Our Study Day this Spring became the second such occasion 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.
 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.