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High Anxiety: A theoretical and clinical challenge to psychoanalysis

The Letter, Issue 6, Spring 1996, Pages 1 - 23


A theoretical and clinical challenge to psychoanalysis

Cormac Gallagher


You will have recognised that the title 'High anxiety' has nothing original about it and is in fact borrowed from Mel Brooks' comedy about the antics of psychiatrists and psychoanalysts.

I chose it as a way of reminding myself that in our often grim profession anxiety can introduce us to comedy as well as tragedy and that wit and humour can be used as tools for transforming unpleasure into pleasure. One of my clients, when she feels particularly anxious, whispers a line from that film to herself: 'Baby steps, baby steps'. The legend goes that Freud, when asked to give an attestation that he had been well treated in the anxiety- ridden days before he left Vienna, scrawled: ’I can recommend the Gestapo to anyone!'

But in fact we know that such a partial transformation of the vinegar of anxiety back into the wine of sexual excitation is not easy to achieve and that the anxiety which drives a client to consult us in the first place or which may suddenly erupt in the course of an analysis confronts us and our method with a severe challenge.

I must admit that on several occasions, at the end of an initial interview, I have recommended highly anxious patients to consult a psychiatrist or a cognitive-behavioural therapist rather than embark on an analysis. Yet I am not at ease with that way of avoiding the question because the whole literature of psychoanalysis, and in particular the work of Freud from beginning to end, could be said to be organised around the use of the talking cure to understand and treat anxiety, making of this most unpleasurable experience a way for the sufferer to gain access to the truth of his or her subjectivity. So that to recommend to someone seeking analysis that they should take the route of suppressing anxiety, by psychological or psychopharmacological means, is in some way a violation of the ethics of analysis in that it advocates a reinforcement of alienation rather than favouring the emergence of desire.

Besides there is the problem of what to do when the overwhelming anxiety makes its appearance in the course of an analysis that has already been engaged in for months or years. To take the option of referring somebody on at that stage is a still more serious matter, ethically and technically, because it implies a serious misjudgment in estimating the capacity of the analysand to tolerate the anxiety that necessarily accompanies a psychoanalytic treatment and involves incalculable transference effects.

Now these are the reflections of someone whose theory and practice have for the past 25 years been guided largely by the work of Jacques Lacan and by an analysis and supervision undertaken with some of his dose associates who seem to me to achieve remarkable results with patients who in our culture would not be taken on for analysis. If I have remained attached to the work of Lacan it is mainly because I have found his way of approaching analysis effective from an operational point of view:a conviction shared by colleagues in the Department of Psychiatry of St Vincent's Hospital, Dublin and by a majority of the students in our Masters in Psychotherapy programme.

I am aware that this is an unusual stance in the English-speaking world where Lacan's genius seems to have been appreciated mainly in departments of literature, so this morning I think that the most useful contribution I can make is to present you with a sample of Lacan's work that tackles precisely the kind of clinical dilemmas with very anxious patients that I have outlined above.

The Seminar on Anxiety

What I have in mind is the seminar on Anxiety, consisting of 25 two- hour lectures, which Lacan delivered in the academic year 1962-63. I have spent the past year translating the unedited and unpublished French manuscript based on a stenographic and audio recording of these lectures and conducting my own seminar with some of our graduates on the basis of this translation.

Lacan's core insight is centred on a rejection of the received wisdom that anxiety is 'a fear without an object'. For him anxiety has an object and throughout this seminar he argues that the pin-pointing of this object is at the basis of a revolution in the notion of what sort of object mobilises human desire and is the prime concern of psychoanalysis. This in turn gives rise to radical questions about psychoanalytic technique and, in particular, about the sort of object the analyst must become for the analysand in the transference relationship.

I am not going to attempt to summarise the argument of this seminar for you this morning. My aim is to offer some indications to guide your own reading of this long and difficult - but very rewarding - text. It is, in any case, a text that is impossible to summarise and such a summary would be completely against the spirit of Lacan's teaching which he explicitly states is intended to evoke rather than to inform.

So let me try to evoke for you something of the background to this year of teaching on anxiety because it has a very particular place in what might be called Lacan's project or mission with regard to psychoanalysis. When I first went to Paris in 1970 Lacan was in his late sixties but had only recently become known outside a small psychoanalytic circle. A collection of articles based on his work since the early 1930's had just been published and had created enormous interest not only among psychoanalysts but also among French intellectuals like Michel Foucault, Louis Althusser and their students; he had founded his own school of analysis after his 'excommunication' from the International Psychoanalytic Association; he seemed to have dozens of people in analysis and supervision and he conducted a weekly case presentation at St Anne, the leading French psychiatric hospital, where he demonstrated the relevance of his theories to clinical work.

Amongst all these activities the seminar, a weekly event open to all and attended by hundreds of analysts, mental health professionals and others, showed most clearly what Lacan was trying to accomplish and how much energy and persistence he put into his task. Anxiety was the tenth of these year-long seminars and there were to be a further seventeen before his death. His stated aim was to form psychoanalysts, to introduce them to a reading of Freud quite at variance with what had become the accepted one in the early 1950's, and in particular to reestablish in the theory and practice of analysis the place of the unconscious and of desire over and against the emphasis on the ego and adaptation to reality. He was also determined to demonstrate to non-analysts the relevance of the psychoanalytic revolution to any discourse on human affairs and Anxiety opens with quite specific appeals to Heidegger and Sartre who had also put anxiety at the centre of their concerns.

The themes of the seminars before Anxiety give some idea of the root and branch reform Lacan undertook in his attempt to restore its cutting edge to psychoanalysis: beginning in 1953-54 with the technique of psychoanalysis, he went on to debate with past and present analysts the ego in Freud's theory, psychosis, object relations, the formations of the unconscious, desire and its interpretation, the ethics of psychoanalysis, transference and identification. One of his constant refrains is that the poor repute into which psychoanalysis fell after the death of Freud came from the fact that individual analysts and particular schools take a partial view of their field and that this partiality leads to deviations in the theory and ineffectiveness in the practice.

This may seem to be a curious criticism from a man who is often accused of a very selective reading of Freud and in particular of concentrating too much on Freud's early texts and of ignoring the whole dimension of affect in favour of a literary and intellectualist approach. I think the English- speaking reader is justified in making such accusations partly because of the peculiar choice of texts that were first translated into English - most clinicians find The Four Fundamental Concepts of Psychoanalysis and the Ecrits difficult to relate to their practice - and the absence in English of such texts as The Family which, though difficult, show a Lacan very much in touch with questions that we can identify with.

The seminar Anxiety has the difficulty that it comes relatively late in Lacan's teaching and presupposes a battery of concepts that had been developed in the nine seminars that preceded it. Lacan forged a set of symbols to designate these concepts in order to differentiate between notions that are often confused and to ensure a consistency in handling them. By way of getting into the main body of this paper and the text of the seminar let me briefly summarise the most important of these symbols because they are relevant to understanding and handling the phenomenon of anxiety.

The Subject of Anxiety and Its Object

The field of psychoanalysis is desire. Desire emerges as the most fundamental and concrete phenomenon of human existence because of the necessity for human subjects to establish themselves in a language that is spoken by those whose desire has brought them into the world. A patient being presented at a case conference told how her father greeted her birth by announcing to his friends, and by maintaining for a number of years, that she was in fact his long desired son. The confusion of sexual identity and desire engendered by this can be imagined and serves to illustrate the power of desire as mediated by language and its crucial role in the destiny of the individual.

Lacan symbolises the source from which the subject receives language, which is most often incarnated by the mother, by the letter O and the potential human subject by the letter S. Once the subject is marked by language by being named or described for example as a boy or a girl he or she is symbolised by the S with a bar: $.

But the word is not the whole of the subject. In the seminar we are considering, Lacan argues that the experience of anxiety highlights how much of the subject is not captured by language, or how much is left over after the most exhaustive attempts to encapsulate or represent the subject in words. This residue, of remainder, he symbolises by the letter o which represents an object that escapes language and is the most vital element in the mobilisation of desire and of anxiety.

Only one more symbol needs to be discussed and it relates to the Mirror Stage which is one of the notions most readily associated with Lacan. The subject's ego, for Lacan, is dominated by an imaginary structure founded on an identification with the mirror image designated by i(o). The distinction between the o-object and i(o) was only firmly established by Lacan in the current seminar and indeed he gives as his principle reason for tackling the subject of anxiety at this particular time the fact that the only subjective expression of this elusive o-object is anxiety.

Let us make use of our small battery of symbols to see whether we can state more exactly what is involved in the emergence of anxiety. A first consequence of the primacy of O, the locus of language, is that for a human being there is no 'natural' relationship to an Umwelt. The objects in our world are all marked by language; it is as if we were only able to see the objects of our world reflected in the large plane mirror of language. We have no way of seeing directly what is on this hither side of the mirror, the dimension of the real, which contains some elements which can be represented and others which cannot. We have no way of thinking or talking about what is not represented in language. It remains at the level of an o-object. On the other hand the paradigm for the objects that form our everyday reality is the mirror image of our bodies, i(o).

For Lacan, this world of stable representations that we know as our reality masks a dimension of strangeness which can emerge for anyone in anxiety dreams or in traumatic situations where we lose our psychological reference points. Our patients know this strangeness all too well- a young man once told me that when he looked in the mirror he was met by a look of hatred and contempt from his own reflection. The look, a typical o-object, a part of the body which in the normal state of affairs has no mirror image, suddenly manifested itself. The image looks back, not just as my reflection, but as a double which has its own malevolent autonomy. There is a representation of something which should remain masked, an intrusion of the o-object into the field of i(o), and it is this ectopic emanation which properly speaking constitutes the object of anxiety.

Now this disturbance of the sense of reality is not caused by perceptual or intellectual deficits - ego weaknesses - but by a radical flaw in the relationship between the subject and the Other. To achieve a stable sense of reality the subject needs the assent of the Other, an assent which may be only partially granted when the the Other fails to acknowledge the questioning glance of the small child.

Lacan tries to convey an extreme in the generation of this strange world by a curious little fable to which he returns a number of times in the course of the seminar and which for him images the primary experience of the emergence of anxiety.

He asks us to imagine someone confronted by a gigantic, man-sized praying mantis, an insect best known for the female's unsettling habit of biting off the head of her sexual partner after they have mated. Rather than finding in the Other the recognition and assent required to support a sense of reality the subject is confronted by a voracious beast whose multi-faceted eyes offer him no image of himself and whose desire for him he has no way of knowing. This is the kind of situation in which the sensation of the desire of the Other highlights the strangeness of the world completely swamping any sense of stability and allowing the subject to be invaded by the highest degree of anxiety.

The strangeness which manifests itself when o-objects appear in the field of i(o), when what should be hidden is revealed, can be more properly described as uncanny, and Lacan argues that the way to give a unified formalisation to the psychoanalytic notion of anxiety, to establish its limits and function in a way that distinguishes it from other phenomena with which it is confused in philosophy or psychology, is to approach it though the uncanny. If I understand him correctly this amounts to saying that we are not dealing with anxiety in the analytical sense unless the affect we experience is coloured by this tinge of strangeness or oddness or uncanniness.

Freud's 'Uncanny'

When he introduced Freud's Das Unheimliche to his seminar, Lacan remarked how little this text had been read or commented on by analysts. Even today the two most accessible discussions of the subject come from a literary critic, Helene Cixous, in a 1976 article in New Literary History, and an architect, Anthony Vidler, who in 1992 published a book entitled The Architectural Uncanny. Curiously enough, when I was preparing this paper I read a report on the Joyce Summer School where a professor of English argued that Joyce's play Exiles could be most fruitfully approached by using the Freudian notion of the uncanny. I am not aware of any analytical literature that takes up Lacan's suggestion that it is the angle from which to approach anxiety, although Gustavo Bernstein, in an unpublished thesis, recently applied it in a very evocative way to the horror-struck anxiety anorectics experience when they contemplate their own bodies.

The uncanny is described by Freud, shortly after the end of an horrendous war, as a feeling lying 'within the field of what is frightening'. He also says quite specifically that it is related to anxiety - a relationship that is masked by the English translation which renders 'Angst' by 'dread'. It is something whose core Freud claims he finds hard to identify in everyday or clinical experience because of his own lack of sensitivity to the phenomenon - Jung remarks somewhere that modern man has lost the sense of the uncanny - and so he proposes that the best way to grasp it initially is in the fictional works of authors who know how to instill in their readers a feeling of dread about some person or situation that has long been familiar.

The first piece of fiction that he chooses is E.T.A. Hoffmann's tale of The Sandman who makes his appearance where? In the familiarity of Nathaniel's home where he is surrounded by the love and protection of his parents. Nathaniel's mother assures him that the phrase 'The Sandman is coming' is only a figure of speech for saying 'It's time for bed' but the nurse gives him a different version: 'He's a wicked man who comes when children won't go to bed and throws handfuls of sand in their eyes so that they jump out of their heads all bleeding.'

This image of eyes plucked from their orbits and thrown on the ground is there of course from the very origins of psychoanalysis in the myth of Oedipus. For Lacan it is the surest key to understanding the phenomenon of anxiety and he struggles to convey what this atrocious image implies:

He who possessed the object of desire and of the law, he who enjoyed his mother, Oedipus to give him his name, takes this further step, he sees what he has done. You know what happens then. How choose the word, how can one say what is of the order of the unsayable and whose image nevertheless I want to make emerge for you? The fact that he sees what he has done has as a consequence that he sees - this is the word before which I stumble - the moment afterwards his own eyes swollen with their vitreous humours on the ground, a confused pile of filth since - how can we put it? - because since he had tom his eyes from their sockets he had quite obviously lost his sight. And nevertheless it is not that he does not see them, see them as such, as the finally unveiled cause-object of the final, the ultimate ... concupiscence, that of wanting to know. The tradition even says that it is from that moment on that he really becomes a seer.

The moment of anxiety is not the mutilation, the plucking out of the eyes, which Freud overhastily reduced to a castration-equivalent: ’It is that an impossible sight threatens you of your own eyes on the ground'.

This same sight is the very one that threatens the young Nathaniel when despite his dread he spies on his father and the lawyer Coppelius - the Sandman - at their mysterious nighttime experiments and is thrown into a state of panic and delirium as redhot coals are about to be dropped into his eyes.

There is a second moment of horror when as a student he falls in love with the human doll Olympia who is being constructed in the apartment opposite and learns that eyes which had so entranced him in her had been stolen from him by Coppola, a new incarnation of the Sandman. After Coppola had quarreled with his fellow-creator Spalazani and fled, 'Nathaniel saw’- an impossible sight - 'a pair of blood-flecked eyes were lying on the ground and staring up at him'. This time the madness that gripped him took the form of a murderous attack on Spalazini which led to his incarceration in the madhouse.

The final episode is when Nathaniel, now recovered, climbs a tower with his bethrothed and sees through a spyglass - the stress again is on the peculiar effects produced on the visual image, is it a moving bush, or a m an?- the figure of Coppelius approaching. His eyes begin to roll, fire flashes and glows behind them and in an attack of mania he tries to murder his beloved and finally, with one last look exchanged with Coppelius and a cry of 'Love-ly eyes! Love-ly eyes!1, he throws himself to his death.

Freud concludes that the feeling of uncanniness is directly attached to the idea of being robbed of one's eyes which he describes as a 'mitigated' form of castration. The notion of castration anxiety as the ultimate in anxiety is a major theme of Inhibitions, Symptoms and Anxiety but the word 'uncanny' does not figure in the index and indeed Freud seems to have referred to the notion only once after writing the present essay when he spoke in The Future of an Illusion about the notion of God as a way of humanising the uncanny forces of nature.

I believe that Lacan's interest in the uncanny comes from the fit he detects between it and his o-object especially as it appears in its spatial dimension at the level of the eye and the look. He finds the power of the look operating once again in The psychogenesis of a case of homosexuality in a woman published the year after The Uncanny.

Here the young woman who has been scandalising her parents by publicly flaunting her devotion to a notorious demi-mondaine makes a sudden and very serious suicide attempt after her father had cast a furious look at her and her companion when he passed them on the street. The irate look had the function of demonstrating that she had become nothing in her father's eyes, of producing a fading in her subjectivity which no longer left her a place in the human drama and which gave rise to the sudden impulse to leave the stage. Throwing herself over a railway bridge was interpreted by Freud as a representation of giving birth, an ambiguity allowed by the German niederkommen, but for Lacan this young woman, who is clinically one of the most serious cases Freud mentions in his writings, was dropping out of ex-sistence in a much more structural way. The fact that she was in turn dropped by Freud again demonstrates the way in which analysts too may find themselves unconsciously mobilised by the o-object while at the conscious level they are motivated by the most altruistic of intentions - in this case the good of the patient.

I have not been giving a chronological account of Lacan's 1962-63 Seminar. Instead I have been following his account of the genesis of the o- object and his reading of two unfamiliar texts which he sees as a prelude to Freud's final attempt to systematise his ideas on anxiety in Inhibitions, Symptoms and Anxiety.

The Coordinates of Anxiety

It is now time to turn to the matrix or table of the coordinates of anxiety which Lacan presented to his listeners in the very first seminar of that year. After seeing the riot of feelings sweeping through Nathaniel in The Sandman and the impulsive suicide attempt of the young homosexual woman I think we may be better prepared to tolerate and perhaps even appreciate the complexity of his analysis. Lacan, like Freud, pays very careful attention to the way in which the nuances of linguistic usage can refine our own sensibility and guide us through the maze of reactions experienced by our clients. In neither of these cases, any more than in any of our own cases, will we find an analysis based on a linear cause-and-effect relationship from anxiety to symptom to inhibition of much use either in understanding the mechanisms at work or in making the interpretations required to modify their effects.

Lacan presented this table element by element over a six-week period so you will have to excuse me for putting it before you in its completed form without this preparation:

Lacan axis of movement - difficulty

This way of presenting psychoanalytic notions in tabular or diagrammatic form so that you are challenged to reflect on the distinction between them and their inter-relationships is very much part of Lacan's teaching style: there are the triads of real, symbolic, imaginary; need, demand, desire and castration, frustration, privation. There is also the highly elaborated Graph of Desire and the generalisation of the mirror stage known as the Optical Schema, not to mention the various schemata, such as the torus and the cross-cap, borrowed from topology. Most of these thinking aids were developed over several years in the course of the seminars and applied again and again in different contexts.

The matrix appears throughout this seminar but, to the best of my knowledge, is never referred to before or after by Lacan. His followers seem to have followed him in this neglect and I have only once seen this matrix in print, in a rather obscure French article on acting-out. However I did attend a brilliant and riveting account of its clinical applications by Marcel Czermak, one of the medical directors of the Hopital Sainte Anne where Lacan held his weekly case conferences. It was this presentation more than anything else that makes me think it worth while to introduce it to you today and to repeat Lacan's invitation to examine the correlations involved to see if they stand the test of experience.

In his introduction to Inhibitions, Symptoms and Anxiety Strachey notes the unusual difficulty Freud had in unifying the three terms of the title. Freud himself remarked that the elements of the triad did not seem to be on the same plane and it is perhaps this remark that led Lacan to place them at different levels as the diagonal of a square and associate each of them with coordinates that are distributed along a horizontal and vertical axis.

Anxiety is the high-point towards which the axes of difficulty and movement tend but the starting point for Lacan's analysis is the term inhibition, a notion so familiar to us that we may fail to see - is this failure an inhibition? - that Freud's use of it in the opening chapter refers mainly to movement, either literally, as in an hysterical inhibition of walking, or metaphorically, in the sense that every exercise of a function, as for example digestion, implies movement. But for Lacan the notion of inhibition can be made more relevant clinically by explicitating the dimension of difficulty that it also contains. His first step in bringing more coherence to the terms of inhibition, symptoms and anxiety is to unpack the notion of inhibition along these two axes of difficulty and movement and to demonstrate visually, as it were, the different aspects of inhibition that refer most directly to symptoms and anxiety.

In the long list of sexual, nutritional, locomotory, and work inhibitions that Freud lists at the beginning of his study there are some - only some - which he suggests might also be classified as symptoms. This gives rise to the difficult question of what exactly a psychoanalytic symptom is and has very practical implications for the choice of patients who are suitable for analysis. Professor Paul Verhaeghe of Ghent University recently argued that it is not so much the severity of symptoms as their nature which determines whether they can be successfully treated by psychoanalysis. It is doubtful whether a simple lowering of function, which is how Freud describes cases of pure inhibition, can be taken as an indication for psychoanalysis.

Lacan's initial contribution to the solution of this question is to extract from inhibition a notion described by the French word empechement, appropriately translated by 'impediment' which in fact shares its etymological derivation from impedicare, to have one's foot shackled or caught in a trap. As the matrix indicates, impediment suggests an inhibition that has symptomatic overtones, as for example in the case of a speech impediment where one senses not just a simple lowering of function but the interference of another dimension in the production of phonic material.

This aspect of impediment relates inhibition to symptom directly and now Lacan takes the further step of isolating the aspect of inhibition that has a direct reference to anxiety. His choice of the word 'embarrassment' may initially surprise us until we restore to embarrassment its strong and indeed correct definition of the subjective experience of being hampered, encumbered or perplexed in the face of outside forces. Embarrassment arises when you no longer know what to do with yourself, when you no longer find anything behind which to barricade yourself. It is the primary experience of being what we have described above as a barred subject, of being confronted with the Other as locus of the signifier and as desiring something of the inchoate subject.

But it is also an experience with which we can all identify. The perplexity which Freud avowed he always felt in the face of female homosexuality and which led him to such errors in the treatment of Dora and the young homosexual woman is a good example of what Lacan means by embarrassment. Freud finds his theory inadequate to the challenge posed by feminine desire and to the added complication of lying dreams which he was confronted with in the latter case. Many of his successors feel their own embarrassment when the discipline in which they have invested so much of their identity is criticised by philosophers, ex-analysts and the media as unscientific, ineffective and, most embarrassing of all, unethical. In this respect embarrassment shares with anxiety an involvement in the innermost part of the subject and is the high point of inhibition from the point of view of the difficulty experienced in maintaining one's subjective position.

If we now return to the movement axis we find a further aspect of inhibition which directly relates to symptoms and is designated by Lacan as emotion. Here his taste for wordplay and etymology has led him into what could be a complete morass given the multiplicity of meanings attached to the term by different schools of philosophy, psychology and psychoanalysis. What he wants to isolate is the experience of being knocked out of the motion that is geared towards a particular goal, which is of course a way of inhibiting appropriate movement: ex-movere, emotion.

One reference-point he returns to is Goldstein's notion of the catastrophic reaction, the vacillating, inadequate, inconsistent and generally- retarded behaviour of someone who has been subjected to a severe shock for which he is unprepared and with which he is unable to cope. But Freud's notion of emotion as an hysterical reproduction of early trauma and most radically of the disordered movements of birth and early infancy is probably more relevant. Anxiety has been defined as a failure of the 'hystericisation' which would have allowed the subject to remain in the imaginary of an ancient drama rather than face the real. Emotion can thus be situated in the matrix as something of the order of symptom which has not reached the extreme distress experienced at the level of anxiety.

Perhaps the greatest benefit to be drawn from the introduction of emotion at this point in the matrix is to highlight the point that for Lacan anxiety is something other than emotion, a very surprising and provocative suggestion for psychoanalysts who generally speaking do not distinguish between feelings, emotions and affects and are thus led into confusions of diagnosis and treatment. I once saw Lacan interview a young woman whose murderous phantasies and violent feelings had led the psychiatrists to diagnose her as a paranoid schizophrenic, a diagnosis that Lacan refuted by pointing out that such violence of emotion was perfectly consistent with the structure of hysteria.

The final point on the axis of movement brings us once again to a coordinate of inhibition that is directly related to anxiety. The word emoi used by Lacan, sounds a little bit like emotion in French, but it has the very specific connotation of a sudden and complete loss of power. It is this suddenness which in French best distinguishes it from emotion which can be a permanent or long-lasting state. Once again there is an English word which completely captures this nuance and has the added charm of sharing the same etymological derivation. That word, which has a much longer history in the language than either emotion or anxiety, is 'dismay'. It appears first in the thirteenth century as a verb meaning to discourage completely and in the fourteenth became a noun describing the state of being completely crushed or overwhelmed. Like embarrassment it has lost some of its force in popular usage where it frequently means no more than a state of mild disappointment, but if we keep to the correct usage we will find 'dismay' a very useful term for thinking about clinical conditions clients describe in various ways.

Dismay is what the Wolfman experienced when he was paralysed with terror as his window suddenly swung open and he saw the white wolves staring fixedly at him from the branches of the walnut tree. Once again it concerns the innermost part of the subject, the o-object or I which supports his very existence, and like embarrassment it is an aspect of inhibition that is directly related to anxiety. It may perhaps be a useful category by means of which to orientate ourselves in the stories of patients who have been suddenly confronted by something which touches on the object of their fundamental phantasy and utterly throws them.

I interrupted my writing at this point to see a patient who during the session described an experience in which she was glancing though a paperback in a bookshop when she suddenly was transfixed by a paragraph which described how a group of delinquents broke into a house and sprayed acid on the face of owner when he tried to resist. She told how the horror she felt projected her into a completely disoriented state which she actually described as uncanny. I think it is something like this reaction of being completely overwhelmed that Lacan describes as emoi or dismay and the introduction of the term encourages us to get a more accurate fix on the patient's state of mind than simply describing it as a reaction to trauma.

Acting-out and passage à I'acte

There are two final coordinates of anxiety to be discussed and they both concern modes of action with which we are continually confronted in our clients' and, more subtly, in our own behaviour. Their position on the table suggests that they occupy a median position, one between dismay and anxiety, the other between embarrassment and anxiety. What they have in common is the use of action to stave off the encounter with the real that is dreaded in anxiety.

Curiously the French have not found a suitable word to express Freud's agieren and have adopted the English 'acting-out'. On the other hand there is a term consecrated in French psychiatric usage which includes such actions as fugues or impulsive suicide attempts and for which we have no inclusive term in English. I suggest that we reverse the French practice and adopt the term of passage à l'acte to describe these phenomena.

The case of the young homosexual woman provides the clearest example of the distinction between acting-out and passage à l'acte. While she was publicly parading her love for the older woman so disapproved of by her parents she was acting-out, playing her defiant part in the oedipal drama, revenging herself on a father who had sired a child when she thought he loved her rather than her mother. But when the irate look of that same father was followed by an impatient rejection by the older woman her reaction was a passage à I'acte, a brutal resigning of her part in the casual comedy, a suicidal leap that was intended to remove her permanently from the scene.

There seems to be a prima facie validity for tiie distinction between these two types of unconsciously motivated action and it may help towards a resolution of the longstanding debate among analysts about the precise actions that can be described as acting-out and how they are to be dealt with in the course of an analysis. Keeping to familiar examples from Freudian texts Lacan categorises the behaviour of Dora in the household of the woman with whom her father was having an affair as an acting-out whereas the violent slap with which she greeted Mr K's declaration of love he sees as a passage à l'acte.

The patient I mentioned earlier told how she was completely devastated when she received a good-bye letter from a lover:’It was as if an atom bomb had exploded in my head. All I wanted to do was rush out into the street and catch someone and say "Don't leave me'" - an experience of dismay leading to an acting-out to prevent the encounter with anxiety. Lacan cautions analysts that their response to patients may fall into one or other category, arguing for example that Freud's decision to drop the young homosexual woman and refer her to a female colleague was a passage à l'acte dictated by his embarrassment at the nature of her desires and the challenge that her lying dreams posed to the validity of his theories. On a more global level it may be that the dropping of psychoanalysis in favour of other more active treatments, which has become so common even among trained analysts, is also a passage à I'acte which shys away from the anxiety provoked by the radical nature of Freud's discoveries. At any rate the notion makes me pause when I find myself wanting to terminate a treatment or perhaps not undertake it at all and demonstrates that Lacan's passion for the mot juste, which conveys the desired shade of meaning with more precision than any other, has practical consequences in the technical and even ethical conduct of a treatment.

Dropping the Matrix

Inhibitions, Symptoms and Anxiety represents the high-point of Freud's life-long meditation on the mystery of anxiety. The practical significance of the work is that it has allowed psychoanalysts to classify the different pathologies their patients present with under one or other of these headings and to see their ultimate resolution in terms of an acceptance of the impasse of castration anxiety.

Lacan proposes his matrix of the coordinates of anxiety not as another attempt to update Rene Descartes' treatise on The Passions of the Soul, in which, incidentally, anxiety is not mentioned, but as a working guide for analysts that builds on Freud's work. Our patients present us with a bewildering array of emotions and actions which can all be referred back to the core notion of anxiety and we ourselves cannot avoid taking into account the different ways anxiety may influence us in our own handling of the transference relationship. To find our way in all of this, to help us respond to our patients in a way that will shepherd them towards a fuller constitution of their desire, is the goal of the matrix. As DSM-4 shows, psychiatry has now posed a further challenge to psychoanalysis by greatly expanding the role it gives to anxiety while situating it in an almost entirely biological frame. It remains to be seen whether Lacan's strategy of preserving the Freudian triad while at the same time situating it in a broader context can contribute to the construction of a viable analytic theory of anxiety and to the effectiveness of our clinical performance in dealing with very anxious patients.

One of the difficulties in assessing the value of the matrix is, as I mentioned above, its subsequent neglect both by Lacan himself and his followers and I would like to suggest an existential reason for this failure to exploit a formalisation that is, at the very least, rich in suggestions for the solution of one of the most serious theoretical and practical problems facing analysis.

Since the split in the Parisian Psychoanalytic Society in 1953 which had led him and his colleagues inadvertently to resign from the International Psychoanalytic Association Lacan had made every effort to secure reinstatement and the renewal of the international contacts he valued so much. However the Edinburgh Congress of 1961 had indicated that his group would be re-admitted only if he were excluded permanently from the training programme. Lacan had met his giant praying mantis which was totally unwilling to offer him any recognition and indeed promised to respond to his advances by biting off his head.

On 19 May 1963, as Lacan was coming towards the end of his seminar on Anxiety, Pierre Turquet came to Paris to tell the dissidents that the International Association was not satisfied that the Edinburgh directives were being complied with. In David Macey's summary: The main problem is the continued presence of Lacan ... and the Society's failure to exclude him from the training programme. The prevailing attitude to Freud ... is not acceptable; his works are being studied obsessionally, in the manner of medieval schoolmen. There is too much concentration on the early texts and too little attention is paid to contemporary psychoanalysis'.

The detailed attention with which Lacan and his followers treated the word of Freud might have led a 'contemporary' analyst to see them as obsessional schoolmen but it must have required a better than average gift for selective inattention to treat the Freudian texts that were the pivot of the seminar on anxiety as 'early' and to ignore the seriousness of the debate that Lacan was carrying on with object relations and ego centred schools of analysis.

Our presentation today may help you form your own opinion on the justice or otherwise of this assessment and of the events that took place in the succeeding months when a section of Lacan's own group went along with the IPA's ultimatum and the remainder shared in what Lacan described as his 'excommunication'. Theywentontodevelop-perhapsasasortofpassagea I'acte motivated by their embarrassment - a style of analytic discourse much less obviously in contact with clinical experience and the Freudian texts and much more turned towards the problems of mathematical logic and epistemology which began to take a larger place in Lacan's teaching. The matrix of the coordinates of anxiety was only one of many elements developed in his middle years which Lacan let drop.

If things had turned out differently with the international community Lacan might indeed have returned to the matrix and developed more fully his theory of affects and in particular of anxiety. But though at the end of the seminar we are left with a sense of incompleteness which is emphasised by the change of style in Lacan's discourse when he finally began teaching again, it is still possible to draw from the seminar some practical consequences for the way in which we conduct our work with highly anxious patients and it is with these that I would like to conclude.

Anxiety and the Desire of the Analyst

In the course of the year or so that I have been occupied with translating and teaching Lacan's seminar on anxiety I have become aware of a curious and unexpected phenomenon. The patients most prone to anxiety and whom I had hoped to be able to help a little better because of my increased knowledge of the subject, reacted to my attempts to understand their condition with sharp and persistent rises in their levels of anxiety. It was only when I made the connection between my attempt at intellectual mastery and their disimprovement that I was able to take steps to reverse the process.

A Lacanian understanding of what was happening can be attempted in terms of the coordinates with which we have become familiar. My focus on the seminar and my increased interest in the anxious patients whom I hoped would provide experiential, or even experimental, verification or otherwise for the theses being advanced in it was in effect a passage a I'acte, an abandonment of the analytic stage which left the patients with nobody to receive their word. With one patient in particular the theme of being abandoned by the mother for long periods of childhood and of being unable to get past the mother's preoccupations even when she was physically present was repeated so often and with such obvious distress that I eventually heard what was being said and reined back my desire to understand and my search for verification.

This is a good illustration of what is a major question for Lacan in his attempt to form practitioners. What desire should inhabit an analyst for him or her to maintain the position that allows an analysis to take place?

In the seminar on anxiety he discusses proposals that range from Margaret Little's notion of assuming total responsibility for every aspect of the patient's life to Thomas Szasz's support for an ideal of scientific detachment in psychoanalytic work. For Lacan the desire of the analyst must not be that of an ideological master who thinks he can mould the patient in accordance with orthodox beliefs, even if the orthodoxy in question is psychoanalysis; nor should it be that of the university researcher striving to find objectifiable patterns in the speech and behaviour of the analysand; nor again that of the hysteric who takes the patient as the one who knows and abandons the direction of the treatment to him.

It is more difficult to state in positive terms what the desire of the analyst should be and it is no doubt impossible to formulate it univocally. At a first approximation it is the wish not so much to cure one's patients or to secure what you think is good for them as to introduce them to their own desire. It is because this desire has not been properly constituted that the patient is anxious. Allowing analysands to become desirers means helping them to tolerate their own lack rather than pretending that this lack can be filled by greater self-knowledge or ego-strength. There is nothing mystical about this insistence on the maintenance of a dimension of lack and desire. It is simply an extension of Freud's notion of analysis as a process that uncovers what has been repressed into the unconscious and as a treatment which owes its efficacy to transference love. But in the seminars of the early 1960's Lacan began to criticise Freud's approach as placing too much emphasis on the diachronic dimension and not enough on the synchronic.

This implies a particular approach to the phenomenon of transference. The stress on the diachronic sees transference phenomena as repetitions of the past which the subject can be got to see as inappropriate to current life circumstances. Witih respect to the topic of this paper in particular it tries to show that anxiety arises from the re-awakening of experiences of object-loss in early childhood, losses which Freud sees as giving rise to separation anxiety, castration anxiety, super-ego anxiety. The analyst's task is to encourage the analysand to remember and work through these early experiences and to analyse the projections that are repeated in the sessions. Whether the analyst emphasises here-and-now interpretations based on counter-transference reactions or focusses with the detachment of a surgeon on a detailed reconstruction of the past the goal is the increase of the analyst's and the analysand's understanding of what has been at the root of the current anxiety. The supposition is that this will slowly resolve the anxiety, or help the patient to live with it, as the analyst's consistent tolerance helps him to realise that there is nothing to be anxious about and that his apprehension is simply a meaningless relic of infancy.

Lacan argues that this emphasis on knowledge has the effect of barring the subject's access to his own desire. The repetition of the slogan that anxiety is a fear without an object and that if the subject realises this his anxiety will evaporate he compares to children whistling in the dark to keep up their courage. Anxiety has an object and that object is the real which manifests itself where it is unexpected. In his more precise terminology it is the appearance of an o-object in the field of i(o). And this is what the analyst must allow to occur in the analytic situation.

Rather than presenting himself as a benevolent, understanding mother- figure who is there to provide emotional re-education for someone whose early history has been traumatic in various ways, an i(o) with whom the patient can identify, the analyst must be prepared to withdraw as far as possible from the dimension of the imaginary and the symbolic in order to embody the real o-object for the analysand. In order to do that he must ensure that the question of the analyst's desire is kept alive for the analysand: 'What does he want of me?'

What is called a Lacanian analysis requires that the analyst should govern his tongue to a quite exceptional degree and intervene not so much with interpretations of an explanatory kind but with ones that highlight the dimension of non-sense in the analysand's discourse. Lacan does privilege Freud's early work in the sense that he considers dreams, slips of the tongue and jokes to be indispensable paths for introducing a patient to the secondary role played by conscious knowledge and motivation in the determination of his behaviour and to the primacy of unconscious desire in the fate of every speaking being. The primary duty of the analyst is to recognise where this desire manifests itself, not in Ms or her counter-transference reactions, but in the gaps of the spoken discourse. It is only where this manifestation occurs that a properly analytic interpretation can be made. In Lacan's teaching one of the most effective ways of making such an interpretation is to end the session.

This has the effect of mobilising the patient's desire but may also run the risk of increasing the patient's anxiety and as a result that of the analyst. Lacan suggests that analysts' anxiety about their patients' capacity to tolerate the difficulties involved in assuming their own desire motivates their practice more than they realise. Behind the desire to spare their patients there lies a desire to spare themselves, an obsessional mechanism which analysts are only too prone to adopt if they make the cure of patients and their adaptation to the conventions of their milieu the primary goal. The cure comes as a bonus, he liked to repeat, stressing however that this implied no lack of care for the patient. On the contrary: 'our justification and our duty is to ameliorate the position of the subject'.

The question is whether this is to be done by abandoning psychoanalysis in favour of methods that put us and our patients at less risk or whether our desire to be analysts is strong enough to allow the strangers who come to us to sustain the anxiety they must endure if they are to escape the alienation of the generalised life, refuse to yield on their desire and keep the rendezvous with their own destiny. And lest this may appear a piece of irrational European romanticism let me end with an unmistakeably American voice, that of Robert Frost:

Ah, when to the heart of man

Was it ever less than a treason

To go with the drift of things,

To yield with a grace to reason,

And bow and accept the end

Of a love or of a season?'

Thank you.

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