Lacanian Structural Diagnosis

The same diagnosis does not mean the same person. Two people may both say, "I'm afraid of losing control" — yet entirely different structures may be at work within them.

In Lacanian psychoanalysis, diagnosis looks not at how a symptom appears, but at the person's position in relation to language, the law, and the "Other." This is called structural diagnosis, and it identifies three fundamental positions: neurosis, perversion, and psychosis. (Here, "psychosis" describes a structural position, not a diagnosis of schizophrenia.) Each represents a different response to the child's entry into the symbolic order: repression in neurosis, disavowal in perversion, and foreclosure in psychosis (Santos et al., 2012; Fink, 1997).

One finding makes this more concrete: a 2023 discourse analysis found marked differences in the key signifiers, positions, and relationships of six people who had all received the same diagnosis of "OCD" (Baltacı et al., 2023). In other words, similar symptoms do not imply the same underlying structure. This matters because it determines the direction of treatment: an approach that works in neurosis may cause destabilization in another structure (Swales, 2010).

Let's be honest: structural diagnosis is not a laboratory test, but a clinical and theoretical framework, and it has its critics. Even so, there is a solid foundation — psychodynamic therapy has been found to be equivalent to other treatments with established efficacy (Steinert et al., 2017, AJP). However, this evidence concerns the therapy in general; evidence for psychodynamic treatment within the psychosis spectrum is limited (Fonagy, 2015).

What should we do in practice? 1) Look at the person, not the symptom. 2) Listen not to what the person says, but to how they position themselves. 3) Do not mistake a label for destiny. 4) Speak without stigmatizing — "psychosis" is not an insult. 5) Structural diagnosis requires expertise; do not diagnose yourself or anyone else.

The symptom tells you what is happening; the structure tells you who you are.

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