Gerald P. Perman, MD

I am writing to congratulate Drs Jerald Kay and Joel Yager for their article “How Reading Current Literature Stimulates Duh and Yawn Responses: An Analysis of Causes and Potential Interventions” in the August 2020 issue of 

. One of the stresses that psychiatrists experience today, and contributes to burnout among all physicians, is the knowledge that it is impossible to keep up with the medical literature. Most of us feel woefully and hopelessly behind in this regard.

I gave a chuckle, however, when I read that yawn responses are “activated by a variety of article types” including “turgid and obscure writing, a cross between legal-ese, technical engineering manuals, and Jacques Lacan” (p16).

As a psychodynamic psychiatrist with an interest in the work of Jacques Lacan for the past 10 years, I refer Drs Kay and Yager to my article published in the December 2019 issue of 

: “Jacques Lacan: The Least and Most Known Psychoanalyst in the World.” Interestingly, Lacan was particularly interested in the idea of “lack” (Lacan/ lack), and Kay and Yager’s article highlights the lack that most psychiatrists experience when attempting to read much of the psychiatric literature today.

is clinical professor in the Department of Psychiatry and the Behavioral Sciences at the George Washington University Medical Center in Washington, DC.

We thank Dr Perman for his kind words about our article in the August issue. Dr Perman takes exception, however, with our characterization of Jacques Lacan as “turgid and obscure.” He refers us to his 2018 article in 

, a heroic attempt to elucidate Lacan’s ideas.

The article begins his article with the comment “Lacan’s written work and transcribed lectures are often difficult, if not impossible, for most American (and other) mental health professionals to comprehend. His ideas are novel and complex and many seem obscure and enigmatic.” Indeed. Despite Perman’s admirable efforts, we remain in the large group of psychiatrists who still lack (ha!) a firm grasp on Lacan’s ideas. The reference to Lacan reflected our attempt to present a strongly provocative yet humorous report on the state of psychiatric literature.

is Professor Emeritus and Past Chair of Psychiatry Wright State University Dayton, OH. He is an Editorial Board member of 

is Professor of Psychiatry, University of Colorado, Denver, CO. He is an Associate Editor of 

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Drs differ on the advisability of reading a certain famous French psychoanalyst. 

Lac-yawn? A Jacques-ular Exchange: From our Readers

Jacques Lacan was a Parisian psychiatrist who was born in 1901 and who died in 1981. He gained an international reputation as an original interpreter of Sigmund Freud’s work. He visited the United State three times, twice in 1966 and once in 1975, where he lectured at a dozen American universities.

Lacan’s written work and transcribed lectures are often difficult, if not impossible, for most American (and other) mental health professionals to comprehend. His ideas are novel and complex and many seem obscure and enigmatic. Despite the difficulties, Lacan has a devoted following throughout much of the non-English-speaking world (where he is the best-known psychoanalyst) but he is mostly unknown to the English-speaking psychiatric community (where he is the least-known psychoanalyst). This paradox can also be accounted for by the fact that Lacan’s mother tongue, French, is closer to the romance languages of Spanish and Italian.

About five years ago, a colleague of mine asked me to review a book by Bruce Fink, a Lacanian psychoanalyst who splits his time between Pittsburgh and Paris, and who has written many books about Lacan and has translated much of what Lacan has written. After reading one such book the scales fell from my eyes, so to speak, and I’ve been hooked on Lacan ever since.

Jacques Lacan was the eldest of three children and was born into an upper middle-class Parisian family where his father, Alfred, was a sales representative for a large firm, and his mother, Emilie, was a housewife and staunch Catholic. Lacan attended Catholic schools through college and his younger brother entered a monastery. Lacan excelled in religious studies and Latin and he later hired a private tutor for a year to give him a crash course in philosophy. His study of Spinoza contributed to him becoming an atheist.

Lacan attempted to join the army after college but was rejected because he was too skinny. Instead he applied to medical school and attended the Faculty of Medicine at the University of Paris from 1927 to 1931. After medical school he specialized in psychiatry and studied under Gaeten de Clerambault, after whom De Clerambault’s Syndrome, or Erotomania, is named, and who had an important influence on Lacan’s decision to become a psychoanalyst. Lacan’s MD thesis, “On Paranoiac Psychosis and its Relationship to the Personality,” previewed his later interest in the psychotherapeutic treatment of patients with psychosis.

In the 1930s, Lacan became acquainted with a group of Avant-guard writers and artists in Paris. He became friends with Salvador Dali in whose paintings he saw expressions of the unconscious in dreams, and Lacan became Pablo Picasso’s personal physician. At the end of his career Lacan developed a renewed interest in James Joyce and attended the first public reading by Joyce of 

. Lacan was analyzed by Rudolf Lowenstein between 1932 and 1938 and gained the status of “psychoanalyst” in 1936.

The Mirror Stage and the imaginary register

In 1936, Lacan presented a paper to the International Psychoanalytical Association in Marienbad, Germany on the Mirror Stage of development. Human beings are born in an immature state, only gradually being able to walk and talk, and Lacan wondered how children developed their relationship to their bodies. He postulated, based on animal behavior and child observation studies, that children between the ages 6 and 18 months, identify with their image in a mirror and that this gives the child the jubilant perception of itself as whole and complete, in contrast to the child’s inner experience of being fragmented and disconnected.

Lacan called this false image of wholeness in the mirror, the “ego.” His use of the word “ego” was different from Freud’s as Lacan frequently put “new wine into old bottles.” At the same time, Lacan called his entire work a “return to Freud,” believing that his was a closer and more accurate reading of Freud than how others understood Freud. “Alienation” was the term that Lacan used to describe the tension between the child’s inner uncoordinated and disconnected perception of self and the integrated image in the mirror.

Following his description of the Mirror Stage, Lacan made a profound leap. He postulated that the child’s false perception of self in the mirror is characteristic of one of the three so-called registers, or orders, in which human beings experience the world. He called this first register the “Imaginary” register, related to the word image and not to “imagination” or “imagining.” The “imaginary” register is the world of sensations-visual, olfactory, auditory, and tactile-and is the register we use to compare ourselves to others. When we meet a patient for the first time, or anyone else for that matter, our initial impression takes place in the “imaginary register. We are indeed “judging a book by its cover.”

In 1895, Freud made a close association between symptoms and speech in his 

. Lacan took this further, describing symptoms literally as “words trapped in the body.” This is not as strange as it sounds. We all believe that when patients speak to us-and their words leave their mouths and their bodies-this has something to do with them feeling better and making positive changes in their lives over time.

 our words, rather the other way around.” It is not we who speak our words, but instead the words that we speak define who we are. A novel thought indeed! And yet, as soon as we speak, we are immediately misunderstood by the listener, for we all attach our own individual meanings to the words we use, that are always going to be more or less different from how the listener understands them. To quote Lacan: “Language is meant to be misunderstood.” Much of psychotherapy consists of asking our patients to clarify and elaborate on what they have just told us, so we can have a closer understanding of what they have in mind.

 the example is given of a girl who repeatedly banged her head on the wall next to her bed each morning.” This symptom disappeared when she connected her behavior in therapy to her mother having told her that her father often “woke up on the wrong side of the bed.”

Lacan became particularly interested in the work of Ferdinand de Saussure, one of the founders of 20th century linguistics. De Saussure described the linguistic sign composed of (1) a 

, ie, acoustic image of the word we hear, connected to (2) a 

, ie, concept. For example, the sound of the word “ox” will make an acoustic impression on the listener. Each of us, however, will have a somewhat different idea of what this “ox” is like. For some of us it will be Paul Bunyan’s sidekick, Babe the Blue Ox, for others, the meat in oxtail soup, and for others the ox in Johann Heinrich Roos’s 15th century painting of an ox, and so on. Therefore, the signified, in this example, is the concept of an ox, and not a particular ox.

Lacan famously said, “The unconscious is structured like a language.” He meant that the unconscious is made up of “chains of repressed signifiers” that relate to one another through their own rules of metaphor and metonymy. These repressed signifiers express themselves through slips of the tongue, associations to dreams, mistaken actions, and through psychiatric symptoms.

By punctuating-a Lacanian term meaning emphasizing-signifiers that stand out to the therapist, the patient will often associate to other signifiers in the signifying chain. For example, when one of my patients used the word “challenging,” referring to her job several times within a brief period I interjected, “challenging”? She replied, “I used to challenge my brother to checkers when we were little and, since he was younger than me, I usually beat him and made him cry. And, I remember exactly where I was when the Challenger blew up and all seven astronauts died.” This allowed the patient to put into words her previously unconscious aggression.

Lacan pointed out that some signifiers have special importance to us, he called these “master signifiers.” These are the limited number of signifiers that most define who we are. A little girl, Susan, showed me a school poster on which she had been asked to write some important things about herself: that her name is Susan, that she is four and a half years old, that she has red hair and green eyes, and that she likes to eat potato chips. These are some of Susan’s master signifiers.

Proper names are special and different from all other signifiers: they only point to one unique signified-the person with that name! I routinely ask patients where their names come from-both their first and last names-and I immediately learn about the symbolic register (see below) into which they were born

In the 1950s, Lacan developed the idea of the “symbolic register,” that part of human existence that includes language, culture, laws, traditions, rituals, and religion. This symbolic register is waiting for us when we are born. Our parents have often already selected a name for us, we learn the language of our family, we take part in our family’s traditions and rituals, etc. Even a vision of our future has often been mapped out for us. It is no accident that the children of musicians, physicians, and even morticians, often follow in their parents’ careers.

The symbolic register increasingly takes its place alongside the imaginary register. In another example from the book, 

 a mother is telling her child who is being held up in front of a mirror: “You’ve got grandma’s eyes,” “You look just like your father,” etc. The child will later identify with, rebel against, or do some of each, with what it has absorbed through the symbolic register.

One of Lacan’s therapeutic goals was to help the patient increasingly move from the imaginary to the symbolic register. Martin Luther King, Jr. expressed this idea well: “I look to a day when people will not be judged by the color of their skin, but by the content of their character.”

In 1953, Lacan identified a third register of human existence, the “real.” Whereas, the imaginary is the world of immediate sensory perceptions, and the symbolic is based on language and gives meaning to everything around us, the real is whatever else there is that is devoid of meaning. Quoting Lacan: “The real is all that cannot be symbolized and that is excluded from the symbolic and imaginary registers.”

Before and soon after a baby is born and has not yet acquired words or language, it is living entirely in the real register. As soon as it learns to say “mama” and other signifiers, the baby has begun to take part in the symbolic register that “makes a cut in the real.”

Whenever we speak, there is always much more that remains unspoken, and whatever is left unsaid and unsymbolized, exists in the real. At the other end of the life spectrum, for patients with advanced Alzheimer disease for whom words have mostly lost their meaning, they are increasingly living in the register of the real.

Lacan, following Freud, had three major diagnostic categories: (1) Neurosis – that he divided into the Obsessive and the Hysteric personality; (2) Perversion; and (3) Psychosis. All DSM V categories collapse into these three major categories of diagnosis for Lacan.

 The hysteric asks: “What is it to be a woman (or a man)?” who lives her (or his) life through “the other.” A young adult patient of mine with many features of borderline personality disorder-self-mutilation, suicidal ideation, substance abuse, unstable relationships, and splitting as a prominent defense mechanism-was obsessed with an idealized young woman movie star who had died by suicide. My patient wanted me (“the other”) to tell her why she shouldn’t also kill herself.

A Lacan quote came to mind: “The patient knows everything and the analyst knows nothing,” meaning that a patient’s conflicts exist entirely within his or her own unconscious and not in the mind of the therapist. Therefore, I told the patient that I couldn’t tell her what she should do because only she had the answer to this question. She expressed immediate relief from the self-destructive idea that she had been entertaining. I believe for three reasons: (1) what I said was true; (2) my response gave her a greater sense of agency; and (3) we now had a method to help her free herself from her self-destructive obsession-with both of us listening to the two sides of her conflict, the part of herself that wanted to follow in the footsteps of her beloved movie star and the part of her that wanted to remain alive. Needless to say, I too was relieved by not needing to justify to my young patient why she should continue to live.

 The obsessive asks: “Am I alive or am I dead?” and procrastinates interminably about getting things done, in an unconscious attempt to forestall the eventual certainty of his or her death.

A man in his 40s was still living at home with his parents and had struggled to complete his bachelor’s degree for many years. He increased the frequency of his appointments with me from once to twice a week but then became increasingly quiet in the sessions. When I said “You’re quiet,” he replied, “Now that I’m coming twice a week, it doesn’t matter if I talk as much as before, since I’m here twice as often.” I remarked: “You act as if you have all the time in the world to get done what you say you want to accomplish in life.”

Each of Lacan’s three major diagnostic categories is based on how the child resolves the Oedipal complex. The neurotic accepts that the “father” is the object of mother’s desire and hopes to find a “mother” substitute (an intimate partner) in the future. The pervert also accepts that the “father” is the object of mother’s desire but denies (

) this traumatic reality and uses a fetish object as a partial substitute for the mother to satisfy his desires. The psychotic maintains a dyadic relationship to the mother because the father figure is absent during the early years of the child’s development. In Lacanian terms, this results in a foreclosure of the paternal function with the psychotic person developing/experiencing feelings of omnipotence, grandiosity, and terror.

When needing to cross the street: The obsessive acts as if he has all the time in the world and waits at the corner until there are absolutely no cars coming. The hysteric puts herself in the place of the other and will only cross the street when others are also crossing the street. The pervert acknowledges that he should cross at the light but disavows the law and jaywalks. And the psychotic acts as if there is no law (there has been a foreclosure of the paternal function) and crosses without paying attention to whether there is traffic.

Lacan believed there was no “normal person” and that we all fall into one or another (or a combination) of the three diagnostic categories. In this regard, Lacan agreed with Elvin Semrad who defined a psychotherapist as: “One big mess treating a bigger mess.”

To Lacan, a “wish” is something we consciously want-for example, a million dollars or a new pair of shoes. A “need” reflects a physiological necessity, such as needing water, food, or sleep, but also love. “Demands” are endless requests for specific things, for example a baby pleading for a ball, a teddy bear, or a coloring book. But as soon as one demand is fulfilled, a new demand takes its place. A parent who tries to keep up with all of the child’s demands, ends up with an extremely spoiled child. The demand for love is also never fully satisfied and requires repeated expressions of reassurance. “Desire” is unconscious and can never be fulfilled but it directs the trajectory of our lives. In addition, according to Lacan: “The subject’s desire is the Other’s desire,” or “A person’s happiness comes from making the other person happy.” A major goal of Lacanian therapy is to help the patient discover his or her own (unconscious) desire. When a patient is five or ten minutes late, I email and phone the patient, letting him know that I am waiting for him and that I hope to see him soon: I want my desire to see the patient become the patient’s desire to be seen by me.

Later in his career, Lacan began to express his ideas in mathematical formulae and diagrams, wanting to make them more precise. Using the three interlocking rings from the 16th century borromean crest, Lacan called this the “RSI knot,” each ring representing the real, the symbolic and the imaginary registers. They all need each other to hold the knot together-if any one of the rings is removed, the other two will come apart. Like a Venn diagram, they all have overlapping and separate surface areas. This design also suggests an equivalence between the three registers.

Toward the end of his life, in the 1970s, Lacan proposed adding a 4th ring to the borromean knot that he called the “sinthome”-an old French word for symptom and making a word play on “Saint Thomas.” This fourth ring held the knot together if one of the other three rings was broken. This suggested that a patient’s symptom is adaptive, often keeping the patient from decompensating. Lacan was introduced to James Joyce early in his career, and he later suggested that Joyce’s writing, itself chaotic and disturbed (eg, 

) was a sinthome that kept Joyce from becoming psychotic.

The idea that a patient’s symptom serves a purpose is reflected in the admonition that we should not immediately try to take the patient’s symptom away before we understand what role it plays in the patient’s life.

Relatively early in his career, Lacan introduced the variable-length, also known as the “short,” session for which he was severely criticized by his non-Lacanian colleagues. Lacan believed that sessions should end unexpectedly to emphasize an important point or interpretation, to prevent the patient from filling up the session with trivia until the last minutes, and to avoid having the patient script the session in advance. His critics attributed his “short sessions” to financial greed and to gain additional adherents to the Lacanian cause.

In 1980, a year before he died, Lacan dissolved the Ecole Francaise de Psychoanalysis that he had founded 16 years earlier and a new school, the Ecole de la Cause Freudianne, continues his work. In the US, there are three “Lacanian Forums” or study groups, one in Washington, DC, one in Denver, Colorado, and one in San Francisco, and there are many Lacanian groups in Europe and three major Lacanian schools in South America.

Let’s Keep Talking: Lacanian Tales of Love, Sex and Other Catastrophes.

A Clinical Introduction to Lacanian Psychoanalysis: Theory and Technique.

Dr Perman is Clinical Professor of Psychiatry, George Washington University Medical Center, Washington, DC. Dr Perman reports no conflicts of interest concerning the subject matter of this article.

Against Understanding: Commentary and Critique in a Lacanian Key

, Vol 1. London; New York: Routledge Taylor & Francis Group; 2014.

Lacan has a devoted following throughout much of the non-English-speaking world (where he is the best-known psychoanalyst) but he is mostly unknown to the English-speaking psychiatric community (where he is the least-known psychoanalyst).

Jacques Lacan: The Best and Least Known Psychoanalyst

Adage: A short statement expressing a general truth.

Our patients’ lives consist of the stories they tell us. These stories describe their pathological symptoms, the vicissitudes of their childhoods, their recent victories and disappointments, their concerns about the future, and often and most importantly, their heartbreaks and longing for love and affection.

Just as patients organize their lives around the stories they tell us, we too sometimes respond to them with stories of our own. Over the years, I have found a number of metaphors, adages, and even a parable to be helpful in letting my patients know that they have been heard and to provide them with psychological comfort and support. The stories that we tell our patients have an element of a good-enough mother telling her children bedtime stories before they fall off to sleep. What follows are a few of the “stories” that I use in my psychodynamic psychotherapy practice with my patients, followed by brief reflections about each one.

1. Though no one can go back and make a brand-new START, my friend, anyone can start from now and make a brand-new END (Anonymous).

This adage is written on a small plaque that hangs on the wall of the bathroom used by my patients. As platitudinous as it is, it offers a message of hope to patients who are mired in unhappy reminiscences of their past and who believe that if only they had not experienced certain early maltreatment, their lives would be perfect.

This brief statement is relevant to the college student who dropped out the previous semester and is starting over again, to the recently divorced mother who feels that she is damaged and will never find another life partner, to the drug- or gambling-addicted patient who has suffered a multitude of self-inflicted losses and who believes that his or her past behavior will put its inevitable and irreversible stamp on
the future.

2. The difference between plants, non-human animals, and human beings is that plants exist in relationship to space, non-human animals live in the moment, and human beings have the capacity to conceptualize the future and the past.

I heard these definitions from a neuroscientist and futurist who spoke at a synagogue in Washington, DC, about 10 years ago. Patients’ anxiety about how things will turn out in the future can interfere with their ability to function in the present, and patients who believe that because they have failed at something in the past, fear that they will inevitably fail in the future. I sometimes cite Michael Jordan in this regard, the incomparable Chicago Bulls basketball forward who, I was told, when he missed a shot, immediately put the missed basket out of his mind and took another shot, not letting the failed shot interfere with his ability to keep scoring.

Dogs and cats, unlike people, probably don’t think about what they will be having for their next meal, or about what they ate last night, but we, human beings, are able to think about the future and to recall the past. In both instances, this has advantages and disadvantages. Being able to think about the future allows us to plan ahead and to anticipate and look forward to enjoyable events. But this also allows us to worry that things will not work out in the future, creating anxiety. Being able to reminisce about the past allows us to recall pleasant experiences with their accompanying glow of good feelings. At the same time, however, this ability to reminisce can fill us with regret about lost opportunities, failed grades, and the excruciating pain accompanying memories of relationships washed up on the rocky shores of broken hearts. Therefore, we will often do better if we can be more like dogs and cats that live in the moment and are not preoccupied with past regrets or anxiety about the future. This idea goes along with the current interest in mindfulness and other ways of “living in the moment.”

3. A companion adage is: To increase the likelihood that you will have the best possible future, have the best possible day today.

A number of college students in my practice struggle academically because they do not go to class or they procrastinate with their homework. I point out that if they are able to do their homework now and prepare today for their exam at the end of the week, they will graduate college with a higher GPA and will have more choices when they apply to graduate school or begin a career.

Lest I come across as sounding overly superficial, I am also interested in hearing about what is getting in the way psychologically of these students doing their work. That is, who are the authority figures in their lives that they are unconsciously trying to frustrate, why are they afraid of being too successful, and why are they getting drunk and high on marijuana every night?

4. If you are on an airplane, and the plane loses cabin pressure, put the oxygen mask on yourself first before putting it on the person sitting next to you (United Airlines, Southwest Airlines, American Airlines, etc).

This adage is for those patients who are trying to save others from disastrous interpersonal or economic situations, while not taking adequate care of their own needs first. The patient is often fearful that the other person will be angry if he or she does not give all of his or her money, possessions, etc, to the dependent person. I see this in patients in their 60s who have children in their 30s living at home, and who are not working full-time, are not in school, are heavily smoking pot, and are being supported by their aging parents. The parents are terrified that if they set limits on their children-ie, insist that they must get a full-time job and move out of the house by a certain date-their son or daughter will commit suicide. There is a powerful element of projected, denied, and disguised aggression directed toward their children. These parents can also feel unconsciously omnipotent about continuing to care for their “impaired” children.

The similar theological adage, God helps those who help themselves, is credited to Algernon Sidney and was later used by Benjamin Franklin in his Poor Richard’s Almanac of 1736.

5. The word “should” should be removed from thedictionary (Gerald P. Perman, MD).

“Should” indicates “an obligation, a duty, or correctness, typically used when criticizing someone’s actions.” This word is used in situations in which the patient is hypercritical of himself or herself, or of another person. This humorous adage will hopefully cause the listener to reflect on their castigating or self-castigating behaviors, and take steps to become more compassionate both toward oneself and toward others.

6. “I had a drink, the drink had a drink, and the drink had me” (Unknown Southern American writer).

This anthropomorphic (“. . . the drink had a drink, and the drink had me”) statement about alcoholism captures the overwhelming quality of addiction, the helplessness that many addicted patients experience, and the powerlessness of many alcoholics to stop drinking in an abusive fashion without getting help. I quote this to patients who drink too much but are not sure whether they fall into the category of someone suffering from alcohol abuse disorder. To mix my metaphors: “If the shoe fits, wear it.”

7. “You can please some of the people all of the time, all of the people some of the time, but you can never please all of the people all of the time” (Attributed to Abraham Lincoln as well as John Lydgate).

This quote was first used in the political sphere, but it is equally applicable in psychotherapy with overly perfectionist patients who tend to see things in an all or nothing manner, perhaps with borderline personality disorder features, and who therefore have difficulty making and accepting compromise.

Patients readily see the humor in this well-known adage, as well as its veracity, making it easier to accept and to help effect personality change.

8. The best way to keep a bird is to let it go free (Unknown source).

This beautiful adage comes from the more complete poetic quotation: “If you love something, set it free. If it comes back, it’s yours. If not, it was never meant to be.”

It is useful with patients who are overly controlling toward others, usually in the context of a romantic relationship. The gist of this idea is that (unless one is a sadist) we would only want to be in a relationship with someone who wants to be in a relationship with us.

This point can be driven home by turning it around and asking: “Would you want someone to be in a relationship with you, not because she loves you, but only because she doesn’t want to hurt your feelings if she leaves?”

The powerful idea expressed in this adage is also an extremely useful principle in managing the relationship between the therapist and the patient. That is, psychodynamic psychotherapy is a delicate procedure based at times on a tenuous therapeutic relationship.

It is crucial that the therapist create an environment in which the patient only continues in treatment because he or she feels that it is in his or her best interest to do so. Therefore, unless the patient is under a legal order to remain in treatment, we always want to leave the door open, so to speak, allowing the patient to feel free to leave anytime. This is how we keep our patients in treatment for a sufficient amount of time to give them the help they are coming to us for in the first place.

This article was originally published on February 16, 2018 and has since been updated. 

Dr. Perman reports no conflicts of interest concerning the subject matter of this article.

Over the years, I have found a number of metaphors, adages, and even a parable to be helpful in letting my patients know that they have been heard and to provide them with psychological comfort and support.

Author | Gerald P. Perman, MD

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