The subject in an uproar: a Lacanian perspective on panic disorder.

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The Subject in an Uproar: A Lacanian Perspective on Panic Disorder Glenn Strubbe and Stijn Vanheule J Am Psychoanal Assoc 2014 62: 237 originally published online 20 March 2014 DOI: 10.1177/0003065114527616 The online version of this article can be found at: http://apa.sagepub.com/content/62/2/237

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APAXXX10.1177/0003065114527616Glenn Strubbe / Stijn VanheuleThe Subject In An Uproar

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Glenn Strubbe / Stijn Vanheule

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The Subject in an Uproar: A Lacanian Perspective on Panic Disorder From Jacques Lacan’s theory of anxiety, principles are deduced for a Lacanian-oriented treatment of panic disorder. This Lacanian approach is related to Freud’s theory of the actual neuroses, and is comparable in some ways with the approach taken in Panic-Focused Psychodynamic Psychotherapy (PFPP). The Lacanian conceptualization of panic retains the idea that both repressed material and unsymbolized mental states lie at its basis. People suffering from panic attacks are overwhelmed by signifiers, aspects of corporeal excitation, and/or existential questions that remain too Real. Psychoanalytic therapy aims to create a name for such Real elements. The three registers that Lacan situates at the basis of his psychoanalytic approach (the Symbolic, the Imaginary, and the Real) are discussed, as well as the treatment principles for conducting this clinical work. The case study of a young woman with panic disorder is presented to illustrate how a brief, Lacanian-oriented treatment (fortyeight sessions) progressed, and where the patient managed to both name and find a symbolic place for psychic experiences that were too Real. During this treatment, the patient overcame her avoidantdefensive mode of functioning and her persistent difficulties related to separation. Keywords: anxiety, Lacan, neurotic disorders, panic disorder, psychoanalysis Birth, and copulation, and death. That’s all the facts when you come to brass tacks: Birth, and copulation, and death. —T. S. Eliot (1932, p. 25)

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he starting point for any psychoanalytic reflection on panic disorder should be sought in Freud’s early work on “anxiety neurosis” (1895). Freud grouped this neurosis with neurasthenia (later adding

Glenn Strubbe, Member, Circle for Psychoanalysis, the New Lacanian School; Teaching Assistant, Department of Psychoanalysis and Clinical Consulting, Ghent DOI: 10.1177/0003065114527616 Downloaded from apa.sagepub.com at UNIVERSITY OF BRIGHTON on June 2, 2014

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h ypochondria) under the rubric of the “actual neuroses,” which he contrasted with psychoneuroses such as hysteria and paranoia (Freud 1894, 1896). The symptoms typically associated with the actual neuroses were limited to bodily phenomena (i.e., unprocessed anxiety and somatic anxiety equivalents) against which the individual has no defense (Freud 1895, 1892–1899; see drafts B and E). Freud (1895) hypothesized that the central mechanism of actual neurotic phenomena was a supposed “deflection of somatic excitation from the psychic sphere” (p. 108). Actual neurotic phenomena result from the individual’s confrontation with somatic excitation that cannot be linked to mental representations (or at least has not been) and thus produces a reaction of Hilflosigkeit, or helplessness (Freud 1926; Verhaeghe, Vanheule, and De Rick 2007). For Freud, in actual neurosis something is presented in the mind, as opposed to being represented symbolically, the latter indicating a certain mediation via mental representations (Scarfone 2013). By contrast, the mechanism of the psychoneuroses is to be found at the level of a psychical elaboration (both representational and defensive) of infantile sexuality. Thus, its accompanying symptoms are largely signifying in nature, and their defining characteristics concern a defense against inner conflict related to sexual desire. Freud located the cause of the actual neuroses at the level of the drive and connected them to problems in the patient’s present-day life, rather than in a repressed event or constellation of events from the past. In this respect, Freud believed that anxiety neurosis was not suitable for classical psychoanalytic treatment and its method of exploring unconscious conflict. Indeed, in Freud’s view, what we now term panic disorder does not even qualify as a symptom, as it cannot be considered a defensive construction against representations deemed unacceptable by the superego. Instead, panic reflects an immediate “automatic” or “traumatic” form of anxiety, which in itself is meaningless, and it is for precisely this reason that it overwhelms the subject (Freud 1926). Such automatic anxiety differs from what he called signal anxiety, which can be understood as anxiety-laden representations (e.g., culminating in a phobia) or warded-off images and ideas (Verhaeghe 2004). Later theories that build on this Freudian model also stress this component of automatic anxiety in panic disorder, rather than conceptualizing it as a symptom that can be deconstructed via an analysis using interpretation. For instance, Verhaeghe (2004) defines panic as an actual

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University, Belgium. Stijn Vanheule, Associate Professor of Psychoanalysis and Clinical Psychological Assessment, Ghent University, Belgium; Member, the New Lacanian School and the World Association of Psychoanalysis. Downloaded from apa.sagepub.com Submitted for publication June at1,UNIVERSITY 2012. OF BRIGHTON on June 2, 2014

THE SUBJECT IN AN UPROAR

neurotic phenomenon (p. 203) that reflects a nonrepresentational expression of endogenous excitation. Other authors refer to this as “problems with mentalization.” For example, Fonagy and colleagues (2002) suggest that at the root of certain panic disorders one might find dysfunctional mirroring of internal states in early attachment relations, rendering them “unlabeled, confusing, and experienced as unsymbolized” (p. 219). This focus on unmentalized states is consistent with Freud’s suggestion that panic reflects automatic anxiety (Verhaeghe, Vanheule, and De Rick 2006). Whereas Freud was quite pessimistic about the analyzability of panic as an actual neurotic phenomenon, a substantial number of authors believe that panic should indeed be thought of as a defensive symptom. The Weill Cornell group has been breaking new ground in this respect (see, e.g., Milrod et al. 1997, 2007; Rudden et al. 2003; Busch, Milrod, and Sandberg 2009). In this context, Milrod, Rudden, and Busch have developed PanicFocused Psychodynamic Psychotherapy (PFPP) and documented its efficacy in a number of recent RCT studies (Beutel et al. 2013; Klein et al. 2003; Milrod et al. 1997, 2007; Busch, Milrod, and Sandberg 2009). Like Freud, these authors make a distinction between automatic and signal anxiety. However, while automatic anxiety is thought to play a role in panic (Busch and Milrod 2010), so too is unconsciously determined signal anxiety: “clinical work and research suggest that panic patients have particular difficulty with angry feelings and fantasies toward close attachment figures, such as wishes for revenge. These wishes are felt to represent a threat to attachment figures, which triggers overwhelming anxiety. . . . Becoming conscious of these aspects of mental life and rendering them less threatening are important components of psychodynamic psychotherapy for panic disorder” (p. 30). In other words, unlike Freud, these authors consider panic a defensive symptom: “Panic attacks, like all symptoms, are multidetermined intrapsychic phenomena” (Milrod 1998, p. 687). Panic is understood as determined by oedipal or preoedipal psychic conflict, combined with ego weaknesses that hinder the psychic elaboration of such conflict (Milrod et al. 1997; Busch et al. 1999). Typical conflicts underlying panic are understood to be related to fear of separation or “suffocation” in close relationships, leading, for example, to ambivalent attitudes with respect to autonomy and dependency (Rudden et al. 2003; Busch, Milrod, and Sandberg 2009), or to “fears of acting on frightening sexual, aggressive or exhibitionistic impulses” (Rudden et al.


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2003, p. 1001). Indeed, panic episodes “often involve conflicted wishes about independence and separation, complicated by the expressions of sexuality and aggression that accompany autonomy” (Rudden et al. 2003, p. 1001). The developmental approach adopted by PFPP is largely consistent with an attachment-based understanding of anxiety disorders (Nolte et al. 2011). In line with its theoretical viewpoint, PFPP aims to work through the unconscious meaning of panic at the level of interpretation, and toward facilitating the patient’s understanding of core unconscious conflicts through the mechanism of transference. Lacan’s model of panic integrates lines of thinking from both models: certain cases of panic may be based on repression, while others may be based on nonrepresented, drive-related tension. In other words, the study of panic should not so much revolve around the question of whether repression can be found at its basis: like Freud (1926) in his later work, Lacan seems to emphasize that actual neurosis and psychoneurosis are usually mixed. However, what Lacan stresses most is that an experience of being overwhelmed is pivotal to panic: a so-called Real element invades consciousness and creates a sudden experience of helplessness. As we explain below, one often finds beneath this a strong “passion for ignorance” (Lacan 1953–1954, p. 277) and a tendency to avoid issues that affect the individual at the core of his or her subjectivity. But before discussing this line of thought, we will first outline Lacan’s distinction between the three registers he situates at the basis of his psychoanalytic work: the Symbolic, the Imaginary, and the Real. T h e S y m b o l i c , t h e I m a g i n a r y, a n d t h e R e a l

Whereas Lacan organized his work around the slogan of a “return to Freud,” it should not be forgotten that it was by introducing a new set of concepts, aimed to preserve the radically innovative message he discerned in Freud’s work, that his Freudian excavation was achieved (see Feldstein, Fink, and Jaanus 1996; Lacan 1953–1954). In this respect, the Symbolic, the Imaginary, and the Real are crucial concepts that pervade the entire period of his teaching (Voruz and Wolf 2007). For Lacan, the Symbolic stands for the inherently structured way we experience the world: humans use language to mentally classify objects and events and, ultimately, to construct reality. For Lacan, both mental life and the process of psychoanalysis is structured around the fact that as 240



people think and speak, they concatenate signifiers in signifying chains. In this context, Lacan adopts the notion of the signifier from Saussure (1916). According to Saussure, speech is composed of signifiers and signifieds. The latter are the ideas or representations that speech evokes and thus are the semantic content of speech. Since all understanding of that content constitutes building mental images, Lacan qualifies this dimension as the Imaginary. Signifiers, by contrast, make up the Symbolic and are the material linguistic building blocks to which representations are attached. Just as computers are programmed to make meaningful operations via the mere combination of numerical digits, so humans generate meaning by combining syllables into words and, by following grammatical conventions, combining words into sentences. Signifiers are connected in chains and webs, or structures, which are like skeletons around which bodies of meaning are constituted. Lacan (1956) believed that structures or clusters of signifiers lie at the basis of symptoms as well as at the root of everyday behavior. Symptoms are like metaphors in that they represent and condense single or multiple lines of speech and representation, which can be unraveled. In his view, repression is a languagebased process, in which signifiers that carry painful or anxiety-provoking associations are kept out of consciousness. For Lacan, such repressed signifiers make up the unconscious. Lacan frequently linked the register of the Symbolic with the concept of the Other. The signifiers we use and the explanatory structures we adopt to make sense of ourselves and the world are acquired through significant others. While we incorporate signifiers from others, once we speak we experience these signifiers, and their associated meaning, as our own. The Imaginary, in its turn, refers to the tendency to discern gestalts or images, on the basis of which a person develops delineated and coherent experiences of self and world, resulting in a narcissistic feeling of completion. Thus, Lacan conceptualized the ego as an Imaginary construction. The ego, in his view, consists of images we have about ourselves and strives for unity of self-experience. More specifically, Lacan suggests that Imaginary tendencies lie at the basis of repression. Like Freud, Lacan assumed that the repressed always returns, and to come to grips with repression he recommended that analysts pay careful attention to the signifiers a patient uses. Words and speech are always ambiguous, and by pointing to this ambiguity, the analyst can invite patients to explore the signifieds that disturb them. As Fink (2007)


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indicates, Lacanian psychoanalysts do not attempt to clarify or explain the meaning of symptoms to the analysand. Rather, they aim to put the analysand to work with his unconscious. By pointing to peculiar signifiers in speech (i.e., words or word sounds that repeatedly emerge in sessions, hesitation to utter specific words, avoidance in speech), they invite the patient to explore and clarify conflictual ideas expressed in their symptoms and in their use of speech. While the ego is driven by a “passion for ignorance”—“a psychic power which urges patients to prefer the deleterious status quo of their symptomatic condition over the even more painful encounter with that which caused it” (Nobus 2000, p. 24) —the analyst is driven by “analytic desire.” In this way, Lacanian analytic work differs significantly from classical analytic work; “psychoanalysts of many non-Lacanian persuasions still cleave to the idea that the analyst, in interpreting, offers the analysand specific significations; Lacanians, however, strive to interpret in such a way . . . that the analysand finds the significations himself, or comes face to face with the fact that what he has been saying makes no sense at all” (Fink 2007, p. 83). As Miller (1996) puts it, there is nothing that interprets in a better way than the unconscious itself, and sometimes the only work of the analyst is to support the unconscious, qua libidinal language machine, in doing its work without interfering too much. While the Symbolic encompasses language insofar as it structures reality, and the Imaginary refers to an image-creating and consistencyseeking mental activity, the concept of the Real refers to the unstructured and senseless elements that pervade human reality (Eyers 2012; Fink 1996, 1997; Vanheule and Verhaeghe 2009). No matter how well we are ensconced in language or how well our ego functions, the human subject is plagued by impulses and experiences that perturb him and can be overwhelming. At the core of our self-experience, aspects of profound otherness and strangeness that cannot be reconciled with our selfimage will always be found. Hence Lacan’s remark that our mental life is characterized by “extimacy,” elements of exteriority that pervade our deepest interiority (Miller 1994). Consider the unease Little Hans experienced around his infantile erections (Freud 1909) or the astonishment Schreber experienced as he first had the impression that it must be beautiful to be a woman submitting to the act of copulation (Freud 1911). In both cases, an element of excess, which Lacan qualified as Real, overwhelmed the ego of the symbolically determined subject. Examples of

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such an overwhelming Real can also be found in life-threatening traumatic experiences that repeatedly return in dreams. In this respect, Lacan’s concept of the Real is connected to Freud's concept of “the actual”: In the actuality of his life, the patient is overwhelmed by an element that he or she can make no sense of. Interestingly, Lacan posits that in the midst of subjectivity, the Real can be found. This is because our idea of who we are is characterized by a radical not-knowing. More specifically, Lacan (1959) argues that the ego covers up a fundamental question—Who am I?—that returns at the level of the unconscious and can be triggered by a variety of life events. This existential question typically revolves around four fundamental issues: sexuality and sexual identity, procreation, relationships and love, and life and death (Eyers 2012; Vanheule 2011). Such issues will stir the subject, as they carry with them a certain inaccessible Real component, which always escapes the subject. On the other hand, this fundamental question forces the subject to determine his or her identity by articulating a subjective response, and thus a position, via language. This is the Symbolic component of the problem. The only way the subject can accomplish this response is by constructing a verbal narrative around this Real component. In clinical work, the Lacanian analyst aims at what Fink (2007) calls “hitting the real” (p. 77). Through his interventions, the analyst seeks “to inspire or to provoke the analysand to engage in the process of symbolization” (Fink 2007, p. 76), so that he can coin a name for what disturbs him. This kind of work is meant not only to prompt the analysand to explore and articulate repressed signifieds or warded-off fantasies and ideas, but also to impel “him to strive to put into words what he has never said before” (Fink 2007, p. 81). Mobilizing this process, which will allow the analysand to explore what he has never before examined, requires interventions that often must be provocative, surprising the analysand to the degree that he actively investigates the otherness of the Real that lies in the midst of his own subjectivity. Indeed, often the interpretation “must startle, perplex, or disconcert the analysand” (Fink 2007, p. 77). The Real is approached via but never by the signifier. A special technique Lacanian analysts use in this context is variable-length sessions. The underlying idea is that sessions should not be ended when the analytic hour is over, but at moments when a poignant, surprising, or difficult theme comes to the fore in the analysand’s speech. Thus, some sessions are shorter than


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standard sessions, while others are longer. Stopping the session at such significant moments makes the analysand more attentive to the otherness in his own speech. It aims to mobilize analysands to negotiate the element of strangeness in their utterances. The case discussed later illustrates this. Anxiety as the “Lack of a Lack”

In the 1940s and 1950s, anxiety and panic didn’t interest Lacan a great deal. Focusing on anxiety, he thought, only diverts our attention from what is really at stake in psychoanalysis, namely, the logic of the signifier (Lacan 1949, 1953–1954, 1959). But then, during the academic year 1962–1963, Lacan held a seminar on anxiety in which a clear change in his thinking can be observed. He addressed anxiety and panic as problems at the intersection between the Symbolic and the Real (Miller 2005), and suggested that anxiety comes to the fore if a Real element breaks through the Symbolic-Imaginary framework, that is, the framework within which an individual defines his position in the world. On the one hand, this Real element might be a signifier that suddenly appears in an unexpected context: the unexpected appearance of a signifier that directly or associatively refers to a repressed signified (a fantasy, a wish) and overwhelms the ego. Here Lacan retains Freud’s reference (1919) to Schelling, who stated that the Unheimlich, the uncanny, is the name for “everything that ought to have remained . . . secret and hidden but has come to light” (p. 224). This evokes helplessness, to which the experience of panic bears witness. An example of this is to be found in the Freud-Fliess correspondence (Freud 1887–1904; see also Vanheule 2011). In a letter dated December, 29, 1897, Freud discusses the case of Mr. E, who had had an “anxiety attack at the age of ten when he tried to catch a black beetle” (p. 290). During a session Mr. E, when speaking about the attack, associated the word beetle (Käfer in German) to the word ladybug (Marienkäfer). Before making this connection Mr. E had been talking about his mother, whose name was Marie. In other words, the theme of his mother established the basis for further associations. In the train of associations, the name Marie led to the word Marienkäfer. Further, when talking about his mother, Mr. E recalled a conversation he had overheard between his grandmother and an aunt when he was a child. The conversation was about his mother’s marriage, and “it emerged that she had not been able to make up her mind for quite some time” (p. 290). As a child, 244



Mr. E had had a French-speaking nurse, and thus learned to speak French before learning German. Just before the following session, “the meaning of the beetle [Käfer] occurred to him; namely: que faire? = being unable to make up one’s mind . . .” (p. 290). The French phrase que faire? (what to do?) expresses his mother’s hesitation about her marriage, an idea that Mr. E obviously avoids. The case shows that in uncovering the unconscious determinants of this patient’s anxiety attack, the signified “bug” or “beetle” is misleading: anxiety doesn’t arise in relation to a particular species of insects. What matters is the signifier: for this man, who subsequently spoke German, Käfer sounds like the expression que faire? from the language of his childhood. Unconsciously, both make up the same signifier. After all, they sound the same. The sudden appearance of the beetle/Käfer is associatively linked with the perturbing issue of his mother’s hesitation about her marriage, of which he, as her child, is the product. This is overwhelming: hence his panic. Indeed, challenging Freud’s idea (1926, pp. 184, 191) that anxiety can be related to loss or castration, Lacan argues that the most fundamental form of anxiety concerns not the lack of something, but the experience of an object or representation that appears where it shouldn’t—hence his hypothesis that anxiety concerns “the lack of a lack” (Lacan 1962–1963, p. 53). Whereas repression creates a lack in the field of mental representations, the sudden emergence of a repressed element renders this lack lacking, to which the primitive experience of panic bears witness (Lacan 1962–1963, p. 187). While the theoretical approach of Lacanian psychoanalysis and PFPP clearly differ in many ways, it is on this point that they agree: radically warded-off elements of mental life (fantasies, memories) can be the unconscious origin of panic. On the other hand, the Real element lying at the basis of panic always has a bodily component of overwhelming corporeal excitation. Starting from Freud’s text on anxiety neurosis (1895), Lacan (1962–1963, pp. 197–198) states that parallel to the representational process, anxiety and panic are marked by an overflow of excitation in the body. Referring to little Hans, Lacan states that what is most terrifying to a male child in the castration complex is not the threat of losing his penis, but the experience of an erection (pp. 57–58). Whereas before the experience of infantile erection the penis is a relatively neutral bodily appendage, sexual stimulation brings about an experience requiring a certain reorganization of the self-representational system. Indeed, at first the penis is not an


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issue, and is marked by a lack. The sudden experience of bodily excitation renders this lack lacking, and the direct effect of being unable to handle this excitation is the eruption of anxiety. Lacan (p. 361) suggests that such excess of excitation will be experienced as “bodily dismay.” In other words, the individual fails to make sense of certain experiences by means of the signifier, and as a result is shaken to the core; the body, so to speak, spirals into a state of uproar. Lacan illustrates this with reference to Freud’s case study of the Wolf Man (1913), who freezes at the sight of wolves sitting in a tree in one of his dreams. This dream, in fact, refers back to a similar reaction of growing stiff as he witnessed the primal scene of his parents copulating. This scene affected him intensely, yet as he could not weave symbolic meaning around it (he lacked a signifier for it) he was subsequently unable to position himself as a desiring subject. In the case of the Wolf Man, the accompanying bodily disarray manifested at the anal level, which in Lacan’s opinion is typically the case in obsessional neurosis (p. 361)1; here the child defecated while witnessing sexual intercourse between his parents (see Vanheule 2004). With this focus on the Real qua overwhelming corporeal excitation, Lacan clearly draws something from Freud’s theory of actual neurosis, as do other psychoanalytic schools that situate an unrepresented, unassimilated element at the heart of the unconscious. Moreover, Lacan connected the experience of panic to the fundamental existential question that repeatedly returns in the unconscious: “Who am I?” In 1959 Lacan suggested that the experience of panic can emerge when the subject has been faced with the Real of its own existence, but fails to determine its own identity in response to this by articulating its subjective position via language. Panic bears witness to a failure at the level of a Symbolic response. Thus, the persistent question “Who am I?” remains unaddressed, far too Real, and, most of all, overwhelming (Lacan 1974). Interestingly, Lacan did not connect his theoretical ideas around panic to developmental trajectories potentially at its root. His line of thinking is thus different from the PFPP approach to panic. Lacan’s theory provides the logic of how subjectivity is structured, but it does 1In hysterical neurosis, such “bodily dismay” will manifest primarily at the oral level in many cases. This can be observed in the case of Katharina, who reported her reaction to a primal scene as follows: “My throat squeezed together as though I were going to choke” (Freud 1895, p. 126).

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not intend to explain how this comes about: “A Lacanian psychoanalyst works with words and language, not with prospective information on human development, and is less concerned with making causal speculations with respect to arrests in mental development or problematic family dynamics” (Vanheule 2011, pp. 50–51). This should not be taken to suggest that the question of what may lie at the root of one’s panic is not relevant in therapy, but a Lacanian answer to such a question will always be open-ended. Here we see the centrality of the Real in a Lacanian treatment of panic. Panic suggests that a person has been overwhelmed: by the sudden appearance of a repressed signifier, by overwhelming corporeal excitation, or by the emergence of an existential question. Thus, the Lacanian analyst will treat panic by bringing the analysand to the point of acknowledging and naming the Real element that challenges his self-experience. In certain cases, the analyst will provide brief suggestions as to what is disturbing for the patient. Yet such suggestions are meant not to explain to the patient why he acts the way he does, but rather to simply mobilize the Symbolic. In other words, the aim of such interventions is to generate new associative material in the patient’s speech, and thus augment (sometimes only minimally) or realign the subject’s position with respect to his narrative and self-image (Hoornaert 2007; Vanheule 2004). This objective of stimulating Symbolic elaboration may resemble Freudian-based practices intended to engender symbolization. Yet, contrary to what takes place in PFPP or in mentalization-based treatment (Bateman and Fonagy 2004), the Lacanian analyst does not seek to review the patient’s emotional life or provide explanations of the unconscious processes that disturb him. Nor will the Lacanian analyst use his own mental life as a mirror or frame of reference to grasp the patient’s internal mental states. Below we report a clinical case of a woman with panic disorder to illustrate how a Lacanian treatment is conducted. Case Report

Angela, a white, Dutch-speaking twenty-eight-year-old, was referred to an outpatient psychiatric service (where the first author works) by her general practitioner. During the intake interview, she reported that she suffered from hyperventilation and panic attacks, two terms she had learned from her doctor. Angela could not link these symptoms to any


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particular problem in her life, but indicated that she had had a panic attack when she was sixteen. She was at the market with her parents and suddenly couldn’t find them; she was lost. Up until three months before this referral, she had had no further panic attacks. She described her childhood as happy, but said she was nevertheless “a nervous type.” She stated that she had a good relationship with her parents and with her partner, Peter, with whom she has two children, one-year-old twins, a boy and a girl. Before Peter, she had had a volatile relationship with a man named Kurt that lasted for three years. She works part-time as a cleaning lady. In terms of DSM-IV-R, a psychiatric diagnosis of panic disorder with agoraphobia was made (no comorbidity). Psychoanalytic therapy was suggested, despite the reluctance of several team members who considered Angela’s poor introspective ability a counterindication. Angela agreed to see the therapist (the first author) on a weekly basis. The therapist, a white, Dutch-speaking male in his thirties, is a clinical psychologist and Lacanian psychoanalyst. The therapy took place over seventeen months, with a total of forty-eight sessions. Given the low frequency and limited number of sessions, this treatment cannot be thought of as a full analysis. Rather, the treatment illustrates how the symptom of panic can be worked with analytically through the use of key Lacanian interventions. Moreover, because the treatment concluded as the symptom of panic alleviated, other aspects of the patient’s functioning remained unaddressed, such as her phantasmatic position in relation to parental figures, in addition to her way of negotiating aspects of maternity. In the first session, Angela stated that she wanted to understand “the origins” of her complaints, and that she wanted the therapist to explain to her what was wrong. She was strongly motivated for therapy, yet this selfdeclared motivation contrasted somewhat with the paucity of her story. The main challenge during the preliminary sessions of a Lacanianoriented therapy lies in turning such requests for answers from the analyst into curiosity on the part of the patient as to what unconsciously motivates her actions. This shift is usually maneuvered by paying very close attention to specific details in the patient’s story or the events in his or her daily life. Angela noted that her panic attacks occur most frequently while she is shopping or standing in a queue, mostly when she is waiting to pay. During these times, she feels she “can’t stand still,” yet she finds it very strange that she gets the attacks in this context, as she loves shopping, just

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as she loves to attend concerts by her favorite singer, where the attacks have also occurred. In her attempt to find some logic to her complaint, she noted that in many of these panic-inducing situations there is a lot of noise. The analyst pointed out, however, that this did not seem to be the case in all instances of her reported attacks. By pointing to this inconsistency, the analyst aimed to broaden the patient’s story and mobilize her to ask what else might be troubling her. Moreover, during the first session Angela briefly mentioned the difficult relationship she has with her mother-in-law. She described this woman as someone who utterly undermines her authority and acts as if the children were her own. ”She pretends,” she said, “that I am not even there.” Angela broke down crying at this moment, adding that she had no idea why she had suddenly become so emotional. The analyst suggested that perhaps she was moved by something she has not yet fully grasped, and that in order to find out what this might be, it is necessary to speak. Such interventions are meant to provoke curiosity in the patient, curiosity about the unconscious determinants of her actions. Angela’s children were the dominant theme of the first three sessions. She felt under enormous pressure raising them, and struggled with the daily routine that was initiated when they were born. The news that she was going to have twins came as a shock to her. She stated that if she had known beforehand, she wouldn’t have had children so early in life. Now she wants to get pregnant again, as she always wanted three children, but Peter doesn't want to take the risk of having a second set of twins. Her first pregnancy was for the most part eight months of fear due to the risks involved in a pregnancy with twins. On the other hand, she stated that she loved being pregnant and didn't want it to come to an end: “I didn't want to share them with anybody. Except with my parents perhaps.” As we can see, the analytic work with this patient started out with the theme of her symptoms, but did not focus on them directly. Instead, by mobilizing free association the analytic work gains access to the history and circumstances of the patient’s life, which are inevitably associatively linked to her panic (such as interpersonal relationships or life events that expose the individual to existential questions at the basis of subjectivity). Moreover, these early sessions brought a wealth of material to the fore— material that was quickly deflected, only to return at a later stage in the therapy, such as her fear of death in relation to the topic of her pregnancy. In Lacanian psychoanalytic work, attention is paid to these avoidances,


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which in the present case were indicative of Angela’s “passion for ignorance,” yet they are not addressed too directly. Psychoanalysts with a different theoretical orientation might use a different approach, immediately pointing out defensive processes. Nevertheless, as we believe themes that are unconsciously distressing for the subject will undoubtedly return, we simply encouraged Angela to be attentive to them, prompting further exploration as to precisely how they affected her. This notion of “avoidance” and “passion for ignorance” bears strong resemblance to the defensive style of “disavowal” and “not knowing” described in PFPP (see, e.g., Busch et al. 1999). During the fourth session, Angela became very anxious, stating that her panic attacks were becoming more frequent and intense. She questioned whether it was wise to continue with the therapy: “I’m going to therapy and it gets worse instead of getting better!” The analyst acknowledged the link between the worsening of the panic attacks and the beginning of the therapy and suggested that only she could decide whether or not to continue: “You are the only one capable of determining whether the effort and the pain are worth the trouble.” By making such an intervention, the analyst aims to “hystericize” the patient: to give her the responsibility of deciding how she wants to deal with her complaint, and whether she wants to give up her “passion for ignorance.” Angela decided to continue with the therapy, saying she would “try anything to make the attacks go away.” This decision allowed the analytic work to get under way: instead of just complaining about her daily problems, Angela adopted a more inquisitive attitude toward what was really troubling her. In the same session, she aligned events concerning her boyfriend, Peter, as a possible source of her panic attacks. She noted problems that occurred during the delivery of her twins: an emergency caesarian section was required, and Angela had to be transferred to the operating theater. After her pregnancy, sexual intercourse was very painful, and it was determined that a mistake had been made in how she was stitched up after the delivery. Initially, however, the gynecologist had told her that the problem was “all in her head.” “I didn't feel like a woman for a year and a half,” she said. Yet, after corrective surgery by another physician, the expected improvement in her sexual life did not come about. “All of a sudden everything had to be fine, but it wasn’t.” Moreover, Angela’s paternal grandfather had died a couple of days after the birth of her children. He had been ill during the last few months of Angela’s pregnancy, and both

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Peter and her parents prevented her from visiting him because they felt the stress involved might put her at risk of a premature birth. For this reason, Angela didn’t attend his funeral. “I couldn't really dwell on his death,” she said. At this point, an important signifier came to the fore. In Dutch “dwell on something” and “standing still” are expressed by the same verb: stilstaan. In other words, the signifier she first connected to her panic attacks, that she couldn’t “stand still” on the queue, reappeared as she spoke about her grandfather’s death. We hypothesized that stilstaan is a signifier that is Real for her, just as the signifier Käfer was all too Real for Freud’s patient. Angela continued: “I focused on the birth to avoid lingering on death.” Dwelling on things, “standing still,” was apparently quite troubling for Angela: “One has to move on: patience isn’t part of my vocabulary.” This fourth session was pivotal in Angela’s treatment: here we see that she refers to sexual problems as affecting her sexual identity and straining her relationship with her partner. Moreover, her concerns around her pregnancy, which she had previously mentioned, were now being connected to the death of her grandfather. Angela’s psychic elaboration of this death was poor, suggesting that her grandfather’s death remained nonsymbolized and rather was Real for her. Further, as she mentioned her avoidant ways of dealing with events that affected her, we did not focus our interpretations on this defensive style in our analytic work; instead we attempted to counteract it by allowing the analytic space to be one in which she could indeed dwell on things, in effect “standing still.” In the same session, Angela observed that sometimes it is as if she triggers the attacks herself “in order to find a way of fighting them.” She explored the notion of whether she needs “something to fight against; I am a fighter.” Following this remark, she immediately amended it: “I don’t mean fighting in the sense of hitting or hurting people.” This amendment, however, was mediated by a brief digression about her bad temper in relation to Peter—a temper she in fact attributed to Kurt, her previous boyfriend. Kurt had cheated on her several times; “He changed me,” she said. “I let him mess around with me. Peter still suffers the consequences, the poor man.” She smiled. Angela confessed that she becomes easily irritated by Peter, at times exploding with rage: “I snarl so easily.” While speaking about Peter, Angela was surprised by her frequent mention of Kurt: “In the end it will become clear it’s his fault I’m having these attacks!” At precisely this moment, the analyst ended the session. As


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noted, it is occasionally preferable to stop the session at a point when something unexpected has come to the fore, like this statement about Kurt, rather than simply adhering to the scheduled end of the session. Such interventions allow the signifier to resonate with the patient more profoundly: they aim to cut into the discourse of the patient so that something of the affective charge connected to the signifier can be “grasped” (Lacan 1962–1963, p. 81). This can provoke further elaboration, or not. In a subsequent session, Angela described her father as severe and overprotective, a hard man. Yet she cherishes and respects him a lot: “When you are sixteen you don't realize that discipline is good for you.” Her father didn’t allow her to go out alone before she was eighteen. He was afraid she would get involved in drugs or get pregnant. She said that she didn’t have much privacy: “The idea of running away didn’t enter my mind,” she said; “if I had run away, my father wouldn’t have wanted me to come back.” She was also afraid of doing things behind his back: “everyone in town knows him.” Angela added that she wouldn’t like to resemble her father. It was during this session that the signifier “sixteen” reemerged; that was the age at which she had had her first panic attack. This return of a signifier drew our attention to the latent connection that thus far she had not made. Moreover, the grammatical structure of her sentences indicated ambivalence about her father (“When you’re sixteen you don’t realize . . .”; “The idea of running away didn’t enter my mind . . .”), which thus far remained to be explored. Angela remarked that she is more like her mother, whom she called a “shopaholic,” and reminisced about how they used to walk through the shopping district every day when her mother picked her up from school. Angela hated this routine, yet speaking about shopping seemed to fill her with joy: “That’s how women are,” she said. In a subsequent session, the signifier “sixteen” appeared again: Angela was sixteen when her maternal grandfather died. At that point she moved in with her grandmother so she wouldn’t be on her own. She planned to stay for a couple of months, but lived there for two years, and it was after those two years that she met Kurt, whom she lived with for three years. Kurt was much older than she. Angela said that her job is very important to her. The majority of her clients are elderly people, whom she likes a lot: “They are a bit like family to me.” Her commitment to them exceeds her official task of cleaning: “I get attached to them too fast. That’s not good, you know, sooner or later

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they will die, like my grandfathers.” Interestingly, we see how, through free association, aspects of her current life are connected with elements from the past and how the issue of the death of her grandfathers is revived. Angela had a great deal of sympathy for one of her clients, René. René was addicted to buying things via mail order and bought her many gifts. She didn’t feel at ease with this, but didn’t refuse his gifts either. Angela said she was not sure about René's motives: he occasionally made envious remarks when she spoke about another man she works for. When René made such remarks, she would respond with an indignant, “You could be my grandfather!” In the eleventh and twelfth sessions, Angela confessed that she acts compulsively in relation to household equipment, to which she associated a number of anxiety-provoking events. Five years ago, her parents’ house caught fire. If her father hadn’t noticed, they would all have died. She commented that photographs of the house are still available online, and that she often looks at them. Her next association was that in primary school a girl once locked her in a barn under the pretense that she would show her her new bike. The analyst responded, “You are the victim of your curiosity.” Angela’s next association was that once, at the age of seven, she fell into a lake. She then asked, in a surprised tone, “What does it mean that I remember all this?” She wanted the analyst to explain this to her, but, in a classically Freudian approach, he remained silent and encouraged her to continue speaking. Angela mentioned that she regularly had panic attacks at night, when Peter was at work, at which point the analyst stopped the session. In Lacanian analytic work, we refrain from offering opinions about why people are the way they are, which is why the analyst remained silent in this session. While providing such explanations may encourage selfawareness, it would also stop the analytic work that is being done by the patient. Indeed, by not responding we aim to put the analysand to work, so he can continue to speak about (and ascertain) what affects him. The analyst’s silence often frustrates the patient, but its aim is to function as a spur to further exploration. It is in this way that change can occur. The analyst’s intervention—“You are the victim of your curiosity”—was meant to mobilize Angela’s self-inquiry. Moreover, the analyst, through his silence, to a certain extent incarnates what may be traumatic to a person, thereby allowing the traumatic experience to be worked over within the transference (Laurent 2011). Obviously this was the case with Angela.


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Angela began almost every session by saying, “I really don’t know what to say,” and frequently remained silent. The analyst repeatedly asked her to tell him about her silence, to which she often replied, “There’s simply nothing on my mind.” Angela wanted the analyst to speak, and when he didn’t she would exclaim that he has to ask questions. In the ninth session Angela argued, with a faint smile, “If you don’t ask for anything, you won’t get anything: that is how women are.” She added: “If the other doesn’t show himself, I become silent.” Angela commented that she wanted to know everything about people, and when the analyst asked what exactly she wanted to know, she replied: “Things about family life. My mother always wants to know who’s died. For me, it’s not about gossiping, but knowing, that’s what I’m after. They’re the things women want to know; I’m sure it doesn’t interest you. It doesn’t interest Peter or his mother. She has no idea what’s going on. That can really annoy me.” At the end of the nineteenth session, Angela remained silent for a long time, which culminated in her bursting into laughter. She made fun of the Winnie the Pooh clock hanging on the wall. “You are certainly someone who likes jokes too,” she said. The analyst waited in silence, until her laughter turned into frustration: frustration about the ticking of the clock. The analyst ended the session when her frustration came to the fore. While Angela’s remarks about the analyst bear witness to transference, Lacanian analytic work is quite specific in that that it typically refrains from interpreting transference as such. In this respect, Lacanian psychoanalysis differs quite significantly from analytic approaches like PFPP. From a Lacanian perspective, focusing interpretations on the transference will merely offer meaning to patients, something we believe they can (and should) eventually construct for themselves. Such explanations will not provide the patient the tools for change. By contrast, in Lacanian psychoanalysis transference is “handled.” Obviously, transference is necessary for the treatment to progress. Through the transference, traumatic material is not so much revived as brought to the fore and reexperienced in bearable doses, so it can be worked through (Laurent 2011). From this perspective, the analyst functions as a “relay” between the subject and the Real. He does this by drawing attention to phenomena in the Real and by creating a symbolic transitional space in which the patient can name the Real. By refraining from responding to the patient’s projections, something at the level of the analysand’s Imaginary expectations can be

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destabilized. A space is thereby created for alternative interpretations. Indeed, Angela’s remark, “You are certainly someone who likes jokes too,” bears witness to the fantasy she had constructed around the figure of the analyst. By not responding to this fantasy or image, the analyst disrupts her expectations. Often at such moments of destabilization, new Symbolic material comes to the fore. It is for this reason that the analyst ended the session at the moment Angela became frustrated. Ending sessions at the precise moment the analysand seems to expect something from the analyst is a way of handling transference. As noted below, the signifier “ticking” returned in the following session, but with a completely different meaning. This is the desired effect of stopping the session at such moments. In the next session, Angela talked about the shortness of breath that accompanies her panic attacks. It reminded her of periods in her life in which she thought she was suffering from heart disease. “It all involves my ticker,” she said. She first began to worry about this when she was thirteen: she would lie down in bed, anxiously listening to her heartbeat. During the session, she began to wonder why she did this and what was really going on. The analyst pointed out that it is at this age that the heart starts to beat faster, an interpretation that was dismissed by Angela. She continued by indicating that once she had to carry around a little box that registered her heartbeat. That was when she was still with Kurt. For a while she had assumed that she had a heart condition, but this didn’t prove to be the case. Her physician told her the problem was stress-related. She then spoke about Kurt’s lies and excuses, and the fact that the more she invested in their relationship, the more fun he made of her. She was terrified of being alone. At the beginning of the twenty-second session, Angela spoke about having had a panic attack at the shopping center. This brought her to comment on her impatience and her fear of boredom. At that point she fell into silence. Given her earlier references to death, and the previously noted link between panic and death, the analyst asked her if she ever thinks about death or dying. The question was posed in order to generate further associations; it hit her like a bombshell. “How do you know that?” she asked. Indeed, by the age of twelve or thirteen she was already afraid of suffering a cardiac arrest (in Dutch, hartstilstand). When the analyst asked her to speak more about that period, she said, “I don’t know . . . there was nobody who died . . . there was when I was eight.” Angela


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remembered a scene in which she was playing and suddenly heard her mother weeping on the phone. “I ran to the toilet because I didn’t want to hear it. I thought I wouldn’t hear it from there, but I still could.” The reason her mother was crying was news that an uncle had died. “That was the first time someone in the family had died. Until that moment, I believed such a thing couldn’t happen in my own family. I wasn’t allowed to go to the funeral; I was too young. It was in the summer, just like my attacks: they are worse in the summer as well. Wham was playing on the radio. If I hear that song now I turn off the radio immediately. I think that was the moment I began to be scared I would die too. That was the first time a family member passed away. The second time was when I was sixteen, with Granddad, and the third time was right after the birth of the twins. With Grandfather. We knew it was going to happen, but still it came as a shock. With Granddad too, we knew it was going to happen. In all three cases, we’d known. Life doesn’t end, whatever happens. It goes on, much too fast even. It passes too quickly.” After a pause, she asked. “How did you know I’m scared of death?” The analyst replied: “You hardly speak of anything else.” What was crucial in this session was that the analyst’s question about death had the desired effect, and brought Angela one step further in elaborating how she has been affected by the death of close relatives. What was also important was the analyst’s answer to the question how he knew she was scared of death: that it was at the level of her own speech that the answer was to be found. This response not only invited her to further explore her unconscious, but also was aimed at “dissolution of the transference.” In other words, it maneuvered the patient into the position of being capable of facing issues concerning death by herself, without the analyst’s help. In the next session, death continued as the main topic. Angela spoke about a friend who died when she was thirteen: “I’ve always been so scared of dying. You hear all sorts of things. It began when that boy in my school died.” She found it ridiculous that she worried about it so much: “I sound like a sixty-year-old!” Another association she made was that she had known Peter for a long time before getting into a relationship with him. Their relationship had started “shortly after his father died.’ She said that she had the impression that Peter has become stuck in mourning. He often listens to the sad music his father would listen to. This irritates Angela. She added that, for her, there is no place she feels more at ease

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than at the graveyard. Her mother had had a similar inclination; Angela reminisced about how they used to walk along the graves at the local graveyard. This evoked the association that she would go shopping later that day, and the next association, that she is afraid of diseases—a topic she hadn’t mentioned until that moment. She is constantly afraid of getting sick and anxiously examines her children for any sign of sickness or disease. At that moment, Angela became overwhelmed by emotion and started to cry. Saying she didn’t know why she was crying, she said, “I’m thinking: what could I say to make me laugh?” In the following session, Angela spoke about death again, this time in relation to her children. She said that being pregnant with twins was unexpected, just like the death of her uncle and grandfathers. The pregnancy had also made her fearful: “Suddenly, there are four people instead of two.” Angela said that her son needs more care than her daughter, and that she calls him “my problem child.” Nevertheless, she tries not to favor one child over the other. But whenever she has nightmares, they are about her son, and this started shortly after the birth of the twins. She often dreams that she suffocates her son by lying on top of him. To the analyst’s question whether she had a gender preference, she responded that she had a slight preference for a baby boy, adding that she had always wanted to have a brother to take care of her. She then reflected on whether the death of her grandfather soon after the birth of the children had anything to do with her complaints. “I never dwelled on his death, I couldn’t. I hid behind the babies when I got the news and tried not to think about it too much. They distracted me. It makes a big difference whether you are there or not.” The analyst repeated this final statement and ended the session. By reflecting this final sentence back to her, he underlined the subjective necessity for the analysand to find a personally relevant way of dealing with death. For her next session, the thirtieth, Angela arrived in a state of anger. She felt that in the previous session the analyst had not been helpful enough: “I don’t understand the origin of the attacks, and I want to get rid of my fear of death.” When the analyst asked what had happened, she explained, with a sigh, that the mother of a child in her kids’ class had died of a heart attack. It was the doctors’ fault, she said, because they gave her the wrong muscle relaxant. “It’s all part of life,” she added. “I will have to accept that.” A couple of sessions before this, she had said much


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the same thing about her boyfriend: “I will have to accept the fact that he is like that.” During the next session, she mentioned a significant drop in the frequency and intensity of her panic attacks. On the other hand, Peter had started to irritate her more and more. When the analyst asked her about their sexual relationship, she said, with some hesitation, that she has an aversion to intimacy. Earlier, Angela had been complaining about gaining weight, and about the eating frenzies that come on whenever she feels bad. Her relation to food clearly bears some relation to Peter, who is obsessed with health and fitness. “He should train his memory for once, instead of his body,” she said mockingly. She had quit smoking out of solidarity with him after his father died of lung cancer. “More and more, I feel like taking up smoking again,” she said. She used the word “disgust” in relation to sex, and complained about Peter’s “clinging” to her. She didn’t understand her aversion to this, especially because she used to be “the clingy one.” She thought it had something to do with the caesarian, but wasn’t sure. For a long time, because of the pain she experienced while making love, she thought of Peter as someone who hurt her. “But I can’t keep on refusing; he was already waiting so patiently before the operation. I’m in a mess with myself . . . about my relationship.” Gradually she spoke more about her irritation concerning Peter’s forgetfulness and clumsiness: “Sometimes it feels like I have three children instead of two.” Next to that, she finds his lack of humor annoying and a bit scary. “He’s like a sixty-year-old! I would do anything not to feel old.” She added that she couldn’t live without laughing. Angela had mentioned her irritation with Peter in previous sessions, but this was the first time she did not situate Kurt between Peter and herself, as a way of rationalizing her anger. This session indicated that as her panic attacks diminished, Angela was starting to have more courage in facing the discontent she was experiencing with Peter. Session forty-three started out with bad news: “René, the man who gives me gifts, has cancer and has only a few months to live.” Angela wept a lot that week. During the session, she started to speak about her grandfather, who had died three years before. She hadn’t witnessed the changes he went through before he died, as she saw him only once, at the start of his decline. René asked her to assist him during his illness, but Angela hesitated, wondering whether it would be better to simply terminate her work with him altogether, adding that Peter thought it would be too hard

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for her. The analyst, by contrast, suggested that she should not run away, and that she should deal with it. By making this remark, he was inviting her to take a step toward reviewing her way of dealing with death. Helping René would provide her the impetus to take a different position with respect to death, and to, indeed, dwell upon the issue she had been avoiding. “He will change physically,” she remarked; “right now the disease is not visible, but it won’t stay like that. I have never witnessed such a thing firsthand.” The analyst asked if she ever dreams about death. “No, luckily enough.” Angela decided to stay by René’s side for the next two weeks, until he passed away, which actually came sooner than expected. During this period, Peter asked Angela how much longer she would go to therapy. Her panic attacks had remained at bay for quite a while; indeed, she had even gone to a concert without having one. The analyst told her the choice was hers, but she decided not to terminate the therapy straightaway. Session forty-six started with her report that René had passed away: “We knew it was going to happen. It was a dreadful sight, toward the end. I suffered. And yet I’m happy I did it. It changed me. It’s as if I’m not that scared of death anymore.” She wondered how it would have been if it was someone in her family who had died. René died at home while Angela sat by his side, and she compared his death with her grandfather’s passing when she was sixteen: “He was lying in a cold basement of the hospital.” In the next session, Angela spoke of a nightmare she had had: “René was on his deathbed and his body contracted for the last time before he died. He sat upright, just like in a typical horror movie. There were also scary noises. From one side it was René, from the other it was my grandfather.” After a while, Angela added: “Actually it was as if it was a theater play. I was the audience and he was on stage.” Two sessions later, Angela said, “I think I’m at the end.” She missed René, but since that nightmare, the uncomfortable feeling she had had was gone, and she was no longer having panic attacks. “It all feels different.” She talked a lot with René’s daughter, but there was still one thing on her mind: she hadn’t told the daughter about the presents René had given her. He had always told her not to tell his daughter. Angela felt bad about this secret and said she might tell her later. Then she said that she wanted to try to manage her life without therapy. “I can come back if it’s necessary, can't I?” She asked what the analyst thought about this, and wondered aloud whether, in the end, anything had really changed. The analyst responded


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by saying that, indeed, something had fundamentally changed: “Your fear has got a face now.” With this reply, the analyst intended to endorse the analytic work Angela had been doing, and to underscore her new orientation toward death and personal relationships. A couple of months later, the analyst got a postcard from Angela acknowledging the beneficial work they had done and informing him that she could now do things that before she couldn’t. She said she would return to therapy if it became necessary. D i s c u ss i o n

To grasp what unfolded during this treatment, it is crucial to focus on the fourth session. At this stage not only had Angela told the story her partner suggested she tell, but the panic attacks were at their most intense. In this session, the issue of death came to the fore, as well as two additional themes: being a woman and being a mother. Another issue permeating the early sessions was her difficulty with separation. This was expressed in the desire that her pregnancy not end, for example, and in her compliance with her family’s advice that she avoid contact with her dying grand father. In later sessions, Angela elaborated these themes, which allowed her to take a different position toward the existential questions affecting her. The analyst noted the frequency with which these themes emerged, and confronted her with them, hoping to mobilize further associations and ideas. On a technical level, we try to put the analysand’s unconscious to work, encourage her to be cognizant of her unconscious motivations, and, finally, to construct a name for the Real. As for the problems Angela experienced in her relationship, and the recurrent question of being a woman, a clear shift seems to have taken place over the course of the therapy. Early in the treatment, Angela attributed her discontent with Peter to her previous partner, Kurt. In this sense, Kurt was the Symbolic object, mobilized in order to negotiate her problems with Peter. She avoided any direct expression of anger toward Peter. Moreover, in the early sessions Angela presented herself as very dependent on him. It was he who advised her to go into therapy, even dictating to her what she should speak about. Angela was submissive and followed his advice. In the middle period of the therapy, this dynamic changed significantly. When Peter began to question the therapy’s relevance, Angela was irritated, but she did not allow this to interrupt the 260



work. In the second half of the therapy, Angela began to address her problems with Peter more directly. The panic attacks seemed to be replaced by experiences of disgust and anger toward him. We infer that the feeling of suffocation experienced during her first panic attacks shifted into the field of the Other; it was increasingly Peter whom she referred to as suffocating her. This was indicated in her comment that whereas she used to be “the clingy one,” the one who needs the presence of the other, now it is his clingy behavior that irritates her. This experience of irritation reflects a certain psychological separation, the creation of a symbolic lack: too much presence of the other (the lack of a lack) has been turned into a “not good enough” (a lack). Henceforth she could express her discontent with Peter more directly. Using the terms of PFPP, one could say that Angela to some extent overcame her conflicted dependency wishes and found new ways of managing her rage (see Busch et al. 1999). Death was the principal theme addressed in this therapy, in that Angela articulated how her frequent confrontation with death affected her and gave rise to avoidant behavior. This avoidance proved to be related to her panic attacks.The appearance of the signifier stilstaan in two different contexts (panic while queuing, her grandfather’s death) brought us to hypothesize early on in the therapy that her attacks were associated with issues related to death. (Indeed, the signifier appeared again midway through the therapy, when she spoke of an early fear of cardiac arrest.) During the therapy, Angela gradually overcame this avoidance, which was clearly part of her family constellation. The analyst prompted her to talk about events relating to death, and several experiences were addressed. By talking about death, another link with the panic attacks came to the fore. At the age of thirteen, Angela had begun to worry about having a heart condition. This fear proved to be connected to the death of an uncle, whose funeral she could not attend, together with the death of a friend at school. It is notable that the theme of “cardiac arrest” first emerged with Angela’s irritation at the silence of the sessions, where the ticking of the clock became associatively connected to her concern about her own ticker. The theme of death also marked the beginning of her relationship with Peter. Indeed, while Angela did not address this in detail, it seems that his mourning strengthened her feelings for him. Angela’s confrontation with the death of her client René, whom she jokingly equated with her own grandfather, was relevant to the overall dynamic of the therapy. Angela spoke freely about René’s decline and about her ongoing


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concern for him. Contrary to her earlier position vis-à-vis death, she did not avoid the pain provoked by René’s impending demise. By taking care of René and his family, Angela occupied a subjective position in relation to the event of death. Death was no longer an elusive idea that she should dread or avoid, but a painful event that she could live through and mourn. Whereas at first death was too Real and overwhelming for her (the lack of a lack), she gradually elaborated a Symbolic framework whereby she succeeded in articulating precisely how it affected her (qua the experience of lack) in the course of her life. To make this possible, the analyst encouraged her to agree to care for her dying client, which crucially functioned to help her surmount her “passion for ignorance.” Finding a way to deal with silence was a major challenge in the therapy. The patient’s silence can be considered in terms of the transition between the Real and the Symbolic. It was not easy for Angela to dwell on the themes that emerged during the therapy, and bearing the silence entailed in such a therapy was frequently difficult for her. Nevertheless, she was often surprised at how much she disclosed. We believe that this element of surprise reveals something about the technique and effects of the treatment. A certain kind of silence, which we call Symbolic silence, can do a great deal of the work. We call it Symbolic silence because it is bordered by words, yet simultaneously created by words. It is a silence that touches fear, but is not paralyzed by it. This type of silence “elevates the unspeakable to the level of quiet speaking” (Laurent 1992, p. 54). We believe that this silent space carried Angela into the realm of symbolization. Speech about silence, for instance, led her to address the topic of death. At times, however, the quiet threatened to become a Real silence because of the too silent composure of the analyst, an empty silence in which Angela lost herself and cried for help, sometimes literally. Consequently, on a number of occasions the therapy became stuck and was difficult to revive. In this respect, it was important that the analyst tried to name elements of her unease. This naming differs from classical interpretation, in that it aims to foster a transition from emptiness to speech. By facilitating the “lacks” that words install, the analyst tries to create a “limit” to all that is Real for the subject (Bassols 1999). In Angela’s case we did not address the classic Lacanian question of structural diagnosis, which carries with it a differentiation between neurosis, psychosis, and perversion. Obviously, during the preliminary sessions we determined that Angela’s mode of functioning evinced a neurotic

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structure, which guided us in choosing appropriate forms of intervention. Had panic disorder presented in the context of a psychotic structure, a different approach would be taken. By explaining the theoretical basis of our approach, and highlighting how a Lacanian psychoanalytic orientation takes shape, we hope to facilitate dialogue between psychoanalytic schools of thought. While a Lacanian approach to panic disorder has thus far not been systematically tested, we believe that it can be effective for a substantial number of patients. References

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Panic disorder: a biological perspective.

Beyond the Impasse - Reflections on Dissociative Identity Disorder from a Freudian-Lacanian Perspective.

Are there subtypes of panic disorder? An interpersonal perspective.

The Lacanian Concept of Paranoia: An Historical Perspective.

Panic disorder.

The effect of agoraphobia on oxidative stress in panic disorder.

Reversible monoamine-A inhibitors in panic disorder.

Panic disorder in the families of patients with normal coronary arteries and non-fear panic disorder.

Panic disorder in a paraplegic patient.

Desipramine treatment in panic disorder.

Rorschach-profile in panic disorder.

Mirtazapine versus paroxetine in panic disorder: an open study.

The hyperventilation provocation test in panic disorder.

Temporal lobe abnormalities in panic disorder: an MRI study.

Breath-holding in panic disorder.

Cholecystokinin-tetrapeptide induces panic attacks in patients with panic disorder.

The structure of phobias in panic disorder.

CSF opioids in panic disorder.

Panic disorder in cardiac outpatients.

The Galway Study of Panic Disorder. I: Clomipramine and lofepramine in DSM III-R panic disorder: a placebo controlled trial.

Physiological aberrations in panic disorder.

Blood groups in panic disorder.

The effects of physostigmine infusion on patients with panic disorder.

Hypertonic saline infusion induces panic in patients with panic disorder.