Issue 64 (Spring 2017)
A crucial part of the work of the School of Psychotherapy in St. Vincent’s University Hospital, Dublin is to represent the contribution which the psychoanalytic field can make to our understanding and treatment of psychopathology.
On 9th December 2016 we held the fourth in a series of conferences in recent years which propose dialogue between psychiatric, medical and psychoanalytic practices. The conference asked a question: What is Anxiety? Treatment Challenges – Psychiatric, Medical and Psychoanalytic Approaches in Dialogue.
This Issue of The Letter Irish Journal for Lacanian Psychoanalysis carries the proceedings of the day. I am honoured to have been asked by its editor, Patricia McCarthy, to contribute this editorial. I am confident that this Issue will join its predecessors in providing very valuable and worthwhile reading for clinicians who are concerned about their practice, particularly when faced with the phenomena of anxiety.
My own paper opened the conference with the objective of introducing a specifically psychoanalytic approach to anxiety. As a counterpoint to prevailing theory which explains anxiety in terms of brain activity the paper represents the argument that follows from the practice of psychoanalysis, namely that anxiety can only be ‘understood’ through the concept of subjectivity as developed in the work of Sigmund Freud and Jacques Lacan. There is no denying that alterations in brain activity – as well as in other systems of the body such as the respiratory and the cardiovascular – announce anxiety. In themselves, however, they do not provide a pathway to understanding the cause of anxiety, fundamentally a subjective experience. My argument is that in order to respond to anxiety clinically it is necessary to work with a hypothesis that unconscious subjectivity drives these observable clinical phenomena. To respond to anxiety clinically it is necessary to listen to each patient in their singularity. To refuse support from this hypothesis is to practice with at least one hand tied behind your back – handicap indeed in the turbulent, unpredictable waters of the mental.
Professor Brendan Kelly provides a very useful, detailed descriptive overview of current psychiatric and mental health treatment responses to the phenomena of anxiety. Thereby, Kelly provides a context within which we can consider the different accounts of anxiety provided by psychoanalysis. A question arising from this exposition asks if diagnosis is the conclusion to a psychiatric assessment or can that intervention assist in launching a conversation in which a patient participates. This is where psychoanalysis can assist psychiatric and general practice. In the panel discussion Professor Walter Cullen spoke of the aim of beginning a conversation with any person attending his General Practice suffering from mental disturbance, including anxiety. Psychoanalysis proposes to patients suffering from anxiety, that they enter into a conversation which is the work of articulating a question fundamental to their lives and which anxiety announces – a conversation more causal than casual.
Patricia McCarthy tells us straight: ‘the term anxiety profoundly questions us.’ She invites the reader to re-orientate their conception of anxiety. Rather than focus on its affective manifestations – panic attacks, generalised anxiety disorder or phobia – if we follow Lacan we can understand that ‘anxiety lies on the hither side of the symptom and is the response of the subject to enjoyment, which is in the real.’ Fundamental to an appreciation of this psychoanalytic account is the concept of the unconscious – a not-knowing – which implies that those who believe themselves anxiety-free do so on the basis of ‘a knowledge that knows not that it does not know.’ In other words, we are again faced with the conclusion that anxiety is an unavoidable part of human life. It is a consequence of subjectivity. Lacan’s concept of the o-object is a necessary piece of theoretical equipment in order to articulate anything about anxiety – it is strange and defies being ‘egoised’. It tells us of a primordial lack underpinning as well as undermining the subjectivity of each of us. This paper sets out the upheaval the psychoanalytic field, particularly as articulated by Jacques Lacan, brings to supposedly stabilisable and stabilising concepts of knowledge, truth, reality and power. McCarthy assists us in our appreciation of anxiety as psychoanalysis discovers it, with an account from the psychoanalytic literature – and discussed by Lacan – of the emergence of the fear of an object – a biting hen – out of an experience of anxiety which is ‘not without an object’, the o-object.
Helen Sheehan returns us to Freud – this essential return through close study of early texts in which Freud, at a crucial time in his life’s work, finds himself questioned by anxiety. Sheehan makes this study immediately relevant to any attempt to articulate a psychoanalytic understanding of anxiety, howsoever we may debate the relation of this epoch of Freud’s work to his later elabovrations. Despite paying the price of popularity as a doctor, Freud could not accept the descriptive approach to psychopathology by, for example, George Beard whose diagnosis of neurasthenia, or American Nervousness – today’s ME, as Cormac Gallagher had us note in the discussion – lets practitioners and sufferers off the hook: ‘anxious and depressed patients were assured that their symptoms were caused by a physical disease (exhausted nerves) and not by any psychological issue.’ Sheehan documents Freud’s discernment that ‘anxiety is not hysteria .. anxiety is not a hysterical symptom. It is an independent entity and has its own structure.’ She highlights a very useful phrase from Freud’s work – specific reactions – the appeal made by the infant in its attempt to solve distressing situations of tension, specific reactions ‘akin to and .. as necessary as breath itself’, Freud wrote. Can this appeal, this call, ever find sufficient response from the Other? Anxiety ‘plants its roots’ in this inevitable failure. Anxiety functions in one sense as a signal, but Sheehan elaborates that this signal is combined with ‘an interruption in the support of the libido’ – another useful phrase this time from Lacan alerting us to the inextricable relation between anxiety and the sexual. Here is the subject – ‘a quotient in the Other … dependent on the Other but the condition of this dependency means that there is a residue, a remainder, something left over. Lacan calls this the objet a .’ Two other concepts crucial for the psychoanalytic formulation on anxiety appear in Freud’s work from this period (1892 – 1895): an account of sexual excitation and its deployment which anticipates Lacan’s use of the term jouissance; and the concept of affect, fundamental to an understanding of anxiety when taken in the sense rigorously articulated in the work of Freud and Lacan.
Guy Le Gaufey proposes we take affect as ‘a sign the ego sends to himself when he faces a certain danger, mostly internal and instinctual.’ Following Freud, he proposes the scenario of the infant, who, yearning for a helpful object, encounters one that is indefinite and lacking, that is, in other words, not quite one. The infant experiences helplessness: ‘We therefore need these two very different dimensions of lack – indefiniteness and lack of object – to get the Freudian clue regarding the “something” of anxiety.’ Le Gaufey provides, with an inimitable lightness of touch, welcome guidance through the conceptual articulation of lack which lies at the heart of anxiety, thus making our approach to anxiety a little less anxiogenic. Central to this account is a definition of what a sign is: ‘.. something that represents (stands for) something else to someone.’ What happens when the ‘something else’ of this definition is indefinite and lacking? Here we are reminded of a major message from this conference and its proceedings published here: if we are to tackle a clinical phenomenon such as anxiety we must be prepared to overcome our own inhibitions, symptoms and anxiety in the face of challenging theoretical formulation. To articulate an understanding of anxiety requires concepts that undermine their own status as concepts – hence an inevitable anxiety on the part of the researcher faced with the collapse of reliable co-ordinates. (In the panel discussion following the morning papers, Dr. Aisling Campbell noted that there was an absence of thinking in psychiatry about clinical phenomena such as anxiety, implying that this need not be the case.)
Le Gaufey adeptly brings us into such formulation through the story of a childhood experience of annihilatory anxiety culminating in fainting told by the German philosopher Friedrich Heinrich Jacobi (1743 – 1819): how is it, Jacobi asks, ‘that a purely speculative representation which a man produces inside himself can act upon him so terribly that he fears, more than any other danger, the danger of awakening it.’ He contrasts Jacobi’s response to this experience with the solution arrived at by René Descartes – after his own crisis – in the form of the Cogito: both found themselves challenged by their own subjective perplexity to ‘deal with a disappearance of what is, in their common space of representation, the usual partner of the representational subject.’ These thinkers are not approached here as august masters of thought. Rather we read their work as accounts of men with little or no choice but to write their way out of subjective crisis – where a debilitating, paralysing illness may have been the only other option? It is here that we appreciate the value of Lacan’s statement that ‘the only sign a subject can give of himself as a subject is the one of his aphanisis, his fading, his fainting.’ Action is a way out of anxiety but again it is a remark from Lacan in his Seminar on Anxiety – thought-provoking in its ambiguous use of the possessive adjective ‘its’ – that indicates the relation between these terms: ‘…it is precisely perhaps from anxiety that action borrows its certainty. To act is to tear from anxiety its certainty.’ Anxiety is so fundamental to the human condition that we must seriously question the expectation of an anxiety-free world: ‘Anxiety is never so high than when someone tries to root it out of his/her life …’ Another strategy is required. One which appreciates the inevitable presence of anxiety in our lives. One provided by psychoanalysis.
To illuminate anxiety Malachi McCoy focuses our attention on what is happening in our mental activities before they manage to produce a phobic object. Making very effective use of the case history by Sigmund Freud of Little Hans, a five-year old boy who found himself in the distress of a phobia, McCoy tells us that anxiety follows on from wishes fed by ‘intensified sexual excitement’. Again we encounter the sexual in the endeavour to uncover the factors behind an eruption of anxiety – and this in a five-year-old boy. Again we face the challenge to consider the existence of a forceful sexual activity in childhood. If we do not allow ourselves this recognition we will remain in the dark regarding childhood difficulties. McCoy’s paper drawing from the work of Freud, Lacan and Melman assures us that there is a very extensive body of work available to us to find our way into the mental activities of children and adults – with the advice from Freud that we must not rush ‘to “understand” a case at once.’ Each child has the unavoidably anxiety-provoking task of setting himself, herself, up, of being inscribed in the Symbolic Order, as a boy or as a girl. A solution to the question of being a boy or being a girl cannot be given by biology – nor, as McCoy strikingly puts it, be assigned by the scalpel. If ‘anatomy is destiny’ it is on the basis of the negotiation of questions of what he is, what she is, as object, what the child wishes to be, to have, vis-à-vis the body parts that represent gender. In other words, it is a negotiation in the field of the Symbolic which can never run smoothly.
With Christian Fierens’ paper we are returned to the question of relations between anxiety and action, between anxiety and enjoyment. He opens stating what is at once obvious but also the acknowledgement of which is almost universally refused: ‘Anxiety is probably one of the most frequent reasons for consulting the social worker, the psychologist, the psychiatrist or even the general practitioner … It is a very unpleasant experience for both the patient who doesn’t know precisely why he is anxious and the practitioner who finds himself powerless to help him: the experience is all the more unpleasant as neither is able to identify the object of such anxieties.’ Fierens is concerned to highlight the influence upon us, in our conceptualisation of a mind-body relation, of the thinking of René Descartes. This influence would have us aspire to the ideal of re-connecting mind and body. Where we are affected problematically by our bodies we should trust our minds to sort this out. Psychological intervention of whatever stripe may take it upon itself to facilitate this process. By such a model, anxiety arises where another route for repressed bodily energy is not found and it is ‘transformed automatically into so-called anxiety.’ What is to be done with anxiety understood as arising from this cause? While a form of psychoanalysis may set out to achieve ‘some amicable arrangement’ between the opposing forces of the ‘unconscious and repressed drives on the one hand and the wise, the conscious and repressing ego on the other’ should we not simply attempt to ‘pacify the whole set-up’ with tranquillizers? With serious import for the direction given to clinical interventions, Fierens is bringing to our attention the mostly un-acknowledged premises of this approach in psychiatry by highlighting an assumption (shared by some psychoanalysts), that anxiety is simply a problem of an excess of bodily energy that needs to be pacified, or excised, by one means or other. He invokes a principle in Lacan’s work: ‘to abide by such a dichotomy – the opposition of body and mind – reflects exactly the intention of hearing nothing about psychoanalysis… we completely miss the point of psychoanalysis.’ Fierens argues that there is a radically different conceptualisation of anxiety in the second theory of anxiety proposed by Freud, which was subsequently elaborated in Lacan’s work. This account of anxiety is based on there being a danger ‘in my sexuality and in my very life. It is the danger of castration or of death that is fundamentally at the root of anxiety.’
Far from eliminating anxiety from our lives – and thereby eliminating our questioning as subjects – because it is conceived of as a flaw, Fierens proposes anxiety be seen as ‘an integral feature of human nature… human nature is made up of anxiety.’ He describes this as an account supported by the work of the Dutch philosopher Baruch Spinoza (1632 – 1677). It would have practitioners approach anxiety, counter-intuitively but perhaps all the more effectively, in terms of an enjoyment. Making use of the Lacanian concepts of the Imaginary, the Symbolic and the Real, rather than running from anxiety, as practitioners as much as patients, we can situate this affect with other manifestations of enjoyment such as a burst of laughter at a funeral service. Anxiety can be approached as the subjective questioning of stable realities – ‘everything that felt and looked like a fixed substance which is impossible to move, enters into a whirlpool of that which goes on without sense and without utility. This is enjoyment whirling.’ Lacan’s formulation on anxiety, action and certainty is again invoked here: ‘To act is to tear its certainty from anxiety.’
Charles Melman, with Cormac Gallagher translating, provided the final paper of the event: Why am I anxious? The question belongs to each of us but Melman utters it as voiced by the psychoanalyst, the practitioner who is anxious to be recognised: ‘Man’s first desire is to be recognised.’ Melman brings home in this paper questions which must be tackled by practitioners in the psychoanalytic field. What is it to practice psychoanalysis? It is not simply a matter of mouthing the words – ego, id, super-ego …repression, sexuality, drive … subject, Real, jouissance. It is not a question of being lauded in the professional group as such. A father names his child but there is no father to nominate a psychoanalyst. Melman is representing to those who lay claim to the title psychoanalyst to describe their practice, the requirement of accepting that there is not a family or a professional body or a code of ethics universally endorsed by society which one can fall back on, or into. Something must be sacrificed: ‘a guaranteed existence’ such as Joyce sacrificed in setting out to make a name for himself literally, in letters on a page. Does the practice of psychoanalysis require a Joycean madness regarding language, the where withal to forego established meanings, doctrinaire diagnoses of traits and behaviours? The courage not to fall back on reference to common sense? The commitment that does not prioritise popularity? And yet, at the same time as letting go these co-ordinates of norms and universalities, the psychoanalyst is required to practice in accordance with an ethics unique to psychoanalysis – the ethics of speaking well – bien dire. My understanding of this phrase in this context is that the psychoanalytic practitioner does not speak a derived tongue; he or she does not say what she or he is supposed to say in accordance with some doctrine laid down by common consent or by protocols or manuals. The psychoanalyst inhabits an anxious place, attentive to the o-object – ‘what is rejected by us, refused, repressed, amputated, cut off’ – so that it can have a different status and its ‘evil ceases to have its attraction’. The only way in which the practitioner can be attentive to the o-object is through his or her own analysis. There is no way around this requirement – so easily fudged – if the practitioner is to address the question: why am I anxious? Only on this basis can psychoanalysis, albeit perhaps inevitably marginalised (the price it pays), can have its effects ‘more necessary than ever’. Melman’s paper is required reading for anyone in the psychoanalytic field as well as those open to appreciating the different practice that it is and how this difference is that upon which its unique contribution depends. In light of the material presented on the day which challenges the tranquilizing tendency of contemporary health care intervention on anxiety, seeking to rid us of the phenomenon, Anthony McCarthy in his concluding remarks asks: is there a way in to anxiety? This issue of The Letter says yes, there is a way in, through the work of psychoanalysis.
I would like to thank all the speakers who engaged so thoroughly with the question of the conference: what is anxiety? I would like to thank each who participated on the panels and each who chaired sessions. I thank Professor Douglas Veale who opened the conference and Professor Anthony McCarthy for his concluding remarks, sending each of us off with the task of finding a way in to the phenomena of anxiety. I thank all who chose to attend and listen and hope this publication of the Proceedings of the day allows you and others the way in.