Borderline Personality Disorder - A Lacanian Perspective 6-30-08

Borderline Personality Disorder: A Lacanian Perspective
To Elisa, my mother En ella y solo en ella estan ahora Los patios y jardines. El pasado Los guarda en ese circulo vedado Que a un tiempo abarca el vespero y la aurora. - Jorge Luis Borges ( El Hacedor, 1960)
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Table of Contents
Preface xi
Acknowledgements The Borderline Concept in America Difficulties in the Definition and Study of the Borderline Patient Early Conceptions of Borderline Pathology Psychological Testing Models Borderline Pathology in Descriptive Psychiatry Post-traumatic and Dissociative Models Borderline Personality in the DSM Psychoanalytic Conceptions of the Borderline Early Psychoanalytic Contributions Froschs Psychotic Character Later Psychoanalytic Theorists II. Otto Kernberg and the Borderline Conditions Post-Freudian Developments In Psychoanalytic Theory Object Relations Kernbergs Theory of the Borderline The Descriptive or Presumptive Diagnosis Kernbergs Structural Analysis The Id in the Borderline Structure
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I.
2 6 8 8 11 12 13 13 15 17
21 21 22 25 27 29 35
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Borderline Personality Disorder: A Lacanian Perspective The Superego in the Borderline Structure The Genetic-Dynamic Analysis and Developmental Theory Kernbergs Three Psychic Structures The Interview as a Diagnostic tool Empirical Assessment of Structural Diagnosis The Clinical Value of Structural Analysis III. Lacanian Psychoanalysis The History of Psychoanalysis in France Structuralism Linguistic Structures Lacans Novel Psychoanalytic Ideas The Mirror Stage: The Scenario of Ego formation Lacans Critique of Developmental Psychoanalysis The Symbolic Order Lacans Conception of the Oedipus Complex The Three Stages of the Oedipus Complex The Prohibition of Incest The Imaginary, the Symbolic and the Real The Unconscious Jouissance Need Demand Desire Diagnostic Considerations in Psychoanalysis Structure and Diagnosis Psychosis Neurosis The Hysterical Structure Hysteria in Men Obsessional Neurosis Phobia 35 36 38 40 41 41
43 45 49 50 54 55 59 63 65 66 70 72 74 75 76 80 81 84 91 93 97 98 102
Borderline Personality Disorder: A Lacanian Perspective Perversion IV. The Case of Katherine Katherine: The Presenting Problem Family Structure and Childhood History Work History Course of Treatment V. Katherine as a Kernbergian Borderline Katherine as a DSM-IV Patient Kernbergs Presumptive Criteria Kernbergs Structural Diagnosis The Structural Interview Katherine: The Diagnostic Interview Identity Diffusion: Neurotic Integration vs. Borderline Fragmentation Use of Primitive Defense Mechanisms Projective Identification Assessment of Reality Testing Non-specific Ego Weaknesses Lack of superego Integration Excessive Pregenital Aggression VI. Katherine as a Lacanian Patient The Demand for the Desire of the Other Identity or Desire? The Didactic Phase of Treatment From Interview to Treatment Lacanian Structural Diagnosis The Analysis of Two Dreams 127 131 131 134 135 136 136 103
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108 109 110 112 113
120 121 122 124 124 126
140 140 143 144 145 145 147
Borderline Personality Disorder: A Lacanian Perspective Oedipal Vicissitudes Katherine's Subjectivity Lacanian Inter-generational Analysis The Name of the Father Katherine as a Neurotic Individual VII. Lacan and the Borderline Conditions Elements of a Lacanian Critique of the Borderline Concept The Merger of Psychiatry and Psychoanalysis The Critique of the Role of the Symptom The Treatment of Borderlines The Role of the Ego and the Ethics of Psychoanalysis Lacan and Family Therapy The Pre-Oedipal vs. the Oedipal Controversy The Critique of Object Relations Theory Borderline Structure as Part of the Human Condition The Continuum of Diagnosis The Rise of the Borderline and the Decline of Hysteria and Perversion Empirical, Philosophical and Ethical Considerations The Borderline Diagnosis in Children and Adolescence Criticisms of the Borderline Conception in Children The Present Study and the Borderline Concept in Children and Adolescents Limitations of Interpretive Theory 184 184 187 199 173 175 179 181 151 152 153 155 157
162 164 164 165 166 167 169 169 170 171 172
Bibliography Index
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Preface
structures of neuroses, psychosis and perversion. However, the borderline diagnosis has been largely ignored amongst psychoanalytically oriented clinicians in Europe and South America. One reason for this is that a major theoretical gulf exists between American and European/South American psychoanalysis, a gulf that can in part be attributed to the dominance of egopsychology and object-relations theory in the United States and an equal dominance of the theories of Jacques Lacan in such places as France and Argentina. Within Lacanian thought, there is a theoretical and clinical emphasis upon the three Freudian structures of neuroses, psychosis, and perversion, and skepticism towards any approach that insists upon adding to this scheme. Lacans own reaction to the concept of the borderline seems to have been that it is the clinician him or herself, rather than the patient, who is undecided and on the border between the traditional structures (Lacan, 1956). Nevertheless, there has yet to be a systematic dialog between American psychoanalysts and Lacanians on the question of the borderline diagnosis. In fact, in spite of a recent surge in interest in Lacan in the United States (mostly outside departments of psychiatry and psychology) there has been very little dialog between American psychoanalysts and Lacanians on any issue of theoretical or clinical significance. When one surveys the literature readily available to American clinicians, one finds hundreds of books and articles pertaining to Lacan, but less than a handful of such comparative purpose.
he diagnosis of borderline personality organization has taken its place in American psychoanalysis as a personality structure, the significance of which has equaled and, in some quarters, even eclipsed the traditionally recognized
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Borderline Personality Disorder: A Lacanian Perspective The present study seeks to make contributions of both a general and specific nature.
Generally, by comparing the psychoanalytic theories of Otto Kernberg and Jacques Lacan in the context of the borderline diagnoses. More specifically, I seek to initiate and contribute to a long overdue dialog between American and French psychoanalysis. By promoting such a dialog I hope to make a contribution that may help refine both theory and clinical work with the severely disturbed patients who have been designated borderline by Kernberg and others. As the main vehicles for this study I have chosen both a critical and comparative review of theories of Otto Kernberg and Jacques Lacan and an analysis of an illustrative case. The case of "Katherine," a 25 year-old woman who the author saw for three years in psychoanalytically oriented therapy is presented and analyzed from both Kernbergian and Lacanian points of view. It is shown that Katherine, who readily meets Kernberg's presumptive and structural criteria for Borderline Personality Disorder, can profitably be understood and treated as a case of neurosis within Lacan's diagnostic scheme. The question of whether those patients described by Kernberg as structurally borderline, do in fact constitute a homogenous group from the perspective of Lacanian theory is a critical one, and the conclusion that I drew is that from a Lacanian perspective, borderline pathology is fundamentally a descriptive category that does not cohere from a theoretical, structural point of view. The reasons for this will become evident in this book, and it will also become clear that from a Lacanian perspective a Kernbergian borderline may well have a neurotic, psychotic or perverse structure. I hope to demonstrate how Lacanian ideas can be of significant value in the diagnosis and treatment of individuals suffering from severe pathology, and that an alternative mode of treatment exists for these patient that is not dependent upon our accepting the borderline concept.
Liliana Rusansky Drob New York, June, 2008
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Acknowledgements
I would like to express my gratitude to Beatriz Azevedo, my psychoanalytic supervisor who helped me clarify my own questions and who has worked with me throughout many years of clinical supervision and Lacanian readings. I am greatly indebted my analyst, Paola Mieli, who has never given up on my path of articulating my desire. I am especially grateful to my husband, Sanford Drob, whose support and psychological knowledge has made possible for me to think aloud on the questions of diagnosis and who has become a role model to follow in his persistence in the completion of a written project. I would also like to thank Dr. Beth Hart and Dr. Florence Denmark, my dissertation chairs at Pace University, for their interest in my clinical work and their support of a psychoanalytically-based doctoral thesis.
The Borderline Concept in America
Chapter One
n recent years, the topic of borderline personality has
not only come to dominate
discussions in clinical psychiatry and psychoanalysis but has filtered down into segments of American culture as well. Films such as Fatal Attraction, Single White Female, and Girl
Interrupted seem to have been written with this diagnosis in mind, and in some circles the term borderline is used indiscriminately in a derogatory manner to refer to any difficult personality, especially if young and female. While most American psychoanalysts regard borderline pathology as a distinct nosological entity requiring a specific dynamic formulation and therapeutic technique, no equivalent acceptance of the borderline concept is to be found amongst European analysts. In particular, Jacques Lacan, whose return to Freud has dominated psychoanalysis in France, much of Europe and South America, specifically rejected the borderline concept, tacitly denying that there are borderline patients, holding that it is the analyst who is on the border in his understanding of a difficult case. Lacan preferred to adhere to Freuds basic nosological distinctions between neurosis, psychosis, and perversion, leaving no room for this fourth pathology which plays such an important role in American diagnosis and treatment. A number of factors have hitherto prevented a meaningful dialogue between American ego, object relations, and self psychologists and their counterparts in France. Amongst these, are Lacans radically different conceptualizations of the ego and his rejection of a unified subject, his notion that the ego is a center of misperception and untruth, and his view that by virtue of language we are constantly miscommunicating. Since the borderline conditions are conceptualized as a failure in the development or regulation of the ego or self, Lacan, who rejects
the notion that there is an ego that must be regulated and developed, appears to have little place for borderline pathology in his conceptual framework. Nevertheless, it is clear that Lacanians are indeed treating many patients who American clinicians would diagnose as borderlines. How these patients are conceptualized and treated within a Lacanian framework will not only provides us with a great deal of insight into the distinction between Lacanian and American psychoanalysis, but should also provide us with a fresh perspective on the treatment of such patients. Further, since the rejection of the borderline concept is one factor preventing a meaningful dialogue between American and French psychoanalysts, a clarification of the reasons for this rejection and the alternative conceptualizations and techniques proposed by Lacan should be helpful in establishing a dialog between these two camps. A careful analysis of this issue will be helpful in discerning not only the points of contrast amongst the respective schools of thought but also points of (thus far) unrecognized convergence as well.
Difficulties in the Definition and Study of the Borderline Personality Clinicians have long described patients who either bordered on schizophrenia or appeared to have features of both neurosis and psychosis. Patients have been classified as borderline according to a variety of not always consistent criteria, some of which emerged as a result of specific methodological tools that are utilized in the study of varying populations (Gunderson and Singer, 1985). In general, there have been three main approaches to the classification of such patients. The first, which has been termed the descriptive approach, is based exclusively on symptomatic and behavioral observations. The second, the psychoanalytic or structural approach, groups patients not on the basis of symptoms but rather on the basis of a presumed underlying psychological dynamic or structure that individuals with varying symptoms and behaviors share in common. A third classificatory approach shares some features with each of the first two, and classifies such patients on the basis of their performance on psychological tests (Stone, Dellis, 1960).
These three classificatory methods are most often utilized in connection with widely varying sources of data and widely divergent ways of conceptualizing such data. Whereas the descriptive, and to a certain extent, psychological testing approaches, are amenable to wideranging empirical studies that examine a large sample on the basis of standardized criteria, the dynamic/structural approach has traditionally been limited to intensive work with individual patients, who in the course of psychotherapy, are found to exhibit specific patterns of transference, resistance, defense, response to treatment, etc (Hoch, Catell, 1959). Psychodynamic theorists argue that the specific features necessary for adequate dynamic/structural diagnosis only emerge in the context of the intensive interpersonal encounter of psychoanalytic treatment, and are largely opaque to standardized empirical research. Frequently these classificatory methods also vary according to the setting in which they are employed. For example, it is frequently the case that behavioral and symptomatic
observations are conducted by psychiatrists in hospital or other residential treatment settings, whereas psychoanalytic formulations have evolved mostly within the context of private, outpatient clinical work. Further, the communication of findings and theory is often limited to a select audience. Psychologists, for example, who have diagnosed the borderline syndrome thorough the administration of a battery of psychological tests, although often working in the same or similar settings as descriptive psychiatrists, generally publish their findings in specialized journals with limited readership among other mental health disciplines (Gunderson, Singer, 1970). Finally, the various groups working with so-called borderline patients are often suspicious of each others methodology, sources and personal biases. Adding to the confusion regarding the borderline diagnosis is the fact that, as a result of a variety of factors, those utilizing different classificatory approaches may not actually be referring to the same, or even similar, patient populations. It may well be that the so-called inpatient borderline subjects will present symptoms and structures that are quite different from those of their outpatient counterparts and that those seen as borderline in public settings may be quite different from those who are so classified as borderline in private practice (Grinker, et.al. 1968). Over the years, research studies on borderline subjects have set varying selection criteria for their samples. One study may include outpatients with or without overt psychotic symptoms such as delusions and hallucinations at the time of the study, while another will be limited to
inpatients who exhibited brief psychosis either on mental status or in their recent psychiatric history. For example, Hoch and Catell (1959) selected their patients on the basis of severe psychoneurotic symptoms but later found on closer evaluation during psychotherapy performed by psychoanalysts that these very patients exhibited signs of schizophrenia in their thinking, feelings and physiological functioning. Others, such as Grinker, et. al (1968) who conducted a widely recognized long-term study of borderline patients, selected subjects on the basis of good functioning in between hospitalizations and the presence of an ego alien quality to any psychotic symptoms. It is clear that patient selection has impacted upon the conclusions reached regarding the borderline diagnosis and its relationship to schizophrenia. Whereas Grinker found very few subjects with psychotic episodes at the end of the study, Hoch and Catell, in contrast, had an expected subgroup of schizophrenics amongst their patients. In summary, four major variables may be considered in any description of the so-called borderline patient: (1) Methods of classifying patientsdescriptive, structural, psychological testing, (2) settings in which research is conductedinpatient, outpatient, public, private, (3) nature of the data baseempirical studies, or intensive psychoanalytic psychotherapeutic investigation, and (4) selection criteria for the borderline classification. Empirical studies using the psychoanalytic model focused on the borderline personality disorder have been developed in the last twenty years (T., 1989). When Gunderson was approaching the issue of borderline diagnosis from an empirical point of view, he posited that unless there was external validation of the criteria or some level of predictability based on family prevalence or course of illness, the diagnosis would not sustain inclusion in the DSM-III. However, he insisted on including two criteria that were essentially psychoanalytic: vulnerability to regression and psychosis under transference-like conditions. (Gunderson, 1975) Certainly by 1990, if not before, the borderline personality was by far the best researched of the personality disorders, indeed accounting for the majority of scientific publications on this topic (Efrain Bleiberg, 1995). While there is a relatively high degree of agreement on the phenomenology of the borderline disorder, a major controversy exists regarding the etiology of this condition, with the role of early childhood trauma (particularly sexual abuse), other parenting factors, genetic predisposition, and socio-economic factors debated in the literature. Further, while psychoanalysts have taken a lead in examining this condition, and there is even a
certain level of agreement regarding the psychostructural characteristics of these patients, the psychoanalytic literature lacks nosological congruence with the general psychiatric descriptions, suggesting that psychoanalytic structural classification may not (in spite of Kernbergs affirmations) correspond to the descriptive (DSM) Borderline Personality Disorder syndrome. Since the nature of the borderline disorder goes to the heart of psychoanalytic ideas regarding the nature of the human subject, the function of the ego, the major drives and their vicissitudes, etc. one might expect different formulations regarding so-called borderline patients among different psychoanalytic theoreticians and schools. This study focuses upon the borderline diagnosis within the context of psychoanalytic theory and treatment. Without discounting their significance, I will not elaborate in detail on the descriptive or psychological testing investigations of the borderline phenomena, except insofar as these methods impact upon psychoanalytic theory. I do not intend in the course of this study to examine the diagnosis of Borderline Personality Disorder in every conceivable context, but rather to focus upon the meaning, relevance, and utility of this diagnosis within the context of psychodynamic theory and treatment. However, the emergence of the borderline concept in American psychoanalysis initially involved a confluence of both descriptive and psychoanalytic formulations. In addition, many analysts who considered the borderline diagnosis (Kernberg among them) were profoundly influenced by developmental theorists who worked within academic psychology. Part of the reason for this, is that during the years of the borderline concepts initial formulation (roughly, 1941-1975). American psychiatry was far more closely identified with psychoanalysis and developmental psychology than it is today. As a result, only by tracing the roots of the borderline concept first within descriptive psychiatry/psychology and then within psychoanalytic and developmental theory can we come to understand its emergence as an important diagnosis amongst American psychoanalysts. After doing so we will be in a position to explore some of the reasons why this diagnosis failed to emerge among psychoanalysts practicing outside of North America.
Borderline Personality Disorder: A Lacanian Perspective Early Conceptions of Borderline Pathology According to Salman Akhtar (1992) the earliest tentative description of a mental disorder
that was not clearly viewed as insanity was made by J.C. Prichard (Treatise of Insanity, 1835). He referred to a syndrome of moral insanity which he characterized as a form of mental derangement in which the intellectual faculties appear to have sustained little or no injury. Prichards initial patient was described as presenting with perverse feelings, habits, and temper, without a defect in his or her reasoning faculties and mainly without illusions or hallucinations. (Prichard, 1835). However, the concept of moral insanity came to be restricted to antisocial individuals, and the other types of dysfunction noted by Prichard were largely ignored. Emil Kraepelin (1905), the German psychiatrist who is often credited with being the founder of modern descriptive psychiatry, took a keen interest in what had been referred to as morbid personalities. He viewed this condition as a borderline state between insanity and normalcy. He presented several different combinations of healthy and abnormal personalities, emphasizing that such individuals, in spite of their eccentricities, were not cognitively deficient and could even be gifted intellectually. Kraepelin even created a nosology of subtypes of the morbid personalities: (1) patients with instability of will (who probably come close to todays borderlines), (2) liars and swindlers (who by todays descriptive criteria would be classified as antisocial), and (3) pseudoquerulous individuals (who might be regarded as paranoid personalities). Kraepelin described the first group as childish, presumptuous, overbearing, irritable, unmanageable, selfish, and with no sympathy for others. Although it appears that he was attempting to describe what might now be classified as personality disorders, the general trend for at least the next decade was to group all such morbid personalities under the diagnosis of psychopathy and again, the borderline disorders fell into a state of neglect. A decade later, Bleuler reopened the investigation of the field of severe non-psychotic disorders. First, Bleuler questioned the term dementia praecox used by Kraepelin and replaced it with the term schizophrenia. For Kraepelin, dementia praecox had represented the end-state of a chronic psychiatric deterioration. For Bleuler, schizophrenia simply represented a
disorganization of psychic functions. Bleuler also described two forms of non-psychotic
disorders characterized by the absence of hallucinations but with a tendency to turn to fantasy in place of reality. These he termed simple and latent schizophrenias, disorders which today would be descriptively classified under schizotypal personality disorder. Bleulers contribution was to broaden the scope of severe non-psychotic psychopathology, expanding the field of clinical psychiatry to the realm of the personality disorders. From then on, a series of researchers were encouraged to embark on clinical and empirical studies of a group of unstable individuals who were thought to be neither neurotic nor frankly psychotic and who, in these researchers views, required not only a new diagnostic category but psychotherapeutic interventions tailored to their particular level of pathology. Zilboorg (1941) described a group of patients that he called ambulatory schizophrenics. These patients presented with a normal appearance, which was, however, accompanied by shallow emotionality, dereistic thinking, an incapacity to settle on one job or life pursuit, and an inability to sustain friendships. Zilboorg noted that these patients were able to function without the need for hospitalization. He included among this group psychopathic personalities, murderers, and sexual perverts. He discarded the term borderline as he viewed these patients as a subtype of schizophrenia. Hoch and Polatin (1949) described a condition which they termed pseudoneurotic schizophrenia. Although these patients appeared to be neurotic, Hoch and Polatin held that behind this faade rested the core features of schizophrenia. No area of their functioning was free from conflict and tension. Their sexual life was characterized by promiscuity and perversion. They displayed multiple severe neurotic symptoms, were extremely sensitive to criticism and often presented with expressions of extreme rage. Hoch and Polatin again emphasized the fact that these patients were not borderline but a subtype of schizophrenia. They viewed these patients symptoms as pathognomonic of schizophrenia but noted that their schizophrenic signs were often evident in subtle rather than global ways. Although the psychiatric community did not accept their conceptualizations at the time, Hoch and Polatin provided a convincing description of pathology in which neurotic and psychotic symptoms at least appeared to overlap.
Borderline Personality Disorder: A Lacanian Perspective Psychological Testing Models The field of psychological testing (Rapaport et al.1945, Singer 1977), provided further
impetus to the study of a group of patients who, although functioning relatively well in social situations, suffered from an underlying fragile, and potentially psychotic personality core. These authors described a group of such patients who showed a predominance of primary process thinking when presented with unstructured tests like the Rorschach. Gil and Schaeffer (1945-6) also provided evidence of preschizophrenic patients who on psychological testing showed weak ego structures and a prevalence of primary process thinking. According to Rapaport (1946), these patients typically provide fabulized, confabulatory and highly elaborate Rorschach responses. He further suggested that borderlines give a higher percentage of emotionally charged responses in the context of simple percepts (Rapaport, 1946). Indeed, as early as 1921, Herman Rorschach (1921) himself described a subgroup of patients whom he described as latent schizophrenics who presented with appropriate surface behavior but whose responses to the inkblots contained elements common to those provided by schizophrenics. For example, the presence of self-referential answers, the belief that the cards are real, scattered attentional processes, and a primitive quality of ideas and associations all suggest the presence of primary process thinking, close to the surface in such latent schizophrenic individuals. However, Rorschach investigators have generally agreed that such patients do not exhibit similar ideational patterns on more structured cognitive and intellectual testing.
Borderline Pathology in Descriptive Psychiatry In 1968, Grinker et al, conducted a study of 53 hospitalized patients in order to establish criteria for the diagnosis of borderline personality. These investigators used 93 behavioral criteria and arrived at what they held to be four fundamental characteristics of the borderline syndrome: (1) chronic anger, (2) defective interpersonal relationships, (3) identity disturbance,
and (4) depression rooted in feelings of loneliness. A cluster analysis of their data yielded four subcategories of the borderline syndrome:
(1) The psychotic borderline, characterized by problems in reality testing, identity disturbance, grossly inappropriate behavior, negativism, outbursts of rage, and depression.
(2) The core borderline, characterized by chronic rage and impulsive self-destructiveness.
(3) The as-if individuals, lacking in authenticity, leading false lives with superficial relationships.
(4) Individuals with chronic anxiety and anaclitic depression, characterized by a dependence on a pregenital love object such as the mother.
The Grinker study was the first large-scale attempt to sort borderline patients via descriptive psychiatric criteria. However, it was criticized, particularly for its poor inclusion and exclusion criteria and the lack of weighted criteria for the diagnosis of borderline personality. As early as 1975, Gunderson and Singer (1975) attempted to define the borderline conditions and clarify the confusion that at the time reigned with respect to this diagnosis. Through an analysis of the data of other investigators they arrived at specific criteria that they believed would establish the borderline disorder as a discrete diagnostic entity. Gunderson and Singers six criteria were: (1) intense affect, (usually hostile and/or depressed); (2) lack of social adaptation, as a result of identity confusion; (3) impulsive behavior with self-destructive tendencies; (4) brief psychotic experiences, especially those precipitated by drug use or in the context of intense intimate relationships; (5) bizarre and primitive responses on psychological tests; and (6) disturbed interpersonal relationships, characterized by a rapid swing from dependency and passivity to manipulative and over-demanding behavior. In spite of Gundersons and Singers synthesis, the borderline diagnosis continued to be criticized (Liebowitz, 1992). One reason for this was that the term borderline continued to be used in a variety of ways: either as a discrete diagnosis, as a form of schizophrenia, as a group of affective disorders and finally as a psychostructural substrate underlying all severe pathology.
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Investigators continued the attempt to identify a series of symptoms that would define the borderline syndrome. Gunderson and Kolb (1978), working with the National Institutes of Mental Health, initiated a new comparative study among borderlines, depressed neurotics and schizophrenic patients. As a result of this study, several psychosocial factors were included as additional criteria, including low school and work achievement, sexual promiscuity, superficially high levels of socialization, and a singular motivation to avoid aloneness. In 1979, Spitzer (1979) and his colleagues created a list of criteria with 17 items based on Gundersons 1978 study and sent it to 4,000 members of the American Psychiatric Association. He asked the participants to judge the lists discriminating ability. Eight hundred and eight participants responded that using these criteria they could discriminate a borderline from a nonborderline 88 % of the time. Although Spitzer called this hypothetically distinguishable condition unstable character rather than borderline, his study provided some evidence for the hypothesis that there was a descriptively identifiable borderline patient. Spitzer produced his own list of eight criteria: 1-anger, 2- unstable affect, 3-chronic feelings of emptiness and depression, 4-identity disturbance, 5- intense emotional relationships characterized by shifts between devaluation and idealization, 6- intolerance to aloneness, 7-impulsivity, (related to substance use) and 8- physically self-damaging acts. Later a ninth criterion, dissociative experiences, was added that proved to be highly discriminatory for this group. A second set of investigators (Sheehy, 1980) compared a group of borderline patients with a matched control group of other personality disorders. This represented an advance in the field, as borderlines were here compared with other personality disorders instead of being compared to schizophrenics and those with affective disorders. Sheehy reached conclusions similar to those of Spitzer but held that there are three core characteristics of borderlines: 1impulsivity, 2- intense affect, and 3- interpersonal difficulties. To Spitzers original eight criteria, these investigators added four additional criteria, (1) absence of hypochondriasis, (2) absence of obsessive compulsive symptoms, (3) periods of social withdrawal and (4) chaotic sexual life with a tendency towards promiscuity. From the 1970s to the 1990s, the diagnosis if borderline personality came to be generally accepted within clinical psychiatry and psychology, and there was an increasing
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interest in this topic amongst both researchers and clinicians. In general, during this period, in addition to psychoanalytically based work, we find studies and conceptualizations that link borderline conditions to the schizophrenic spectrum of disorders (Kety et al, 1975) and others that emphasize the connection between the borderline and affective disorders. (Klein 1975).
Post-traumatic and Dissociative Models More recently a number of clinicians have come to see borderline personality as a disorder of chronic post-traumatic stress (Bleiberg, 1990). These clinicians suggest that a history of trauma, in particular sexual abuse, is present in the borderline patient. Accordingly, the borderline patient was exposed to a traumatic event that produced an overwhelming stress response. Later in life any pattern of further re-traumatization produces the impulsive acting, avoidance, hyperarousal, dissociation, and even psychotic-like symptoms that had become the coping style for borderline patients, a style that is best accounted for in the context of a posttraumatic stress model. Along these lines it might be argued that a qualitative distinction can and should be made between the true psychosis found in genuine schizophrenic spectrum disorders (which is believed to be biologically based) and the apparent psychosis (e.g. auditory hallucinations) that is often observed in dissociative (and borderline) patients, who as a result of early childhood trauma have split off (dissociated) aspects of their identity, which in later life returns as an alien voice. These patients, according to those who study the dissociative disorders, are qualitatively distinct from schizophrenics, though they are often mistakenly given the latter diagnosis because of their bizarre behavior and symptoms. Such patients (who at one time might have been diagnosed as suffering from hysterical psychosis) are thought to have developed their pathology as a result of defenses they put in place in response to early childhood trauma. On this view the schizophrenic is unable to develop a stable ego and identity because of a biological failure, whereas the borderline/dissociative has the biological equipment to develop properly, but doesnt do so because of an abusive and unstable early environment. As such, the borderline
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psychoses are purely defensive/dynamic in nature and wax and wane in response to environmental demands.
Borderline Personality in the DSM The American Psychiatric Association officially acknowledged the Borderline Personality Disorder for the first time in the version of their Diagnostic and Statistical Manual (DSM-III), published in 1980. From that point on there was a veritable explosion of literature, much of it related to the differential diagnosis between borderline personality and affective disorders. At the present time, the DSM-IV describes the Borderline Personality Disorder as follows:
a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following criteria:
1) Frantic efforts to avoid real or imagined abandonment. 2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3) Identity disturbance: markedly and persistently unstable self-image or sense of self. 4) Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). 5) Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior. 6) Affective instability due to a marked reactivity of mood (intense episode lasting only a few hours). 7) Chronic feelings of emptiness. 8) Inappropriate intense anger or difficulty controlling anger. 9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
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These criteria do not vary much from those proposed by Spitzer or Sheehy in the early 1980s. It should be noted that since only five out of nine possible criteria must be met in order to reach the diagnosis, two patients diagnosed with the Borderline Personality Disorder, as defined by DSM-IVs descriptive criteria, can be markedly different, even from a descriptive point of view.
Psychoanalytic Conceptions of the Borderline Patient In an effort to clarify the underlying psychological characteristics that characterize borderline patients from a deeper (and not merely descriptive) point of view, we must turn to a psychoanalytic understanding of the borderline concept. While a psychoanalytic model is not the only possible means of conceptualizing the deep structure of psychopathology, in the case of borderline personality, it has been the American psychoanalysts who have made the most persistent efforts in this direction. American psychoanalysis, with its emphasis on ego development and defenses provided fertile ground for developing an understanding of these patients intrapsychic structure and dynamics and provided a significant avenue for the investigation of this new diagnostic entity that had been suggested by more descriptive research. The early psychoanalytic contributions to the borderline diagnosis helped set the stage for more systematic psychoanalytic investigations of severe (borderline) psychopathology in the 1970s and later. In this section I will review the earlier psychoanalytic contributions to the borderline diagnosis and, with the notable exception of Kernberg and his school (which will be reviewed later) some later psychoanalytic conceptions of the borderline personality.
Early Psychoanalytic Contributions A. Stern (1938) was perhaps the first psychoanalyst to utilize the term borderline to refer to a distinct pathological entity in between neurosis and psychosis. He described borderline
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pathology as a stable intrapsychic entity, and in this sense prepared the ground for Kernbergs later conceptualization of a stable structural organization of the borderline conditions. Stern found his borderline patients to be poor candidates for psychoanalysis and characterized them as exhibiting ten basic features, including a history of cruel, rejecting mothering, hypersensitivity to criticism and rejection, defensive rigidity, pervasive inferiority and lack of self-assurance, masochism and depression, the use of projection, and problems in reality testing. Stern also described these patients as frequently experiencing a negative therapeutic reaction to psychoanalytic interventions. Melanie Kleins contributions (1939) were particularly relevant to the borderline concept; of specific importance were her descriptions of splitting of object representations and her illuminating discussion of the defense mechanism she termed projective identification. Each of these mechanisms took an important place in later psychoanalytic theories of the borderline structure. According to Klein, the innate helplessness of the infant is an early expression of the death drive which floods the child with negative emotion. This negative affect is projected onto the caretaker, with the result that the child succeeds in placing the negative object outside, at the expense of experiencing persecutory anxiety from this object as a retaliatory response. In order to allay this anxiety, a new defense mechanism arises that serves to protect the ego from aggression: a splitting of the object into good and bad aspects (This is what Klein terms the paranoid position). The maintenance of this split brings about an idealization of the good part of the object and sadistic expressions towards the bad part of the object. However, the infant later integrates these two parts in what Klein describes as the depressive position, with a resultant change in the childs affective organization. Whereas in the paranoid position the child is plagued by envy, destruction and greed, in the depressive position these emotions are redirected into feelings and expressions of gratitude, guilt, sadness and reparation. If this process of integration does not occur, the paranoid position governs the personality organization with splitting as the characteristic mode of defense. We will see that such splitting provides an important organizing principle in Kernbergs later conception of borderline pathology. In 1942 the psychoanalyst Helen Deutsch used the term as-if personality to describe patients who appeared to be normal but whose personality is conditioned by pathological internalized objects. These individuals suffer from an inner feeling of emptiness, marked
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passivity, suggestibility, and symptoms of derealization and depersonalization. Deutsch felt that these patients were somewhere on the continuum between neurosis and psychosis and that they had failed to integrate early identifications into a stable personal identity. In 1953, Knight used the term borderline to refer to individuals whose weakened ego structures placed them midway between neurosis and psychosis. While these patients were superficially adapted to the environment and were not obviously psychotic, they demonstrated a number of weaknesses in such ego functions of concept formation, judgment, planning, and the capacity to defend themselves against primitive unconscious impulses.
Froschs Psychotic Character Frosch (1964) coined the term psychotic character to describe individuals with psychotic personality features but who had certain ego strengths, including sufficiently adequate reality testing to permit them to recover quickly from psychotic regressions. Frosch held that these individuals might suffer certain illusions or perceptual distortions, but were sufficiently realityoriented to know that their perceptions were indeed not real. Froschs contributions centered on his conceptualization of reality in regard to which he described three distinct components:
1) The relationship with reality, a measure of how the individual copes with and relates to the external world. This, for Frosch, is a measure of adaptation, which is to be distinguished from reality-testing per se (e.g. a patient with reality testing problems can adapt reasonably well to reality by accommodating to his perceptual impairment). Perceptual disturbances such as hallucinations and illusions are, in Froschs terms, distortions in the relationship with reality. However, the difference between psychosis and the psychotic character is that in the latter, such disturbances are transient and reversible, with the relative retention of the capacity to test reality. (Frosch, 1969).
2) The feeling of reality, or defects in the sense of reality, which relate to the ability to experience ones self and body, along with external events, as real and familiar. Examples of
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pathology in this area include the experience of a confused or grossly distorted body image, and feelings of derealization, depersonalization and estrangement that occur under stressful situations,
3) The capacity to test reality refers to the ability of the individual to evaluate appropriately the phenomena in their world. For Frosch, this concept implies the conventions of a culture and is dependent upon conformity to a socially agreed upon notion of reality. For Frosch, a hallucination may be present as a distortion of a perception, but if the individual is able to recognize the phenomenon as internally derived, this person has retained his/her capacity to test reality. Frosch provides an example that illustrates this point, as well as his conception of the psychotic character: A female patient suddenly felt the floor tremble while at a concert. She asked the people beside her if they felt the same. When the answer was that they had not, the patient took a few moments to think about this event and told Frosch that she was puzzled by her experience but concluded that the trembling must have been a projection of her own vaginal orgasm. The trembling of the floor represents a distortion of her relationship with reality; later the patient was able to recognize that these phenomena had been a personal experience, which in Froschs view indicates that her reality testing remained intact. Nevertheless, the bizarre nature of her explanation of her own distortions is, according to Frosch, typical of the flood of sexualized content which overcomes the psychotic characters ego defenses. According to Frosch all three aspects of reality are deficient in psychosis, whereas the psychotic character shows impairments in the adaptation to and feeling of reality, but is able to maintain adequate reality testing. The vulnerability to breaks in reality testing that Frosch occasionally observed in these patients are on his view attributable to extreme stress, where the patient suffers an ego regression resulting in a brief psychotic break that is completely reversible. Frosch reports that some of these patients experience constant cycles of regression and reversals according to the degree of their subjective vulnerability. (Frosch, 1970).
The Borderline Concept in America Later Psychoanalytic Theorists
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Kernberg, whose work will be discussed in detail in Chapter Two, is the next major psychoanalytic thinker to make contributions to our understanding of the borderline, and the psychoanalyst who has been most influential in contemporary discussions of borderline personality. Beginning in1966 Kernberg commenced work on a synthetic and comprehensive model of the borderline personality that integrated both descriptive and psychoanalytic criteria, and which assisted the psychiatric community to reach something of a consensus regarding the nature of this disorder. However, Meissner (1978, 1982) concluded that those patients who have been classified as borderline cannot be properly brought together under a single structural diagnosis, but rather represent a spectrum or range of personality dysfunction. According to Meissner, there are two broad groupings of borderline patients, those belonging to (1) the hysterical, and (2) the schizoid continuums. Each of these groups is in turn comprised of several sub-categories. The hysterical group is comprised (in descending order of pathological severity) pseudo-schizophrenia, the psychotic character, the dysphoric personality (borderline personality proper), and the primitive hysteric. The schizoid continuum includes the schizoid and as-if personalities, the false self personality organization and patients who can be characterized as suffering from identity diffusion. (Meissner, 1978). Further, Meissner proposed that we should think of borderline personality disorder in terms of a variety of subgroups in the same way we do with respect to schizophrenia. He concluded that the variety of psychopathological phenomena that have been subsumed under this disorder may account for the resistance to attempts to create an integral theoretical formulation (1978). While many clinicians and theoreticians have found Meissners sub-groupings useful, we should here note that Meissners sub-classificatory scheme actually calls into question the possibility of defining the borderline personality in structural or dynamic terms. We might ask what remains of the original borderline concept and the presumed psychotic-neuroticborderline diagnostic triad, after the borderline concept is splintered into so many different pathological entities. While the various subcategories of the hysterical subgroup can be classified according to a criteria that has traditionally been associated with the borderline concept
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(affective lability, poor frustration tolerance, ego-weaknesses, lack of self-cohesion, primitive defenses, etc.), the schizoid group is not readily classifiable in these terms. Rather these patients seem to be characterized by what has been called the need-fear dilemma, an intense conflict between a need for others and a fear of being engulfed and destroyed by them. In 1983, Abend, Porter and Willick, provided a critique of the borderline concept as it is understood by Kernberg and his followers. They conducted an in-depth evaluation of four patients who met eleven descriptive borderline criteria and who had completed classical psychoanalysis. They presented their findings to the Kris Study Group at the New York Psychoanalytic Institute. Their diagnostic criteria derived from a review of the literature and included reversible defects in reality testing, infantile interpersonal relationships, impaired adjustment, polysymptomatic neurosis, primary process thinking, narcissistic personality features, aggressive conflicts, substantially disturbed affect, and intense transference reactions in treatment. In contrast to Kernberg, these authors suggested that such patients suffer from severe oedipal as opposed to pregenital or pre-oedipal difficulties. These researchers argued that their patients could not be distinguished on the basis of specific defenses (such as splitting and projective identification) or level of defense. Further, the four patients studied did well in traditional psychoanalysis. According to Abend and his colleagues, the term borderline does not refer to a discrete diagnostic syndrome but to a rather loose catch-all classification for a large number of heterogeneous patients. Goldstein (1985), a psychiatrist who adopts Kernbergs theoretical understanding of the borderline disorder, argues that in spite of the fact that Kernberg diagnosed two of Abends patients as borderline, these patients were healthier than the typical borderline treated by Kernberg and his associates. Masterson and Rinsley (1972, 1976) emphasized the disturbed character of the borderlines mother. They based their work in part on the developmental theories of Bowlby and Mahler and agreed with Kernbergs conception that impaired object relations play a significant role in borderline pathology. They described the mother of the borderline as a borderline herself who encouraged symbiotic clinging, but who became unavailable if the child displayed any desire for independence. The borderlines early family experiences were, according to these authors, characterized by an absent father. As the individual matures she/he is torn by a constant
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conflict between individuation and symbiosis, and experiences individuation as synonymous with abandonment (involving a loss or rejection by the mother). As a result of this conflict, the borderline personality is destined to spend her life changing relationships, swinging from extremes of idealization to betrayal and disappointment with their partners. Harold Searles, who in the 1970s and 80s treated several outpatient and inpatient borderline and psychotic individuals with intensive psychodynamic therapy, described how the borderline individual is unable to differentiate between reality and dreams or fantasy, between emotions and sensations, between a thought and an action, and, in general, between symbolic and concrete realms. According to Searles (1969), these difficulties are subtle and are not easily recognizable unless the patient is in treatment for some time. The failure to differentiate between reality and fantasy allows the borderline to believe his/her omnipotent thoughts, and this seriously impacts upon his/her capacity to integrate the experiences of everyday life. For Searles, borderlines either feel that they can harm themselves or others or that they have become totally vulnerable and will be destroyed. Searles points out that the clinician treating a borderline will frequently hear references to the self as a thing, or find that their patient fails to use the pronoun I, replacing it with we. This phenomenon of multiplicity is typical of a state of undifferentiation or depersonalization. Singer (1977) goes a step further in detailing the experience of depersonalization in the borderline patient. He describes the fear of the borderline as resulting not only from an intrusion by others but from a sense of being devoid of the self. Singer theorizes that the borderlines masochistic tendencies, along with an extreme anxiety and self-centeredness are the result of a need to a focus on the self as a means to ensure their continued existence. Finally, Volkan (1981) has presented a rather thorough psychoanalytic metapsychology of the borderline patient. Volkans work is based on object relations theory, and he theorizes that borderlines externalize their split self and object representations only to re-internalize the resulting distorted object images. He describes this phenomenon in some of his patients who experience a flooding of ideas mixed with intense emotions. They talk unintelligibly, perhaps using only one or two words to describe their memories. Their speech is bizarre and they display intense motor activity. When such patients later recall their actions, they agree that a strange perceptual experience overtook them. In an effort to explain the causes of the disorganization
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that occurs in the self and object representations, Volkan points to failures in the dyadic relationship with the mother, in connection with a lack of environmental support. Volkan describes several parenting patterns that can result in borderline pathology, including the singleparent relationship in which intense frustration builds up as a result of the parents unavailability resulting in a failure to integrate the negative and positive experience of others and self; multiple mothering, in which varied, often contradictory identifications of the mother function wreak havoc on the childs intrapsychic stability, and a third scenario in which the child experiences himself as a depository of a representation of someone else who existed in the mind of the parents. (Volkan, 1980).
Otto Kernberg and the Borderline Conditions
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Chapter Two
ore than any other theorist, Otto Kernberg has brought the notion of the borderline conditions into the center stage in American psychoanalysis. In this chapter I will briefly place Kernbergs work within the context of post-Freudian
developments in psychoanalysis, and provide a more detailed description of Kernbergs theory of the borderline personality, which will later be used as a springboard for dialog with Lacanian psychoanalysis.
Post-Freudian Developments in Psychoanalytic Theory

The history of post-Freudian developments in psychoanalysis, particularly as they pertain to the development of psychoanalysis in America has been amply described in the literature (Greenberg, J., 1983). As is well known, even before Freuds death, the developments in postFreudian thought was well on the way to being established. These developments included, (1) the departures of Jung and Adler, (2) revisions in technique, particularly in the direction of briefer forms of treatment initiated by those such as Sandor Ferenczi and Otto Rank, (3) the development of ego psychology and an emphasis upon the theory of defenses by such analysts as Anna Freud, Heinz Hartmann, Rudolph Lowenstein, and Ernst Kriss, and (4) the elaboration of the major neo-Freudian schools by Erich Fromm, Harry Stack Sullivan and Karen Horney during the 1930s. After the 1930s a schism occurred between Melanie Klein (and the so-called
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British school) and those who embraced what came to be known as American ego psychology. Klein and her followers formed the British school of object relations (Gabbard, 1994). As will be discussed in Chapter Three, psychoanalysis in France developed along lines that in some ways paralleled the developments in England and the United States, and which in other ways were radically different. France, in the decades after Freuds death was a great center of philosophical activity, where the study of phenomenological and existential philosophy (e.g. Husserl, Heidegger, Sartre, Merleau-Ponty) had a major impact upon intellectual life in general, and psychoanalysis in particular, and where structural anthropology (e.g. Levi Strauss) and linguistics (Saussure) rivaled existentialism for authority in intellectual circles. Amongst French psychoanalysts, Jacques Lacan, was able to provide an integration of these currents within French thought with what he described as a return to Freud, and which involved a focus upon language and the unconscious, and eschewed such notions as adaptive functioning and the conflict free sphere, which were the staples of ego psychology. Within France, a major schism occurred in the 1950s with the expulsion of Jacques Lacan from the core of the International Psychoanalytic Association (IPA), as a result of his direct challenges to ego psychology and his declaration that its basic tenets were opposed to the core of Freudian thinking. For this reason, psychoanalysis in France became increasingly separated from developments within England and the United States, with the result, for example, that Kernberg could create, and others develop, his theory of borderline personality organization, without either a consideration of, or a response from those in France who had developed their thinking largely upon the work of Lacan. Indeed, it is only in the last several years that Lacanian analysts have taken up the question of the border and the beginnings of a clinical and theoretical exchange between American and French psychoanalysts on the subject of the borderline conditions has appeared. ( Roudinesco, 1993).
Object Relations
Interestingly, in spite of the various schisms in post-Freudian psychoanalysis, and the virtual estrangement between French and English speaking psychoanalysts, a single theme can
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be said to dominate discussions in many if not all of the competing schools. What appears to be common to all psychoanalysts today is an interest in peoples interactions with others, and the role of the other in the construction of the individuals psyche, leading to the concept of the object and object representation. By the early 1980s, Greenberg and Mitchell (1983) declared that the problem of object (the other as internalized and represented in the individual psyche) had come to be the main focus within the various psychoanalytic schools. The three major theoretical positions in psychoanalytic thought in America today are the ego-psychological approach, object relations theory and the school of self-psychology. (Gabbard, 1997) All of these positions are currently characterized by their de-emphasis of the concepts of drive and defense and their theoretical prioritization of relationships, in particular early relationships, in the formation of the human psyche. The concept of the borderline conditions finds its place within each of these three psychoanalytic schools. I will initially focus my discussion on object relations theory, in order to provide background for my elaboration of its main representative regarding severe personality pathology, Otto Kernberg. While there are elements within Kernbergs theory that are best approached from an ego-psychological perspective, and Kernbergs theory has indeed been labeled ego-psychological, I believe Kernbergs greatest debt is to the (American) object-relations school. As I have already indicated, object relations theory originated in England with the theories and clinical practice of Melanie Klein. However, a group of prominent psychoanalysts such as Donald Winnicott, Michael Balint, Ronald Fairbairn, and John Sutherland who were much enamored of Kleins thinking, but did not want to take sides in the debate between Klein and Anna Freud, developed what we now refer to as the object relations school (Gabbard, 1997) According to Greenberg and Mitchell (1985), Freud initially developed his theory around the concept of drives, and did not focus upon the individuals relations to others and the world until much later in his career, after taking up the problem of the ego. His early psychoanalytic formulations understood all facets of personality and psychopathology as a function or derivatives of drives and their transformations. Thus, when a theorist considers the issue of object relations within the framework of drive theory, an object will be conceptualized as a derivative of a drive or drives. Kernberg is largely in accord with this view of objects as a
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drive derivative, a view he shares with Edith Jacobson, amongst others. A second group of analysts, including Fairbairn, tried to replace the drive theory altogether, substituting a model of object relations as the basic building blocks of mental life. Object relations theory is therefore not an interpersonal model of psychoanalysis, but rather a theory of unconscious internal object relations that involves the transformation of relationships with external objects into internalized introjects and structures. According to this position, the self-object (the mental representation of who we are) is not the result of an identification with either or both of our actual parents but instead results from powerful affective experiences and the experience of an object (usually the mother before the 16th month) that produces either satisfaction or frustration. The real mother may be internalized as a distorted image, according to the degree and quality of the demands of the infant and regardless of how competent the mother may be. The feeding experience provides a good example of this process. When the infant cries desperately for his food he experiences the self as unpleasant, frustrated and angry, and the mother (object) as inattentive and unavailable. When the food arrives, the experience is colored by positive feelings towards himself and his mother. However, the childs object representation will be largely a function of his fantasized images and representations. For example, if the mother delays the feeding, regardless of the cause of the delay, (even a realistically necessary delay), the infant will experience the mother in a very negative way, as evil and ungratifying, rejecting and abandoning. This fantasized mother will then be internalized as an introjected or identificatory object. Object relations analysts also provide for the possibility of partial internalizations which reflect different positive or negative aspects of the mother (the good and bad mother) as she is experienced in the fantasy life of the child. The infant will internalize the positive aspect of his mother as a soothing mechanism in order to deal with the possibility of losing his/her mother. On the other hand, the infant attempts to gain control over the negative aspect of the mother by capturing it within himself, in some cases attempting to transform the bad into the good object., and in other cases hanging onto the bad object because possessing a bad object is better than having no object at all. The development of the self-object unit involves two mechanisms:
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(1) Introjection: This mechanism involves the taking in of an object (and its qualities) but in a manner that assures that it will be simultaneously experienced as an other. Freud opposes introjection to projection, in which undesirable parts of the individual are externalized (as in paranoia). Although an introject is experienced in the child as a soothing mechanism, it is still considered an object rather than a part of the self (Laplanche-Pontalis, J. 1987).
(2) Identification: This mechanism explains how the self is modified as a result of an internalization of a significant external figure that is used as a model. The childs self experiences are those parts of the parent that the child identified with (Laplanche-Pontalis, 1987). Whereas ego psychology views conflict as a struggle between different psychic agencies (id, ego, and superego), the object relations theorists perceive unconscious conflict as a struggle between different self-object units. Object relations theory views conflict and character formation as intensely influenced by the constellations of self and object representations derived from introjections and identifications.
Kernbergs Theory of the Borderline Kernberg belongs, along with Edith Jacobson to what has been spoken of as the mixed model of theoretical psychoanalysis in America. Each of these analysts tried to integrate aspects of an ego psychological point of view with the British school of object relations, mainly the theory of Melanie Klein. While the term borderline has been called an idiosyncratic catchall term for difficult patients (Gunderson, 1989), Kernberg has attempted to define it in both descriptive and dynamic terms, as a specific structure of psychic organization that is to be distinguished qualitatively from the neuroses and psychosis. As described by Kernberg and his followers, the term borderline refers to a level of personality organization. As we have seen in Chapter One, there are two different though overlapping uses of this term, borderline personality disorder and borderline personality organization. Borderline personality disorder is a descriptive designation that refers to a more or less specific psychiatric
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syndrome characterized by a set of well known symptoms: impulsivity, chronic anger, unstable relationships, identity disturbance, feelings of emptiness and boredom and the tendency to act out on self-destructive ways (Akhtar, 1975). By way of contrast, borderline personality organization is a broader concept with definite psychostructural implications. It refers to a character pathology in which there is evidence of identity diffusion, predominance of splitting over repression as the main ego defense mechanism, and an arrested separation-individuation process resulting in an unintegrated ego marked by pre-oedipal aggression. While the contrasting perspectives can be synthesized one does not logically imply the other. Kernberg, for example, holds that borderline personality organization underlies all cases of borderline personality disorder, but that not all cases of borderline personality organization will present with the descriptive features of a descriptive borderline. This is because, on Kernbergs view, borderline personality organization also underlies narcissistic, paranoid, schizoid, antisocial, hypomanic, and as-if personalities. In effect, Kernberg is attempting to introduce a structural and (to a certain extent) etiological model of severe psychopathology that lies between neurosis and psychosis regardless of its phenomenological presentation (Akhtar, 1975). Kernberg understands borderline patients as suffering from a rather stable pathological personality organization, characterized by a specific ego psychological structure that is highly resistant to change except through intensive psychotherapy (Goldstein, 1985). In Kernbergs scheme, all patients who present themselves for psychoanalytic treatment fall into one of three groups: neurotic, psychotic and borderline. We will see that Kernbergs tripartite structural classification of psychopathology stands in stark contrast to that of Lacan, who regards the basic three structures proposed by Freud (neurotic, psychotic, and perverse) to be without any need of augmentation or revision. It is Kernbergs view that the presenting symptoms of the (structural) borderline may be quite similar to the presenting symptoms in the neuroses and (non-borderline) character disorders and it is therefore only through a thorough structural diagnostic examination that the borderline organization will emerge. In fact, from a descriptive point of view, the borderline personality organization often initially presents as neurosis. While a peculiar combination of symptoms (some of which are clearly in the psychotic range) provide a presumptive diagnosis, only a
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careful examination of the individuals ego pathology, achieved through a structural interview, can lead to a more definitive diagnosis.
The Descriptive or Presumptive Diagnosis Kernbergs descriptive model consists of a number of symptoms that he believes are suggestive of borderline personality organization (Goldstein, 1985). According to Kernberg, from a descriptive point of view, borderline patients typically present with the following characteristics: (1) Anxiety: The anxiety is typically diffuse, free-floating and accompanied by other symptoms or character traits. In the borderline personality, anxiety exceeds the binding capacity of the ego, and is accompanied by other pathological signs. (Kernberg, 1966). The clinician must rule out chronic anxiety related to conversion symptoms or as in the case of patients in intensive psychotherapy, anxiety appearing as a form of resistance. (2) Polysymptomatic Neurosis: This includes:
(a) Multiple Phobias: Kernberg refers to phobias in which the patient is socially restricted and/or phobias related to the patients body or appearance (such as fear of being looked at, fear of talking in public). These fears need to be distinguished from phobias related to external objects such as animal phobias or fear of heights, as these are not presumptive evidence of borderline pathology.
(b) Obsessive-compulsive symptoms, especially, those patients whose symptoms are colored with paranoid or hypocondriacal themes.
(c) Multiple and severe conversion symptoms of an elaborate kind, usually bordering on bodily hallucinations.
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(d) Dissociative reactions with a hysterical quality such as fugues and amnesia.
(e) Hypochondriasis, especially if chronic, associated with a withdrawal from social life, and accompanied by health rituals. Severe anxiety with mild hypocondriacal reactions is not indicative of borderline pathology.
(f) Paranoid trends associated with hypochondriasis: Kernberg believes this combination is typical of borderline personality disorder. He holds that both symptoms should appear as strong trends and not secondary to other pathologies. (3) Polymorphous Perverse Sexual Trends: According to Kernberg, patients who manifest sexual deviation with several perverse trends likely have a borderline personality organization. Perversions may not be clearly manifested until later in treatment when the patients fantasies are explored. However, complex fantasies, usually involving several coexistent perversions as a basic condition for sexual satisfaction, are a sign of borderline pathology. According to Kernberg, the more chaotic and multiple the perverse fantasies, the more unstable the object relations connected with these interactions (Kernberg, 1977). Patients whose sexual life is centered on a stable deviation with a constant object are not included in this category. (4) The Pre-psychotic Personality: This includes the paranoid, the schizoid, the hypomanic and the cyclothymic personality disorders; however, the depressive personality disorder is not included, particularly if presenting with masochistic traits. (5) Impulse Neurosis and Addictions: Character pathology with repetitive impulsive behavior is presumptively borderline in Kernbergs structural sense of the term. Drug addiction, alcoholism, psychogenic obesity, and kleptomania are also grouped under this category. Often these individuals also manifest sexual deviation with a compulsive quality and acting out personality types.
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Object relations theorists typically view character disorders on a continuum from high level types, such as the avoidant personality, to the low level types represented by chaotic and impulse-ridden individuals. These distinctions are made on the basis of the degree to which repressive mechanisms (high level) or splitting mechanisms (low level) predominate. Kernberg regards borderlines as manifesting a low-level character disorder. Such formulations, of course, are not descriptive, but rather refer to presumed underlying structural characteristics. When Kernberg refers to low level character pathology as being presumptive evidence for borderline personality organization he has already begun to discard descriptive diagnosis in favor of a structural approach.
Kernbergs Structural Analysis From the psychoanalytic point of view, a structural analysis originally involved the analysis of mental processes in terms of the three psychic structures id, ego, and superego. However, Hartmann (1946) and Rapaport and Gill (1959) broadened the term structural to refer to ego structures or configurations that have a slow rate of change, which determine the channeling of mental processes that are functions in themselves, and represent thresholds in development. This new concept of structure broadened the psychology of the ego and emphasized its cognitive and defensive aspects. Further, the object relations theorists further broadened the term structural to include the analysis of the derivatives of internalized object relationships (Fairbairn, 1951). In his theory of the borderline Kernberg encompasses all of these meanings of structure, the Freudian, ego-analytic and object-relational. He holds that in order to arrive at a conclusive diagnosis regarding borderline personality organization, the clinician must rely upon structural analysis. Such an analysis is done step by step, beginning with the analysis of the ego and its relationships to the other psychic agencies, and finishing with an analysis of internalized object relationships. Kernbergs structural analysis of the borderline yields several basic criteria:
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Borderline Personality Disorder: A Lacanian Perspective (1) Nonspecific manifestations of ego weakness: Kernberg holds that several non-
specific ego weaknesses are typical of the borderline patient. These include (a) an inability to tolerate anxiety that does not result simply from the degree of anxiety but is rather a function of the individuals failure to adequately cope with stress overload; (b) a lack of impulse control, which involves unpredictable, erratic, behavior as a dispersion of intrapsychic tension rather than a specific enactment or an acting out in relationship to the transference, c) a lack of developed sublimatory channels, for example, an absence of creative enjoyment or creative achievement; and (d) a blurring of ego boundaries as a result of the lack of differentiation of self and object images. (2) Shift toward primary process thinking: According to Kernberg, while borderline patients are generally capable of engaging in secondary process thinking, involving the implementation of reason and judgment in their everyday lives, they are subject to increased primary process thinking in unstructured situations and in response to stress. While the findings are not completely definitive, research has shown, for example, that borderline patients engage in secondary process thinking on the structured cognitive tasks such as intelligence testing, but show increased primary process thinking in comparison to neurotics, on unstructured psychological tests like the Rorschach (Kernberg, Goldstein, Carr, et. al. 1981). Primary process thinking appears in the form of primitive fantasies and the use of peculiar verbalizations and emotionally charged associations (Kernberg, 1977). According to Kernberg, the reality testing of the borderline is essentially intact, except for brief regressive psychotic episodes that can occur under stress, particularly in relation to the transference in intensive psychotherapy, and/or with the use of alcohol and drugs. What is noteworthy about the borderlines psychotic episodes is not their particular form or content, but rather their brevity and reversibility. While not all borderlines have such transitory psychotic episodes (which can range from a few minutes to as long as perhaps two days) their presence in many borderlines illustrates the fragility of the ego-function of reality testing in these patients. (3) Specific defensive operations: Kernberg elaborates six primitive defenses that he regards as pathognomonic for the borderline diagnosis. The most important of these defenses,
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splitting, serves the borderline in much the same way that repression serves the neurotic. Amongst the other primitive psychological defenses employed by borderline patients are primitive idealization, infantile projection and projective identification, denial, omnipotence and devaluation. According to Kernberg, whereas the neurotic employs such primitive defenses in childhood, he or she moves on to develop more mature psychological defenses centered on repression. This developmental milestone is, according to Kernberg, never fully achieved in the borderline patient. While the borderline typically uses more mature defenses in his/her daily functioning, he or she has a tendency to fall back upon these six borderline defenses under stress.
(i) Splitting: The concept of splitting as a defense mechanism was first elaborated by Freud. However, as we have seen in Chapter One, the British school, beginning with Melanie Klein (and later Fairbairn) further developed this concept in relation to the issue of ego integration. Splitting, which is said to characterize a very early stage of psychological
development, involves the isolation of opposing affects and emotions and a failure to integrate negative and positive aspects of self and others. Its most important role is in the defense against libidinal drives and their derivatives, and it has a significant impact upon the childs introjects and identifications. At the infant stage of development the erotic and aggressive drives operate separately; good and bad, positive and negative, are aspects that are not integrated in experience. At this stage splitting serves to prevent contamination of good introjects by negative affective experience. In normal development there is an integration of good and bad, as the child achieves libidinal object constancy. In the process the ego evolves from the use of splitting to the use of higher, more mature defenses such as reaction formation, isolation, or undoing. In severe pathology, splitting persists to protect the ego by dissociating introjects and identifications of a conflictual nature (Kernberg 1977). According to Kernberg, the use of splitting is typical of the borderline structure, where it is frequently combined with denial and a selective lack of impulse control.
(ii) Primitive Idealization: this defense, which is related to splitting, refers to the tendency to see external objects as totally good in order to make sure that they are protected from the all bad. Such idealization represents a protection against contamination, spoilage and
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destruction of the good object, which the patient believes can be influenced or even destroyed through his or her own aggression. Primitive idealization is not related to developmentally later forms of idealization that are present in depressive states, in which the patient idealizes someone out of guilt over their aggression for that object. Sometimes, primitive idealization manifests as identification with an omnipotent, idealized object that is viewed as incapable of being or engaging in anything negative.
(iii) Projective identification: This term, which was introduced by Melanie Klein, designates a mechanism through which the individual introduces fantasies of his/her own projected aggression onto the object in order to hurt it, to possess it and control it. However, in the borderline this mechanism is diagnostic. It is characterized by the lack of differentiation between self and object (in the particular area of projection of aggression). The individual experiences the aggressive impulse as well as the fear of the retaliatory response and therefore feels a need to control the external object in order to ensure that neither destruction of self nor object will occur (Kernberg, 1966). The development of this pathological defense has an impact upon the development of the superego and the ego ideal.
(iv) Primitive denial: The denial Kernberg has in mind is blatant and global, and is typically accompanied by splitting. For example, the patient remembers a painful event or experience with no emotional connection or awareness of pain. When pressed, the patient will intellectually acknowledge the presence of such negative affect but will not be able to integrate it with the rest of his or her emotional experience. This mechanism is different from neurotic denial in the sense that in primitive denial the material was never repressed and the patient was never at any time aware of the essential emotional connections. Kernberg views denial on a continuum of higher to lower levels; the higher level is represented by negation or isolation and the lower level by maniacal denial, in which the individual expresses feelings that are opposite those that are actually felt, in an effort to reinforce the egos stand against a threatening aspect of selfexperience.
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(v) Omnipotence and (vi) devaluation: As is the case with primitive idealization, omnipotence and devaluation are derivatives of splitting. Devaluation is the negative component of the split (bad object), whereas omnipotence is the positive component (good object). Omnipotence is evident in the borderlines expectation of gratification and the strong conviction that he or she must receive homage from others and be treated as special. Devaluation is the other side of omnipotence; if an external object can no longer provide gratification, it is dropped, dismissed and devalued. There is never a real concern or love for the object. This shift to devaluation is often accompanied by feelings of revenge and destructive fantasies in relation to the object that frustrated the patients (typically oral) needs. According to Kernberg, these mechanisms also have an impact on the development of object relations and superego formation. (4) Pathology of internalized objects: According to Kernberg,. the building blocks of the psyche consist of internalized object relations that are formed by primitive self and object representations that are formed in accordance with a dominant affect or drive. Kernberg holds that the mechanism of splitting interferes with the synthesizing functions of the ego, resulting in different degrees of differentiation characteristic of primitive personality organization in psychosis and borderline pathology. In the case of the borderline (and in contrast to the psychoses) differentiation of self and object images has occurred to a sufficient degree to achieve a certain integration of ego boundaries. However, ego boundaries falter in those areas where projective identification and fusion with idealized objects take place, and this is experienced especially in the transference with the analyst. According to Kernberg it is for this reason that such patients develop a transference psychosis rather than a transference neurosis. According to Kernberg, the failure of the borderline to synthesize the good and the bad introjections and identifications is in large measure due to excessive primary (constitutional) aggression and/or aggression secondary to frustration. This produces a deficiency in ego
development accompanied by an intolerable degree of anxiety in borderline patients. Later the failure of integration between libidinal and aggressive drives interferes with the egos capacity to modulate both thought and affect, leading to the borderlines tendency to experience sudden eruptions of emotions and ideas. Further, the affective states of concern, guilt and depression cannot be achieved if positive and negative introjections are not brought together (Kernberg,
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1966). Only the conflict or tension between two contradictory affective states in the ego can produce a genuine depressive reaction. These feelings are not present in the borderline; their socalled depressive affects take the form of rage and defeat before external forces. (5) Identity Diffusion: Kernberg appeals to Erik Eriksons notion of identity diffusion in describing the pathological internalized objects in borderline psychopathology (Goldstein, 1985). The subjective experience of identity diffusion is characterized by chronic emptiness, a shallow, flat and contradictory perception of others and, especially, the self. The failure to integrate contradictory aspects of self and others is presumably due to the early aggression activated in these patients. Such dissociation also serves the defensive function of protecting good aspects of the self from contamination by hate and badness. (Kernberg, 1975). A poor and partial view of self and others is also evident in the inability of borderline individuals to describe themselves in a meaningful and consistent way. The lack of temporal continuity regarding self and others explains the difficulty these patients have in locating actions and people when relating material in session. During the initial interviews in psychotherapy they provide confusing contradictory and descriptions of life events, and the interviewer experiences a great deal of difficulty seeing the person as a whole (Goldstein, 1985). Kernberg gives as an illustrative example, an infantile borderline patient who presents as her main complaint the feeling of disgust for being treated as a sexual object by men, and who elaborates on mens predatory attitudes with respect to sex. She further confides that she has become socially withdrawn in an effort to avoid sexual advances from men. However, she also mentions that she has worked as a bunny for Playboy magazine, and is utterly surprised when confronted with this contradiction in her presentation. By way of contrast, Kernberg holds that a hysterical (neurotic) patient will be more prone to express her ambivalence and fear of arousing both herself and men. Unlike the borderline, a neurotic would be aware of the ambivalence within herself.
Otto Kernberg and the Borderline Conditions The Id in the Borderline Structure
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Kernberg emphasized an excessive amount of pre-genital aggression in the borderline patient as a causative factor in the genesis of the pathology. This aggression is generally expressed in an overt way. Direct exploitiveness, unreasonable demands, and manipulation of others without any consideration of their feelings are typical expressions of the borderlines crude aggression. As we have seen, Kernberg thus focuses upon id organization; in particular, the aggressive drive and its vicissitudes, in his discussion of the genesis and development of the borderline disorder.
The Superego in the Borderline Structure For Kernberg, specific superego traits are not essential to the borderline diagnosis. While superego characteristics differ greatly from one borderline individual to the next, in general the borderline suffers from a primitive and unintegrated superego corresponding to her fragile ego and self. The undifferentiated state of all good and all bad images impacts upon superego integration, and it is common for these patients to present with a very sadistic superego related to internalized bad objects of the pregenital stage. This superego state is so intolerable that it gets re-projected onto external objects. Thus, these patients are constantly encountering sadistic or evil objects, and their opposites, idealized objects full of power, greatness and perfection. As the borderline cannot adequately integrate good and bad aspects of the parental figures, the internalization of parental demands becomes extremely prohibitory, punitive, and even sadistic in nature. On the other hand, there is also a fusion of ideal self and ideal object images, which, rather than producing a modulating ego ideal, tends to reinforce a sense of personal omnipotence. These structural failings are observed in certain characteristics of borderlines, such as their very limited capacity to make realistic evaluations of others, their experience of people as distant objects, and their incapacity for intimate relationships, which results, in part from their failures to empathize with others, or to feel either guilt or concern. As such, borderlines are typically always right and feel fully justified. The emotional shallowness
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that we observe in our clinical work with these patients is related to their lack of integration of libidinal and aggressive drive derivatives and their unrealistic appraisal of others. The borderline also maintains a distance from others in order to protect him/herself from an intimate encounter that might activate primitive defensive operations, especially projective identification.
The Genetic-Dynamic Analysis and Developmental Theory Closely linked to Kernbergs ego-psychological/structural model of the borderline personality is an object relations theory of borderline development that was first elaborated in Kernbergs (1976a) second book, Object Relations Theory and Clinical Psychoanalysis. In this book, Kernberg describes how before the end of the first year there is little or no differentiation between self and object, and all self-object representations are linked to either purely positive or purely negative affects. By the end of the first year, self and object have become differentiated and are integrated when they are associated with positive and negative affect states. Kernbergs theory here is related to and compatible with the developmental theory of Margaret Mahler. According to Kernberg, the central developmental defect in psychosis is a complete failure to differentiate self from other and hence to establish the ego boundaries that would provide the basis for a view of a reality apart from the self. While the borderline has succeeded in this basic task, he or she has not achieved what Kernberg refers to as libidinal object constancy, the recognition that an object, i.e. the mother, can retain both good and bad qualities, or can be associated with both positive and negative affect states, without losing her basic identity. This task, which is normally achieved at the age two or three, enables the child to surrender splitting as its basic mode of relating and recognize that people and things in its environment are both bad and good. The borderline patient has not surmounted this developmental hurdle and continues to utilize splitting as a means of coping with the vicissitudes of his or her emotional life. A person in the borderlines life is either all good or all bad, and thus the borderline remains continually prone to use idealization and devaluation as his/her basic mode of interpersonal defense.
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As we have seen, Kernberg provides a rather deterministic theory of the factors involved in the genesis of borderline personality organization. According to Kernberg, an excessive degree of aggressive drive during the first years of life, either as a result of congenital factors or early frustrations, has the result of reinforcing splitting in the developing child or interferes with the attainment of libidinal object-constancy as Kernberg defines it (Goldstein, 1985). The ever-present oral aggression gets projected and causes a paranoid distortion of the early parental images, in particular, the mother. Thus, the mother is viewed as potentially dangerous. These oral and anal sadistic impulses become contaminated in the father as well and later the family is viewed as a threatening united group (Kernberg, 1966). Moreover, the dyad dangerous mother-father gets translated into the realm of the sexual relationships, which is regarded by the borderline as an aggressive act. Therefore, genital strivings are permeated by pregenital oral rage with the result that the individual attempts to fulfill unmet oral-aggressive needs through genital activity. The issue of oral rage in the genital arena becomes a difficult issue for the borderline. The typical oedipal vicissitudes which, in the normal case, increase castration anxiety and its derivatives. produce greater disorganization in the borderline. Fears of a rageful father and of a dangerous castrating mother develop, and these are translated into the typical self-defeating patterns in the borderlines later relationships. According to Kernberg, this process determines what we see in our clinical work with borderlines, i.e. their polymorphous perverse trends as pathological compromise solutions to their interpersonal anxieties. These solutions always represent unsuccessful attempts to deal with aggression and lead to several pathological formations. One pathological path for a boy is that of orally determined homosexuality. In this case, the boy, afraid of his mother, turns masochistically to the father in order to fulfill his oral needs. In these cases, heterosexuality is viewed as threatening as the boy regards his mother as dangerous. Usually such homosexuality is accompanied by aggression. Such borderline men can become very promiscuous, as their constant involvement in homosexual acts and relationships involve an effort to fend off the reappearance of oral frustration and aggression.
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Borderline Personality Disorder: A Lacanian Perspective Severe oral pathology in girls tends to produce premature genital striving for the father
as a substitute for gratification of genuine dependency needs that have been frustrated by the girls mother. As a consequence, such girls typically experience a reinforcement of masochistic needs and a flight into promiscuity in order to deny their dependence on men. On psychological testing, both sexes appear lacking in sexual identity. However, as Kernberg will emphasize, the presence of polymorphous trends is the result of the combination of chaotic pregenital and genital tendencies. These patients lack of sexual identity is not a reflection of their confusion around sexual definition but more of a complex symptom involving strong fixations designed to cope with unmet oral needs. In sum, in both sexes excessive development of pregenital oral aggression tends to induce a premature development of the oedipal vicissitudes. As a result, pregenital and genital aims are conflated under the influence of intense aggressive needs.
Kernbergs Three Psychic Structures Kernberg holds that there are three broad ways in which the psyche can be structured: the neurotic, borderline and psychotic personality organizations. These structures perform the function of stabilizing the mental apparatus, mediating between the patients history, environment, and the direct behavioral manifestations of mental illness. Each individuals psychic organization, regardless of which specific factors contributed to the etiology of the illness, becomes the underlying matrix from which behavioral symptoms develop. (Kernberg, 1984). The main characteristics, which define these three broad categories, relate to: (1) the degree of identity integration (referring specifically to the integration of self and object representations, (2) types of defensive operations that the person employs, and (3) the individuals capacity for reality testing. Table 1 summarizes Kernbergs distinctions between neurotic, borderline, and psychotic levels of personality organization.
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Table 1: Kernbergs Structural Criteria for Neurosis, Borderline and Psychosis (adapted from Kernberg, 1966)
Structural Diagnosis Identity Integration Neurosis Self-representations and object representations are sharply delimited. The contradictions between self and others images are conceptually integrated Defenses protect individual from intrapsychic conflict. Repression and highlevel defenses such as reaction formation, isolation, undoing, rationalization and intellectualization. Capacity to test reality is preserved, differentiation of self and others, as well as intrapsychic from external origins of perceptions and stimuli is achieved. Capacity to evaluate self and others realistically and in depth.
Borderline Presence of identity diffusion: contradictory aspects of self and others are poorly integrated and kept apart. The use of splitting and low-level defenses such as primitive idealization, projective identification, denial and omnipotence. Alterations occur in relationship with reality and in feelings of reality.
Psychosis Self-representations and object representations are poorly integrated with the presence of delusional identity.
Defensive operations
Defenses protect patient from disintegration and self/object merging. Interpretation leads to regression.
Reality testing
Capacity to test reality is lost.
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Borderline Personality Disorder: A Lacanian Perspective The Interview as a Diagnostic tool From the practical point of view, Kernbergs approach involves judgments derived
from a series of interviews and interactions that are crucial for proper diagnosis. He requires between five to six interviews to elicit the information necessary to assess a patients level and quality of psychopathology. He will introduce certain inquiries or confrontations to assess the interaction with the therapist and the patients interpersonal functioning in general. He is not primarily interested in information regarding the patients personal history, as is typically gleaned from a psychosocial inventory (Shapiro, 1988). For Kernberg the diagnostic interview is the essential feature of a psychoanalytic assessment in accord with the principles of dynamic personality theory (Kernberg, 1977). It involves exploration of the patients awareness and mode of handling conflictual material. Kernbergs interview is essentially a provocative test designed to activate latent dynamisms and constellations, thereby permitting the interviewer to classify the patient according to the variables described above. In Kernbergs research the interviews are typically tape recorded and later judged independently by qualified professionals. While Kernberg acknowledges that structural constructs, for example, those involving object representations and defenses, are not easily inferred, the structural diagnostic interview is the most effective tool for this purpose (Shapiro, 1988). Whereas Deutsch (1942) advocated a psychoanalytic method of interviewing that would reveal the unconscious connections between current problems and the patients past, Kernberg considers that this type of interview has the disadvantage of minimizing objective data and does not explore the patients psychopathology and assets in a systematic fashion (Kernberg, 1984). Kernbergs interview combines the traditional mental status examination with a psychoanalytically oriented inquiry that focuses on the patient-therapist interaction. This
interaction is characterized by an active participation on the part of the therapist, who utilizes clarification, confrontation and interpretation of identity conflicts, defenses and reality distortion, particularly as these are expressed in the transference. Kernberg uses clarification as a non-challenging, cognitive means of exploring the limits of the patients awareness of certain material. Confrontation attempts to make the patient
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aware of potentially conflictual and incongruous aspects of their presentation. Interpretation seeks to resolve the conflictual nature of the material by assuming underlying unconscious motives and defenses that make the previously contradictory material appear logical. Kernbergs early focus on patients relationship with the interviewer is anxiety producing for the patient, as it tends to bring underlying psychic conflicts to the surface. However, this technique should not be confused with a traditional stress interview, which induces artificial conflicts to produce anxiety in the patient. To the contrary, the structural interview requires tact and empathy and should be carried out in an atmosphere of respect that does not highlight the interviewers superiority.
Empirical Assessment of Structural Diagnosis Kernberg and other researchers have subjected their work on the borderline personality organization to empirical evaluation (Koenisberg et al., 1985). This work provides a paradigm for future approaches in the study of second-order inferences removed from the immediate observational field, i.e. those belonging to the realm of descriptive classification. In such research, the concept of structure is put to the test using a psychoanalytic frame of reference. Indeed, one of the advantages of Kernbergs theory is that it has been subject to empirical testing. The issue of empirical testing will be discussed in greater detail when we take up the dialog between Kernberg and Lacan.
The Clinical Value of Structural Analysis Theoretically, Kernbergs structural diagnostic approach is meant to contrast with the descriptive approach that is present, for example, in the DSM-IV. Practically speaking there may be little difference, as a high correlation has been demonstrated to exist, for example, between Kernbergs structural and Gundersons descriptive methods of classifying borderline patients (Kernberg, Goldstein, Carr, et. al. 1981). Kernberg (1980) has taken such high
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correlations to suggest that structural and descriptive classifications of the borderline are complementary approaches to the same diagnostic entity. They may also, however, signal the possibility that Kernbergs object relations and ego-psychological approach to the borderline is another form of description, albeit one that is couched in structural terminology. Nevertheless, Kernbergs borderline classification is clearly broader than that what is described in the various editions of the DSM, as Kernberg believes that nearly all anti-social personalities and many schizoid, paranoid, cyclothymic, narcissistic and impulsive characters are best conceptualized as having a borderline level of personality organization (Goldstein, 1985). Typically, such individuals are lacking in such higher-level personality traits as empathy, humor, depth, warmth, creativity, and genuine guilt. Their inclusion in the borderline category would have major implications, not only for diagnosis, but for treatment as well. The question of whether Kernbergs diagnostic scheme is truly structural in the psychoanalytic sense will be taken up in later chapters. Meanwhile, In the meantime, the next chapter offers an alternative approach to structural diagnosis in psychoanalysis, that of Jacques Lacan.
Lacanian Psychoanalysis
Chapter Three
hile the past decade has seen an upsurge in interest in Lacan amongst American philosophers, literary and art critics, familiarity with Lacans ideas and approach to treatment remains quite limited amongst American psychologists and even
most American psychoanalysts.1 A number of factors can account for this situation. Amongst these are 1) the fact that Lacans writings and seminars were originally published in French and until recently the majority have remained untranslated into English, 2) the notorious difficulty and obscurity of Lacans writingsan obscurity that, in part, reflects Lacans views about the inherent ambiguity of all language, 3) Lacans difficult tendency to develop and alter his views without clearly demarcating differences with his former approach, 4) the numerous references in Lacans writings to philosophers, literary works, and linguistic theorists, with whom American readers are relatively unfamiliar, 5) Lacans break with, and ultimate expulsion from the International Psychoanalytic Association and his harsh criticisms of its members and dominant theories (ego psychology, object relations theory) and 6) Lacans staunch opposition to the emphasis upon practical utility in American clinical practice and his direct criticisms of American pragmatism.
This is in spite of the fact that a recent literature search (American Psychological Association: Psych Info) covering worldwide psychology journals over the past decade reveals 369 articles making explicit reference to Lacan whereas in comparison, only 160 make reference to Otto Kernberg, a psychoanalyst with whose theories most American psychologists are familiar. The majority of the cites to Lacan, however, are in non-English language journals.
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Borderline Personality Disorder: A Lacanian Perspective Renee Major, in his review of Elizabeth Roudinescos The One Hundred Years Battle
The history of Psychoanalysis in France, examined the cultural differences that have impacted upon the development of psychoanalysis in France and the United States. As Major points out, American and French psychoanalysts read Freudian theory in very distinct ways. An example of this is what Americans refer to as Freuds structural theory (Id, Ego, and Superego) the French refer to as the second topographical system (Major, 1984). More importantly, whereas American analysts generally hold that Freuds second structural model superseded the first topographical one, the French typically regard them on equal footing, or, as in the case of Lacan, place a far greater emphasis on the earlier point of view. We will see that a key area of disagreement and potential miscommunication between American and Lacanian psychoanalysts centers upon their respective uses of terms relating to psychic structures. Whereas American psychoanalysts have tended to identify psychic structure with what they call Freuds structural theory, i.e. the relations between the id, ego, and super-ego, Lacanians utilize the term structure to refer to an anthropological and linguistic concept that refers to a particular organization of elements defined by their system of relationships, in such a way that when one element changes, the whole system of relationships changes as well. While Americans have experience with such French structuralism in the fields of anthropology, literary criticism and philosophy, these ideas have not taken root in American psychology or psychoanalysis (Major, 1984). As we will see, Lacan develops such structural concepts in an original manner, and links them to the traditional Freudian diagnostic distinctions between neurosis, psychosis and perversion, in a manner that differs radically from American ego-analytic and object-relations structural theories. As we will also see, any attempt to conceptualize borderline psychopathology within a Lacanian context must take these critical differences regarding the nature of psychic structure fully into account. Another major area of difference between American and French psychoanalysis relates to their respective writing styles. French readers tend to (critically) view American journal articles as having a medical narrative style, while Americans view French writing as (overly) philosophical and literary. However, as Major indicates, these differences in style do not necessarily indicate that American psychoanalysis is more scientific and that French psychoanalysis is more artistic. They do, however, indicate that psychoanalysis in each
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country has developed, and is expressed, in accordance with each cultures intellectual values. In the United States, experimental science is generally regarded to be the paradigm of scientific truth and rigor, whereas in France critical conceptual analysis occupies a similar position. This distinction, we might add, can be traced back to the debate between the Cartesian rationalists and British empiricists. Whereas Lacan and other French psychoanalysts see themselves within the former tradition, American ego psychologists are much more closely linked to the latter. French psychoanalysis has therefore taken seriously developments in rationalist and idealist philosophy (Kant, Hegel, phenomenology and existentialism) that, at least until recently, have been relatively ignored by American empiricist philosophers and psychologists. Finally, we need to evaluate the history of the psychoanalytic movement (as any other institution) within a social, political and historical context (Oliner, 1988). In the following section I will briefly examine the history of psychoanalysis in France and Lacans place within that history.
The History of Psychoanalysis in France As is well known, Freud had an important first-hand experience of French psychiatry and neurology while studying at the Salpetriere Clinic from October 1885 to February 1886, several years prior to his initial psychoanalytic collaboration with Josef Breuer. Freud developed a close relationship with the leading figure at the Salpetriere, Charcot, J., who took a liking to his then 30-year old German student, and with whom he shared ideas on the links between sexuality and neurosis. Although Freud published three papers in France, he was, at the time, a relatively unknown researcher who was not read by the French psychiatric community. Further, when after the publication of The Interpretation of Dreams and The Psychopathology of Everyday Life the first generation of analysts was firmly established as Freuds circle, the French had no representation in the group (most of whom were German speaking with Ernest Jones and Abraham Brill the two English-speaking exceptions). There was also no trace of the French at the first International Congress of Psychoanalysis in 1908, presided by its then newly-elected president Carl Jung. It wasnt until 1914 that Freuds original Five Lectures on Psychoanalysis
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were translated into French and became readily accessible to the French psychiatric community. It was Rene Laforgue (1925) who was the earliest promoter of psychoanalysis in France. Along with Rene Allendy, Laforgue organized the psychoanalytic group, LEvolution Psychiatrique, and the first French psychoanalytic journal appeared in 1925. Interestingly, this early French school distanced themselves from what they regarded to be Freudian dogmatism, and they appeared more interested in facts that could be put to strict scientific test than in matters related to the unconscious or the vicissitudes of sexuality. At a certain point this group took steps, under the direction of Henry Ey, to transform itself into an organodynamic psychiatric entity that would limit membership to medical doctors. (De Mijolla, A.1982) In the meantime, the International Psychoanalytic Association obtained a foothold in France under the auspices of the Princess Marie de Bonaparte (a French woman, granddaughter of the Emperor, who had maintained a close relationship with Freud after having been an analysand of his). Bonaparte later acquired the letters that Freud wrote to Fliess and was instrumental (with the help of the United States ambassador) in securing Freuds visa to exit Austria and obtain residence in England in 1938. Bonaparte served as Freuds personal French translator and became the most important propagator of Freuds ideas in France. While she had no personal clinical training and thus had no ability to publish her own cases (in spite of her wish to be an analyst), she became extremely involved in the clinical training of psychoanalysts and, as a non-physician, she was very cautious regarding the French medical community. She founded, with Lowenstein, Allendy and Laforgue, The Societe Psychoanalytique de Paris (SPP). A strong controversy ensued, in which The Evolution Psychiatrique proclaimed that the field of psychoanalysis was directly related to general medicine, neurology and psychiatry, and the SPP opposed that view. Bonapartes group, the lay group, held that psychoanalysis was the realm of the psychology of the unconscious, which belonged to the clinical, but not exclusively medical, field. Jacques Lacan, a young psychiatrist, was present at the meetings where these issues were heatedly debated. He applied for admission at the SPP (at this point, fully supported by Freud himself) to become a training analyst, and by December 1938 he became a full member after starting a personal analysis with Rudolf Lowenstein. In 1936 Lacan presented a paper at the 14th International Congress of psychoanalysis in Marienbad entitled The Mirror Stage. He was the first psychoanalytic theorist in France to take
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an innovative path with respect to the development of psychic formations. Lacan based his ideas about the nature of the ego on Wallons work with primates and their experience of confronting their image in a mirror. (Wallons research suggested that whereas primates learn that the image is illusory and quickly lose interest in it, the human child becomes fascinated with his mirror imagesee below). After the war, psychoanalysis in France was re-organized along two, rather different lines. On the one hand, a number of French psychoanalysts had a vision of a small society carefully filtering and controlling its membership. Others held the ideal of a large movement that would bring together members from different disciplines: philosophy, linguistics, medicine, psycho-pedagogy, and even religion. In part because of the polarizing political impact of World War II, there was an atmosphere of mistrust towards psychoanalysis during the post-war years in France, and many intellectuals saw it as a new corrupting agent of imperialism. Most of the members of the SPP were communists or were involved in what they called the humanism of the Resistance. However, for many, psychoanalysis was viewed as one more individualistic expression that amounts to a denial of any possibility of transforming the social order (De Mijolla, 1982). Since the late 1960s psychoanalysis in France has extended in three directions: 1) the medical direction, represented by the medically trained analysts who have focused mainly on psychoanalytic psychosomatic research, 2) the psychological analysts, who have pursued a rigorous academic program to achieve psychoanalytic qualifications and 3) Lacan and his followers, who moved their investigations in the direction of forging a synthesis of linguistics (Ferdinand de Saussure), philosophy (e.g. Merleau-Ponty, Jean Hyppolite and Hegel) and what Lacan called the return to Freud or the building of psychoanalysis based on Freuds early writings and cases. Due to his extraordinary capacity to articulate ideas and handle large crowds, Lacan became a major figure in the 60s and 70s, not only for psychoanalysts, but in other intellectual circles as well. Whereas in other countries divergent groups have made attempts to synthesize their theoretical tendencies, the French have tended towards a rather clear separation between their schools of thought. Interestingly, each of the heads of the above mentioned (medical,
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psychological, and Lacanian) schools (Nash, Lagache and Lacan) had the same analyst: Lowenstein. As a member of the SPP, Lacan had experienced problems in connection with what was termed his lack of orthodoxy in the practice of psychoanalysis. Amongst the more controversial issues was the question of whether an analytical candidate was to obtain the consent of his analyst prior to establishing his or her own analytic practice. Later, when Lacan came to establish his own school, he held that the analyst must be able to authorize him or herselfa notion that flew the face of psychoanalysis as an institution. At the time of his first arguments with the Society, the controversy related to the standard practice of four to five sessions of 45 minutes each week and a minimum of a two-year training analysis. Lacan held that psychoanalysis was ill-served by a rigorous prescription regarding the length and number of analytic sessions as well as the total duration of treatment. According to the SPP, Lacans practice of variable length sessions (the so-called short sessions) lacked psychoanalytic rigor. Further, the members did not accept the clinical reasons that sustained the rationale for the short session. Marie Bonaparte was his most radical
opponent. The heads of the Institute demanded a return to the rules, but Lacan was the most popular analyst among the trainees, and idea of a Free Institute was on Lacans mind, as well as on the minds of many French, including some of the analysts in the SPP and their trainees. This new model was to oppose the medical model and was to be founded on a university model. The new organization, the SFP (Society Francaise de Psychanalyse) was founded in 1953. The International Psychoanalytic Association (IPA) voted to exclude the new organization from their meetings and publishing resources. Even when Lowenstein tried to intervene in the SFPs favor, the request was rejected by Hartmann, Bonaparte, Jones, Nacht and, above all, Anna Freud. This split was significant, as up to 50% of the members of the SPP became members of the new SFP. The SFP proclaimed in its constitution that there were no theoretical differences with the former society but that the differences were in the moral order. They aspired to have an institute with a more democratic climate and one that would be guided by mutual respect and freedom. In 1953 Lacan began his famous Wednesday evening seminar that for more than a quarter of a century exercised a profound influence on both psychoanalysis and intellectual life in France. This seminar constituted the first regular psychoanalytic meetings that were not
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reserved only for analysts. As a result of this, a form of psychoanalytic education was available to all, even those who were not themselves in analysis. In addition to the seminar, Lacan also held a case presentation every Friday. The situation became so serious regarding the refusal of IPA to accept some of the most famous analysts of France, that they decided to accept these analysts under the category of Study Group Under the Sponsorship of the IPA. This initially meant that there was an IPA committee that was to watch over training problems and make recommendations accordingly. Later, the study group was informed that in order to continue with IPA sponsorship, Lacan had to distance himself progressively from the training program. In 1964, Lacan founds his own school The Freudian School of Paris. He did this with a certain reticence, as Lacan did not believe in the institutional transmission of psychoanalysis. His way of working and transmitting psychoanalysis was felt to be peculiar by some and ambiguous by others. This school remained a training center for sixteen years and trained analysts who eventually established practices throughout the world. However, in 1980, one year before his death, Lacan dissolved his school as a result of the discord and infighting among its members.
Structuralism Having provided a brief history of psychoanalysis in France, it remains, by way of introduction to Lacans theory, to provide some background in the theory of French structuralism. Although Lacan refused to accept structuralism as an epithet for his work, (and much of his work can be regarded as both pre-structuralisti.e. phenomenological, and poststructuralist) the impact of structuralism upon him was undoubtedly great, and it is impossible to understand his contributions to psychoanalytic theory and, particularly, diagnosis, without at least a basic understanding of structuralist thought. The structuralist movement has left its mark both in science and the humanities. Included amongst those who have been influenced greatly by structuralist modes of thought are the cognitive psychologist Jean Piaget, the anthropologist, Claude Levi-Strauss and the linguist
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Roman Jakobson (Feher Gurevich, 1999). Structuralism involves a novel manner of regarding objects and entities studied in the human sciences. Instead of defining such entities in terms of their inner or essential characteristics, structuralism situates them in the context of their relationships with other objects. It is the system of such relationships that defines a structure as a matter to be studied. Such structured relationships can be understood in terms of laws that are implicit in the structure and are initially difficult to grasp and articulate, most often going unnoticed by those individuals to whom the structure applies. Examples of such structures include the rules of grammatical formation of sentences adhered to but not necessarily known to the speakers of natural languages, and the rules of marriage and kinship adhered to, but not always articulated, by both primitive and modern societies. Another common example might involve the hierarchical rules of verbal deference and exchange that are implicitly adhered to by participants at an academic, corporate or other institutional meeting. Lacan ultimately applied the notion of structure to the formation of the unconscious, and he understood dreams, slips of the tongue, and especially symptoms in structural terms. Most significantly for our purposes here, Lacan came to regard the basic diagnostic categories of neurosis, psychosis, and perversion in terms of the position that individuals take with respect to a generalized Other, one that is embodied in language, law, and, what Lacan refers to as, the symbolic order.
Linguistic Structures Lacan regards language to be the most basic and paradigmatic structure in human life and society, and he proceeds to utilize linguistic structures as his preferred model both of the human psyche and for his work as a psychoanalyst. His famous dictum, i.e. that the unconscious is structured like a language, follows from this view. Lacan founded his views on structure upon the work of the structural linguists, in particular, that of Ferdinand de Saussure. Structural linguistics distinguishes units of language on different levels, (e.g. phonemes, monemes, words, sentences and phrases) on the basis of the relationships they have with one another at the same level (moneme with moneme) or at different levels (phoneme with moneme) (Benveniste, 1966). The grammatical or semantic significance of any one unit is a variable function of the relationship it has with all the others. For example, the change of one element in a phrase, e.g. a
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word, a pause, a comma, a question mark) can alter the entire meaning of the statement in question, and changes the significance of each of its component parts. As such, we can say that structural linguists privilege the relationships between elements over the element themselves. A structure is thus defined as an organization of the parts of a whole in accordance with certain definite rules of mutual and functional conditioning. Structural linguistics defines language as a global unit containing parts that are formally arranged in obedience to certain constant principles forming different hierarchical levels ranging from simple to higher and more complex elements, such as the transition from the utterance of a sound to a complete narrative (Lemaire, 1986). In effect, Lacan reconceptualizes a number of basic psychoanalytic ideas via the application of a structuralist model. Lacan understands the human subject as a schema composed of layers of structures. In the first place, these layers correspond to Freuds first topographical model of conscious, preconscious and unconscious. The unconscious, what Lacan describes as the subject matter of psychoanalysis is structured like a language, in which the elements that comprise it are summable and distinctive but still articulated in sub-sets according to specific laws. These laws are linguistic in nature, and, as we will see, involve metaphor and metonymy. Lacan derives his distinctive understanding of these terms from Saussure. Saussure describes a sign as a double-sided unit (Lemaire, 1984), composed of a concept and its acoustic image. The acoustic image is not a sound per se but is rather the psychical imprint of a sound. Saussure proposes to call the acoustic image, the signifier and the concept, the signified. The sign then becomes the relation of a signifier to a signified. Lacan appropriates this dual model of the sign and emphasizes that the signifier and signified are autonomous with respect to each other, i.e. that there is no fixed relationship (of value or meaning) between them. The sign remains meaningless unless is interpreted in the context of its relationship with the totality of language. Two words when enunciated can sound the same, but we can only determine what the speaker means when we place these words in the context of the signs that follow (e.g. as in the sentence Two people are going to the store too). Furthermore, we can never be absolutely certain of the meaning of any particular sign, as further words, i.e. a wider
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context, can always prompt us to a new interpretation of what was said (For example, with regard to the aforementioned sentence we may subsequently learn that the speaker was speaking emphatically Two people are going to the store; Two!). Hence, the value or meaning of a word is not intrinsic to it but is determined by the presence of other words in the system. The concept of value supersedes the concept of signification, as what matters are the system of relations between concepts rather than any absolute meaning determined by the relationship between a particular signifier and signified. A quarter, for example is a coin made of metal, the value of which is not intrinsic to itself, but is rather a function of its position in relation to other coins within a monetary system. Lacan will apply these ideas in a number of theoretical and clinical contexts, one of which is his insistence that one proper role of the analyst is to serve as a punctuation of the analysands speech in such a manner as to reveal his or her relation to the Other and the unconscious. Structural linguists hold that the sign is arbitrary, i.e. that is there is no natural relationship between the sound of a word and its signification. This is evidenced in the idea that the enunciation of the word is different in different languages. However, we are able, through a thorough understanding of contexts and relationships amongst signs, to determine, for example, that blue in English, and azul in Spanish mean the same thing. Nevertheless, the mutability of the sign is a paradox, as no individual can change language at will, since signs in a given language are tied to the tradition of a linguistic community. It is only in relation to the entire community that a given sign is arbitrary. While there is no necessary relationship between signifier and signified, Saussure held that once established there is an immutable bond between a signifier and the concept it signifies. Lacan, however, held that even this relationship is completely mutable. According to Lacan, the signifier is constantly slipping out from under its signified, and that, in effect, we are constantly meaning much more and/or less than, what on first reflection, we seem to write or say. The signifier can only be pinned to a given signified for a brief moment, via what Lacan refers to as points de capiton, anchoring or quilting points (punctuation, definitions, basic metaphors) that provide language with at least the illusion of stability. Such anchoring points involve a delimitation in the flow of the chain of signifiers with the flow of signifieds. According to Lacan, the anchoring point is above all the operation by which the signifier stops the otherwise
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continuous sliding of signification (Lacan, 1960). The sentence completes its signification only with the last term, each term anticipating something of the meaning but not quite yielding it until the end when almost by a retroactive function, meaning can be established. This retroactive dimension of meaning is represented by the anchoring point (it is after the fact, or aprs coup). Interestingly, Lacan holds that one of the defining features of psychosis is that, in contrast to neuroses, even these anchoring points (points de capiton) are not present, and the psychotic slips into a use of language that is idiosyncratic, and from our point of view, seemingly arbitrary. However, even in the absence of psychosis, signification is always in flux (see Dor, 1997). This flux is a function of two linguistic axes, what Lacan describes as the axes of metonymy and metaphor. In Lacans usage (and here he is indebted to the linguist Roman Jakobson) metonymy2 refers to the shift in the signified that results from the contiguous flow in language and to its links. The change in the signified is a function of its relationship to later words and punctuation in the chain of signifiers, and the signifiers impact on former elements in the change. Lacan holds that, as a result of such chaining, meaning is constantly deferred or displaced, and he links the metonymic axis of language, with Freuds notion of displacement as a key element in the dreamwork and in the formation of psychological symptoms. Metaphor, on the other hand, refers to the fact that linguistic units can be selected and substituted for others on the basis of some similarity within a chain of signifiers. Thus, a given signifier can represent more than one signified. Metaphor, according to Lacan, corresponds to the mechanism of condensation in the dreamwork and in symptom formation. Lacan goes on to hold that psychological symptoms are, indeed, metaphors (Lacan, 1970). According to Lacan, identification is also a metaphor, since identification always involves the substitution of oneself for the identified object (Lacan, 1955 ). For Lacan, the notions of metaphor and metonymy are the basic concepts through which he understands the phenomena of the unconscious. Topics such as the primary process, dreams, the
In ordinary usage metonymy is a form of speech in which a term is used to denote an object that it does not specifically refer to but with which it is closely related (Evans, 1996). An example would be City Hall denied all involvement, where City Hall is used to mean mayor. While he acknowledges that this is one form of metonomy (giving the example of thirty sail for thirty ships) Lacan uses metonymy in a much broader sense to refer to the entire chain of contiguous language, contrasting it with metaphor, which he also uses broadly, to denote the possibility of substituting elements in a chain of signification with other elements.
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formation of the symptom, jokes, and all other formations of the unconscious are understood by Lacan in terms of these two axes of language. According to Lacan, even such psychotic phenomena as neologisms, glossolalia, and delusional language are metaphoric and metonymic formations (Dor, 1997). Finally, and these are amongst Lacans major contributions to psychoanalytic theory, the process of desire is viewed as a metonymic development (as desire is continuously being displaced and deferred from object to object without ever reaching satisfaction) and castration is viewed in terms of a primal metaphor, i.e. The Name of the Father or paternal metaphor, which becomes the means through which the individual gains access to the symbolic order. Each of these themes will be made clear as we proceed. As will also become clear, Lacan links Freuds ideas regarding the Oedipus Complex and structural diagnosis with his structural analysis of language. He holds that the individuals capacity to utilize language in a normal manner is a function of his or her entry into the symbolic order, the rules of discourse and laws of the community that are fundamental to human society. Such entry is dependent upon the presence of a primal signifier, what Lacan calls the Name of the Father, which, on Lacans view, is instituted as a result of the restrictions (castration) imposed by the Oedipal triangle. Whereas the neurotic is said to repress castration and the paternal metaphor, and the individual with a perverse structure is said to disavow it, the psychotic is said to foreclose it, in such a manner that he or she is never fully implanted within the symbolic order. These ideas, which will be the subject of a more detailed discussion, both later in this and in subsequent chapters, are critical for any Lacanian understanding of the so called borderline personality.
Lacans Novel Psychoanalytic Ideas As I have indicated in the previous section, any understanding of Lacanian psychoanalysis is dependent upon an understanding of his use of structuralist linguistics. Lacan proposes, in effect, to read the human psyche like a text, and in order to grasp his reading we must come to terms with his basic theories regarding language. Lacans originality, however, is by no means limited to his reading of Freudian ideas through the lens of structural linguistics.
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His corpus is filled with original and often controversial theoretical and clinical formulations, many of which are grounded in structuralism, but others of which are more closely linked to Hegelian philosophy, phenomenology and existentialism, intellectual movements that are generally thought to be opposed to the structuralist program. Lacans career as a psychiatrist and psychoanalyst spanned nearly fifty years, during which time his ideas were in constant development and flux. He spent 25 years of his professional life diagnosing and treating psychosis. However, Lacans death in 1980 has only increased the multiple interpretive possibilities that can and have been gleaned from his work. In the following sections, rather than attempt to provide even a cursory review of Lacans prolific theorizing, I will focus upon several of his key contributions, which (though they span different points in his career) promise to be most helpful in our efforts to grasp the borderline phenomena in Lacanian terms. While it may well be that Lacan would not have, at any given point in his career, maintained each of these positions, Lacanian analysts have not, in general, troubled themselves with maintaining a position that is consistent with a single period in Lacans thought, and have found it fruitful to incorporate into their own theorizing ideas from different phases of his long career.
The Mirror Stage: The Scenario of Ego formation Lacan wrote his paper on the mirror stage in the late 1930s when he was still part of the International Psychoanalytic Association (Feher Gurevich, 1999). In this paper he elaborated the formation of the ego as the encounter of the subject with the other in what he terms the imaginary realm of existence. Lacan will later make a distinction, critical to an understanding of all his later thinking, between the registers of the real, the imaginary, and the symbolic, but at this stage of his thought his views on the imaginary were only beginning to take form. For Lacan the imaginary realm is characterized by conscious life; the way the subject is immersed in his reality and how he perceives it. The encounter with the imaginary realm is what Lacan calls the mirror stage. While Lacan seems to have initially regarded it as a developmental stage, he soon came to view the mirror stage as reflecting the very nature of human subjectivity.
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For Lacan, the mirror stage is a structural formation that accounts for the formation of the ego, and what is ultimately experienced in the transference between the patient and the analysts ego. The mirror stage is primordial not because of its developmental status, but rather because it prefigures the dialectic between alienation and subjectivity, what Lacan terms the divided subject (Lemaire, 1986). Lacan early on became fascinated by the discoveries of Wallon and later Baldwin (Evans, 1996) that the child obtains self-recognition in the mirror between the ages of six and nine months, during a period when the child gradually becomes conscious of his body and his image. These researchers noted that unlike a chimpanzee, who quickly realizes that his image in the mirror is illusory and thus loses interest in it, the human child becomes fascinated with his image in the mirror and seems to comprehend that it is an image of himself. This recognition becomes the foundation for the formation of an image of the self via identification with an other, who is outside. According to Lacan the entire process of identification is grounded in the imaginary dimension. Lacan elaborates on the concept of the imaginary by comparing animal instincts with the human drives. He describes how animals are naturally drawn to the satisfaction of their needs and can grow to function competently in a short period of time. On the other hand, a human baby is underdeveloped during the first six months of life, specifically in terms of motor coordination and motility. However, this immaturity is balanced by a strong sense of visual perception. The child can recognize a human face very early in life and respond to it. When the child recognizes himself in the mirror he feels joy, which is a sign of awareness, and the beginning of his fantasy life. According to Lacan, the mirror stage occurs in three successive phases. First, the child confuses reflection and reality by looking for himself behind the mirror. Second, the child understands that the image is a reflection, not the real being. Third, he understands that it is not only a reflection of himself but that it is different from the image of the other. Lacan holds that the mirror stage is the key to the formation of the ego. The child experiences his body as fragmented and uncoordinated, but because of the advanced development of his visual system, he is able to recognize himself in the mirror in spite of the fact that he lacks control of his own movement. The child sees his image as an integrated gestalt,
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which contrasts markedly with the fragmentation of his own bodily experience. While initially there is an aggressive tension with this image, the child resolves this tension by identifying with it, leading to an imaginary sense of mastery and wholeness (Lacan, 1956). The identification with the image in the mirror extends as well to the identification with other children. When he is around other children his age, the child expresses his identification with the human form with the others in his games: the child who strikes will say that he has been struck, the child who sees his fellow fall will cry (Lacan, 1977). According to Lacan, the child now wishes to be recognized by others in his newfound sense of self, and even imposes himself on the other and dominates him. We see here the imaginary processes at work, a merging of self and other, and, according to Lacan, it is in the other that the child lives and registers himself (Lemaire, 1986). On Lacans view, the experience of the mirror is prior to the capacity for cognitive recognition and also to the advent of the body schema (Dor, 1997). The identification with the mirror image and the body is fragmented, but its function is to unify the self, to bring about a total representation of ones own body. However, the childs identification with an image outside of himself also carries a negative connotation, in that the ego becomes, in effect, a narcissistic image with an inverted structure, the very nature of which is external to the subject and objectified. Lacan follows a tradition in French philosophy that regards the ego as an objectified phenomenon that is outside of, and alienated from the human subject; the ego is above all a construct produced by the gaze of the other. For Lacan, the ego is hardly the seat of
subjectivity, judgment, reality testing, etc. that it is for the ego-psychologists, it is rather a narcissistic construction utilized by the subject to provide a false, and alienating, sense of coherence and value. This is a key concept in understanding Lacans critique of ego-psychology, and will be of significance to any Lacanian deconstruction of the borderline concept. According to Lacan, through the mirror stage the child acquires a sense of the totality of his own body but only does so by way of narcissistic identification with the others, and in the process establishes a fundamental alienation in an image that will produce a chronic misrecognition. In other words, the child identifies with an optical image of himself, rather than with his own subjectivity.
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Borderline Personality Disorder: A Lacanian Perspective According to Lacan, it is because of this alienating identification with an image outside
of itself that misrecognition becomes the fundamental characteristic of the ego. Far from being the governing agency of the subject or self as it is in ego-psychology, the ego, for Lacan, is a snare and an illusion. While ego psychologists hold that by analyzing defenses they allow the ego to recover its discerning abilities and recognize external reality, Lacan holds the opposite view, namely that the ego is the psychic representative, not of the reality principle, but of an imaginary reality (Lacan, 1966). The ego is trapped in the fundamental division of the subject, who is alienated and is unable to understand why reality constantly disappoints him. This misrecognition also has profound implications in the realm of language and speech. We have a mistaken belief that we know what we are saying when we speak, but we speak about a self that is fundamentally alienated and displaced. Lacan provides other far-ranging criticisms of ego-psychology, one being that since egopsychologists identify the subject with the conscious ego, they neglect Freuds dictum that the the ego is not the master in its own house and, as such, neglect the fundamental discovery of psychoanalysis itself, the unconscious. For Lacan, ego-psychology, like modern man in general, has identified with the object in the mirror, to the neglect of his genuine subjectivity. As we will see, since that object in the mirror is essentially the other, the identification with the ego leads to an acceptance of the desires of the other, at the expense of the true desire of the subject or self. In elevating this misrecognition, ego-psychology furthers a program of identification with the analyst and adaptation, which is at complete odds with the radical, liberating nature of psychoanalysis. Lacan recognizes that misrecognition serves an adaptive function as the instinct of survival does for the animal. However, this adaptive function is at the expense of the subjects own truth. However, all is not lost. Misrecognition is not ignorance; as Lacan states, if the subject is able to misrecognize something, he must know something that needs to be recognized. For Lacan misrecognition is the content of consciousness. According to Lacan, when we work exclusively with the patients ego, our patients dont progress; in fact they continue to suffer and wonder about their symptoms, sometimes to the point of deteriorating psychologically. Out of the asymmetry of the mirror stage, the ego defenses arise. For Lacan, there is no point in differentiating ego from its defenses, since the ego itself is a defense, a cover-up for the
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fragmentation and then for the split that constitutes us as subjects. With the process of primal repression the subjects original sense of helplessness retreats to the unconscious. However, it is only with the advent of the symbolic order (or acquisition of language) that the child will bring his/her ego into the realm of the symbolic and the ego will appear more integrated. However, each time the image of the other imposes itself on the ego, the subject will be challenged again, in all his or her social relations. According to Lacan, this is most obvious in subjects who feel insecure in their recognition by others or who fear being devoured by others, but it is present in all of us. Lacan has a number of other things to say about what American analysts speak of as preOedipal formations which presumably impact upon later adult structure. Lacan views the preoedipal period as the time of total dependence on the mother. However, the child must come to terms with the fact that the mother is not always available, or that at times she does not understand his needs and frustrates them. This unavailability produces frustration and confusion, even rage. (Here Lacan is close to the object-relations theory of Melanie Klein.) The question that arises in the face of Lacans account of these pre-Oedipal events is how the human subject (child and later the adult) can organize itself with respect to this essential loss, as well as with respect the alienation incurred by the mirror stage, and, in effect, replace what is missing. This is the crisis that Lacan places at the entrance to the symbolic order, via the acquisition of language and along with it, the birth of the unconscious .
Lacans Critique of Developmental Psychoanalysis It is important to point out that while Lacan, in articulating his theory of the mirror stage (and other pre-Oedipal phases), appears to be presenting a developmental theory of the ego, he does not, in the end, propose a developmental study of the child. Lacan goes so far as to state that it is not the place of psychoanalysis to conduct infant research. Infant research belongs to the field of developmental psychology or other pertinent disciplines. For Lacan, what is known psychoanalytically about the childs psychological universe, psychic structure, and human motivation is always understood retroactively; it is always a construction made a posteriori
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(Feher Gurevich, 1999). Further, according to Lacan, the subject matter of psychoanalysis is neither child development nor personal history per se, but the unconscious as it is studied in the context of the psychoanalytic situation. For Lacanian psychoanalysts it is more appropriate to discuss structural moments of psychic development rather than developmental phases or stages. This is why language and its rules are crucial to the understanding of these structures as they are produced in the analytic exchange between analyst and patient. It will be worthwhile to reflect in some more depth on Lacans position in this regard, as it constitutes a major difference between Lacanian psychoanalysts and their American counterparts, and could prove a major stumbling block in their potential communication. While Lacan may be criticized on the grounds that he utilizes developmental concepts and then denies that they are developmental, I believe that, at least in his more mature formulations, Lacan conceives his mirror stage (and other concepts, including the Oedipus Complex), in logical/structural as opposed to developmental terms. He certainly does not hold that human psychopathology emerges according to a set sequence, at critical periods, during prescribed libidinal or developmental stages. Although in other contexts Lacans theories might be conceptualized in quasi-developmental terms and even be put to empirical test, and it is clear that at least in the case of the mirror stage he was stimulated in his thinking by developmental events, in his own work, including his thinking regarding the mirror stage, etc. is based upon reconstructions from working with adult patients. Lacans distrust of developmental approaches to psychic structure follows in a rather straightforward manner from his view of language, and hence his view of narration and history. Just as the significance of a chain of signifiers and each of its elements along the way is not revealed until the end, the significance and structure of the subjects psyche is only reinterpreted and resignified as an adult, particularly in the psychoanalytic situation. For Lacan, makes no sense to try to understand adult psychological functioning through an analysis of meanings that were present for the child, as these meanings have been altered and resignified in the adult psyche. Lacan articulates certain moments in the constitution of human sexuality via the Oedipal complex, by re-working the topics of privation (the mother gives or deprives according to her wishes), frustration (when the child does not receive what he needs), and castration (the
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understanding of the child that the mother is lacking something and that he is not the one who can satisfy her). These moments, Lacan argues, are necessary but are not developmental phases that follow a prescribed temporal sequence; they occur at some point when the child is dealing with the contingencies of his environment. They can occur at one age for one child and another age for another. Further, and most importantly, these events do not have the same meaning at the time of their occurrence as they do in the psychoanalytic situation. Lacan explains that the timing of human development is not evolutive but logical. In Ecrits (1945) he concludes that the modus operandi of the unconscious, what he calls the formations of the unconscious (dreams, parapraxis, symptoms) follows a logical, but not temporal sequence. This logic implies that for an individual to arrive at his or her truth each significant psychic event implies a time, as he puts it, to see, a time to comprehend and a time to conclude. (Lacan, 1945). This is the logic followed by the unconscious processes, and has nothing to do with objective time. Although these moments are described as a temporally ordered sequence, they are in fact atemporal. The following general account of the way Lacanian analysts work using the so-called short (but really atemporal) session should help clarify the atemporality of the analytic process. When a patient relates his or her history in treatment, he/she makes a historical presentation of the facts and events that occurred during his/her life, accentuating or underlining what he or she believes is important (usually the suffering related to the symptom). This narrative constitutes the patients psychic reality. Regardless of what occurred objectively (if such a concept even makes sense) what matters is the analysands psychic experience. At a certain moment in the session, the patients says something that the analyst is puzzled about and the analyst makes a punctuation, by, for example, repeating or questioning what the patient has said. The patient listens and processes the new data. (This is the moment of seeing). The patient may elaborate further. However, the analyst decides to interrupt the session and suspend the analytic process. (This cut of the session indicates the moment of conclusion). When the patient comes in the next session, he may have come back to the words he spoke and the exchange with the analyst in a different way; the patient may have done his working through outside of the session (This is, according to Lacan, the moment of understanding). As a result of analysis the patient has constructed a new logical discourse regarding something that at one point had a
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different meaning. Thus, according to Lacan, chronological time has no meaning in analytic work. The actual events in objective time are not analytically meaningful until they are signified, understood and re-signified by the patient. Further, the actual length of the analytic session is also unimportant. The words exchanged in five minutes may be enough for a patient to open a new chain of signifiers, whereas a hundred sessions may prove ineffective for this purpose. Indeed, if the analyst would have extended the session to forty-five minutes, everything could well have been lost in a torrent of words that confuse things to the point where neither analyst nor patient knows what they are working on. In terms of infant development, Lacan does not deny the existence of growth and development; however, such development is not explicitly relevant to the psychoanalyst, whose work is directed to the issues of discourse and unconscious processes. We want to hear the history of the patient, not because we want to find evidence for possible causes of the patients suffering, but rather because, as analysts, we must attend to the particular linguistic structures the patient chooses, and, most significantly the position the patient occupies in his discourse with the other. Lacan does not deny the role of time in child development. However, he holds that in focusing on such development the analyst will inevitably fail to understand the structure of the human subject. Another example can be useful in explaining Lacans position: the significance of a traumatic situation. According to Lacan, whether an event has a traumatic effect is not the result of the intrinsic nature of the trauma but rather because such trauma represents a resignification of that which was structurally traumatic on an earlier occasion, one for which, as a result of primary repression, the subject has no recollection. Although the mechanisms of trauma and resignification may be universal, the singularity of each subject renders different meanings for presumably similar or even identical life events. For example, life in a concentration camp (which all would regard as objectively traumatic) may be overwhelmingly traumatic for one individual, who commits suicide or allows himself die, and a challenge to live and achieve meaning for another (Frankl, 1959). In effect, Lacans problem with a developmental psychoanalytic approach to the structure of the human psyche is analogous to a historians objection to our trying, say, to understand the significance of events in Germany in the 1920s, without reference to Hitler and World War II.
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No amount of contemporary narrative from the 1920s will substitute for our re-comprehension of those same events after the war. All understanding for Lacan is apres coup (after the fact). While we may be able to learn much about the child by observing him/her in his development, the phases and events in childhood are only explanatory of adulthood to the extent that, they are presented in the form of symptoms, slips of the tongue, etc. Having said this, however, Lacan found it impossible not to speak in terms of historical developmentalbeit a development that is understood in terms of its re-signification in adult life.
The Symbolic Order For Lacan, the acquisition of language marks a new structure in the mind of a child, one that is characterized by the loss of his world vis--vis his mother in order to become his own being. The symbolic order is the order of language and culture, a structure into which the child is unknowingly inscribed even before he was conceived. As we will see, the childs inscription in the symbolic order marks, for Lacan, the point of differentiation between neurosis, psychosis and perversion. However, for Lacan, the symbolic order, like the imaginary order, is one more vehicle through which the individual is trapped by the other, and his subjectivity possessed by something that is outside himself. Lacan, will also hold that language has a liberating function, but (in the logical sense) it is at first alienating, and at the very origin of the unconscious. To elaborate upon this aspect of the symbolic order, Lacan takes the example of Freuds observations of his 18-month-old grandson who would throw and retrieve a spool as he uttered the words: fort, da (gone, there). Freud understood this event as the way the child could master the situation of the loss of his mother by taking symbolic control through words indirectly referring to his mothers presence and absence. However, as the child is expressing a certain mastery through his words, his feelings of loss are being repressed. Lacan interprets the fort/da as an indication of primary repression, and this, according to Lacan, is how the unconscious comes into being. From then on, the unconscious will be the repository of all phonemic traces, words and subsequent representations of lack or loss. This moment inaugurates the childs subjective experience in the world of language and as he increases his vocabulary, he grows to
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encompass many possible experiences and facts of reality. The acquisition of language is a paradoxical process; on the one hand, it provides the child with a certain autonomy, on the other hand, it is deceptive in so far as the subjects unconscious remains bound up with the signifiers of the others desire. What Lacan means to say by this is that since the child is born into a language he/she inherits from others (his parents, grandparents, and general society/culture), the language through which he expresses himself, the language within which he resides, and the language he represses insures that his subjectivity is not his own but is rather completely inundated with the purposes and desire of an other. It is because the language we speak is imbued with others meanings and intentions, that our unconscious is, according to Lacan, not something that simply resides within our own intrapsychic depths, but is rather, more properly, something that resides out in the world. For Lacan, language both saves and deceives; it causes both the formation of the subject and, like the imaginary constructions provided by the mirror stage and the ego, it fosters the subjects splitting and alienation. However, unlike the imaginary, the register of the symbolic offers an opportunity for the subject to transcend his alienation and partake of a new subjectivity that is only possible through the act of speaking. This is why Lacan believes that language is such a powerful tool, and in fact the only proper tool, in psychoanalysis. On the one hand words alienate, they are composed of a signifier and a signified (which Lacan symbolically divides with a bar) and thus express and embody the division between what the subject says consciously and what is barred from the conscious discourse. As Lacan states it in his Ecrits (1977): We can say that it is in the chain of the signifier that the meaning insists but none of the elements consists at any given moment. We are forced, then, to accept the notion of an incessant sliding of the signified under the signifier. (1977, p. 153). However, it is only in the register of language that this sliding can, at least temporarily, be brought to a halt, and the subject can learn to differentiate his subjectivity and desire from the demand of the other (see below).
Lacanian Psychoanalysis Lacans Conception of the Oedipus complex
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For Lacan, the symbolic order is instituted as a result of the Oedipus complex, and the resultant insertion of the paternal metaphor into the unconscious psychic structure. The Oedipus complex as we know it from Freud is an unconscious set of relationships that occur in a triangular form and is characterized by specific affects related to the parents (Freud, 1908). In the positive form of the complex, the subject desires the parent of the opposite sex and develops a rivalry with the parent of the same sex. The child enters the complex around the age of three and leaves it by the age of five or six when several important factors emerge: the child identifies with the rival and as a consequence resolves gender identity, the superego develops as an internalization of the parental prohibitions as a self-censoring agency, and the child enters a new phase, latency, in which sexual desires are displaced by other more intellectual interests prior to adolescence. Freud argued that all psychopathological structures could be traced to a problem in the resolution of the Oedipus complex (Freud, 1910). By 1910, Freud had made the Oedipus complex the central focus of psychoanalytic investigations into the neurosis and after that time, it became the motor of psychoanalytic theory. Lacan initially addressed the issue of Oedipus in 1938 in an article called The Family. Lacan defined a complex as a whole constellation of interacting imagos or the earliest internalization of the subjects social structures (parents, grandparents, and other meaningful actors in the life of a child even before his arrival to the world). These multiple identifications provide a script in which the subject is led to play out the drama of conflicts among the members of the family (Lacan, 1957). In the 1950s, Lacan began to produce a distinctive re-conceptualization of the Oedipus Complex. In his view, whether the subject is male or female, the subject always desires the mother, and the father is always the rival. Lacans thinking here produces a radically asymmetrical way of understanding the Oedipus Complex and has enormous consequences for the issues of sexual difference and gender identity. However, of greatest significance in the present context, the Oedipus complex is, for Lacan, a paradigmatic triangular structure opposed to all dual structures, via the introduction of a third term between the mother and the child,
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namely, the father (inserted through language). According to Lacan, this complex represents the passage from the imaginary phase to the symbolic phase, and in the process the subject is confronted with the problem of sexual difference. Further, the Oedipus complex has important consequences for the formation of the symptom and for the psychic organization of the adult. We can ask ourselves if the oedipal tragedy can actually represent the human condition and the vicissitudes of human sexuality. Lacan believes that without the Oedipus Complex, psychoanalysis cannot be sustained. However, he makes several changes from the original version of the myth as it was interpreted by Freud. First, he disassociates the complex from the primal scene and all the specificities of the familial relationships, that is, he elaborates this complex as a structural moment that occurs at the level of discourse. He asks the question: How is sexuality established in human beings? The answer is related to the German word Trieb, (English: drive) a word that has a very different meaning than its usual English translation as an instinct. Animals have sexual instincts, they have a copulating season, they mate always for reproductive purposes and they dont have conditions in their choice of mates. Human sexuality is completely different. Our anatomy does not absolutely determine our sexual identity. In addition, we can have sexual relationships only for pleasure, with the frequency and intensity we wish, and we have specific conditions for choosing one mate over another or for selecting an object to fulfill our sexuality. All of these issues are determined as a result of the oedipal vicissitudes.
The Three Stages of the Oedipus Complex In Seminar V, The Formations of the Unconscious (1958) Lacan identifies three stages that are necessary in order to achieve the passage to the symbolic order. These stages follow a logical as opposed to chronological order. Lacan holds that the first phase or time of the Oedipus Complex occurs in the context of the imaginary level of existence; the other is the mother, and the child is initially involved in a dual relationship with her in which the child comes to recognize himself somewhere else beyond himself, i.e. in the mirror or in the mothers gaze. If the child is someone, it is only
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because he is someone for his mother. This position of total dependence leads the child to believe that his satisfaction is tied to the place he occupies for his mother. The child wants to be everything for her, to be that which she desires, and the compliment of her fulfillment. We are here in the realm of primary narcissism, in which the child, having no symbolic substitution for himself, is a blank surface for the mother to write upon. However, according to Lacan, any attitude of the mother that will favor her possession of the child will alienate the child from subjectivity and a place in society. Although it appears that there is a dyad functioning between mother and child, there is already a triangle between the mother, the child, and that which the mother lacks. It is this lack which Lacan terms the phallus. For Lacan, the phallus, is not to be confused with the biological organ, but is rather simply a representation of what the mother lacks or desires. In identifying himself with the phallus, the child is simply trying to satisfy the mothers desire, and, in effect, become the phallus for her. Lacan regards the presence of the imaginary phallus as the third term in this early stage of the Oedipus Complex, indicating that even here the imaginary father is already functioning, representing that object which the mother desires beyond the child (unless the mother is implying that the child is occupying that place which means she does not lack anything). Therefore, there is never a dual relationship per se. In this stage, we have the prohibition of the father already operating over both mother and son/daughter. Lacans introduction of the concept of the phallus is a potential source of controversy and confusion. Lacan uses the term phallus to indicate that what concerns psychoanalysis is not the biological presence of a penis but the signifier of desire (that which we lack). Freud referred to the concept of phallus as the fantasy of having or not having. It is unclear if he made a clear distinction between phallus and penis, but it is clear that he referred to the fantasy and not to the real thing in most of his discussions on sexual difference. In Lacans writings, the concept of the imaginary phallus in the first stage of Oedipus, differs from Freuds conceptualization, inasmuch as, according to Lacan, both the mother and the child are marked by a lack, namely, the imaginary phallus. For the mother, the lack is that which she desires beyond the child, and for the child, the lack is the place in filling the mothers desire that he wants to, but cannot, occupy. With the strong emergence of sexual impulses in the child (infantile masturbation), anxiety in the child increases. As a result, the child is filled with
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feelings of impotence and confusion. In Freudian terms, this stage is what is denominated primary repression and is constituted essentially by alienation. In the second phase of Oedipus, there is an intervention by what Lacan refers to as the symbolic father. According to Lacan, if the father is to be recognized by the child, the mother, who acts as a sort of gatekeeper to the child, must first recognize his speech. (Lacan, 1977). It is speech alone that gives a privileged function to the father, and not the recognition of his role in procreation. This is called the Name-of-the-Father. (Lacan refers to this as the power of heterogeneity, which is the basis of the symbolic order as opposed to the power of homogeneity, the fusion with the mother, which occurs, in the imaginary order). The fathers speech denies the mother access to the child as phallic object and forbids the child complete access to the mother. This intervention, which is called castration in psychoanalytic theory, has an implication of privation. However, while the father initiates this privation, it can only operate via the mediation of the mother. The mothers acknowledgment of the fathers presence enables the father to occupy the third position in the Oedipal triangle in which the child sees the father as a rival for the mothers desire. In Freudian terms, this second stage of the Oedipal phase is called
secondary repression and essentially corresponds to a phase of separation. The third time of Oedipus is marked by the real intervention of the father who signals to the child what he can and cannot have. Lacan discusses that the father, in introducing to the child the law of the symbolic order, relieves the child of the anxiety associated with occupying the place of the phallus for the mother. He can thus, identify with the father and transcend the aggressivity inherent in his imaginary identifications. This is what Lacan calls the normative function of the Oedipus complex, as it introduces a law establishing difference between the child and his parents as well as the norms of generational and sexual difference. If the child does not accept the Law, or if the mother does not recognize the position and speech of the father, the subject will remain identified with the phallus and continue to be subjected to his mothers desire. If on the other hand, the child does accept this law, he identifies with the father, who, in the childs mind, possesses the phallus. In this way, the father reinstates the phallus as the object of the mothers desire but the child is no longer identified with it. According to Lacan, this process, allows the child to give and receive in a full sexual relationship and to also have a
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Name, which for Lacan constitutes a place in a family constellation that promotes the realization of the self through participation in the world of culture, language and society. Thus for Lacan castration is understood in both a negative (limiting) and positive sense; the negative aspect enforces the prohibition of incest and the positive aspect assures the childs inscription in the generational order of a family and society. Castration is not the fear of losing the penis, castration is the symbolic operation that cuts the imaginary bond between mother and child, and grants the child (boy or girl) the ability to symbolize this loss in words. This Law is not proper to the father; it is actually inscribed in a language that was already present before any of the participants in the oedipal triangle were born. We must emphasize the obvious fact that for Lacan, the childs parents also had to experience the situation of loss with their own mothers. When Lacan discusses the father, he does not generally refer to the real father, but rather to the one who implements the paternal function, a function that could be carried out by an uncle, a friend or another female, or even an institution. Freuds case of Little Hans (Freud, 1909) provides an important illustration of the oedipal vicissitudes as they are interpreted by Lacan, and the consequent development of a phobia incident to these vicissitudes. In this case, we have a very permissive mother who is very attached to her son and a father who, in spite of being quite sympathetic, is unable to separate Hans from his mothers excessive loving demands. For example, Hans would bathe with his mother, and his mother would at times take him to her bed. The father who wanted to be a friend to his child placed no restrictions on him. (see Ferrari, 1999). When Hans starts, around the age of five, to experience sexual feelings accompanied by masturbatory activity, he becomes very anxious. At the same time, his sister Hanna is born and his mother becomes less available to him; in fact, she is busy with the baby and can no longer devote the same time and attention to him that she had previously. Subsequently Hans develops a phobia to horses. What is it that Hans is anxious about? He is anxious about his sexual pleasure, which is linked to his mother coupled by the abrupt appearance of his sister as a threat to the loss of love that he represents for his mother. On a Lacanian view, the presence of the baby represents the evidence that he is not everything for his mother, (and here we see the birth of sibling rivalry). Thus, the phobia of being bitten by a horse becomes his protection against castration anxiety. As long as the horse is feared, he does not experience anxiety. Like other phobics he has demarcated a specific
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(presumably manageable) territory for his anxiety. He only has to avoid that territory, i.e. avoid the phobic object, in order to avoid experiencing anxiety. We can infer that Hans father, although with the best intentions, did not intervene in separating Hans from his mother, which is clear from his own decision to consult with Freud about his sons symptoms. This necessary separation would have enabled Hans to identify with his own father, without the need to project his anxiety regarding sexuality and loss onto a phobic object.
The Prohibition of Incest Lacan studied carefully the myths described by Freud in Totem and Taboo and took a great interest in the regulation of culture and the transformation of the law of nature to the law of culture. Lacan took note of the structural anthropologist Levi-Strauss (1949), who pursued this theme in field studies that he carried out in Australia and South America on the rules governing various social practices, primarily those concerning the exchange of women, words and goods, the institution of marriage and the establishment of familial relationships. In his book The Elementary Structures of Kinship Levi-Strauss described how in society there are laws that govern these relationships, and that these laws are organized in ways that are analogous to the structure of language. He defined a structure of kinship as a system in which all the members who are related in a family fall into two categories: the possible marriages and the forbidden ones. Through his analysis of the changes allowed or prohibited in a social system, Levi-Strauss believed that he was able to establish that the prohibition of incest constitutes the foundation of the symbolic system, separates animals from humans, and marks the division between nature and culture. A man or a woman is separated from his/her biological family in order to be united with a member of another clan assures the perpetuation of the species (Feher Gurevich, 1999). What is so original about Levi-Strauss work is not the discovery of the law, but the fact that the individuals who operate within it are unaware of the conditions for mating, which operate at the an unconscious level; that is, these individuals know the rules of marriage without being conscious of the principle of prohibition imposed on the blood marriages.
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On the basis of Levi Strauss findings, Lacan re-formulated the theory of the prohibition of incest within a psychoanalytic framework. Contrary to Freuds statements that this prohibition is transmitted phylogenetically, Lacan states that this prohibition is cultural. According to Lacan, the childs fantasies actually defy the law of the prohibition of incest (if not literally then imaginatively) that is imposed on the subject by the culture. This is not a natural event; rather it is a cultural/symbolic one that raises the child out of the realm of biology into the matrix of language, culture and law. Further, Lacan implies that prohibition is a necessary condition for the existence of desire. In our culture, we have certain sexual prohibitions, but in other cultures such prohibitions might differ. It is not the specific prohibition, but the very fact of a prohibition that is universal, and makes human sexuality unique. While it can be debated whether the objects of incest prohibition are completely trans-cultural, the imposition of some sexual prohibition is is universal. An imposition of our occidental culture, a condition of our language, is that the symbolic father is the representative to cut the bond with the mother. If the name of the father operates, the child is empowered to speak about his own lack, and is thereby further empowered to enter into the world of interpersonal relationships. While, according to Lacan, a psychotic individual may be able to speak, his language does not reflect the inscription of the Name of the Father, and he is therefore not fully inscribed in the symbolic order. As a result, the psychotic is not able to express his loss and lack as a full desiring subject. We will later explore how this theme is of significance in understanding differential diagnosis and in particular the inability of the so-called borderline patient to withstand intimate relationships without losing his/her sense of personal integrity. Why is it that Lacan insists on the significance of the metaphor of The-Name-of-thefather, and how is it that we can apply this metaphor in our daily clinical work? The most important function of the paternal metaphor is a symbolic one. It provides the child with an explanation of his or her origins and pre-history, intimates how his parents desires were played out, and situates other family members such as grandparents, aunts and uncles, in the childs life. Finally, according to both Freud and Lacan, the paternal metaphor represents a boundary or limit that permits the child entry into the laws and traditions of his culture, and enables him/her to achieve an adult identity that will permit him/her to establish his/her own family.
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The Imaginary, the Symbolic and the Real One of Lacans most innovative contributions is his distinction between the three registers of the symbolic, the imaginary and the real, distinction, which plays an important role in his structural diagnoses, and his conception of the essence of neuroses, psychoses, and perversion. We have already discussed the register of the imaginary in the context of the mirror stage and Lacans critique of the ego, and we have discussed the symbolic register (or order) in the context of Lacan's understanding of the Oedipus complex and the role of language in the structuring of the unconscious. We will have more to say about these two registers in the context of Lacanian diagnostics. However, it remains for us to describe what is Lacans very difficult conception of the third register, the real. Although Lacan's use of the term real shares something with both common sense and its application in the history of philosophy, the real should not be confused with "reality " as it is commonly understood. In the first place for Lacan "reality" is often used in a sense that is completely opposite to that which he refers to by the real. For Lacan reality, as we normally use the term, is completely enclosed and determined by symbolism and language, whereas the "real" is used to indicate a register that is completely opposed to and unassimilated by language. For Lacan, the "real is closer to what to philosophers have referred to as being in itself," that is, a pre-linguistic being that exists prior to the subjects constructions of or about it. According to Lacan, the real is completely undifferentiated in itself and is absolutely without fissure (Lacan, 1954). It is only the symbolic that introduces a "cut into the real, and it is only language that permits the real's differentiation into a world of things. The real, as it was formulated by Lacan in the early 1950's, is simply that "which resists symbolization absolutely" (Lacan, 1953) In Ecrits, Lacan says the real is whatever exists outside of symbolization and language (Lacan, 1953). In Seminar 11, Lacan, refers to the real as "the impossible." The reason for this is that the real can neither be imagined nor symbolized, and as such it is impossible " to attain it in any way. It is because the real is not assimilable by the subject that it takes on a traumatic character. However, the real as trauma cannot be permanently identified with any specific objects or things, but simply appears in experience as that which is intrusive and traumatic, and beyond the power
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of the subject to conceptualize and symbolize. In Seminar Four Lacan describes the real elements that intrude upon Freuds "Little Hans": the real penis as it is experienced in masturbation, and the birth of Little Hans sister. Such elements will later take on imaginary and symbolic significance. However, at the moment of their initial entry into consciousness they represent a traumatic intrusion of the real. Common examples of the real might be a car that seems to come out of nowhere to cause an accident, or a sudden, and unexpected natural disaster, elements that enter the psyche but which at least, initially, escape a linguistic narrative. Lacan also links the real to the concept of matter and especially to the realm of biology, particularly the human body in its pure physicality (as opposed to its imaginary and symbolic functions). For Lacan, the real is the primal object of anxiety. Since it is completely unmediated and cannot be "understood by the subject, its intrusion into experience is traumatic and anxiety producing. The real need not necessarily intrude upon the subject from the outside, however. Lacan points out that when an experience cannot be assimilated into the symbolic order, the real may return in the form of a hallucination. This might occur, for example, as the result of a trauma that returns to consciousness as flashbacks and intrusive dreams, until such point that the individual is able to symbolize and thereby assimilate their experience. For Lacan, the real is both outside and inside the subject (Lacan, 1959). It can be either material or psychical. It is by no means an equivalent of external reality. The real represents a limit to both imaginary construction and symbolic knowledge. While at times Lacan seems to suggest that the real can be assimilated to reason, it most often serves in his psychology as a radical unknown. For Lacan, both the imaginary and symbolic orders are superstructures that are built upon a foundation of the real. He will go on to describe neuroses, psychoses and perversion in terms of the various linkages between these three registers. Further, certain Lacanian theorists (e.g. Muller) have held that a failure to bind the real effectively is characteristic of so-called Borderline psychotic states (Muller, 1982). Because the real is connected with the limits of human experience it becomes a major concern for psychoanalysis. In fact, Lacan holds that whereas psychology focuses upon (symbolized) reality, the job of the psychoanalyst is to approach the real. For Lacan, psychoanalysis is committed to "treating the real by means of the symbolic."
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Borderline Personality Disorder: A Lacanian Perspective The Unconscious According to Lacan, the subjects unconscious is fully constituted by his/her insertion in
the symbolic order. As we have seen, according to Lacan, the unconscious has the structure of a language. Its elements are organized according to particular laws which Freud denominated condensation and displacement and which Lacan refers to as metaphor and metonymy. The language of the unconscious is always revealed in speech, the arena of spoken language. This speech is what Lacan calls the chain of signifiers. It is not a reflection of the language in which the child lives and also the tongue spoken to the child by its mother (Nasio, 1998). Lacan names this particular language, la langue. As we have seen, aspects of the unconscious are formed even prior to the childs birth. This is because even before the child is born he is assigned a place in the world of language. While his mother is expecting him, carrying him in her body, the parents symbolize the child in their minds, give him/her a name, and ultimately, the child comes to carry the burden of the parents expectations regarding their own desires and even those of their own parents. As such, the parents signifiers are projected onto the child at the time of his birth. By the time the child learns how to speak these signifiers have had their impact upon the childs unconscious. This is what Lacan refers to when he says the unconscious is the discourse of the Other. It is important to point out here that the signifiers in the unconscious are not an already formed chain of words with a given meaning; rather the unconscious is always something that is actualized in speech, or in a dream according to metonymic and metaphoric processes one signifier taking the place of another (metonymy/condensation) or one signifier being replaced by an adjacent one in the associative chain (metaphor/displacement). The role of the analyst is to listen for these key signifiers and to be in tune with the patients discourse. For Lacan, as for Freud, free association is the main tool for accessing the unconscious; the signifier moves constantly as free association proceeds. In Lacanian analysis the affects or emotions of the patient are also treated as signifiers. The complaint that a patient shares regarding her husbands aloofness may in fact reflect her current marital situation; however, the analyst may be listening to the marriage of the patients parents.
Lacanian Psychoanalysis Jouissance
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Lacan elaborates upon the concept of the function of the pleasure principle that Freud had discussed in 1920 (Freud, 1920). According to Freud, it appears that most of our symptoms tend to repeat in a constant search for pain that contradicts the principle of constancy, according to which the psychic apparatus tends to reduce the tension to a minimum or to keep it as constant as possible. Freud, in Beyond the Pleasure Principle, recognized that interpreting the meaning of a symptom to a patient does not end his or her suffering. There appears to be an investment that many patients have in maintaining their neurosis. Freud believed that in order to explain such therapeutic failure he needed to go beyond the pleasure principle. Lacan too, takes up this theme by arguing that if people do not learn from their painful past experiences, continue to engage in self-defeating behaviors, and repeat negative relationship it is because they have a great investment in their suffering. Again, Lacan uses developmental metaphors to describe his understanding of what he refers to as jouissance. According to Lacan, an infant has an enormous amount of energy that is completely focused upon its own organism. However, as the child grows, he is obliged to limit or drain that energy from his body in order to conform to the demands of its social environment; such as weaning, education, rules, and the norms of social life. This environment or as Lacan calls it (the other) insists upon the systematic inhibition and, ultimately, emptying out of the pleasure that the child takes in its body. According to Lacan, a portion of the energy
corresponding to this pleasure is trapped in what we call erogenous zones, and a portion of it comes to constitute the symptom, which can be expressed as bodily or psychological suffering. According to Lacan, the symptom represents that portion of primal pleasure or enjoyment that has refused to be articulated and returns, in effect, to make the subject suffer. For Lacan,. there is a paradox inherent in the pleasure principle as the principle actually comes to function as a limit to enjoyment; it is a law that commands the subject to enjoy as little as possible. At the same time, the subject constantly attempts to transgress the prohibitions imposed on his enjoyment, to go beyond the pleasure principle. The result of this transgression is not more pleasure, but pain, since there is only a certain amount of pleasure that the subject
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can endure. Beyond this limit, pleasure becomes pain, and this painful pleasure is what Lacan calls Jouissance. According to Lacan, enjoyment is actually experienced most of the time as intolerable suffering. The energy and feeling that represents a transgression of the symbolic structure of language, which is almost a pure expression of unconscious drives, is not hedonistic pleasure, but on the contrary it is an energy that keeps returning to provoke suffering. How does this process occur? In order to answer this, we must review the idea of Trieb or the drive. Lacan describes the circuit of the drive starting at the erogenous zone, circumventing the object and returning to its source, to re-start the circuit over and over again. Lacan underlines the fact that the drive never appropriates the object, but just goes through it. When the drive is trapped in the linguistic expression, it becomes a discourse, which is the complaint we hear from the patient. While manifested in discourse, the drive is to a certain extent, appeased; however it continues its path to return to the source of pleasure and to re-start the process all over again. The amount of pleasure produced represents a surplus that the subject cannot tolerate. This excess of satisfaction is the subject of Freuds essay, Beyond the pleasure principle (1920). The position of the subject in relation to his jouissance, i.e. his painful enjoyment, is, as we will see shortly, the avenue Lacan takes to confirm diagnosis.
Need Demand Desire Lacans theory of desire is central to his conception of psychoanalysis. Lacan situates his discussion of desire in the context of two other concepts, need and demand. For Lacan "need" is the biological instinct that drives hunger and other requirements of the organism. According to Lacan, need is something that human beings share with animals. Need is the basic stance of a human infant at the time of birth; he or she is completely at the mercy of a caretaker who is generally the mother but who may be any person or institution responsible for the infants care. Lacan holds, however, that the power of the motherer actually fosters an experience of helplessness in the child that goes beyond the one that he/she is born into. This is not only because the caretaker can appease the babys sensations by producing pleasure. It is, moreover,
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because the motherer is a speaking being, immersed in the world of language, that whatever she hears or senses from the child is mediated through her own interpretation. Soon the growing infant learns that he must understand what the mother wants in order to keep receiving pleasure and avoid pain. Further, the mother appears and disappears from the childs immediate experience, while at the same time speaking to the child and immersing the infant in language. As the infant becomes attuned to the mothers communications and desires, he learns how to manage his suffering while she is absent. The childs basic needs are soon transformed within a relational context via the register of language. When the child asks his mother for something, the specifics of the request are not as important as the nature of the mothers response. According to Lacan, the childs need-driven requests are transformed into a demand for the mother herself. The child will continuously demand something, which appears to be a request to satisfy a need, but in actuality, is a demand for love. Thus "demand" is initially the child's articulation of its needs vocally and eventually in speech. However, because the "other," (generally the mother) becomes associated with the fulfillment of the child's demands, she attains an importance that goes beyond the mere satisfaction of the child's needs. As such, the child's demands become for the mother per se, and with this his demand becomes a demand for the mother's love. However this demand for love cannot be completely satisfied. Even if the mother fulfills all of the child's needs, there is still an excess of demand for the mother's love. According to Lacan, while a need can be completely satisfied, a demand is always a demand for an object that cannot be supplied. Children demand continuously, not because they need something, but because they are demanding love. However, according to Lacan, the child pushes its demands to the point where the mother cannot meet them, and in this way learns what the mother cannot give. At this point demand becomes the opposite of need. This is because, according to Lacan, the child is actually demanding his own separation, and in order to accomplish this, he/she places impossible demands on the mother. In this way the child proves to himself that his motherer cannot provide everything, and it is in this way that he will, on Lacans view, begin to identify his own desire.
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Borderline Personality Disorder: A Lacanian Perspective That which constitutes the childs excess demand and that which can never be completely
satisfied is what Lacan calls desire." The reason why children are so demanding is that it is only through demanding the impossible that they can begin to understand what it is that they themselves desire. Thus, for Lacan, desire takes form when demand becomes separated from need. It is the nature of desire that it can never be satisfied. Whereas need can be satisfied, with the result that it ceases to motivate the subject, desire can never be fulfilled and, according to Lacan, desire seeks to perpetuate and reproduce itself in a nearly infinite "chain of signifiers," as the subject continuously displaces his desire onto new objects that he mistakenly believes will fulfill him/her. Thus from the concepts of need and demand Lacan derives the concept of desire, which for him is the mark of the subject and the arena in which analysis does its fundamental work. The difference between demand and desire is important in clarifying certain issues of diagnosis. For example, an anorexic young woman who has decided not to eat satisfies a desire that goes beyond the demand of her mother. This position of the daughter, with a symptom that represents a refusal to eat is the expression of her desire; she wants to eat nothing. According to Lacan, desire is always unconscious, and is to be contrasted with a wish, which is something that we want consciously. Desire is equivalent to the process of distortion that converts a wish into a particular image. Desire dominates our lives and sets us apart from the animals. Desire, according to Lacan, is another word for lack, that which is the missing object of desire. Desire changes objects that are also revealed in dreams and slips of the tongue; that is why in psychoanalysis it is less important to listen to the content of a phrase than to the particular words chosen by the patient. Lacan holds that man's desire is "always the desire of the other." This famous phrase has a number of meanings, which according to Lacanians are complementary. One does not desire the other as an object to be possessed, but rather as a subject who reciprocates one's own desire in love. Lacan illustrates this view that desire is for the desire of the other in his description of the first time of the Oedipus complex, where the child desires to be the phallus that is the allfulfilling object, for the mother. Another meaning connected to the desire of the other is that our desire is always for that which is desired by others; it is the others desire that makes what we desire desirable. A
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third meaning is that desire is always for something other than what we have. In fact, Lacan tells us, one cannot desire what one already has. While the objects of desire constantly escape the subject, desire can be articulated in speech, and for Lacan the purpose of analytic treatment is this very articulation. To summarize: a need belongs to the biological realm, to sensations of the body and refers to something that can be given (like food, warmth), demand is always for an object that cannot be given (this is what neurotics do all the time, they demand from the other endlessly). Desire is for an object that sometimes can be reached but because of its metonymic essence, once achieved, it is no longer desired and another object takes its place. To take a mundane example, we want to own our dream home and surmount many difficulties to obtain it; however, once we have it, something else becomes our desired object, we even forget how important the house was for us. For Lacan the subject is always alienated from his desire. According to Lacan, it is not only the illusions of the mirror stage that alienate the individual from his own desire (by making him believe that he is something that he is not), but the entire symbolic order that envelops the subject in its network of language, rules and communal structures. The symbolic order is therefore another source of the subjects alienation. However language, which on the one side is a source of alienation, also provides the avenue for a partial escape from the network of symbolism that threatens to dominate and obliterate the individual subject. Lacan holds that desire is continuously being displaced into a symbolic demand. The subject is continuously attempting to articulate his or her desire. However in doing so he moves from one demand to another, from one signifier to another, each of which is meant to fulfill the lack or want-of-being at his core, and each of which he futility believes will be the answer to his own desire. Human life becomes a chain of demands as the subject moves from signifier to signifier in a vain effort to fulfill himself. According to Lacan, the ego is intrinsically related to this metonymy of desire, as the individual's identity is continuously linked to each of the demands she makes in an effort to fulfill herself. In addition to seeking a material fulfillment for its demands, the ego seeks fulfillment in the other. Learning to recognize and to speak of the essential gap in ones being, of the futility of ones succession of demands, is a condition for psychoanalytic cure.
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Borderline Personality Disorder: A Lacanian Perspective Diagnostic Considerations in Psychoanalysis Lacanian Views Lacan takes seriously the question of what makes for a psychoanalytic diagnosis in
contrast to a medical or even psychological diagnosis. The question was posed by Freud himself, as he realized the contradictions inherent in the problem. We use a diagnostic framework to make decisions regarding treatment; however, diagnosis evolves during the course of treatment and in the process, a very different picture may emerge. In order to make a medical diagnosis, the examiner has at his disposal technical and biological instruments that allow for the collection of objective data (MRI, blood samples, XRays, etc). This type of assessment leads to a classification of diseases that includes a wide range of pathologies. A medical doctor can then, establish with a reasonable degree of certainty the presence of a particular illness. The psychoanalyst, according to Lacan, has only one instrument: his/her listening skills. Although the patient can relate a history of suffering in a convincing manner, his speech is saturated with the fantasies and deceits that underlie all human communication. Even when the subject wants to be honest, Lacan asserts that he is always blind to his suffering. What he or she says cannot be taken at face value for diagnostic purposes. The direct observation of a patients symptoms is unavailable as well. Lacan agrees that diagnosis and treatment are interconnected. Thus, in order to be consistent with a psychoanalytic approach Lacan suggests that diagnostic inferences and treatment interventions are to be suspended for a period of time during the initial interviews with a potential patient, and no contract between patient and therapist should be formed until after a series of initial sessions. Lacan approaches the problem of diagnosis through an extensive series of preliminary interviews, where the analyst allows him or herself to wonder about the patient, to allow a transference to be established and, most importantly, to listen to the unconscious at work. Lacans preliminary interviews are considered a trial period in which the work of the patient is to produce speech, i.e. to speak of whatever he wishes to speak about. The beginnings of a diagnostic picture will be drawn primarily through the analysts careful listening to the patients choice of words rather than through the content of the patients discourse. From the utterance of
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the patients words a particular structure will appear. One question that underlines and directs the importance of the analysts attention is, What is the position of the subject, in his discourse? or What position does he occupy in relationship with his desire of others? Lets examine an illustrative example. A patient, (a fashion designer) at the beginning of her analysis makes the following statement: I believe that it is possible to be a man and a woman at the same time. We listen to that statement from the Lacanian diagnostic premise: Why did she utter these particular words in the form of a statement that expresses her presenting problem to the therapist? What is the position of the subject in her discourse? On first observation, she enunciates a clear ambivalence at the level of gender, and following her words, something that reminds us that choosing to be something also implies losing what is not chosen. We can start thinking that the patient has an issue in the realm of the imaginary, in her struggle to be one or the other. We suspend judgment here to find out more from her own account. In a later session, she discusses her job and she says that her work is to produce an image of a woman and she keeps thinking of the image of a pregnant woman that imposes itself on her drawings more than any other image, in spite of her believing that it is not a marketable idea. How is it that she came up with this choice of words and images? Does her mother populate her thoughts by being together with her? Is her image of a male/female fusion the way she resolves the issue of sexual difference? It appears that the direction of her treatment will be directed to a problem that is connected with her image, perhaps the way her mother saw her. It is interesting how in clinical work we can almost see the way the words trace a circle around the major, unconsciously determined, structural issues. There are a multitude of words that she might have chosen to express her concerns; however, we create hypotheses on the basis of the language she chooses to express her suffering.
Structure and Diagnosis Psychic causality is very difficult to determine since its laws, if any, are not, according to Lacan, manifest in fixed, and predictable ways. Even when we are aware of the subjects dynamics and we understand his intrapsychic and interpersonal vicissitudes we cannot make an
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immediate logical correlation between his psychic structure and the nature of his psychological symptoms. Our clinical practice shows us that psychopaths have sadistic behaviors without possessing the structure of perversion, and even an obsessive-compulsive personality can have a strong histrionic component in his presentation, yet remain essentially obsessive in his structure. Therefore, we are not justified in making a diagnosis based on symptom manifestations. Lacan modifies Freuds famous phrase about dreams by calling speech the royal road to the unconscious. This formulation allows us to understand Lacans statement that his theory is essentially a return to Freud. The psychoanalytic experience finds in the unconscious the whole structure of language (Lacan, 1954). Lacan, like Freud, holds that symptoms, are always overdetermined, that is linked to the primary process, via displacement and condensation. Lacan states, A symptom is a metaphor, a signifying substitution and a metaphor is a signifier that stands for another signifier which represents the subject (Lacan, 1954). The chain of associations continually substitutes one signifier for another in the very manner Freud had described in his Interpretation of Dreams (Freud, 1900). The choice of words is left entirely to the fantasies of the subject. And no matter how clear a subject is in his communication, the fact that he utilizes language and must choose one form of expression rather than another, assures that he will be misunderstood. As Lacan constantly reminds us, we, as subjects, are alienated by language. So, if the symptom has no fixed meaning, what is the analyst relying upon? He/she is relying upon listening and observing the way the subject handles his desire, which will reveal a particular psychic structure. This operation occurs in the presence of the analyst, as desire is put in motion in the transference. Lacans understanding of the transference is one of his unique contributions to psychoanalysis. The analyst is invested by the analysand with what Lacan designates as the place of the supposed knowledge, in which the analyst is presumed to know the causes of the patients pain. This supposition, which exists only in the mind of the analysand, is, according to Lacan, the motor of the transference in analysis. This is an interesting observation in light of Lacans insistence that the analyst has no special knowledge to give to her patients. According to Lacan, this paradox exists in all human relationships, parents and children, lovers, teachers and students, etc. One supposes that the other has something to give. Lacans view here is
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particularly opposed to the common idea of a psychoanalyst as someone who objectively has a particular expertise on psychic problems and moreover, as a model who the patient can emulate. It should be clarified that Lacan does not believe in the concept of mental health or normality, but like Freud, holds that all individuals exist in varying degrees of disease. For Lacan, disease is not something that happens to living things but is the very condition for life. There are no normals to be contrasted with, but a variety of pathologies. On Lacans view everyone is neurotic, psychotic or perverse. These three categories are essentially those that were formulated by Freud. According to Lacan, the subjects desire is involved and expressed in different ways in each of these structures. Throughout the interviewing process, through careful listening of what is said, the manner in which it is said and, moreover, what is not said, the analyst follows the subjects own desire, in order to induce the patients cause of his desire, his efforts to have his desire fulfilled, and the factors that stand in the way of that fulfillment. Lacan conceptualizes the three main categories of diagnosis through the particular mechanism of negation that determines what he calls the position of the subject, rather than through a classification via symptoms. The mechanism of negation functions differently in neurosis, psychosis or perversion. Lacan leans in part on Freuds description of repression in the neurotic versus disavowal in the pervert. Lacan describes a third mechanism of negation in the psychotic, which he terms foreclosure, and which, for Lacan, represents the impossibility of accepting or rejecting that which is negated. This method of arriving at a diagnosis, i.e., by the way someone negates something, is the single defining characteristic of Lacanian diagnostics. (Fink, 1997). Lacanians do not look favorably upon the multiplication of categories and subcategories that continues to grow in the American psychiatric literature on diagnosis. This system utilizes literally dozens of pathological categories such as dysthymia, polysubstance dependence, panic disorder, etc, each of which can be combined with other features such as personality traits, psychotic traits, etc, in specifying a diagnosis. This is essentially the system adopted in the various editions of the DSM. The method that psychiatrists use in order to make a diagnosis is to break down each part of a patients presentation into its constitutive parts and then bring them back together to form a syndrome. Lacan is critical of this tendency of the medical model that arrives at overly specified diagnoses by considering human beings as mechanisms which can
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then be treated with mechanically designed and approved remedies. Lacans conceptualization of psychopathological structures is far broader. Although the number and presentation of symptoms can vary throughout the life of a person, their essential structure does not change. For example, a man may be diagnosed as a substance abuser, and this diagnosis is evident in the fact that he uses certain drugs with a particular frequency, etc.. However, if we conceptualize his psychic structure as that of an obsessive, then we understand that the role played by the drug use in his adult years may be the same as his defiance in early school years, and his controlling approach in his relationship with his employees and wife.
Psychosis For Lacan, the psychic structure that refers to psychosis is produced by foreclosure of the Name-of-the-father (Lacan, 1955). As has been elaborated in previous sections, this refers to the absence of the symbolic function of the father. Foreclosure involves the rejection of the particular element that, on Lacans view, anchors the entire system of the symbolic order for the individual. The paternal function does not refer to the real person of the father but rather to that which is symbolized by the fathers name, which can be effected in the presence or absence of the real father, which can be carried out by another person who is not the father of the child, and which can even function beyond the death of the father or his disappearance. Indeed, the paternal function can even operate with only a name, as an authority and as the carrier of the law of prohibition. For example, a child who never met his father but carries his name will have a mark of the father. Later interpretations made by his mother and family about his father can resignify the name of the father; however, the child knows he carries that name and the name situates his place in the family and society as a whole. As we have seen, the paternal function involves separating the child from the mother when the childs independence is threatened by the mothers desire or by the perception of the child that he is everything for the mother. Although cultural norms differ and change over time, and with them the role of the father, Lacanians hold that it is universally the case that a restriction, the fundamental function of
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no must come from a third element that is inscribed beyond the relationship between mother and child. When Lacan discusses the paternal function in relation to psychosis he holds that it is an all-or-nothing occurrence, in the sense that the paternal metaphor either enters into the childs language as a symbolic function or does not. There is, on this view, no room for borderline structure, a claim that we will examine carefully in later chapters. Psychoanalytic treatment can help to make psychotic symptoms recede but, for Lacan, there is no cure for psychosis. Lacanians assert that an individual either has a psychotic structure or does not, and even those who have their first psychotic break later in adulthood have always been psychotic, and further, there are those with a psychotic structure who often remain undiagnosed by virtue of never having had an overt break. It is helpful to make a clear distinction between the real father, the imaginary father and the symbolic father in the theory of Lacan. The real father is the father here and now, the one who is the actual, biological father. However, this real father is never the one who operates directly in the course of the Oedipus Complex; this is the role of the imaginary father. The child does not grasp the idea of a real father until much later; what he receives is the imaginary father, a paternal imago which reflects the childs experience of the father according to his imagination, coupled with the idea of father given by the mother, via the way the mother speaks of him.(Dor, 1987). According to Lacan, the symbolic father is a signifying effect within the oedipal dialectic that produces a new structure: a child inscribed in castration and therefore, in the world of language, of signification. Lacan uses a particular linguistic image to indicate the function of the paternal metaphor, in which the symbolic father overrides, for the child, the desire of the mother:
Name of the father Mother as desire So far we have seen that the real father has no (direct) implications in this process; in some ways it is irrelevant if he is present or not, if he is deficient or not. Issues pertaining to the real father do not affect the entrance of the child into the symbolic order. This is because it is only the father who is imagined and signified that enters into the childs psychic structure. Thus,
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it is the relationship of the child with the imaginary or symbolic father that will have important consequences. What is structuring for the child is that his father is the origin of the childs words, and that the child is able to fantasize a father. Lacans observations with respect to the paternal metaphor is that as much as this function regulates certain aspects of life from sexuality to responsibilities and obligations, the law of the father is also fairly distributive. This means that while the father signals what is his, he also signals what belongs to his child. While the father may deny something, he gives something else in return. Lacans insistence on the primacy of the imagined over the real father in the structure of psychosis would seem to close off hypotheses regarding the absence or failure of actual fathers in the etiology of psychosis, and, by extension, borderline states. However, without questioning Lacans view that it is the childs signification and experience of the father imago that is relevant to his theory, we can say that his view implies that the absence and/or behavior of actual fathers will impact upon the development of psychotic (and other psychopathological) structures. One reason for this is that the actual father provides an occasion or opportunity for fantasy and signification. It would not, in my view, be a stretch to argue that Lacans theories suggest certain empirical hypotheses: one of which is that, all other things being equal, absent, malevolent or inadequate fathering may contribute to psychotic structure. Returning to our discussion, the question arises; what are the tools that Lacanians rely upon to confirm a diagnosis of psychosis? Although the best indicator of psychosis in American psychiatric circles is always the presence of hallucinations, Lacanian analysts suggest that the presence of hallucinations is not definite proof of the presence of psychosis. In fact, hallucinations are a form of primary process thinking, used very early on by the infant and which play an important role in ordinary daydreams, fantasies and dreams. Further, it is important to differentiate between true hallucinations and voices and visions that non-psychotic people have. Such individuals, although reporting a vision or having heard someone who was not present, may be surprised and wonder about these phenomena. Fink (1988) reports on a patient who believed he saw his ex-wife at the end of a corridor in his home. He was surprised but at the same time questioned this vision, thinking that he had to have noticed her entrance or the possibility that he let her into the house. He did believe he had a vision but did not believe in its content. This example recalls Froschs
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patient (discussed on chapter I) who felt the floor tremble and asked her neighbor about it, but who later postulated that this trembling was a projection of her own orgasm. In both Finks and Froschs cases, the patient hallucinates but is able to recognize the phenomenon as part of his or her psychic reality. In spite of the hallucinatory symptom, the capacity for reality testing is intact, and the diagnosis of psychotic structure is not substantiated. Further, many hysterics have the most elaborate fantasies that are so hypercathected that they appear to be real; they see and hear things that are not present to others and experience them as if they were palpable. (Indeed, the diagnosis hysterical psychosis was at one time quite widespreadsuch patients may be classified today as dissociative disorders). However, according to Lacan, in the end, the hysteric will be doubtful about the veracity of his experience, which again speaks to her intact reality testing and the ruling out a psychotic diagnosis. Therefore, the symptom of hallucinations and the whole question of reality is not a foolproof guiding principle for diagnosis since it is difficult to distinguish socially-constructed reality versus psychic reality. For Lacan, the characteristic most salient in psychotic thinking is that of certainty. The psychotic patient is certain that reality in the form of a thought, vision, noise, etc, has a meaning and that the meaning involves her or him. The psychotic thought is without error or misinterpretation. Statements such as; My wife is trying to poison me, or The CIA is reading my thoughts are found in psychosis, and are made without hesitation or doubt.. The certainty of their statements is irreversible for the psychotic. On the other hand, hysterics and obsessives always doubt. Doubt is a characteristic of a neurotic process. In sum, when hallucinations are reported, the clinician has to explore this phenomenon conscientiously, if there is no conclusive evidence one way or another, other criteria should be employed. These other criteria are focused around language disturbances. Lacan goes so far as to say, Before making a diagnosis of psychosis, we must make sure that language disturbances exist (Lacan, 1955). He states that the psychotics relation to language is quite different from that of a neurotics. In order to fully comprehend this assertion it is important to again think in terms of the registers mentioned earlier, the imaginary, symbolic and real. As described above, the imaginary register is the first structure that organizes the chaos within which the child lives (i.e. his fragmentation, uncoordinated perceptions and sensations). As we have also seen, this
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register provides an image of the self that is invested libidinally by the child... Later his parents and other caretakers will provide a better definition of this sense of self, yet one that is still not developed to the point where the child becomes capable of uttering the word I. The symbolic order, on the other hand, actually pre-exists the child, as he is immersed in it by being subjugated to his parents language. The language of the parents, their approval of and recognition of the child, through their gestures, voice and words, ratifies his mirror identification. The earlier formation of the mirror stage, which represents a somewhat primitive organization, is finalized through a symbolic act that comes from outside the child. (Lacan, 1955). This supremacy of the symbolic over the imaginary is instrumental to the formation of subjectivity. Where aggresivity and rivalry were the main affects in the imaginary order, in the symbolic order the child is organized around different criteria: guilt, law, performance, achievement, etc. The symbolic order is linked to the castration complex, which, according to Lacan, initiates this new order for the child. On Lacans view, this initiation occurs in neurosis and perversion but not in psychosis. In psychosis there is no symbolic process overriding the imaginary order, therefore, the psychotic person lives in an imaginary world where even language is imaginarized. For the psychotic, language is not assimilated but rather imitated. The idea of foreclosure of the name of the father is rooted in the notion that the psychotic has no chance to reject or accept a symbolic function, for there is no precedent for him to even consider. Freud discussed this process in relation to the concept of ego ideal; as the child internalizes his parents values and expectations, he himself sees his actions in accordance to what his parents have seen. Without an ego ideal to rely upon, the individuals self-image is fluid, transient and ephemeral. Therefore, with the establishment of the symbolic order several interrelated factors are put into motion: the function of the paternal metaphor, the overriding of the imaginary world, the separation of the child from the mother, the creation of desire (for that which is prohibited will be desired), and the immersion of the child in the world of language. According to Lacan, the paternal function ties a knot amongst the three registers of the real, imaginary and the symbolic, i.e. between the fathers law and a specific meaning to particular words (socially constructed reality). If this does not occur, if this initial knot is not tied, the individual will have no anchor point in a public language; indeed he will create his own language, leading to the language disturbance that is evident in psychosis. Psychotic patients will have difficulty
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producing a whole sentence, as they will be unable to punctuate, anchor and convert the chain of signifiers. The anticipatory and retroactive movements involved in producing meaning (that is, the possibility of the metaphoric substitution) are absent in the psychotic person. Words become things (Fink, 1999). Neologisms are the most salient evidence of psychosis. The formation of neologisms in psychosis replaces the metaphoric function, by creating new words with an idiosyncratic meaning known only to the psychotic himself. Thus these terms do not refer to others in language; we cannot infer any meaning by association or contiguity. They are untranslatable. Among other criteria of psychosis, Lacan discusses the predominance of imaginary relations. While the neurotic generally has conflicts derived from his struggle with the symbolic order, such as conflicts with parents or other authoritative figures, social expectations or issues of self-esteem, the psychotic typically presents with conflicts related to someone approximately their own age usually in the figure of a peer or a lover. The issue for the psychotic is not manifest in terms of obtaining parental approval; rather, according to Lacan, psychotics have the experience that someone is usurping their place. The phenomenon of paranoia is typically encountered in psychosis as a type of imaginary relationship. Lacan holds that because there is no true access to language the psychotic is directly related to the imaginary world. However, while this relation to the imaginary is an important feature of psychosis, a positive diagnosis is, according to Lacan, only possible when language disturbance is present. One interesting aspect of Lacans theory of psychosis relates to the notion of the drives. Whereas the neurotic organizes his libido, refocusing it from his body as a whole to his erogenous zones, the psychotic feels invaded by libido, his body is taken over by it. This, according to Lacan, touches upon the register of the real. We have seen that, according to Lacan, as we enter language and the process of socialization is initiated, our body slowly gets emptied out of its libidinal contents. The body is literally, as Lacan puts it, overwritten with signifiers, biology is for the most part lost, only maintained in the erogenous zones. In the psychotic person, however, we can usually hear in our clinical work the extreme sensations of the body, the ecstasy of the body or the unbearable pain in the body for which no medical problem is found (Kaplan H., Sadock B, 1994). This lack of hierarchy in the drives organization is a result of the failure of the symbolic order, and is, according to Lacan, also associated with a lack of morality
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or conscience. This means that the psychotic is prone to, in the face of any slight provocation; express his or her lust or aggression overtly. Because there is no repression, guilt is not present in these patients and when they are hospitalized for a criminal act towards others they do not feel genuine guilt for their actions. Another symptom that is present in psychotic men is a slow process towards feminization. Schreber (Freud, 1911), the paranoiac who Freud discussed in his initial study of the psychotic process, initially related how the rays of God were penetrating him. This thought evolved into the belief that he was the wife of God. In clinical practice some psychotic patients claim to feel like a woman and they sometimes request sex change surgery. For Lacan, the attitude of the father towards his son is to delimit a space for the child, in a distributive way, by giving himself certain rights and bequeathing others to the child. This important aspect of the paternal function does not occur in psychosis. A father may act in an authoritarian, antagonistic or aggressive manner towards his child. He could also be an all-demanding father whose sons behavior is never good enough and who is unable to set limits for himself or his children. At this point the child may take the feminine position before this dominating imaginary figure, especially when no triangularization is possible. If and when the patient later becomes psychotic, he may feel that this feminine position is imposed on him. Therefore the presence of feminization appears to be the result of identification with an imaginary father but not a symbolic one. Although this feminization may take place in a neurotic person as well, it is usually intermittent and of short duration, whereas the psychotic person feels invaded by a feminine identity that he cannot escape. A final note on the issue of diagnosis in psychosis is provided by Lacan in his discussion of the absence of self-questioning in psychotics. While neurotics ask themselves about their desires and those of others and they change in the course of therapy, psychotics are characterized by inertia of movement, in their thoughts and interests in general. The psychotics phrases are always the same, presented in a cycle of repetition without end. Lacan adds, where repression is missing, desire is missing as well (Lacan, 1953). The failure of desire is seen in the failure of movement in the psychotics language.
Lacanian Psychoanalysis Neurosis
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For Lacan the defining mechanism in neurosis is repression. Further, according to Lacan, primary repression effects an individuation of the unconscious in the individual subject. As mentioned above, the fort-da, or the naming of the childs demands in words, are interpreted by Lacan to perform the function of filling an absence with words. At that time the unconscious is constituted in a singular way for each particular individual. The child inserts himself in language, in the Other, where all signifiers exist, and positions himself in the discourse. However, in this immense world of signifiers, some things escape the child, things that remain outside of signification, as he/she cannot control all language. Therefore, the position that the subject occupies allows him a place but also represents a loss, one that is tied to the lost promise of being the phallus of the mother, the object that will be lost forever. According to Lacan, this object never existed, but throughout life we keep looking for it. This loss is what he denominates primary repression. From this moment on, other things will be repressed by association, provoking an excess of pleasure, a most painful pleasure, that is beyond the pleasure principle, a pleasure that is at once sexual and traumatic and about which the patient consistently complains. In contrast to the psychotics foreclosure where a thought or a perception is never even granted entry, in repression (which characterizes neurosis) reality is initially affirmed in some way and is later pushed out of the realm of consciousness. According to Lacans reading of Freuds (1915) On Repression, the unconscious is formed by thoughts that can only be expressed in words or signifiers. Repression impacts upon the connection between thoughts and affects, and this disconnect is the source of neurotic symptoms; for example, the neurotic may experience emotions that he cannot link to any knowledge; even his own rationalizations fail to explain his emotions. However, the different neuroses have specific modes of repression. For example, hysterics have an overabundance of feelings without thoughts, whereas obsessives have a profusion of thoughts that evoke no feelings. Repressed thoughts and affects reveal themselves in what Freud denominated the return of the repressed (Freud, 1915), which, for example, in the conversion symptoms of hysteria, may be expressed as bodily symptoms
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Borderline Personality Disorder: A Lacanian Perspective For Lacan, all neurosis is rooted in the symbolic order. The more interesting question
from a Lacanian point of view is the differentiation of one neurosis from another. According to Lacan, since all neurotic symptoms, even those that appear to be somatic, are governed by the laws of language, the key to distinguishing neuroses is to understand how the neurotic is linguistically or significantly situated in connection to what he calls the locus of the other. This locus refers to the fundamental fantasy of how the subject positions himself in relation to the other in the imaginary realm. Lacan writes a formula to depict this relationship: ($ a) where the barred S denotes the division of the subjects unconscious and conscious experience, the a stands for the cause of desire (in the other, in French autre) and the diamond is the relationship between them. Lacan utilizes this formula to clarify how the subject imagines him or herself in relation to the Other. Hysteria and obsession can be defined as radically different ways in relation to the Other. (Fink, 1997). In analysis, the analysand is always recreating his or her fundamental fantasy in relation to the analyst, by pleasing the analyst, making her anxious or neglecting her, etc. and in this transference the patient always recreates his position in his fundamental fantasy. According to Lacan the individuals reaction to separation from the primary object constitutes his/her fundamental fantasy and as such constitutes the basis of Lacanian structural diagnosis. Lacan describes three sub-categories of neurosis and thus three fundamental fantasies: hysteria, obsession and phobia. Why is it that there arent more than three categories? The positions of the hysteric, obsessive and phobic, that we are about to describe are, according to Lacan, simply the three positions that clinical experience has shown analysands take up in the transference. Psychoanalysis is concerned with the position of the analyst in the transference as a means to orient the interventions with different patients. Further, Lacan studied and worked with these three fundamental neuroses in a manner that neither Freud nor other analysts had ever done previously. Lacanians have long affirmed that these three categories are extremely useful in clinical work and that there is no need for further classifications.
Lacanian Psychoanalysis The Hysterical Structure
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In Lacanian practice, in order to diagnose a structure we need to assess the subjects economy of desire, his position in the discourse (in relationship to the others and the analyst) and the problematic of the phallus for each particular individual. As we have explored in our discussion of Lacans theory of the Oedipus Complex, as long as the mother can realize the presence of the father and let him lay down the law, the symbolic father will be established as the vehicle through which the child is brought to the third and final phase of Oedipus, what is termed the register of castration. The child will then realize that not only is he not the phallus of the mother, but that he does not possess it, and cannot, therefore, be an all fulfilling object for her. The possibility of castration is based on the idea that someone has it and someone does not have it. This quest for the possession of the phallus, this idea of having it, is the quest of the hysteric. The hysterics assumption is that he/she has been unfairly deprived of the phallus and must re-appropriate it. Although sexual difference is an important determinant of the way hysterics behave, (e.g. being a woman who pretends to be a man, or a male hysteric who is unsure of his virility), both male and female hysterics have the same fantasy: the conquest of the phallus. Thus, the other, the one who is supposed to have it carries the enigma of what the hysterics desire entails. This other serves a very important identificatory function and is the key to all meaning that emerges in analysis. When Dora pursues Mrs. K, in the famous case of hysteria analyzed by Freud, (1905) what she wants is the answer to the question: what does a man want from a woman? This question presupposes that Mrs. K knows the answer, that she has the key to the enigma of what constitutes a woman, and it is on this tacit assumption that Dora pursues her endlessly. The hysteric makes herself into the object of the others desire so she can master it. It is important to note that the hysteric can also take the position of the male partner and desire as if she were him. Many hysterics find themselves in love triangles in which they identify with the mans desire and thus, desire the other woman. The quest is always to complete the object of their desire. That is why the hysterics main question has something to do with sexual difference. Am I a man or am I a woman? This question has a direct connection with the dual identification of their desire. In the case of a satisfied couple, the hysteric always finds a
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way to provoke a desire for something else that her partner does not have. It is a typical scenario to hear a hysteric speak about the highlights of her partners life: his achievements, his looks etc. This characteristic is a subtle way of shining through the other, by displacement. Hysterics are capable of self-sacrifice and self-abnegation in order to fulfill what they imagine as the others desires. Therefore, we can encounter hysteria at the level of being the phallus for the others desire, or having the phallus by identifying with the male partner. This position appears to be a reflection of an earlier residue in hysterics relationship with their mothers. Hysterics always feel that they have not received enough from their mother and this comes through via their identification with the phallus; instead of being an ideal object worthy of total love, they see themselves as devalued and unworthy objects. Their sense of identity is always deficient and unfulfilled. The search to become the perfect object is always present, and as a result of this stance, the hysterics desire is always unsatisfied. The ideal object is an impossible object, but the hysteric never ends the cycle of aspiring to be one. Therefore all of their efforts tend to be drawn towards a phallic narcissistic identification as a way of avoiding the issue of castration (or the lack thereof). When they put on a show, they put themselves in the others gaze as the embodiment of the ideal object (Dor, 1997). This is the most important aspect of hysteria. They are to be the cause of the others desire (Seminar IV) by identifying with this perfect object (the phallus). This position assures that the hysteric will forever be linked with the mother. Throughout his/her life (and within the psychoanalytic transference) the hysteric will maintain a posture of being the pleasing object for an Other imbued with knowledge and power. The phallus could be represented in the arena of the image, or through their speech or in their bodies. The way they do this, the hysteric method, is to keep the other in suspense, to delay their satisfaction, to produce an enigma. The hysteric always manages to keep the other unsatisfied so as to ensure a permanent role as an object of the others desire. How does the hysterical woman approach this encounter? Curiously, with ideas based on stereotypes supported by the culture. This search for the ideal is viewed through the eyes of the models of beauty and femininity that are purported in the media. In the hysterical woman, beauty equals femininity and in that sense, she does not spare any efforts, as perfection as it is culturally defined (i.e. defined by the other) is her goal. The hysteric is very critical of herself
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and attempts to erase all of her imperfections. As the ideal cannot be attained, we usually hear self-descriptions such as I have too little of this, I dont have enough of that, My face should look like that, etc. As a result, her behavior and speech will reflect a permanent state of indecision and doubt and at a later date she will voice regrets. Hysterics are plagued by indecision and doubt. The difficulty the hysteric has in making up her mind is very acute in relation to a choice of lover. She will pick a lover but continue to be absent in the intimacy of the relationship, as she needs to remain unsatisfied at any cost. Her indecision is a reflection of her imperfection, and she will do many things to cover it up, masking her doubts with the most sophisticated moves: speeches, role playing, clothing, and intellectual remarks. This is why hysterics appear to be phonies, they have an emotionally labile and inauthentic aspect. In many cases, she tries to cover up her lack of knowledge as in her mind, knowledge has to be absolute. Either you know everything or you are totally ignorant. The hysteric woman will try to gain access to peoples knowledge in various ways, for example, by becoming an unconditional supporter of the wise one. In this way she imagines that she overcomes her deficits. The search for perfection is related to another characteristic of hysteria: the identification with a woman from which she will learn what femininity is all about. In this case, we have the emergence of a hysterical homosexuality that is not related to a choice of love object but to an identificatory process. As a result of this identification, the hysteric wants to think like her, be like her, love like her, to have her men, etc. as if the other woman has somehow achieved a perfected state of femininity. Many times the hysteric will steal the other womans man. The choice of lover plays the most important role in the hysterics life. Perfection is that to which she aspires, therefore, there is always a man better equipped, more charming, more intelligent than the one she has.. What is important to address is that the man she pursues is always unattainable; if she could get him, she would not be interested in him any longer. In the area of sexual encounters the hysteric has a discourse of claim or demand usually surrounding phallic potency. This challenge to men usually starts a cycle of continuous misunderstandings; the man trying to desperately prove his virility and the hysteric constantly disappointed. The quest of the hysteric is to continuously claim dissatisfaction which, according to Lacan, actually incidentally constitutes her only pleasure.
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Borderline Personality Disorder: A Lacanian Perspective It is important to underline a common error that clinicians make when they presuppose
that the hysteric is looking for a man who can be a substitute father figure. According to Lacan, this is not really the case. Hysterics are looking for a man that is complete, what could be represented as an ideal father. Usually we find hysterics dating men of importance, full of knowledge, powerful men. These types of men will make up for the deficiencies of her imaginary father. Along these lines, it is common to hear the fantasy of prostitution in hysterics who are in treatment. In the figure of a prostitute, we have a woman who can offer herself for money to all men, insofar as she can give herself to only one, the pimp. This man does not really possess any special talent but the assurance of lacking something. He needs her and her money to be complete. The more she pays, the more she completes him. The sacrificial position of the hysteric is a very important topic. It relates to the operation that Freud (1912) referred to as versagung and later adopted by Lacan. Versagung is the renouncing of that which is the essence of ones self, ones desire. In the name of that renouncing we constantly hear in the clinical work how people renounce their own pleasure in favor of that of their children, their husbands, their country, etc. This position allows the hysteric to keep her desire unsatisfied (many of the protagonists in opera portray this aspect of hysteria quite well). The versagung was taken by the post Freudians as frustration, however, Lacan sees it as refusal. The word versagung implies a relationship in which there a refusal of the demand of another (the root sagen implies saying) (Laplanche, Pontalis, 1987). The term frustration implies that the subject is frustrated passively, from the exterior, whereas the term versagung suggests an act of relinquishment. A good example of this occurs in the case of those people who become ill when they are successful, where there appears to be a mechanism by which the person refuses the satisfaction of his desire. As we will see, the idea of sacrifice is noteworthy in the obsessive individual as well. In the name of his sacrifice he will give up everything to keep his desire impossible and unattainable. In analysis, we must ask ourselves, what is the subject renouncing when he presents to the analyst an endless list of possible motives for his sacrifices? What benefits does this sacrifice have? Lacan answers pure jouissance. It is in the role of the martyr that the hysteric and the obsessive find the most pleasure. It is not only important to sacrifice but to let the others
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know about ones actions; thus the hysteric is continually drawing attention to her sacrifice and martyrdom.
Hysteria in Men Hysteria in men is difficult to diagnose because of the way it is concealed by our culture. On the one hand we have a refusal of the medical community to recognize it, and on the other, the environment supplies apparently reasonable explanations for mens behaviors. Instead of looking for explanations within the psyche of a man, external causes are found to explain the male hysterics behaviors. Joel Dor (1987) states that traumatization (such as war traumas and post-traumatic stress disorders) are good examples of means for camouflaging male hysteria. However, from the psychoanalytic point of view, hysteria concerns men, particularly those who parade their traumatic symptoms as trophies in the eyes of everyone who gazes at them, and later obtain secondary gain for having them. Lacan will describe a particular group of men who share similar characteristics that resemble the hysteric presentation. These men exhibit the following presentation: 1) major outbursts of rage as a result of frustration. Although these frustrations involve every day events, it appears that these men are prone to exaggeration and pathetic efforts to call for negative attention. This rage appears to be the expression of some impotency that is mainly repressed; 2) the presentation of somatic, conversion symptoms and hypochondria. In contrast to the womens presentation (which usually evokes a part of the body), the mens complaint is typically directed to the whole body. In every other sense, the position of the hysteric male resembles that of the hysteric woman, in the effort to obtain or be the all-satisfying object. Like their female counterparts, hysterical men pursue dissatisfaction and always desire that which they dont have and which appears so much better in their eyes. Regrets and complaints regarding what he does not have are plentiful. His pleasure in unfulfilled satisfaction usually sets the stage for self-defeating behaviors, which are typically manifest in the hysterics professional activities and love relationships. A belief in his incapacity also leads him into trying to compensate for his impotence by using alcohol and drugs. In the context of male hysterics, these substances provide a compensation for a sense of not feeling adequate as a
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man. Under the influence of alcohol the hysterical male feels more at ease picking up women or ridding himself of a male competitor. In the area of sexuality, hysteric men (as hysteric women) place the feminine other in an idealized place that is totally unattainable. Further, they never experience women as desiring subjects, but rather view them as challenges to their virility. Therefore, the hysteric male avoids women as much as possible, hiding behind a mask of homosexuality or impotence. This type of hysteric male men is not a true homosexual since his choice is not for a male love object but is rather based on an avoidance of women. In the case of impotence and in the related cases of premature ejaculation, we have a subject who confuses virility with desire (Joel Dor, 1987). In psychic terms the confusion is based on equating the phallus with the penis (the organ) and the impossibility to be the phallus leads him to present himself as not having a functional penis. There are several typical cases that Lacanians conceptualize as hysteric men: one is the playboy or Casanova. This man searches for one woman after another as trophies that he shows off to everyone, in particular, other males. Clinical work with these men reveals that they are generally impotent with the women they select, in part, because the only women who can mobilize their desire are their mothers and in part as a function of their rivalry with other men (who in their mind possess the phallus). In the eyes of the others, they are really manly men but in the intimacy of their bedroom they cannot satisfy a woman (which in their mind is the phallic test they are suppose to pass or fail).
Obsessional neurosis Although it appears that most obsessive neurotics have a special or privileged relationship with their mothers, it is important to underline that this perception is not entirely correct. When we take into consideration the oedipal vicissitudes and the position of the four elements of the process: mother, child, phallus and the father, we can understand the way the obsessive has arrived at a resolution of his own that carries the mark of obsessive traits: an emotional distancing from all relationships.
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Typically, the appearance of the symbolic father should produce an identification with the phallus in the figure of the father. Only after accepting that a certain place belongs to his father, the child realizes that he has the possibility to have the phallus someday (in the sense of having a special knowledge about what can satisfy a woman, whatever that may be). However, if the mother is enigmatic about her desire, the child may still believe that he can fulfill her in spite of the fathers intervention. This is the scenario of obsessional neurosis, one in which the child continues to believe he can be the total satisfaction for the mother. If that would actually be the case (i.e. if the mother fully colluded in this idea) we would have a perversion instead of a neurosis. In obsessive neurosis, the mothers desire turns to the father but she does not seem to get everything she wants from him. A space of dissatisfaction is created in which the child perceives himself as a possible supplement in providing the mother complete satisfaction. If the mother appeals to the child to supply that which she is missing, the child may be libidinally charged by her. This is clearly seen in the erotic fantasies that obsessives have: they are plagued by passive-aggressive fantasies with respect to women who seduce them and at the same time, abuse them. Because of this particular relationship with the mother, the future obsessive will have difficulties accessing the fathers law and therefore will subsequently have difficulties with all authority figures. What is the position of this child with the father? We find here the key to what Freud called the anal character, in which an interminable struggle with the representative of the Law is always at stake. This interminable struggle is displaced into different routes of libidinal investment, with perseveration, obstinacy and defiance being typical. The obsessive does not want to dethrone the father, but rather to constantly erode the value of his power, to repeat the scenario by which he is captive of his mother in the presence of his father. The law of the father is always present in the obsessionals desire, and because of his privileged position with his mother, he cannot but feel extremely guilty. Further, the fear of castration is always an imaginary threat that haunts the obsessive. Since the paternal figure is always present, he also has feelings of rivalry and competitiveness with him, constantly wishing to take his place (the same situation occurs with any other person who occupies a place of authority and who symbolically represents his father, such as a boss, a trainer, or a professor). The child cannot articulate his own desire as it is tied up with his mothers. Thus, the obsessional
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person has difficulty articulating a demand to express his desire. This is because the emergence of desire is absolutely threatening. The obsessional cannot manage to find his desire, and sometimes asks others to do so for him. Such passivity puts him at risk to be sadistically mistreated by others. The fear of castration in obsessive neurosis is what is at the basis of the obsessives intolerance for loss. Any loss is equated with castration. Obsessives want to master everything to make sure they will lose nothing of the other. As a result, we see the rigidity and constant attempts to control the behavior of others that characterize the obsessive personality. The experience of totality, of achieving a global experience is a compensation for the obsessives castration anxiety. On the surface, obsessives are law-abiding citizens, to the point of becoming preoccupied with legal matters and of exhibiting a rigid adherence to rules. However, this is a reaction formation or a way to defend themselves from the wish to transgress. It is in this area of transgression of the law that they deploy their defenses most consistently. The use of isolation is manifested in their rituals and pauses of speech. In this way, speech becomes the vehicle for rigid control and detachment of feelings, even when they are on the verge of a crisis. It should be noted that generally obsessives are unlikely to seek analysis. They prefer conducting their own self-analysis or writing their dreams in a journal. They usually explain to themselves that it is better to work out their problems by themselves. What makes them come to therapy? Usually an intense manifestation of the others desire that the obsessive cannot manage to control precipitates anxiety and serious self-doubt. The abrupt and intense emotional opening of someone close, or an imminent loss of a dear one could disarm the obsessive and prompt an analysis. When in treatment, obsessives have difficulty free-associating, which is experienced as threatening to their self-control. Rather, they prefer to express themselves in long speeches filled with rationalizations. They also make use of black humor or sarcasm both in therapy and in the public arena. Obsessives use their words as tools of control of the other and in the process they acquire a secondary gain of discharging affect. This sarcasm is designed to neutralize the others feelings. Undoing, in which an act or a thought is treated as if it never occurred, is another defense that obsessives use to neutralize contradictory affects such as love and hate,.
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For the obsessive a relationships becomes an all and nothing situation (Fink, 1997) Since the obsessives core issue is his fear of castration, the condition for a relationship is that his partner is passive, not in touch with her own desire, and will, in effect, play dead and not desire anything for herself. The lover is thus, experienced as complete, lacking in nothing. In this way, the obsessive can continue to control a being who has no desire of her own. On the other hand, any threat of abandonment on the part of the lover, will immediately be experienced as a loss that the obsessive will go to great extremes to prevent. There is nothing that the obsessive is not willing to provide, give or offer to keep his lover in place. The relationship resembles very much a jailhouse in which everything is provided to the lover on the condition that she will relinquish all subjective desires that do not include her partner. Pleasure cannot be experienced without his authorization. Frequently in long term relationships, the partner of an obsessive is turned into an undesirable image by which the obsessive guarantees the death of he own wishes, sometimes imposing conditions on her looks, her clothing, insisting in that she adopt a prudish and morally correct appearance. If, on the contrary, the obsessive views his partner as an attractive, erotic object, he interprets that fact as a reflection of his own value and prides himself on his possession. These men can treat their partners like a trophy; another of their personal belongings. It is noteworthy that Lacan does not discuss the question of the etiology of neurosis, but only indicates that repression is its primary mechanism. His few comments on the process by which an individual becomes a hysteric or an obsessive suggests that social causes are involved in the maintenance of these structures. Lacans position seems to be that in Western society, desire is organized predominantly around the symbolic phallus. It would be interesting to record differences or changes in neurotic structures as social roles vary within the cultures and as a result of changes in contemporary society.
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Borderline Personality Disorder: A Lacanian Perspective Phobia Lacan considered phobia the most radical form of neurosis. (Lacan, 1960). He also
considered it to be the most extreme form of the problem of the establishment of the paternal metaphor (Fink, 1997). In phobia we have the presence of a weak father function and a strong attachment between mother and child. As the paternal metaphor is diffuse or precarious, the child has to instate it him or herself by replacing it with a symbol that substitutes for the fathers failure to cancel out the mother. Lacan did not consider phobia to be a separate structure, however, it is clearly a neurosis as it successfully addresses triangularization by providing a symbolic solution. The case of Little Hans in Freud (1909) clearly illustrates how the child creates a limit to his engulfing mother, as his father is unable to separate mother from son. Hans was usually allowed to sleep in his parents bed or to watch his mother change in the bathroom. (Ferrari, 1999). As his mother forces the child into placing himself as her imaginary phallus, he experiences an excess of sexual pleasure that he cannot tolerate. As Hans father does not fulfill the symbolic function of castration, one that would create a limit to the childs pleasure, a horse phobia is marshaled by Little Hans to perform the paternal function (Horse = Name-of-thefather). For Lacan, phobia is closer to hysteria than to obsessional neurosis in the sense that the subject is placed in a situation where he must constitute himself as an object of completion for the other, to be the object of the others desire.
Perversion Most patients, who by descriptive criteria are diagnosed as perverse, are, for Lacan, neurotics or psychotics. Further, for Lacan, all human sexuality is descriptively perverse and polymorphous as we come to this world as pleasure-seeking beings with neither a fixed object nor a higher purpose to guide our sexual drive. Such perverse behavior, which has no connection to our reproductive function continues throughout life and is unrelated to the diagnostic category of perversion. In Lacanian psychoanalysis the so-called perverse sexuality is a position of the subjects desire produced as a result of his oedipal vicissitudes. Thus,
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perversion is not a derogatory term to designate a deviation from the norm but a structural category in its own right. In order to understand what is at stake in the diagnostic structure of perversion we must, according to Lacan, keep in mind the questions of the mechanisms of negation and the Name-ofthe-father. Whereas in psychosis there is an absence of the law, and in the neurosis a reinstatement of the law in fantasy, in perversion, the subject struggles to bring the law into existence. Lacan terms the negating mechanism at work in perversion as disavowal. According to Lacan this is the very same negation that Freud had distinguished from the repression at work in neurosis. Freud had made this distinction in 1938: whereas repression relates to the putting out of mind a perception of the internal world, negation involves a disavowal of a perception in the external world. (Freud, 1909). However, for Lacan the barrier between outside and inside is more equivocal. Lacan agrees with Freud (1938) that repression involves pushing away a thought related to a drive (which gets dissociated from its affect and returns as a symptom), and that with negation, a thought related to a particular perception of the real world is put out of mind. (Freud, 1938). However, as the latter negation/disavowal is connected to a thought, some part of which is related to the psychic reality of a subject, the barrier between inside and outside is broken. Actually, neither of the two mechanisms involves perception, and each is applied to thoughts. Lacan is critical of the idea that we can distinguish internal from external dangers, threats and anxieties, as each of these are dependent upon the subjects thinking or signification. For Lacan, disavowal clearly involves the father and all the themes related to him; the law, the fathers name and the fathers desire. As we have seen, as the oedipal vicissitudes become the stage for a triangular relationship the child will have to relinquish part of his jouissance with his mother. This occurs as the paternal metaphor institutes a distinction that will bring about an identification with the father and with it, the hope to enter the symbolic world. However, the pervert will not relinquish this pleasure (associated with masturbatory fantasies with the mother or mother substitute). He refuses to do so. (I am using the pronoun he in the context of perversion as Lacanian psychoanalysts consider perversion a male diagnostic entity). So, who accepts the fathers law and who refuses to do so? Perversion usually occurs in the context of a very strong relationship bond between a mother and a male child who provides
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her with sexual pleasure. This contributes to a situation in which the child narcissistically invests his penis with an erotic power that he is not willing to relinquish. This mother constantly demands that her child satisfy her. This situation is coupled by the presence of a weak father (who is unsure of his own desire) or a father who is confused about his role and is overpowered by the childs mother (who has a secret pact with the child). At this point, we need to remind ourselves that mothers will somehow make a demand (by naming it) regarding her dissatisfaction (either with herself or with her husband). When the mother names what she lacks she creates a desire in the child to sort out her enigma: What does my mother want? Desire is put in motion in the search for the answer. In the mothers pervert, however, no demand has been named, there is no signifier provided by either parent that will articulate the mothers lack at the symbolic level; the child does not actually have to wonder what his mother wants, in fact, he knows what she wants and that is the child himself. She is completely fulfilled with her child; symbolic castration is not permitted to disrupt the dyad as there is no rival in the mother-child relationship. This is what in other contexts might be called an oedipal victory on the part of the child, or collusion between mother and child to deny the fathers power. The denial of the symbolic father and the denial of the sexual difference represent a disavowal based on the fact that the mother does not lack anything, therefore she is complete, and nothing is missing. We sometimes see these cases in mothers who experience their child as a narcissistic extension of themselves, as an object of their desire and cause of their bodily pleasure and we may view them as attachment disorders. This is the oedipal vicissitude of the future adult pervert. The child, who is identified as the phallus of the mother at the imaginary level, cannot accede to the symbolic register in the same manner as a neurotic can. He will be that which completes the mother forever. Although the first stage of the oedipal process was achieved successfully (the child is placed as the imaginary phallus of the mother), the second stage which renders separation from the mother, does not occur as the paternal function is not strong enough to name the mothers lack and separate her from the child. However, this oedipal victory or denial of the paternal function is unsettling for the pervert who fears being engulfed by the maternal object. As such, in these cases the child himself supplies the paternal function through a fetish, a shoe or a punishing act in an attempt to separate himself from the mother and at the same time, to bind the anxiety that he feels by being engulfed by this overwhelming Other.
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This is the function of the perverse object in the fetishists scenario. The presence of the element of perversion, whether it be a fetishistic object, a ritual, or a sadistic activity, needs to be repeated ad infinitum, as no one-single-event can resolve the situation for the pervert; he must engage in a scene that must incessantly be staged same way to fulfill its function. Although the suffering of the pervert at times resembles that of the melancholic, or a severe depression, it is very difficult for a pervert to be in analysis. From one day to the next, they can reverse a terrible feeling and feel absolutely nothing (disavowal of pain). They usually start treatment after having suffered a significant loss or if they are facing death in some way (like suffering from an incurable illness). The topic of death is usually in the perverts vocabulary, representing the only inscription of time. When faced with these circumstances, perverts suffer from agitated anxiety. Another difficulty for the progress of treatment, if started, is that the pervert wants to be the cause of his analysts desire, instead of the analyst being the cause of his desire, making the transference almost impossible to be established. Moreover, perverts tend to e acting-out behaviors in which they diminish the analyst, humiliate him/her and try engendering castration anxiety in the analyst. Table 2 incorporates some elements that help us in the diagnosis of the three main diagnostic categories. (Fink, 1997)
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Borderline Personality Disorder: A Lacanian Perspective Table 2: Psychosis, Neurosis, Perversion
Psychosis
Symbolic Order Is lacking, thus does not exist as such. The psychotic tries to provide this function by creating a metaphoric delusion. Total invasion Never barred by the name of the father, psychotic never becomes a separate subject. Psychotic whole body and being is engulfed with the mother
Neurosis
Exists in all cases
Perversion
Must be made to exist. It is brought into existence by the subject enacting his own law.
Jouissance Mother
Avoidance Barred by the name of the father. Neurotic emerges as a subject.
He is seduced by setting limits to it. The pervert brings about the law to bar the mother in order to exist as a separate object of her desire The perverts real penis is required by the mother.
Mothers desire
Oedipal stages
Psychotic never grows out of the imaginary level. He is trapped in alienation with the mother.
Neurotic achievements are required but never suffice as the mother always wants something else. Goes through three stages of Oedipus with the focus on the Others ideals which render different types of neurosis.
Pervert does not go through the second stage that is the separation from the mother, due to the inability of the name of the father to name the lack of the mother.
Chapter Four
The Case of Katherine
n this book I have proposed a theoretical and clinical dialog between Kernbergian and Lacanian schools of psychoanalysis. Central to this dialog is the question of whether psychiatry, and moreover, psychoanalysis has provided a satisfactory account of the
borderline personality disorder to justify its existence as a distinct diagnostic entity, requiring a conceptualization and treatment that is, for example, distinct from the neurosis and psychoses. Further, if Borderline Personality Disorder is indeed a viable and distinct diagnosis, the question arises as to whether Otto Kernberg, as the pre-eminent proponent of a psychoanalytic theory of the borderline, has provided an adequate diagnostic and therapeutic characterization of this structure. Finally, the question also arises as to how patients considered by Kernberg to be borderlines are handled both clinically and theoretically from a Lacanian psychoanalytic point of view. The borderline diagnosis has implications for psychoanalytic theory as a whole, as several important issues including, (1) the relationship between psychoanalytic and psychiatric diagnosis, (2) the meaning of psychoanalytic "structure", and (3) the controversies surrounding the question of whether psychoanalysis is essentially a study of unconscious, as opposed to ego and relational, processes, come into sharp focus when one considers the so-called borderline patient. Psychoanalysis, one might say, reaches its most controversial moment in the topic of the borderline personality disorder, as the whole body of psychoanalytic thought is relevant to this issue, and potentially stands to be revised in the process. In Chapter One I introduced the problem and the Borderline personality. Subsequently, I presented the points of view of two psychoanalytic thinkers, Otto Kernberg and Jacques Lacan,
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who have interpreted the main tenets of psychoanalytic theory in what appear to be radically different ways. At the same time, I explored their roots in Freudian thought and how they were influenced or (in the case of Lacan) largely rejected the post-Freudian developments of the past 40 years. My goal, from the outset, was not only to provide a basis for understanding the theoretical issues raised by the borderline diagnosis, but also to consider the implications for clinical/therapeutic practice in the differing conceptualizations of Kernberg and Lacan. To this end, it is my intention to structure much of the subsequent "dialog" between Kernbergian and Lacanian points of view around a clinical case. The presentation of such a case will, I believe, not only further clarify the dialog between contrasting Kernbergian and Lacanian positions, but also provide clinicians working with severe personality disorders an opportunity to clarify their thinking regarding clinical interventions with severely disturbed patients. The clinical case I am about to present is an altered, and to a certain extent composite and fictionalized version of a case that I treated over a three year period. The procedure of altering and fictionalizing this case was utilized in order to protect the identity of the patient. However, every effort has been made, at all points to retain the essential features of the clinical presentation and treatment. As I will discuss in more detail later in this study, the procedure I am about to use is illustrative as opposed to probative; the entire thrust of this work being one of hypothesis generation as opposed to hypothesis testing. The case of Katherine serves as a test case only in the following sense: that it permits us to consider Kernbergian and Lacanian conceptualizations in the context of actual clinical material. I will begin by describing the history of the patient, outline the presenting problems at the time of her entry into treatment, provide a description of the basic therapeutic problems that were encountered, and describe diagnostic considerations based on the two different approaches (Kernbergian and Lacanian) to clinical interviewing. Both Kernberg and Lacan hold that the course of the initial interviews, and the analysand's responses to certain early interventions, can provide extremely valuable diagnostic information. In this regard, Kernberg and Lacan agree on the importance of the first meetings between analyst and patient as a means of maximizing the value of the interview as a tool for clinical diagnosis. As such, I will occasionally use excerpts of the case, derived from my notes of the early interviews, to illustrate some of the issues in differential diagnosis.
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I should point out that my work on this case was conducted during a period (which continues to this day) during which I was struggling with the conceptualization of severely disturbed patients from both object-relations (Kernbergian) and Lacanian points of view. In presenting the case here I have attempted to be as descriptive as possible, limiting any theoretical intrusions for subsequent chapters, where I will discuss this case from each of the dual perspectives that have been the subject of this book.
"Katherine": The Presenting Problem
Katherine is a 25-year-old single woman living in New York City. She was seen in psychodynamic treatment with the writer for three years. Sessions, which were paid for by the patient on a minimal fee/sliding scale basis, and were scheduled for one to two times per week, as dictated by the needs of the treatment and the capacity of the patient to tolerate more than one weekly session. The setting of the treatment was a university-based psychology clinic. When Katherine entered treatment, she presented a long list of complaints, including feeling fatigued, depressed and isolated, experiencing severe family conflicts and feeling misunderstood by her boyfriend. She was also concerned that her aggressive thoughts might, at times, make people fear her and therefore make her as she put it undesirable in the eyes of others. She related that the smallest slight or hint of rejection would be extremely upsetting to her, and that she was unable to recover from such upset, sometimes for days. Early on in the treatment Katherine expressed feelings of uncontrollable rage towards her father. However, as she reported in other sessions, she experienced similar rage in connection with several other significant others, including her boyfriend, Christian, her sibling, Michael (age 23) and half-sibling, Susan (age 30). Just prior to commencing treatment she had run away from home for two days and had made several phone calls to family members in which she accused her father of abusing her, and of rejecting her boyfriend and calling him a "bum." As a result of these incidents, the family had initially been offered structural family therapy . As is quite common amongst chronically unstable individuals, it later became clear that Katherine had
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a history of varied and multiple treatments, including group psychotherapy and psychopharmacological treatment. Katherine reported that she was unable to earn enough money to rent her own apartment. She continued to live with her father and stepmother, but managed to arrange for her own food stamps, as well as welfare benefits, in the amount of $150.00 a month. She reported that her father insisted that she pay her share of the apartment rental and she complained bitterly of this, stating that she had very little money left over for her own use. She further complained that although she paid rent to her father every month, she did not have her own bedroom and was sleeping in the living room with no privacy. By way of contrast, her sister and her parents had their own bedrooms. As later became clear, Katherine had episodically moved from her parents home to a neighbor, as well as briefly into the homes of several other new nice people who she had met while out in the streets, and her situation in her parents' home was far from stable. Katherine found her inability to achieve a career or sustain a creative outlet, very stressful. This stood in stark contrast to her brother's professional success.
Family Structure and Childhood History Katherines father (age 55) is a construction worker. The family resides in a middle class section of Brooklyn, in a two-bedroom ground floor apartment. Katherines stepmother, Betty, age 57, works as a housekeeper in the neighborhood. Katherines brother Michael, 23, is a computer engineer who recently graduated from a small west coast college and who has obtained a job in a major corporation. Michael had always lived with his biological mother and moved out of her home when he went to college. Katherines mother, who was originally from South Carolina, lives in Virginia, where she is currently employed as a hotel receptionist. Katherines mother has never remarried and complains in her weekly phone calls to Katherine that she is terribly lonely. Katherine also has a 30-year-old half-sister, Susan (from a former relationship of Katherines mother) who lives in a Buddhist community in South Dakota. Katherine describes her as reclusive and non-communicative, and reports that she has been diagnosed with depression in the past. Katherine also reports that Susan had been treated with psychiatric
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medications but after a few years had stopped taking them in favor of meditation. Katherine has had very little contact with this half-sister. Katherine was born in New York City and lived with both parents until the age of ten. Her mother met Katherines father (who is of Italian descent) in a bar in New York City where she was working as a cook. Katherine at times describes her mother as cold and detached. She also relates that her mother is extremely moody, has an unpredictable temper, and suffers from extremely low self-esteem. Katherine relates that her mother seemed to be uninterested in her role as a parent and that she worked all day, returning home very late almost every evening. Katherine also relates that her mother was "like two different people in one," at times behaving in a crazy manner. For example, Katherine recalls that as a child if she would upset her mother, she (Katherine) would be left alone on the sidewalk while her mother went inside their home, leaving Katherine in a state of extreme emotional distress. Based upon Katherine's descriptions it appears possible that her mother suffered from an affective disorder. As an adult, Katherine felt a certain responsibility for her mothers well being, calling her every week at home, and constantly urging her to seek treatment for her depression. With regard to her mothers cold and aloof stance, Katherine initially stated that her mother is a woman totally lacking in maternal instincts. However, Katherine did not blame her for this, preferring to feel sorry for her, and offering justifications regarding how difficult it must be to be a mother. However, as the treatment progressed it became clear that Katherine believed that her mother was aloof only in regard to her, and not, for example, in regard to her brother. Katherine described her father as a chauvinistic second generation Italian-American male who was all talk, and although she remembers him as her primary caretaker, she also describes him as violent and abusive towards herself and her mother. She depicted her father as a domineering, explosive man who would vent his anger on the women around him and constantly ridicule them; behaviors which enraged Katherine. Katherine spoke about her father during almost every session and this relationship and the intensity of her rage towards him, was the major theme throughout at least the first year of treatment. The tense relationship between Katherines parents ended in a separation after her father left the home. When her parents divorced, Katherine's mother took the children to another state without the father's consent. A court battle ensued between the parents and Katherine and her brother
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became a negotiating chip between the couple. Katherine became so upset about the conflicts between her parents that at age 14 she ran away from her mothers home and lived in various homes where she was taken in, as she put it, as a daughter. For example, at one point she moved into her boyfriend's home, where she was treated as another child in the family. On another occasion, she became friends with an older widow who took her in and she spent six months living with her, taking care of her pets. However, almost immediately after Katherine would start a relationship, she would start lying and (sometimes stealing) in the new home until such time that she outstayed her welcome. At such times she would find another person or people who would become the new good parents. At the age of 23, she returned to New York to live with her father in spite of her perception that he, like her mother, was a neglectful parent. Katherine herself came to realize that in spite of her hatred for him, her father was always providing for her and she would turn to him in moments of crisis. A pattern of idealization and later, frustration and disappointment were the characteristics of the encounters with people in Katherines adolescence and continued to be reflected in her interpersonal relations as she became an adult. This pattern was observed to occur with friends, in particular her boyfriend, employers, and, most clearly, with the therapist herself.
Work History During the first year of her treatment Katherine was pursuing a degree in communications at a public College in New York City. However, it soon became apparent that in spite of her above average intelligence, she lacked both focus and motivation to remain in school, and after a semester of excessive absences she decided to leave school without completing any of her courses. She was constantly concerned about not being able to pay her tuition, complaining that the financial aid office was denying her the help she needed. She later confessed that she had outstanding loans from previous attempts to begin college. She explained that this combination of circumstances rendered her incapable of continuing her studies. Katherine had a series of short-term jobs that ranged from an attendant in a geriatric home, to a boutique salesperson, a florist, a tour bus guide and a belly dancer. However, she quit
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one job after another, each after only a few weeks of employment. A common scenario was a conflict with an authority figure, in which she would feel she was being overly observed by her employer, wrongly judged and finally driven away. Katherine felt singled out by her supervisors and she engaged each of them in heated arguments that at times led her to threaten them with lawsuits. Katherine would generally leave her job after she had been out several days as a result of somatic symptoms (pre-menstrual cramping, headaches, digestive problem) that exhausted her. In sessions, it became clear that her decisions to accept employment were always impulsively undertaken and never well thought through. Typically some superficial aspect of the job had appeared to offer her a sense of meaning and/or financial opportunity. However, each time she would fail in a job, she would single out certain elements of the job (e.g. number of employees, working hours, type of setting, or the job location) and add them to a list of to avoid factors in any future job search. Each of these experiences left Katherine tired, disillusioned and more pessimistic regarding her prospects of becoming a self-supporting adult.
Course of Treatment During the initial interview session Katherine was asked to describe the nature of her problems and how they impacted upon her life. Katherine expressed discomfort with this openended inquiry, and requested that the examiner ask her more direct and specific questions about her condition, a demand that initially appeared to both express her need to feel more in control of the interview and to serve as her means of evaluating the therapists own experience, knowledge and ability. She stated quite openly that the idea of freely discussing her concerns made her feel uncomfortable. The interviewer inquired about this discomfort, asking Katherine to explore its origins, after which Katherine immediately began discussing her depressive feelings and how her body was affecting her mood. She described what she referred to as her imbalanced hormonal state which she said led her to experience very painful pre-menstrual pain and periodically rendered her unable to function. She presented these somatic preoccupations in the context of her depression and she wondered if she might be "contributing to her pain in some way."
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Borderline Personality Disorder: A Lacanian Perspective At the time Katherine entered treatment she was already being seen by a hospital
psychiatrist on an outpatient basis and had been prescribed Prozac, 20 mg. a day. She reported that her psychiatrist had found it helpful to bring in her father and stepmother to discuss her mental and emotional status. In one of these meetings Katherine had voiced the opinion that her father and stepmother believed she was mentally challenged, mean with other family members, and had caused them worry and constant concern. Her stepmother wanted to bring the whole family into therapy but her father refused on the grounds that Katherine was again playing tricks." Katherine also asked this interviewer if it would be useful to bring the family in to help her clarify her emotional issues. I suggested leaving the family out of her individual therapy until this issue could be explored further. Katherine denied any history of alcohol or substance abuse. However, she early on acknowledged periodically engaging in episodes of self-injurious behavior that took the form of making superficial cuts on her stomach and/or her arms. Although Katherine described these as suicidal acts, it soon became apparent that they largely functioned to prompt others into providing her with attention and concern. These episodes would mobilize her boyfriend and her parents and would typically lead either to a brief hospitalization or a period of at-home care where her stepmother would continuously watch her. Katherine reported that during her suicidal episodes she would feel out of control. Her gestures which suggested serious deficits in frustration tolerance and impulse control emerged at times of intense rage. In addition, her actions appeared to be designed to re-establish control over the environment by evoking guilt feelings in significant people in her life. These episodes would invariably be followed by a period of severe depression, characterized by sleeping late in the mornings, decreased energy, lack of motivation, boredom, social isolation and withdrawal from nearly all of her activities. At such times Katherine would typically complain about some medical or physical ailment that accompanied her emotional suffering (mostly focused on her reproductive/genital area). The issue of management of potential self-destructive behavior, however, was a delicate matter, as any increase in attention (number of sessions, or phone calls) threatened to reinforce and encourage further negative behavior. Yet, in this regard, the self-mutilation although serious, was not the most severe type, and could have been managed on an outpatient basis. With the passage of time, the therapist learned that the patient was honest about the severity of her intentions and
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did not actually have suicidal intent. While she reported that she also had aggressive fantasies towards others, she denied any plan or intent to act on them. In addition to her severe menstrual cramping, which typically disabled her for several days just prior to her menstrual period, Katherine complained of being overweight (an evaluation she initially attributed to her boyfriend), experiencing tightening in her chest, and difficulty breathing. However, her incessant somatic complaints contrasted markedly with her involvement in various sports and her investment in developing a powerful and trim physique. Katherine was a strong bicyclist who spent several hours per day on the road, often riding to the point of exhaustion. She was also an avid swimmer and reported that she had taken several parachute jumps. She explained that her physical activity was very important to her and that she would try to push herself as much as she could. As Katherine related to the therapist, she was always trying to find a causal relationship between her physical illness and her depression. She was an avid reader of psychiatry, psychology and self-help books. She explained her illness as a depression caused by a chemical imbalance in her brain. Katherine revealed that she had made numerous previous visits to a local psychiatric emergency room due to suicidal ideation. However, none of these visits to the emergency room resulted in her being admitted to the hospital. Katherine reported she was well known to the oncall hospital staff, who had indeed diagnosed her as a borderline personality. Indeed, her psychiatrist and an on-call resident each described Katherine as someone who engaged in acting out behavior and sought the attention of the medical community to enhance her victimization role. Katherine complained that the hospital doctors appeared not to be concerned about her pursuing an actual act of aggression directed towards herself or others, but she insisted that at such times she was really very dangerous. Although she never actually hurt or attacked anyone directly, Katherine's own concern in this regard underlined the vivid aggressive fantasies she expressed in regard to her parents, employers, and (when at work) her clients. One salient symptom that Katherine reported was a sense of depersonalization, which was generally accompanied by the sense that she had lost memory for certain periods of her life. As treatment progressed, she reported that certain memories returned in connection with her sexuality, her family history, and her early childhood experiences.
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Borderline Personality Disorder: A Lacanian Perspective Katherines treatment lasted nearly three years. When treatment began, she requested that
she be seen twice weekly. However, she would frequently be excessively late or cancel her appointments, so a new schedule was set for a once a week, 45-minute session. An agreement was reached that in time there would be an increase in the number of sessions if that seemed appropriate. The schedule, frequency, and length of sessions varied throughout the treatment. Her commitment to the therapy increased over time, as reflected in the depth of the material and her willingness to share it. Several themes soon dominated Katherine's associations. She had a strong ambivalence regarding her family and boyfriend, as shown by her continually expressing a desire to be closer to them yet at times, acting out against them in ways that assured their distance. Katherine's acting out was usually directed at her father or her boyfriend Christian, but at times, it was directed against an authority figure (e.g. an institution such as a school, the subway system, the police, etc). Father and daughter would argue intensely. She would scream at him until the neighbors would threaten to call the police. Katherine accused him of being an abuser and not providing for her, of eavesdropping on her phone conversations and controlling/restricting her use of the phone. On the other hand, Katherines father made terrible scenes whenever she brought a young man home. He was particularly harsh with her boyfriend, Christian. He would make fun of his education and his pursuit of a career in fashion. Her father regarded Christian as an adventurer with no prospects. On other occasions, Katherines father would be completely oblivious to Katherines requests or demands, to the point of indifference (from Katherines point of view). Once, when driving with her father in his car, she went so far as to jump out of the moving car in protest against his indifference to her. Katherine was also highly conflicted regarding her relationship with her boyfriend. Her demands for attention took a toll on their relationship, mostly as a result of her doubting his feelings for her and the genuine nature of his love. A cycle would ensue in which Christian would leave Katherine and then she would follow him, begging for his forgiveness to the point of becoming obsessed with the loss. They would finally make up, usually after an intense sexual encounter, and the cycle would begin again with another argument. At the same time, Katherine would seek the attention of other men, for example, friends in college or a man she would meet
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bicycling in the park. Although she reported not being aroused by these encounters, she allowed other men "to touch her." A similar pattern was clear in Katherine's relationship towards the therapist. On one hand, she came to trust the therapist enough to share deep and intimate thoughts and feelings. Yet in the session immediately after such a sharing, she would often become resistant trying to upset the therapist, at times by missing sessions, appearing at the wrong time or openly devaluing the therapy. The treatment initially centered on the development of trust and the working alliance. Katherine was very needy at that time, calling the clinic frequently and at all hours to talk to the therapist. When the therapist returned her repeated phone calls Katherine was agitated and unable to calm herself, stating for example, that she absolutely could not wait to talk until her next session. My position during these phone calls as it was throughout the early phases of the treatment was to provide some containment for Katherines anxiety, and assure her of my presence in spite of distress, her acting out and the expression of negative affect towards the therapy. During the first year of treatment Katherine had a quarrel with Christian that resulted in his requesting a temporary separation during which time they would both have time to think over their relationship. Katherine acknowledged that the theme of loss and separation was very difficult for her, and she attempted to hold on to her own fragile sense of being during this period by having encounters with other men. She reported that she would not have sexual intercourse with them, but allowed them to touch her as she passively enjoyed being "physically manipulated". After two weeks of not hearing from her boyfriend (who had taken a trip), Katherine made a suicide gesture/attempt by swallowing 25 aspirins. She explained that late one night while everyone was sleeping in her family's home, she became more and more thoughtful about Christian, felt betrayed and lied to, convinced herself he was never going to return, and had the urge to "do something to herself" in order to alleviate her pain. After Katherine swallowed the aspirins she developed stomach pains, and her step-mother was awakened by her moaning. Katherine confessed her act, the family became very concerned, and she was brought to a local hospital.
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Borderline Personality Disorder: A Lacanian Perspective The emergency admitting psychiatrist concluded that Katherine was indeed very
depressed and admitted her to the hospital. She was discharged a week later against her wishes. I spoke with her treating psychiatrist several times to discuss her aftercare. The psychiatrist diagnosed Katherine as suffering from a Borderline Personality Disorder and it was agreed that her psychiatric aftercare would consist of psychopharmacological treatment (Prozac, 40 mg. a day), with continued psychotherapy sessions, and a group psychotherapy at the hospital from which she was discharged. Katherine took up the recommendation and joined a women's psychotherapy/support group. However after a few months she left the group reporting that the other women thought she was monopolizing their time and had confronted her about this. In addition she felt that they were jealous of her as she was the youngest and, in her view, the healthiest of the group members. At this time, it became clear that the patient's and therapist's earlier goals would need to be scaled back in an effort to stabilize her acting out and regressive behavior. It also became apparent that it was important to establish short-term goals and be prepared for serious regressive behaviors when Katherine was confronted with separation and loss. We explored issues of trust and separation at great length and took certain steps to minimize the risk of a psychiatric decompensation when I was away. For example, I would communicate to her by phone and send her a postcard when I was on vacation. It was important for her to conceptualize that I was not lost forever. Transferentially, at the beginning of treatment, Katherine either idealized or devalued the therapist and the treatment. She had previous therapeutic experiences, had made frequent visits to hospitals and psychiatrists, and fancied herself something of an expert on therapy. However, only when the therapist placed limits on her intense demands did Katherine actually become interested in the therapeutic process, and began questioning herself and her actions, allowing the transference to become more firmly established. Strong countertransferential feelings were evoked in me, as a result of the patients frequent and intense demands. Feelings of being suffocated by this patient along with fantasies of terminating her were at play as well. These feelings were discussed in my supervision and personal analysis, in order to facilitate my own growth and clarify my stance with this patient.
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As the case progressed, I began to encourage Katherine to engage in free association. Over time a dialogue between Kernbergian and Lacanian perspectives on treating this patient began to emerge in my own mind. A theoretical exploration of the two techniques and how they could bring about therapeutic change evolved as my work with Katherine proceeded.
Chapter Five
Katherine as a Kernbergian Borderline
here can be little doubt that Katherine can be understood as a borderline within Kernbergs understanding of this term. In this chapter I will review Kernberg's diagnostic procedure and demonstrate how the use of the interview techniques he
prescribes reveals Katherine to have both the "presumptive" and "structural" characteristics that, according to Kernberg, define borderline pathology. As we have seen in Chapter Two, Kernbergs technique has been influential in differentiating between neurotic, psychotic and borderline syndromes. In contrast, as will be described more fully in Chapter Seven, Lacan would assert that the call for a borderline structure is the result of a failure to conduct a subtle and comprehensive analysis within the diagnostic categories of neuroses and psychoses. I will show how from a Lacanian perspective, in spite of the claim to go beyond descriptive psychiatry, Kernbergs analysis involves a re-labeling of descriptive criteria as structural personality features. For Lacan, descriptive diagnosis is of virtually no psychoanalytic value. In Chapter Seven, I will show how from Lacanian point of view Katherine can be conceptualized within a neurotic structure, without recourse to a "borderline" diagnostic category. The strengths and limitations of each of these approaches will then be considered.
Katherine as a Kernbergian Borderline Katherine as a DSM-IV "Borderline"
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As discussed in Chapters One and Two, Kernberg's criteria differ from, but are in many ways compatible to, the criteria for Borderline Personality Disorder set forth in the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association (Fourth Edition, Text Revised, 2000). As these criteria have become prevalent in a majority of clinical settings, it will be instructive to briefly examine Katherine in DSM-IV-TR terms. Even a cursory review of this case reveals that Katherine meets the DSM-IV-TR criteria for Borderline Personality Disorder. We can here recall the DSM-IV-TR criteria for Borderline Personality Disorder:
a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following criteria: 1) Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviors covered in Criterion 5.
2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3) Identity disturbance markedly and persistently unstable self-image or sense of self. 4) Impulsivity in at least two areas that are potentially self-damaging e.g. spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating behaviors covered in Criterion 5.
5) Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior. 6) Affective instability due to a marked reactivity of mood (episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
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7) Chronic feelings of emptiness. 8) Inappropriate intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights). 9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
During the introductory (diagnostic) sessions at the beginning of Katherine's treatment, it became abundantly clear that she met at least seven, if not all nine of these DSM-IV criteria. Her desperation and suicidal gestures in the face of the threatened abandonment, her idealizations regarding boyfriends, employers, and job opportunities which invariably turned to devaluations, her inability to form and maintain a stable self-image, the extreme reactivity of her mood to various interpersonal and bodily events, her feelings of emptiness in response to perceived abandonment, her sudden displays of temper, and her brief paranoid episodes in connection with each of her employers, clearly qualified Katherine for a DSMI-IV diagnosis of Borderline Personality Disorder.
Kernberg's Presumptive Criteria As will be recalled, Kernberg's diagnosis of the borderline condition involves a twotiered process (Kernberg, 1984). Initially a "presumptive" diagnosis is made on the basis of certain symptomatic features, which even if they are not part of a structural diagnosis, are descriptive features that a clinician should observe (and even elicit) while interviewing the patient. They include one or more of the following: (1) pan-anxiety, (2) polysymptomatic neurosis, including: a) obsessive-compulsive symptoms, especially in conjunction with paranoid or hypochondriacal themes, b) multiple and severe conversion symptoms, c) dissociative reactions, and, d) hypochondriasis, (3) polymorphous perverse sexual trends, (4) pre-psychotic personality traits, including paranoid, schizoid, hypomanic and the cyclothymic personality features, (5) impulse neurosis and addictions, (6) lower level and/or narcissistic personality
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features (including shallow affect, limited empathy, intense envy and ego exhibitionism (Kernberg, 1975). Again, in Katherine's case, Kernberg's presumptive criteria are easily met based on the clinical data. Katherine presented with chronic, diffuse anxiety accompanied by bodily concerns. She presented several neurotic complaints and symptoms such as inappropriate preoccupations and obsessions, which she had in conjunction with brief dissociative episodes (periods of memory loss in connection with her bodily experiences), hypochondriasis (pre-menstrual cramps, digestive problems) and paranoid trends (expressed in her relationships with others, mostly with authority figures, but also with the interviewer). As described in Chapter Three, the presence of hypochondriasis in combination with paranoid trends is, according to Kernberg, particularly suggestive of a borderline personality organization. Katherine also presented with certain perverse sexual trends that became the focus of considerable attention in her treatment. She insisted on taking a submissive, masochistic role in the context of aggressive/sadistic sexual encounters. Although this presentation was not bizarre it involved the replacement of genital pleasures by partial ones, as when she allowed strange men to fondle her without sexual intercourse. The presence of impulsive behavior was evident in several contexts, the most noteworthy being her suicidal gestures, her episodic and often ego-dystonic sexual acting out, and her sudden rages against family members and employers. Although in the initial interviews Katherine had denied use of alcohol and drugs, it later became clear that in her adolescence she had used marijuana and alcohol, at times to excess. During the treatment I wondered whether she might not be "addicted" to her psychiatric medication, as she became extremely distressed when she could not get her prescriptions filled and would sometimes wait for hours in the waiting room of an emergency psychiatric service for a prescription renewal from her psychiatrist. Katherine's need to substantiate a "chemical imbalance" as her explanation for her problems may have helped her rationalize an underlying addictive tendency. Katherine also presented a preoccupation with obesity and weight loss that became evident later in treatment. Kernberg suggests that this is another form that addictive behavior can be manifest in borderline patients (Kernberg, 1984).
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Borderline Personality Disorder: A Lacanian Perspective Finally, Katherine exhibited features of several "lower level character disorders" that,
according to Kernberg often signal the presence of an underlying borderline organization. Katherine's masochistic, impulsive and infantile personality traits were unmistakable, as were certain narcissistic features, such as her intense envy and exhibitionism. Any or all of the above-described traits may, according to Kernberg, point the clinician in the direction of a diagnosis of a borderline personality. However, the diagnosis can only be confirmed by a careful assessment of certain structural characteristics that involve the quality of the individual's object relations, his/her defensive organization, and the presence of certain identity issues (Kernberg, 1975).
Kernberg's Structural Diagnosis As we have seen in Chapter two, according to Kernberg, the presumptive diagnosis of borderline personality is only confirmed when a structural interview reveals certain features that are characteristic of the borderline personality structure. These features are: (1) certain
manifestations of ego weakness, including poor anxiety tolerance, a lack of impulse control, a lack of developed sublimatory channels, and a blurring of ego boundaries (2) a shift toward primary process thinking, in spite of intact reality testing, (3) specific defensive operations, including: splitting, primitive idealization, projective identification, primitive denial, omnipotence and devaluation, (4) a pathology of internalized objects, (5) identity diffusion, (6) excessive pre-genital aggression, and in general, (7) a primitive and unintegrated superego corresponding to a fragile ego and self. In addition, Kernberg describes the borderline as having differentiated self and object but having failed to achieve a sense of libidinal object constancy, as described by Mahler (1972). The Structural Interview For Kernberg (as for Lacan) the diagnostic interview is not simply a gathering of information. Rather, the structural inquiry involves a sophisticated level of listening and
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observational skills, hypothesis formation, interventions and other techniques that are part of the psychotherapeutic process (Kernberg, 1981). Only by implementing such techniques can the interviewer gather the data necessary to form a "structural" diagnosis based on an assessment of ego functioning, typical defenses, object-relatedness, etc. Technically, an initial interview extends from one and a half to two hours. The diagnostician faces simultaneous tasks during the structural interview. First he/she needs to keep his/her attention constantly on the patient, observing her behavior and listening to the verbal communications, while generating hypotheses regarding her symptoms. At the same time, he/she needs to assess the nature of the interaction, utilizing his/her own emotional reactions as a means of clarifying the nature of the patient's object relations and use of defensive operations. At the start of the interview the patient will be asked for a description of her symptoms and difficulties, her reasons for seeking therapy, and her expectations regarding treatment. The open-ended nature of the initial contact has great value for the diagnostic process. Kernberg encourages clinicians (and particularly those who have limited experience with this type of interviewing) to perform a systematic search by following the cycle of anchoring symptoms (Kernberg, 1984). This cycle follows a path from neurotic symptoms to character traits to the major marker of borderline condition (identity diffusion) and then to psychotic symptoms (reality testing and functional symptoms) to the more organic brain syndromes (based on an evaluation of sensorium, intelligence and judgment). In contrast to the classic psychiatric interview, Kernberg proposes specific challenges to the patient's defensive structure that will permit the structural hallmarks of the borderline conditions to emerge. A further advantage of the structural interview is its flexibility, as it permits the clinician to move to a more classical format (what is referred in clinical settings as the Mental Status Exam) in cases of organic and/or functional psychosis or back towards a more structural approach if more neurotic or borderline characteristics appear. Although the structural interview poses a risk of raising primitive defenses too early in the treatment, the classical interview as performed in most outpatient settings, has the disadvantage of allowing the patients defenses to go underground, making it easy for the patient to "adapt" to the questions and mask important personality traits, while at the same time decreasing anxiety and blocking early transference developments that would themselves be of diagnostic (and later therapeutic) significance.
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Borderline Personality Disorder: A Lacanian Perspective As a clearer picture emerges from the interview the clinician should focus on the
exploration of significant symptoms and traits, but now emphasizing their appearance in the current interviewing situation. It is at this point that Kernberg begins more active efforts to clarify those aspects of the patient's presentation that appear incongruous. This is done by confronting the patient with that material (verbalizations, ideas, affects and behaviors) around which the patient is clearly ambivalent or confused, and by being attentive to how the patient handles the interviewers query. Further, the therapist, following Kernbergs procedures, moves constantly from clarification to confrontation when the patients incongruities arise. This helps the therapist focus attention on a major cluster of symptoms, at the same time, monitoring the quality of reality testing, especially in the context of regression.
Katherine: The Diagnostic Interview The initial phase of the interview with Katherine provides an illustration of Kernberg's ideas regarding the structural vs. classical interview. Almost immediately Katherine herself attempted to control the interview, requesting that the analyst move away from her open-ended (structural) approach and ask her a series of questions (perhaps corresponding to the more classical history gathering and mental status format) that she was expecting. As the interviewer challenged the patient to talk freely about herself, defensive operations accompanied by an increase in Katherine's anxiety became obvious. This anxiety is judged by the clinician to be intense but manageable. Katherine became vague and "off target" when trying to pinpoint her problems and complaints. As the therapist continued to press her, Katherine became more intellectualized and avoidant. Had she become more disorganized, showing signs of disabling anxiety, acute paranoia, or psychosis, the interviewer would have indeed shifted to the more classical mental status/history examination. It is clear from the outset that Katherine had difficulty communicating in the therapeutic setting, and was quite vague regarding both her symptoms and conflicts. Her vague, inadequate and confusing communication was evident in spite of otherwise strong verbal skills and a level of intelligence that, based upon an assessment of her vocabulary and linguistic style, was, at
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least, in the average range. However, neither severe verbal disturbances nor bizarre thinking were noted. In Kernberg's style of interviewing, the psychoanalytic and psychiatric thinking and technique go hand in hand in an effort to collect data that will enable the clinician to make inferences regarding the major categories designated by Kernberg in his structural analysis. I will examine each of these areas as they apply to Katherine's case.
(a) Identity Diffusion: Neurotic Integration vs. Borderline Fragmentation A lack of an integrated identity is perhaps the defining feature of borderline organization and manifestations of this lack are thus important markers for the borderline diagnosis. Amongst such manifestations are the patient's complaints of emptiness, evidence of emotionally lability with respect to self and others and a flat, impoverished personal and interpersonal perception in which the patient cannot convey a clear and adequate idea of himself and others to the clinician. (Kernberg, 1984). The therapist should evaluate the issue of potential identity diffusion in detail, probing and even confronting the patient regarding any verbalizations about self and others that are contradictory in character. It is here useful to examine the criteria used by Kernberg to define self-integration, which, on his view, characterizes neurotic individuals. Kernberg states there should be a central subjective integration of the self concept on the basis of which the interviewer can construct a mental image of the patient" (Kernberg, 1984). If after a reasonable period of time, the construction of such a mental image is impossible, there is prima facie evidence for "identity diffusion." As we shall see later in connection of our discussion of Katherine from the perspective of Lacan, this criterion opens up a controversy regarding the issue of integration in neurotics vs. borderlines as a distinctive feature in differential diagnosis. For example, it was evident from the description of the jobs she held and the sense of self she attempted to forge around them how porous Katherines ego identity was. At one time, she wanted to be a nurse, speaking enthusiastically about serving people in disadvantaged circumstances, wanting to be of assistance to others (even volunteering in a homeless shelter). At other times, she saw herself more as a performer who attracted men and felt a sense of being when she was on the stage being looked at, as when she took a job as a belly dancer. However,
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this sense of identity did not last long. Soon after she spoke candidly about her skills as, and desire to be, a physical trainer, and so on. This perspective on integration vs. diffusion of the self allows the therapist to form an initial hypothesis, which may or may not be sustained through the current and subsequent interviews. The patient may be exhibiting poor self-concept formation within a range from a mild identity crisis to a full identity diffusion state, one that may result in a presumptive diagnosis of a borderline personality organization. It is noteworthy, in Katherine's case, that as she began to regress, her anxiety was transformed into physical discharge (scratching, rocking, and squirming), and she was unable to articulate her feelings or the position of herself in relation to others, leaving the impression of an empty core about which nothing could be said. Kernberg states that in borderline organization there is enough differentiation between self and others to maintain a porous ego boundary, in contrast to a psychotic presentation in which the ego and the objects are fused and virtually no differentiation has been achieved. Kernberg theorizes that the origin of this lack of differentiation rests on a failure in the transition from a symbiotic to an individualized phase of development (Mahler, 1967). Kernberg emphasizes the issue of time management as a diagnostic marker of identity diffusion. The way borderline patients report their past history is so contaminated with the negative and confused experience of their present psychopathology, that it is mostly unreliable. The patient's historical account has a chaotic quality making it difficult to interpret or link past material with the present symptoms. In his view, this is an important marker differentiating borderlines from neurotics whose accounts of the past flow naturally and for whom dynamic links can be made quite easily, thus, yielding the possibility of a therapeutic interpretation. When Katherine was asked to describe in detail the argument she had with her father the day before a particular session, and to elaborate on the themes of that heated argument, she instead related her suffering with him as a child, describing her lonely mood after spending many hours alone in the family apartment. This was followed by a description of how abusive her father had been with her in the past, as she remained oblivious to the therapists request that she speak about the events of the prior day.
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By inquiring into the history of the patient, the therapist is not so much concerned with data gathering per se, but should be more attentive to the capacity of the patient to differentiate past from present and to forge a link between them. One looks for evidence of a contamination of the past with present events as a marker of borderline personality organization. When discussing a topic, Katherine would interchangeably discuss her feelings as a girl and as a woman with little or no awareness of the temporal differences or the different qualities of affect expression and experience in the child and adult, and certainly without considering the series of events that might have impacted upon her experience during the years in between. Katherine had difficulty differentiating her past boyfriends from her current boyfriend. Frequently, the therapist found herself confused about who she was referring to. In borderlines, the past and the present cannot be linked, material is presented out of order, fragmented in pieces, reminding us of how a dream might be presented. The borderlines presentation not only express her intrapsychic conflicts, but also the fragile nature of her ego, the fluidity of her experience of space and time, and the failure to link present with past life events. (Kernberg, 1984). This lack of integration reflects the patient's poor comprehension of her whole life. Kernberg does not advise pursuing the exploration of the past and its linkage to present material in the form of an interpretation in borderline cases. This is because an attempt to do so may render the patient incapable of making such connections herself, as she is overwhelmed by the emotional intensity of the here-and-now (which extends into the past but cannot be articulated as such for the moment). It is typically easier to make such linkages in the treatment of a neurotic (although in some cases the neurotic patient will be limited in her understanding by the repressive barrier of her unconscious). The therapists perception of Katherines emotional experience was that of a wounded, vulnerable child. However, in testing the limits, it became clear that Katherine's blurring of past and present, and of self and other, was not psychotic in nature and that for the most part her reality testing remained grossly intact (see "Reality Testing" below). The issue of identity diffusion is inextricably linked with that of the borderline's defensive operations. In neurotic individuals the exploration of conflict brings the defense mechanisms to the fore, yet the presence of more adaptive defenses such as repression,
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rationalization or intellectualization are difficult to pinpoint in the course of an early interview since these defenses do not immediately intrude on the therapist's work, appearing in the verbal content but not generally affecting the therapeutic interaction. However, in interviewing a borderline and particularly in the exploration of the patients identity diffusion, the activation of primitive defenses (such as denial, projective identification, etc.), affects not only the patient's verbalization but the whole interaction with the therapist which becomes distorted, altered and radically transformed. This, according to Kernberg, is a significant structural criterion for the diagnosis of borderline personality organization. For Kernberg, identity diffusion is clinically evident in a poorly integrated concept of both the self and significant others (Kernberg, 1984). The chaotic nature of Katherine's object relations was reflected in her interactions with the interviewer, and involved acting out behaviors regarding all aspects of the treatment, demeaning verbal communications in session and constant questioning of the format of the meeting and the payment for the therapy. If the therapist would ask to change a session time, she would agree; however, she would not show up or cal to change or cancel her appointment. Katherine also expressed little regard for others in her immediate environment, in spite of complaining about how everyone in her life was abandoning her. For example, in one session, Katherine reported that she started reading some letters that her father had sent her stepmother years ago when they were first dating. Although she felt guilty about the fact that she did not have permission to do so, she was more worried about being caught than by the fact that she was disrespecting her familys privacy. Katherines chaotic interpersonal relationships were evident in her strong ambivalence regarding family members. She would complain about the warmth of the relationship between her mother and brother, but when invited to attend a show with them, she would reject the invitation even if it meant that she was going to spend the night alone. In sum, with respect to the issue of identity diffusion the interviewer will attempt to arrive at a picture of the patient's self and object representations and their integration or lack thereof. She will also evaluate the patient's thoughts, affects and behaviors and judgment (as in a mental status exam). Lastly, the interviewer will evaluate the patients stance towards the therapist's needs and experience, which will reflect the patients level of relatedness, capacity for
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empathy and reality testing. By each of these criteria, Katherine showed clear evidence of identity diffusion as it is defined by Kernberg.
(b) Use of primitive defensive mechanisms - Projective Identification For Kernberg, the nature of defensive functioning is another important structural marker of borderline pathology (Kernberg, 1984). In contrast to neurotics who utilize such higher defenses as repression and intellectualization, borderlines and psychotics tend to utilize such primitive defenses as projective identification, splitting, primitive idealization, denial, omnipotence and devaluation. Contradictions in the patient's communications reflect the presence of conflict, and are typically accompanied by either adaptive (neurotic) defenses or the predominance of primitive defense processes (in borderline or psychotic states). For Kernberg, the function of primitive defenses in the borderline is to avoid intense experience of anxiety and severe conflict, an avoidance that is achieved at the cost of weakening the adaptive functions of the ego. One of the most salient of these defenses is the mechanism of splitting, which protects the ego from conflict by keeping self and others representations dissociated in such a manner that it becomes impossible for the individual to have contradictory (good and bad) experiences at the same time. When anxiety arises, one or the other ego state is activated and this serves to control anxiety that might otherwise overflow the ego (Kernberg, 1975). Kernberg asserts that the interpretation of splitting to a borderline patient can be tolerated and improves her functioning. By way of contrast, for a psychotic individual, where splitting protects the patient from a complete disintegration of self and other boundaries, interpretation of splitting promotes further regression. The use of defensive splitting was evident in Katherine's often contradictory descriptions of her mother. Katherine sometimes portrayed her mother as a plain and simple hard worker who cared for her children as she was subjugated by her husband's severe temper. At other times, Katherine portrayed her mother as a sadistic, unpredictable and domineering woman who was calculating and self-centered. The patient was unable to differentiate the times and events that led her to form such contradictory images of her mother. While she was indeed able to tolerate an interpretation of this contradiction she never achieved a single image of a mother with both good and bad qualities.
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Borderline Personality Disorder: A Lacanian Perspective Another example of primitive mobilization of defenses is evident in the following excerpt
from one of the early interviews. An initial negative feeling towards the interviewer is here characterized by mistrust and detachment. As the interviewer continued to challenge the patient, further weakening of her ego functions occurred in the context of the interaction, and the use of paranoid defenses and projection, typical borderline defenses, emerged:
I: Have you noticed that you have remained vague when asked to elaborate the issues you have with your father?
(Patient squirms in her chair as she begins scratching the surface of her arms by reaching each arm with the opposite hand, leaving red marks everywhere). Silence sets in and the patient continues with the scratching, adding a rocking movement while looking down at the floor.)
I: I can see that you are certainly quite uncomfortable with this topic. However, I wonder if you can see my point about avoiding discussing the last interactions you had with your father that might have brought you to therapy?
K: I was trying to make a point about how bad my father has treated me all these years. Are you suggesting that it is all my fault?
I: It appears that my asking you what specific difficulties you had in the last weeks with your father has been interpreted by you as an accusation that you are to blame for something Are you hearing that from me?
K: Well, I did not hear it, but I certainly feel that there is a possibility that I have done something wrongsomething that he really hates from me.
In the above excerpt, Katherine's own guilt is projected into the person of the therapist. However, when this defense is questioned, Katherine is able to assimilate the interpretation and
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regain her reality testing. In making such trial interpretations the experienced interviewer creates a number of hypotheses related to defensive functioning, object relations, and anxiety tolerance. The following excerpt is a continuation of the previous one, and further illustrates the use of primitive defenses.
I: So, what I am hearing is that you become very anxious when something goes wrong and more anxious if you have to review it, no matter what it is, call it your father, your health.
K: Yes, indeed.
I: How are you feeling right now, here sitting with me talking about all of these topics?
K: A bit better now, but distressed. I had a therapist before but she disliked me very much. As a matter of fact, she terminated our treatment saying that I did not cooperate with it. I admit having difficulties to arrive on time, but with my depression it is very hard at times to get up from bed.
In this case, the interpretation of this defense led to a decrease of anxiety and improvement of the patient's functioning within the interaction, but at the same time, a displacement of her feelings of rejection and abandonment onto the figure of her past therapist. The use of denial was quite common in Katherine. In the early interviews it became clear that she denied the emotional implications of many of her actions in relation to both self and others. For example, she would calmly describe putting herself in a dangerous situation without giving voice to affects that would normally be elicited by such danger. For example, when the therapist inquired about Katherine's throwing herself out of the moving car, she just dismissed the event as her father "overblowing everything she did". She projected a nonchalant and at times callous attitude that actually reflected her denial of the emotional impact that her actions might have on herself and others.
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Borderline Personality Disorder: A Lacanian Perspective Katherines primitive defenses were manifest not only in the way Katherine expressed
her problems (e.g. instead of discussing her difficulties regarding her father, she started somatizing and expressing them in body language), but also in the relationship with the therapist, who, as a result of the patient's projective distortions began to feel more restricted in her freedom to interact with her.
c) Assessment of reality testing Clinically speaking, intact reality testing is recognized by the absence of hallucinations and delusions, the absence of grossly inappropriate or bizarre affect, thought content and behavior, and by the capacity of the individual to empathize with others points of views. On a more subtle level, reality testing is grossly intact when the patient proves capable of responding in a generally realistic manner to challenges to her major distortions. For example, in the interaction with her therapist described above, Katherine distorts the implications of her therapist's questioning (regarding her avoidance) and says "Are you suggesting that its all my fault?" However, when asked if she actually heard blame from the therapist she responds: "Well, I did not hear it but I certainly feel that there is a possibility that I have done something wrong." To take another example, Katherine related that during her adolescent years she had an experience in which a few classmates tried to sexually seduce her in her room during a camping trip. She stated that she finally overpowered them and threw them of her tent. She reported to the therapist that she heard the voice of one of her girlfriends inciting the boys to this behavior. Upon exploration, however, the patient was able to cast doubt on her own beliefs about what she had heard (she stated that she was under a lot of stress that night). The voice was described as something she heard, coming from outside of her mind but which ultimately was experienced as an intrusive thought. In light of Katherines description of the event, the therapist again found herself with an unclear picture of what had occurred, how the patient felt, perceived the events and handled the situation. However, it was clear that Katherine was able to take a reality-oriented attitude even towards her own perceptual distortions. Based on this and other data as well as the overall clinical presentation of this patient, a psychotic organization could be ruled out. As Kernberg puts it: "The presence or absence of
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identity diffusion differentiates borderline from non-neurotic character pathology, and the presence or absence of reality testing differentiates borderline personality from psychotic structures" (Kernberg, 1978).
d) Non-specific ego weaknesses The non-specific ego weaknesses in the borderline patient are, according to Kernberg, reflected in the presence of anxiety and poor impulse control, each of which the patient has difficulty managing, both with others and in the transference relationship. Further, such individuals lack sublimatory channels for enjoyment and achievement. It is noteworthy that Kernberg differentiates specific from non-specific ego weaknesses. Specific ego-weaknesses, which are also present in borderline patients, refers to a weakening of the ego as a result of the predominance of primitive defense mechanisms that renders the individual dysfunctional in spite of a faade of "tolerable social functioning Katherine had very low tolerance for frustration which interfered with her capacity to formulate and implement life goals. Under circumstances that evoked anxiety, she would typically engage in an impulsive act that was undertaken virtually without any self-monitoring. For example, on one occasion she had an argument with her college financial aid office. She had applied for a scholarship and it was denied. She was offered a federal loan but she felt so angry that she walked out and never returned to the school. It took several sessions in treatment before Katherine was able to examine the negative consequences of her impulsive behavior. Further, she made several important life decisions impulsively. She would quit a job out of anger and frustration with no other employment lined up; on one occasion she angrily packed her belongings and left her parents home only to realize a few hours later that she had nowhere to spend the night. Her lack of sublimatory channels was reflected in her jumping from hobby to hobby and from job to job without ever committing herself to a sustained creative or career pursuit, in spite of her stated wish to do so. At one point she expressed interest in pursuing a sewing project and at another point, in taking a class in sculpture. Yet in the first instance, after an initial effort, she decided that her work was unacceptable, and in the second instance she quit after an argument with her teacher following his attempt to counsel her on a particular technique.
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None of her hobbies or pursuits ever resulted in a finished work or a sense of personal achievement. It could be argued that Katherine's extreme physical activity (i.e. working out in the gym) had a sublimatory function. However, the approach that the patient had towards these activities appears to have had more of a compulsive, aggressive quality and might be better understood in light of her aggressive and self-destructive tendencies. Her excessive biking to the point of exhaustion, her pursuit of high-risk physical activities such as parachuting, all had a selfdestructive quality. Katherine's poor impulse control was also clearly evident in such acts as a turnstile jumping on the subway and stealing money from her father. Impulsive aggressive acts also emerged in the treatment, especially on occasions when the patient felt blamed for her feelings towards the therapist. Her impulsive acting out included stealing a pen from the therapists office, taking out food from her bag and beginning to eat in the middle of session, and cursing at the clinic receptionist when she was told that she had arrived early for her session.
(e) Lack of Superego Integration - Excessive pre-genital aggression In classical psychoanalytic theory, the superego is thought to evolve out of the resolution of the Oedipus Complex, and to embody identifications with an ego ideal and the development of a moral conscience that reflects the childs understanding of right and wrong. Depression and obsessive-compulsive disorders are thought to be characterized by a punitive, rigid, critical superego that reproaches the ego regarding its wishes or behaviors and demands their modification. It is often thought that because borderline pathology is mostly associated with preOedipal issues of development, the effect of superego is not particularly important (Goldstein, 1985). However, in typical neurotics, the superego, although severe, is well-integrated. In borderline disorders, Kernberg asserts that in addition to, and along the same lines of a poorly integrated ego, the superego of these patients, while variable in its effects, typically reflects a lack of integration. This lack of integration is manifest in the individual's contradictory attitudes towards self and others that swing from idealization to aggressive devaluation according to the patients mood.
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The presence of a victimized self-concept is evident when Katherine initially suggests that she is to blame for her ailments. When asked to elaborate on her thoughts, she is unable to do so. This self-punishing quality of the superego is typical of borderline organization, and reflects parental introjections and identifications:
K: I think I am feeling quite ill today, and although I know I suffer from chronic PMS, I have always wondered if I am somehow responsible for making myself sick.
I: How is it that you experience this idea of making yourself sick?
K: Well, I am very depressed and I wanted to stay in bed today more than ever, you know the day of our first meeting, and I just think that my sadness and lack of energy might be related to my PMS.
I: If I heard correctly, you also think that there is a possibility that somehow you are able to put yourself in that situation, making yourself sick. How is it that you do that?
K: I just, I just have a series of problems that have happened to me over and over and I thought...maybe its me.
I: What sort of problems are you referring to?
K: Since I was a little girl, I have been physically and verbally abused by my parents, well, some psychologists call it neglect, but I feel its more of abuse because it has been constant. My father used to scream at me for the slightest misbehavior and you see.... He is such a malicious man, very selfish and the least concerned about me.
The quality of Katherine's superego functioning indeed paralleled her wavering selfconcept and was manifest in an alteration between antisocial behaviors, intense aggression towards others, and an extremely harsh, aggressive and self-punitive relation towards her own
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self. On the one hand, Katherine presented a sense of entitlement that was expressed in egosyntonic, antisocial behaviors. She would lie and create fictional stories about herself, at times with the ostensive purpose of gaining an advantage with others. At other times, however, her deceits seemed to be motivated by the desire to punish others or herself. An alternating cycle between masochistic/passive versus aggressive/sadistic superego features was reflected in aspects of the therapeutic relationship. As we have seen, she would become inordinately upset, even tearful, if the therapist announced a vacation or requested even a slight alteration in the time of her session. However, she would become enraged at those points when she interpreted the therapist's intentions as agreeing with the narrow-mindedness of the authorities. At one point, for example, she complained about the clinic receptionist who would not immediately release her records to her treating psychiatrist. When I explained to her that there was a simple written release procedure that applied to everyone, she angrily told me I was petty and narrowminded. Further, she would frequently devalue and attempt to negate any progress related to our work in therapy, an act that both expressed her aggression towards the object (her therapist) and aggression towards the self (I guess it is nice to talk to a pleasant woman about my personal life, but I do not see the value of being questioned so much). This primitive aggressive core was transformed, on occasion, into paranoid ideation. At such times her masochistic, submissive attitude was converted into an openly hostile response towards the therapist and the treatment. (This whole thing is a scam to steal peoples money!) Kernberg traces the genesis of the borderlines superego development to the internalization and identification of an overpowering parental figure perceived as omnipotent and cruel. While on one hand Katherine reported intense gratification in her aggressive fantasies, which included cutting others, shooting them or pushing them to their death, on the other hand, she could be totally manipulated by men in a sexual context, resulting in her feeling humiliated and depreciated. This combination of sadistic fantasies and masochistic behaviors not only illustrate Katherine's primitive, pre-genital aggression--one of the hallmarks of borderline structure--but also the primitive, unintegrated nature of both her ego and superego functioning. Kernberg invokers the concept of "excessive pre-genital aggression" in order to explain the complexity of symptom formation in the borderline patient. Kernberg theorizes that all the processes involved in the unconscious resolution of the oedipal vicissitudes acquire destructive
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and primitive qualities that are expressed later in masochistic-sadistic and paranoid tendencies. On the other hand, the possibility of idealization of a love object (because of its absence and longing) is rapid and total. Therefore, the borderline can shift from total dedication to an other, to total rage or withdrawal. This was amply evidenced in her expressed feelings and attitudes towards her boyfriend, father and the therapist. Kernberg underscores the idea that frustrated oral dependency needs expected from the mother are displaced onto the father, increasing castration anxiety in girls in the form of penis envy and severe superego prohibitions against genitality in general. It is possible to find distorted and severely aggressive versions of the primal scene that impact upon the future sexuality of the girl in her choice of love objects. Further, because of gender identity conflicts around the figure of the parents, there is a tendency towards bisexuality in the condensation of both sexes in both parents. These sexual features of the fantasy of the patient may not be accessible in the first interviews but appear in long-term treatment, in the exploration of the sexual difficulties that the patient eventually acknowledges. As Katherines treatment evolved she discussed her fantasies of being raped by a man and/or a female, or of being forced into performing oral sex. These fantasies typically, and contradictorily, also involved her as the seducer of her sadistic partners.
In sum, a review of Katherine's case reveals her to meet both Kernbergian "presumptive" and "structural" criteria for the borderline diagnosis. Kernberg's structural interview is a multistep task that requires psychological, psychiatric and psychoanalytic knowledge. It also demands psychotherapeutic experience on the part of the interviewer along with a substantial clinical background. From one perspective, this type of interview reflects a fusion between descriptive psychiatry and psychoanalysis in a highly effective form. As we shall see, an alternative, more critical point of view, suggests that Kernberg perpetuates descriptive psychiatry by importing its terms and criteria into, and under the guise of, psychoanalytic theory.
Chapter Six
Katherine as a Lacanian Patient

The Demand for the Desire of the Other Having discussed Katherine from within Kernbergs perspective on the borderline it remains for us to pursue a Lacanian interpretation of this case. The analysis I will provide will not only serve to illustrate significant differences between Lacan and Kernberg but will also document a shift in the direction of the therapeutic process in Katherine's therapy, as certain Lacanian notions were incorporated into the treatment. The interpretation presented here will draw upon several of the Lacanian concepts that were introduced In Chapter Three but is by no means meant to be exhaustive or complete. A Lacanian perspective takes its cue from the very first moments of the initial interview. Recall that in the initial interview when Katherine was asked to describe the nature of her difficulties, she expressed discomfort with this open-ended request, and answered this question with her own request that the examiner formulate direct and specific questions about her condition. From a Lacanian perspective, Katherine's request, in effect, her opening gambit, in the initial encounter with the therapist, provides important data regarding how Katherine chooses to position herself with respect to the therapist, as well as towards others in general. Whereas from a Kernbergian perspective the request for a more structured interview mainly signals a weakness or fragility in the structure of Katherine's ego, for a Lacanian, the request for an "interrogation-
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type" of interview can be understood as potentially suggesting something regarding Katherine's fundamental (unconscious) fantasy. When asked why she wanted to be questioned in such a manner, Katherine simply stated that the idea of freely discussing her concerns made her feel uncomfortable. An inquiry into the nature of this discomfort led not to a description of anxiety about a particular mode of questioning, but rather into a description of some of her core symptomatology. These included her depressive feelings, the impact of her bodily states on her mood, and reflection regarding whether she herself might at least in part be responsible for her own pain. This move into a description of her symptoms represents a subtle break in the associative chain, as the therapist's questioning of the particular interpersonal stance that Katherine "signs in with" leads to an expression of her core symptoms. Here, at least, either a Kernbergian (fragile ego) or Lacanian ("fundamental interpersonal fantasy") perspective fits the data, as each perspective can explain how it is that Katherine would become "symptomatic" in response to the initial patient-therapist exchange. At this point, it is not a question of eliminating one or the other point of view, but rather of recognizing the possibility for both Kernbergian and Lacanian perspectives. However, we should note that a "choice" on the part of the therapist at this very early juncture in the treatment--whether to see Katherine's behavior as an expression of the state of her ego or an expression of her fundamental fantasy will have ramifications that will ultimately pervade and condition the diagnostic picture, and even the therapeutic process. From a Lacanian point of view, Katherine's insistence that the therapist pose her own direct and specific questions can be seen as the patient's demand to know what the other wants or is looking for. In the previous chapter, we considered the possibility that this demand is a conscious attempt on Katherine's part to learn something about the therapist's techniques and abilities. Here, I am suggesting that it may well (also) be an expression of an unconscious pattern of interpersonal relatedness. From a Lacanian point of view, Katherine's request is not so much an expression of the ego's conscious goals, such as a need to control the therapeutic situation or a means of managing first-visit anxiety. Rather, it speaks of some profound style that the patient has developed throughout the years, which would be manifest not only in the here-and-now with the therapist, but with her family, her boyfriend and others: the idea that Katherine must figure
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out the nature of a demand coming from an external source which she feels prompted, even compelled to fulfill. This fundamental fantasy would, if verified in other instances and contexts, suggest for Lacan, the likelihood of a hysterical neurotic structure. So with one turn of the interpretive dial we have already moved from a way of thinking that is considering a "borderline personality" to one that may have no need for such a purported new structure, and which, at least for the moment, considers Katherine within the more traditional psychoanalytic category of a presumptive "hysterical neurosis." Of course, both the Kernbergian and the Lacanian perspectives are, at this very early stage of the diagnostic interview, simply hypotheses, to be refuted or confirmed by subsequent data that will emerge as the interviews and analysis proceed. There is, of course, a danger here of being locked into one's initial hunches and then seeking (and finding) only data that confirm one's theoretical prejudices. Katherine's hesitancy to take the lead in her own discourse may simply be an example of the resistance that nearly all psychoanalytic patients' have to their analyst's request to engage in free-association. More data is needed. Such a problem, however, is endemic to all forms of psychotherapy and is neither unique to Kernberg or Lacan, nor, for that matter, to psychoanalysis. So let us proceed and see where the Lacanian perspective leads us. As we will see, this patient's demand to be questioned by the therapist will indeed prove to be a key to the "Lacanian Katherine," for, repeatedly throughout the course of her treatment, asks of the other: "What do you want to hear, what do I need to be?" The patient, we will see, appears to be invested in questions (and answers) ready-made by others. For example, during many of our sessions, she would enter the office, sit down and ask, What is the matter with me? Tell me, you know what is going on, what do I have that people seem to dislike me so much? How should I be so that Ill be liked? Early on in treatment, the therapist's response to these queries was to reflect the question back on Katherine herself; What are your thoughts about what's wrong with you? However, this approach yielded little if any insight or working through. In response, Katherine would resort to repetitive discussion of daily family situations and a therapeutic opportunity would be lost. Rather, it was only when the therapist shifted the discourse from what the others found wrong with Katherine, to querying more directly regarding the significance of her, What do you want? that Katherine was forced to move off her attempts to please others and examine (how little she was aware of) her own desire.
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Katherine would often inquire of the therapist How are you feeling today? Is everything OK with you? In spite of never having discussed or being encouraged to discuss any aspect of the therapist's personal life, she was intently invested in discerning the desire of the analyst and to position herself in such a manner as to become its cause. It might be said that rather than questioning herself, Katherine was in search of a question. During the interview process, when the therapist refused to meet Katherine's demand, and instead asked why she was feeling uncomfortable, Katherine began to describe her general symptoms, and inquired about the condition of her suffering, but eluded any self-questioning that could lead her to the condition of her own desire.
Identity or Desire? Indeed, Katherine is very astute in ascertaining what she presumes to be the desire of the other, but is almost without a clue with respect to what it is that she herself wants. She moves from school to job and then job to job, finding herself engaged in a varied matrix of "pursuits" without ever settling on what it is she "desires." She is a an attendant in a geriatric home, a salesperson in a boutique, a florist, a tour bus guide and a belly dancer, and each of these jobs ends in a conflict with her employer. From a Kernbergian perspective, we have a failure to consolidate a unified ego or strong identity along with lack of sublimatory channels (in what has been described as an "as if personality). From a Lacanian point of view, we have a failure to understand and own one's desire. Once again, what for Kernberg is a structural weakness in the ego, for Lacan understood in terms of the unconscious. Lacan is uncompromising in his focus upon the unconscious. It is as if he is telling us, "Whenever you are tempted to understand the patient's symptoms or behavior as a manifestation of his or her ego-state, ask yourself how the behavior or symptom provides a clue to his or her unconscious desire." This, in essence, is Lacan's famous "return to Freud." Lacan states that desire is the central point or crux of the entire economy we deal with in analysis (Lacan, Seminar VI, 1959). When the desire of the patient becomes the center of the treatment, then both therapist and patient lose interest in a discussion of everyday social reality,
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as these are generally not reflective of who the patient is as a subject. Indeed, one can say that when the analysand begins to speak about his or her desire, she moves from being a patient describing symptoms and occurrences (making demands), to being a subject of desire. As a "patient," Katherine is happy to be asked and to answer every question of an ordinary mental status or psychosocial evaluation, and is uncomfortable or even unable to relate in the psychoanalytic "free-associative" manner that alone can provide the clue to her desire.
The Didactic Phase of Treatment Since Freud, psychoanalysts have recognized that it is important to be somewhat didactic in the initial interviews and phase of analysis, to teach the patient what the goal of an analysis is, and to provide him or her with a hint as to what kind of communications (manner of speech and subject matter) are useful in an analysis and which ones are not. Thus, the early part of the analysis is devoted to an explanation of the role of the analyst and the expectations of the work that the patient is embarking upon. Following Freud's instructions on this, the patient needs to hear that any and all of her communications are important, that she should speak everything that comes to mind (no matter how ugly, unacceptable or insulting it may appear). An emphasis is placed on the analysand bringing material related to dreams, forgetfulness, fleeting thoughts and fantasies, along with blocked actions and misunderstandings. The analyst, from her side, must continually and without fail encourage the patient to share her thoughts. It appears that despite all of her previous treatments, and her report that in at least one of her prior treatments she was in analysis, Katherine had not been taught what was expected of her in analytically oriented treatment. Often therapists mistakenly take for granted that their patients, especially those with prior experience in therapy, know what is expected of them as an analysand. In a Lacanian analysis what is important is that the patient puts a particular aspect of her life into question for the analyst, and also that she initially (though this must eventually change) experiences a desire for her symptoms to disappear. Early on, when questioned about the
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possibility that she bears some responsibility for the production of her own symptoms, Katherines anxiety would peak. Such inquiry when conducted too early or too forcefully may constitute a technical error as it may actually deter the patient from becoming motivated for treatment. Further, had Katherine's underlying personality structure been psychotic, a persistent confrontation by the therapist could have resulted in a severe psychological decompensation. While it is true that the preliminary interviews are utilized to attain an overall life picture of the patient and to make a determination regarding the clinical structure, it is not always possible to attain clarity in these matters in a few sessions. The therapist should not attempt to push the process beyond the patient's capacity simply in order to quickly arrive at a diagnosis. Indeed, the very process of diagnosis goes hand in hand with determining in a more refined manner what position the analyst must take with respect to the patient in question. (Fink, 1997).
From Interview to Treatment One important technical milestone in any treatment is the sorting out of the therapeutic value of the preliminary interviews versus the treatment proper. During the interviewing process the patient brings a presenting problem that she/he tries to explain by associating it with some present or past event that brought about a crisis which led her to therapy. In the treatment proper phase, the patients whole life is put into the question as the transference relationship is initiated with the analyst who supposedly knows something that the patient does not. This starts the beginning of an analysis.
Lacanian Structural Diagnosis The goal of Lacanian structural diagnosis is to determine the correct position of the analyst in the transference, the specific interventions that can or cannot be attempted, and, hence, the treatment approach that will be most suitable for the individual patient, The most important distinction that must be made (with due care but as early in the treatment process as possible) is
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between a neurotic versus a psychotic structure. As we have seen in Chapter Three, Lacan accomplishes this through a careful assessment of the defining mechanisms of "negation" that appear in psychosis (foreclosure), neurosis repression), and perversion (disavowal). These mechanisms of negation are not to be confused with the ego's mechanisms of defense, which, according to Lacan, are a secondary development. Rather they are constitutive of the pathology. In Lacan's view, repression is the cause of neurosis, not just a characteristic of it, while foreclosure constitutes psychosis and disavowal constitutes perversion. This strict way of conceiving diagnosis would seem to rule out the possibility of the borderline diagnosis, since no particular form of negation is associated with it. (Lacan, 1953). For Lacan, an important diagnostic marker involves the use of language, particularly the choice of words. What is the particular use of language that this patient brings to each of her sessions? Listening rather than observing becomes the most important part of this work. Although the patient discusses numerous symptoms related to her physical conditions (her premenstrual pains, headaches, fatigue, etc.) the clinician should not be led into producing a list of symptoms that can classify the patient in one or other nosological category. Patients with severe hysterical presentations have such a vivid fantasy life that they can relate, and seemingly produce at will, virtually any symptom imaginable; these imaginative inventions" are particularly common in hysterical dissociative states". Obsessive patients also can be so persistent in their perseverations as to be confused with paranoid psychotics.. It is important to note here that, for Lacan, the capacity of the patient to work with and achieve insight through free-association to dreams and other materials is a mark that he or she is conditioned by "repression" and therefore has a neurotic, as opposed to a psychotic structure. Thus, the therapist's tentative efforts to work with dream material can provide important insights that will help formulate both diagnosis and treatment (Fink, 1997).
Katherine as a Lacanian Patient The Analysis of Two Dreams
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In this regard, it is important to note that an important turning point in Katherine's treatment came as a result of two dreams she brought into therapy after she was released from the hospital subsequent to her suicidal gesture (during which she ingested 25 aspirins). The analytic work with these dreams gave the therapist a better picture of the meaning that Katherine gave to her body and in particular, to her genital/reproductive organs. More importantly, the dreams provided both patient and therapist an entrance into several important aspects of Katherine's repressed desire. At the time, Katherine was advised to attend twice-weekly sessions in order to help process and contain her intense affect. While she reluctantly agreed at that time, increased contact paid off with an intensification of productivity in the verbalization of her thoughts and emotions. 1st Dream: Patient had a dream in which she was entering a deli with her mother and brother when she saw her friend Maria eating from the salad bar. She was amazed at Maria's lack of "table manners"; she was eating with her hands and stuffing food in her mouth and swallowing it in great gulps. The patient tried to stop her and explain the correct and acceptable behavior but her friend looked puzzled and responded with incoherent speech.
The following week the patient brought a second dream to session. 2nd Dream: She is looking at herself in the mirror and she sees herself naked from the waist up. She turns around as she is frightened by an image she has seen in the mirror, which looks like a small red knife that is coming at her at a fast speed. She quickly moves away but the knife hits her in the wrist opening up a hole. She is horrified.
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As will be explained in due course, the first dream, which Katherine reported at the time when her boyfriend abandoned her, became a marker of a new phase in her treatment. The second dream, which she reported a week later, marked the experience of a structural change. As we will see, it is this dream that marks Katherines movement from an incessant aggressive posture towards males to an exploration of feminine needs and her relation to the maternal figure. What follows is a condensed version of the associations and interpretations of three dreams that arose over several sessions. In the first dream, the patient dreams of a friend who is a 22-year-old pregnant runaway girl. Katherine had made her acquaintance in a shelter for women where she went twice a month to do volunteer work. Katherine had taken a special interest in this young woman who she described as a heavy smoker and as possibly mentally ill. Katherine was concerned about how poorly her friend took care of herself and she made various attempts to assist her in improving her hygiene, dress, eating habits, and make-up. Katherine's associations to this dream revealed that she had projected her own conflicts onto this young woman. In the dream, her mother and brother accompany Katherine. We should recall that whereas Katherine had described her own mother as completely lacking in maternal feelings towards herself, her mother had expressed a strong tenderness, and in fact had been quite loving, in relation to Katherines brother. As the associations to Katherine's dream developed, it became clear that the dream image condensed a projection of Katherine's oral maternal needs and her feelings of sibling rivalry towards her brother. Katherines own associations led to the judgment that "needing something very badly" can be interpreted as "bad manners or bad behavior." After all, wasnt Katherine herself the hungriest of all in her need of a maternal figure? The patient's associations led her to conclude that she not only felt that she did not have enough of her needs fulfilled ("oral needs in psychoanalytic terms) but that she had also been deprived of attaining an understanding of what it was to be a woman, as her father had raised her and had taken on many of the roles that Katherine felt should have been taken by her mother. (This conclusion pointed to genital identifications that were unfulfilled as well). In associating to the bleeding of the second dream, Katherine recalled that on the day she experienced her period for the first time, her mother was not at home, and her father was the one who was available to her. She told her father what had happened and he sent her to bed to rest. When her
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mother arrived home late that night Katherine told her about the change. Katherine initially had feelings of satisfaction for being a grown-up woman and also experienced a need to be hugged by her mother. Profound dissatisfaction ensued when her mother refused to discuss the subject. The second dream advances the working through and enabled Katherine to change her position, as she recalled other events in her life that were totally blocked from consciousness until she freely associated to them in session. Katherine, in part, answers the questions raised in the first dream. The image of the mirror (process of identification) now is on the experience of the body, yet, she wonders if this is truly her own body. Katherine questions who is in the mirror. Is it herself or her mother? From a Lacanian point of view this dream involves a fantasy of the imaginary fusion between the self and the imaginary other. The second moment of the dream, in which she observes an object coming at her in the form of a red knife, brought many associations. One of them was to an accident that Katherine sustained as a child as she was playing on a seesaw. Her brother was sitting on the other side and at one point, Katherine who was in the air, lost hold of the seesaw and landed hard on the ground. She started to bleed in her trousers. Her mother became so anxious about this incident that she not only brought her to the pediatrician but also demanded that he examine her for a possible loss of [her] virginity. This incident brought a further association regarding an incident that Katherine heard about, but which she had not recalled for a long time. The incident related to her mother being seduced by a family member in Katherine's grandparents' home. This had been a chapter in the family history that precipitated all kinds of blaming and self-loathing in her maternal grandparents. As the patient's associations continued, it became clear that the hole opened by the entrance of the knife established the definition of a woman and further the particular definition of what it is to be a woman in Katherine's family. Women in this family took pleasure in a masochistic stance. Further, Katherine views herself in this dream as "a failure" in comparison to the figure of the brother, who is "on top", the one that does not fall or bleed. In discussing her brother, Katherine explored in depth her feelings of jealousy and envy. Her brother's
relationship with their mother had been very different from Katherine's. Her description of a cold, detached woman did not seem to comport with her brother's experience. Further, her brother grew up to be a successful young man who had achieved what he desired ("he was on top
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of the game"). However, as she was describing her feelings about her sibling, it became clear that women in her family had a destiny marred by depression, failure and loneliness, and further, that they, herself included, had difficulty enjoying a sexual relation. The analysis of these two dreams produced a turning point in Katherine's therapy, one in which productive work began in several important areas, in regard to Katherine's failure to acknowledge her own needs and assume her own desire, her relationship to her mother and with men, and Katherines quest for personal achievement. These analyses also provided much insight into the inter-generational role and destiny that Katherine was repeating in each of these areas, an insight that, as I will discuss below, becomes possible within a Lacanian treatment. Dream analysis as the analysis of primary process and the libidinal significance of linguistic structures is often avoided in the treatment of "borderline" patients. As such, this material might not have been available given the limitations that psychoanalysts often have with so-called "borderline patients." Such clinicians are often concerned about "tipping the balance" of an unstable, weakened ego structure and of pushing such patients into a psychotic break by asking them to free associate to such primary process material. Although it is important to determine, before plunging headfirst into dream analysis and free-association, whether the patient has a psychotic structure, this cannot be accomplished through a descriptive diagnostic procedure. Some individuals (such as Katherine) who meet descriptive criteria for borderline, or even psychotic disorders, are excellent candidates for analytic work. This, according to Lacan, is because they have a neurotic structure constituted by repression. The work with Katherine's dreams seemed to verify that in spite of her florid borderline symptomatology, her structure was indeed neurotic in Lacan's sense, and it is Lacan's view that we simply cannot create a psychosis in a neurotic individual. I should also point out that Kernberg (1984) limits interventions with borderline patients to interpreting defenses in the here and now and does not advise the use of genetic interpretation and reconstruction in borderline cases. However, I would argue that the dream work described above permitted Katherine to profit from a genetic (i.e. historical) understanding of her conflicts.
Katherine as a Lacanian Patient Oedipal Vicissitudes
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Another important phase in Katherine's treatment was marked by an in-depth exploration of her parent's marital relationship. Katherine had brought into treatment concerns about her mother's bouts of depression. As Katherine would contact her mother weekly to "check on her depression" a pattern appeared that showed that most of the time these conversations between mother and daughter were closely followed with some of Katherine's most heated arguments with her father. The interpretation of this pattern opened up a wealth of significant associative material. In one session in particular, Katherine stated that she was convinced that her mother was still in love with her father in spite of the years that they had been separated. When asked about the particularities of their divorce and the circumstances surrounding the separation of the couple and its impact upon the children, Katherine explained that her mother was always very busy outside the home in an attempt to increase her income by working overtime. As such, Katherine's mother would leave early in the morning and return late at night. It appears that Katherine's mother accused her husband of having an affair with a woman who Katherine did not know. Katherine's father denied this when his wife confronted him. However, they seemed to share very little if any enjoyment. Katherine expressed surprise that she had spoken about this "other woman" with the therapist. She then reported that as time went on, and her parent's quarrels increased, this woman became increasingly central to her parents' arguments. On those occasions, her father would recriminate his wife for her greediness, lack of sexual interest and her self-absorption. Katherine's father never admitted to the affair. However, after the couple's separation, common friends of the couple confirmed the veracity of the extra-marital relationship. It appears that this affair, although it lasted throughout Katherine's parents' marriage, did not continue after the divorce. Katherine's father met his current wife a year later and married to her soon thereafter. Katherine's recollection of these sets of relationships is extremely important. Katherine grew up in a home-setting where there was an absent mother, a father who was fulfilling part of the maternal function, and where the shadowy presence of another woman signified the desirable qualities that her mother did not have in order to maintain her father's interest.
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Borderline Personality Disorder: A Lacanian Perspective It became evident from Katherine's statements about her boyfriend, that she would
scrutinize carefully his interest in other women. In fact, at times, she became convinced that he was cheating on her. Such a thought not only justified her "feeling abandoned" but also provided a new element in the circuit of desire: another woman. On the other hand, it helped us to corroborate Katherine's partial identification with her mother, with her depression, and with the idea that "men are not to be trusted" since there is always another woman more interesting and desirable than oneself. Further, her inhibitions in the enjoyment of sex, out of solidarity with her mother, ensured a faithful tie between them.
Katherine's Subjectivity According to Lacan, an individual's sense of subjectivity is comprised of a very complex network of meanings that not only belong to the person in question but carry forth representations from parents and even earlier generations. Katherine's unconscious
representations of her parents along with what has been said or unsaid in her family had enormous consequences for her process of individuation. Lacanian thought does not place a unique emphasis on the dyadic relationship with the mother. For Lacan, the subjective human condition involves the interplay between at least four elements that are always present: the mother, the child, the father and language/culture at large. Even the body is overwritten by language and this, according to Lacan, is why it is possible, for example, to have a psychosomatic illness. Given this complex schema, and the potential obstacles it places in the path of the child's becoming someone, we can imagine how difficult it is for a child to achieve the process of individuation. For Lacan, the process of becoming oneself involves loss and aggresivity and in his model, this process originates in the mirror stage. However, the aggresivity that the child needs to marshal in order to assert his individuality is not connected in any way with the aggression that Melanie Klein and later, Kernberg will discuss. Kernberg's view is that at the root of the borderline disorders is an excessive amount of primitive aggression that fuels the borderline's rage against a mother-object who has not provided sufficient affirmation. By way of contrast,
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Lacan makes a distinction between aggresivity and aggression. While aggression is associated with a violent act, aggresivity refers to the tension present in all relationships which in Lacans view involve both love and its opposite. This tension is referred to, in Freud, as ambivalence, and, according to Lacan, it has its origins in the mirror stage. The child feels extreme tension, as the wholeness he sees in the mirror or in his mother is not reflective of the sense of fragmentation and disintegration that he experiences as a helpless human being. This
fundamental ambivalence underlies all relationships from then on and all future forms of identification (linking it to the development of narcissism) and leads, according to Lacan, to aggresivity. According to Lacan, it is not only the borderline who experiences this sense of threat, fragmentation and rage but all humans. Thus the presence of ego-fragmentation in Katherine is not diagnostic of any disorder, but is rather endemic to the human condition. The topic of borderline pathology and the human condition is a matter that we will return to in the final chapter.
Lacanian Inter-Generational Analysis One of the most important tasks in a Lacanian psychoanalysis is to arrive at an understanding of the place of the patient in the generational representations of the family. In the current case, one must inquire regarding Katherine's understanding of her place in the fantasies of her mother and father. In essence we ask what questions did Katherine carry for her mother and father that they did not address with their own parents. It is interesting to note that a key to understanding some of this material was derived from Katherine's dream associations. Here I will underscore several of her associations/recollections to Dream #2 described above, especially in regard to her childhood bleeding accident and her mothers response to it. It was in this context that Katherine first (and to her own surprise) expressed her recollection that her own mother had been sexually abused by a male relative and had never worked that problem through with her own mother, who blamed Katherines mother for the incident. We might here ask whether Katherines mother's neglect of her own daughter might be reflective of this painful experience that she herself never discussed with her own mother. And how did Katherine's
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mother's early traumatic experience with a man impact upon Katherines father? Of greatest significance, of course, is the question of how these events are signified and later re-signified in Katherine's own psyche. Although it was relatively far into the therapy, Katherine eventually turned a questioning gaze upon her own casual encounters with men. After the above noted dreams, she spent considerable time discussing this matter in treatment, and began to unravel her own puzzle in regard to the history of her family's encounter with femininity. As briefly mentioned earlier, Katherine reported that at the age of 17, during a High School weekend trip, she found herself in a difficult situation. Like some of the other students in her group she had smoked some marijuana and drank a fair amount of liquor. The group had gathered in one of the hotel rooms and girls and boys were conversing, and playing cards. When the group dispersed after a school supervisor indicated it was time for bed, Katherine went to her room. Not long after, a group of three of her male classmates entered her room and made sexual advances towards her. Although she initially engaged them, she refused any further contact with these boys and requested that they leave. On further exploration Katherine explained that she had overpowered these boys one by one, and afterwards she locked herself in the room and stayed awake all night long, fearful of their return. As time went on, she became convinced that one of her girlfriends had sent these boys to her room. The next morning an enraged Katherine walked up to her friend and started a quarrel. As we have seen, Katherine initially stated that she recalled hearing the young woman's voice urging these young men into her room, but later came to doubt that this could have possibly been the case. In the process of working through her recollection of this event, Katherine not only made many references to her mothers sense of revenge related to men (also reflected in her relationship with Katherines father) but also to a deep sense of being a slut in the eyes of her own mother. As Katherine proceeded with her work, she formed a link between her mother having been abused as a child, her mother's neglectful and scornful attitude towards herself, and her own self-image of being a "slutty woman." This example is illustrative of how the core of an identification that seemingly appears to belong to a patient in question is often best understood as the residue of another persons identification. This unprocessed identity was later foisted on the patient and she carried it throughout her life. Katherine was taking her mothers badness on her
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own shoulders in order to exculpate her and free her mother from any guilt. We should here recall how Katherine referred to her mother in the initial interviews, characterizing her as lacking in maternal instincts but not blaming her for it, even justifying her aloofness on the grounds of the intrinsic difficulty of the maternal function. Here again we see with a so-called "borderline" patient that it is only through a freeassociative analysis and an articulation of hitherto unrecognized (repressed) thoughts into speech that the patient can attain an insight that will enable her to move beyond the desire of the other and achieve her own individuation. According to Lacan, such work must occur within the context of what is called the Symbolic Register in the presence of the other (analyst) who enables the recollection to be fully explored.
The Name of the Father Having explored several of the vicissitudes in relation to Katherine's mother, we are left to ask about Katherines position in relation to her father. How did Katherine deal with the passage from the first love object (the mother) to her father, and how was the inscription of the name of the father achieved? As the treatment progressed it became clear that Katherine experienced herself as a repository of her mothers rage and self-loathing. As noted above, the work that began with associations to Katherine's dreams revealed that this was the place that she had been assigned within the context of the family. This unprocessed enraged affect as a result of an identification with a depressed, abused mother was now projected onto her father, who, in Katherines own view was her primary caretaker. On the one hand we have the presence of a father who is fulfilling some aspects of the maternal function. On the other, we have a father who is the source of desire for Katherines mother but who comes to reject and abandon her. Katherines father is not interested in his wife but he is invested in his daughter. It is interesting that Katherine will become an important part of their negotiations in their conflicted divorce. Her brother, who was always by her mother, and was of little interest to their father, was able to develop his own individuality without having to overcome major hurdles. Katherine, on the other hand, ended up
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being cared for by her father all the time, and proved unable to live as an independent adult. It appears thus far, that in her relationship with her father, several important psychological problems occur; on the one hand, Katherine identifies him with a maternal figure who can protect her, yet, on the other hand, this maternal figure is a man who desires a woman who is not Katherine's mother. The work of analysis, thus, becomes a reconstruction of a true identity by traversing the different meanings that have been placed upon us by others. That is why it is not enough for an analyst to be an empathic listener and try to produce what Lacan might call imaginary reparation in the transference (as in a Kohutian analysis). Rather, every patient has to conceptualize his/her symptoms through his/her own words and articulate the particular meanings of his/her history that have hitherto resisted symbolization. Such meanings, we might say, first appeared in a "traumatic" fashion and thereby escaped representation and meaning. In Lacanian terms, this initial lack of symbolization places them in the so-called Real register. There is thus a defect in articulation, a defect in symbolic transmission that appears as a formation of the unconscious. Noting this defect, and further articulating it in the Symbolic Register is, according to Lacan, the only real tool that the analyst can count on in the process of the cure. Therefore, for Lacan the unconscious is not a place somewhere in the brain, but a process put in motion through language in the presence of the Other (Lacan, 1954). The symptoms related to Katherine, including her inability to succeed as an adult, her poor relationships in general, and in particular with her father and boyfriend, her somatic complaints, and her depression were ultimately put in motion within the transference. The question of aggressivity or the intrinsic ambivalence in all relationships is also demonstrated in the negative transference. However, Lacan suggests that this aspect of the imaginary realm in transference, although identified, is not central to the relationship between analyst and analysand. Rather than interpreting these feelings, Lacan moves into the symbolic axis of the transference, the world of words themselves. According to this view, transference refers to "the subject supposed to know" (Lacan, 1964). As we have seen, treatment begins when the transference is established, and the belief that the analyst knows something that patient does not know. It is the analyst's response to this belief that is the motor of the treatment. Indeed, Lacan insists that the analyst must refuse to use this power of knowledge given by the patient. This refusal thrusts the
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work of the analysis back onto the patient, who must ultimately surrender the fantasy that the secret of her being is contained in an other, and in this way begin to assume her own desire. While classical psychoanalysis takes the idea of interpreting the transference as one major means of producing insight in the patient, Lacanians reject this view of insight. For example, in the present case, pointing out the difference between Katherine's aloof style towards the therapist (resembling her relationship with her mother) or interpreting the underlying commonalities of her anger towards her father, boyfriend and therapist does not, in Lacan's views helps produce insight. Such interpretations rest on the belief that the analyst has a better grasp on reality than the analysand, and that by interpreting her relationships in light of past ones, the analyst will address that part of the ego that is conflict-free, has rational understanding and is capable of restoring the patient to health. For Lacan, this position reduces psychoanalytic treatment to a suggestive method and keeps the patient in the neurotic position of assuming that knowledge of her desire rests in the other. For Lacan, the curative quality of interpretation in the context of the transference is illusory. Rather than interpreting the fact that Katherine might be angry with the therapist in the same way that she was angry at her father, it is better to question directly the content of the speech to produce more associations. The work of the therapist resembles the work of in inquirer rather than of an interpreter. The cure develops when the patient begins to shed her self-defeating identifications with the desire of the other, and assumes the direction of both her treatment and life.
Katherine as a Neurotic Individual As described above and in Chapter Three, the particular mode in which a subject negates his/her desire or the law (the name of the father or castration) serves as the basis for Lacans distinctions within his structural system of diagnosis. Although the simplicity of the theory may appear to make matters easy to elucidate, the determination of which mechanism is at work requires a great deal of clinical acumen. The three mechanisms of foreclosure, repression and disavowal provide the bases for neurosis, psychosis and perversion respectively (Lacan, 1956). These particular modes are determined by the way the "name-of-the-father" (or what Lacan
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denominates the paternal metaphor) operates in the individual, i.e. how the symbolic order overwrites the imaginary realm of being. As described above, the world of the imaginary that of visual images, olfactory sensations, mirror perceptions and fantasy is re-interpreted through the words or language provided by the childs caretakers. In this way the cultural and the linguistic come to overwrite what is natural in the human condition. The predominance of symbolic relations through which the imaginary realm is subordinated characterizes neurosis, and it is in neurosis that the paternal metaphor or symbolic function has operated and separation from the mother has occurred On the other hand, the predominance of imaginary relations is the
predominant feature in psychosis, where the paternal metaphor, and hence the symbolic/cultural order is "foreclosed". When the Name-of-the-Father is foreclosed in a particular subject, it leaves a "hole" in the symbolic order that can never be filled. When the Name of the father reappears in the real, the subject is unable to assimilate it. This marks the onset of psychosis, characterized by the presence of hallucinations, delusions and language disturbances. (Lacan, 1954). Therefore, in psychosis, even though the individual makes use of language, his speech is imaginarized (Fink, 1999). The psychotic individual is at the mercy of his imaginary structures and to use a non-Lacanian metaphor, his ego boundaries are totally non-existent. Lacan links the psychotic's inability to produce new, original metaphors (e.g. neologisms) to the absence of "the essential (paternal) metaphor." As the child matures, he/she is forced to give up a particular pleasure with the mother via the institution and representation of the paternal law. This imaginary and later symbolic law produces a prohibition that neutralizes the mothers desire for the child as well. Repression then occurs. Although repression has a qualitative difference in both genders, the basic result is the same. So the first meaning that the paternal metaphor introduces is that the longing for the mother is wrong for the child, establishing a first No! According to Lacan, this initial prohibition is what ties social reality to language in a constitutional way and serves as the basis for all linguistic meaning. How did this mechanism work in Katherine? Repression certainly worked. Katherine had words for her symptoms (a description of her suffering), recovered memories in session (indicating the presence of repressed material), the capacity to doubt her speech (she would wonder about her level of responsibility for her symptoms and she questioned their meaning),
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and the tendency to have pleasure in fantasy as opposed to direct sexual contact (cf. Fink, 1999). Further, the presentation of conflict related to authority figures, such as supervisors, teachers, and adults in general, indicates the presence of the paternal metaphor as having instituted repression as a mark for castration. Whereas in psychosis the reality of something is totally refused, in repression, the reality in question has to first be accepted in the psyche and later pushed out of consciousness. Katherines management of dream material, the fact that she was able to bring dream materials into session, free-associate and make connections between the dream material and her early life, was, in Lacanian terms, clearly indicative of the presence of neurosis. However, in the actual course of therapy, where Katherine presented with so many "borderline" features, the diagnosis of a neurotic structure could not be achieved for quite some time. It was only in the unfolding of the therapy and its progress, and a constant active listening to the verbalizations of the patient that would lead to this conclusion. Indeed, many of Katherines communications could have been interpreted as suggestive of a psychotic formation, and at several points early in the treatment were hypothesized as such in the mind of the therapist. A good example, which we have already referred to, is evident in Katherine's recollection of the sexual scene on her high school trip, where she reported "hearing" a young female friend purposely sending a group of men to her room. However, such auditory perceptions, or even "hallucinations" that are common in psychosis do not suffice to make a diagnosis of psychosis according to the Lacanian model. Many traumatized people going through an acute anxiety crisis, and easily suggestible hysterics have experiences of this sort without possessing a psychotic structure. As I have indicated, Katherine had great difficulty in free associating at the beginning of the treatment; a difficulty which Kernberg tells us is typical of borderlines. From a Lacanian perspective, in the early phases of treatment, Katherine can be considered a "borderline," not because she has a borderline psychic structure, but rather because her therapist is unsure in making a determination regarding the true (neurotic or psychotic) nature of her pathology. As it turned out in Katherines case, it ultimately became clear that not only had the paternal metaphor been inscribed in the patient's psyche, but the influence of the (symbolic) father had surpassed anybodys expectations, since the father occupied a space she yearned her mother to occupy.
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Borderline Personality Disorder: A Lacanian Perspective The next question from a Lacanian perspective is what kind of neurosis does Katherine's
represent? Since repression is verified in the eyes of the analyst through the return of the repressed, then the manifestations of such a return must take a particular form. We have previously discussed the importance of the historical/familial network into which the child is born, and we must here again raise this issue in order to arrive at an understanding of the fundamental fantasy of the subject. What does Katherine know about her parents? Why did they have her? What did she represent for them and at the same time, what is her significance in comparison to her brother? It is in the vicissitudes of the separation with her mother that, Katherine encounters the difficulties that define the precise nature of her neurosis. As we have seen in Chapter Three, for Lacan the issue of separation forces the child to experience the loss of the intense satisfaction characteristic of the infant-mother relationship. The child is confronted with the loss of the object of satisfaction, which is identified with the mother. In actuality such a totally satisfying object never really existed, which is why, according to Lacan, the search for "the object" is always unsatisfactory. When we encounter what we call satisfaction in an object, it never appears in the form that was expected and thus, it always carries some form of disillusionment. However, when the child is confronted with the initial loss he/she refuses to passively accept it. He or she will try to compensate for it in some fashion. In hysteria, this separation from the object is what creates hysteric desire: "she will be the object" that the mother has missed. The hysteric's loss will be interpreted as the mother's loss, not only to ensure that she is not the loser, but to retain the power of being the source of desire itself. A space of being is thus guaranteed for her. The peculiarities of Katherine's early family life, and thus the specific and complex nature of her oedipal triangle laid down conditions that were particularly conducive to the development of a hysterical neurosis. It appears that at the time Katherine was growing up, her mother's absences and unavailability made her mother a sort of "enigma" and therefore an object of great interest. Moreover, as there was another woman in her father's life, this yielded the perfect scenario for Katherine to believe that she cannot only be there for, but actually become the object of desire for her mother. As a result of divorce and a new life change, Katherine's mother's depression also increased. The mother's need for the daughter (who retains a grasp on the father's desire) leads to a reinforcement of Katherine's hysteric solution. Katherine now
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becomes necessary to the mother as a negotiating chip in the mother's effort to reclaim the father's interest. The father does not want the mother, but wants Katherine, and Katherine thus becomes a pawn in the vicissitudes of her parents desires. In exploring the events surrounding the divorce, Katherine described how at the time, she was extremely concerned for her mother, and that her mother would beg Katherine to go back to the city where her father lived, to find out about her father, carrying letters for him in which she would ask him to reconsider their marriage. In effect Katherine's neurotic solution to her oedipal loss was to believe, on some level, that she is the object of the mother's desire. This, however, was a particularly pernicious belief, as the mother actually only desired the father through Katherine, and, as was repeatedly evident, never showed much genuine affection for Katherine herself. Thus in attempting to be the "phallus" for the mother, Katherine was doomed to play the part of one who is never genuinely desired but is rather "seen through" as a vehicle to the desire of another. It is no wonder that her own desire is so hard to fathom in treatment. It is buried under layer upon layer of the others' desire that defines her, in Lacanian terms, as an alienated human subject.
Chapter Seven
Lacan and the Borderline Conditions
n this Chapter I will discuss a number of broad theoretical issues that inform or underlie the Kernbergian and Lacanian approaches to Katherine that were described in Chapters Five and Six, formulate aspects of a dialog on the question of the borderline, and consider the
possibility that certain aspects of Lacanian theory can be formulated as testable, empirical hypotheses. My goal in the previous two chapters was the modest one of attempting to show that a patient who meets DSM-IV, as well as Kernbergian (presumptive and structural) borderline criteria, can be conceptualized and treated from a Lacanian point of view, without resorting to the introduction of the borderline category. My analysis of the Katherine case is not an empirical demonstration, nor is it a refutation of the Borderline diagnosis, even as it might be applied to the limited case in question. Rather, the case of Katherine has been utilized as a vehicle for presenting two quite different approaches to diagnosis and treatment of an individual who presents with severe pathology, and who might be regarded as meeting criteria for a Borderline Personality Disorder. The value of the exercise I have undertaken in the two previous chapters is far more hypothetical and theoretical than it is empirical or probative, and it has been undertaken with the simple goals of (1) familiarizing American psychologists with the Lacanian perspective on diagnosis and treatment, and (2) stimulating dialog on the issue of the borderline between those in the Kernbergian and Lacanian camps. In critiquing Kernbergs concepts my goal is certainly not that of disproving his theory or eliminating his diagnosis, but the more modest goal of providing an initial critique of Kernbergs borderline concept from a Lacanian point of view.
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This being said, it will become clear in this closing chapter that a Lacanian perspective on borderline personality can lead to a questioning, if not a deconstruction, of the borderline diagnosis. Before proceeding, however, it is important to clear up one potential source of confusion. The case of Katherine was analyzed herein from a Lacanian perspective, as a case of neurosis, more specifically hysterical neurosis. As I will discuss momentarily, it is my view that the rise of the borderline diagnosis shows an interesting correspondence to the decline of interest in hysteria amongst psychiatrists and specifically, American psychoanalysts. It is thus worth considering the hypothesis that many individuals who exhibit borderline features might also, or better, be conceptualized as hysterics in either classical Freudian or Lacanian terms. This does not, however, mean that it is my view, or a proper Lacanian view, that all of Kernbergs borderlines are hysterics. Indeed, such an assertion would be very far from Lacans own suggestion that in the case of the so-called borderline it is the analyst, and not the patient, who is on the border (Lacan, 1954). As Di Ciaccia (1999) points out, the borderline concept was originally introduced in regard to cases that were difficult to diagnose from either a descriptive or psychoanalytic perspective. So we might reasonably expect that a certain percentage of descriptive or Kernbergian borderlines would end up, from a Lacanian point of view, having a psychotic, neurotic, or perverse structure. We must keep in mind that for Lacan, these structures are in no way defined by symptoms, or even by the nature of the patients ego and defenses, but rather represent different, mutually exclusive, ways in which the individual positions him or herself in relation to the other, his/her own and the others desire, and the Symbolic Order (the paternal metaphor, language, and the law). Thus, it was perhaps only an accident that our borderline (i.e. Katherine) turned out to be a neurotic hysteric. A Lacanian diagnosis and therapy of another so-called borderline might very well reveal the presence of another type of neurosis, or a psychosis or perversion.
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Borderline Personality Disorder: A Lacanian Perspective Elements of a Lacanian Critique of the Borderline Concept The task of bringing together the theories and practices of two giants of psychoanalysis
such as Kernberg and Lacan is a difficult one. As I have attempted to show in earlier chapters, each theory is highly sophisticated and complex, and each is based upon certain fundamental metapsychological and even philosophical assumptions that create an immense divide between American and French psychoanalytic thought. Here I will only be able to map out the territory for further dialogue, first presenting the fundamental elements of a Lacanian critique of the borderline concept, and then by briefly examining certain aspects of Lacanian theory through what French analysts will surely seem to be a very foreign lens: the lens of empirical, even experimental psychology.
The Merger of Psychiatry and Psychoanalysis From a Lacanian perspective, the problem of the borderline can be understood as resulting from an American psychoanalytic tendency to merge descriptive psychiatry and psychoanalysis (Di Ciaccia, 1999). As we have seen in our discussion of Lacans critique of American ego psychology, by focusing on the various functions, defenses and adaptations of the ego, the ego-psychologists, beginning with Hartmann and continuing through Kernberg have downplayed the significance of Freuds initial insights regarding the unconscious. Amongst these insights are that nearly all of human behavior is comprehensible as a function of unconscious conflicts, and that therefore nearly all human behavior is interpretable in terms of the mostly unconscious intentions and motivations of an actor or subject who is defined by a cultural/linguistic web of meaning and significance. In formulating an ego-psychoanalytic theory of the borderline that accounts for this disorder in terms of "incomplete," "inadequate," "primitive," or "broken" structures, Kernberg and others have imported descriptive psychiatric categories into the unconscious and discarded the essential psychoanalytic insight that symptoms are a symbolic manifestation of unconscious motives, that they are the expression of a "wish."
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Kernbergs " borderline structures" are, from a Lacanian perspective, actually relatively abstract descriptions (e.g. of ego weaknesses, poor anxiety tolerance, a lack of impulse control, lack of developed sublimatory channels, a shift toward primary process thinking, intact reality testing, identity diffusion, the presence of specific defensive operations, etc.) that remain largely at the same level of analysis as his presumptive (and the DSM-IV) criteria. Kernbergs theory is not, on a Lacanian view, a proper psychoanalytic structural theory, one that would account for the existence of certain symptoms and behaviors by appealing to an individuals unconscious intentions, motivations, and goals. Rather, Kernberg runs the risk of treating the borderline as a mechanism, more specifically, a maladaptive mechanism whose failure at adaptation is the result of various deficits in cognitive, perceptual, and affective regulation, rather than a desiring human subject in need of insight and understanding. Defenders of Kernberg can point out that that even Freud himself (e.g. in his distinction between the actual and psycho neuroses(Freud, 1895), held that there were certain symptom pictures that lay outside the frame of unconscious meaning and conflict. On the Kernbergian view, the borderline is not analyzable as a neurotic, precisely because his or her psychic apparatus has not developed to the point where it is beneficial to make genetic interpretations (Kernberg, 1984). As the borderline patient improves, he or she may take on aspects of a neurotic structure, and thus become the subject of more traditional (interpretive) psychoanalytic techniques.
The Critique of the Role of the Symptom Lacanians are critical of the use of symptoms and symptom complexes in diagnosis. A Lacanian critique is especially applicable to Kernberg's use of such "higher order" symptom complexes such as "identity diffusion" as structural criteria for a borderline diagnosis. From a Lacanian point of view the important question to be asked about identity is not whether it is diffused, but rather precisely how it manifests itself in contradictory ways at conscious and unconscious levels, and at the levels of the Imaginary, Symbolic and the Real.
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Borderline Personality Disorder: A Lacanian Perspective For Kernberg, diagnosis does not begin with the identification of symptoms but rather
from an understanding of typological organization (Di Ciacca, 1999). While Freud originally held that a typical symptom was necessary for diagnosis, a problem emerged for him when the symptom was atypical, as was illustrated most forcefully in the case of the Wolfman (Freud, 1918) (where obsessive and psychotic symptoms were present but the patient functioned well socially). Within the Lacanian framework of diagnosis, a symptom that appears to be atypical within the general picture of one individual may belong to the imaginary order, while in another subject, the same symptom is better analyzed as part of the symbolic order. Thus, at an
imaginary level (at the level of the fantasy of the person about himself, i.e. the Lacanian "ego") a man can have a feminine identification, whereas at the symbolic level of everyday life, the person identifies himself exclusively as a man. For this reason, the whole idea of identity is difficult to pinpoint and must be elucidated in the particularities of each subjects analysis. For Lacan, the subject of the unconscious takes one position and the self another one opposite to it. This is how hysterical and obsessional symptoms can co-exist in the same individual. This complex view of who we are has clear implications for the construct of identity and further, for Kernbergs criterion of identity diffusion. For Freud and Lacan a symptom represents a substitution. This substitution is not a directly observable fact, but must be pursued at the level of meaning. For a Lacanian, the issue of Katherines so-called identity diffusion amounts to a question of what does it mean to be a woman? While this question can be answered in an indefinite number of ways, it is important for the analyst to ascertain what the unique answer is for Katherine. Kernberg, on the other hand, takes a symptom or a manifestation of an ego structure (e.g. identity diffusion) and makes a diagnosis without any reference to subjective meaning.
The Treatment of Borderlines Lacanian analysts hold that since the advent of ego-psychology, American analysts have become seduced by defenses, levels of object-relations and adaptive mechanisms, and have, in many cases, even failed to consider the unconscious, and how an interpretive perspective can be
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brought to bear on many severely disturbed patients. In working with Katherine, I myself was impressed by the degree to which an interpretive psychoanalytic perspective was indeed applicable to her case. It is noteworthy that clinicians in general and psychoanalysts in particular share intense countertransferential feelings towards these difficult patients. These attitudes reflect the aggressive and chaotic fantasies that patients have (in general) and leads the clinician to make recommendations that, at times, may not be properly thought through. The question of face to face treatment versus the couch, the issue of avoiding dream analysis and, further, the question of having contracts drawn with these patients in which they agree to not kill themselves or go to the next emergency room, etc., may only reflect our deep countertransferential feelings towards these patients. Amongst such countertransference feelings are a sense of responsibility for the patient (experienced as a burden), feeling intruded upon, and at times being devalued as a professional, etc.
The Role of the Ego and the Ethics of Psychotherapy It is an implicit and at times explicit view amongst ego-psychologists that once Freud developed the structural model of the mind, that he discarded, or at least downplayed the significance of the topographical model of unconscious, preconscious and conscious. Lacan argues that by working only at the level of the Freudian structural model, the subject is lost. Psychoanalysis, from a purely structural point of view, essentially becomes an adaptive model of human behavior, one in which the ego is understood as forging an adaptive compromise between its drives (id) and the demands of society (superego). Within this model, certain ethical questions arise: Who is to say what is adaptive or not? Who is a healthy individual and who is mentally ill? The importance of such an ethical context and the whole question of "adaptation vs. the assumption of ones own desire" provide the basis for a further Lacanian critique of the American perspective on the borderline. Kernberg and other American theorists argue that the therapeutic task with borderline patients is one of supporting, shoring up, and, eventually, building the patient's ego. As detailed in Chapter Three, for Lacan, the ego, including its various
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functions of defense, reality testing and adaptation is an illusion that obscures the genuine psychoanalytic subject. The ego, in Lacans theory, is a self-deceptive and alienating product of the mirror stage. It is, according to Lacan, a product of illusory identifications with, and the objectifying gaze, of the other, and is responsible for the subjects alienation from his own desire. By centering their theory of severe pathology within the vicissitudes of ego-functioning the borderline theorists participate in and perpetuate the basic deception that, according to Lacan, is at the core of psychopathology. Further, from an ethical perspective, the use of ego-building techniques in the treatment of so-called borderline patients runs the risk of promoting an adaptation to the desire of the other which suppresses the subjectivity and freedom of the patient him or herself. While Kernberg does not directly state that identification with the analyst is central to the therapy of borderline disorders, the practical work with borderlines often amounts to an interpretation of their primitive defenses without genetic interpretation (Kernberg, 1974), and a modeling of a presumably more rational approach to one's relationships and conflicts, which the patient can incorporate through identification with the analyst. However, for Lacan, the analyst cannot serve as a model for the patient. To the extent to which borderline or other patients internalize the analysts ego characteristics, such a patient becomes further enmeshed in the desire of the other and further from their own subjectivity. Advocates of ego- and self-psychology are, of course, open to retort that not all identifications are as self-alienating as Lacanians would suggest; some, it would seem, are necessary for the development of and fulfillment of the self. In discussing the case of Katherine, we saw that even for Lacan there is a period of education/identification that must take place in order for an individual to become a psychoanalytic patient. It would also seem that the analyst/therapist cannot help but be an identificatory object for the patient, as the patient must learn to identify and ultimately assume the analysts curiosity about himself. The question nevertheless remains, as to whether the psychotherapeutic process with borderlines and others should primarily be one that strips away identifications or creates new ones
Lacan and the Borderline Conditions Lacan and Family Therapy
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Here I would like to point out that Lacans emphasis that the individual pathology can also be understood as an expression of inter-generational conflicts, meanings and significance should make Lacan of interest to family therapists, those working outside of as well as within a psychoanalytic framework. Such theorists typically hold that the deep structure of an individuals symptoms and pathology cannot be traced to the individuals psychology alone, but is rather a function of events that have transpired within a family, or wider interpersonal system. Lacan shows a similar interest in the manner in which the patients parents, grandparents, etc. enter into and condition the individuals psyche, to such an extent that (at the start of analysis) what the patient generally feels as her own desire, is inevitably someone elses desire that she has adopted through unconscious identifications. The goal of analysis becomes the working through of these various obscuring identifications so that the analysand can develop as a subject conscious of her own desire. In this way Lacans theory adapts certain notions that are
compatible with a family systems perspective on pathology and places them within a psychoanalytic and existential context.
The Pre-oedipal vs. Oedipal Controversy Several other Lacanian notions that I will consider here in brief relate to the general critique of American ego-psychology. One of these is that by emphasizing pre-oedipal developmental issues in their theory of the borderline, American analysts have again moved away from the intrapsychic conflict model and the theory of the unconscious that were the core theoretical constructs of Freudian psychoanalysis. Further, focus on such pre-oedipal issues as separation/individuation prevents the Kernbergian analyst from gaining a full understanding of patients relationships to others, their interpersonal conflicts, and relationship to their own and others desires, that are constitutive of adult (as opposed to infant) functioning. With regard to Katherines case, as was pointed out in Chapter 6, it is clear that one could understand this patients pathology in terms of the pre-oedipal or narcissistic issues that resulted from her
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mothers failure to fulfill her maternal function, and the ensuing deficits in Katherines identity and object-relations. However, as became clear later in the treatment, superimposed upon this early narcissistic issue was the role that Katherine was forced to play in the triangle between herself, her father and her mother, and the way in which her experience of this triangle produced a new re-interpretation of her early childhood experiences. For Lacan, the distinction between oedipal and pre-oedipal issues is itself an illusion, as on Lacans view, the human infant is born into a world in which he or she already has significance in the wider family and culture. We are, according to Lacan, born into a web of language and symbolic meanings that have existed for generationsit is not only when we learn to speak that we become conditioned by culture and language. Before we have uttered our first word we are embedded in a maze of others
meanings, conflicts and desires. The focus on attachment and so-called pre-verbal developmental issues in the theory of the borderline raises the question of the role of language and speech in the constitution of human subjectivity. Lacan views the subjects alienation in the Other as structural (i.e. universal) rather than accidental (occurring in some cases and not in others). For Lacan all human subjectivity is constituted, immersed in and annihilated by languagea language that pre-exists the individual subject. The belief that one can focus on pre-verbal issues fails to recognize the allpervasiveness of language in the development of human subjectivity and the re-structuring of former psychic formations once language is acquired. A further criticism of Kernbergs reliance on object relations theory (see below) relates to its shift of emphasis from oedipal issues to the mother-child interaction, while disregarding the important factor of triangularization and the effect of the father.
The Critique of Objects Relations Theory Kernberg can be described as a theorist that blurs the distinctions between object relations and ego psychology, since, on the one hand, he focuses mainly on objects (self and object representation rather than drives) while on the other hand he places a strong emphasis on the defensive structure of the ego, its autonomous functions and the concept of adaptation.
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While there are certain similarities between Kernberg and Lacan's approach to intersubjectivity, there are radical differences, not only with respect to their understanding of the ego, but also in their conception of the nature of the object and its relation to desire. For Lacan, there is no possibility of complete satisfaction between subject and object (Lacan, 1953). In Lacanian terms, the object of object relations theory is not the symbolized, psychoanalytic object, but rather the object of biology, without reference to any symbolic function. Lacans polemic with object-relations theory has enormous consequences with respect to treatment; for example, when analysts expect their patients to achieve "mature object relations" or "genital aims." For Lacanians, the designations of "good object" and "bad object" involves an ethical, even moralistic, position that is dangerous in the field of psychoanalysis. The same can also be said with respect to the ego psychologists concept of reality testing which comes dangerously close to legislating for patients what they should experience and believe. For Lacan reality is a construct, based upon the pleasure of the subject (Lacan, 1959).
Borderline Structure as Part of the Human Condition As we have already remarked in passing, a further critique of the borderline concept is that the particular difficulties that presumably characterize the borderline personality are endemic to the human condition as a whole. For example, the notions that borderlines suffer from broken structures and an unintegrated self suggests that others are not broken and that their selves are integrated. Lacan follows Freud in holding that the human subject is essentially divided and unintegrated. It may well be that what is projected on to the borderline is, in fact, a universal human condition. The broken, divided nature of human experience may be easier to contend with it is confined to a particular group of impaired individuals. However, for Lacan, it is not just borderlines who suffer from a division of the self; such a division is the inevitable result of our immersion in a language and problem of identification with the other. As we have seen, even before the child himself begins to speak he is caught in the symbolic/linguistic web of his parents, family, and community, and his needs and their satisfactions are channeled through the language of his family/culture. According to Lacan, as the infant develops, his bodily
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feelings are gradually linguisticized, taken away from the body, and the body is thereby emptied out. What was once pleasure becomes anxiety, as a distance is set up between need and its satisfaction. The subject of the analytic inquiry is thus split, divided, an idea that has important implications when compared with the holistic view of a bio-psycho-social integration portrayed by much of what goes under the name of personality theory (Harari, 1986). The idea that only "borderlines" are split, broken and divided is according to, Lacans way of thinking, predicated on the ego-psychological (and common) illusion that there is a normal state of "wholeness" and "unity." The belief in an integrated self, according to Lacan, is a function of our taking our specular image for the real subject. Another of the effects of the mirror stage is the illusion of autonomy. Any adult who is questioned about himself will insist that he knows that he is free, knows what he wants and he has to do, etc. because he is his own person.. However, this view of the self is a narcissistic illusion, whereby the ego hides its imaginary identifications and presents them as its own choices. Moreover, we also believe we know what we are saying, that we own our words, a belief that can be expressed as I first think, then I select my words and finally I enunciate them. Psychology typically adheres to this view, in its study the acquisition of language as if it is one of the egos cognitive functions. Lacan, on the other hand, believes that the subject is an effect of language, rather than the other way around. For Lacan the subject is inscribed in a language that is hardly of his own choosing.
The Continuum of Diagnosis A further criticism of the borderline construct stems from the notion that it appears to open the door to an indefinite number of new diagnoses. Indeed, the ego-psychological construct of the borderline rests on the view that there is a continuum of psychopathology. The borderline is said to share certain ego strengths with the neurotic and certain ego weaknesses with the psychotic. Thus an indefinite number of gradations of pathology are possible between neuroses and psychoses, and several borderline theorists, e.g. Meissner (1978), have attempted to
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enumerate a number of them. For Lacan there is no continuum between the three basic structures. Whoever is neurotic cannot become psychotic or perverse. The continuum view actually undermines the very idea of structures. On the other hand, Lacan himself can be criticized for holding an overly rigid view of the strategies that can potentially shape the human subjects relationship to the other, language, culture and desire. For Lacan, there are only three major strategiesthose described in our discussion of psychosis, neurosis and perversion in Chapter Threeand several sub-strategies that define the various types of neuroses. Here Lacans existentialism seems to come into sharp conflict with his structuralism. The theorist who rails against any attempt to rob the subject of his freedom and to define the patient in mechanistic terms, holds a structural theory of the human psyche that appears to do just that, limiting the subject to just one of three possible illusory life-strategies. Lacans view is that once one has completed analysis one can, to a certain extent, shed the identifications that obscure ones own desire (Lacan, 1981), but there remains within his thinking, a fundamental tension between the potential for liberation afforded by psychoanalysis and his structural analysis of the human personality. Indeed, it may well be that it is precisely this tension between fixed structures and freedom that generates Lacans dialectical appeal.
The Rise of the Borderline Diagnosis and the Decline of Interest in Hysteria and Perversion As we have seen, according to both Kernberg and Lacan one cannot diagnose psychopathology on the basis of symptoms and behavior. For Lacan, this is because most symptoms and behaviors can occur in the context of any of Lacans three basic structures: neurotic, psychotic and perverse. Any symptom, obsessions, phobias, poor impulse control, even hallucinations and delusions can each be present in the context of each of the three basic psychopathological structures. Here I would point out that hysterics and individuals who suffer from severe dissociative disorders (e.g. Dissociative Identity Disorder, Possession states) can present with auditory hallucinations and delusions without having a psychotic structure in either
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Kernbergian or Lacanian terms. Followers of Kernberg would typically classify such individuals as borderlines, whereas Lacanians might give prime consideration to a possible diagnosis of neurosis. One can easily forget how psychotic Freuds and Breuer hysterics were. Anna O, who was later revealed to be Bertha Pappenheim, a woman who later emerged as one of the founders of social work and the womens movement in Germany, suffered from all sorts of delusional and hallucinatory experiences (Freud and Breuer, 1895). Such hysterical individuals were the common psychoanalytic patients around the turn of the century, but, as Michele Tort has pointed out, interest in hysteria, particularly in America has all but disappeared. Tort (1999) suggests that the appearance of the borderline diagnosis coincided with a decline of interest in hysteria, and may possibly be understood as a reframe of the hysterical patient, who has certain symptoms that appear to be psychotic, but who does not suffer from a formal thought disorder or broad and chronic disruptions in reality testing. In this regard, one might question how a Lacanian would understand the various multiple personalities, possession states, fugues and other dissociative disorders that have recently become so common in certain psychotherapeutic circles. Clearly, the question of patients who have psychotic symptoms but not psychotic structures is one that has emerged into prominence in recent years. A further thought, also suggested by Tort (1999) is that as with hysteria there has been a progressive decline in interest in perversion within psychoanalytic circles, except as it is narrowly defined as a sexual deviation or paraphilia. As we have seen, for Lacan perverse structure is a position of the subject in relation to others rather than a sexual deviation per se. From a Lacanian perspective, those who have interests in the character pathologies, e.g. borderline. narcissistic, and anti-social personality disorders, would be well to consider whether the dynamics of some of these patients can be accounted for in terms of the perverse strategy Recall that for Lacan, whereas in psychosis there is an absence of the law, and in the neurosis a reinstatement of the law in fantasy, in perversion, the subject struggles to bring the law into existence. For Lacan the negating mechanism at work in perversion is disavowal, disavowal of the father and all the themes related to him: the law, the fathers name and the fathers desire. Perversion is a refusal to relinquish the pleasure associated with ones (preoedipal) jouissance and thus a refusal to form an identification with the father and the law. Perhaps, new insight can be gained into the anti-social, unempathic, and overly-entitled
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presentation of many so-called borderline and other personality disordered patients by reconsidering them in the context of Lacans perverse structure.
Empirical, Philosophical and Ethical Considerations If we are to truly make an effort to create a dialogue between American ego psychology and Lacanian psychoanalysis we will do well to consider a Lacan's major contributions to psychoanalytic theory and practice apart from the idiosyncratic and polemical context and language in which he presents them. While Lacanians themselves would be hesitant to move in this direction, a number of Lacans contributions can be reframed as empirical hypotheses that may be subject to clinical, field, sociological, and even experimental study. Other Lacanian propositions fall in the realm between empirical science and philosophy, and might be referred to as meta-theoretical. Finally, a significant group of Lacan's claims fall more properly in the realm of philosophy, or what might be termed the conceptual foundations of psychology and psychoanalysis; a subset of these are correctly termed by Lacan as ethical propositions. Amongst the Lacanian propositions that are most readily reframed as empirical hypotheses are:
Lacan's assertion of the critical significance of both the actual and symbolic father in the genesis and structure of psychopathology. (Here studies could be reviewed --and conducted-regarding the image and concept of the father held by children and adults with various disorders, or regarding the implications of the actual father's absence, aggression, etc. on the development of psychopathology).
Lacan's emphasis on the role of language and its inherent connection with law and convention in the genesis, structure and treatment of psychopathology. (Here studies could be conducted regarding the language of psychotics, for example, testing Lacan's proposition that the psychotic patient exhibits unpunctuated speech. Such a lack of punctuation might even be operationalized and measured.)
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Lacan's views on the specific genesis of desire from need and demand, his claim that the child desires to be an all fulfilling object (what he refers to as the phallus) for the mother, and that individuals with specific structural pathology engage in distinct "fundamental fantasies" in their interpersonal relationships. (Here such fantasies might be assessed in a variety of ways, e.g. via an analysis of the individuals images and ideation during masturbation and sex).
Lacan's views on the emergence of the oedipal triangle in the establishment of language and law in the family and society. (Here again, studies might be reviewed and conducted regarding the impact of paternal absence and familial discord, and the individual's processing of such absence and discord on the use of language and internalization of societal norms in children).
Lacan's thesis that psychosis involves a failure of the paternal metaphor, that is, a failure of the psychotic to internalize the paternal restrictions on the child's relationship with a maternal object. (Again, projective and qualitative interview studies could be used as a means of operationalizing this concept).
Lacans criteria for the diagnosis of psychosis, including hallucinations coupled with problems in reality testing, specific language distortions (e.g. their inability to construct complete sentences), inundation by their own libido, feminization in males, absence of selfquestioning and the failure of desire. (Each of these criteria could potentially be operationalized and efforts to describe "presumptive" Lacanian criteria for psychosis could be worked out).
The assertion that social and cultural forces are the major if not exclusive determinants of individual motivation, and that these determinants are unknown to the subject and, in particular, are present in those motives that he initially regards as his own. (Desire is always desire of the other). (Here qualitative studies could be conducted regarding what individuals
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identify as their own motivations in comparison to the values and motives that appeared in parents, grandparents, and their sub-culture).
While Lacanians might argue that restating Lacans theses in empirically testable terms distorts their meaning, and that such ideas can only be properly understood within the context of the psychoanalytic situation, we are entitled to hold that his theory should make some, at least potentially testable, predictions. Operationalizing and testing specific Lacanian hypotheses is beyond the purview of this study, but it is reasonable to suppose that as Americans become more familiar with Lacans work several of the hypotheses I have enumerated above, as well as others, will be subject to empirical and even experimental scrutiny.
Among Lacan's more conceptual contributions are:
Lacans conceptualization of the ego as essentially linked with an illusory narcissism, and his critique of the possibility of the ego as a reality oriented, conflict free agency.
His notion that psychological defenses are best conceptualized as linguistic structures dependent upon metaphor and metonymy (as Lacan defines these terms).
Lacans theory that meaning is always after the fact (apres coup), i.e. that language is always reinterpretable in terms of subsequent contexts, and that (developmentally) early events are always re-signified at later points in the individuals life.
While it is difficult to see how such ideas can be formulated in testable terms, it is also difficult to picture Lacanian theory without them. These, like the ideas considered below, have a certain philosophical moment, and are likely to be subject to more conceptual debate and discussion than empirical testing. As is the case with all theorists, Lacan makes certain untestable assumptions.
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Borderline Personality Disorder: A Lacanian Perspective As I have indicated, a number of other Lacanian contributions are more properly
philosophical or ethical. Amongst these are: Lacan's view that both the imagination and language are critical elements in the construction of reality. Lacan's view that reality is constructed is at odds with the fundamental logical empiricist position that until recent years dominated AngloAmerican philosophy. His views have more in common with post positivist philosophy of science, as exemplified, for example, in Kuhn's The Structure of Scientific Revolutions (Kuhn, 1996), where it is argued that there are no facts independent of theory, no data independent of interpretation. Lacan's theory that the human subject is essentially constructed, lives within, and only transforms himself in the context of language. Lacan's ethical charge that the work of psychotherapy is to permit the patient to forge himself as a creative subject rather than to adapt him or herself to reality. This thesis is the foundation of what Lacan regards to be the ethics of psychoanalysis, resulting in a debate with American ego psychology, which he sees as promoting identifications with the analyst and adaptation to society, at the expense of the freedom and creativity of the individual.
It is important to distinguish between those aspects of Lacans thought (and his implicit critique of the borderline concept) that can be subject to empirical test, and those which are meta-theoretical or philosophical in nature. Because many of the differences between Kernberg and Lacan are best understood as theoretical and philosophical in nature, we cannot expect empirical research to settle all the differences between them (any more than it has settled the philosophical differences between other major theories and paradigms in psychology). Nevertheless, we are entitled to demand of Lacanian psychoanalysis, as we demand of any other theory in psychology, that at least some of its propositions be put in testable form.
Lacan and the Borderline Conditions The Borderline Diagnosis in Children and Adolescence
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The questions that have been raised in this study regarding borderline pathology take on particular moment when this diagnosis is utilized in connection with children and adolescents. The reason for this is that to call a child or adolescent "borderline" clearly has a disparaging connotation which can have a negative impact not only in the mind of the child's therapist, but upon the child's teachers and others in the childs world. As such, the controversy regarding the existence of this diagnostic entity takes on significance in a child-psychological setting, something that has been recognized by a number of practitioners (Gualtieri, Koriath and Van Bourgondien, 1996). Some practitioners have suggested, for example, that the diagnosis of borderline personality in childhood actually represents a re-labeling of children who suffer from Post-traumatic Stress Disorder (Famularo, Kinscherff and Fenton,1991). In this context, it is important to recall that studies of early child development have had a profound impact on the evolution of the borderline concept within psychoanalysis. In this section I will briefly review some of the direct contributions by psychoanalytic developmental psychologists to the theory of borderline personality disorder in children along with the problems that this diagnosis poses when it is applied to children and adolescents. Mahler (1958) identified children with severely impaired object relations but who evidenced a less severe presentation than psychotics. They were conceptualized as a mild or an attenuated variant of psychosis. Mahler supports her findings with observational studies on the separation individuation process. According to her, the infant is not able to differentiate between self and object representations and experiences his or her primary caretaker in a symbiotic mode. It is not until the child is approximately ten months of age that he will differentiate his psychic identity as separate from his mothers. The process of separation and independence is long, and is accompanied by intense anxiety, as the child understands that he has very little control over his caretakers and the satisfaction of his needs. Mahler describes different stages in the development of individuation, (a process that takes place from 12 to 36 months) and which involves internalizing soothing mechanisms and acquiring the capacity to achieve affective equilibrium as the child eventually achieves an awareness of his/her position with respect to others and the environment. If the child can accept the reality of self and others, he will achieve object
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constancy. Mahler defined object constancy as the capacity to maintain relationships and evoke the loving and comforting image of the loved person in spite of separation or frustration. The etiology of borderline disorders is thought to be related to a derailment of the normal developmental process described above. If this is indeed the case, one would expect to find evidence of such failures in separation/individuation at various points in both childhood and adolescence. Indeed the psychoanalytic literature soon began to provide a clinical description of children whose impulsivity, low frustration tolerance, uneven developmental patterns, tendency to withdraw into fantasy, primitive responses to stress (primary process response), lack of structure, pervasive intense anxiety, and multiple neurotic symptoms (such as compulsions, rituals, phobias, somatic complaints and sleep disturbances) suggested that they were on the psychological path predicted by the developmental account of borderline personality disorder. Paulina Kernberg (1982) contends that the borderline diagnosis in children under 12 is indeed valid. She states that children have particular patterns of thinking, perceiving and feeling that endure over time and any pattern that becomes rigid, chronic and maladaptive or produces subjective distress warrants a personality disorder diagnosis. However, only careful long-term studies can clarify if the children diagnosed, as borderline today will be the borderline adolescents and adults of the future. Paulina Kernberg is largely in accord with the developmental views of Mahler and goes further to describe a particular affect in the borderline child: excessive aggression. According to Paulina Kernberg, the childs aggression threatens the good object and splitting occurs to keep the good and the bad as separate as possible. This defense is the protection that is necessary to keep the bad introjects away from the ideal good object. The bad introjects are activated by separation, frustration or an inability to live up to the expectations of others. Clarification of terms such as introjects, good and bad object, aggression, maternal and paternal representations, etc. are necessary in order to further a consideration of the problem of the borderline in children. In particular the issue of subject and object as it is understood in object relations theory must be adequately contrasted with Lacans use of these terms. James Masterson and Donald Rinsley (1975) are also in accord with the view that borderline psychopathology in children is due to a particular pathological mother-child interaction that affects the separation-individuation process. They further describe the type of
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mother of a borderline patient; she is characterized as one who finds gratification in her childs dependency, rewarding clinging behavior and sanctioning any move towards autonomy. Such mothers are warm and loving when the child is helpless and in close proximity but punishing when the child strives towards independence. They argue that the behavior of such mothers fosters a split in the mother representation in which gratification is associated with dependency and punishment associated with autonomy. This pattern becomes particularly acute in times of psychosocial change and identity crisis such as adolescence. G. Adler (1986) follows the theory of Donald Winnicott in utilizing the notion of the the holding environment as a theoretical construct useful in explaining the genesis of borderline pathology in children. When the parent fails to provide a caring environment the child internalizes a maternal object representation that does not provide soothing and comfort when separation and distress arises. The child, therefore experiences a sense of emptiness that needs to be constantly mollified with transitional objects such as food or, later, drugs,. Such children (and adults) also become angry and manipulative in order to call the attention of others. As indicated above, a number of authors have suggested a close link between so-called borderline pathology in children and post-traumatic stress. For example, Guzder, et. al. (1999) cite sexual abuse and parental criminality as the major factors discriminating borderline from non-borderline children. Goldman, et. al (1992) showed that "borderline" children have a greater prevalence of physical and combined physical/sexual abuse, leading them to suggest that borderline personality may be in part a function of such trauma. Johansen (1992) has suggested that abused children develop symptoms of borderline personality disorder because they are rejected repeatedly when entering into various situations that would normally produce caring.
Criticisms of the Borderline Concept in Children The question of a borderline personality in children is riddled with conceptual difficulties, foremost of which is that a personality disorder is universally understood to be a relatively enduring and pervasively maladaptive pattern of experiencing, relating and coping. Children and adolescents are involved in a fluid developmental process in which their
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personalities are in formation. As such, one can ask whether it is even valid to ascertain a distinct personality disorder in childhood. Further, there are well-known difficulties inherent in any attempt to distinguish childhood borderlines from children diagnosed with several other disorders, such as Attention Deficit Disorder, conduct and eating disorders. For example, when borderline and non borderline children (ages 6-12) after admission to a psychiatric hospital, were compared in an effort to discriminate specific borderline traits, the following variables were identified: self-destructive behavior, irritable affect, anhedonia, and externalizing behaviors. None of these symptoms are useful in distinguishing the borderline from the conduct disordered versus the antisocial child or the sexually abused child (Wood, , D., Arents,1992). In another study it was noted that the borderline label was not helpful for treatment planning or disposition, and in some instances the negative impact of the label was actually detrimental (Gualtieri, Koriath, Van Bourgondien,1997). Some studies have suggested that "borderline" behavior in children can be produced on a transient basis by stress. For example, a study, which examined this problem from a qualitative point of view, indicated that disruptions in foster care placement and neglectful situations produce behaviors that resemble those of borderline children (impulsivity, conduct disorder, defiance to authority, poor school performance) (Aquino,1998). Other researchers (e.g. Berg, 1992) associates borderline children with impulse control problems and emphasize the role of learning problems and neuropsychological problems in the disruptive behavior of individuals diagnosed with s conduct disorder, borderline personality, and ADHD. Although there appears to exist some overlap of these conditions, some studies indicate children with these problems often grow to become borderline adults. Other studies have focused on a present vulnerability to separation anxiety that is present in these children from birth. It is associated with hyperarousal and panic and makes these children more vulnerable in the case of parent unavailability. As they grow these children feel helpless and angry. The rage appears as self or other destructiveness and their dramatic behavior represent a protection against their perceived neglect from others which confirms the unconscious affirmation of their inner badness.(Bemporad, 1982) Joseph Palombo (1982), in his article A critical review of the concept of the borderline child, argues that there is no data to support the assumption that there is similarity between the
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concept of borderline in adults, as we know it, and the concept of the borderline child. He criticizes the explanation that the borderline condition arises in childhood as a result of poor nurturance or improper parenting. Rather, this author holds that some of the symptoms displayed by these children may be found in the presence of minimal brain dysfunction or a severe learning disability. Gunther Klosinki, (1980) in his paper Diagnosis of borderline personality organization in adolescents criticizes the term borderline personality as a diagnostic category for adolescents. On his view, each of the behavioral characteristics of the so-called borderline personality is also typical of the normal adolescent, that is: the presence of free-floating anxiety, multiple phobias, compulsions, dissociation, hypochondria, depression, sexual perversions, and loss of impulse control. Both groups of adolescents alternate between their identifications with idols and feeling completely impotent, reflecting their compensation for self-doubts and identity crisis. Klosinki (1980) believes that most young people diagnosed with borderline personality disorder are in fact in the early stages of schizophrenia, while others are going through a difficult time in their normal adolescent crisis. He finally advises to avoid the use of this diagnosis in adolescence, as many of these young men and women will have a much more favorable diagnosis or none at all by the time they become adults. He concludes that making the borderline diagnosis and associating it with biological and developmental problems such as ADHD can itself lead an adolescent to become more vulnerable to problems in self-esteem, impulse control etc. affecting his self-esteem and his regard within the family and at school, which in turn creates a series of negative responses. In short, there is as much if not more controversy regarding the etiology and nature of borderline conditions in children and adolescence as there is with respect to adults. This has led Gualtieri, et. al (1997) to assert that clear guidelines for this ambiguous and controversial diagnosis in child psychiatry were nonexistent.
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Borderline Personality Disorder: A Lacanian Perspective The Present Study and the Borderline Concept in Children and Adolescence The present study has only indirect implications for the diagnosis of borderline
personality in children and adolescents. The Lacanian critique provides one more vantage point from which to question the utility of this diagnosis in both adults and children. Criticisms of the borderline concept in children on the basis that borderline symptoms are actually common to many if not most adolescents parallels the Lacanian view that the broken structure of the socalled borderline adult is actually part and parcel of the human condition. In the present study, the case of "Katherine" illustrates a situation in which a young adult manifests with both presumptive and so-called structural criteria for this disorder, but who can profitably be understood and treated from a Lacanian perspective as a neurotic. Such a situation can be expected to occur frequently amongst adolescents who, because of the turmoil and chaos associated with this developmental period, are very likely to exhibit the markers of "borderline personality" in a way that may mask their neurotic (psychotic or perverse) Lacanian structures. Indeed, Katherine, at age 25, appeared to have many characteristics of an extended adolescence, and it may very well be that it was these characteristics that were being manifest when she appeared to meet borderline criteria. Child, adolescent and school psychologists may wish to consider this possibility prior to settling upon a borderline (or equivalent) diagnosis and to consider the possibility that diagnosis and treatment in accord with Lacan's notions of the fundamental fantasy, the major forms of negation, and the alienation of desire may be an equally, if not more useful approach in the treatment of more enduring features of adolescent's psychodynamics.
Limitations of Interpretive Theory The limitations of the current study flow from several factors, some of which are intrinsic to hermeneutic theories in psychology as discussed before. The nature of interpretation is such that it is always subject to re-interpretation. In the present context this indefinite regress of interpretability not only applies to the case that I have used for illustrative purposes, but also to
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my understanding of the theories themselves and their relation to one another. In the case of Lacan, not only are their conflicting interpretations of Lacan, but conflicting interpretations of his interpreters. As such, the possibility of anything like a definitive reading of either a case, or even a theory about a case, is, on the very assumption of a hermeneutic theory impossible. While the limitations in terms of verifiability and consensus of an interpretive theory of the human psyche are obvious, its strengths, on the view of this author, more than make up for its shortcomings. One does not have to be a Lacanian to recognize that human beings are themselves interpreting agents who live in a world that is constituted as much by values, meanings and significance as it is constituted by things. We are continuously interpreting, understanding, misinterpreting and misunderstanding each other, and (according to psychoanalytic theory) ourselves. A psychological theory that takes as its starting point the interpretive nature of the human condition has this much to recommend itself: it considers people as they actually are, rather than what an operationally driven science dictates they should be in order to measure them and pin them down. What a hermeneutic psychology loses in precision it gains in scope and depth. With regard to this particular study, as I have repeatedly emphasized, its main purpose is to generate dialog on the subject of the borderline from a Lacanian point of view. The case study, which has been presented, perhaps provides some prima facie evidence that a Kernbergian borderline can be diagnosed, and treated, in Lacanian terms without recourse to the borderline concept, but even here we cannot be definitive. The presentation of a case study is by necessity selective; indeed the selection process has already begun in the consulting room, and is conditioned by the clinicians own interests, prejudices, etc. There is no raw data so to speak, available to check this authors hypotheses and assertions, and even if such data were available, e.g. in the form of videotapes of all the Katherine sessions, that data would itself be colored by the direction that the therapist chose to bring the treatment, again, according o her theoretical prejudices, etc. Further limitations of studies of this kind are inherent in the fact that the author herself was a participant in the case which serves as its main illustration, and she conducted the treatment. Her own limitations in her understanding of both Kernberg and Lacan, and the broader psychiatric and psychoanalytic scene within which these theorists, and the theory of the
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borderline are imbedded are also potential sources of confusion. As this study attempts to articulate the Kernbergian and Lacanian theories in some detail, and to place them into the beginnings of a dialog, the value of this study will be, of course, limited by the authors own limitations in her understanding of the theories presented and discussed, limitations that, it is hoped, will be overcome by future participants in what promises to be an interesting and fruitful dialog between American psychoanalysts and the followers of Jacques Lacan.
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Index
abandonment, 12, 19, 101, 121, 122, 133 Abend, S., 18, 187 academic psychology, 5 adaptation, 9, 15, 16, 58, 164, 165, 167, 170, 178 addiction, 28 Adler, A., 21, 187 Adler, G., 181 affective disorders, 9, 10, 11, 12 affective instability, 12, 121 affective organization, 14 aggresivity, 88, 152 aggression, 14, 26, 32, 33, 34, 35, 37, 38, 90, 115, 124, 136, 137, 138, 152, 175, 180 aggressive, 18, 31, 32, 33, 35, 36, 37, 38, 57, 90, 99, 109, 115, 123, 136, 137, 138, 139, 148, 167 aggressivity, 68, 156 Akhtar, S., 6, 26 alcoholism, 28 alienation, 56, 57, 59, 64, 68, 79, 106, 168, 170, 184 ambulatory schizophrenia, 7 American Psychiatric Association, 10, 12, 121, 187 American psychoanalysts, xi, 1, 5, 13, 43, 44, 163, 186 anger, 8, 10, 12, 26, 111, 122, 135, 157 Anna O, 174 anorexic, 78 anthropology, 22, 44 antisocial, 6, 26, 137, 182 anxiety, 9, 14, 19, 27, 28, 30, 33, 37, 41, 67, 68, 69, 73, 100, 104, 105, 117, 121, 122, 123, 124, 125, 126, 128, 131, 133, 135, 139, 141, 145, 159, 164, 172, 179, 180, 182, 183 aprs coup, 53, 63, 177 Aquino, D., 182, 187 Arents, M., 182, 198 as-if, 9, 14, 17, 26 atemporality, 61 Attention Deficit Disorder, 182, 183 avoidant personality, 29 Azevedo, B., xiii Balint, M., 23 being-in-itself, 72 Bemporad, J., 182, 187 Benveniste, E., 50, 187 Berg, M., 182, 188 Beyond the Pleasure Principle, 75 black humor, 100 Bleiberg, E., 4, 5, 11, 188 Bleuler, E., 6 Bonaparte, M., 46, 48 borderline conditions, 1, 9, 11, 14, 21, 22, 23, 125, 183
200
Borderline Personality Disorder: A Lacanian Perspective demand, 64, 76, 77, 78, 79, 95, 96, 100, 104, 113, 141, 142, 143, 176, 178 dementia praecox, 6 denial, 31, 32, 39, 47, 104, 124, 130, 131, 133 dependency, 9, 38, 139, 181 depression, 9, 10, 14, 33, 105, 110, 111, 113, 114, 115, 133, 150, 151, 152, 156, 160, 183 depressive position, 14 dereistic thinking, 7 descriptive criteria, 6, 13, 102, 120, 150 descriptive point of view, 13, 26, 27 desire, xiii, 18, 54, 58, 64, 67, 68, 71, 76, 77, 78, 79, 81, 82, 83, 84, 85, 88, 90, 92, 93, 94, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 116, 128, 138, 142, 143, 144, 147, 150, 152, 155, 157, 158, 160, 161, 163, 167, 168, 169, 171, 173, 174, 176, 184, 198 desire of the other, 78, 157, 168 deterministic, 37 Deutsch, H., 14, 40, 188 devaluation, 10, 12, 31, 33, 36, 121, 124, 131, 136 Devaluation, 33 developmental, 5, 18, 31, 36, 55, 59, 60, 61, 62, 75, 169, 170, 179, 180, 181, 183, 184, 195 developmental theory, 5 Di Ciaccia, A., 163, 164, 188 dialectic, 56, 85 didactic, 144 disavowal, 54, 83, 103, 104, 105, 146, 157, 174 dissatisfaction, 95, 97, 99, 104, 149 dissociation, 11, 34, 183 dissociative, 10, 11, 12, 87, 122, 123, 146, 173 dissociative disorders, 11, 174 Dissociative Identity Disorder, 173 dissociative reactions, 28 Dor, J., 53, 54, 57, 85, 94, 97, 98, 188 Dora, 93
Borderline Personality Disorder, xii, 5, 12, 13, 107, 118, 121, 122, 162 borderline state, 6 boredom, 26, 114 Bourgondien, 179, 182 Bowlby.J., 18 Breuer, 45, 174 British empiricists, 45 British school, 22, 25, 31 broken structures, 171 Carr, 30, 41 Cartesian rationalists, 45 Casanova, 98 castrating, 37 Catell, J., 3, 4, 192 certainty, 80, 87 chain of signifiers, 52, 53, 60, 62, 74, 78, 89 character pathology, 26, 29, 135 chimpanzee, 56 clarification, 2, 40, 126 confrontation, 40 contradictions, 39, 80 Contradictions, 131 contradictory, 20, 34, 39, 41, 100, 127, 131, 136, 165 conversion, 27, 91, 97, 122 coping style, 11 core borderline, 9 countertransference, 118, 167 culture, 1, 16, 45, 63, 64, 69, 70, 71, 94, 97, 152, 170, 171, 173, 177 cure, 79, 85, 156, 157 cyclothymic, 28, 42, 122 De Mijolla, 46, 47 deconstruction, 57, 163 defense, 3, 14, 18, 23, 26, 31, 32, 36, 58, 100, 129, 131, 132, 133, 135, 146, 167, 180 defense mechanism, 14 defenses, 11, 13, 16, 18, 21, 30, 31, 39, 40, 41, 58, 100, 125, 129, 131, 132, 133, 134, 150, 163, 164, 166, 168, 177 defensive mechanisms, 131 Dellis, 2
Index dreams, 19, 50, 54, 61, 73, 78, 82, 86, 100, 144, 146, 147, 148, 150, 154, 155, 190 dreamwork, 53 drives, 5, 23, 31, 33, 35, 36, 37, 56, 66, 76, 89, 102, 103, 167, 170 DSM, vii, ix, 4, 5, 12, 13, 41, 42, 83, 121, 122, 162, 165, 191 dysthymia, 83 eating disorders, 182 Ecrits, 53, 57, 61, 64, 72 ecstasy of the body, 89 Efrain, E., 4, 187 Ego, viii, ix, x, 44, 55, 167, 188, 192 ego functions, 15, 132 ego ideal, 32, 35, 88, 136 ego-fragmentation, 153 ego-psychological, 23, 25, 26, 36, 42, 172 ego-psychology, xi, 57, 58, 166, 169 Elementary Structures of Kinship (LeviStrauss), 70 empirical, 3, 4, 7, 41, 60, 86, 162, 164, 175, 177, 178, 196 empirical research, 3, 178 emptiness, 10, 12, 14, 26, 34, 122, 127, 181 erogenous zones, 75, 89 ethical, 167, 171, 175, 178 Evans, D., 53, 56, 188 existential, 22, 169 existentialism, 22, 45, 55, 173 experimental science, 45 Ey, H., 46 Fairbairn, W., 23, 24, 29, 31, 188 family Therapy, x, 168 Famularo, R., 179, 189 Fatal Attraction, 1 Feher Gurevich, J., 50, 55, 60, 70, 189 Fenton, T., 179, 189 Ferenczi, S., 21 Fink, B., 83, 86, 89, 92, 102, 145, 146, 158, 159, 189, 193 Fliess, W., 46 flooding, 19 foreclosure, 54, 83, 84, 88, 91, 146, 157
201 Formations of the Unconscious (Lacan Seminar), 66 "fort, da, 63 France, viii, xi, 1, 22, 44, 45, 46, 47, 48, 49, 188, 195, 197, 198 Frankl, V., 62 free association, 74, 119 French psychoanalysts, 2, 22, 44, 45, 47 Freud, A., 21, 23, 48 Freud, S., 1, 21, 22, 23, 25, 26, 31, 44, 45, 46, 47, 51, 53, 54, 58, 63, 65, 66, 67, 69, 70, 71, 73, 74, 75, 76, 80, 82, 83, 88, 90, 91, 92, 93, 96, 99, 102, 103, 144, 153, 164, 165, 166, 167, 171, 174, 188, 189, 190, 191, 194, 197, 198 Freudian, vii, xi, 21, 22, 29, 44, 46, 49, 54, 68, 108, 163, 167, 169, 198 Fromm, E., 21 Frosch, J., vii, 15, 16, 86, 191 Gabbard, G., 22, 23, 191 genetic, 4, 150, 165, 168 genital, 35, 37, 38, 114, 123, 124, 136, 138, 147, 148, 171 Gill, M., 29, 196 Girl Interrupted, 1 Goldman, S., 181, 191 Goldstein, 18, 26, 27, 30, 34, 37, 41, 42, 136 good and bad, 14, 24, 31, 35, 36, 131, 180 good object, 24, 32, 33, 171, 180 grandparents, 64, 65, 71, 149, 169, 177 gratification, 33, 38, 138, 181 Greenberg, J., 23, 191 Grinker, R., 3, 4, 8, 9, 192 Gualtieri, 179, 182, 183 guilt, 14, 32, 33, 35, 42, 88, 90, 114, 132, 155 Gunderson, J., 2, 3, 4, 9, 10, 25, 41, 191 hallucinations, 3, 6, 7, 11, 15, 16, 27, 73. 86, 87, 134, 158, 159, 173, 176 Harari, R., 172, 192 Hartmann, H., 21, 29, 48, 164, 192 Hegel, G., 45, 47 Hegelian, 55 Heidegger, M., 22
202
Borderline Personality Disorder: A Lacanian Perspective instinct, 58, 66, 76 integration, 14, 22, 31, 33, 35, 38, 127, 128, 129, 130, 136, 172 International Congress of Psychoanalysis, 45 International Psychoanalytic Association, 22, 43, 46, 48, 55 interpersonal functioning, 40 interpersonal relationships, 8, 9, 12, 18, 71, 121, 130, 176 interpretation, 39, 41, 45, 82 intersubjectivity, 170 interviews, 34, 40, 80, 108, 123, 128, 132, 133, 139, 142, 144, 145, 155 intrapsychic, 13, 14, 20, 30, 39, 64, 81, 129, 169 introjection, 25, 33, 137 introjects, 24, 31, 180 Jakobson, R., 50, 53, 192 Johansen, R., 181, 192 jokes, 54 Jones, 45, 48 jouissance, 75, 76, 96, 103, 174, 189 Jouissance, viii, 75, 76, 106 judgment, 15, 30, 57, 81, 125, 130, 148 Jung, C., 21, 45 Kant, I., 45 Kaplan, H., 89, 192 Katherine, ix, x, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 166, 168, 169, 184, 185 Katherine, case of, xii, 107-120, 140-162 Kernberg, O., vii, viii, ix, xi, xii, 5, 13, 14, 17, 18, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 107, 108, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 134, 135, 136, 138, 139, 140, 142, 143, 150,
hermeneutic, 184 heterogeneity, 68 heterosexuality, 37 Hoch, P., 3, 4, 7, 192 homogeneity, 68 homosexuality, 37, 95, 98 Horney, K., 21 human condition, 66, 152, 153, 158, 171, 184, 185 Husserl, E., 22 hyperarousal, 11, 182 hypochondriasis, 10, 28, 97, 122, 123, 183 hypocondriacal, 27, 28 hypomanic, 26, 28, 122 Hyppolite, J., 47 hysteria, 91, 92, 93, 94, 95, 96, 97, 102, 160, 163, 174, 198 hysterics, 87, 91, 93, 94, 95, 96, 97, 159, 163, 173 Id, vii, 34, 44, 190 idealization, 10, 12, 14, 19, 31, 33, 36, 39, 112, 121, 124, 131, 136, 139 identification, ix, 15, 20, 24, 25, 31, 32, 33, 53, 56, 57, 58, 65, 68, 88, 90, 93, 94, 95, 99, 103, 131, 136, 137, 138, 148, 149, 152, 153, 154, 155, 157, 165, 167, 168, 169, 171, 172, 174, 178, 183 identity, 8, 9, 10, 11, 15, 17, 26, 34, 36, 38, 39, 40, 65, 66, 71, 79, 90, 94, 108, 124, 125, 127, 128, 129, 130, 135, 139, 143, 154, 156, 165, 166, 169, 179, 181, 183 identity diffusion, 26, 34, 127, 128, 130, 131, 166 Identity disturbance, 12, 121 imaginarized, 88, 158 imaginary, 55, 56, 57, 58, 63, 64, 66, 67, 68, 69, 72, 73, 81, 85, 86, 87, 88, 89, 90, 92, 96, 99, 102, 104, 106, 149, 156, 158, 166, 172, 198 imaginary father, 67, 85, 90 imaginary phallus, 67, 104 impulsivity, 10, 12, 26, 121, 180, 182 infant, 14, 24, 31, 59, 62, 75, 76, 86, 160, 169, 171, 179
Index 152, 159, 162, 163, 164, 165, 166, 167, 168, 170, 173, 178, 180, 185, 192, 193 Kernberg. P., 180 Kernbergian, ix, xii, 107, 108, 109, 119, 120, 139, 140, 141, 142, 143, 162, 163, 165, 169, 173, 185, 186 Kety, S., 11 Kinscherff, R, 179 Kinscherff, R., 189 kinship, 50, 70 Klein, M., 11, 14, 21, 22, 23, 25, 31, 32, 59, 152, 193 kleptomania, 28 Klosinki, G., 183, 193 Kohutian analysis, 156 Koriath, 179, 182 Kraepelin, 6 Kriss, E., 21 Kuhn, T., 178, 194 Lacan, J., viii, x, xi, xii, 1, 2, 22, 26, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 95, 96, 97, 101, 102, 103, 107, 108, 120, 124, 127, 140, 142, 143, 146, 150, 152, 155, 156, 157, 158, 160, 162, 163, 164, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 180, 184, 185, 188, 189, 192, 193, 194, 195, 196, 197, 198 Lacanian, viii, ix, x, xi, xii, xiii, 2, 21, 22, 43, 44, 48, 54, 55, 57, 60, 61, 72, 73, 74, 80, 81, 83, 86, 92, 93, 102, 103, 107, 108, 109, 119, 120, 140, 141, 142, 143, 144, 145, 149, 150, 152, 153, 156, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 169, 171, 173, 174, 175, 176, 177, 178, 184, 185, 186, 188, 189, 195, 196, 198 Lacanian psychoanalysis, 21, 54, 102, 175, 178, 189 Lacanians, xi, 2, 44, 78, 83, 84, 85, 86, 92, 98, 157, 165, 168, 171, 174, 175, 177
203 lack, 9, 14, 18, 20, 30, 31, 32, 34, 35, 38, 48, 63, 67, 71, 78, 79, 89, 94, 95, 104, 106, 114, 124, 127, 128, 129, 130, 135, 136, 137, 143, 147, 151, 156, 164, 175, 180 Laforgue, 46 Lagache, 48 Laplanche, J., 25, 96, 195 latent schizophrenics, 8 law, 50, 68, 70, 71, 75, 84, 86, 88, 93, 99, 100, 103, 106, 157, 158, 163, 174, 175, 176 L'Evolution Psychiatrique, 46 Lemaire, A., 51, 56, 57, 195 Levi-Strauss, C., 22, 49, 70, 71, 195 libidinal, 31, 33, 36, 37, 60, 89, 99, 124, 150 linguistics, 22, 47, 50, 51, 54 Little Hans, 69, 73, 102 Lowenstein, R., 21, 46, 48, 192 Mahler, M., 18, 36, 124, 128, 179, 180, 195 Major, R., 44, 195 masochism, masochistic, 14, 19, 28, 37, 38, 123, 124, 138, 139, 149 Masterson, J., 18, 180, 195, 196 Meissner, W., 17, 172, 196 mental apparatus, 38 mental status examination, 40 Merleau-Ponty, M., 22, 47 metaphor, 51, 53, 54, 65, 71, 74, 82, 85, 86, 88, 102, 103, 158, 159, 163, 176, 177 metaphoric, 54, 74, 89, 106 metapsychology, metapsychological, 19, 164, 196, 197 metonymic, 53, 54, 74, 79 metonymy, 51, 53, 74, 79, 177 Mirror Stage, viii, 46, 55 misrecognition, 57, 58 Mitchell, S., 23, 191 moment of conclusion, 61 moment of seeing, 61 moment of understanding, 61 moral insanity, 6 mother, v, 9, 18, 20, 24, 36, 37, 38, 59, 60, 63, 65, 66, 67, 68, 69, 71, 74, 76, 77, 78, 81, 84, 85, 88, 91, 93, 94, 98, 99, 102,
204
Borderline Personality Disorder: A Lacanian Perspective panic disorder, 83 Pappenheim, P., 174 paranoid, 6, 12, 14, 26, 27, 28, 37, 42, 122, 123, 132, 138, 139, 146 paranoid position, 14 paraphilia, 174 parental, 35, 37, 65, 89, 137, 138, 181 parenting, 4, 20, 183 parents, 20, 24, 64, 65, 68, 69, 71, 74, 82, 88, 89, 102, 110, 111, 114, 115, 135, 137, 139, 151, 152, 153, 160, 161, 169, 171, 177 Parmelee, D., 182, 198 passivity, 9, 15, 100 paternal function, 69, 84, 85, 88, 90, 102, 104 paternal metaphor, 54, 71, 102, 158 penis, 67, 69, 73, 98, 104, 106, 139 perceptual distortions, 15, 134 perfection, 95 perversion, xi, 1, 7, 44, 50, 63, 72, 73, 82, 83, 88, 99, 102, 103, 105, 146, 157, 163, 173, 174, 198 phallus, 67, 68, 78, 91, 93, 94, 98, 99, 101, 102, 104, 161, 176 phenomenological, 22, 26, 49 phenomenology, 4, 45, 55 philosophical, 22, 44, 164, 177, 178 philosophy, 22, 44, 45, 47, 55, 57, 72, 175, 178 phobia, 69, 92, 102 Phobias, 27 phobics, 69 Piaget, J., 49 Playboy magazine, 34 pleasure, 66, 69, 75, 76, 91, 95, 96, 97, 102, 103, 104, 149, 158, 159, 171, 172, 174, 191 points de capiton, 52, 53 Polatin, P., 7 Polymorphous Perverse, 28 polysubstance dependence, 83 Polysymptomatic, 27 polysymptomatic neurosis, 18, 122
103, 104, 106, 110, 111, 117, 130, 131, 139, 147, 148, 149, 150, 151, 152, 153, 154, 155, 157, 158, 159, 160, 161, 169, 170, 176, 179, 180, 196 Muller, J., 73, 196 multiplicity, 19 mutability of the sign, 52 Name of the Father, x, 54, 71, 155 narcissism, 67, 153, 177, 190, 193 narcissistic, 18, 26, 42, 57, 94, 104, 122, 124, 169, 172, 174, 187, 193 Nash, 48 Nasio, 74 National Institutes of Mental Health, 10 need, 7, 18, 19, 26, 27, 32, 45, 70, 73, 76, 77, 78, 79, 92, 93, 104, 113, 118, 123, 141, 142, 148, 149, 160, 165, 172, 176, 192, 196 negative therapeutic reaction, 14 neuroses, xi New York Psychoanalytic Institute, 18 normative function, 68 obesity, 28, 123 object relations, 1, 18, 19, 22, 23, 24, 25, 28, 29, 33, 36, 42, 43, 124, 125, 130, 133, 170, 179, 180 Object Relations Theory and Clinical Psychoanalysis (Kernberg), 36 object representations, 14, 19, 25, 33, 36, 38, 39, 40, 130, 179 object-relations theory, xi, 59, 171 obsessive, 10, 82, 84, 92, 96, 98, 99, 100, 101, 122, 136, 166 obsessive-compulsive, 10, 27, 82, 122, 136 oedipal, x, 18, 54, 59, 60, 68, 106, 136, 151, 169 oedipal victory, 104 Oedipus Complex, viii, 54, 60, 65, 66, 67, 85, 93, 136 omnipotence, 31, 33, 35, 39, 124, 131 operationalizing, 176 oral, 33, 37, 38, 139, 148 overwritten by language, 152 Palombo, J., 182, 196
Index Porter, M., 18, 187, 194 position, 5, 14, 24, 45, 50, 52, 55, 60, 62, 67, 68, 76, 78, 81, 83, 90, 91, 92, 93, 94, 96, 97, 98, 99, 101, 102, 117, 128, 140, 143, 145, 149, 155, 157, 166, 171, 174, 178, 179 possession states, 173 post positivist philosophy, 178 post-Freudian, 21, 22, 108 Post-traumatic Stress Disorder, 179 pregenital, 9, 18, 35, 37, 38 pre-linguistic, 72 pre-oedipal, 18, 26, 59, 169, 174 preschizophrenic patients, 8 presumptive, 26, 27, 29, 120, 122, 123, 124, 128, 139, 142, 162, 165, 176, 184 presumptive criteria, xii Prichard, J., 6 primal scene, 66, 139 primary process, 8, 18, 30, 53, 82, 86, 124, 150, 165, 180 primary process thinking, 30 primary repression, 91 primitive, 8, 9, 15, 17, 18, 30, 32, 33, 35, 39, 50, 88, 124, 125, 130, 131, 132, 133, 134, 135, 138, 139, 152, 164, 168, 180 projection, 14, 16, 25, 31, 32, 87, 132, 148 projective identification, 14, 18, 31, 32, 33, 36, 39, 124, 130, 131 promiscuity, 7, 10, 37, 38 Prozac, 114, 118 Psychoanalysis, viii, x, 43, 44, 45, 59, 80, 92, 107, 164, 167, 189, 195, 196, 197, 198 psychoanalytic, xi, xiii, 2, 3, 4, 5, 13, 14, 17, 19, 23, 26, 29, 40, 41, 42, 45, 46, 47, 48, 49, 51, 54, 60, 61, 62, 65, 68, 71, 79, 80, 82, 94, 97, 107, 120, 127, 136, 139, 142, 144, 148, 157, 163, 164, 165, 166, 167, 168, 169, 171, 174, 175, 177, 179, 180, 185, 192, 195 Psychodynamic, 3, 191 psychological testing, 2, 3, 4, 5, 8, 9, 30, 38 Psychopathology of Everyday Life (Freud) , 45
205 psychopathy, 6 psychosis, xi, 1, 2, 4, 11, 13, 15, 16, 25, 26, 33, 36, 44, 50, 53, 55, 63, 83, 84, 85, 86, 87, 88, 89, 90, 103, 125, 126, 146, 150, 157, 159, 163, 173, 174, 176, 179, 198 psychosomatic, 47, 152 psychotherapy, 3, 4, 26, 27, 30, 34, 110, 118, 142, 178, 193 psychotic borderline, 9 psychotic character, 15, 16, 17 psychotic-like symptoms, 11 rage, 7, 9, 34, 37, 59, 97, 109, 111, 114, 139, 152, 155, 182 Rank, O., 21 Rapaport, D., 8, 29, 196 real, 8, 12, 15, 24, 33, 55, 56, 67, 68, 69, 72, 73, 84, 85, 86, 87, 88, 89, 103, 106, 121, 156, 158, 172 real father, 84, 85 reality principle, 58 reality testing, 9, 14, 15, 16, 18, 30, 38, 57, 87, 124, 125, 126, 129, 131, 133, 134, 135, 165, 167, 171, 174, 176 relationship with reality,, 15 repression, 26, 31, 59, 62, 63, 68, 83, 90, 91, 101, 103, 129, 131, 146, 150, 157, 158, 159, 160 resignification, 62 resignified, 60 resistance, 3, 17, 27, 142 return of the repressed, 91, 160 return to Freud, 1, 22, 47, 82, 143, 193 Rinsley, D., 18, 180, 196 Rorschach, H., 8, 30, 196 Roudinesco, E., 44, 197 Sadock, B., 89, 192 Salpetriere Clinic, 45 sarcasm, 100 Sartre, J., 22 Saussure, F., 22, 47, 50, 51, 52 schizoid, 17, 18, 26, 28, 42, 122 schizophrenia, 2, 4, 6, 7, 9, 17, 183, 188, 192 schizotypal, 7
206
Borderline Personality Disorder: A Lacanian Perspective subjectivity, 55, 57, 58, 63, 64, 67, 88, 152, 168, 170 suggestibility, 15 suicidal, 12, 114, 115, 121, 122, 123, 147 Sullivan, H., 21 superego, viii, ix, 25, 29, 32, 33, 35, 44 65, 124, 136, 137, 138, 139, 167 Sutherland, J. 23 symbolic, 19, 50, 54, 55, 59, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 79, 84, 85, 87, 88, 89, 90, 92, 93, 99, 101, 102, 103, 104, 156, 158, 159, 164, 166, 170, 171, 175, 198 symbolic order, 50, 54, 59, 63, 65, 66, 68, 71, 73, 74, 79, 84, 85, 88, 89, 92, 158, 166 Symbolic Register, 155, 156 The Family (Lacan), 65 thought disorder, 174, 197 three Freudian structures, xi three registers, 72, 73, 88 topographical model, 51, 167 Tort, M., 174, 189 transference, 3, 4, 18, 30, 33, 40, 56, 80, 82, 92, 94, 105, 118, 125, 135, 145, 156 trauma, 4, 11, 62, 72, 73, 181 Treatise of Insanity (Prichard), 6 unconscious, 15, 22, 24, 25, 40, 41, 46, 50, 51, 52, 53, 58, 59, 60, 61, 62, 63, 65, 70, 72, 74, 76, 78, 80, 82, 91, 92, 107, 129, 138, 141, 143, 152, 156, 164, 165, 166, 167, 169, 182 versagung, 96 Volkan, V., 19, 198 Wallon, H., 47, 56 Willick, M., 18, 187 Winnicott, D., 23, 181 Wolfman (case of S. Freud, 166 Wood, I., 182, 198 Zilboorg, G., 7
Schreber, 90 Searles, H., 19, 197 second topographical system, 44 secondary process thinking, 30 self-defeating, 37, 75, 97, 157 self-destructive, 9, 26, 114, 136, 182 self-psychology, 23, 168 sexual, 4, 7, 10, 11, 28, 34, 37, 38, 65, 66, 67, 68, 69, 71, 81, 91, 93, 95, 102, 104, 116, 117, 122, 123, 138, 139, 150, 151, 154, 159, 174, 181, 183, 191 sexual difference, 66, 104 Shapiro, T., 4, 40, 197 signified, 51, 52, 53, 62, 64, 85, 151, 154, 177 signifier, 51, 52, 53, 54, 64, 67, 74, 79, 82, 104, 192 Singer, M., 3, 8, 9, 19, 191, 197 Singer, M., 2 Single White Female, 1 sliding of the signified, 53, 64 slips of the tongue, 50, 63, 78 Societe Psychoanalytique de Paris, 46 Society Francaise de Psychanalyse, 48 specular image, 172 Spitzer, 10, 13 splitting, 14, 18, 26, 29, 31, 32, 33, 36, 37, 39, 64, 124, 131, 180 Stern, A., 13 Stone, M., 2, 198 stress interview, 41 structural, xii, 2, 3, 4, 5, 14, 17, 22, 26, 28, 29, 35, 36, 40, 41, 42, 44, 50, 54, 56, 60, 66, 70, 72, 81, 92, 103, 109, 120, 122, 124, 125, 126, 127, 130, 131, 139, 143, 145, 148, 157, 162, 165, 167, 170, 173, 176, 184 structuralism, 44, 49, 50, 55, 173 structuralist, 49, 51, 54 Structure of Scientific Revolutions (Kuhn), 178

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