The Practice of Lacanian Psychoanalysis

Theories and Principles

Raul Moncayo

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780367342371
• eBook ISBN: 9781000207170
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

The Practice of Lacanian Psychoanalysis lays out an Aristotelian framework to account for the different types of knowing and not-knowing operative in the theory and practice of psychoanalysis.

The book proposes a new model for diagnosis, giving preference to fewer over more diagnoses, and seeks to better organize them by distinguishing between structure and surface symptoms. It examines many principles of Lacanian clinical practice, including different types of frames and evidence, the practice of citation and listening, the resistance and desire of the analyst, transference love as a metaphor, the role of negative transference at the end of analysis, and the identification with the sinthome as Lacan's last formulation regarding the end of analysis. The text also suggests that there are three forms of love and hate based on the works of Lacan and Winnicott.

Underpinned by extensive practical knowledge of the clinic and case examples for clinicians, analysts, and practicing Lacanian analysts, this book should be of interest to academics, scholars, and clinicians alike.

1
Lacanian theory and a multidimensional and topological approach to diagnoses

Before considering DSM-5 or the contemporary manual of psychiatric diagnoses, a few words are in order regarding the etymological roots of the word ‘diagnosis.’ Literally, it means to know apart, discern specific differences, or even the knowing of difference. We need to know of what and how things are made so as to know how they can fall apart, malfunction, and be repaired. When things fall apart, we can know what they are made of. Finally, the knowing of relative differences directly translates into the ability to read and interpret signs, signifiers, and symptoms. A medical doctor reads signs; a psychoanalyst reads signifiers.

DSM-5, a new updated version of DSM, has finally been published after ten years of a heated debate. DSM-5 raised a lot of controversy (American Psychiatric Association, 2013). Allen Frances, MD, who chaired the DSM-IV Task Force, expressed his concern that “DSM 5 will result in the mislabeling of potentially millions of people who are basically normal.” With the new version of the manual, grief may quickly turn into major depressive disorder. In this chapter, I begin by looking at some of the DSM-5 changes mentioned previously with the help of Lacanian theory and in the light of a psychoanalytic understanding of psychopathology and diagnoses. In addition, I intend to discuss the prevalence of the diagnosis of bipolar disorder and the controversy between grief and clinical depression, examine the similarities and differences between mood swings in a personality disorder and in bipolar II disorder, and, finally, distinguish between neurotic and psychotic forms of paranoia and between paranoia and metanoia.

In contrast to Vanheule’s (2014) book, this chapter will not be focused on questions surrounding the statistical validity or reliability of DSM-5 or on a detailed analysis of DSM-5 itself. Vanheule, in line with psychodynamic and social psychiatry, argues that psychiatric diagnoses are not diagnosing medical/organic conditions per se and that diagnoses are intrinsically related to social-historical and subjective conditions. Ten years earlier, Verhaegue (2004) wrote a critique of DSM from a Lacanian and psychoanalytic perspective. He criticized the DSM system as a simplistic laundry list description of symptoms that produces stigmatization, promotes conventional forms of identity and normality, is unreliable, and has no meaning for treatment.

Finally, this chapter also differs from the Psychodynamic Psychodiagnostic Manual (PDM) (Alliance of Psychoanalytic Organizations, 2006), meant to offer a psychodynamic manual of personality disorders, since this manual does not follow Freud’s diagnostic categories and instead relies on a laundry list of personality disorders and ego functions that also confuses symptoms/traits with personality types. Freud and Lacan’s are structural diagnostic categories and, therefore, many of the traits of the various personality disorders can be subsumed under the two types of neurosis (hysteria and obsessional neurosis). For example, depression is a symptom that could appear in the two types of neurosis, as well as in psychosis, but does not warrant being classified as a personality disorder unto itself.

From a Lacanian point of view, for example, depression (Moncayo, 2008) is not only genetic and/or caused by the accidental loss of a reality object/family member but also by the lack of loss of an object in normal development. By pathologizing grief, psychiatry risks that people may not want to grieve or could feel that they should not grieve, but if they don’t grieve, they may, thereby, be paradoxically predisposed to depression.

I will also discuss the popular diagnosis of bipolar disorder and explore DSM changes in the context of psychoanalytic theories. What can Lacanian theory offer to DSM? For example, is bipolar disorder a psychotic or neurotic structure? There are a number of features that point to bipolar disorder being a neurotic structure.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is an interesting “encyclopedia of human madness.” For centuries, human beings have wanted to categorize and find patterns in the world. It seems natural, then, that at some point we would attempt to create a taxonomy of human activity and the human mind.

The origins of DSM date back to 1840. At that time, the government wanted to collect data on mental illness. It is interesting that the census used the terms ‘idiocy/insanity’ without any inhibitions. In a sense, someone was either ‘normal’ or ‘insane’ – the classification was very simple. Over a 40-year period of time, ‘insane’ included seven categories: “mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy.” But none of these classifications were yet DSM, as DSM-I was born in 1952.

DSM’s main goal was to create a common language that health professionals could use to communicate across borders and collect and compare information on mental illness. Of course, the previous was supposed to lead to better treatment and better outcomes for people who happened to be outside of the ‘norm.’ Between 1880 and 1952, from seven categories, DSM-I featured descriptions of 106 disorders, which were referred to as ‘reactions.’ Sixteen years later in 1968, DSM-II further increased the number of disorders to 182. Both DSM-I and II were driven mainly by the psychodynamic view up until 1980, when DSM-III came out with a whole new perspective to focus on empirical descriptions. At that point, psychiatry had 265 diagnostic categories. With DSM-IV in 1994, the 300-category line was reached with not too many changes. DSM-5 has over 1,000 pages’ worth of checklists of symptoms that psychiatrists around the world use to diagnose their patients.

There was one big change in the history of DSM that occurred between DSM-II and III. The changes reflect how mental health professionals viewed mental illness at first mostly through psychodynamic lenses and conceptualized it as the product of conflict between internal drives/wishes and defenses. DSM-III opted to follow Emil Kraepelin rather than Sigmund Freud. The idea of separate syndromes and disorders was created, and so bipolar disorder, schizophrenia, and major depressive disorder were supposed to be treated differently and had unique causes.

Certainly, many changes took place since the 1840s’ ‘one disorder’ of insanity to the over 300 nicely described illnesses and disturbances with outlined symptoms and their duration. Unfortunately, patients don’t read the textbooks. Psychiatrists and other mental health professionals are often frustrated that their clients rarely fit into neat categories. In addition, symptoms frequently change over time. It often leads to patients becoming a sort of “collectors” of different diagnoses, which can be very upsetting to them. It can also lead to polypharmacy that can be outright dangerous. We try to bring basic research to help with the clarification. Psychiatry dreams about genetic, metabolic, imaging tests that will help diagnose better and faster. Unfortunately, the biological tests only support the idea that psychiatric disorders overlap and that perhaps less is more.

Studies with functional magnetic resonance imaging show that people with anxiety disorders and those with mood disorders share a hyperactive response of the brain’s amygdala region to negative emotion and aversion. Similarly, those with schizophrenia and those with post-traumatic stress disorder both show unusual activity in the prefrontal cortex when asked to carry out tasks that require sustained attention.

(Dichter, Damiano and Allen, 2012) Genetics brings similar findings (Craddock and Owen, 2010)

Publication of DSM-5 brought a lot of critique, not only from more psycho-dynamic providers but also biological psychiatrists and researchers. The National Institute of Mental Health (NIMH) withdrew its funding from DSM two weeks before its publication. Thomas R. Insel, M.D., director of the NIMH, criticized DSM for “its lack of validity” and suggested that, “Patients with mental disorders deserve better.” He suggested that a new way for psychiatric nosology is reliance on biology and that “mapping the cognitive, neuronal circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.”

It is a highly promising approach, although “anatomy is not destiny” and humans are even more complicated than cognitive, neuronal circuits, and genetic aspects of their being. Somehow an individual patient/subject is lost in the classification battle. Moreover, no one is asking them how they feel about their ‘disorders’ or why they think they may have them. People become like broken machines spitting out symptoms at the time of diagnosis. Diagnoses can also be made by diagnostic machines capable of prescribing medication without the need for a human being. An interesting paper by Sam Kriss, “Book of Lamentations,” makes such an observation:

A person who shits on the kitchen floor because it gives them erotic pleasure and a person who shits on the kitchen floor to ward off the demons living in the cupboard are both shunted into the diagnostic category of encopresis. It’s not just that their thought-process don’t matter, it’s as if they don’t exist. The human being is a web of flesh spun over a void.

(http://thenewinquiry.com/essays/book-of-lamentations/)

Lacanian theory and the Diagnostic and Statistical Manual of Mental Disorders

In his famous lectures, Lacan explored Freud’s discovery of the unconscious. One of his most misrepresented statements, “the unconscious is structured like a language,” allowed him to disagree with Freud’s “anatomy is destiny.” He also redefined the concept of drives and did not think that they are purely biologically driven. What interests us most here is that during the 1950s, he spent a lot of time trying to combine the topology of surfaces (torus, Moebius band, Klein bottles, cross caps) with mental life. He claimed that the linguistic signifier, the logic of desire, fantasy, and drives, follows the logic of topology or, in broader terms, mathematics. Lacan claimed that it is the best way we can describe the subject in his or her complexity.

When we speak of the human subject, or of the influence of language on the mind/brain, and how culture shapes our otherwise natural inclinations or how topology may describe psychical structures, we are referring to phenomena beyond the distinction between normality and pathology. Social life is a world of symbolic relationships that describe normal and abnormal facts. For every society, normal and abnormal modes of behavior are complementary.

So why is the study of psychopathology necessary and important? Why do we need psychopathology? Lévi-Strauss (1950) pointed out that in tribal cultures, “Witch doctors were recruited from the disabled, ecstatic, nervous types, outsiders” (p. 14). At the same time: “No shaman is in daily life an abnormal individual, a neurotic or paranoiac, if he were, he would be classed as a lunatic, not respected as a priest” (p. 19). “Shamans exploit psychopathology but also channel and stabilize it” (p. 20). More shamans mean less psychopathology in society.

Just as there is health and illness in the body, there is also a mental ‘dis-ease’ and a serenity of the mind. And nature shows that the dis-ease of the mind tends to break down in discernible patterns and structures. Psychoanalysis is distinguished from psychiatry in that for psychoanalysis, there is continuity between normality and pathology. Despite mainstream society considering psychiatrists abnormal, or needing a psychiatrist themselves, psychiatry is the field that establishes conventional and normative definitions of normality within society.

Freud was the first to call his theory of mind a topographical theory. The deep topological structures can manifest via their structures but also through what appears on the surfaces that correspond to what we call symptoms. The structure–surface relationship is even stronger in Lacan’s topological theory than in Freud’s topographical theory. The latter involves the spatial metaphor of adjacent rooms, or a bicameral mind composed of conscious and unconscious rooms, while Lacan’s topological theory places the conscious and unconscious on a Moebius strip where the unconscious inside goes into the conscious outside and the conscious outside goes into the unconscious inside, and the two dimensions are two sides of the same band.

In Seminar V (Lacan, 1957–1958), Lacan had written that: “We are thereby introduced to a true dialectic of double meaning, where the latter already involves a third party. There are not two meanings one behind the other, with a second meaning, located beyond the first and the more authentic of the two” (p. 130). With Lacan’s later theory, the Third is not the battery of signifiers (the Other), already included within the two sides of band, but the Real topological figure itself.

Neurosis as representing a divided form of subjectivity is the basic character-ological condition of human beings. Human beings are caught between nature and culture, and culture demands that they shape their biological bodies and minds according to cultural forms. This is where both normality and pathology begin. Such neurosis is built into a person’s characterological structure. The various types of personality traits may or may not turn into dysfunctional and incapacitating symptoms, but the possibilities lie within the traits and the corresponding brain mechanisms.

Before we go into the question of how to use topology to think about DSM diagnoses, consider first this clinical vignette. A 22-year-old female with no past psychiatric history arrives for a first consultation to your office. When asked about her goal of the assessment, she says that she “just wants to manage her highs and lows.” She then goes into a detailed description of how both ends of her mood fluctuations wrecked her relationships and her entire semester in college. She says that she experienced her most intense ‘high’ in her senior year of high school. At that time, her boyfriend broke up with her, which almost as a chain reaction started her on a self-destruction path; she did not need to sleep and felt very energetic. She described herself as hypersexual, reckless, careless, and very impulsive. She said the episode lasted for about two weeks until her friends stopped talking to her and, completely exhausted, she ‘rolled into’ her ‘low.’

She mentioned that her ‘lows’ are usually marked by extreme sadness, lack of drive, anhedonia, fatigue, and ‘complete shutdown.’ Interesting that she also raised the question whether she has adult ADHD – a new feature of DSM-5. She did great in elementary school, but since high school, she has been unable to focus on anything. Upon further questioning, our patient admitted to cutting as the only thing that helped her with mood swings. She said that she tends to get obsessed about people only to drop them when her interest fades away. She has a hard time tolerating being dumped by her boyfriends and lists it as the main cause of her ‘highs.’

What does she have? Bipolar disorder type I, II, or maybe we could explain most of her symptoms with untreated borderline personality disorder? Does she have comorbid adult ADHD? Maybe she has all of these? Why does a seemingly ‘typical’ case presentation present such a challenge? Here we suggest that perhaps because DSM is not a very precise diagnostic tool, symptoms that ‘create’ disorders are not very specific, and they often overlap.

Lacanian topology can help us to be more precise. The main advantage of topology is that shape has no meaning there; it can even be called the “geometry of the rubber sheet.” We can stretch it, bend it; it does not matter as long as its structure is preserved. If nothing else, it is a wonderful metaphor where for once we don’t judge people by appearances, but we are more interested in their structure. The geometry of the rubber sheet is also a good metaphor for how to make a creative use of Freudian and Lacanian theory: concepts can be stretched like a rubber sheet while preserving the structure of the theory.

For Lacan...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Introduction
• 1 Lacanian theory and a multidimensional and topological approach to diagnoses
• 2 The signifying chain(s) in the graph of desire
• 3 The clinical evidence for psychoanalysis, standard and non-standard frames, and the question of pure and applied psychoanalysis
• 4 Preliminary sessions and considerations
• 5 The singular frame, logical time, and the scansion of sessions
• 6 The subject supposed to know(ing), love and hate, and the question of the negative transference
• 7 The payments of the analyst and the direction of the treatment
• 8 Interpretation, punctuation, citation, and the scansion of speech
• 9 The resistance and desire of the analyst, and the question of the countertransference
• 10 The function of the One in sexual difference and the question of feminine jouissance
• 11 Time, and the phases of analysis and Oedipus in analytic treatments writ large
• 12 The third phase of pure analysis: the aim and end of analysis proper
• 13 Clinical psychoanalysis in the public clinic and the question of trauma
• Appendix I: Energy, jouissance, and affect versus signifiers and representations
• Appendix II: Two half-sides of truth: Aléthes and Léthes, truth and forgetting
• Index