2018 Manoeuvres of Transference in Psychosis - Vanheule
2018 Manoeuvres of Transference in Psychosis - Vanheule
2018 Manoeuvres of Transference in Psychosis - Vanheule
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MANOEUVRES OF TRANSFERENCE
IN PSYCHOSIS: A CASE STUDY
OF MELANCHOLIA FROM
A LACANIAN PERSPECTIVE
CASE: HANS
Hans is a single man in his 50s, consulting because of a depressive mood that has
been present for over a year. In the first consultation, Hans talked about how he has
been feeling very depressed and sad over the last few months; he has been unem-
ployed for over a year, ever since his last job ended. He is overwhelmed with sadness
when asked about his studies or employment because he feels he has failed at both.
He said that he used to enjoy sculpting and expressing himself creatively, but that
recently he has been unable to engage in those activities for months on end. More-
over, his life has become a heavy burden and he is unable to experience joyful or sat-
isfactory moments; the depressive mood and lack of pleasure had been especially
pronounced during the last year. However, he has struggled with feelings of emptiness
and anxieties throughout his life, which led to him being hospitalized multiple
times for approximately 6 months each time. He was first hospitalized following very
negative feedback during a course he took in high school. His last hospitalization was
just 5 years ago, some months after his mother had passed away. Importantly, during
this last stay in hospital, Hans was able to speak about the loss of his mother; how-
ever, he was unable to utter a single word regarding his loss in the company of family
members (so as not to burden his father any more than he already was). He felt he
could talk about this in the hospital because people pointed out to him ‘that it was a
normal thing to grieve’.
When Hans lost his mother, it hit him very hard; he felt like he had lost the one
person in the world whom he was certain would help him through any difficulty.
Even though his mother was rather quiet, grumpy and easily upset by any form of
conflict or quarrel, Hans said she became more genial towards the end of her life.
Nonetheless, her loss caused him to face severe difficulties in his life. In some ses-
sions, he spoke of a dream he had about his mother, in which she was alive, but had
disappeared.
Hans's father was characterized as a sad and anxious man who had been that way
for as long as Hans could remember. Hans linked his father's disposition to the death
of one of his father's siblings when Hans was just a few months old. Following this
death his father lost all enjoyment in life, and the familial atmosphere seemed to have
been characterized by a permanent state of mourning. No one was now allowed to
play music in the house, even though Hans and his mother loved music and enjoyed
In Search of a Limit
One of the most important themes in the treatment was raised by Hans. On conclud-
ing the first session, he asked me: ‘Will you say when I go too far?’. At first I
responded to this question by inviting him to elaborate, hoping to clarify what these
words meant to him. However, when the underlying (psychotic) structure of Hans's
suffering became more salient, the clinical strategy changed. As a first important
manoeuvre in the transference, I stated that Hans could not telephone me in between
sessions. However, he could send me e‐mails with what he wanted to say, and he was
given reassurance that his e‐mails would be discussed in the following session. The
underlying motive for this intervention was in the perceived difficulties Hans had
managing the absence of the Other, not in the comfort of the analyst.5 The interven-
tion aimed to prevent the occurrence of moments when Hans would feel the need to
cross a boundary (‘go too far’) by installing this boundary in the therapeutic frame.
What is more, I stated that I would indicate when Hans had crossed the line or
when he went too far. I did so on several occasions: when Hans did call once because
he was worried, when he drank too much, when he became insistent and demanding
towards other professionals (e.g. his GP) in his communications. These interventions
aimed to limit jouissance and avoid his actions leading to him feeling bad or suffering
from nausea or bodily tensions afterwards. I didn't explore what the question of going
too far meant for Hans. I committed myself as a partner in the process of Hans's
search for a limit, however this did not mean that the treatment became directive or
restrictive in a general sense. Rather, following Hans's discourse closely, several
themes emerged that were central to his feelings of crossing the line.
Free flowing exchanges: interrupting self‐hatred The root of his feeling of having
crossed the line is the idea of being a worthless person and the jouissance attached to
it. In that sense, finding a limit to certain behaviours he felt were transgressive essen-
tially boiled down to finding ways to avoid the idea of being ‘a difficult’, ‘worthless’,
‘burdensome’ … becoming too present. When Hans's discourse became increasingly
self‐destructive in a session, I interrupted him and actively introduced a different
topic; I asked Hans about volunteer work, for instance. As is often the case in melan-
cholia, the jouissance of his self‐reproach was not cancelled out by speaking about it,
but might rather have been maintained by it (Zenoni, 2008). Being too empathetic at
that point would have amounted to being an ally to his most intimate destructiveness.
So as to make another discourse possible, it was necessary to regularly halt this type
of speech. This conversational style could be characterized as ‘free flowing
exchanges’: different topics could be discussed, one after the other, but without the
Communication and alcohol Hans felt he transgressed social norms, even though
he attested to not knowing the rules of communication; he wanted to learn when his
communication could be perceived by the other as a reproach. Therefore, his position
was akin to the main character in Kafka's novel The Trial, who is put on the stand but
remains in the dark as to the charges made by the prosecution. In the session, I intro-
duced the idea that every communication is essentially flawed; people sometimes
hear a message differently than intended. Moreover, I added that when misunderstand-
ings do occur, this always involves at least two people; no one can be held solely
responsible for miscommunication. The idea behind these interventions was to intro-
duce a little space for error in the Other. However, I did not consider the communica-
tion per se to be the problem. Although undoubtedly Hans struggled with
communication, the underlying dynamic had to do with jouissance (either of being
worthless, or being at the mercy of an abandoning Other). By pointing to communica-
tion, I attempted to divert the idea that the fault lay on Hans's side alone; others have
problems too and communication in itself is distorted.
When Hans felt he had transgressed or when he felt excessively bad or worthless,
he took recourse to alcohol. After having a lot to drink, he felt he had gone too far.
The drinking can be understood as a form of self‐medication, an attempt at regulating
jouissance that bypasses the Other – when too many bad things had come out of his
mouth, he put bad things in it (alcohol). Afterwards, the guilt over having drank too
much (again) pervaded him. In the sessions, I proposed that he drank less because of
its after effects, by asking for instance, ‘What else could you do when you feel bad?’.
Time Lacanian therapists demonstrate flexibility regarding how they use frequency
and time, standard elements of the analytic situation or frame, to have interpretative
effects in analyses with neurotic subjects. In psychosis, however, time is not used to
make particular themes or signifiers resonate in between sessions. Following the logic
in Hans's case particularly, the framework was tailored to a standard weekly session
of 50 minutes. Variable sessions could put too much emphasis on the arbitrariness of
the analyst; they risk putting the analyst in the place of an almighty and whimsical
Other. Time is a symbolic aspect of life6 that has an important role both in the experi-
ence of psychosis as well as in the handling of the therapeutic frame. Of course, time
also regulates a lot of social practices in general. It is one of the signatures of modern
times that we live by the clock. If the analyst adheres to a fixed time, this conveys
how he is a dupe of a symbolic pact as well – the analyst is not a character out of time,
but suffers the same time limit as anyone else. The framework of the therapy thus
DISCUSSION
The case of Hans demonstrates the many faces of transference (Nobus, 2000) in a
case of psychosis. In relation to his previous psychiatrist and psychologist, the
dynamic became one of erotomaniacal transference wherein Hans was the object of
the Other's love. The phone call where he apologized for not being kind enough
revealed how the love of the Other needs to be addressed by him: the Other's initia-
tive and love were primary. According to Zenoni (2008), in psychosis transference
has an inverse structure: from the Other to the subject – here, Hans was the object of
the jouissance of the Other, both in terms of love as well as hate (where a more para-
noid colouring infiltrated his experience of the Other). Prior treatments fell prey to
the pitfalls of this dual transferential relationship, and in my work with Hans, I
attempted to avoid this position. In order to maintain a manageable transference, I
described how I tried to counter this position of the Other in the treatment by signify-
ing a limit. Moreover, both myself as well as others were interpreted, so as to put a
limit to my and their whimsicality. However, I did not interpret or explain the relation
I had to Hans. The relation to the Other was to a large extent the focus of the treat-
ment, studying and interpreting this in order for Hans to find a position where he was
not the object of the Other. This meant a perpetual translation of the enigmatic Other
to avoid ending up in the position of being prey to the Other's jouissance. Even
though Hans's relation to the Other was a central topic in the treatment, it was never
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STIJN VANHEULE PhD is a clinical psychologist and professor of psychoanalysis and clini-
cal psychological assessment at Ghent University, Belgium, where he is the chair of the
Department of Psychoanalysis. He is also a psychoanalyst in private practice (member of the
New Lacanian School). He is the author of numerous journal articles and of the books The
Subject of Psychosis: A Lacanian Perspective and Diagnosis and the DSM: A Critical
Review. Address for correspondence: Department of Psychoanalysis and Clinical Consulting,
Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium [[email protected]]