Our Study Day this Spring became the second such occasion1 when a dialogue took place at St Vincent‟s University Hospital between psychoanalysts and psychiatrists. The subject of our dialogue was the challenge we face in the treatment of bipolar affective disorder. Borrowing from the programme literature, it was expected that both groupings would offer rich, robust and relevant perspectives on this disabling condition. This proved to be the case. A spirit of willing and generous engagement was displayed among colleagues with sincerely held positions, some differing, some in accord, but all committed to the advancement of an exchange of views, questions and concerns on a complex and troubling subject.
The proceedings were opened by Noel Walsh, Professor Emeritus of Psychiatry in University College Dublin and St Vincent‟s University Hospital, Dublin who, along with myself and Dr Mary Darby, former Consultant Psychiatrist at SVUH formed the Organising Committee for the event.
In the first contribution of the day – with its echoes of Alastair Cooke’s intimate journalistic style in Letter from America – Daniel Burston, Associate Professor of Academic Psychology at Duquesne University, set a challenging tone with his account of the shocking rise in the US of the diagnosis of bipolar disorder, particularly among children. This, in his view, was directly related to the flagrant and unregulated conflict of interest between heads of psychiatry research departments and drug companies and the consequent alarming over-reliance on newer and newer drugs to treat every existential ill. It made for a disturbing picture. Let’s hope that the ripples of complacency that ‘surely such a thing can’t happen here on this more cautious and ‘enlightened’ side of the Atlantic?’ are well founded.
Lionel Bailly, Honorary Senior Lecturer at University College London, a psychoanalytically trained Child Psychiatrist and member of Association Lacanienne Internationale – though not speaking directly to Burston’s spirited paper – proposed in his talk later in the day, that the newly minted Temper Dysregulation Disorder with Dysphoria TDDD might come to replace the inappropriately named category of bipolar disorder in children. Essentially a medicalised name for recurrent temper tantrums in response to ‘the exigencies of life’, TDDD is to be included in DSM-V and at least will represent a move away from the organically grounded construct of paediatric bipolar. His emphasis on the essential place of Lacan’s paternal metaphor offered an engaging and accessible model to understand the factors contributing to why parents are unable to handle their children‟s difficulty in regulating their enjoyment.
Brendan Kelly, Psychiatrist and Senior Lecturer in Psychiatry at UCD in his contribution acknowledged a unique role for psychoanalysis in encouraging the patient in his search for meaning in his symptom. While he supported the traditional psychiatric view where psychoanalysis is essentially seen as an adjunct to other treatment approaches, the openness of his support was welcome.
Mary Cannon, Psychiatrist and Associate Professor of Psychiatry in RCSI put forward an evolutionary hypothesis to explain the findings of a much higher than anticipated prevalence of psychotic symptoms in the general population. These findings have been gleaned from epidemiologic and neuroimaging studies. For the psychoanalyst it would appear that such studies are unwittingly playing ‘catch-up’ with the fact of psychotic symptoms being an expression of unconscious thinking. Lacan’s signifying chain or the concept of ça parle or ‘it speaks’ might yet provide the required contextualization within psychiatry for hallucination where the implications of a psychoanalytic understanding of psychotic symptomatology might be explored. Even in the absence of such an exploration, the move toward therapies, as highlighted by Professor Cannon, where the psychotic‟s account of their symptoms is taken seriously, is important.
Cormac Gallagher, Psychoanalyst, former director of the School of Psychotherapy and founder of The Irish School for Lacanian Psychoanalysis proposed that a synthesis between psychiatry and psychoanalysis was achieved by Lacan in the importance he assigned to the psychiatric case presentation enriched by the application of Freudian methods to public conversations with psychotic patients. Coming as Lacan did from a background as a classically trained psychiatrist in the Kraepelinian tradition to become the psychoanalytic theoretician of the twentieth century, this proposal has credence. Dr Gallagher‟s account of his own movement away from working as a clinical psychologist where he abandoned any reliance on psychological testing – inimical as it had become for him in the face of the primacy of the subjective truth of the patient – makes for compelling reading.
My own contribution – along with describing the laws of chance at stake in psychoanalytic interpretation – tried to convey why psychoanalysis has to reject a traditional evidence-based justification for its practice. It also pursued the continuum between the unconscious on the one hand and what we name conscious thought on the other hand – even when such thought is disordered, as in bipolar disorder or schizophrenia.
And at the end of the day came the round-table discussion where a panel of psychiatrists and psychoanalytic practitioners spoke to us about their own personal and professional relationship to psychoanalysis. This important session was sensitively chaired by Professor Fiona McNicholas, Child Psychiatrist and Professor of Child and Adolescent Psychiatry at UCD, rounding off a most interesting day of reflection and communication where contradictions and impossibilities were put to one side and something of the Study Day’s promise was achieved.
1 The reader is referred to Issue 40 (Spring 2009) of The Letter Irish Journal for Lacanian Psychoanalysis which contains the proceedings of the Conference Psychoanalysis and Psychosis organised by Dr Tom Dalzell and held on December 8th 2008.
Issue 46 (Spring 2011) Pages – 1
Good morning ladies and gentlemen and welcome to our conference. My task is very simple and pleasant – to welcome you all. Let me begin by congratulating Dr. Patricia McCarthy for organising with our committee, this very interesting conference. I‟m not going to mention all the Irish speakers by name, but just to say a special word of welcome to Dr. Bailly who is a French Psychoanalyst – you‟ll be hearing from him later – and also to Professor Daniel Burston from Duquesne University, Pittsburgh. And also to say welcome to Dr. Cormac Gallagher who was a co-founder of the School of Psychotherapy and has made a very important contribution to psychotherapy and psychoanalysis especially Lacanian psychoanalysis here in Ireland…..
Issue 46 (Spring 2011) Pages – 3-11
During the last quarter of the twentieth century neo-Kraepelinian psychiatry joined forces with non-psychiatric critics to repudiate and ridicule Freud and his followers. This paper addresses some of the causes and consequences of the decline of psychoanalysis within mainstream psychiatry, and argues that many of the reproaches once leveled at Freud by his late twentieth century critics could now be directed with equal or even greater justice to neo-Kraepelinian psychiatry. This is especially true with reference to bipolar disorder, where contemporary psychiatry would be wise to heed its own motto: ‘Back to Kraepelin’.
Keywords: Bipolar disorder; DSM; Freud wars; Kraepelin; polypharmacy
In March of 1987, I was an Oscar Diethelm Fellow at the History of Psychiatry Section at The Payne Whitney Psychiatric Clinic in New York City. My supervisor was Eric (“Ted”) Carlson, a specialist in the history of phrenology, hypnotism, American psychoanalysis and multiple personality disorder. …
Issue 46 (Spring 2011) Pages – 13-19
Bipolar disorder comprises a pattern of symptoms characterised by disproportionate changes in mood, possible psychosis and various other symptoms at different times. Biopsychosocial management approaches often involve medication (e.g. lithium), psychological therapy (e.g. cognitive-behaviour therapy) and social interventions (e.g. social work support). Psychoanalytic contributions to the understanding of bipolar disorder have come from a range of therapists, including Karl Abraham, Sigmund Freud, Otto Fenichel and others. In recent years, emphasis has been placed on identifying the defence mechanisms most commonly associated with mania, and the relationship between pharmacological and psychoanalytic approaches to the disorder (e.g. links between lithium blood levels and mental processes). It is important that, amidst such therapeutic endeavour, and in the context of emergent neurobiological approaches, the individual’s search for meaning in their experience is not lost. Psychoanalytic approaches have a unique role in this respect. Regardless of resource challenges in public mental health services, there is a strong need for a diversity of approaches to all mental health problems, including bipolar disorder, in order to reflect the diversity of individuals affected, problems faced and pathways to recovery.
Keywords: Bipolar disorder; psychosis; psychoanalysis; therapy; lithium
A Vision for Change, Ireland‟s most recent statement of mental health policy, states that „each citizen should have access to local, specialised and comprehensive mental health service provision that is of the highest standard‟ Services should be delivered through community mental health teams, each comprising two consultant psychiatrists, two doctors in training, two psychologists, two psychiatric social workers, six to eight psychiatric nurses, two or three occupational therapists, one or two addiction counsellors or psychotherapists, two or three mental health…
Issue 46 (Spring 2011) Pages – 21-38
There is a common view that there are two irreconcilable approaches to the understanding and treatment of mental illness. For most of the twentieth century Freudian psychoanalysis was dominant, and many professors of psychiatry were also analytically trained. In more recent years Emil Kraepelin, who had put psychiatry on a scientific footing in the nineteenth century, has regained what many consider to be his rightful preeminence. But are Freud and Kraepelin incompatible? This paper proposes that some synthesis between them was achieved by Jacques Lacan, a classically trained psychiatrist with links to Kraepelin, who nevertheless demonstrated that the psychiatric case-presentation was enormously enriched by the application of Freudian methods to public conversations with psychotic patients.
Keywords: Wilhelm Wundt; Franz Brentano; Thesis-antithesis-synthesis; psychological testing.
For Daniel Burston the ‘neo-Kraepelinian manifesto’ published by Gerald Klerman of Yale in 1978 is a major source of the plague of misdiagnosis and excessive use of drugs that he sees as characteristic of contemporary…
Issue 46 (Spring 2011) Pages – 39-46
Previously-held ideas about the intrinsically pathological nature of hallucinations and delusions are being challenged by findings from epidemiology, neuroimaging and clinical research. Population-based studies show that the prevalence of psychotic symptoms is far greater than had been previously considered. Therefore it may be timely to re-evaluate our perspective on these psychotic symptoms and their meaning in an evolutionary context. These symptoms may hold the key to understanding the persistence of psychosis in the population. We discuss how these findings also have implications for the public perception of stigma and the development of new therapies that directly engage with the psychotic symptoms. These therapies have the potential to increase patient satisfaction with treatment, increase adherence and ultimately lead to better outcomes.
Keywords: psychosis; psychotic symptoms; evolution; hallucinations; psychotherapy
Nothing in biology makes sense except in the light of evolution.
Hallucinationary experiences are as old as humankind and, until the nineteenth century, these experiences were generally attributed to mystical sources such as gods or demons. Esquirol (1845) first proposed the use of the term hallucination as it is currently understood, making a distinction between normal sensory experiences and „pathological‟ hallucinations. Over the twentieth century, hallucinations have generally been regarded as…
Issue 46 (Spring 2011) Pages – 47-56
Between 1994 and 2003 the number of outpatient pediatric psychiatry visits associated with the diagnosis of Bipolar Disorder in the USA apparently increased 40-fold. Such an increase was not supported by any new research evidence and illustrated a shift of professional towards a purely organic model of child behaviour. The preparation of DSM 5 showed a return to a more psychological model of disturbances in children with the introduction of a new disorder: Temper Dysregulation Disorder with Dysphoria. However, psychoanalytical models can provide a deeper understanding of the process leading to the observed symptoms.
Key words: Paediatric Bipolar; Temper Dysregulation Disorder with Dysphoria; paternal metaphor; enjoyment; psychoanalysis.
This presentation is going to be marked by my scepticism towards some aspects of what has been called Paediatric Bipolar, a Disorder that will not be included in DSM 5 and I‟m going to try to justify this scepticism through the examination of clinical features described in children…
Issue 46 (Spring 2011) Pages – 57-71
Post-modernism, quantum theory, psychoanalysis-buzz words of the twentieth century likely to be misunderstood by the non-specialist – are domains that are governed by abstract sets of laws whose effect cannot be predicted and, into which, participants have to make their way. To acknowledge such domains is to broaden the definition of science and perhaps allow for a better understanding of one of them – psychoanalysis, which is governed by the laws of the unconscious. Freud discovered these laws, Lacan formalised them. How they work is the ‘evidence base’ of psychoanalysis which uniquely serves subjectivity and thereby excludes the objectifying eye of measurement. My argument is that to ignore this ‘evidence base’ is a loss to psychiatry and psychiatry’s patient – especially the psychotic. The implications of this loss will be further discussed by examining the parallels between thought disorder and the process at work in forming that simple ‘given’ of our psychical lives – the dream, continuous as it is with waking thought.
Keywords: evidence-based practice; quantum theory; thought disorder; the dream; subject–effect; schizophrenia
In the half hour allocated to me to speak to you, I am confronted with an immediate difficulty. In addressing a mixed audience of psychoanalysts and psychiatrists I am aware of the gaps in knowledge that define both groups differently. To impute a gap in knowledge to such august groupings is to risk alienating both sections of my audience all at once, but of course that is not my intention on this April Fools’ Day where it has already emerged so far from the papers and the questions arising, that the gaps in knowledge displayed are more badges of honour, equivalent to the participants, like knights of old, having handed in their individual weapons…
Issue 46 (Spring 2011) Pages – 73-92
INTRODUCTIONS: Kim Spendlove: My name is Kim Spendlove, I work with the Clondalkin Probation Team out in Dublin 22, so my background is in psychology and criminology. I came by psychoanalysis via the MA in Psychoanalytic Psychotherapy in DBS. I work with violent offenders, who are referred to me by their probation officers. These include people that have either come out of prison or who may be referred to me pre-trial. So some of them would have very, serious charges, including murder and manslaughter and I‟d see them on a weekly basis.
John Sheehan: My name is John Sheehan. I‟m a psychiatrist at both the Mater and Rotunda Hospitals in Dublin. My background is as a medical doctor, qualifying in UCD in 1980. I worked in branches of medicine for six years and then specialised in psychiatry. I did the Masters here in St. Vincent‟s in Psychoanalytic Psychotherapy, graduating in 1990. So, I have an interest in psychoanalytic psychotherapy and psychotherapy in general going right back to the 1980‟s. Currently, my work in the Mater includes things like medically unexplained symptoms – so psychotherapy and psychoanalytic psychotherapy are very useful. ….