Lacanian Treatment

Psychoanalysis for Clinicians

Yehuda Israely

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000160994
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Secret wishes, forbidden pleasures, and painful memories hide below the false bottom of consciousness. How do we decipher the desire and pleasure located between the words spoken in psychotherapeutic treatment, and how can we identify and interpret them? This book, following the author's previous work which focused mainly on Lacanian theory, is dedicated to the practice of psychological treatment. Given its general clarity, the book can also be useful to those who are not deeply versed in Lacanian thinking.

How does one interpret symptoms, dreams, and other expressions of the unconscious? What is transference, and how is it put to work in treatment? How do we work with anxiety, depression, suicidal tendencies and other types of distress? What is the Lacanian approach to these things? How does diagnosis relate to how we orient the treatment? And, finally, what is the secret of termination of the treatment, which happens to coincide with the analyst's training process?

CHAPTER ONE

Ethical foundations

Ontology—anti-essentialism and a desire-based reality

For Lacan things do not have an essence as such—an approach whose core can already be perceived in Freud’s writings. Lacan points out the fundamentally anti-essentialist spirit first manifests in Freud’s Beyond the Pleasure Principle (1920g). While in the case of animals, gratification only occurs once food is actually digested, humans can actually transform the absence of nourishment (hunger, that is), into an entity in its own right by means of statements like: “I am hungry.” While, in other words, for animals, absence only presents itself as absence (and presence as presence), language makes it possible for humans to make something present even when it is absent. Lacan’s anti-essentialism is directly associated with the central role he ascribed to language in the formation of the psyche, and especially to this particular quality of language, namely its ability to turn nothing into something, what lacks actuality into a symbolic-conceptual entity (Lacan, 1992 [1959], p. 187). Anti-essentialism is not a new way of thinking. Heraclitus, the pre-Socraric philosopher, argued that one cannot enter the same river twice because its water is in constant flux (so that on our next dip, it cannot be the same). In addition, the person who enters the river a second time will never be quite the same as on the previous occasion, since she or he too changes constantly. This is the logic Lacan adopts—but he explains that even if one cannot enter the same river twice, or indeed even once, where it comes to the river qua concept, it can be entered again and again. Thus, we can enter “the Jordan river” time and again. It is conceptualisations like “Jordan river” that create the illusion of essence.

This principle of conceptualisation—or signification, in Lacan’s terminology—is what allows experiential continuity and object permanence. Similarly, continuity and permanence also form the basis of the clinical phenomenon Freud called repetition compulsion (which is why Lacan attributes what Freud identified as repetition compulsion to language as a system of signifiers) (Efrati & Israely, 2007, p. 62). During her treatment, one patient said: “I’m having a hard time adjusting to this foreign culture. Something about it doesn’t suit me.” In subsequent free associations, she talked about how she hadn’t fitted in with her high school’s floor gymnastics team because she was too tall, and how her mother had commented about something she embroidered, when she was a girl: “That doesn’t fit.” Some of the cultural misfit this patient experiences due to being an immigrant is influenced by the repetition of the charged signifier in her mother’s criticism: “That doesn’t fit.” Repetition, in other words, is based on signifiers (“doesn’t fit” or “inappropriate”, in this case). For Lacan, a signifier is any mode of representation—whether an expression, a word, or even an icon—and its meaning he calls signified.¹

The Freudian unconscious, it is important to note, rather than an organic entity, is a system of meanings that have become repressed as a result of the wish not to know. There are various autonomous systems that are responsible for physiological functions like intestinal activity, heartrate, sleep regulation—and about which we might say that they are not conscious, but these are of no interest to psychoanalysis. Though it is obviously possible to reduce mental suffering by non-verbal means (whether through medication or through alternative methods), the Freudian unconscious is inextricably bound up with language, and hence the work of Lacanian treatment is work with words (Lacan, 2002 [1964a], p. 703).

This anti-essentialism implies that every patient is intimately and specifically involved in the perception of their own reality. Lacan adopts Descartes’ notion that reality is not self-evident—reflected in his famous dictum “I think therefore I am” or rather “I doubt therefore I am”.

Following Freud, however, Lacan—unlike Descartes—sees existence validated through desire rather than by means of thought (“I desire therefore I am”) (Lacan, 1966). It is through the symptom that the subject maintains desire while not identifying it as such. Thus, for instance, a patient who suffers from being looked at wishes not to acknowledge her own exhibitionist desire.

This approach raises the following question: What reality do the symptoms of which the patient complains constitute? It transpired, for instance, that a patient who was suffering from chronic fatigue and sleeping many hours each day had heard from his mother, early in his life, that he looked just like a prince when asleep. In his unconscious the reality of sleep turns him into a prince. Or, in other words: the desire to be a prince produces a symptomatic reality of chronic fatigue. Dreams are another site where reality bases itself on desire. If a patient dreams she enters a labyrinth in the course of her morning run and doesn’t manage to get out of it, one may assume that in the dream she creates a reality in which it is impossible to run—because she’s trying to find a way out of running. Treating the spraining of a foot during a run as a Freudian bungled action reflects a similar logic.

The manner in which desire shapes reality is well illustrated by the phenomenon of depression. Someone who experiences depression feels that she or he is losing out on something. What is it that they are missing? Depression is a state in which desire is absent. Since desire requires the absence of a gratifying object (absence, that is), depression is a state in which the absence necessary for desire is not available. The paradox in depression is that the absence required for desire is absent. The depressed person, then, loses the possibility to live with loss, that is with lack, with desire. Whereas animals take pleasure in what actually is present— they are gratified, reach homeostasis, by eating or sleeping, for instance—humans, given as they are to language, also seek the satisfaction offered by hunger—linguistically signified by the word “appetite”. Appetite and yearning are real for us. This is how mankind distinguishes itself from animals, according to Lacan. While the pleasure principle is responsible for the animal gratification associated with satiety, which originates in the consumption of a real object, satisfaction in the order of yearning—beyond the pleasure principle—is realised by virtue of language. “At last I’m having an appetite again. I had absolutely no appetite when I was depressed”—these are the words of someone whose attitude to lack has recovered by means of the recovery of her or his linkage to language-reality. The latter allows for satisfaction from living, beyond the animal gratification achieved by eating and sleeping. So, for instance when a depressed person grows angry, this should be considered a certain demandingness that involves desire. Interpretation then should release the demand that the anger holds and, subsequently, the desire held by the demand. Anger as it were signals a burgeoning sense of hunger. When all goes well, this hunger will evolve into an appetite, into a desire for life. If we take a didactic position, assuming that anger is a way of avoiding responsibility, we’ll miss the opportunity to channel this anger beyond the pleasure principle, in other words: to extract the potential for desire from within anger.

To Freud, the positivist, for whom the dream was less real than waking life and thus opened the door to unconscious fantasy, the dream seemed the royal road to the unconscious. As for Lacan, the postmodernist, reality too takes the shape of an illusion. The non-mediated actuality of existence, according to him, manifests itself at rare moments only, for instance on waking, only in order then to become submerged in a multitude of identifications grounded in concepts and images (Lacan, 1966). Hence Lacan believes that speech no less than the dream is an inroad to the unconscious.

The validity of reality

Where, then, originates the feeling that reality necessarily exists and that it is accessible? If the word (or signifier) does not fully describe the thing and mainly generates meaning, then where does the illusion of full representation derive? Freud and Lacan had different answers to this question. While Freud’s point of departure was his work with neurotic patients, Lacan began his psychoanalytic career with patients who were psychotic. Psychosis even more urgently raises the question of participation in reality—the case of delusions is a good example. What is it that neurotic patients have, unlike psychotic patients, and that allows them to take part in a common reality? Could it be some shared delusion? What’s that wink of those who’re in on the secret, that the psychotic person doesn’t get? The function enabling this participation in reality, Lacan calls the “Name of the Father” (Lacan, 1992 [1955], p. 193). The Name of the Father is a very particular signifier whose very meaning is that signifiers carry meanings. The recorded laughter in American TV comedies, for instance, constitutes a signifier that tells spectators: “This is a funny joke and you should laugh now.” The Name of the Father, on similar lines, is, as it were, the zero-commandment that stipulates that the following Ten Commandments are meaningful.

This function, validating reality as something that has existence, works overtime in the case of neurotic people. Neurotics, we might even say, take reality religiously. They ardently believe in reality. They hold tight onto reality and say: “This exists!” “This is!” In the case of an obsessive neurosis, for instance, the compulsive urge to touch certain objects (doorknobs, for instance) can be understood as a way of finding release from the virtual, symbolic aspect of reality (by taking hold of an actual object). Typical symptoms of hysterical neurosis—like the urge to take centre stage, to be seen—come to counteract the fragility of reality in so far as it is reinforced by the gaze by the following logic: “I am seen therefore I am.”

Neurotic individuals have very little access to reality’s basic foundation. Those suffering from psychosis, by contrast, lacking that foundation, know that they somehow fail to get the wink of those who are in on the secret, and are therefore aware of the existence of a common secret. This wink, which is transparent to neurotic people who are convinced that reality is one and the same thing as actuality—this wink is alien to psychotic patients, who are therefore aware of the language bond in which they are not included. Psychotic people can, nevertheless, dwell in reality by joining a social structure that is maintained by others. A patient with a psychotic personality structure will be too shy to phone a girl whom he would like to get to know, except when he is in the building where the clinic he attends is also located. It is only under the actual protection of the Other² that he is capable of using the function of the Name of the Father by way of a key to conducting himself in the Symbolic order of reality. Other with a capital O is the English rendering of the French Autre which refers to the other (Other) not as equal but as authority.

As opposed to neurotic people who cannot disengage themselves from reality (about whose Imaginary and Symbolic nature, as mentioned, they do not know), and as opposed to psychotic people who cannot take a hold on it—people with perversions play with reality. And they most particularly play with the tension between the existence and the absence of the foundations of reality, the name of the father. Thus, the one who’s playing knows what the other doesn’t: the reality in which the latter lives is illusory, and the conditions validating the reality of the one who’s being played with, and which allow them to believe in the game, are controlled by the one who plays. This is how the one who plays upholds reality while knowing it’s an illusion. Between the player and the object of her or his play the reality is alternatingly confirmed and denied. Perverse individuals use the law to confirm reality. The function of the Name of the Father that validates reality is supported in the case of perverse structure by the presence of the law. In order to summon the law that supports the validity of language they need to break the law. So that in perverse logic, the crime makes the law appear as broken, and once the law exists reality is validated.

Lacan’s view of reality as an invention does not leave clinical work untouched. The fact that the psychoanalyst interprets validates—for Lacan—the assumption that there is something to be interpreted: that there is an unconscious. The unconscious too is a conceptualisation in language. Slips were not Freudian until Freud referred to them as such. When the psychoanalyst reflects about a Freudian slip, she produces a reality in which unconscious desires are associated with the patient’s symptoms. Psychoanalytic discourse establishes a reality and sub-realities in order to allow for therapeutic analytical effects (Lacan, 1966).

This reality-generating mechanism operates by means of a logic of “afterwardsness” (Nachträglichkeit). In simple positivist logic, an existing phenomenon (say, the existence of God) entails certain consequences (for instance, the ritual of prayers). According to the logic of afterwardsness, the outcome is what produces the reason: prayer maintains the assumption that God exists. Gods come into existence by the observance of their injunctions. The assumed reality produces itself in hindsight. From a positivist perspective—which thinks of symptoms as the result of an a-priori reality—one may argue that a man is lacking in confidence because his father died when he was very young. The Lacanian view, postulating that it is the symptom that creates the reality, allows us to think of the symptom of lack of confidence as a way for the patient to position himself “below” the confident father. The patient creates a structure including an authority figure to whom he is subjected, and his lack of confidence allows him to maintain this structure. That is to say, due to the symptom of insecurity a patient keeps hold of the dead father as though he were alive (the same father without whom there is no security).

When a child says something clever that causes the grown-ups to laugh he will repeat it on other occasions in order to make people laugh.

The annals of his memory will record that he told a joke, even though what he said, when he did so for the first time, was not meant to provoke hilarity. On similar lines, it is only once we have reacted to a Freudian slip as something enfolding an unconscious desire—i.e., only once we refer to the slip as Freudian—that we can conclude there is an unconscious desire.

This motivation to adopt such a position, according to which reality is an invention, underlies the ethics of subject formation. People with neurosis identify themselves with their mirror image as if reality prescribed it. Psychoanalysts try to slightly shift the mirror so they may become aware of its existence, thus to understand that they’re dealing with a mere reflection. We want to unsettle their fanatic faith in reality so as to help them evolve an ambiguous space in which they stand out as subjects who decide between meanings. In the work with psychotic patients whose reality is fragile and consists of a patchwork of delusions, our effort will be the opposite: to help them participate in a common reality. In the case of psychotic patients, the aim is exactly to generate a shared (and therefore less delusional) patch in those places where reality is without roots or foundation. Here, then, substantiating identity or defining one’s aim in life are actually appropriate therapeutic objectives. The aim of treatment is to consolidate a reality in which patients can function as subjects. We, as psychoanalysts, are part of the structure that maintains them as subjects.

Ambiguity and subject position

Emerging as a result of conceptualisations, reality is not actual and this means that it is not unambiguous either. Rather than objective factors it is the desire of the subject that dictates reality perception, and this desire involves deliberation at sites of vagueness or ambiguity. Since it is through such decision making that the subject comes into being, we try, in clinical work with patients suffering from neurosis, to make an appeal to (or to make present) the one who is responsible for choosing, for creating the reality, where reality seems objective. One way of doing this is by directing attention to the ambiguities in patients’ words, a code that requires deciphering, on the lines of the Freudian slip which holds a secret. That it is possible to decide how we understand or perceive the meaning of a word is an opportunity to bring to bear desire. One can offer patients the interpretation that their choice for one meaning rather than another is evidence of their desire, thus suggesting their existence as subjects who make choices.

To illustrate this, take a patient who says: “I am off putting” by which he consciously intends to say that he is “disgusting”. The analyst, by asking “… putting it off to another time?”, suggests the ambiguity of the statement (he might here be identifying a theme in the patient’s way of talking). Exposing the ambiguity comes to allow the patient to raise his unconscious desire to the surface (which in this case may express itself in a refusal to stick to appointments).

Still, in principle, meaning can be interpreted endlessly: Another meaning can always be found, but this may undermine the effort to make subjectivity present. Dwelling on all possible meanings is tantamount to sitting on the fence in terms of one’s desires. Cutting the session (see the subsection, below, on this issue) at the point of one meaning is the same as cutting it at the point of one wish. Desire is the wish for the sake of whose realisation one is willing to give up on other wishes. For desire to be what it is, it does not have to be realised. But it does exact a price or an effort, the foregoing of some meanings or other desires. This is why the psychoanalyst sometimes halts the slippage of meanings by linking signifier with signified, word and meaning (through cutting a session, for instance). This type of linking, Lacan calls it capitonnage (buttoning or quilting), stabilises the reality of the patient’s desire. Here the psychoanalyst actually goes with a certain meaning, relying on her judgment of the choice made by the patient’s unconscious (sometimes, therefore, she might take the initiative to end a meeting).

Lack of ambiguity is a hallmark of fascism or perversion, which are typically free of the burden of choice. Ambiguity, then, is on one line with an anti-fascist reality (liberation from the tyranny of the great Imaginary Other, as will transpire below) (Lacan, 1974),—a reality that can be considered in terms of creativity. So, for instance, the power of the poetic text is associated with the fact that it never holds out one clear meaning. Hence, in the work with people with neurosis, the objective is to reduce the hold of their belief in the language-culture-meaning system which Lacan calls the “Other”—without however arrogating the place of this Other (for instance by preaching rejection of that Other). When working with psychotic individuals any interpretation touching on ambiguity may precipitate a psychotic attack, since they are only tenuously linked into the system of the Other. Once the validity of the system comes under question delusions may arise which are aimed to create an Other, like the God whom the psychotic patient serves as his messiah.

Loss of the object as a condition for desire

If reality is made up of objects, and if an object is an event that has been singularised and defined by means of a signifier or even the creation...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ACKNOWLEDGEMENTS
• PREFACE
• INTRODUCTION
• CHAPTER ONE Ethical foundations
• CHAPTER TWO The clinic as a symbolic space
• CHAPTER THREE Transference
• CHAPTER FOUR Symptom
• CHAPTER FIVE Trauma, anguish, and depression
• CHAPTER SIX Clinical structures as subject positions
• CHAPTER SEVEN The end of treatment
• NOTES
• REFERENCES
• INDEX