A Space for the Unaddressable
The 388 and Psychoanalytic Treatment for Psychosis
Tracy McNulty
Danielle Bergeron, Lucie Cantin, and Willy Apollon. Photo by Jocelyn Riendeau.
In January 2025, the psychoanalytic community learned that the provincial government of Quebec had summarily decided to close the Center for the Psychoanalytic Treatment of Young Psychotic Adults. A treatment center known locally by its street address, the “388,” the Center had operated in Quebec City since 1982. The 388 was an interdisciplinary and multimodal treatment center in which each patient worked with a psychoanalyst as well as a treatment team that included a psychiatrist and a social worker. It offered a unique approach to community-based care, focusing not only on clinical treatment but on the reintegration of patients into their communities. Psychoanalysis was the core of the treatment, however, and every aspect of the Center was conceived and designed with the aim of supporting the confidential individual analysis undertaken by each patient beginning in their first or second year at the Center. Created by psychoanalysts Willy Apollon, Danielle Bergeron, and Lucie Cantin and operated by the Interdisciplinary Freudian Group for Research and Clinical Intervention (GIFRIC), the Center attracted international interest for its successful psychoanalytic treatment of patients with psychosis, many of whom had extensive histories of psychiatric treatment and hospitalization and were unable to live independently before seeking treatment at the 388.[1] Over the forty-two years of its operation, the Center treated as many as one hundred patients at a time. At the time of its closure, more than eighty people were in active treatment.
The 388’s results were rigorously documented and reviewed.[2] It was evaluated many times by teams of specialists who consistently offered the highest praise for the quality of the treatment it offered and its unprecedented success rate, delivered at a cost to the government of Quebec that was among the lowest per capita in the field of mental health care and dramatically less expensive than long-term commitment or hospitalization. Before treatment, fifty-seven percent of the clients admitted to the Center were not independent and lived either with their parents, in supervised apartments, or in hospitals; after just three years of treatment, hospitalizations were reduced by sixty-five percent, and eighty-two percent of clients lived independently. Sixty-five percent of the patients who entered the Center and completed the program were treated successfully, as defined by their ability to break free of the symptomatology that once controlled their lives, to reduce reliance on medication, and to live independently, go to school, or pursue careers as productive members of society. This success rate is both astonishing and without precedent for patients with debilitating symptoms and low levels of social participation, for whom treatment options are limited and prognoses generally poor.
Despite these impressive results, and against the wishes of the patients themselves, the provincial agency responsible for the administration of healthcare in Quebec decided to close the 388 on the grounds that the use of psychoanalysis undermined the “uniformity” of mental health offerings within the province, was outdated and “not scientific,” and was not consistent with what it called “accepted” treatment protocols for psychosis.[3] This judgment is perplexing, not only because I know of no treatment center anywhere in the world that can claim similar results, but because there is no “accepted treatment” for psychosis. While pharmacological treatment with powerful antipsychotic medication is by far the most common approach to the management of psychotic symptoms in the twenty-first century and may provide adequate relief for some patients with less serious symptomatology, no one would claim that it constitutes a definitive treatment. The patients served by the 388 were proof of the limitations of such treatment, since many of them had already spent years cycling through the mental health care system, trying various drug-treatment regimens, and enduring multiple hospitalizations, all without obtaining real relief or managing to reclaim their autonomy. This is the lacuna the analysts of GIFRIC sought to address through psychoanalysis, which does not merely manage symptoms but allows the analysand to understand and take responsibility for what passes to the act in her psychotic episodes.
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In mental health settings, psychotic disorders are generally recognized and diagnosed on the basis of particular symptoms classed by the DSM-5 (2013) as schizophrenic or paranoid: difficulty recognizing what is real and what is not; disorganized or catatonic behavior; auditory or visual hallucinations; or delusional thinking that centers what many psychiatrists call “fixed false beliefs.” Sometimes a diagnosis of psychosis is made solely on the basis of the perceived severity or resistance to treatment of symptoms, regardless of presentation.
Considered psychoanalytically, however, psychosis is neither an illness nor an index of the severity of an individual’s symptoms or degree of detachment from reality. Like neurosis or perversion, it is a psychic structure that is not innately pathological. Instead, it implies a particular orientation toward mental life and the drives. Understood in this way, the psychotic is, and will always be, a psychotic.
Psychoanalysis distinguishes between structure and phenomenology—between an ethics of subjectivity and the symptoms, behaviors, or deficits that might be classed as signs of illness. Most people with a psychotic structure are not ill and do not have significant symptoms or impairments: They attend school, work, create, and lead full lives, often while making significant contributions to society and humanity. Illness and dysfunction are inherently tied not to psychotic structure, but to the fact that the subject has not been able to confront, speak about, and find another means of expression in her life for what is repeating in the form of symptoms, uncontrolled acts, or delusional states.
“Understood in this way, the psychotic is, and will always be, a psychotic.”
If psychosis is simply identified with certain symptoms and their severity, then we’re functioning within a paradigm of illness and its possible cure or management. If, on the other hand, psychosis as a structure is associated with what Apollon calls “the untreatable”—and thus with the core of the analysand’s subjectivity, inseparable from their desire, creativity, and capacity to contribute to the shared project of humanity—then it must be understood as the manifestation of a subject position with its own ethics, not as something to be eliminated or contained. Apollon’s “untreatable” translates the French intraitable, whose meaning is not “incurable,” as in the case of a disease for which there is no cure, but rather “intractable, inflexible, uncompromising.” It names what is most fundamental to the subject, the manifestation of an unconscious quest from which it will not be derailed.
Apollon, Bergeron, and Cantin are psychoanalysts of Lacanian orientation who accomplished with the psychoanalytic treatment of psychosis what Lacan had only aspired to. Apollon began to develop the seeds of his approach to psychosis when he was still a student of Lacan’s in the early 1970s. The mainstream view at the time was that psychotics could not be treated analytically because they did not dream and could not enter into transference. Even as a student, however, Apollon was certain that the obstacle was not the psychotic subject, but a conception of transference that was too narrowly adapted to the experience of the neurotic. He therefore resolved to develop a new approach to the transference that would be capable of welcoming the human subject as such, not only certain profiles or disorders.
Apollon brought a unique background to this endeavor. Born and raised in Port-au-Prince, Haiti, he had originally come to Paris to complete a doctoral thesis in philosophy under the direction of Gilles Deleuze and Claude Lévi-Strauss, which led to the publication in 1976 of Le Vaudou: Un espace pour les “voix” (Vodou: A space for the “voices”). This remarkable study identifies Vodou spiritual practices with the creation of a constrained space for the manifestation of “voices” that cannot be assimilated to individual or collective consciousness. It therefore anticipates in many respects not only his later critique of the cultural biases of psychoanalysis, but his own contributions to the psychoanalytic metapsychology that he developed with Bergeron and Cantin after moving to Quebec, especially regarding the treatment of psychosis.
Apollon, Bergeron, and Cantin identify a certain number of elements that define the psychotic structure. First, the psychotic is aware of a serious threat, a defect in the very order of the universe, that imperils the future of humanity. In his well-known case study of the psychotic jurist Daniel Paul Schreber’s Memoirs of My Nervous Illness, Freud describes Schreber’s experience of “a flaw in the Order of Things.” The subject typically learns of this flaw through some kind of “revelation,” as Bergeron puts it, which may have been delivered by voices or prompted by reading a sacred text or a newspaper story. A delusional enterprise is elaborated in response to this flaw, typically beginning in the subject’s adolescence. It offers an account of how the flaw came about and the nature of the threat it represents. It also promotes a specific solution, articulated as a mission through which the psychotic will attempt to address and repair this flaw, often through a redemptive undertaking or act of self-sacrifice.
The delusion typically identifies some Other—Satan, the CIA, a billionaire capitalist—who is responsible for this flaw and who presents all kinds of obstacles to the psychotic’s mission to repair it. The Other does this in part by inserting into the psychotic’s body what Apollon, Bergeron, and Cantin describe as an “internal object,” through which the Other controls him. This could be “the heart of Christ beating in his abdomen, a microphone hidden in his tooth without his knowledge,” or the bowel that Schreber complains is subjected to God’s command to shit at the most inopportune moments. The subject is also persecuted by voices, often emissaries of this same Other, who berate and belittle him, issue contradictory imperatives, and repeat ad nauseam certain nonsensical phrases.
Very often, the flaw pinpointed by the delusion relates to a problem with language itself, which the psychotic seeks to repair through the invention of a new language. Schreber, for example, is horrified to discover that God, who created the world, is nevertheless incapable of understanding living men and able to communicate only with corpses. One consequence is that the “root” language spoken by God—as Freud describes Schreber’s representation of it, “a somewhat antiquated German . . . characterized by its great wealth of euphemisms”—is cluttered with vacuous and nonsensical utterances. But, Freud writes, Schreber also speaks repeatedly of his own struggle to convey matters that human language is incapable of expressing, which have been revealed to him alone through a “direct inspiration” that bypasses the limits of ordinary language.
Apollon develops this “flaw in the Order of Things” as a defect in language that makes it incapable of expressing essential dimensions of human experience. He defines language (le langage) as the means through which every culture takes control of the objects of speech (la parole) by delimiting not only what it is possible for one person to say to another, but what can be named or even counted as real. It renders some experiences unspeakable and strands others out of language, where they become unaddressable. Because they cannot be named or addressed, these experiences are relegated to the unconscious and inscribed in the subject’s body.[4]
Every human being is marked in one way or another by this defect. The neurotic child, however, chooses to live within the reality circumscribed by language and the social link it founds, even if this means repressing the unconscious and the body of the drives. Through the process Jacques Lacan called “the mirror stage,” the neurotic ego is constructed in childhood as an object offered up to an Other who delimits the field of reality by determining what parts of the child’s experience are receivable. The child rejects those parts of his being that cannot be addressed to others in the language of the social link, which therefore undergo repression.
The psychotic child, on the other hand, rejects the censorship of these dimensions of being by culture and civilization: not only in his own life experience but in the experience of humanity. Whereas the neurotic—and especially the hysteric—often believes there is something defective in them that they must get rid of to obtain love and recognition from others, the psychotic rejects the violent censorship of the human that they discover in puberty and adolescence and refuses, often from an early age, to enter into the “mirror.” The autistic child may choose not to enter language at all, while the young psychotic will develop both a delusion to diagnose the problem and a mission to repair this intolerable state of affairs and liberate human beings from the servitude it implies. Considered in this light, the “flaw in the Order of Things” can be understood as an indictment not only of a specific persecutory Other but of the censorship imposed by civilization. The God promoted by Judeo-Christian civilization as the Other of last recourse and as the guarantor of meaning is profoundly indifferent to human beings and forces them to reproduce an order of things in which they are merely pawns to be manipulated and used. Thus instrumentalized, humans are subject to “soul murder” and effectively reduced to “corpses.”[5]
The delusion cannot be dismissed as a fixed false belief or deluded fancy. It must be understood as a response to the way the psychotic has encountered the reduction of the human being to an object pressed into the material and ideological reproduction of culture and civilization, including the reduction of desire to sex. The problem is neither the delusion’s diagnosis of the problem nor the drive to address it, but the mission that requires the subject to solve it alone in a way that generally proves impossible and often requires his own destruction or self-sacrifice.
“The psychotic child, on the other hand, rejects the censorship of these dimensions of being by culture and civilization: not only in his own life experience but in the experience of humanity. ”
When we consider the lives of those psychotics who managed to influence decisively the course of human history, it is clear that their projects were successful not because they were free of delusions but because they managed to convince others of the dangers presented by the “flaws” they diagnosed and to involve them in the work of creating new solutions. Consider, for example, the case of Jean-Jacques Rousseau. From the opening line of its first chapter—“Man is born free; and everywhere he is in chains”—Rousseau’s Social Contract argues forcefully for the need to distinguish the sovereignty of the people from that of the king or the nation-state that bends them to its will, pressing human beings into servitude and setting them against one another on the basis of national interests. Rousseau’s solution is the invention of a new social contract oriented by what he calls the “general will” of the people, defined as a shared commitment to the general good that overrides both individual and national interests. This also involves the displacement of a defective language, that of the laws and institutions that attempt to limit and circumscribe the general will and so “bind it for the future.” The same could be said of Jesus, who argues that mere submission to the law cannot lead to grace. He preaches a gospel of salvation whose only commandment is to love and, in the process, creates a more inclusive spiritual community not limited by birthright. Both projects were animated by an unmistakable ethics of concern for the human, which is a more important hallmark of the psychotic structure than the mental illness with which Rousseau sometimes struggled or the self-sacrifice through which Jesus is said to have redeemed the world.
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What, then, are the implications of treating psychosis as the manifestation of a particular subjective stance with its own ethics? There is much to be said about how the analysts of the 388 worked clinically with the delusion, which is a topic they have written about extensively.[6] Here I will stress just two points. First, the treatment model developed at the 388 does not involve a contestation of the delusional enterprise in the name of some “reality” the patient cannot access or refuses to accept. Second, the analyst is neither a caregiver who takes responsibility for the patient nor an expert who evaluates his symptoms or reaction to medication, but someone who is prepared to listen to him. In this position, “defined structurally by the listening ear that creates a kind of rupture in the place of the Other,” the psychotic begins to uncover, as they speak about it, how they encountered this defect in the Other and became captured in the work of trying to repair it. The guiding assumption of the treatment is that “the only thing that can counterbalance the subject’s psychotic certainty is the discovery they are called upon to make about the defect in the Other, an experience they are led to by the constraint of the analyst’s desire under transference, [which the patient] must then transmit according to a certain logic.”
How, then, should we understand the transference on which this treatment depends? In a recent essay, Apollon advances the idea that transference can be defined most simply as a “subversion of the cultural structure of the address by the unconscious of the psychoanalyst.” The structure of the address delimits what can or cannot be said to another person within a given culture or civilization. It therefore constitutes the Other, who is addressed as the guardian of the limits of the receivable. While the construction or postulation of that Other of the address will vary from one civilization to the next depending on its language and dominant religion—for example, the English language and the Protestant religion that shape the structure of the Anglophone social bond—every civilization determines what can be addressed to another person and constitutes in a specific way the Other who is posited as the ultimate guarantor of the address.
The silence of the analyst subverts this structure by emptying out the place of the Other who is addressed. It opens up a space beyond the restrictions collective consciousness imposes on what may or may not be said, thereby enabling the passage à l’acte of what, until now, was unaddressable in the experience of the psychotic subject. This subversion “creates a space of welcome for the lived experience of an out-of-language (hors langage), putting the psychotic in the ethical position of an analysand who must manage the consequences of his act in the social link.”
Concretely, the analyst creates a space where something that is out of language can come into the session through a dream, a symptom, or an act, and then constrains the analysand to find a way to speak about what has been inscribed in the body, repeating in silence, or passing to the act.[7] The aim is not merely to lift repression by getting the analysand to recall memories, thoughts, and experiences that had once been conscious but were later rejected, however, but to create a locus of address for experiences that are fundamentally alien to language and consciousness and therefore cannot be named or addressed to others. The lifting of repression is useful only for the neurotic, who has rejected essential parts of her being in a bid to gain the love and acceptance of others. Even for a neurotic, however, the lifting of repression, which can be easily achieved by most psychotherapists, does not by itself constitute a psychoanalysis, because it doesn’t allow the analysand to access those dimensions of her lived experience that have never been conscious or to discover a desire that has nothing to do with what is proposed or allowed in the field of interpersonal relationships.
This aim is possible only if the analysis subverts what Apollon calls the cultural structure of the address, since a psychoanalysis that remains within that structure cannot possibly create a space for an address that exceeds its framework. For a neurotic, the question this raises is whether the analysis will allow her to disentangle her own quest of desire from the aims of culture and civilization or will inadvertently reinforce them. For the psychotic, who chooses not to enter into the cultural structure of the address in the first place, the question is whether the analyst can create a space of welcome for the unaddressable without censoring it or trying to bring it under the control of culture (e.g. , through a therapeutic strategy that prioritizes social and behavioral adaptation).
Apollon’s determination to offer an address for the psychotic led him to completely reconsider the stakes of the transference. Prior to his intervention, the treatment of psychosis was an urgent but as-yet unrealized ambition of Lacan’s, who significantly developed Freud’s own theorization of psychosis but failed to achieve any notable clinical breakthroughs. Apollon was therefore compelled to reconsider Freudian metapsychology in its entirety, incorporating Lacan’s own additions and reformulations while also moving beyond them. He reconceives psychoanalysis as an offer to the human as such, a practice that is not internal to, or in the service of, a particular cultural construction of the human, but capable of opening up a space for something within the human being that transcends both the demands or requirements imposed on it by culture and the civilization that validates those requirements.
Apollon’s recent work underscores the extent to which Freud’s metapsychology, with its focus on the experience of the neurotic, remains largely internal to the horizon of culture. It also highlights the degree to which even Lacan, who pushed against the limits of that cultural frame, was unable to conceive and implement a psychoanalytic practice that would transcend the limits of his own Francophone and Christian civilization and the Other it promotes as the guardian of the receivable. To cite just one example, Lacan famously predicates the transference on the structure of the address and, more specifically, on the assumption that the analysand invariably addresses the analyst as an Other who is supposed to know: “As soon as the subject who is supposed to know exists somewhere ... there is transference.” This formulation effectively makes the neurotic’s appeal to the Other for help, and thus his capture in the field of the address, the condition for the triggering of the transference. The psychotic, however, does not make such an appeal to the Other.
Thus, Lacan believed it was not possible to initiate a transference with a psychotic without triggering erotomania or the patient’s identification of the clinician with the imaginary and persecutory Other of the delusion, as with Schreber’s conviction that he was being persecuted by his former physician Dr. Flechsig, whom he came to denounce as a “soul-murderer” conspiring with God to bring about his ruin. If the analyst positions himself as a “subject supposed to know” and a guarantor of the receivable, rather than a listening ear that creates a space for something that has never been said and to which no one else has access, then erotomania is indeed a real risk. Apollon’s solution is not to give up on analytic work with psychotics, however, but to abandon the reliance of the transference on the address to a subject presumed to know, a mechanism that both limits the offer of analysis to the neurotic analysand and conceives of the trajectory of analysis, in neurotic terms, as the successful negotiation of the structure of the address and its pitfalls.
Welcoming what is unaddressable in the experience of the analysand, regardless of psychic structure, involves not merely offering a space for a different kind of speech, but triggering the symptoms and the passages à l’acte that will allow for the staging of experiences that were stranded out of language and inscribed in the body. The analyst must solicit the unaddressable while being fully cognizant that it will pass to the act in ways that cannot be known in advance and that will necessarily be destabilizing. Freud memorably spoke of the transference as a “playground” in which what is expressed through the passage à l’acte or compulsion to repeat can be fully unleashed: “We admit it into the transference as a playground (Tummelplatz) in which it is allowed to expand in almost complete freedom and in which it is expected to display to us everything . . . hidden in the patient’s mind.”
In the treatment of psychosis, the transference will also trigger crises and delusional episodes. For a majority of patients at the 388, the crises experienced prior to their treatment at the Center led to psychotic decompensation and required hospitalization. Once they began their analysis and entered into transference, however, they were able to go through these crises at the Center without recourse to hospitalization, thanks to the support of the treatment team whose members were trained to listen and accompany without being afraid of the patient. Most importantly, they could continue uninterrupted the work of analysis that now offered an address for what had previously passed to the act. The treatment team anticipated and welcomed the crisis as an opportunity to gain access to the subject as such, not merely a problem to manage.
In the 388’s treatment model, the first crisis the patient traverses is called the “crisis of inscription” to underscore that it marks the beginning of the transference, where what is staged in the form of acts can now pass into speech. Every member of the treatment team works together to maintain a place for the unaddressable that is called forth by the analysis and to help the analysand manage the phenomena it unleashes, the possible threats to their organism, and the individual and social consequences that follow. Their role is not to contain or control the analysand in crisis with restraints or medication, however, but to allow what is inscribed in the analysand’s body to pass fully to the act without threatening their life or endangering others. Apollon identifies four distinct crises that are indispensable to the unfolding of a psychotic’s analysis, each of which has its own logical place and function in the solicitation and passing to the act of what is unaddressable—and, with it, the subject’s construction of a knowledge that will allow them to develop a new ethics to manage its consequences.[8]
“Their role is not to contain or control the analysand in crisis with restraints or medication, however, but to allow what is inscribed in the analysand’s body to pass fully to the act without threatening their life or endangering others.”
What this requires of the analyst is, first and foremost, the completion of his own psychoanalysis. Though often disregarded or ignored today, this is a requirement that goes back to the early days of psychoanalysis. In “Recommendations to Physicians Practising Psycho-Analysis,” a 1912 paper on technique, Freud describes how the clinician who aspires to pick up the transmissions emitted by the patient’s unconscious must first turn his own unconscious into a “receptive organ” adjusted to its signals. This attunement is not just a matter of technique, however; what is at issue is not only how to listen and to what, but whether the clinician can welcome what comes from the patient’s unconscious without “substituting a censorship of his own.” If the clinician wishes to use his unconscious as an instrument in the analysis, writes Freud, they “may not tolerate any resistances in himself which hold back from his consciousness what has been perceived by his unconscious,” thereby constituting “a ‘blind spot’ in his analytic perception.”
How, though, can the clinician know whether they are listening selectively, or even substituting their own projections and fantasies for the products of the analysand’s unconscious? “It is not enough for this,” Freud emphasizes, “that [the clinician] should be an approximately normal person.” Instead, it must be insisted that the clinician undergo a “psycho-analytic purification” to “become aware of those complexes of his own which would be apt to interfere with his grasp of what the patient tells him.” After expressing his approval of the Zurich school’s requirement that “everyone who wishes to carry out analyses on other people shall first himself undergo an analysis,” Freud cautions that anyone who scorns this recommendation
will not merely be punished by being incapable of learning more than a certain amount from his patients, he will risk a more serious danger and one which may become a danger to others. He will easily fall into the temptation of projecting outwards some of the peculiarities of his own personality, which he has dimly perceived, into the field of science, as a theory having universal validity; he will bring the psycho-analytic method into discredit, and lead the inexperienced astray.
Freud’s account is completely at odds with the conception of the clinician that later came to dominate early ego psychology and many versions of psychotherapy—that of someone whose “healthy” ego allows them to perceive and evaluate the patient’s pathologies, false beliefs, or degree of detachment from reality. Freud is not addressing the treatment of psychosis specifically, but his thinking anticipates and even refutes in advance the widespread view that the psychotic’s own delusions and projections, including his propensity for erotomania, constitute the biggest obstacle to psychoanalytic treatment. Instead, Freud’s primary concern is that the clinician will end up projecting his own unexamined complexes and defenses onto the patient. In Apollon’s terms, the clinician who acts as if they have access to “reality” that the patient does not, or whose relationship to the patient is mediated by the structure of the address that determines the social link, cannot create a space for what is unaddressable in the experience of the analysand.
“Purification” is a striking term here, as it implies the purging or removal of something, rather than the acquisition of new insights or techniques. Apollon takes this notion further when he stresses that the analyst cannot open the space of the transference unless they have completed their own analysis by traversing symbolic castration and leaving behind the cultural montage of sexuality and the structure of the address. The analyst must necessarily discover in their own psychoanalysis that it is only through the passage à l’acte of what had been unaddressable that they are able to access their own unconscious quest, create a new space for it, and take responsibility for its consequences.
This also involves a different understanding of what it means to undergo an analysis, which goes beyond the removal of complexes and resistances referenced by Freud. Completing an analysis is not just a matter of logging a certain number of hours or years on the couch, even if this typically takes ten or more years, but reaching the logical end of the experience by passing through its different phases. Many training institutes that offer psychoanalytic licensure allow trainees to begin seeing patients after just one year, without regard for either how long they have been in analysis or what stage they have reached. While these licensing protocols may be legitimate from a legal or professional perspective, they authorize something inherently in contradiction with psychoanalysis. This puts the clinician in a position where they have nothing more to draw upon than the theory or the technical tips they have managed to learn—or, worse, can only offer help or advice from a perspective that is necessarily still overdetermined by a resistance to the unconscious and to what is unaddressable in the patient’s experience.
If the clinician is not able to initiate a transference with a psychotic analysand, there will be no psychoanalysis and no possibility of psychoanalytic treatment. If, on the other hand, the clinician is able to initiate a transference and to call forth dreams, symptoms, and acts that will offer an opportunity for the psychotic to speak about those dimensions of experience that have been censored and to encounter the defect in language as something that exceeds the scope of a flaw introduced by some specific Other or the salvational aims of the mission, the transference will necessarily destabilize the solutions the analysand had hitherto relied upon to organize and give meaning to life and to manage the action of the free drive in the body. This will, in turn, place the subject in a precarious position that requires uncompromising ethics on the part of the analyst and analysand alike, as well as the support provided by the whole treatment team to both manage and sustain what the transference unleashes.
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The 388 enjoyed considerable popular support among Quebecers, and many political representatives and government officials outside the healthcare bureaucracy who vocally supported its existence continue to strategize about how to revive it. GIFRIC hopes to reopen a clinic within the next few years and to use it as an opportunity for a new generation of analysts to assume responsibility for the psychoanalytic treatment of psychosis.
The analysts who created the Center are regularly inundated with requests from clinicians and training candidates in the US and abroad who want to learn and apply their approach; many go on to attend GIFRIC’s summer Training Seminar in Psychoanalysis for English speakers. While this surge of interest is a tremendous opportunity, it is important to understand both the conditions of this treatment and how rigorously they must be implemented and upheld. Just as pharmacological treatment alone is not adequate for most patients, it does not suffice to have a multidisciplinary, multimodal treatment team or a focus on talk therapy to obtain the same success.
In my discussions with interested clinicians of various backgrounds, I’ve been struck by how often they give voice to some of the same expectations. First, they assume that a person with no psychoanalytic background could simply learn and apply the metapsychology Apollon developed to guide the treatment at the 388, as if it constitutes a body of knowledge and a theoretical orientation that can be separated from the psychoanalytic clinic and adopted as a nosography or interpretive framework. Second, many clinicians expect that it might be possible to imitate the clinic superficially—to reproduce its institutional structure and distribution of roles and get the same results without involving psychoanalysis by, for example, having a clinical psychologist or a psychotherapist offer some form of individual therapy that might serve a roughly equivalent function within the structure.
To be clear, I am not suggesting that a therapist, a psychologist, or a clinical social worker have nothing to offer a person with psychosis. There are now, and should continue to be, a range of social services and treatment options available to people who are seeking help. Nonetheless, these offers are not psychoanalysis and must not be confused with it. The 388 was not just a multidisciplinary treatment center that “also” offered psychoanalysis, but one with an approach to treatment that was structured by and organized around psychoanalysis and the transference it enables at every level.
[1] GIFRIC, or Groupe interdisciplinaire freudien de recherche et d’interventions cliniques, is the organization responsible for the 388, the École freudienne du Québec and its Circles in Quebec and in the US, and the Training Seminar in Psychoanalysis and the Clinical Cases Seminar offered every year in both French and English in Quebec City, Canada.
[2] The most exhaustive of these, Évaluation Clinico-Administrative du 388, was completed by Jean-François Denis, MD, member of the Royal College of Physicians and Surgeons of Canada; Raymond Morissette, MD; and Pierre Gagnon, PhD, in 2002. In 2005, a research team funded by the National Institute of Mental Health and led by Norma C. Ware, PhD, Associate Professor of Social Medicine and Psychiatry at Harvard Medical School, made two extensive visits to the 388 and published a comprehensive study entitled “Connectedness and Citizenship: Redefining Social Integration,” in which the clinical innovations, results, and approach to social integration of the 388 figured prominently. During the first ten years of the Center’s operation the “evaluability of its approach was a central preoccupation of several evaluation reports. For an excellent discussion both of these reports and of the larger methodological questions raised by the institutional evaluation of a psychoanalytic clinic, see Alexander Miller, “What Was the 388?: Opening the Dossier,” Psychoanalysis and History 27, no. 2 (2025), doi.org/10.3366/pah.2025.0554.
[3] The patients of the 388 mobilized to prevent the center’s closure and addressed formal appeals both to the Citizen’s Protector of Quebec and to the CIUSSS, the regional healthcare bureaucracy responsible for the closure. Those appeals were never heard. It is striking that the healthcare bureaucracy moved to close the 388 immediately after the publication of a book that offered the most comprehensive data to date about clinical results and long-term outcomes: Willy Apollon, Danielle Bergeron and Lucie Cantin, Le traitement psychanalytique des psychoses. Sa clinique et ses résultats (Éditions du Gifric, 2024).
[4] For detailed accounts of each of these concepts and their different stakes, see Lucie Cantin, Jeffrey Librett, and Tracy McNulty, A Psychoanalysis for a Reemergent Humanity: The Metapsychology of Willy Apollon (SUNY Press, 2025).
[5] As a court judgment described it, Schreber “believed that he had a mission to redeem the world and restore it to its lost state of bliss. This, however, he could only bring about if he were first transformed from a man into a woman.” In that state, what he called his “female nerves” would attract and entangle this capricious God, protecting others from His whims and predations while Schreber, his female nerves impregnated by God, gives birth to “a new race of men.” The resource the mission draws on is thus the femininity of his own erogenous body, which others do not perceive or recognize as real, but which is a dimension of his own experience with which he aspires to create something new for the benefit of humanity.
[6] See Willy Apollon, Danielle Bergeron, and Lucie Cantin, “The Treatment of Psychosis,” trans. Tracy McNulty, in Stephen Friedlander and Kareen Malone, eds., The Subject of Lacan: A Lacanian Reader for Psychologists (SUNY Press, 2000); After Lacan: Clinical Practice and the Subject of the Unconscious, ed. Robert Hughes and Kareen Ror Malone (SUNY Press, 2002); La cure psychanalytique du psychotique. Enjeux et strategies (Éditions du Gifric, 2008); Le traitement psychanalytique des psychoses. Sa clinique et ses résultats (Éditions du Gifric, 2024).
[7] It is important to stress how different this is from the account of transference we find in relational psychotherapy, which describes how the patient repeats and reenacts past relationship dynamics with the therapist. Because it limits the investigation of unconscious dynamics to those that occur within interpersonal relationships, and thus within the social sphere, the relational take on transference is not only internal to the cultural structure of the address but also tends to reinforce its boundaries, inasmuch as it assumes that only what occurs within interpersonal relationships is real and that the unconscious is situated there as well.
[8] Alexander Miller, who is completing a book-length study of the 388 and its treatment model, observes that “crisis” is derived etymologically from a Greek root meaning “decision”: A crisis is a decision point in an analysis, a moment at which it is possible to act on the basis of what it brings to light, and not simply a moment of destabilization or danger.