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…. Read More
Articles in this Issue:
Issue 64 Spring 2017 (Pages 1-13)
What Is Anxiety?
In his comprehensive and scholarly Hearing Voices, The History of Psychiatry in Ireland Professor Brendan Kelly writes ‘In the early twentieth century, the preeminent intellectual movement of the day, psychoanalysis, conspicuously failed to grab the imagination of psychiatrists in Ireland as much as it did elsewhere.’ I argue here that we do not have to make the same mistake twice, that psychiatry and mental health work in Ireland, in the early twenty first century can make it their business to draw from the well of psychoanalysis with the confidence that it can provide an understanding of, and a clinical technique for, the handling of aspects of mental life that otherwise escape attention and care.
How often do we hear, as a conclusion to the carrying out of a raft of necessary medical investigations the conclusion: no organic cause can be found so it must be …. anxiety or depression. Full Stop. The psychoanalytic field does not stop with these catch-all words. On the contrary it is from these words that psychoanalysis begins its interrogation of the field of the mental. In this paper it is argued that psychoanalysis can provide direction for the treatment response, specifically, to anxiety. To make this case the first step is to open up the question: what is anxiety?
In what follows there are indicated a number of responses to this question that we find in the work of Sigmund Freud and Jacques Lacan with the assistance of the work of Cormac Gallagher and Charles Melman. To assuage frustration with the fact that the responses do not necessarily reduce to some ideal synthesis, we note Sigmund Freud’s remark made after over forty years of serious work on the question ‘Anxiety is not so simple a matter. Up till now we have arrived at nothing but….
Issue 64 Spring 2017 (Pages 15-26)
What Do Psychiatrists Mean By Anxiety?
Brendan D. Kelly
In contemporary psychiatry, the term ‘anxiety disorders’ covers a broad range of conditions including phobias, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and other conditions with varying relationships with anxiety, such as acute stress reaction, adjustment disorder, conversion disorder and somatoform disorder. Anxiety disorders are treatable conditions. Treatment tends to involve combinations of psychological therapies, medication and social inputs. Psychotherapy, chiefly cognitive-behaviour therapy, is usually the mainstay of treatment, augmented by other measures as indicated. For all patients and families, psychoeducation, self-help and support groups can also be extremely helpful. The vast majority of people with anxiety disorders are treated successfully in primary care or as outpatients, and the outlook for improvement is very good in the absence of complicating factors (e.g. alcohol misuse) and provided there is sensible, sustained treatment in the context of a good, steady therapeutic relationship. A wider diversity of psychotherapeutic approaches is, however, needed, in order to reflect the wide diversity of anxiety disorders that present, and the even wider diversity of people who present with them.
Keywords: anxiety; cognitive behavior therapy; medication; psychoanalysis; psychiatry
In psychiatry, the term ‘anxiety disorders’ covers a broad range of conditions, including phobias, panic disorder, generalised anxiety disorder and obsessive compulsive disorder (OCD). This paper looks at the current understanding of various diagnoses relating to anxiety and provides an overview of treatments commonly provided.
How are anxiety disorders conceptualised in contemporary psychiatry?
Diagnosis is psychiatry is, at least in theory, based on the World Health Organisation’s International Classification of Mental and Behavioural Disorders (ICD-10) or the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th Edition (DSM-5). While these diagnostic manuals are not routinely applied in individual cases in day-to-day clinical practice, they do….
Issue 64 Spring 2017 (Pages 27-37)
On Anxiety And Its Symptom(s)
Taking Freud’s 1926 paper Inhibitions, Symptoms and Anxiety as a major reference, Lacan teases out the distinctions between these three terms in the course of his 1962 – ‘63 seminar Anxiety. He concludes that to consider anxiety solely as a symptom that we name pathological by virtue of its affective manifestations – as these, for example, present themselves in panic attacks, generalised anxiety disorder or phobia – does not encompass what anxiety signals at the level of subjectivity. For Lacan, anxiety lies on the hither side of the symptom and is the response of the subject to enjoyment, which is in the real. What should be found shocking is the psychoanalytic understanding that we all suffer from the effects of anxiety, effects that, by definition, are symptomatic of how we negotiate enjoyment. For those who do not consider themselves to be neurotic, anxiety’s symptom has taken the form of a knowledge that knows not that it does not know.
We are challenged therefore to understand anxiety differently, no longer simply as a pathology but as a fact of structure. This has ethical implications for our approach to the many patients who indeed suffer from anxiety’s effects.
Keywords: anxiety; phobia; knowledge as a symptom; power; enjoyment; self-consciousness; the lacanian subject; projection
Anxiety can consume the body and the mind, Aristotle tells us. For him, anxiety was an affection of the soul – it being the first principle of what defines us as living beings – and the soul could not be separated from the body. In his major treatise of the same name de Anima, he writes
It seems that all the affections of soul involve a body – passion, gentleness, fear, pity, courage, joy, loving and hating; in all these there is a concurrent affection of the body. In support of this we may point to….
Issue 64 Spring 2017 (Pages 39-46)
Searching For The Lost Cause
FREUD’S FIRST STEPS –
(TOWARDS A THEORY OF ANXIETY)
This paper follows Freud’s first tentative steps towards his understanding of the origins of anxiety. It will deal in particular with his work from 1892 until 1895 and will engage briefly with Lacan’s comments on the matter.
Keywords: anxiety; origin; aetiology; neurasthenia; George Beard; anxiety neurosis; transformation; jouissance; affect; soma; psyche; Other
It is important to remember that we cannot separate theory from practice for Freud and to remember that every discovery Freud has made has in one way or another been influenced not only by his theoretical work but by what was happening in his personal life and this is because, it seems to me, for Freud, theory is not something you do – you write about. What you write about are the little threads of significance that go to frame a Life and then we call this theory. In other words, as Lacan insists, the unconscious is that which does not stop not writing itself.
And, in this context, it is interesting to note that it was at the time of his definitive separation from a valued friendship with Dr Joseph Breuer that Freud began to work on anxiety states.
Freud met Breuer at the Institute of Physiology in Vienna in the late 1870s and sharing the same interests and outlook, they quickly became friends. He became as Freud says, ‘my friend and helper in my difficult circumstances. We grew accustomed to share all our scientific interests with each other.’
From December 1880 to January 1882 Breuer treated what has become recognised as a classical case of hysteria – that of Fraulein Anna O. This fascinating case history will have to be left for another day, but suffice to say that for Breuer the case did not….
Issue 64 Spring 2017 (Pages 47-53)
The Object Of Anxiety
Guy Le Gaufey
I will tackle the question of anxiety from a semiotic viewpoint in so far as Freud, in Inhibitions, Symptoms and Anxiety, presents this affect as a sign the ego sends to himself when he faces a certain danger, mostly internal and instinctual. In the face of this kind of danger, a helpful ‘object’, the mother, is supposed to have regulated the situation previously. Now, she is no longer in sight and available, so that the child is overwhelmed with a feeling of ‘helplessness’. This occurs almost mathematically in Freud’s writing: take the ‘helpful’ away and you get the ‘helpless’.
That is why Freud characterises anxiety by considering the infant longing for this helpful object. He writes:
Anxiety [is] about something (Die Angst ist Angst vor etwas). It has a quality of indefiniteness [Unbestimmtheit] and lack of object [Objektlosigkeit]….
Its connection with expectation belongs to the danger-situation, whereas its indefiniteness and lack of object belong to the traumatic situation of helplessness (Hilflosigkeit) – the situation which is anticipated in the danger-situation.
The ‘lack of object’ refers clearly to the expectation of the ‘helpful’ object, but the previous ‘indefiniteness’ refers to the fact that the ‘something’ anxiety is about cannot be considered as something possessing unity and identity. If it were to have such qualities, it would be definite, and then we would have fear, not anxiety. 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. So far, so good. But our question now is: if anxiety is truly a sign, what kind of sign is it (there are so many!)? How does it work? Are we going to consider it according to the definition Lacan borrows from….
Issue 64 Spring 2017 (Pages 55-64)
Dr Aisling Campbell (CHAIR): Consultant Psychiatrist, Cork University Hospital and University College Cork (UCC)
Dr Mary Cosgrave: Old Age Psychiatrist, Executive Clinical Director for North Dublin Mental Service and St Joseph’s Disability Service
Prof. Walter Cullen: GP Dublin North Inner City and Professor of Urban General Practice, School of Medicine, University College Dublin (UCD)
Tony Hughes: Psychoanalyst, Former Editor of The Letter. Irish Journal for Lacanian Psychoanalysis
Aisling Campbell: I’d like to welcome my fellow panel members, Tony Hughes, Mary Cosgrave and Walter Cullen.
There seem to be two main themes running through this morning’s papers; on the one hand, we had some talks that addressed the place of anxiety, at the moment, in the clinical field, with something of an emphasis on how psychiatry thinks about anxiety vis à vis how psychoanalysis might approach anxiety – and I think Patricia’s talk in particular was at that border – and then, the remainder of the papers of the morning were more about a psychoanalytic attempt to look at anxiety and to have some kind of analytic way of thinking about it.
And the thought that struck me is that it seems to me – I mean, I’m a psychiatrist – that in psychiatry, we actually don’t really think about anxiety very much. There are all these disorders that Brendan Kelly alluded to which, I think we all know, are just a kind of vain attempt to put some kind of set of descriptors on something not very satisfactory. Most of us are a bit vague, to be honest – I know I am – about what the diagnostic criteria for generalised anxiety are, as opposed to agoraphobia. I really wouldn’t be able to tell you what the difference is – I’d probably fail if I had to answer that question in an exam – and I think that’s partly because we don’t really treat those patients very much. They’re kind of ‘hived off’, if you like, to the psychologists….
Issue 64 Spring 2017 (Pages 65-72)
‘My dear Professor, I am sending you a little more about Hans – but this time, I am sorry to say, material for a case history.’ The boy woke up one morning in tears; asked why he was crying, he said to his mother ‘When I was asleep I thought you were gone and I had no Mummy to coax with.’ It is therefore ‘An anxiety dream.’ In 1909 the publication of the case-history ‘caused a great stir and even greater indignation’. Would the findings of a psychoanalysis of a suffering child today meet with the same agitations and scorn as Freud’s case history of the analysis and recovery of Little Hans? Or, can we learn from it and find hope? It’s my hope that this paper, rather than giving a chronological account, can remind us of the mental activities driving the anxious and fearful child before calling up the intervention of his phobic object. Freud writes ‘We must regard [this dream] as a genuine punishment and repression dream and, moreover, as a dream which failed in its function, since the child woke from his sleep in a state of anxiety. We can easily reconstruct what actually occurred in the unconscious.’ Thanks to Freud’s monumental gift we remember that ‘The interpretation of dreams is the royal road to a knowledge of the unconscious activities of the mind’. 5 As the most common victims of anxiety dreams are children 6 how are we to understand Hans’s distress given that Freud asserts ‘…children’s dreams prove beyond a doubt that a wish that has not been dealt with during the day can act as dream instigator. But it must not be forgotten that it is a child’s wish, a wishful impulse of the strength proper to children.’ How are we to hear the….
Issue 64 Spring 2017 (Pages 73-82)
What Can Be Done With Anxiety?
ENJOYMENT AND ACTING
There are two different answers to the question ‘What can be done with anxiety’? depending on two different conceptions of psychoanalysis. The first one depends on a more or less Cartesian conception of the affect and is related to Freud’s first theory of anxiety. The second depends on a more or less Spinozist conception of the affect and is related to Freud’s second theory of anxiety and to Lacan’s theory of affects.
Keywords: anxiety is not a flaw; affect; Descartes; Spinoza; enjoyment; action
Anxiety is probably one of the most frequent reasons for consulting the social worker, the psychologist, the psychiatrist or even the general practitioner. But it seems that they may achieve nearly nothing by addressing anxiety simply as an affect. Anxiety affects. 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: that experience is all the more unpleasant as neither is able to identify the object of such anxieties. We are afraid of or frightened by something: we know or at least we have a premonition of an object which is frightening. But in anxiety, it seems that we are being affected in the absence of any concrete object. Of course, the psychoanalyst may say that anxiety has an object, it is the object of an unconscious wish. He may state that much, but we usually fail completely to locate such an object; and even if we could fathom in imagination its hidden object, anxiety keeps going on – as it does not crystallize in any usual kind of fear. The object remains a mere theoretical point of view (as we may not directly….
Issue 64 Spring 2017 (Pages 83-88)
Why Am I Anxious?
With his opening question ‘Why am I anxious?’ Dr Charles Melman is addressing the psychoanalyst who, in the face of the hole in the big Other, has to resolve his or her concerns regarding filiation, identity and recognition as a psychoanalyst. How Joyce differently managed these same concerns is a reference here. Psychoanalysis is more necessary than ever in a globalised world where these same concerns about identity insist and are being responded to
by a psychology of the masses which threatens becoming ‘our new reality’.
Keywords: the hole in the big Other; the sickness of psychoanalysts; identity; the Name-of-the-Father; bien dire; globalisation; psychology of the masses
Many thanks to Dr Barry O’Donnell for this invitation. It’s nice to meet you again. Many thanks also to Cormac for his friendship, a long friendship now, and for his translation. First, why am I anxious? You are always anxious when you find yourself in a position where you must give something and you don’t know what to give; when you don’t know what you should say or what you should keep quiet about; when you have to assure the audience that they are recognised and, at the same time, be assured that you yourself are recognised. Now, imagine that you find yourself before an audience that doesn’t know you, whose language you do not speak, who act as if you didn’t exist. This is a dream that you can have where you would certainly be anxious. You would be anxious to know what you have to give or what you have to say, anxious to show that you have recognised this audience and that it has recognised you.
Man’s first desire is what? What could we say about what man’s first desire is? Man’s first desire is….
Issue 64 Spring 2017 (Pages 89-97)
Evening Discussion And Closing Remarks
Professor Anthony McCarthy (CHAIR): Consultant Psychiatrist, St Vincent’s University Hospital (SVUH) and National Maternity Hospital; Clinical Director, Elm Mount, SVUH
Mary Cullen: Group Analyst and Psychoanalytic Psychotherapist; Board Member, Community Action Network; Former Chair, Southside Partnership
Dr Gabrielle O’Kelly: Assistant Professor, School of Nursing, Midwifery and Health Systems, UCD; Programme Director, HDip Mental Health Nursing, UCD
Terry Ball: Psychoanalyst; Subject Leader, Department of Psychotherapy and Psychoanalysis, Dublin Business School
Kim Spendlove: Psychoanalytic Practitioner; Tower Project, Probation Service; Criminologist
Gabrielle O’Kelly: I’m Gabrielle O’Kelly. Hearing Dr. Fierens speak about anxiety as a form of joy, I was very much put in mind of my background in nursing. I trained as a nurse when I was about 19 and recall how, after patients that you might have been looking after had died, one or two of us would be maybe washing the body and how in spite of all our respectful care we would find ourselves giggling. I suppose it was something to do with the anxiety of course, of being with somebody who was now dead after being alive just a short time earlier. We’d turn to the person and say ‘I’m so sorry’ and then we would start laughing again, half shocked at ourselves. And then I was also thinking today about Isabel Menzies who in 1959 wrote a very interesting paper called The Social System as a Defence Against Anxiety. This study was based in London where she had been called in to investigate why nurses were leaving hospital work. She carried out a lot of interviews, held focus groups, spoke to doctors, spoke to nurses. And in her findings, she said that at the core of the anxiety situation faced by nurses was the relationship with the patient and, of course, the connections with death. She gave a few very good examples of how the social system worked and one of these was, for example, the de-personalising of the patient when he is referred to as ‘bed nine’ rather than as a person. Another frequent example….