1. Dr Gerard Moore Dublin City University
Lacanian theory usefulness in understanding critical incidents which reflect the trauma that precipitated admission
Dr Gerard Moore
Dublin City University

2. The trauma
‘They still warrant an admission because they are very unwell and their families are sick of them’

3. Inscription of Trauma
Trauma is marked by “an event in the subject’s life defined by its intensity, by the subject’s incapacity to respond adequately to it, and by the upheaval and long-lasting effects that it brings about in the psychical organization” (LaPlanche and Pontalis, 465).
Trauma or wound is an inscription on the body of something that can not be spoken

4. Beginnings of an understanding of Trauma
Initially, Freud believed that all neurosis was a result of previous traumatic experience (“seduction”), and could be cured by abreaction and catharsis. His view changed in favour of an emphasis on the child’s sexual fantasies and the excitement they provoked
Actual, real trauma was downgraded as a causative factor, in favour of the excitement and guilt over instinctual sexual fantasies
Later analysts placed more emphasis on the importance the mothering relationship provided for the developing infant

5. ‘Sick of’
‘You see how busy we are and bed blockers, there does not seem to be anywhere for them to go – ahm – you talk to the consultants, their hands are tied as well. Yet some of them, in the community, they just seem to have the same patients, you know, good patients if you know what I mean, if there is such a thing as good patients, but they are the ones that they want and they don’t want the troublesome ones or ones that they have to work at’
‘What is fundamental is that transference love – as Freud rightly pointed out – is true love, and love, in turn, is necessarily a deception’(Harari, 2001)p96.

6. What is the paper about
The subject – Other relationship - unconscious aspects of human relations

7. Who is the Other?
The Other is the unconscious, language, the (m)Other and later authority figures both real and imagined and the subject is constructed in the split between conscious and unconscious, always alienated, feeling somewhat incomplete, lacking some knowledge and desiring to be desired in order to redress this balance
This fundamental structure of the human condition creates a world in which those who possess knowledge have a privileged position in the unconscious of those who seek it

8. Lacan’s Discourse Theory
The four discourse are Lacan’s description of the nature of social order, what binds society together, his way of structuring social interaction, they represent the fundamental elements of social reality (Novie, 2008)
Master
University
Hysteric
Analyst

9. Psychoanalysis as a treatment
Psychoanalytic theory holds that interpersonal relationships are influenced by unconscious process, transference – a manifestation of these processes, can be managed to positive effects in the context of a alliance
With a psychoanalytic orientation, ‘helping insights to develop, freeing thinking about problems, helping the client to get away from unhelpful methods of thinking and behaving, facilitating the evolution of ideas for change, and then helping him to bear the anxiety and uncertainty of the change process’, positive change can be achieved {Menzies Lyth, 1989 #30} p33
The work of psychoanalysis is the work of relationship management
It is simply put the talking cure

10. Transference
The attribution of the qualities of a significant person from the past onto a person in the present
When we experience strong feelings of love or hate in an interaction there is an attempt to rationalise what is occurring. Conscious rationalisation invariably attributes the reaction to the social situation the overt relationship to anOther
Psychoanalysis’s concept of transference exposes the unconscious source, purpose and potential of these powerful affects

11. Love
‘Things that have to do with love are incommensurable with everything else’ (Freud, 1915b)p160
The challenge of being loved or hated is too great and results in a flight into science, which in its failure to provide a workable method for managing the subject-Other relationship leaves staff in a therapeutic and theoretical vacuum where engagement with the patient is kept to a minimum

12. The Hospital is ill
‘Transference occurring with the greatest intensity and in the most unworthy forms, extending to nothing less than mental bondage, and moreover showing the plainest erotic colouring’ (Freud, 1912)p101
‘The breaking out of a negative transference is actually quite a common event in institutions. As soon as a patient comes under the dominance of the negative transference he leave the institution in an unchanged or relapsed condition’ (Freud, 1912)p106
‘Transference is determined by the function it has in a particular praxis’ (Lacan, 1994)p124

13. Signifiers are inadequate
The signifier is nothing if not inadequate
Inadequacy has to do with the way the signifier comes into being out of nothing
The signifier comes into being only insofar as it marks the subject with a certain lack, something of a primal plenitude is lost
This is always imagined as the symbiotic relationship between the child and the mother. The traumatic loss of this primal experience of satisfaction, this original homeostasis, is the price the subject must pay for entry into the symbolic and the differential relations of desire
The signifier cuts the subject, leaving a gap or lack. This lack splits the subject. The subject also registers the signifier's inadequacy insofar as it is the signifier that is inadequate to fill in or make a complete restitution for the traumatic loss the subject suffers as its split. The signifier, that is, cannot make good the loss the subject suffers
What is lost (castrated) is a certain guarantee that satisfaction can be attained through the signifier. One always has a failed relation to a primary experience of satisfaction
This failure, this cut on the body, marks the birth of knowledge and its counterpart, desire. It marks the birth of the human as desiring subject

14. Trauma and the Real Register

15. Encounter with the Real
Trauma occurs when there is an encounter with the Real, which is that which denies signification. Something is encountered and all words cease and all categories fail - the object of anxiety par excellence
This encounter with the real is an encounter with a something – something that defies description
The Real is the state of nature from which we have been forever severed by our entrance into language
The real is impossible
We cannot express it in language because our entrance into language marks our irrevocable separation from the real
The real exert its influence throughout our lives since it is the rock against which all our fantasies and linguistic structures ultimately fail
The real erupts whenever we are made to acknowledge the materiality of our existence, an acknowledgement that is usually perceived as traumatic

16. Unspeakable belongs to the real
If something can not be represented it can only come to a halt in front of the mysterious Real Order
This is the order where life meets only death and enjoyment
The real order can not be spoken about for it does not belong in language

17. Sexuality (trauma) leads to silence
There is something which language cannot express, but which demands recognition; Freud saw this in the painful symptoms of the hysterics, there was something related to sexuality
His patients could not talk about it, so instead of expressing sexuality verbally the revealed the marks of sexuality on their minds and bodies

18. Living challenges our beliefs creates anxiety

19. Symbolisation
Encounters with the Real are traumatic experiences where the “link between two thoughts have succumbed to repression and must be restored” through moving the event into the realm of the Symbolic (Fink 1997)
In analysis the patient would symbolize whatever has led his or her desire to become fixated or stuck (Fink 1997)
The desire is not to symbolize the entirety of the Real (as that would not be possible), but instead to symbolize that which the patient has become fixated on, the traumatic Real

20. Trauma as a place holder
Lacan’s theory suggests that an encounter with the Real acts as a place-holder and the true trauma only occurs belatedly and through repetition
This repetition of the event can activate symbolic meaning where the “scene was traumatized, elevated into a traumatic Real, only retroactively, in order to help the person to cope with the impasse of his symbolic universe” Žižek 2006
This notion of belatedness creates a chain
There is a Real(1) corresponding to a Symbolic(1) that creates anxiety in a person who has become fixated on the Real(1)
Through analysis, the person signifies the event draining a portion of Real(1) away and into the Symbolic, creating a new Symbolic(2) and Real(2)

21. Two distinct phases following trauma
Initial breakdown when our defences are breached by trauma, and there may be a catastrophic disruption of functioning. There is a sense of impending danger and that death is imminent, or that one is threatened by total annihilation of the self. The person is often shocked and confused, perhaps unable to take in what has happened
The person may attempt to return to normal functioning by seeking a rational explanation for the event – attempting to explain it – understand it make sense of it. They seek to attribute cause or blame to an agency either external to themselves (“It was the other driver’s fault.”), or internal (“If you hadn’t made me feel so bad….”) that is felt to be responsible for their predicament
In the wake of a catastrophe, we are all likely to feel intensely persecuted, and we may link this with deep suspicions we harbour unknowingly about the unreliable nature of those whom we usually trust to care for us
There is a loss of belief in the fundamental goodness of loved ones – how could they let this happen? Sometimes people wish to make sense of the experience by searching for meaning. A trauma in the present may be linked up with troubled relationships and disturbing events from the past which have previously been more or less manageable. And the sense of meaning that is discovered is held on to in an entrenched way that may eventually influence later relationships.

22. Apparent damage
One seeks to understand the way in which the person links the traumatic event with the frightening phantasies of their internal world that belong to an occasion in earlier life when the survival of the self was threatened.
An important sequel for some people, is the loss of a capacity for thinking about mental states and emotional experience, after the event
It may be as though the mind no longer has a capacity to sort out incoming signals – if the feared sound, sight, smell, etc. is re-experienced, the mind responds with an immediate flood of anxiety
Flashbacks refers to the sense that you are not just thinking about something that happened in the past but reliving it in the present
As though a function of the mind that previously provided an ability to contain anxiety has been disrupted. The internal space in which one could think about events has been lost, and the past becomes real in the present , accompanied with a flood of anxiety
The patient is so overwhelmed by this trauma in his adult life, because it links with, re-enacts, a previous circumstance in which the infantile self was overwhelmed that the very survival of the self was threatened

23. Repetition
The compulsion to repeat the event, either in a directly recognisable form, or symbolically emerges. This repetition is a sign that something has not been worked through
Traumatic experience is grounded in the repetition of an impossibility, it is indelibly tied to the real beyond the signifier
It is tied to the materiality of the signifier and, therefore, to our social and linguistic destiny
This drives the subject beyond the social to an encounter with the inadequacy of the signifier as she moves beyond the particular event of her suffering to a failed encounter with the very possibility of knowing that suffering completely
The psychoanalytic intervention assures us, then, that we are responsible in the face of something that exceeds symbolic guarantee.

24. Love in a hopeless place
Asking the patient to re-tell the traumatic experiences, in the hope of relieving stress, only exacerbates the severity of symptoms as if the trauma experienced has resulted in damage to the structure of the mind
What is required is an opportunity to develop a new relationship via the social bond the transference that emerges in the analysis

25. Conclusion
Central to the work of the mental health services is the patient, without the patients the can be no services, this should be the service aim to have no patients.
This aim can only be achieved if patients are enabled to speak and to speak in their own language.
The most radical thing staff could do is listen and listen carefully by setting aside the formality of assessment and categorisation by abandoning the structured formation of dancing in unison and adopting an appreciation for the individual subjective Sean-nós expressionism of the patient; recognition that madness is rendered meaningless by ignoring the concept of truth.

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