, this latest teaching, along with the RSI and Le Sinthome seminars, does not erase the initial structuralism. The shift from structural logic to Borromean logic is not a replacement of one by the other. The clinic introduced through topology proves to be more capable of representing a subjective logic, particularly because it allows us to think about subjective elaborations and the paths of cures. When he applies it to Joyce’s writing, it is to represent the compensatory ego. This theory laid the foundations for a clinic specific to the subjective structure of psychosis, enabling psychosis to be considered outside of its pathological aspects as a unique way of functioning. This also has the effect of directing the course of treatment not towards discovering meaning, but rather towards identifying what enables each individual to defend themselves against the Real (which is not reality) they are facing.
The knot clinic proposed from the 1974 R.S.I seminar (unpublished) insists in some way on fluidity: it takes into account the dynamic nature of the symptom within the structure (Maleval, 2019) to move from a logic of psychic conflict to a logic of arrangements (Miller, 1998). Since then, the Lacanian psychosis clinic has evolved to the point where it has practically broken with the distinction between normal and pathological, as exemplified by “ordinary psychosis”, a term conceived above all as a space for discussion (Miller, 2009). In response to the decompensation of certain psychoses during psychoanalysis as mentioned by Lacan as soon as 1956 (Lacan, 1955-56/1996, p. 285), and the proliferation of subjects whose symptoms were not clearly delusional, three clinical conversations were organised in France (Le Conciliabule d’Angers, La Conversation d’Arcachon and La Convention d’Antibes). These conversations led to the proposal that certain subjects in analysis presented a psychotic structure without necessarily presenting a pathology in the medical sense. These include ‘compensated psychosis, supplemented psychosis, non-triggered psychosis, mediated psychosis, psychosis in therapy, psychosis in analysis, evolving psychosis, sinthomatous psychosis’ (Deffieux and Dewambrechies-La Sagna, 1999). Reference could also be made to cured psychoses or those presenting discrete symptoms. This diagnostic approach allows us to reconnect with the work of classical psychiatry, which was familiar with subtle signs of pathology, but also to think about psychosis outside of these moments of decompensation: in the absence of triggers, but also afterwards, when the subject has been able to reintegrate into a social environment that suits them. This clinic of discrete signs does not, however, call into question the existence of subjective mechanisms specific to psychosis (Grammatopoulos, 2017; Lippi, 2015; Maleval, 2000, 2019; Peoc’h, 2022; Redmond, 2013; Trichet, 2018; Vanheule, 2014, 2017).
While autism spectrum disorders are now undoubtedly the most widely used category in child psychopathology, mainly due to the broadening of inclusion criteria, the Lacanian psychoanalytic approach frequently distinguishes them from child psychoses (Grollier & Maleval, 2022) to the point of proposing to make them a structure in their own right (Brenner, 2020; Frigaux et al., 2018, 2021; Lefort & Lefort, 2003; Maleval, 2021). One of the major arguments of these authors is that infantile autism does not evolve into adult psychosis. The prominence of autism in child psychopathology does not necessarily mean that childhood psychoses have disappeared, but that a differential clinic exists (Frigaux et al., 2021; Grollier & Maleval, 2022).
In a Lacanian orientation, the subjective structure as such has no pathological value, and can be reconciled with the idea that a modification of symptoms is possible: moving the subject from a position of illness, in difficulty with the social bond, to a position where a satisfying insertion is possible.
Lacanian psychosis theory implies that psychotic decompensation is the unveiling of a pre-existing structure, hitherto masked by more or less effective compensations for integration into the social bond (Trichet, 2011). The most accomplished elaboration, via a Borromean conception of the subject, implies the existence of multiple possibilities of subjective knotting. In this way, it paves the way for current work on so-called “ordinary” psychoses. These not only highlight the multiple possibilities of compensation or substitution, but also turn the very concept of psychotic structure on its head, from the point of view of symptomatology. Ordinary psychosis is not a specific category; it is, in fact, the ordinary of psychosis: it indicates a mode of structuring that can be identified by clues, but whose symptoms are sufficiently tempered to allow insertion into the ordinary social bond.
All statistical studies agree that, whether in children or adults, chronicity is not the norm, even for subjects whose psychosis may have required hospitalization (Bleuler, 1968; Ciompi & Müller, 2014; Eggers et al., 1999; Eggers & Bunk, 1997; Modestin et al., 2003). While the value of identifying certain determinants of psychotic structure has been demonstrated (Maleval, 2019) for the conduct of treatment, there seems to be little work on extrapolating this to symptoms presented in childhood. In the case of psychotic adults, subjective experience must be taken into account as part of a recovery-oriented dynamic (Best et al., 2020; Moernaut et al., 2023). Thus, an interest in the symptomatic constructs of children with a psychotic structure could help shed light on the paths to recovery in child psychiatry. This is if we accept the idea of their potentially self-therapeutic value, as demonstrated in the wake of Freud (Freud, 1999; Lacan, 2015; Maleval, 2019; Trichet, 2011; Vanheule, 2017). Most of this work focuses on adult psychoses, but considering the unity of subjective structure implies identifying the equivalence of child and adult psychoses from the point of view of psychic economy. This could indicate that there is an interest in investigating these possibilities in the field of childhood. However, while a similar logic can be detected in the subjective constructs of children and adults, daily clinical practice does reveal differences in symptomatic expression.
We will therefore develop the interest of thinking of psychosis as a structure, in order to take into account its possible compensations. Then, using the treatment of a few young subjects, we’ll show that a therapeutic orientation that considers the symptom as a singular construction aimed at preserving psychic equilibrium - following the initial Freudian hypothesis (Freud, 2005) - can lead to a favourable outcome, by distinguishing some frequently encountered modes of compensation, and what they respond to from a structural point of view. In this way, we aim to demonstrate the clinical value of an approach centred on the elaborations of psychotic children to improve their subjective position.
Childhood psychosis and compensation
Behind the difficulty of defining a specifically infantile psychosis, it is the complexity of distinguishing child psychiatry from adult psychiatry that first emerges. In 2004, Goëb raised the still lively debate between childhood schizophrenia and schizophrenia from childhood onwards (Goëb, 2004) reminding us that the symptoms of childhood schizophrenia are similar to those of adult schizophrenia, and cannot be subsumed under the idea of an incipient pathology. This is also echoed in the study by Driver et al. who agree not to differentiate symptoms, but age of onset (Driver et al., 2013) in line with Kolvin’s work (Kolvin, 1971) regularly cited as the first to clearly separate childhood schizophrenia, childhood psychosis and autism - although the diagnosis remains complex, both from a psychoanalytic perspective (Brémaud, 2017) phenomenological (Poletti & Raballo, 2020) as well as from a somatic perspective (combining brain imaging, studies of responses to medication, and genetic exploration) (Driver et al., 2013; Grim, 2017). Lacanian theory, for its part, proposes a breakdown based on the consideration and treatment of what constitutes a symptom (Grollier & Maleval, 2022). It should also be remembered that, from its very beginnings, child psychiatry has drawn heavily on psychodynamic theories. The works of post-Freudians such as Melanie Klein, Anna Freud and Winnicott are still frequently used in clinical child psychiatry practice. The French classification of mental disorders in children and adolescents1, drawn up under the direction of Roger Misès, takes these theories into account, with reference to the notion of transitional spaces, for example, and differentiates between autism and psychotic disharmonies, as a counterpoint to a vision that would encompass all childhood disorders under the category of neurodevelopmental disorders. According to Misès, Garret-Gloanec and Coinçon, the differentiation of these different modes of being in the world would also lead to the possibility of specific therapeutic actions, notably aiming at the remission of symptoms associated with psychotic disharmonies (Misès et al., 2010).
The Lacanian approach differs somewhat from these theories, in that it is not based on the Freudian developmental stages of the subject, but on his subjective logic, and in particular on the way in which the subject contains jouissance. As a young psychiatrist, Lacan co-authored an article pointing out the similarities between childhood schizophrenia and adult schizophrenia, based on a case study (Claude et al., 1933). Several years later, in 1968, as a psychoanalyst closing a conference on child psychoses, he reaffirmed that the child is immediately in language, even if it means covering its ears (Lacan, 2001a) This is a sign that the child is a fully-fledged subject, and that there is no specifically infantile logic. Lacan’s other classic text on the infantile clinic, the “Note on the Child” (Lacan, 2001b) defines two positions: either the child is a symptom of the parental couple, or it would be in the position of an object fulfilling the fantasy. Again, we note that there is nothing in these texts to indicate a specificity of child psychopathology.
On the other hand, Lacan’s distinct subjective positions do not presage a lifelong pathological evolution. His medical thesis in 1931 was devoted to the study of a paranoid subject whom he considered to have recovered. In 1958, following in Freud’s footsteps, he put forward the idea that, at the end of his delirium, President Schreber showed an elegant solution rather than demonic chaos. In this sense, it is possible to understand the psychoanalyst as saying that Schreber had rather recovered from his clinical psychosis by the time his testimony was published. (“D’une question préliminaire à tout traitement possible de la psychose”, 1966) - although some delusions persisted. It wasn’t until the 1970s, with his theorization based on Joyce (Lacan, 2005) to lay the solid foundations for a conception of psychosis that is not subordinated to its pathological aspect. In fact, the very notion of triggering appears much more fluid: as psychosis is characterized by a non-Oedipal knotting, there is nothing to suggest that there is necessarily a prior state of equilibrium that would be durably shaken, and the emphasis has since been placed on the study of discrete signs (Discrete signs in ordinary psychoses, 2017). There are structural clues that can be perceived before an outright onset - without, however, deciding on the subject’s future. There is no way of predicting whether the undermining of compensations will be long-lasting or give rise to a new, satisfactory elaboration for the subject. This leads to a conception of the psychotic structure as a subjective mode of being in the world, which may or may not have pathological moments (Maleval, 2019). This theory is perfectly compatible with the aspirations of classical alienism, which knew no incurable pathology, as well as with Lantéri-Laura’s criticism of chronicity in psychiatry (Lantéri-Laura, 1997). It also makes it possible to bring together different clinical phenotypes behind the same structuring mode, and responds to the reality that the same patient can present such heterogeneous symptomatologies over the course of his or her life that two successive hospitalizations can lead to two distinct diagnoses. There is no reason why this concept should not be valid in child psychopathology. Indeed, the only large-scale catamnestic study of early-onset psychoses - conducted by Eggers - invalidates the idea of chronicity in this population. (Eggers et al., 1999; Eggers & Bunk, 1997). On the contrary, a model that takes into account the existence of possible moments of disconnection (Hulak, 2009) is able to transcribe the clinical experience of hospitalization or medical-social support, but also of insertion into a satisfactory social bond, of complete or transitory re-establishment, of new equilibrium. This theoretical approach allows us to think of the pathological nature of psychosis as potentially transitory. Thus, the psychotic structure can decompensate without this necessarily being definitive. Bridges can then be built with the study of ordinary lucid psychosis (Trichet, 2018) or subjective recovery in schizophrenia (Moernaut et al., 2023) for example, and it would not seem incongruous to consider that the same phenomenon - involving personal meaning, knowledge of one’s own subjective functioning, personal compromises enabling one to accept certain symptoms - can be found in the infantile clinic.
These considerations seem the indispensable prerequisite for designing a practice that keeps as its compass the possibility of a singular sustainable subjective arrangement (Rabeyron, 2021). The Lacanian clinic of psychosis is also guided by a number of theoretical beacons of importance to the conduct of treatment. Maleval (Maleval, 2019) categorized the types of problems encountered by psychotic subjects based on a Borromean conception of structure, as well as some symptomatic montages responding to them as compensations in ordinary psychosis, by bringing Lacanian theory of psychosis into dialogue with descriptions of classical psychopathology. Miller, for his part, refers to these clinical clues to a psychotic structure that is not frankly triggered as a “triple externality”: social, bodily and subjective (Miller, 2009).
Social externality is the difficulty of embodying a social identity. It’s a clinic of over-identification with a social role. The As if personalities described by Hélène Deutsch are a good example: a role may be highly invested in by the subject, but it also differs from one position to another as encounters take place. The Typus melancholicus described by Tellenbach and Kraus is also related to this, and presents particularly well the idea of a subjective arrangement enabling the subject to maintain himself in a social bond unless his imaginary support fails (Englebert & Stanghellini, 2016). In children and adolescents, this type of clinic is encountered in particular with subjects who find equilibrium by structuring themselves around the idealized image of a model - a parent, a playmate, an invested figure - behind whom they line up without symbolic deviation to fulfill a role. But more massive symptoms also exist: the subject finds himself without symbolic reference points, and doesn’t know how to occupy a place in his own space.
Bodily externality refers to the body phenomena classically described in psychosis, whether as massive symptoms (such as the “fragmented body” described in schizophrenia or disharmonies), psychotic psychomotor agitation, or more camouflaged when the subject manages to compensate for the effects of the mirror sign, for example (Maleval, 2019).
Subjective externality indicates the difficulty some people have in positioning themselves within a desiring logic: in pathological forms, we’re thinking in particular of certain infantile-juvenile depressions, and more generally of clinical manifestations in which the subject cannot position itself as the subject of enunciation. Some have difficulty deciding on the meaning of what is said to them, or fail to recognize themselves in the actions they have taken.
This proposed division is an interesting way of thinking about the various symptoms encountered in psychosis from a logical point of view. A therapeutic orientation can be deduced from it, one that aims to support subjective inventions that help to absorb this externality and enable the subject to become part of a social bond (Peoc’h et al., 2022). Conceiving of the uniqueness of the psychotic structure implies applying these considerations to the support of subjects with decompensated infantile psychosis. If ordinary psychosis is sometimes conceived as a structure that does not decompensate in a truly pathological form (Avdelidi & Marret, 2016) the syntagm is in fact coined to name a variety of psychoses: mediated, compensated, in therapy, evolving, etc. (Deffieux & Dewambrechies-La Sagna, 1999). The term is well-suited to describing subjects with a psychotic structure whose symptoms do not lead to total disengagement from social ties. So there’s nothing to stop us thinking in terms of an ordinary post-trigger psychosis, which is perfectly compatible with current accounts of recovery from clinical psychosis (Moernaut et al., 2023).
Conceiving, on the one hand, the uniqueness of the psychotic structure (child and adult, ordinary psychosis - decompensated psychosis), and on the other, the possibilities of compensating for the symptoms of psychosis, enables us to conceive of the possibilities of recovery from decompensated psychosis at an early age, based on the guidelines of a Lacanian theory. While there is no guarantee of a successful recovery, we do recognize that, by keeping this option open, the possibility of inventing a path other than that of chronicization appears for the subject. The observations below will illustrate the effects of this orientation with a few young subjects. The names and clinical history data that would allows these subjects to be identified have been changed, in accordance with their wishes. These three subjects were addressed over many years in two different public or semi-public care facilities for children with psychopathological symptoms. A combination of psychological support, medical (psychiatric) care, nursing care and educational support was provided. The authors of this article, who are clinical psychologists at these institutions, each individually treated the children whose cases are presented here.
Maxime
Currently of age, and enrolled in a vocational training program, Maxime was 15 at the end of our meetings and in 9th grade, despite a manifest psychosis whose symptoms had made schooling virtually impossible five years earlier. Attending school only twice an hour and a half a week, he was unable to contain what he called “crises”, which manifested themselves in violent agitation requiring several adults to restrain him, despite treatment with risperidone. His crises are essentially triggered by a delusional interpretation of the malevolence of others. He says he recognizes this aggression by the looks he receives. The hospitalizations that were sometimes necessary had enabled the neuroleptic treatment to be set up, and the patient to become part of the care circuit. During the early stages of his treatment, the asylumfunction of the hospital continued to constitute a recourse on a few occasions, when persecution and aggressive defence became too incompatible with life in society. Since the age of 13, he has had no further recourse to this treatment modality.
Maxime was quick to mention the need to channel his stress through a very unusual practice. He did “Bjjj”. This was a quasi-autistic practice of enjoyment, during which no noise from the person accompanying him was allowed. Nothing should interrupt this practice, which usually lasts a few minutes during a journey. He indicates the intimate nature of this practice, since he only indulges in it in places where he can trust: with the service’s professionals, or at his mother’s, alone in his room. “It relaxes me”, he used to say. It’s all about messy finger movements, waving like little figures at face level, accompanied by noises that reveal words, but mostly onomatopoeia. When asked about this activity, he was able to say that he was playing with his fingers, and that he was running a scenario from a Japanese series in his head, without the two practices - thought and finger movement - being linked. These “bjjj” are an essential invention, enabling him to separate himself from too much pleasure in a senseless activity (Maleval, 2000) in other words, meaningless and non-dialectisable. The interest of this practice lies in its localized character. He would never, he says, do this in the presence of others. If he realized a little late that he hadn’t done his “bjjj” on the way back to where he lived or went to school, he’d rush to do it, so as to get through the rest of the day in peace. After a few years, he discovered that the cell phone had the same function for him, and that if he regularly indulged in “a bit of screen time”, he obtained the same self-therapeutic result as with his sound effects. The gain in terms of social integration is certain, and this relief can then be obtained without danger under the gaze of others, who do not attribute any pathological character to this banal practice for those who confine themselves to the status of observer.
One of Maxime’s other supports was a desire not to be stigmatized as disabled. Deeply devalued, occasionally feeling like “a piece of shit”, or “a demon”, “an insignificant thing”, one of his most frequent interpretations involved the dislike, or even hatred, he felt. To escape this persecution, he would model his appearance and behaviour on “typical” adolescent models, in order to blend in. The lack of a fundamental fantasy (Maleval, 2019) is thus compensated for by identifying the right position to adopt based on what he observes in others. However, while identifications are very common in adolescence, when many seek to build their identity by taking on models, Maxime’s strategy is not based on a fantasy or values, but on a pure image he constructs for himself by observing his peers as an ethnologist. He was well aware of his permeability to the environment, and still holds a grudge against a former care service for inviting him to take part in a therapeutic group with “unruly children”. “It only made me more boisterous - he said - they kept looking for me!” He says he himself made efforts to at least pretend to be with the others. He did his best not to throw a tantrum in front of his classmates, supervisors and teachers. He was a studious student, who made a point of taking part in the charitable events of the private religious establishment he attended, not out of devotion, but out of a concern to fit in.
Lastly, its reliance on transference seems crucial in establishing a cushioning point to weigh down the signifying chain (Maleval, 2000). Very early on, when our appointments were not yet formal, he left a used handkerchief, saying: “I entrust you with my germs and my sense of smell”, a real piece of his body, which we kept “safe from contamination”, in a box, for the five years of the treatment. Recently, when he got back in touch with us about a detail in his file, he asked us about this handkerchief. In the context of his reception, he found the guarantee of a particularized place and the transferential link enabling him to intervene seriously when the paranoid defence gave way to the feeling of unworthiness. It wasn’t a question of getting him to talk about himself. This directly opens up the real hole into which he falls like a waste object, without really defending himself. His suicidal talk is sometimes very elaborate, and it seemed reasonable to fear for his life at such moments. With the practice of conversation (Maleval, 2022) in the course of conventional sessions, but also during car journeys, he elaborates a point from which he can speak in order to be recognized, even if this remains precarious. In this way, he reinstates a kind of I by making himself the subject of his enunciation.
At present, although he still sometimes displays a great deal of confusion, he is concentrating his efforts on finding a suitable career direction. His originality may not go unnoticed when he’s with someone long enough, but it’s rarely interpreted as pathological. He has friends, and is recognized in certain communities.
Paul
Paul arrived in a medical-social service when he was around ten years old. Having been treated in private practice since an early age, he himself testifies to having been “completely crazy” when he was younger. What he calls “crazy” seems to refer to agitation, with regular selfand hetero-aggressive acts, banging his head against the floor or walls, and having no friends his own age. By the age of eleven, he was no longer self-harming, but he still had no friends, and he sometimes presented episodes that brought together the characteristics of the paranoid delusion of classical psychiatry. His paranoia is particularly evident in the run-up to the class delegate elections, for which he is a fairly systematic candidate. As the election campaign progresses, which he takes very seriously, he becomes convinced that he is being slandered. He loses his temper, rebelling against those he interprets as his enemies. All signs point to his dropping out of the competition, swearing that he is misunderstood, and his classmates choosing the candidate they like over him, the only guarantor of a reasonable - if tyrannical - program (which he himself admits, since he believes that dictatorship is undoubtedly the best political path in his class).
Unlike Maxime, it’s not the gaze of others that he interprets, but the malignity he lodges in their words. For him, the language of the Other is constantly laden with innuendo, because it is not weighted down by the phallic signifier, which produces a gap between signifier and signified, enabling a meaning to be inferred (Maleval, 2000). Over time, however, he gains imaginary support from his father, recognizing that he possesses a certain sense of humour. He himself begins to use it in the course of the sessions, turning it into a weapon at school - which we support. Rather than acting out, he tries to disorientate his interlocutor, with varying degrees of success. This practice enables him to take a step back from the bullying he claims to have suffered, and the melancholy backlash that follows. When he gives up, he reveals a great sense of helplessness, and raises fears of suicide. His phlegmatic sense of humour helps to keep him away from it: one day, he announces that he is going to start writing the “diary of a poor schoolboy”, in which he will retrace his misadventures. Although the promised work never saw the light of day, always postponed, the regular reference to it as an address for his torments was enough to inject a little desire back into his suicidal ruminations. In 1886, Paul Pottier found in the writings of persecuted-persecutors “a style evoking the misery with which they are burdened by innuendo” (Pottier, 1886). If this indication is consistent with Paul’s practice, it should also be added that these writings are a precious support in the construction of a subjective solution, as witnessed by the frequency and abundance of writings by paranoid subjects. Paul also developed a liking for the book trade, and tried his hand at it during an internship, before finally abandoning it.
The transfer and recognition of his own know-how has enabled him to draw on the department as a whole to deal with the persecution or perplexity he felt, by coming to lodge physically with it sometimes between two hours of lessons, outside his usual appointments. A turning point seems to occur for him at the same time as he gains recognition for his qualities as an artist. He confides his delirious certainty: he knows he is God, since nothing existed before him and nothing will exist after him, but recognizes that he cannot share this with anyone but us without risking being mocked. Only the intimate setting of the sessions and the trust established by the transference enable him to confide this at a time when he has precisely ceased to impose this vision on others. When he entered high school, he was able to put his skills as a writer and comedian to good use, working with a small group of friends to write and perform sketches. He also asked for his treatment to be terminated, which of course the department agreed to in view of the marked improvement in his condition.
A few months later, he seems to have experienced a form of “disconnection”. (Castanet & De Georges, 1999) which resembled the prodromes of schizophrenic decompensation: perplexity, invaded by voices, anhedonia among other things. He re-addressed to us for a short time, which was enough for him to regain his footing. He now attends ordinary high school, where his preoccupations go largely unnoticed.
These two examples show that it is possible to aim for and sometimes obtain sufficient subjective elaboration for these subjects to be considered “recovered” if we take into account studies on subjective recovery (Castelein et al., 2021; Moernaut et al., 2023; Vanheule, 2017). This is because, in addition to being able to integrate into ordinary social relationships, and no longer expressing embarrassment about the symptoms they presented in childhood, they have acquired a form of knowledge about their own functioning that enables them to accept certain symptoms or avoid certain problematic situations. Pre-established recovery programs tend to focus on the patient’s acceptance of his or her disorders, which is partly accompanied by the patient’s necessary submission to medical knowledge. This submission is sometimes impossible for the patient to accept. Psychoanalytic conversations, on the other hand, place the emphasis on the subject’s assumption of his or her own position of enunciation, enabling him or her to identify his or her own singularities rather than recognizing him or herself in a generic discourse. In this sense, the notion of “lucid ordinary psychosis” (Trichet, 2018) could be heuristically invoked. It makes it possible to think of a practice oriented towards recovery without ceding on subjectivity. A few clues suggest that Paul and Maxime’s reliance on the symptom gives them a certain use of invention to deal with anguish. Their elaborations enable them to deal with the symptoms of their psychoses in their own way. One responds to persecution with humour, while the other blends in with his age group to be less directly targeted. They deal with the lack of fantasy: one by focusing on his professional future - for the sake of normality - the other by nurturing an artistic writing project and relying on peers. Finally, they enable a position of enunciation, by making use of their symptoms to become part of the social fabric.
Louis
In the case of Louis, the therapeutic effects are less clear-cut, as the solution the patient is trying to work out is still in progress. Insofar as recovery is a process, and cure is not conceived as a definitive, objectivizable stage, even a seemingly tenuous evolution must be noticed in its details in order to identify what may constitute a “path to therapy” (Freud, 1994) specific to the patient.
Louis was twelve years old when he joined the weekday hospitalization unit. He had previously been in the day hospital. During his early childhood, Louis was first seen in outpatient child psychiatry consultations for behavioural problems at school and at home: at the age of five, he learns very little, attacks other children in the playground, and at home he can also be violent towards his two older brothers. The move from the day hospital (where Louis had been from age 5 to 11) to the week hospital was linked to his age, his behavioural problems, which were becoming increasingly uncontrollable, and his father’s exhaustion. Because of his behavioural problems, Louis no longer goes to regular school; the father brings his son with him to work. It’s a precarious balance, because while Louis follows his father around and seems to find a place with him that stabilizes him somewhat, he doesn’t always manage to stay calm and puts himself in danger on the job (for example, by taking the driver’s seat on a tractor, and turning on the engine after finding or stealing the keys).
On the first day and for the first few weeks in the institution, Louis is unmanageable: he doesn’t want to go home, tries to escape by any means, putting himself in danger, hits the carers in paroxysmal moments, spits in their faces, insults them. When we go looking for him, he goes even further. We’ve noticed that he’s much calmer if the ward allows him to bring his phone, and from then on, arrivals calm down considerably.
During interviews with the unit doctor, Louis cannot be left alone and leaves the office, unless his father is present. In this case, he stands by his side, seems to speak very little, and most often answers questions with: “I don’t know”. When the doctor suggests that he meet me alone for an interview, and I make the same suggestion to him when he first arrives, Louis simply says no and leaves. Nevertheless, a year’s work was carried out, and we can see in hindsight that it involved two stages.
The first is to set up markers for what Louis calls “the construction site”. On his arrival, Louis seems particularly interested in the roadworks taking place on the hospital site, and in particular in the passage of several backhoe loaders and trucks. A machine operator leaves his post for a moment, leaving the engine running. Louis suddenly bolts for the controls! We tell him that we don’t yet have the license to do so, but that we can ask the driver if he’d be willing to let him sit alongside him for a few moments. The truck driver agrees, and Louis is very happy. Thereafter, he follows the progress of the site, naming the stages of progress, the vehicles and machines used, as well as their parts and functions, keeping an eye on the order of work and potentially faulty parts. Louis will talk to the professionals at the edge of their jobsite and discuss the situation with them. In the unit, he is then able to talk to the nursing staff about the work site, and explains that it has a lot in common with those on which he accompanies his father.
On the other hand, if he is offered so-called therapeutic activities that have nothing to do with his interest in the workcamps, Louis becomes extremely agitated and can no longer be contained by the nurses. Weekly slots are therefore set aside to help him structure his world around the workcamps. Louis notices that the department has its own cars for outings with patients, and asks for a “ride”. Louis shows us the way, which at first is rather random. Side by side in the car, Louis can spontaneously talk about himself, explaining, for example, the progress of his father’s construction site and the vehicles on it.
From then on, a “vehicle outing” was also fixed in Louis’ timetable. On subsequent occasions, he brings along little slips of paper with addresses of truck and construction equipment signs he wants to go to, which his father has written down for him. He asks us to enter them into the GPS. On the way, Louis talks about this or that type of truck and its functions, which he hopes to find when he arrives. He also talks about the “welcome” we’re going to get, hoping that people will be nice and let us see the equipment. I tell him that we can indeed expect a warm welcome, and that we increase our chances of being well received if we present ourselves clearly. So, Louis prepares his polished, well-structured presentation text.
While we’re waiting to arrive at our destination, he lets us read his work from the hospital school, based on his interests: trucks are drawn and named, with their parts named too. Once we arrive at the company, Louis is very careful to locate the premises of the company or store. He punctuates after a good meeting with the sales staff: “We’ll go back to reception; reception is the best!”. The people who work there are generally happy with this surprise visit, and Louis knows how to make himself appreciated.
The second stage involves the circulation of an object of sound, enabling Louis to organize his relationship with the Other at a minimum. One day, Louis comes in with an empty bag. He has decided to ask the companies we go to for “little gifts”, i.e., goodies bearing the brand’s effigy. He’d especially like caps, T-shirts, work jackets, but also electronic items like USB sticks. We enter the addresses into the GPS, anticipating how many businesses we might visit, given the distance between them and the time available. During the journey, Louis names what he’d like to receive, and hopes to increase his chances by being polite. Each time, he obtains the items he wants with relative ease, and sometimes even surprises! He remarks almost weekly: “we were lucky today!” Which, in fact, we approve of, pointing out the quality of his organization, and the interest these objects have and the relationships he builds with the sellers.
Then, this search for gifts is combined with a search for salvaged electronic equipment, which we pick up at used equipment depots. These are mostly cell phones. Louis tries to repair them, with the pleasure of making them work again, charging them, and then being able to use them sometimes. He plugs one into the car to play music. Louis returns to the ward with his bag, often full, and checks in advance with the carers who will be present and whom he now knows, so that he knows who he can show - and be named and listed by - what he has received. He sometimes gives some of these objects to the care staff when he has received too many. He also counts his items and anticipates what he needs to get, so that he can give them to family members on certain occasions, especially for his brothers’ or parents’ birthdays, or Christmas. Sometimes, if he doesn’t find what he’s hoping for, he can get quite anxious and agitated, but he calms down if he’s told that he already has a stash of items he can dip into if need be. He’s also building up a stock of materials from our harvests, which he can dismantle and reassemble in the department or at home. Louis sometimes gets very anxious when he thinks he doesn’t have enough: “I don’t have enough to keep me busy this weekend”.
In Louis’s case, recovery over the course of a year of clinical work was far less convincing than for Maxime and Paul. However, discrete signs of compensation for his psychic disorganization are evident, and have acted as therapeutic levers enabling him to achieve a noticeable appeasement. In this case, the young patient’s first task was to rely on objects that could be used to circulate, repair and build. At the same time, the trucks are the bearers of an ideal self, as Louis identifies with the driver’s job, and thus projects himself into a social role and a lively animation of his own body through work. In so doing, he can engage in discussion and socialize, and even speak a little about himself in his own name. School knowledge then connects with this elaboration, in the form of writing down addresses and sign names, and developing an interest in the courses he receives at the hospital. In this process, the body, the relationship with others and symbolic landmarks all begin to structure and calm down. Before, Louis would run away from or attack other people; he couldn’t say what he wanted or what he liked, and seemed unable to project himself into anything. Now, he can organize himself, initiate a request, share an activity with the other person, be appreciated and pass on his knowledge as much as receive it. If this remains within the perimeter of the “worksite”, this solution is as precious as it is tenuous, and we can hope that continued clinical support might enable him to consolidate the use of imaginary identifications compatible with social integration - for the moment, the machine operator - even if we can assume that this path will not be without difficulties.
Discussion
Choosing Lacanian indications of psychotic structure (Lacan, 2005; Lacan, 1955-56/1996) and those of some of his students concerning the conduct of treatment and the identification of discrete signs (Brémaud, 2020; Maleval, 2019; Vanheule, 2014) is therefore of undoubted clinical and theoretical interest for child psychopathology, but also has a number of limitations. Although a psychoanalytical reading of the subject departs from the normal-pathological divide, we cannot ignore the fact that the psychotic structure requires the subject to make a supplementary creative effort in order to fit into the ordinary social bond. Maleval, drawing on a Borromean representation of the subject, points out that supplementary retains the trace of the defect from which it springs. It was in this sense that the term “ordinary psychosis” was coined, to describe compensated, mediated psychoses, and to introduce a space for discussion rather than a new clinical category (Miller, 2009). These are psychoses in the classic sense of the term, but their structural clues are more discreet, as they are veiled by subjective inventions. For a number of subjects, this complicates their integration into the conventional educational system, and there is no guarantee that this will ever be possible. Extracting oneself from a predictive model makes it possible to avoid assimilating child psychosis to a chronic pathology, but there is no guarantee that a noticeable subjective improvement will occur.
Another limitation to mention would be that the structural hypothesis could have the same deleterious effects that diagnostic assignment can have: while psychotic structure should not be equated with deficit, it is readily understood as risk (Schimmelmann et al., 2013). It is no doubt for this reason that Maleval (Maleval, 2019) proposes to rename it ‘structure suppléante’ (compensating structure), in order to consummate the break with the pathological aspect, as much as with an approach that would be nosographic.
In the specific case of the juvenile clinic, the risks are high of promoting prophylactic treatment without giving the subject the possibility of evolving other than according to statistical projections. The debates surrounding the famous psychosis risk category at the time of publication of the fifth edition of the DSM suffice to show that an ethical question exists around such prophylaxis (Carpenter, 2009).
The assumption of the uniqueness of psychosis also carries with it the risk of giving consistency to the idea of a psychic handicap, which is particularly strong when it comes to children’s clinics, since certain manifestations of psychosis can sometimes hinder readiness to learn at school. However, apart from the fact that psychosis, as described in this article, is not necessarily deficient, several critics have shown the low clinical and theoretical relevance of the concept of psychic handicap (Lotte & Séraphin, 2009; Moreau, 2010; Zygart, 2014; Peoc’h, 2024). Yet this concept is widely used in infant and juvenile clinics, where there are frequent transitions between health and medico-social structures. An effort is therefore needed to accommodate subjects presenting manifestations of clinical psychosis other than in relation to their elaboration capacities. This effort is all the more important in an infant-juvenile clinic, since it concerns subjects in the process of intellectual as well as emotional development.
The interest of the Lacanian concept of psychotic structure in the juvenile clinic can only be understood, therefore, if it is understood as a tool for thinking about the clinic, rather than as a diagnostic appointment: faced with symptoms that hamper the subject’s life, structural identification makes it possible to refer this or that supplementary construction effort to self-treatment, and thus to distinguish the subjective effort to be sustained from that which may confront the subject with anguish. from that which may confront the subject with anguish.
Conclusion
The interest of Lacanian theory in clinical work with children, beyond providing an orientation for the clinician dealing with a young subject, lies largely in its heuristic capacity to apprehend symptomatic movements in the course of individual history. Psychoanalysis, based on psychodynamic theory, enables us to grasp the living nature of the subject and therefore of his symptoms, whose presentation varies enormously over the course of treatment. The fact that it avoids any pretension to prognosis means that the subject is not locked into a predetermined destiny, a different approach to the evolution from pathological positions, which are embarrassing for the subject, to positions in which anxiety is treated in a way that does not hinder the subject’s integration into a social bond that suits him/her (Peoc’h et al., 2022). However, according to J. Begoin and F. Guignard-Bégoin, recourse to a structural point of view would fail to produce a definition of infantile psychosis, as children would not allow themselves to be locked into a structure (Begoin & Guignard-Bégoin, 2018). This criticism, emanating from the field of psychoanalysis, bears witness to the fact that the idea of structure can be misinterpreted. If the psychotic structure is differentiated from the neurotic or autistic structure, for example, it is only from the point of view of an unconscious psychic organization, the identification of which is based on a few precise points, but the diagnosis of which is in no way suggestive of any pathology. However, this structural diagnosis remains the clinician’s wager, and it is not the age - child or adult - that complicates this diagnosis, but the fact that it has value only as a therapeutic orientation, not as a truth about the subject. Rather, this research shows that, from a Lacanian perspective, identifying psychosis in children with symptoms that interfere with their daily lives is not only heuristic, but also has practical implications for the clinic. These two examples demonstrate the therapeutic value of such an approach, and we believe they can be counted among the positive evaluations of psychodynamic therapies that are beginning to be recorded (Rabeyron, 2021). Despite the reservations raised in the discussion, and the petrifying effect that a diagnosis can have, this study shows that Lacanian infantile psychosis must be approached without prognostic certainty, and thus necessarily departs from a deficit perspective of psychosis. Winnicott (Winnicott, 2016) recalled that he had always rejected the term maladjusted to describe a child. As all catamnestic studies over the past two and a half centuries have shown, chronicity has no statistical basis in psychiatry (Lantéri-Laura, 1997). Why should it be any different in child psychiatry? Undoubtedly, the current craze for neurodevelopmental studies is helping to give consistency to the idea of a somatic inscription of mental pathology - currently without formal proof. Although these studies are essential in their own right, they should not obscure the fact that the symptomatic changes that can be observed on an individual scale can only be achieved through treatment based on the spoken word and the transferential relationship. While Lacanian theory suggests a structural diagnosis, its ethical principle is opposed to chronicity. This approach does not deny the symptoms or the discomfort - the anguish - they cause subjects, even in the case of decompensated infantile forms. But as a practice oriented by singularity, the Lacanian approach to child psychosis enables us to take into consideration what, in the symptoms, is an attempt by the subject to deal with what is invading him or her. Structural modelling does not divide symptoms into good and bad, but guides the clinician towards a reading of the function of these symptoms.
At a time when psychodynamic approaches are being routinely criticized in France, when some are calling for child and adolescent care centres - already under-resourced in the opinion of all professionals - to be transformed into diagnostic platforms, and when inclusion policies for children with psychological problems are based on the functional handicap model, this study demonstrates that analytically-oriented care can have significant therapeutic effects. As Rabeyron concludes (2021) the belief in a cognitive or neurodevelopmental whole that currently drives public policy is without scientific foundation, and it is therefore important to continue research in other paradigms. Thinking of child psychosis as a neurodevelopmental disorder probably limits approaches focused on subjective experience and individual elaborations.
This research demonstrates, following other works, the heuristic and clinical relevance of a practice of psychoanalytic conversations (Maleval, 2022) with children with a psychotic structure. The examples cited show that this practice can lead to symptomatic improvement or resolution, better social integration and greater self-awareness (insight), all of which are essential elements of recovery. The aim is to move from a symptomatically incapacitating clinical psychosis to an ordinary psychosis, compatible with satisfactory social integration.
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Editores do artigo/Editors:
Nelson da Silva Jr., Renata Bazzo
