Lacan Borderline PDF

Borderline Personality Disorder: A Lacanian Perspective
Borderline Personality Disorder: A Lacanian Perspective v
To Elisa, my mother
En ella y solo en ella estan ahora

Los patios y jardines. El pasado
Los guarda en ese circulo vedado
Que a un tiempo abarca el vespero y la aurora.
- Jorge Luis Borges ( El Hacedor, 1960)

Borderline Personality Disorder: A Lacanian Perspective vii
Table of Contents
Preface xi
Acknowledgements xiii
I. The Borderline Concept in America 1

Difficulties in the Definition and Study of the Borderline
Patient 2
Early Conceptions of Borderline Pathology 6
Psychological Testing Models 8
Borderline Pathology in Descriptive Psychiatry 8
Post-traumatic and Dissociative Models 11
Borderline Personality in the DSM 12
Psychoanalytic Conceptions of the Borderline 13
Early Psychoanalytic Contributions 13
Froschs Psychotic Character 15
Later Psychoanalytic Theorists 17
II. Otto Kernberg and the Borderline Conditions 21

Post-Freudian Developments In Psychoanalytic Theory 21
Object Relations 22
Kernbergs Theory of the Borderline 25
The Descriptive or Presumptive Diagnosis 27
Kernbergs Structural Analysis 29
The Id in the Borderline Structure 35
viii Borderline Personality Disorder: A Lacanian Perspective
The Superego in the Borderline Structure 35

The Genetic-Dynamic Analysis and Developmental Theory 36
Kernbergs Three Psychic Structures 38
The Interview as a Diagnostic tool 40
Empirical Assessment of Structural Diagnosis 41
The Clinical Value of Structural Analysis 41
III. Lacanian Psychoanalysis 43

The History of Psychoanalysis in France 45
Structuralism 49
Linguistic Structures 50
Lacans Novel Psychoanalytic Ideas 54
The Mirror Stage: The Scenario of Ego formation 55
Lacans Critique of Developmental Psychoanalysis 59
The Symbolic Order 63
Lacans Conception of the Oedipus Complex 65
The Three Stages of the Oedipus Complex 66
The Prohibition of Incest 70
The Imaginary, the Symbolic and the Real 72
The Unconscious 74
Jouissance 75
Need Demand Desire 76
Diagnostic Considerations in Psychoanalysis 80
Structure and Diagnosis 81
Psychosis 84
Neurosis 91
The Hysterical Structure 93
Hysteria in Men 97
Obsessional Neurosis 98
Phobia 102
Borderline Personality Disorder: A Lacanian Perspective ix
Perversion 103
IV. The Case of Katherine 108

Katherine: The Presenting Problem 109
Family Structure and Childhood History 110
Work History 112
Course of Treatment 113
V. Katherine as a Kernbergian Borderline 120

Katherine as a DSM-IV Patient 121
Kernbergs Presumptive Criteria 122
Kernbergs Structural Diagnosis 124
The Structural Interview 124
Katherine: The Diagnostic Interview 126
Identity Diffusion: Neurotic Integration vs.
Borderline Fragmentation 127
Use of Primitive Defense Mechanisms 131
Projective Identification 131
Assessment of Reality Testing 134
Non-specific Ego Weaknesses 135
Lack of superego Integration 136
Excessive Pregenital Aggression 136
VI. Katherine as a Lacanian Patient 140

The Demand for the Desire of the Other 140
Identity or Desire? 143
The Didactic Phase of Treatment 144
From Interview to Treatment 145
Lacanian Structural Diagnosis 145
The Analysis of Two Dreams 147
x Borderline Personality Disorder: A Lacanian Perspective
Oedipal Vicissitudes 151

Katherine's Subjectivity 152
Lacanian Inter-generational Analysis 153
The Name of the Father 155
Katherine as a Neurotic Individual 157
VII. Lacan and the Borderline Conditions 162

Elements of a Lacanian Critique of the Borderline Concept 164
The Merger of Psychiatry and Psychoanalysis 164
The Critique of the Role of the Symptom 165
The Treatment of Borderlines 166
The Role of the Ego and the Ethics of Psychoanalysis 167
Lacan and Family Therapy 169
The Pre-Oedipal vs. the Oedipal Controversy 169
The Critique of Object Relations Theory 170
Borderline Structure as Part of the Human Condition 171
The Continuum of Diagnosis 172
The Rise of the Borderline and the Decline of Hysteria and
Perversion 173
Empirical, Philosophical and Ethical Considerations 175
The Borderline Diagnosis in Children and Adolescence 179
Criticisms of the Borderline Conception in Children 181
The Present Study and the Borderline Concept in Children and
Adolescents 184
Limitations of Interpretive Theory 184
Bibliography 187
Index 199
Borderline Personality Disorder: A Lacanian Perspective xi
Preface
T
he diagnosis of borderline personality organization has taken its place in
American psychoanalysis as a personality structure, the significance of which
has equaled and, in some quarters, even eclipsed the traditionally recognized
structures of neuroses, psychosis and perversion. However, the borderline diagnosis has been
largely ignored amongst psychoanalytically oriented clinicians in Europe and South America.
One reason for this is that a major theoretical gulf exists between American and European/South
American psychoanalysis, a gulf that can in part be attributed to the dominance of ego-
psychology and object-relations theory in the United States and an equal dominance of the
theories of Jacques Lacan in such places as France and Argentina. Within Lacanian thought,
there is a theoretical and clinical emphasis upon the three Freudian structures of neuroses,
psychosis, and perversion, and skepticism towards any approach that insists upon adding to this
scheme. Lacans own reaction to the concept of the borderline seems to have been that it is the
clinician him or herself, rather than the patient, who is undecided and on the border between
the traditional structures (Lacan, 1956).
Nevertheless, there has yet to be a systematic dialog between American psychoanalysts
and Lacanians on the question of the borderline diagnosis. In fact, in spite of a recent surge in
interest in Lacan in the United States (mostly outside departments of psychiatry and psychology)
there has been very little dialog between American psychoanalysts and Lacanians on any issue of
theoretical or clinical significance. When one surveys the literature readily available to American
clinicians, one finds hundreds of books and articles pertaining to Lacan, but less than a handful
of such comparative purpose.
xii Borderline Personality Disorder: A Lacanian Perspective
The present study seeks to make contributions of both a general and specific nature.
Generally, by comparing the psychoanalytic theories of Otto Kernberg and Jacques Lacan in the
context of the borderline diagnoses. More specifically, I seek to initiate and contribute to a long
overdue dialog between American and French psychoanalysis. By promoting such a dialog I
hope to make a contribution that may help refine both theory and clinical work with the severely
disturbed patients who have been designated borderline by Kernberg and others.
As the main vehicles for this study I have chosen both a critical and comparative review
of theories of Otto Kernberg and Jacques Lacan and an analysis of an illustrative case. The case
of "Katherine," a 25 year-old woman who the author saw for three years in psychoanalytically
oriented therapy is presented and analyzed from both Kernbergian and Lacanian points of view.
It is shown that Katherine, who readily meets Kernberg's presumptive and structural criteria for
Borderline Personality Disorder, can profitably be understood and treated as a case of neurosis
within Lacan's diagnostic scheme.
The question of whether those patients described by Kernberg as structurally borderline,
do in fact constitute a homogenous group from the perspective of Lacanian theory is a critical
one, and the conclusion that I drew is that from a Lacanian perspective, borderline pathology is
fundamentally a descriptive category that does not cohere from a theoretical, structural point of
view. The reasons for this will become evident in this book, and it will also become clear that
from a Lacanian perspective a Kernbergian borderline may well have a neurotic, psychotic or
perverse structure. I hope to demonstrate how Lacanian ideas can be of significant value in the
diagnosis and treatment of individuals suffering from severe pathology, and that an alternative
mode of treatment exists for these patient that is not dependent upon our accepting the borderline
concept.
Liliana Rusansky Drob

New York, June, 2008
Borderline Personality Disorder: A Lacanian Perspective xiii
Acknowledgements
I would like to express my gratitude to Beatriz Azevedo, my psychoanalytic supervisor

who helped me clarify my own questions and who has worked with me throughout many years
of clinical supervision and Lacanian readings.
I am greatly indebted my analyst, Paola Mieli, who has never given up on my path of
articulating my desire.
I am especially grateful to my husband, Sanford Drob, whose support and
psychological knowledge has made possible for me to think aloud on the questions of diagnosis
and who has become a role model to follow in his persistence in the completion of a written
project.
I would also like to thank Dr. Beth Hart and Dr. Florence Denmark, my dissertation
chairs at Pace University, for their interest in my clinical work and their support of a
psychoanalytically-based doctoral thesis.
The Borderline Concept in America
Chapter One
The Borderline Concept in America
I
n recent years, the topic of borderline personality has not only come to dominate
discussions in clinical psychiatry and psychoanalysis but has filtered down into segments of
American culture as well. Films such as Fatal Attraction, Single White Female, and Girl
Interrupted seem to have been written with this diagnosis in mind, and in some circles the term
borderline is used indiscriminately in a derogatory manner to refer to any difficult personality,
especially if young and female. While most American psychoanalysts regard borderline
pathology as a distinct nosological entity requiring a specific dynamic formulation and
therapeutic technique, no equivalent acceptance of the borderline concept is to be found amongst
European analysts. In particular, Jacques Lacan, whose return to Freud has dominated
psychoanalysis in France, much of Europe and South America, specifically rejected the
borderline concept, tacitly denying that there are borderline patients, holding that it is the analyst
who is on the border in his understanding of a difficult case. Lacan preferred to adhere to
Freuds basic nosological distinctions between neurosis, psychosis, and perversion, leaving no
room for this fourth pathology which plays such an important role in American diagnosis and
treatment.
A number of factors have hitherto prevented a meaningful dialogue between American
ego, object relations, and self psychologists and their counterparts in France. Amongst these, are
Lacans radically different conceptualizations of the ego and his rejection of a unified subject,
his notion that the ego is a center of misperception and untruth, and his view that by virtue of
language we are constantly miscommunicating. Since the borderline conditions are
conceptualized as a failure in the development or regulation of the ego or self, Lacan, who rejects
2 Borderline Personality Disorder: A Lacanian Perspective
the notion that there is an ego that must be regulated and developed, appears to have little place
for borderline pathology in his conceptual framework.
Nevertheless, it is clear that Lacanians are indeed treating many patients who American
clinicians would diagnose as borderlines. How these patients are conceptualized and treated
within a Lacanian framework will not only provides us with a great deal of insight into the
distinction between Lacanian and American psychoanalysis, but should also provide us with a
fresh perspective on the treatment of such patients. Further, since the rejection of the borderline
concept is one factor preventing a meaningful dialogue between American and French
psychoanalysts, a clarification of the reasons for this rejection and the alternative
conceptualizations and techniques proposed by Lacan should be helpful in establishing a dialog
between these two camps. A careful analysis of this issue will be helpful in discerning not only
the points of contrast amongst the respective schools of thought but also points of (thus far)
unrecognized convergence as well.
Difficulties in the Definition and Study of the Borderline Personality
Clinicians have long described patients who either bordered on schizophrenia or appeared
to have features of both neurosis and psychosis. Patients have been classified as borderline
according to a variety of not always consistent criteria, some of which emerged as a result of
specific methodological tools that are utilized in the study of varying populations (Gunderson
and Singer, 1985). In general, there have been three main approaches to the classification of such
patients. The first, which has been termed the descriptive approach, is based exclusively on
symptomatic and behavioral observations. The second, the psychoanalytic or structural
approach, groups patients not on the basis of symptoms but rather on the basis of a presumed
underlying psychological dynamic or structure that individuals with varying symptoms and
behaviors share in common. A third classificatory approach shares some features with each of
the first two, and classifies such patients on the basis of their performance on psychological tests
(Stone, Dellis, 1960).
The Borderline Concept in America 3
These three classificatory methods are most often utilized in connection with widely
varying sources of data and widely divergent ways of conceptualizing such data. Whereas the
descriptive, and to a certain extent, psychological testing approaches, are amenable to wide-
ranging empirical studies that examine a large sample on the basis of standardized criteria, the
dynamic/structural approach has traditionally been limited to intensive work with individual
patients, who in the course of psychotherapy, are found to exhibit specific patterns of
transference, resistance, defense, response to treatment, etc (Hoch, Catell, 1959). Psychodynamic
theorists argue that the specific features necessary for adequate dynamic/structural diagnosis
only emerge in the context of the intensive interpersonal encounter of psychoanalytic treatment,
and are largely opaque to standardized empirical research.
Frequently these classificatory methods also vary according to the setting in which they
are employed. For example, it is frequently the case that behavioral and symptomatic
observations are conducted by psychiatrists in hospital or other residential treatment settings,
whereas psychoanalytic formulations have evolved mostly within the context of private,
outpatient clinical work. Further, the communication of findings and theory is often limited to a
select audience. Psychologists, for example, who have diagnosed the borderline syndrome
thorough the administration of a battery of psychological tests, although often working in the
same or similar settings as descriptive psychiatrists, generally publish their findings in
specialized journals with limited readership among other mental health disciplines (Gunderson,
Singer, 1970). Finally, the various groups working with so-called borderline patients are often
suspicious of each others methodology, sources and personal biases. Adding to the confusion
regarding the borderline diagnosis is the fact that, as a result of a variety of factors, those
utilizing different classificatory approaches may not actually be referring to the same, or even
similar, patient populations. It may well be that the so-called inpatient borderline subjects will
present symptoms and structures that are quite different from those of their outpatient
counterparts and that those seen as borderline in public settings may be quite different from those
who are so classified as borderline in private practice (Grinker, et.al. 1968).
Over the years, research studies on borderline subjects have set varying selection criteria
for their samples. One study may include outpatients with or without overt psychotic symptoms
such as delusions and hallucinations at the time of the study, while another will be limited to
inpatients who exhibited brief psychosis either on mental status or in their recent psychiatric
history. For example, Hoch and Catell (1959) selected their patients on the basis of severe
psychoneurotic symptoms but later found on closer evaluation during psychotherapy performed
by psychoanalysts that these very patients exhibited signs of schizophrenia in their thinking,
feelings and physiological functioning. Others, such as Grinker, et. al (1968) who conducted a
widely recognized long-term study of borderline patients, selected subjects on the basis of good
functioning in between hospitalizations and the presence of an ego alien quality to any psychotic
symptoms. It is clear that patient selection has impacted upon the conclusions reached regarding
the borderline diagnosis and its relationship to schizophrenia. Whereas Grinker found very few
subjects with psychotic episodes at the end of the study, Hoch and Catell, in contrast, had an
expected subgroup of schizophrenics amongst their patients.
In summary, four major variables may be considered in any description of the so-called
borderline patient: (1) Methods of classifying patientsdescriptive, structural, psychological
testing, (2) settings in which research is conductedinpatient, outpatient, public, private, (3)
nature of the data baseempirical studies, or intensive psychoanalytic psychotherapeutic
investigation, and (4) selection criteria for the borderline classification.
Empirical studies using the psychoanalytic model focused on the borderline personality
disorder have been developed in the last twenty years (T., 1989). When Gunderson was
approaching the issue of borderline diagnosis from an empirical point of view, he posited that
unless there was external validation of the criteria or some level of predictability based on family
prevalence or course of illness, the diagnosis would not sustain inclusion in the DSM-III.
However, he insisted on including two criteria that were essentially psychoanalytic: vulnerability
to regression and psychosis under transference-like conditions. (Gunderson, 1975)
Certainly by 1990, if not before, the borderline personality was by far the best researched
of the personality disorders, indeed accounting for the majority of scientific publications on this
topic (Efrain Bleiberg, 1995). While there is a relatively high degree of agreement on the
phenomenology of the borderline disorder, a major controversy exists regarding the etiology of
this condition, with the role of early childhood trauma (particularly sexual abuse), other
parenting factors, genetic predisposition, and socio-economic factors debated in the literature.
Further, while psychoanalysts have taken a lead in examining this condition, and there is even a
certain level of agreement regarding the psychostructural characteristics of these patients, the
psychoanalytic literature lacks nosological congruence with the general psychiatric descriptions,
suggesting that psychoanalytic structural classification may not (in spite of Kernbergs
affirmations) correspond to the descriptive (DSM) Borderline Personality Disorder syndrome.
Since the nature of the borderline disorder goes to the heart of psychoanalytic ideas regarding the
nature of the human subject, the function of the ego, the major drives and their vicissitudes, etc.
one might expect different formulations regarding so-called borderline patients among different
psychoanalytic theoreticians and schools.
This study focuses upon the borderline diagnosis within the context of psychoanalytic
theory and treatment. Without discounting their significance, I will not elaborate in detail on the
descriptive or psychological testing investigations of the borderline phenomena, except insofar as
these methods impact upon psychoanalytic theory. I do not intend in the course of this study to
examine the diagnosis of Borderline Personality Disorder in every conceivable context, but
rather to focus upon the meaning, relevance, and utility of this diagnosis within the context of
psychodynamic theory and treatment. However, the emergence of the borderline concept in
American psychoanalysis initially involved a confluence of both descriptive and psychoanalytic
formulations. In addition, many analysts who considered the borderline diagnosis (Kernberg
among them) were profoundly influenced by developmental theorists who worked within
academic psychology. Part of the reason for this, is that during the years of the borderline
concepts initial formulation (roughly, 1941-1975). American psychiatry was far more closely
identified with psychoanalysis and developmental psychology than it is today. As a result, only
by tracing the roots of the borderline concept first within descriptive psychiatry/psychology and
then within psychoanalytic and developmental theory can we come to understand its emergence
as an important diagnosis amongst American psychoanalysts. After doing so we will be in a
position to explore some of the reasons why this diagnosis failed to emerge among
psychoanalysts practicing outside of North America.
Early Conceptions of Borderline Pathology
According to Salman Akhtar (1992) the earliest tentative description of a mental disorder
that was not clearly viewed as insanity was made by J.C. Prichard (Treatise of Insanity, 1835).
He referred to a syndrome of moral insanity which he characterized as a form of mental
derangement in which the intellectual faculties appear to have sustained little or no injury.
Prichards initial patient was described as presenting with perverse feelings, habits, and temper,
without a defect in his or her reasoning faculties and mainly without illusions or hallucinations.
(Prichard, 1835). However, the concept of moral insanity came to be restricted to antisocial
individuals, and the other types of dysfunction noted by Prichard were largely ignored.
Emil Kraepelin (1905), the German psychiatrist who is often credited with being the
founder of modern descriptive psychiatry, took a keen interest in what had been referred to as
morbid personalities. He viewed this condition as a borderline state between insanity and
normalcy. He presented several different combinations of healthy and abnormal personalities,
emphasizing that such individuals, in spite of their eccentricities, were not cognitively deficient
and could even be gifted intellectually. Kraepelin even created a nosology of subtypes of the
morbid personalities: (1) patients with instability of will (who probably come close to todays
borderlines), (2) liars and swindlers (who by todays descriptive criteria would be classified as
antisocial), and (3) pseudoquerulous individuals (who might be regarded as paranoid
personalities).
Kraepelin described the first group as childish, presumptuous, overbearing, irritable,
unmanageable, selfish, and with no sympathy for others. Although it appears that he was
attempting to describe what might now be classified as personality disorders, the general trend
for at least the next decade was to group all such morbid personalities under the diagnosis of
psychopathy and again, the borderline disorders fell into a state of neglect.
A decade later, Bleuler reopened the investigation of the field of severe non-psychotic
disorders. First, Bleuler questioned the term dementia praecox used by Kraepelin and replaced it
with the term schizophrenia. For Kraepelin, dementia praecox had represented the end-state of a
chronic psychiatric deterioration. For Bleuler, schizophrenia simply represented a
disorganization of psychic functions. Bleuler also described two forms of non-psychotic
disorders characterized by the absence of hallucinations but with a tendency to turn to fantasy in
place of reality. These he termed simple and latent schizophrenias, disorders which today would
be descriptively classified under schizotypal personality disorder. Bleulers contribution was to
broaden the scope of severe non-psychotic psychopathology, expanding the field of clinical
psychiatry to the realm of the personality disorders. From then on, a series of researchers were
encouraged to embark on clinical and empirical studies of a group of unstable individuals who
were thought to be neither neurotic nor frankly psychotic and who, in these researchers views,
required not only a new diagnostic category but psychotherapeutic interventions tailored to their
particular level of pathology.
Zilboorg (1941) described a group of patients that he called ambulatory schizophrenics.
These patients presented with a normal appearance, which was, however, accompanied by
shallow emotionality, dereistic thinking, an incapacity to settle on one job or life pursuit, and an
inability to sustain friendships. Zilboorg noted that these patients were able to function without
the need for hospitalization. He included among this group psychopathic personalities,
murderers, and sexual perverts. He discarded the term borderline as he viewed these patients as
a subtype of schizophrenia.
Hoch and Polatin (1949) described a condition which they termed pseudoneurotic
schizophrenia. Although these patients appeared to be neurotic, Hoch and Polatin held that
behind this faade rested the core features of schizophrenia. No area of their functioning was free
from conflict and tension. Their sexual life was characterized by promiscuity and perversion.
They displayed multiple severe neurotic symptoms, were extremely sensitive to criticism and
often presented with expressions of extreme rage. Hoch and Polatin again emphasized the fact
that these patients were not borderline but a subtype of schizophrenia. They viewed these
patients symptoms as pathognomonic of schizophrenia but noted that their schizophrenic signs
were often evident in subtle rather than global ways. Although the psychiatric community did not
accept their conceptualizations at the time, Hoch and Polatin provided a convincing description
of pathology in which neurotic and psychotic symptoms at least appeared to overlap.
Psychological Testing Models
The field of psychological testing (Rapaport et al.1945, Singer 1977), provided further
impetus to the study of a group of patients who, although functioning relatively well in social
situations, suffered from an underlying fragile, and potentially psychotic personality core. These
authors described a group of such patients who showed a predominance of primary process
thinking when presented with unstructured tests like the Rorschach. Gil and Schaeffer (1945-6)
also provided evidence of preschizophrenic patients who on psychological testing showed weak
ego structures and a prevalence of primary process thinking. According to Rapaport (1946),
these patients typically provide fabulized, confabulatory and highly elaborate Rorschach
responses. He further suggested that borderlines give a higher percentage of emotionally charged
responses in the context of simple percepts (Rapaport, 1946).
Indeed, as early as 1921, Herman Rorschach (1921) himself described a subgroup of
patients whom he described as latent schizophrenics who presented with appropriate surface
behavior but whose responses to the inkblots contained elements common to those provided by
schizophrenics. For example, the presence of self-referential answers, the belief that the cards are
real, scattered attentional processes, and a primitive quality of ideas and associations all
suggest the presence of primary process thinking, close to the surface in such latent
schizophrenic individuals. However, Rorschach investigators have generally agreed that such
patients do not exhibit similar ideational patterns on more structured cognitive and intellectual
testing.
Borderline Pathology in Descriptive Psychiatry
In 1968, Grinker et al, conducted a study of 53 hospitalized patients in order to establish

criteria for the diagnosis of borderline personality. These investigators used 93 behavioral
criteria and arrived at what they held to be four fundamental characteristics of the borderline
syndrome: (1) chronic anger, (2) defective interpersonal relationships, (3) identity disturbance,
and (4) depression rooted in feelings of loneliness. A cluster analysis of their data yielded four
subcategories of the borderline syndrome:
(1) The psychotic borderline, characterized by problems in reality testing, identity disturbance,
grossly inappropriate behavior, negativism, outbursts of rage, and depression.
(2) The core borderline, characterized by chronic rage and impulsive self-destructiveness.
(3) The as-if individuals, lacking in authenticity, leading false lives with superficial relationships.
(4) Individuals with chronic anxiety and anaclitic depression, characterized by a dependence on
a pregenital love object such as the mother.
The Grinker study was the first large-scale attempt to sort borderline patients via descriptive
psychiatric criteria. However, it was criticized, particularly for its poor inclusion and exclusion
criteria and the lack of weighted criteria for the diagnosis of borderline personality.
As early as 1975, Gunderson and Singer (1975) attempted to define the borderline
conditions and clarify the confusion that at the time reigned with respect to this diagnosis.
Through an analysis of the data of other investigators they arrived at specific criteria that they
believed would establish the borderline disorder as a discrete diagnostic entity. Gunderson and
Singers six criteria were: (1) intense affect, (usually hostile and/or depressed); (2) lack of social
adaptation, as a result of identity confusion; (3) impulsive behavior with self-destructive
tendencies; (4) brief psychotic experiences, especially those precipitated by drug use or in the
context of intense intimate relationships; (5) bizarre and primitive responses on psychological
tests; and (6) disturbed interpersonal relationships, characterized by a rapid swing from
dependency and passivity to manipulative and over-demanding behavior.
In spite of Gundersons and Singers synthesis, the borderline diagnosis continued to be
criticized (Liebowitz, 1992). One reason for this was that the term borderline continued to be
used in a variety of ways: either as a discrete diagnosis, as a form of schizophrenia, as a group of
affective disorders and finally as a psychostructural substrate underlying all severe pathology.
Investigators continued the attempt to identify a series of symptoms that would define the
borderline syndrome.
Gunderson and Kolb (1978), working with the National Institutes of Mental Health,
initiated a new comparative study among borderlines, depressed neurotics and schizophrenic
patients. As a result of this study, several psychosocial factors were included as additional
criteria, including low school and work achievement, sexual promiscuity, superficially high
levels of socialization, and a singular motivation to avoid aloneness.
In 1979, Spitzer (1979) and his colleagues created a list of criteria with 17 items based on
Gundersons 1978 study and sent it to 4,000 members of the American Psychiatric Association.
He asked the participants to judge the lists discriminating ability. Eight hundred and eight
participants responded that using these criteria they could discriminate a borderline from a non-
borderline 88 % of the time. Although Spitzer called this hypothetically distinguishable
condition unstable character rather than borderline, his study provided some evidence for the
hypothesis that there was a descriptively identifiable borderline patient. Spitzer produced his
own list of eight criteria: 1-anger, 2- unstable affect, 3-chronic feelings of emptiness and
depression, 4-identity disturbance, 5- intense emotional relationships characterized by shifts
between devaluation and idealization, 6- intolerance to aloneness, 7-impulsivity, (related to
substance use) and 8- physically self-damaging acts. Later a ninth criterion, dissociative
experiences, was added that proved to be highly discriminatory for this group.
A second set of investigators (Sheehy, 1980) compared a group of borderline patients
with a matched control group of other personality disorders. This represented an advance in the
field, as borderlines were here compared with other personality disorders instead of being
compared to schizophrenics and those with affective disorders. Sheehy reached conclusions
similar to those of Spitzer but held that there are three core characteristics of borderlines: 1-
impulsivity, 2- intense affect, and 3- interpersonal difficulties. To Spitzers original eight criteria,
these investigators added four additional criteria, (1) absence of hypochondriasis, (2) absence of
obsessive compulsive symptoms, (3) periods of social withdrawal and (4) chaotic sexual life with
a tendency towards promiscuity.
From the 1970s to the 1990s, the diagnosis if borderline personality came to be
generally accepted within clinical psychiatry and psychology, and there was an increasing
interest in this topic amongst both researchers and clinicians. In general, during this period, in
addition to psychoanalytically based work, we find studies and conceptualizations that link
borderline conditions to the schizophrenic spectrum of disorders (Kety et al, 1975) and others
that emphasize the connection between the borderline and affective disorders. (Klein 1975).
Post-traumatic and Dissociative Models
More recently a number of clinicians have come to see borderline personality as a

disorder of chronic post-traumatic stress (Bleiberg, 1990). These clinicians suggest that a history
of trauma, in particular sexual abuse, is present in the borderline patient. Accordingly, the
borderline patient was exposed to a traumatic event that produced an overwhelming stress
response. Later in life any pattern of further re-traumatization produces the impulsive acting,
avoidance, hyperarousal, dissociation, and even psychotic-like symptoms that had become the
coping style for borderline patients, a style that is best accounted for in the context of a post-
traumatic stress model.
Along these lines it might be argued that a qualitative distinction can and should be made
between the true psychosis found in genuine schizophrenic spectrum disorders (which is
believed to be biologically based) and the apparent psychosis (e.g. auditory hallucinations) that
is often observed in dissociative (and borderline) patients, who as a result of early childhood
trauma have split off (dissociated) aspects of their identity, which in later life returns as an alien
voice. These patients, according to those who study the dissociative disorders, are qualitatively
distinct from schizophrenics, though they are often mistakenly given the latter diagnosis because
of their bizarre behavior and symptoms. Such patients (who at one time might have been
diagnosed as suffering from hysterical psychosis) are thought to have developed their
pathology as a result of defenses they put in place in response to early childhood trauma. On this
view the schizophrenic is unable to develop a stable ego and identity because of a biological
failure, whereas the borderline/dissociative has the biological equipment to develop properly, but
doesnt do so because of an abusive and unstable early environment. As such, the borderline
psychoses are purely defensive/dynamic in nature and wax and wane in response to
environmental demands.
Borderline Personality in the DSM
The American Psychiatric Association officially acknowledged the Borderline

Personality Disorder for the first time in the version of their Diagnostic and Statistical Manual
(DSM-III), published in 1980. From that point on there was a veritable explosion of literature,
much of it related to the differential diagnosis between borderline personality and affective
disorders. At the present time, the DSM-IV describes the Borderline Personality Disorder as
follows:
a pervasive pattern of instability of interpersonal relationships, self-image and affects,

and marked impulsivity beginning by early adulthood and present in a variety of contexts,
as indicated by five or more of the following criteria:
1) Frantic efforts to avoid real or imagined abandonment.

2) A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
4) Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex,
substance abuse, reckless driving, binge eating).
5) Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior.
6) Affective instability due to a marked reactivity of mood (intense episode lasting only a
few hours).
7) Chronic feelings of emptiness.
8) Inappropriate intense anger or difficulty controlling anger.
9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
These criteria do not vary much from those proposed by Spitzer or Sheehy in the early
1980s. It should be noted that since only five out of nine possible criteria must be met in order
to reach the diagnosis, two patients diagnosed with the Borderline Personality Disorder, as
defined by DSM-IVs descriptive criteria, can be markedly different, even from a descriptive
point of view.
Psychoanalytic Conceptions of the Borderline Patient
In an effort to clarify the underlying psychological characteristics that characterize

borderline patients from a deeper (and not merely descriptive) point of view, we must turn to a
psychoanalytic understanding of the borderline concept. While a psychoanalytic model is not the
only possible means of conceptualizing the deep structure of psychopathology, in the case of
borderline personality, it has been the American psychoanalysts who have made the most
persistent efforts in this direction.
American psychoanalysis, with its emphasis on ego development and defenses provided
fertile ground for developing an understanding of these patients intrapsychic structure and
dynamics and provided a significant avenue for the investigation of this new diagnostic entity
that had been suggested by more descriptive research. The early psychoanalytic contributions to
the borderline diagnosis helped set the stage for more systematic psychoanalytic investigations of
severe (borderline) psychopathology in the 1970s and later. In this section I will review the
earlier psychoanalytic contributions to the borderline diagnosis and, with the notable exception
of Kernberg and his school (which will be reviewed later) some later psychoanalytic conceptions
of the borderline personality.
Early Psychoanalytic Contributions
A. Stern (1938) was perhaps the first psychoanalyst to utilize the term borderline to refer
to a distinct pathological entity in between neurosis and psychosis. He described borderline
pathology as a stable intrapsychic entity, and in this sense prepared the ground for Kernbergs
later conceptualization of a stable structural organization of the borderline conditions. Stern
found his borderline patients to be poor candidates for psychoanalysis and characterized them as
exhibiting ten basic features, including a history of cruel, rejecting mothering, hypersensitivity to
criticism and rejection, defensive rigidity, pervasive inferiority and lack of self-assurance,
masochism and depression, the use of projection, and problems in reality testing. Stern also
described these patients as frequently experiencing a negative therapeutic reaction to
psychoanalytic interventions.
Melanie Kleins contributions (1939) were particularly relevant to the borderline concept;
of specific importance were her descriptions of splitting of object representations and her
illuminating discussion of the defense mechanism she termed projective identification. Each of
these mechanisms took an important place in later psychoanalytic theories of the borderline
structure. According to Klein, the innate helplessness of the infant is an early expression of the
death drive which floods the child with negative emotion. This negative affect is projected onto
the caretaker, with the result that the child succeeds in placing the negative object outside, at the
expense of experiencing persecutory anxiety from this object as a retaliatory response. In order
to allay this anxiety, a new defense mechanism arises that serves to protect the ego from
aggression: a splitting of the object into good and bad aspects (This is what Klein terms the
paranoid position). The maintenance of this split brings about an idealization of the good part
of the object and sadistic expressions towards the bad part of the object. However, the infant later
integrates these two parts in what Klein describes as the depressive position, with a resultant
change in the childs affective organization. Whereas in the paranoid position the child is
plagued by envy, destruction and greed, in the depressive position these emotions are redirected
into feelings and expressions of gratitude, guilt, sadness and reparation. If this process of
integration does not occur, the paranoid position governs the personality organization with
splitting as the characteristic mode of defense. We will see that such splitting provides an
important organizing principle in Kernbergs later conception of borderline pathology.
In 1942 the psychoanalyst Helen Deutsch used the term as-if personality to describe
patients who appeared to be normal but whose personality is conditioned by pathological
internalized objects. These individuals suffer from an inner feeling of emptiness, marked
passivity, suggestibility, and symptoms of derealization and depersonalization. Deutsch felt that
these patients were somewhere on the continuum between neurosis and psychosis and that they
had failed to integrate early identifications into a stable personal identity.
In 1953, Knight used the term borderline to refer to individuals whose weakened ego
structures placed them midway between neurosis and psychosis. While these patients were
superficially adapted to the environment and were not obviously psychotic, they demonstrated a
number of weaknesses in such ego functions of concept formation, judgment, planning, and the
capacity to defend themselves against primitive unconscious impulses.
Froschs Psychotic Character
Frosch (1964) coined the term psychotic character to describe individuals with psychotic
personality features but who had certain ego strengths, including sufficiently adequate reality
testing to permit them to recover quickly from psychotic regressions. Frosch held that these
individuals might suffer certain illusions or perceptual distortions, but were sufficiently reality-
oriented to know that their perceptions were indeed not real. Froschs contributions centered on
his conceptualization of reality in regard to which he described three distinct components:
1) The relationship with reality, a measure of how the individual copes with and relates
to the external world. This, for Frosch, is a measure of adaptation, which is to be distinguished
from reality-testing per se (e.g. a patient with reality testing problems can adapt reasonably well
to reality by accommodating to his perceptual impairment). Perceptual disturbances such as
hallucinations and illusions are, in Froschs terms, distortions in the relationship with reality.
However, the difference between psychosis and the psychotic character is that in the latter, such
disturbances are transient and reversible, with the relative retention of the capacity to test reality.
(Frosch, 1969).
2) The feeling of reality, or defects in the sense of reality, which relate to the ability to
experience ones self and body, along with external events, as real and familiar. Examples of
pathology in this area include the experience of a confused or grossly distorted body image, and
feelings of derealization, depersonalization and estrangement that occur under stressful
situations,
3) The capacity to test reality refers to the ability of the individual to evaluate
appropriately the phenomena in their world. For Frosch, this concept implies the conventions of
a culture and is dependent upon conformity to a socially agreed upon notion of reality. For
Frosch, a hallucination may be present as a distortion of a perception, but if the individual is able
to recognize the phenomenon as internally derived, this person has retained his/her capacity to
test reality. Frosch provides an example that illustrates this point, as well as his conception of the
psychotic character: A female patient suddenly felt the floor tremble while at a concert. She
asked the people beside her if they felt the same. When the answer was that they had not, the
patient took a few moments to think about this event and told Frosch that she was puzzled by her
experience but concluded that the trembling must have been a projection of her own vaginal
orgasm. The trembling of the floor represents a distortion of her relationship with reality; later
the patient was able to recognize that these phenomena had been a personal experience, which in
Froschs view indicates that her reality testing remained intact. Nevertheless, the bizarre nature
of her explanation of her own distortions is, according to Frosch, typical of the flood of
sexualized content which overcomes the psychotic characters ego defenses.
According to Frosch all three aspects of reality are deficient in psychosis, whereas the
psychotic character shows impairments in the adaptation to and feeling of reality, but is able to
maintain adequate reality testing. The vulnerability to breaks in reality testing that Frosch
occasionally observed in these patients are on his view attributable to extreme stress, where the
patient suffers an ego regression resulting in a brief psychotic break that is completely reversible.
Frosch reports that some of these patients experience constant cycles of regression and reversals
according to the degree of their subjective vulnerability. (Frosch, 1970).
Later Psychoanalytic Theorists
Kernberg, whose work will be discussed in detail in Chapter Two, is the next major
psychoanalytic thinker to make contributions to our understanding of the borderline, and the
psychoanalyst who has been most influential in contemporary discussions of borderline
personality. Beginning in1966 Kernberg commenced work on a synthetic and comprehensive
model of the borderline personality that integrated both descriptive and psychoanalytic criteria,
and which assisted the psychiatric community to reach something of a consensus regarding the
nature of this disorder.
However, Meissner (1978, 1982) concluded that those patients who have been classified
as borderline cannot be properly brought together under a single structural diagnosis, but rather
represent a spectrum or range of personality dysfunction. According to Meissner, there are two
broad groupings of borderline patients, those belonging to (1) the hysterical, and (2) the schizoid
continuums. Each of these groups is in turn comprised of several sub-categories. The hysterical
group is comprised (in descending order of pathological severity) pseudo-schizophrenia, the
psychotic character, the dysphoric personality (borderline personality proper), and the primitive
hysteric. The schizoid continuum includes the schizoid and as-if personalities, the false self
personality organization and patients who can be characterized as suffering from identity
diffusion. (Meissner, 1978). Further, Meissner proposed that we should think of borderline
personality disorder in terms of a variety of subgroups in the same way we do with respect to
schizophrenia. He concluded that the variety of psychopathological phenomena that have been
subsumed under this disorder may account for the resistance to attempts to create an integral
theoretical formulation (1978).
While many clinicians and theoreticians have found Meissners sub-groupings useful, we
should here note that Meissners sub-classificatory scheme actually calls into question the
possibility of defining the borderline personality in structural or dynamic terms. We might ask
what remains of the original borderline concept and the presumed psychotic-neurotic-
borderline diagnostic triad, after the borderline concept is splintered into so many different
pathological entities. While the various subcategories of the hysterical subgroup can be classified
according to a criteria that has traditionally been associated with the borderline concept
(affective lability, poor frustration tolerance, ego-weaknesses, lack of self-cohesion, primitive

defenses, etc.), the schizoid group is not readily classifiable in these terms. Rather these patients
seem to be characterized by what has been called the need-fear dilemma, an intense conflict
between a need for others and a fear of being engulfed and destroyed by them.
In 1983, Abend, Porter and Willick, provided a critique of the borderline concept as it is
understood by Kernberg and his followers. They conducted an in-depth evaluation of four
patients who met eleven descriptive borderline criteria and who had completed classical
psychoanalysis. They presented their findings to the Kris Study Group at the New York
Psychoanalytic Institute. Their diagnostic criteria derived from a review of the literature and
included reversible defects in reality testing, infantile interpersonal relationships, impaired
adjustment, polysymptomatic neurosis, primary process thinking, narcissistic personality
features, aggressive conflicts, substantially disturbed affect, and intense transference reactions in
treatment. In contrast to Kernberg, these authors suggested that such patients suffer from severe
oedipal as opposed to pregenital or pre-oedipal difficulties. These researchers argued that their
patients could not be distinguished on the basis of specific defenses (such as splitting and
projective identification) or level of defense. Further, the four patients studied did well in
traditional psychoanalysis.
According to Abend and his colleagues, the term borderline does not refer to a discrete
diagnostic syndrome but to a rather loose catch-all classification for a large number of
heterogeneous patients. Goldstein (1985), a psychiatrist who adopts Kernbergs theoretical
understanding of the borderline disorder, argues that in spite of the fact that Kernberg diagnosed
two of Abends patients as borderline, these patients were healthier than the typical borderline
treated by Kernberg and his associates.
Masterson and Rinsley (1972, 1976) emphasized the disturbed character of the
borderlines mother. They based their work in part on the developmental theories of Bowlby and
Mahler and agreed with Kernbergs conception that impaired object relations play a significant
role in borderline pathology. They described the mother of the borderline as a borderline herself
who encouraged symbiotic clinging, but who became unavailable if the child displayed any
desire for independence. The borderlines early family experiences were, according to these
authors, characterized by an absent father. As the individual matures she/he is torn by a constant
conflict between individuation and symbiosis, and experiences individuation as synonymous

with abandonment (involving a loss or rejection by the mother). As a result of this conflict, the
borderline personality is destined to spend her life changing relationships, swinging from
extremes of idealization to betrayal and disappointment with their partners.
Harold Searles, who in the 1970s and 80s treated several outpatient and inpatient
borderline and psychotic individuals with intensive psychodynamic therapy, described how the
borderline individual is unable to differentiate between reality and dreams or fantasy, between
emotions and sensations, between a thought and an action, and, in general, between symbolic and
concrete realms. According to Searles (1969), these difficulties are subtle and are not easily
recognizable unless the patient is in treatment for some time. The failure to differentiate between
reality and fantasy allows the borderline to believe his/her omnipotent thoughts, and this
seriously impacts upon his/her capacity to integrate the experiences of everyday life. For Searles,
borderlines either feel that they can harm themselves or others or that they have become totally
vulnerable and will be destroyed. Searles points out that the clinician treating a borderline will
frequently hear references to the self as a thing, or find that their patient fails to use the
pronoun I, replacing it with we. This phenomenon of multiplicity is typical of a state of
undifferentiation or depersonalization.
Singer (1977) goes a step further in detailing the experience of depersonalization in the
borderline patient. He describes the fear of the borderline as resulting not only from an intrusion
by others but from a sense of being devoid of the self. Singer theorizes that the borderlines
masochistic tendencies, along with an extreme anxiety and self-centeredness are the result of a
need to a focus on the self as a means to ensure their continued existence.
Finally, Volkan (1981) has presented a rather thorough psychoanalytic metapsychology
of the borderline patient. Volkans work is based on object relations theory, and he theorizes that
borderlines externalize their split self and object representations only to re-internalize the
resulting distorted object images. He describes this phenomenon in some of his patients who
experience a flooding of ideas mixed with intense emotions. They talk unintelligibly, perhaps
using only one or two words to describe their memories. Their speech is bizarre and they display
intense motor activity. When such patients later recall their actions, they agree that a strange
perceptual experience overtook them. In an effort to explain the causes of the disorganization
that occurs in the self and object representations, Volkan points to failures in the dyadic
relationship with the mother, in connection with a lack of environmental support. Volkan
describes several parenting patterns that can result in borderline pathology, including the single-
parent relationship in which intense frustration builds up as a result of the parents unavailability
resulting in a failure to integrate the negative and positive experience of others and self; multiple
mothering, in which varied, often contradictory identifications of the mother function wreak
havoc on the childs intrapsychic stability, and a third scenario in which the child experiences
himself as a depository of a representation of someone else who existed in the mind of the
parents. (Volkan, 1980).
Otto Kernberg and the Borderline Conditions 21
Chapter Two
Otto Kernberg and the Borderline Conditions
M
ore than any other theorist, Otto Kernberg has brought the notion of the
borderline conditions into the center stage in American psychoanalysis. In this
chapter I will briefly place Kernbergs work within the context of post-Freudian
developments in psychoanalysis, and provide a more detailed description of Kernbergs theory of
the borderline personality, which will later be used as a springboard for dialog with Lacanian
psychoanalysis.
Post-Freudian Developments in Psychoanalytic Theory

The history of post-Freudian developments in psychoanalysis, particularly as they pertain
to the development of psychoanalysis in America has been amply described in the literature
(Greenberg, J., 1983). As is well known, even before Freuds death, the developments in post-
Freudian thought was well on the way to being established. These developments included, (1)
the departures of Jung and Adler, (2) revisions in technique, particularly in the direction of
briefer forms of treatment initiated by those such as Sandor Ferenczi and Otto Rank, (3) the
development of ego psychology and an emphasis upon the theory of defenses by such analysts
as Anna Freud, Heinz Hartmann, Rudolph Lowenstein, and Ernst Kriss, and (4) the elaboration
of the major neo-Freudian schools by Erich Fromm, Harry Stack Sullivan and Karen Horney
during the 1930s. After the 1930s a schism occurred between Melanie Klein (and the so-called
British school) and those who embraced what came to be known as American ego psychology.
Klein and her followers formed the British school of object relations (Gabbard, 1994).
As will be discussed in Chapter Three, psychoanalysis in France developed along lines
that in some ways paralleled the developments in England and the United States, and which in
other ways were radically different. France, in the decades after Freuds death was a great center
of philosophical activity, where the study of phenomenological and existential philosophy (e.g.
Husserl, Heidegger, Sartre, Merleau-Ponty) had a major impact upon intellectual life in general,
and psychoanalysis in particular, and where structural anthropology (e.g. Levi Strauss) and
linguistics (Saussure) rivaled existentialism for authority in intellectual circles. Amongst French
psychoanalysts, Jacques Lacan, was able to provide an integration of these currents within
French thought with what he described as a return to Freud, and which involved a focus upon
language and the unconscious, and eschewed such notions as adaptive functioning and the
conflict free sphere, which were the staples of ego psychology. Within France, a major schism
occurred in the 1950s with the expulsion of Jacques Lacan from the core of the International
Psychoanalytic Association (IPA), as a result of his direct challenges to ego psychology and his
declaration that its basic tenets were opposed to the core of Freudian thinking. For this reason,
psychoanalysis in France became increasingly separated from developments within England and
the United States, with the result, for example, that Kernberg could create, and others develop,
his theory of borderline personality organization, without either a consideration of, or a response
from those in France who had developed their thinking largely upon the work of Lacan. Indeed,
it is only in the last several years that Lacanian analysts have taken up the question of the
border and the beginnings of a clinical and theoretical exchange between American and French
psychoanalysts on the subject of the borderline conditions has appeared. ( Roudinesco, 1993).
Object Relations
Interestingly, in spite of the various schisms in post-Freudian psychoanalysis, and the

virtual estrangement between French and English speaking psychoanalysts, a single theme can
be said to dominate discussions in many if not all of the competing schools. What appears to be
common to all psychoanalysts today is an interest in peoples interactions with others, and the
role of the other in the construction of the individuals psyche, leading to the concept of the
object and object representation. By the early 1980s, Greenberg and Mitchell (1983) declared
that the problem of object (the other as internalized and represented in the individual psyche) had
come to be the main focus within the various psychoanalytic schools.
The three major theoretical positions in psychoanalytic thought in America today are the
ego-psychological approach, object relations theory and the school of self-psychology.
(Gabbard, 1997) All of these positions are currently characterized by their de-emphasis of the
concepts of drive and defense and their theoretical prioritization of relationships, in particular
early relationships, in the formation of the human psyche. The concept of the borderline
conditions finds its place within each of these three psychoanalytic schools. I will initially focus
my discussion on object relations theory, in order to provide background for my elaboration of
its main representative regarding severe personality pathology, Otto Kernberg. While there are
elements within Kernbergs theory that are best approached from an ego-psychological
perspective, and Kernbergs theory has indeed been labeled ego-psychological, I believe
Kernbergs greatest debt is to the (American) object-relations school.
As I have already indicated, object relations theory originated in England with the
theories and clinical practice of Melanie Klein. However, a group of prominent psychoanalysts
such as Donald Winnicott, Michael Balint, Ronald Fairbairn, and John Sutherland who were
much enamored of Kleins thinking, but did not want to take sides in the debate between Klein
and Anna Freud, developed what we now refer to as the object relations school (Gabbard, 1997)
According to Greenberg and Mitchell (1985), Freud initially developed his theory
around the concept of drives, and did not focus upon the individuals relations to others and the
world until much later in his career, after taking up the problem of the ego. His early
psychoanalytic formulations understood all facets of personality and psychopathology as a
function or derivatives of drives and their transformations. Thus, when a theorist considers the
issue of object relations within the framework of drive theory, an object will be conceptualized
as a derivative of a drive or drives. Kernberg is largely in accord with this view of objects as a
drive derivative, a view he shares with Edith Jacobson, amongst others. A second group of
analysts, including Fairbairn, tried to replace the drive theory altogether, substituting a model of
object relations as the basic building blocks of mental life.
Object relations theory is therefore not an interpersonal model of psychoanalysis, but
rather a theory of unconscious internal object relations that involves the transformation of
relationships with external objects into internalized introjects and structures. According to this
position, the self-object (the mental representation of who we are) is not the result of an
identification with either or both of our actual parents but instead results from powerful affective
experiences and the experience of an object (usually the mother before the 16th month) that
produces either satisfaction or frustration. The real mother may be internalized as a distorted
image, according to the degree and quality of the demands of the infant and regardless of how
competent the mother may be. The feeding experience provides a good example of this process.
When the infant cries desperately for his food he experiences the self as unpleasant, frustrated
and angry, and the mother (object) as inattentive and unavailable. When the food arrives, the
experience is colored by positive feelings towards himself and his mother. However, the childs
object representation will be largely a function of his fantasized images and representations. For
example, if the mother delays the feeding, regardless of the cause of the delay, (even a
realistically necessary delay), the infant will experience the mother in a very negative way, as
evil and ungratifying, rejecting and abandoning. This fantasized mother will then be internalized
as an introjected or identificatory object.
Object relations analysts also provide for the possibility of partial internalizations
which reflect different positive or negative aspects of the mother (the good and bad mother) as
she is experienced in the fantasy life of the child. The infant will internalize the positive aspect of
his mother as a soothing mechanism in order to deal with the possibility of losing his/her mother.
On the other hand, the infant attempts to gain control over the negative aspect of the mother by
capturing it within himself, in some cases attempting to transform the bad into the good object.,
and in other cases hanging onto the bad object because possessing a bad object is better than
having no object at all. The development of the self-object unit involves two mechanisms:
(1) Introjection: This mechanism involves the taking in of an object (and its qualities) but in a
manner that assures that it will be simultaneously experienced as an other. Freud opposes
introjection to projection, in which undesirable parts of the individual are externalized (as in
paranoia). Although an introject is experienced in the child as a soothing mechanism, it is still
considered an object rather than a part of the self (Laplanche-Pontalis, J. 1987).
(2) Identification: This mechanism explains how the self is modified as a result of an
internalization of a significant external figure that is used as a model. The childs self
experiences are those parts of the parent that the child identified with (Laplanche-Pontalis,
1987).
Whereas ego psychology views conflict as a struggle between different psychic
agencies (id, ego, and superego), the object relations theorists perceive unconscious conflict as a
struggle between different self-object units. Object relations theory views conflict and character
formation as intensely influenced by the constellations of self and object representations derived
from introjections and identifications.
Kernbergs Theory of the Borderline
Kernberg belongs, along with Edith Jacobson to what has been spoken of as the mixed
model of theoretical psychoanalysis in America. Each of these analysts tried to integrate aspects
of an ego psychological point of view with the British school of object relations, mainly the
theory of Melanie Klein. While the term borderline has been called an idiosyncratic catchall
term for difficult patients (Gunderson, 1989), Kernberg has attempted to define it in both
descriptive and dynamic terms, as a specific structure of psychic organization that is to be
distinguished qualitatively from the neuroses and psychosis. As described by Kernberg and his
followers, the term borderline refers to a level of personality organization.
As we have seen in Chapter One, there are two different though overlapping uses of this
term, borderline personality disorder and borderline personality organization. Borderline
personality disorder is a descriptive designation that refers to a more or less specific psychiatric
syndrome characterized by a set of well known symptoms: impulsivity, chronic anger, unstable
relationships, identity disturbance, feelings of emptiness and boredom and the tendency to act
out on self-destructive ways (Akhtar, 1975). By way of contrast, borderline personality
organization is a broader concept with definite psychostructural implications. It refers to a
character pathology in which there is evidence of identity diffusion, predominance of splitting
over repression as the main ego defense mechanism, and an arrested separation-individuation
process resulting in an unintegrated ego marked by pre-oedipal aggression. While the contrasting
perspectives can be synthesized one does not logically imply the other. Kernberg, for example,
holds that borderline personality organization underlies all cases of borderline personality
disorder, but that not all cases of borderline personality organization will present with the
descriptive features of a descriptive borderline. This is because, on Kernbergs view,
borderline personality organization also underlies narcissistic, paranoid, schizoid, antisocial,
hypomanic, and as-if personalities. In effect, Kernberg is attempting to introduce a structural
and (to a certain extent) etiological model of severe psychopathology that lies between neurosis
and psychosis regardless of its phenomenological presentation (Akhtar, 1975).
Kernberg understands borderline patients as suffering from a rather stable pathological
personality organization, characterized by a specific ego psychological structure that is highly
resistant to change except through intensive psychotherapy (Goldstein, 1985). In Kernbergs
scheme, all patients who present themselves for psychoanalytic treatment fall into one of three
groups: neurotic, psychotic and borderline. We will see that Kernbergs tripartite structural
classification of psychopathology stands in stark contrast to that of Lacan, who regards the basic
three structures proposed by Freud (neurotic, psychotic, and perverse) to be without any need of
augmentation or revision.
It is Kernbergs view that the presenting symptoms of the (structural) borderline may be
quite similar to the presenting symptoms in the neuroses and (non-borderline) character disorders
and it is therefore only through a thorough structural diagnostic examination that the borderline
organization will emerge. In fact, from a descriptive point of view, the borderline personality
organization often initially presents as neurosis. While a peculiar combination of symptoms
(some of which are clearly in the psychotic range) provide a presumptive diagnosis, only a
careful examination of the individuals ego pathology, achieved through a structural interview,
can lead to a more definitive diagnosis.
The Descriptive or Presumptive Diagnosis
Kernbergs descriptive model consists of a number of symptoms that he believes are

suggestive of borderline personality organization (Goldstein, 1985). According to Kernberg,
from a descriptive point of view, borderline patients typically present with the following
characteristics:
(1) Anxiety: The anxiety is typically diffuse, free-floating and accompanied by other
symptoms or character traits. In the borderline personality, anxiety exceeds the binding capacity
of the ego, and is accompanied by other pathological signs. (Kernberg, 1966). The clinician must
rule out chronic anxiety related to conversion symptoms or as in the case of patients in intensive
psychotherapy, anxiety appearing as a form of resistance.
(2) Polysymptomatic Neurosis: This includes:
(a) Multiple Phobias: Kernberg refers to phobias in which the patient is socially restricted and/or
phobias related to the patients body or appearance (such as fear of being looked at, fear of
talking in public). These fears need to be distinguished from phobias related to external objects
such as animal phobias or fear of heights, as these are not presumptive evidence of borderline
pathology.
(b) Obsessive-compulsive symptoms, especially, those patients whose symptoms are colored
with paranoid or hypocondriacal themes.
(c) Multiple and severe conversion symptoms of an elaborate kind, usually bordering on bodily
hallucinations.
(d) Dissociative reactions with a hysterical quality such as fugues and amnesia.
(e) Hypochondriasis, especially if chronic, associated with a withdrawal from social life, and
accompanied by health rituals. Severe anxiety with mild hypocondriacal reactions is not
indicative of borderline pathology.
(f) Paranoid trends associated with hypochondriasis: Kernberg believes this combination is
typical of borderline personality disorder. He holds that both symptoms should appear as strong
trends and not secondary to other pathologies.
(3) Polymorphous Perverse Sexual Trends: According to Kernberg, patients who

manifest sexual deviation with several perverse trends likely have a borderline personality
organization. Perversions may not be clearly manifested until later in treatment when the
patients fantasies are explored. However, complex fantasies, usually involving several co-
existent perversions as a basic condition for sexual satisfaction, are a sign of borderline
pathology. According to Kernberg, the more chaotic and multiple the perverse fantasies, the
more unstable the object relations connected with these interactions (Kernberg, 1977). Patients
whose sexual life is centered on a stable deviation with a constant object are not included in this
category.
(4) The Pre-psychotic Personality: This includes the paranoid, the schizoid, the
hypomanic and the cyclothymic personality disorders; however, the depressive personality
disorder is not included, particularly if presenting with masochistic traits.
(5) Impulse Neurosis and Addictions: Character pathology with repetitive impulsive
behavior is presumptively borderline in Kernbergs structural sense of the term. Drug
addiction, alcoholism, psychogenic obesity, and kleptomania are also grouped under this
category. Often these individuals also manifest sexual deviation with a compulsive quality and
acting out personality types.
Object relations theorists typically view character disorders on a continuum from high
level types, such as the avoidant personality, to the low level types represented by chaotic and
impulse-ridden individuals. These distinctions are made on the basis of the degree to which
repressive mechanisms (high level) or splitting mechanisms (low level) predominate. Kernberg
regards borderlines as manifesting a low-level character disorder. Such formulations, of course,
are not descriptive, but rather refer to presumed underlying structural characteristics. When
Kernberg refers to low level character pathology as being presumptive evidence for borderline
personality organization he has already begun to discard descriptive diagnosis in favor of a
structural approach.
Kernbergs Structural Analysis
From the psychoanalytic point of view, a structural analysis originally involved the
analysis of mental processes in terms of the three psychic structures id, ego, and superego.
However, Hartmann (1946) and Rapaport and Gill (1959) broadened the term structural to
refer to ego structures or configurations that have a slow rate of change, which determine the
channeling of mental processes that are functions in themselves, and represent thresholds in
development. This new concept of structure broadened the psychology of the ego and
emphasized its cognitive and defensive aspects. Further, the object relations theorists further
broadened the term structural to include the analysis of the derivatives of internalized object
relationships (Fairbairn, 1951). In his theory of the borderline Kernberg encompasses all of these
meanings of structure, the Freudian, ego-analytic and object-relational. He holds that in order to
arrive at a conclusive diagnosis regarding borderline personality organization, the clinician must
rely upon structural analysis. Such an analysis is done step by step, beginning with the analysis
of the ego and its relationships to the other psychic agencies, and finishing with an analysis of
internalized object relationships. Kernbergs structural analysis of the borderline yields several
basic criteria:
(1) Nonspecific manifestations of ego weakness: Kernberg holds that several non-
specific ego weaknesses are typical of the borderline patient. These include (a) an inability to
tolerate anxiety that does not result simply from the degree of anxiety but is rather a function of
the individuals failure to adequately cope with stress overload; (b) a lack of impulse control,
which involves unpredictable, erratic, behavior as a dispersion of intrapsychic tension rather than
a specific enactment or an acting out in relationship to the transference, c) a lack of developed
sublimatory channels, for example, an absence of creative enjoyment or creative achievement;
and (d) a blurring of ego boundaries as a result of the lack of differentiation of self and object
images.
(2) Shift toward primary process thinking: According to Kernberg, while borderline
patients are generally capable of engaging in secondary process thinking, involving the
implementation of reason and judgment in their everyday lives, they are subject to increased
primary process thinking in unstructured situations and in response to stress. While the findings
are not completely definitive, research has shown, for example, that borderline patients engage in
secondary process thinking on the structured cognitive tasks such as intelligence testing, but
show increased primary process thinking in comparison to neurotics, on unstructured
psychological tests like the Rorschach (Kernberg, Goldstein, Carr, et. al. 1981). Primary process
thinking appears in the form of primitive fantasies and the use of peculiar verbalizations and
emotionally charged associations (Kernberg, 1977).
According to Kernberg, the reality testing of the borderline is essentially intact, except
for brief regressive psychotic episodes that can occur under stress, particularly in relation to the
transference in intensive psychotherapy, and/or with the use of alcohol and drugs. What is
noteworthy about the borderlines psychotic episodes is not their particular form or content, but
rather their brevity and reversibility. While not all borderlines have such transitory psychotic
episodes (which can range from a few minutes to as long as perhaps two days) their presence in
many borderlines illustrates the fragility of the ego-function of reality testing in these patients.
(3) Specific defensive operations: Kernberg elaborates six primitive defenses that he
regards as pathognomonic for the borderline diagnosis. The most important of these defenses,
splitting, serves the borderline in much the same way that repression serves the neurotic.
Amongst the other primitive psychological defenses employed by borderline patients are
primitive idealization, infantile projection and projective identification, denial, omnipotence and
devaluation. According to Kernberg, whereas the neurotic employs such primitive defenses in
childhood, he or she moves on to develop more mature psychological defenses centered on
repression. This developmental milestone is, according to Kernberg, never fully achieved in the
borderline patient. While the borderline typically uses more mature defenses in his/her daily
functioning, he or she has a tendency to fall back upon these six borderline defenses under stress.
(i) Splitting: The concept of splitting as a defense mechanism was first elaborated by
Freud. However, as we have seen in Chapter One, the British school, beginning with Melanie
Klein (and later Fairbairn) further developed this concept in relation to the issue of ego
integration. Splitting, which is said to characterize a very early stage of psychological
development, involves the isolation of opposing affects and emotions and a failure to integrate
negative and positive aspects of self and others. Its most important role is in the defense against
libidinal drives and their derivatives, and it has a significant impact upon the childs introjects
and identifications. At the infant stage of development the erotic and aggressive drives operate
separately; good and bad, positive and negative, are aspects that are not integrated in
experience. At this stage splitting serves to prevent contamination of good introjects by negative
affective experience. In normal development there is an integration of good and bad, as the
child achieves libidinal object constancy. In the process the ego evolves from the use of splitting
to the use of higher, more mature defenses such as reaction formation, isolation, or undoing. In
severe pathology, splitting persists to protect the ego by dissociating introjects and identifications
of a conflictual nature (Kernberg 1977). According to Kernberg, the use of splitting is typical of
the borderline structure, where it is frequently combined with denial and a selective lack of
impulse control.
(ii) Primitive Idealization: this defense, which is related to splitting, refers to the
tendency to see external objects as totally good in order to make sure that they are protected from
the all bad. Such idealization represents a protection against contamination, spoilage and
destruction of the good object, which the patient believes can be influenced or even destroyed
through his or her own aggression. Primitive idealization is not related to developmentally later
forms of idealization that are present in depressive states, in which the patient idealizes someone
out of guilt over their aggression for that object. Sometimes, primitive idealization manifests as
identification with an omnipotent, idealized object that is viewed as incapable of being or
engaging in anything negative.
(iii) Projective identification: This term, which was introduced by Melanie Klein,
designates a mechanism through which the individual introduces fantasies of his/her own
projected aggression onto the object in order to hurt it, to possess it and control it. However, in
the borderline this mechanism is diagnostic. It is characterized by the lack of differentiation
between self and object (in the particular area of projection of aggression). The individual
experiences the aggressive impulse as well as the fear of the retaliatory response and therefore
feels a need to control the external object in order to ensure that neither destruction of self nor
object will occur (Kernberg, 1966). The development of this pathological defense has an impact
upon the development of the superego and the ego ideal.
(iv) Primitive denial: The denial Kernberg has in mind is blatant and global, and is
typically accompanied by splitting. For example, the patient remembers a painful event or
experience with no emotional connection or awareness of pain. When pressed, the patient will
intellectually acknowledge the presence of such negative affect but will not be able to integrate it
with the rest of his or her emotional experience. This mechanism is different from neurotic denial
in the sense that in primitive denial the material was never repressed and the patient was never at
any time aware of the essential emotional connections. Kernberg views denial on a continuum of
higher to lower levels; the higher level is represented by negation or isolation and the lower level
by maniacal denial, in which the individual expresses feelings that are opposite those that are
actually felt, in an effort to reinforce the egos stand against a threatening aspect of self-
experience.
(v) Omnipotence and (vi) devaluation: As is the case with primitive idealization,
omnipotence and devaluation are derivatives of splitting. Devaluation is the negative component
of the split (bad object), whereas omnipotence is the positive component (good object).
Omnipotence is evident in the borderlines expectation of gratification and the strong conviction
that he or she must receive homage from others and be treated as special. Devaluation is the
other side of omnipotence; if an external object can no longer provide gratification, it is dropped,
dismissed and devalued. There is never a real concern or love for the object. This shift to
devaluation is often accompanied by feelings of revenge and destructive fantasies in relation to
the object that frustrated the patients (typically oral) needs. According to Kernberg, these
mechanisms also have an impact on the development of object relations and superego formation.
(4) Pathology of internalized objects: According to Kernberg,. the building blocks of

the psyche consist of internalized object relations that are formed by primitive self and object
representations that are formed in accordance with a dominant affect or drive. Kernberg holds
that the mechanism of splitting interferes with the synthesizing functions of the ego, resulting in
different degrees of differentiation characteristic of primitive personality organization in
psychosis and borderline pathology. In the case of the borderline (and in contrast to the
psychoses) differentiation of self and object images has occurred to a sufficient degree to achieve
a certain integration of ego boundaries. However, ego boundaries falter in those areas where
projective identification and fusion with idealized objects take place, and this is experienced
especially in the transference with the analyst. According to Kernberg it is for this reason that
such patients develop a transference psychosis rather than a transference neurosis.
According to Kernberg, the failure of the borderline to synthesize the good and the bad
introjections and identifications is in large measure due to excessive primary (constitutional)
aggression and/or aggression secondary to frustration. This produces a deficiency in ego
development accompanied by an intolerable degree of anxiety in borderline patients. Later the
failure of integration between libidinal and aggressive drives interferes with the egos capacity to
modulate both thought and affect, leading to the borderlines tendency to experience sudden
eruptions of emotions and ideas. Further, the affective states of concern, guilt and depression
cannot be achieved if positive and negative introjections are not brought together (Kernberg,
1966). Only the conflict or tension between two contradictory affective states in the ego can
produce a genuine depressive reaction. These feelings are not present in the borderline; their so-
called depressive affects take the form of rage and defeat before external forces.
(5) Identity Diffusion: Kernberg appeals to Erik Eriksons notion of identity diffusion
in describing the pathological internalized objects in borderline psychopathology (Goldstein,
1985). The subjective experience of identity diffusion is characterized by chronic emptiness, a
shallow, flat and contradictory perception of others and, especially, the self. The failure to
integrate contradictory aspects of self and others is presumably due to the early aggression
activated in these patients. Such dissociation also serves the defensive function of protecting
good aspects of the self from contamination by hate and badness. (Kernberg, 1975). A poor and
partial view of self and others is also evident in the inability of borderline individuals to describe
themselves in a meaningful and consistent way. The lack of temporal continuity regarding self
and others explains the difficulty these patients have in locating actions and people when relating
material in session. During the initial interviews in psychotherapy they provide confusing
contradictory and descriptions of life events, and the interviewer experiences a great deal of
difficulty seeing the person as a whole (Goldstein, 1985). Kernberg gives as an illustrative
example, an infantile borderline patient who presents as her main complaint the feeling of
disgust for being treated as a sexual object by men, and who elaborates on mens predatory
attitudes with respect to sex. She further confides that she has become socially withdrawn in an
effort to avoid sexual advances from men. However, she also mentions that she has worked as a
bunny for Playboy magazine, and is utterly surprised when confronted with this contradiction in
her presentation. By way of contrast, Kernberg holds that a hysterical (neurotic) patient will be
more prone to express her ambivalence and fear of arousing both herself and men. Unlike the
borderline, a neurotic would be aware of the ambivalence within herself.
The Id in the Borderline Structure
Kernberg emphasized an excessive amount of pre-genital aggression in the borderline

patient as a causative factor in the genesis of the pathology. This aggression is generally
expressed in an overt way. Direct exploitiveness, unreasonable demands, and manipulation of
others without any consideration of their feelings are typical expressions of the borderlines
crude aggression. As we have seen, Kernberg thus focuses upon id organization; in particular,
the aggressive drive and its vicissitudes, in his discussion of the genesis and development of the
borderline disorder.
The Superego in the Borderline Structure
For Kernberg, specific superego traits are not essential to the borderline diagnosis.
While superego characteristics differ greatly from one borderline individual to the next, in
general the borderline suffers from a primitive and unintegrated superego corresponding to her
fragile ego and self. The undifferentiated state of all good and all bad images impacts upon
superego integration, and it is common for these patients to present with a very sadistic superego
related to internalized bad objects of the pregenital stage. This superego state is so intolerable
that it gets re-projected onto external objects. Thus, these patients are constantly encountering
sadistic or evil objects, and their opposites, idealized objects full of power, greatness and
perfection. As the borderline cannot adequately integrate good and bad aspects of the parental
figures, the internalization of parental demands becomes extremely prohibitory, punitive, and
even sadistic in nature. On the other hand, there is also a fusion of ideal self and ideal object
images, which, rather than producing a modulating ego ideal, tends to reinforce a sense of
personal omnipotence. These structural failings are observed in certain characteristics of
borderlines, such as their very limited capacity to make realistic evaluations of others, their
experience of people as distant objects, and their incapacity for intimate relationships, which
results, in part from their failures to empathize with others, or to feel either guilt or concern. As
such, borderlines are typically always right and feel fully justified. The emotional shallowness
that we observe in our clinical work with these patients is related to their lack of integration of
libidinal and aggressive drive derivatives and their unrealistic appraisal of others. The borderline
also maintains a distance from others in order to protect him/herself from an intimate encounter
that might activate primitive defensive operations, especially projective identification.
The Genetic-Dynamic Analysis and Developmental Theory
Closely linked to Kernbergs ego-psychological/structural model of the borderline

personality is an object relations theory of borderline development that was first elaborated in
Kernbergs (1976a) second book, Object Relations Theory and Clinical Psychoanalysis. In this
book, Kernberg describes how before the end of the first year there is little or no differentiation
between self and object, and all self-object representations are linked to either purely positive or
purely negative affects. By the end of the first year, self and object have become differentiated
and are integrated when they are associated with positive and negative affect states. Kernbergs
theory here is related to and compatible with the developmental theory of Margaret Mahler.
According to Kernberg, the central developmental defect in psychosis is a complete
failure to differentiate self from other and hence to establish the ego boundaries that would
provide the basis for a view of a reality apart from the self. While the borderline has succeeded
in this basic task, he or she has not achieved what Kernberg refers to as libidinal object
constancy, the recognition that an object, i.e. the mother, can retain both good and bad qualities,
or can be associated with both positive and negative affect states, without losing her basic
identity. This task, which is normally achieved at the age two or three, enables the child to
surrender splitting as its basic mode of relating and recognize that people and things in its
environment are both bad and good. The borderline patient has not surmounted this
developmental hurdle and continues to utilize splitting as a means of coping with the
vicissitudes of his or her emotional life. A person in the borderlines life is either all good or all
bad, and thus the borderline remains continually prone to use idealization and devaluation as
his/her basic mode of interpersonal defense.
As we have seen, Kernberg provides a rather deterministic theory of the factors

involved in the genesis of borderline personality organization. According to Kernberg, an
excessive degree of aggressive drive during the first years of life, either as a result of congenital
factors or early frustrations, has the result of reinforcing splitting in the developing child or
interferes with the attainment of libidinal object-constancy as Kernberg defines it (Goldstein,
1985).
The ever-present oral aggression gets projected and causes a paranoid distortion of the
early parental images, in particular, the mother. Thus, the mother is viewed as potentially
dangerous. These oral and anal sadistic impulses become contaminated in the father as well and
later the family is viewed as a threatening united group (Kernberg, 1966). Moreover, the dyad
dangerous mother-father gets translated into the realm of the sexual relationships, which is
regarded by the borderline as an aggressive act. Therefore, genital strivings are permeated by
pregenital oral rage with the result that the individual attempts to fulfill unmet oral-aggressive
needs through genital activity.
The issue of oral rage in the genital arena becomes a difficult issue for the borderline.
The typical oedipal vicissitudes which, in the normal case, increase castration anxiety and its
derivatives. produce greater disorganization in the borderline. Fears of a rageful father and of a
dangerous castrating mother develop, and these are translated into the typical self-defeating
patterns in the borderlines later relationships. According to Kernberg, this process determines
what we see in our clinical work with borderlines, i.e. their polymorphous perverse trends as
pathological compromise solutions to their interpersonal anxieties. These solutions always
represent unsuccessful attempts to deal with aggression and lead to several pathological
formations.
One pathological path for a boy is that of orally determined homosexuality. In this case,
the boy, afraid of his mother, turns masochistically to the father in order to fulfill his oral needs.
In these cases, heterosexuality is viewed as threatening as the boy regards his mother as
dangerous. Usually such homosexuality is accompanied by aggression. Such borderline men can
become very promiscuous, as their constant involvement in homosexual acts and relationships
involve an effort to fend off the reappearance of oral frustration and aggression.
Severe oral pathology in girls tends to produce premature genital striving for the father
as a substitute for gratification of genuine dependency needs that have been frustrated by the
girls mother. As a consequence, such girls typically experience a reinforcement of masochistic
needs and a flight into promiscuity in order to deny their dependence on men.
On psychological testing, both sexes appear lacking in sexual identity. However, as
Kernberg will emphasize, the presence of polymorphous trends is the result of the combination
of chaotic pregenital and genital tendencies. These patients lack of sexual identity is not a
reflection of their confusion around sexual definition but more of a complex symptom involving
strong fixations designed to cope with unmet oral needs.
In sum, in both sexes excessive development of pregenital oral aggression tends to
induce a premature development of the oedipal vicissitudes. As a result, pregenital and genital
aims are conflated under the influence of intense aggressive needs.
Kernbergs Three Psychic Structures
Kernberg holds that there are three broad ways in which the psyche can be structured:
the neurotic, borderline and psychotic personality organizations. These structures perform the
function of stabilizing the mental apparatus, mediating between the patients history,
environment, and the direct behavioral manifestations of mental illness. Each individuals
psychic organization, regardless of which specific factors contributed to the etiology of the
illness, becomes the underlying matrix from which behavioral symptoms develop. (Kernberg,
1984). The main characteristics, which define these three broad categories, relate to: (1) the
degree of identity integration (referring specifically to the integration of self and object
representations, (2) types of defensive operations that the person employs, and (3) the
individuals capacity for reality testing. Table 1 summarizes Kernbergs distinctions between
neurotic, borderline, and psychotic levels of personality organization.
Table 1: Kernbergs Structural Criteria for Neurosis, Borderline and Psychosis

(adapted from Kernberg, 1966)
Structural Diagnosis
Neurosis Borderline Psychosis
Identity Integration Self-representations Presence of identity Self-representations
and object diffusion: and object
representations are contradictory representations are
sharply delimited. aspects of self and poorly integrated
The contradictions others are poorly with the presence of
between self and
others images are
integrated and kept delusional identity.
conceptually apart.
integrated
Defensive operations Defenses protect The use of splitting Defenses protect
individual from and low-level patient from
intrapsychic conflict. defenses such as disintegration and
Repression and high- primitive self/object merging.
level defenses such as
idealization, Interpretation leads
reaction formation,
isolation, undoing,
projective to regression.
rationalization and identification, denial
intellectualization. and omnipotence.
Reality testing Capacity to test reality Alterations occur in Capacity to test
is preserved, relationship with reality is lost.
differentiation of self reality and in
and others, as well as feelings of reality.
intrapsychic from
external origins of
perceptions and
stimuli is achieved.
Capacity to evaluate
self and others
realistically and in
depth.
The Interview as a Diagnostic tool
From the practical point of view, Kernbergs approach involves judgments derived
from a series of interviews and interactions that are crucial for proper diagnosis. He requires
between five to six interviews to elicit the information necessary to assess a patients level and
quality of psychopathology. He will introduce certain inquiries or confrontations to assess the
interaction with the therapist and the patients interpersonal functioning in general. He is not
primarily interested in information regarding the patients personal history, as is typically
gleaned from a psychosocial inventory (Shapiro, 1988). For Kernberg the diagnostic interview is
the essential feature of a psychoanalytic assessment in accord with the principles of dynamic
personality theory (Kernberg, 1977). It involves exploration of the patients awareness and mode
of handling conflictual material.
Kernbergs interview is essentially a provocative test designed to activate latent
dynamisms and constellations, thereby permitting the interviewer to classify the patient
according to the variables described above. In Kernbergs research the interviews are typically
tape recorded and later judged independently by qualified professionals. While Kernberg
acknowledges that structural constructs, for example, those involving object representations and
defenses, are not easily inferred, the structural diagnostic interview is the most effective tool for
this purpose (Shapiro, 1988).
Whereas Deutsch (1942) advocated a psychoanalytic method of interviewing that
would reveal the unconscious connections between current problems and the patients past,
Kernberg considers that this type of interview has the disadvantage of minimizing objective data
and does not explore the patients psychopathology and assets in a systematic fashion (Kernberg,
1984). Kernbergs interview combines the traditional mental status examination with a
psychoanalytically oriented inquiry that focuses on the patient-therapist interaction. This
interaction is characterized by an active participation on the part of the therapist, who utilizes
clarification, confrontation and interpretation of identity conflicts, defenses and reality distortion,
particularly as these are expressed in the transference.
Kernberg uses clarification as a non-challenging, cognitive means of exploring the
limits of the patients awareness of certain material. Confrontation attempts to make the patient
aware of potentially conflictual and incongruous aspects of their presentation. Interpretation

seeks to resolve the conflictual nature of the material by assuming underlying unconscious
motives and defenses that make the previously contradictory material appear logical. Kernbergs
early focus on patients relationship with the interviewer is anxiety producing for the patient, as
it tends to bring underlying psychic conflicts to the surface. However, this technique should not
be confused with a traditional stress interview, which induces artificial conflicts to produce
anxiety in the patient. To the contrary, the structural interview requires tact and empathy and
should be carried out in an atmosphere of respect that does not highlight the interviewers
superiority.
Empirical Assessment of Structural Diagnosis
Kernberg and other researchers have subjected their work on the borderline personality
organization to empirical evaluation (Koenisberg et al., 1985). This work provides a paradigm
for future approaches in the study of second-order inferences removed from the immediate
observational field, i.e. those belonging to the realm of descriptive classification. In such
research, the concept of structure is put to the test using a psychoanalytic frame of reference.
Indeed, one of the advantages of Kernbergs theory is that it has been subject to empirical
testing. The issue of empirical testing will be discussed in greater detail when we take up the
dialog between Kernberg and Lacan.
The Clinical Value of Structural Analysis
Theoretically, Kernbergs structural diagnostic approach is meant to contrast with the

descriptive approach that is present, for example, in the DSM-IV. Practically speaking there may
be little difference, as a high correlation has been demonstrated to exist, for example, between
Kernbergs structural and Gundersons descriptive methods of classifying borderline
patients (Kernberg, Goldstein, Carr, et. al. 1981). Kernberg (1980) has taken such high
correlations to suggest that structural and descriptive classifications of the borderline are
complementary approaches to the same diagnostic entity. They may also, however, signal the
possibility that Kernbergs object relations and ego-psychological approach to the borderline is
another form of description, albeit one that is couched in structural terminology.
Nevertheless, Kernbergs borderline classification is clearly broader than that what is
described in the various editions of the DSM, as Kernberg believes that nearly all anti-social
personalities and many schizoid, paranoid, cyclothymic, narcissistic and impulsive characters are
best conceptualized as having a borderline level of personality organization (Goldstein, 1985).
Typically, such individuals are lacking in such higher-level personality traits as empathy, humor,
depth, warmth, creativity, and genuine guilt. Their inclusion in the borderline category would
have major implications, not only for diagnosis, but for treatment as well.
The question of whether Kernbergs diagnostic scheme is truly structural in the
psychoanalytic sense will be taken up in later chapters. Meanwhile, In the meantime, the next
chapter offers an alternative approach to structural diagnosis in psychoanalysis, that of Jacques
Lacan.
Lacanian Psychoanalysis
Chapter Three
Lacanian Psychoanalysis
W
hile the past decade has seen an upsurge in interest in Lacan amongst American
philosophers, literary and art critics, familiarity with Lacans ideas and approach
to treatment remains quite limited amongst American psychologists and even
most American psychoanalysts.1 A number of factors can account for this situation. Amongst
these are 1) the fact that Lacans writings and seminars were originally published in French and
until recently the majority have remained untranslated into English, 2) the notorious difficulty
and obscurity of Lacans writingsan obscurity that, in part, reflects Lacans views about the
inherent ambiguity of all language, 3) Lacans difficult tendency to develop and alter his views
without clearly demarcating differences with his former approach, 4) the numerous references in
Lacans writings to philosophers, literary works, and linguistic theorists, with whom American
readers are relatively unfamiliar, 5) Lacans break with, and ultimate expulsion from the
International Psychoanalytic Association and his harsh criticisms of its members and dominant
theories (ego psychology, object relations theory) and 6) Lacans staunch opposition to the
emphasis upon practical utility in American clinical practice and his direct criticisms of
American pragmatism.
1
This is in spite of the fact that a recent literature search (American Psychological Association: Psych
Info) covering worldwide psychology journals over the past decade reveals 369 articles making explicit
reference to Lacan whereas in comparison, only 160 make reference to Otto Kernberg, a psychoanalyst
with whose theories most American psychologists are familiar. The majority of the cites to Lacan,
however, are in non-English language journals.
Renee Major, in his review of Elizabeth Roudinescos The One Hundred Years Battle
The history of Psychoanalysis in France, examined the cultural differences that have impacted
upon the development of psychoanalysis in France and the United States. As Major points out,
American and French psychoanalysts read Freudian theory in very distinct ways. An example of
this is what Americans refer to as Freuds structural theory (Id, Ego, and Superego) the French
refer to as the second topographical system (Major, 1984). More importantly, whereas
American analysts generally hold that Freuds second structural model superseded the first
topographical one, the French typically regard them on equal footing, or, as in the case of
Lacan, place a far greater emphasis on the earlier point of view.
We will see that a key area of disagreement and potential miscommunication between
American and Lacanian psychoanalysts centers upon their respective uses of terms relating to
psychic structures. Whereas American psychoanalysts have tended to identify psychic
structure with what they call Freuds structural theory, i.e. the relations between the id, ego, and
super-ego, Lacanians utilize the term structure to refer to an anthropological and linguistic
concept that refers to a particular organization of elements defined by their system of
relationships, in such a way that when one element changes, the whole system of relationships
changes as well. While Americans have experience with such French structuralism in the fields
of anthropology, literary criticism and philosophy, these ideas have not taken root in American
psychology or psychoanalysis (Major, 1984). As we will see, Lacan develops such structural
concepts in an original manner, and links them to the traditional Freudian diagnostic distinctions
between neurosis, psychosis and perversion, in a manner that differs radically from American
ego-analytic and object-relations structural theories. As we will also see, any attempt to
conceptualize borderline psychopathology within a Lacanian context must take these critical
differences regarding the nature of psychic structure fully into account.
Another major area of difference between American and French psychoanalysis relates
to their respective writing styles. French readers tend to (critically) view American journal
articles as having a medical narrative style, while Americans view French writing as (overly)
philosophical and literary. However, as Major indicates, these differences in style do not
necessarily indicate that American psychoanalysis is more scientific and that French
psychoanalysis is more artistic. They do, however, indicate that psychoanalysis in each
Lacanian Psychoanalysis 45
country has developed, and is expressed, in accordance with each cultures intellectual values. In
the United States, experimental science is generally regarded to be the paradigm of scientific
truth and rigor, whereas in France critical conceptual analysis occupies a similar position. This
distinction, we might add, can be traced back to the debate between the Cartesian rationalists and
British empiricists. Whereas Lacan and other French psychoanalysts see themselves within the
former tradition, American ego psychologists are much more closely linked to the latter. French
psychoanalysis has therefore taken seriously developments in rationalist and idealist philosophy
(Kant, Hegel, phenomenology and existentialism) that, at least until recently, have been
relatively ignored by American empiricist philosophers and psychologists.
Finally, we need to evaluate the history of the psychoanalytic movement (as any other
institution) within a social, political and historical context (Oliner, 1988). In the following
section I will briefly examine the history of psychoanalysis in France and Lacans place within
that history.
The History of Psychoanalysis in France
As is well known, Freud had an important first-hand experience of French psychiatry

and neurology while studying at the Salpetriere Clinic from October 1885 to February 1886,
several years prior to his initial psychoanalytic collaboration with Josef Breuer. Freud developed
a close relationship with the leading figure at the Salpetriere, Charcot, J., who took a liking to
his then 30-year old German student, and with whom he shared ideas on the links between
sexuality and neurosis. Although Freud published three papers in France, he was, at the time, a
relatively unknown researcher who was not read by the French psychiatric community. Further,
when after the publication of The Interpretation of Dreams and The Psychopathology of
Everyday Life the first generation of analysts was firmly established as Freuds circle, the French
had no representation in the group (most of whom were German speaking with Ernest Jones and
Abraham Brill the two English-speaking exceptions). There was also no trace of the French at
the first International Congress of Psychoanalysis in 1908, presided by its then newly-elected
president Carl Jung. It wasnt until 1914 that Freuds original Five Lectures on Psychoanalysis
were translated into French and became readily accessible to the French psychiatric community.
It was Rene Laforgue (1925) who was the earliest promoter of psychoanalysis in France. Along
with Rene Allendy, Laforgue organized the psychoanalytic group, LEvolution Psychiatrique,
and the first French psychoanalytic journal appeared in 1925. Interestingly, this early French
school distanced themselves from what they regarded to be Freudian dogmatism, and they
appeared more interested in facts that could be put to strict scientific test than in matters related
to the unconscious or the vicissitudes of sexuality. At a certain point this group took steps, under
the direction of Henry Ey, to transform itself into an organodynamic psychiatric entity that
would limit membership to medical doctors. (De Mijolla, A.1982)
In the meantime, the International Psychoanalytic Association obtained a foothold in
France under the auspices of the Princess Marie de Bonaparte (a French woman, granddaughter
of the Emperor, who had maintained a close relationship with Freud after having been an
analysand of his). Bonaparte later acquired the letters that Freud wrote to Fliess and was
instrumental (with the help of the United States ambassador) in securing Freuds visa to exit
Austria and obtain residence in England in 1938. Bonaparte served as Freuds personal French
translator and became the most important propagator of Freuds ideas in France. While she had
no personal clinical training and thus had no ability to publish her own cases (in spite of her wish
to be an analyst), she became extremely involved in the clinical training of psychoanalysts and,
as a non-physician, she was very cautious regarding the French medical community. She
founded, with Lowenstein, Allendy and Laforgue, The Societe Psychoanalytique de Paris
(SPP). A strong controversy ensued, in which The Evolution Psychiatrique proclaimed that the
field of psychoanalysis was directly related to general medicine, neurology and psychiatry, and
the SPP opposed that view. Bonapartes group, the lay group, held that psychoanalysis was the
realm of the psychology of the unconscious, which belonged to the clinical, but not exclusively
medical, field. Jacques Lacan, a young psychiatrist, was present at the meetings where these
issues were heatedly debated. He applied for admission at the SPP (at this point, fully supported
by Freud himself) to become a training analyst, and by December 1938 he became a full member
after starting a personal analysis with Rudolf Lowenstein.
In 1936 Lacan presented a paper at the 14th International Congress of psychoanalysis in
Marienbad entitled The Mirror Stage. He was the first psychoanalytic theorist in France to take
an innovative path with respect to the development of psychic formations. Lacan based his ideas
about the nature of the ego on Wallons work with primates and their experience of confronting
their image in a mirror. (Wallons research suggested that whereas primates learn that the image
is illusory and quickly lose interest in it, the human child becomes fascinated with his mirror
imagesee below).
After the war, psychoanalysis in France was re-organized along two, rather different
lines. On the one hand, a number of French psychoanalysts had a vision of a small society
carefully filtering and controlling its membership. Others held the ideal of a large movement that
would bring together members from different disciplines: philosophy, linguistics, medicine,
psycho-pedagogy, and even religion. In part because of the polarizing political impact of World
War II, there was an atmosphere of mistrust towards psychoanalysis during the post-war years in
France, and many intellectuals saw it as a new corrupting agent of imperialism. Most of the
members of the SPP were communists or were involved in what they called the humanism of the
Resistance. However, for many, psychoanalysis was viewed as one more individualistic
expression that amounts to a denial of any possibility of transforming the social order (De
Mijolla, 1982).
Since the late 1960s psychoanalysis in France has extended in three directions: 1) the
medical direction, represented by the medically trained analysts who have focused mainly on
psychoanalytic psychosomatic research, 2) the psychological analysts, who have pursued a
rigorous academic program to achieve psychoanalytic qualifications and 3) Lacan and his
followers, who moved their investigations in the direction of forging a synthesis of linguistics
(Ferdinand de Saussure), philosophy (e.g. Merleau-Ponty, Jean Hyppolite and Hegel) and what
Lacan called the return to Freud or the building of psychoanalysis based on Freuds early
writings and cases.
Due to his extraordinary capacity to articulate ideas and handle large crowds, Lacan
became a major figure in the 60s and 70s, not only for psychoanalysts, but in other intellectual
circles as well. Whereas in other countries divergent groups have made attempts to synthesize
their theoretical tendencies, the French have tended towards a rather clear separation between
their schools of thought. Interestingly, each of the heads of the above mentioned (medical,
psychological, and Lacanian) schools (Nash, Lagache and Lacan) had the same analyst:
Lowenstein.
As a member of the SPP, Lacan had experienced problems in connection with what was
termed his lack of orthodoxy in the practice of psychoanalysis. Amongst the more controversial
issues was the question of whether an analytical candidate was to obtain the consent of his
analyst prior to establishing his or her own analytic practice. Later, when Lacan came to
establish his own school, he held that the analyst must be able to authorize him or herselfa
notion that flew the face of psychoanalysis as an institution. At the time of his first arguments
with the Society, the controversy related to the standard practice of four to five sessions of 45
minutes each week and a minimum of a two-year training analysis. Lacan held that
psychoanalysis was ill-served by a rigorous prescription regarding the length and number of
analytic sessions as well as the total duration of treatment.
According to the SPP, Lacans practice of variable length sessions (the so-called short
sessions) lacked psychoanalytic rigor. Further, the members did not accept the clinical reasons
that sustained the rationale for the short session. Marie Bonaparte was his most radical
opponent. The heads of the Institute demanded a return to the rules, but Lacan was the most
popular analyst among the trainees, and idea of a Free Institute was on Lacans mind, as well
as on the minds of many French, including some of the analysts in the SPP and their trainees.
This new model was to oppose the medical model and was to be founded on a university model.
The new organization, the SFP (Society Francaise de Psychanalyse) was founded in 1953. The
International Psychoanalytic Association (IPA) voted to exclude the new organization from their
meetings and publishing resources. Even when Lowenstein tried to intervene in the SFPs favor,
the request was rejected by Hartmann, Bonaparte, Jones, Nacht and, above all, Anna Freud. This
split was significant, as up to 50% of the members of the SPP became members of the new SFP.
The SFP proclaimed in its constitution that there were no theoretical differences with the former
society but that the differences were in the moral order. They aspired to have an institute with
a more democratic climate and one that would be guided by mutual respect and freedom.
In 1953 Lacan began his famous Wednesday evening seminar that for more than a
quarter of a century exercised a profound influence on both psychoanalysis and intellectual life
in France. This seminar constituted the first regular psychoanalytic meetings that were not
reserved only for analysts. As a result of this, a form of psychoanalytic education was
available to all, even those who were not themselves in analysis. In addition to the seminar,
Lacan also held a case presentation every Friday. The situation became so serious regarding the
refusal of IPA to accept some of the most famous analysts of France, that they decided to accept
these analysts under the category of Study Group Under the Sponsorship of the IPA. This
initially meant that there was an IPA committee that was to watch over training problems and
make recommendations accordingly. Later, the study group was informed that in order to
continue with IPA sponsorship, Lacan had to distance himself progressively from the training
program.
In 1964, Lacan founds his own school The Freudian School of Paris. He did this with
a certain reticence, as Lacan did not believe in the institutional transmission of psychoanalysis.
His way of working and transmitting psychoanalysis was felt to be peculiar by some and
ambiguous by others. This school remained a training center for sixteen years and trained
analysts who eventually established practices throughout the world. However, in 1980, one year
before his death, Lacan dissolved his school as a result of the discord and infighting among its
members.
Structuralism
Having provided a brief history of psychoanalysis in France, it remains, by way of

introduction to Lacans theory, to provide some background in the theory of French
structuralism. Although Lacan refused to accept structuralism as an epithet for his work, (and
much of his work can be regarded as both pre-structuralisti.e. phenomenological, and post-
structuralist) the impact of structuralism upon him was undoubtedly great, and it is impossible to
understand his contributions to psychoanalytic theory and, particularly, diagnosis, without at
least a basic understanding of structuralist thought.
The structuralist movement has left its mark both in science and the humanities.
Included amongst those who have been influenced greatly by structuralist modes of thought are
the cognitive psychologist Jean Piaget, the anthropologist, Claude Levi-Strauss and the linguist
Roman Jakobson (Feher Gurevich, 1999). Structuralism involves a novel manner of regarding
objects and entities studied in the human sciences. Instead of defining such entities in terms of
their inner or essential characteristics, structuralism situates them in the context of their
relationships with other objects. It is the system of such relationships that defines a structure as
a matter to be studied. Such structured relationships can be understood in terms of laws that are
implicit in the structure and are initially difficult to grasp and articulate, most often going
unnoticed by those individuals to whom the structure applies. Examples of such structures
include the rules of grammatical formation of sentences adhered to but not necessarily known to
the speakers of natural languages, and the rules of marriage and kinship adhered to, but not
always articulated, by both primitive and modern societies. Another common example might
involve the hierarchical rules of verbal deference and exchange that are implicitly adhered to by
participants at an academic, corporate or other institutional meeting. Lacan ultimately applied the
notion of structure to the formation of the unconscious, and he understood dreams, slips of the
tongue, and especially symptoms in structural terms. Most significantly for our purposes here,
Lacan came to regard the basic diagnostic categories of neurosis, psychosis, and perversion in
terms of the position that individuals take with respect to a generalized Other, one that is
embodied in language, law, and, what Lacan refers to as, the symbolic order.
Linguistic Structures
Lacan regards language to be the most basic and paradigmatic structure in human life
and society, and he proceeds to utilize linguistic structures as his preferred model both of the
human psyche and for his work as a psychoanalyst. His famous dictum, i.e. that the unconscious
is structured like a language, follows from this view. Lacan founded his views on structure upon
the work of the structural linguists, in particular, that of Ferdinand de Saussure. Structural
linguistics distinguishes units of language on different levels, (e.g. phonemes, monemes, words,
sentences and phrases) on the basis of the relationships they have with one another at the same
level (moneme with moneme) or at different levels (phoneme with moneme) (Benveniste, 1966).
The grammatical or semantic significance of any one unit is a variable function of the
relationship it has with all the others. For example, the change of one element in a phrase, e.g. a
word, a pause, a comma, a question mark) can alter the entire meaning of the statement in
question, and changes the significance of each of its component parts. As such, we can say that
structural linguists privilege the relationships between elements over the element themselves.
A structure is thus defined as an organization of the parts of a whole in accordance with
certain definite rules of mutual and functional conditioning. Structural linguistics defines
language as a global unit containing parts that are formally arranged in obedience to certain
constant principles forming different hierarchical levels ranging from simple to higher and more
complex elements, such as the transition from the utterance of a sound to a complete narrative
(Lemaire, 1986).
In effect, Lacan reconceptualizes a number of basic psychoanalytic ideas via the
application of a structuralist model. Lacan understands the human subject as a schema composed
of layers of structures. In the first place, these layers correspond to Freuds first topographical
model of conscious, preconscious and unconscious.
The unconscious, what Lacan describes as the subject matter of psychoanalysis is
structured like a language, in which the elements that comprise it are summable and distinctive
but still articulated in sub-sets according to specific laws. These laws are linguistic in nature,
and, as we will see, involve metaphor and metonymy. Lacan derives his distinctive understanding
of these terms from Saussure.
Saussure describes a sign as a double-sided unit (Lemaire, 1984), composed of a
concept and its acoustic image. The acoustic image is not a sound per se but is rather the
psychical imprint of a sound. Saussure proposes to call the acoustic image, the signifier and the
concept, the signified. The sign then becomes the relation of a signifier to a signified. Lacan
appropriates this dual model of the sign and emphasizes that the signifier and signified are
autonomous with respect to each other, i.e. that there is no fixed relationship (of value or
meaning) between them.
The sign remains meaningless unless is interpreted in the context of its relationship
with the totality of language. Two words when enunciated can sound the same, but we can only
determine what the speaker means when we place these words in the context of the signs that
follow (e.g. as in the sentence Two people are going to the store too). Furthermore, we can
never be absolutely certain of the meaning of any particular sign, as further words, i.e. a wider
context, can always prompt us to a new interpretation of what was said (For example, with
regard to the aforementioned sentence we may subsequently learn that the speaker was speaking
emphatically Two people are going to the store; Two!). Hence, the value or meaning of a word
is not intrinsic to it but is determined by the presence of other words in the system. The concept
of value supersedes the concept of signification, as what matters are the system of relations
between concepts rather than any absolute meaning determined by the relationship between a
particular signifier and signified. A quarter, for example is a coin made of metal, the value of
which is not intrinsic to itself, but is rather a function of its position in relation to other coins
within a monetary system. Lacan will apply these ideas in a number of theoretical and clinical
contexts, one of which is his insistence that one proper role of the analyst is to serve as a
punctuation of the analysands speech in such a manner as to reveal his or her relation to the
Other and the unconscious.
Structural linguists hold that the sign is arbitrary, i.e. that is there is no natural
relationship between the sound of a word and its signification. This is evidenced in the idea that
the enunciation of the word is different in different languages. However, we are able, through a
thorough understanding of contexts and relationships amongst signs, to determine, for example,
that blue in English, and azul in Spanish mean the same thing. Nevertheless, the mutability
of the sign is a paradox, as no individual can change language at will, since signs in a given
language are tied to the tradition of a linguistic community. It is only in relation to the entire
community that a given sign is arbitrary.
While there is no necessary relationship between signifier and signified, Saussure held
that once established there is an immutable bond between a signifier and the concept it signifies.
Lacan, however, held that even this relationship is completely mutable. According to Lacan, the
signifier is constantly slipping out from under its signified, and that, in effect, we are
constantly meaning much more and/or less than, what on first reflection, we seem to write or say.
The signifier can only be pinned to a given signified for a brief moment, via what Lacan refers to
as points de capiton, anchoring or quilting points (punctuation, definitions, basic metaphors)
that provide language with at least the illusion of stability. Such anchoring points involve a
delimitation in the flow of the chain of signifiers with the flow of signifieds. According to
Lacan, the anchoring point is above all the operation by which the signifier stops the otherwise
continuous sliding of signification (Lacan, 1960). The sentence completes its signification only
with the last term, each term anticipating something of the meaning but not quite yielding it until
the end when almost by a retroactive function, meaning can be established. This retroactive
dimension of meaning is represented by the anchoring point (it is after the fact, or aprs coup).
Interestingly, Lacan holds that one of the defining features of psychosis is that, in
contrast to neuroses, even these anchoring points (points de capiton) are not present, and the
psychotic slips into a use of language that is idiosyncratic, and from our point of view, seemingly
arbitrary. However, even in the absence of psychosis, signification is always in flux (see Dor,
1997). This flux is a function of two linguistic axes, what Lacan describes as the axes of
metonymy and metaphor. In Lacans usage (and here he is indebted to the linguist Roman
Jakobson) metonymy2 refers to the shift in the signified that results from the contiguous flow in
language and to its links. The change in the signified is a function of its relationship to later
words and punctuation in the chain of signifiers, and the signifiers impact on former elements in
the change. Lacan holds that, as a result of such chaining, meaning is constantly deferred or
displaced, and he links the metonymic axis of language, with Freuds notion of displacement
as a key element in the dreamwork and in the formation of psychological symptoms. Metaphor,
on the other hand, refers to the fact that linguistic units can be selected and substituted for others
on the basis of some similarity within a chain of signifiers. Thus, a given signifier can represent
more than one signified.
Metaphor, according to Lacan, corresponds to the mechanism of condensation in the
dreamwork and in symptom formation. Lacan goes on to hold that psychological symptoms are,
indeed, metaphors (Lacan, 1970). According to Lacan, identification is also a metaphor, since
identification always involves the substitution of oneself for the identified object (Lacan, 1955 ).
For Lacan, the notions of metaphor and metonymy are the basic concepts through which he
understands the phenomena of the unconscious. Topics such as the primary process, dreams, the
2
In ordinary usage metonymy is a form of speech in which a term is used to denote an object that it does
not specifically refer to but with which it is closely related (Evans, 1996). An example would be City
Hall denied all involvement, where City Hall is used to mean mayor. While he acknowledges that
this is one form of metonomy (giving the example of thirty sail for thirty ships) Lacan uses
metonymy in a much broader sense to refer to the entire chain of contiguous language, contrasting it with
metaphor, which he also uses broadly, to denote the possibility of substituting elements in a chain of
signification with other elements.
formation of the symptom, jokes, and all other formations of the unconscious are understood by
Lacan in terms of these two axes of language. According to Lacan, even such psychotic
phenomena as neologisms, glossolalia, and delusional language are metaphoric and metonymic
formations (Dor, 1997). Finally, and these are amongst Lacans major contributions to
psychoanalytic theory, the process of desire is viewed as a metonymic development (as desire is
continuously being displaced and deferred from object to object without ever reaching
satisfaction) and castration is viewed in terms of a primal metaphor, i.e. The Name of the Father
or paternal metaphor, which becomes the means through which the individual gains access to the
symbolic order. Each of these themes will be made clear as we proceed.
As will also become clear, Lacan links Freuds ideas regarding the Oedipus Complex
and structural diagnosis with his structural analysis of language. He holds that the individuals
capacity to utilize language in a normal manner is a function of his or her entry into the
symbolic order, the rules of discourse and laws of the community that are fundamental to
human society. Such entry is dependent upon the presence of a primal signifier, what Lacan
calls the Name of the Father, which, on Lacans view, is instituted as a result of the restrictions
(castration) imposed by the Oedipal triangle. Whereas the neurotic is said to repress castration
and the paternal metaphor, and the individual with a perverse structure is said to disavow it, the
psychotic is said to foreclose it, in such a manner that he or she is never fully implanted within
the symbolic order. These ideas, which will be the subject of a more detailed discussion, both
later in this and in subsequent chapters, are critical for any Lacanian understanding of the so
called borderline personality.
Lacans Novel Psychoanalytic Ideas
As I have indicated in the previous section, any understanding of Lacanian

psychoanalysis is dependent upon an understanding of his use of structuralist linguistics. Lacan
proposes, in effect, to read the human psyche like a text, and in order to grasp his reading we
must come to terms with his basic theories regarding language. Lacans originality, however, is
by no means limited to his reading of Freudian ideas through the lens of structural linguistics.
His corpus is filled with original and often controversial theoretical and clinical formulations,
many of which are grounded in structuralism, but others of which are more closely linked to
Hegelian philosophy, phenomenology and existentialism, intellectual movements that are
generally thought to be opposed to the structuralist program.
Lacans career as a psychiatrist and psychoanalyst spanned nearly fifty years, during
which time his ideas were in constant development and flux. He spent 25 years of his
professional life diagnosing and treating psychosis. However, Lacans death in 1980 has only
increased the multiple interpretive possibilities that can and have been gleaned from his work. In
the following sections, rather than attempt to provide even a cursory review of Lacans prolific
theorizing, I will focus upon several of his key contributions, which (though they span different
points in his career) promise to be most helpful in our efforts to grasp the borderline phenomena
in Lacanian terms. While it may well be that Lacan would not have, at any given point in his
career, maintained each of these positions, Lacanian analysts have not, in general, troubled
themselves with maintaining a position that is consistent with a single period in Lacans thought,
and have found it fruitful to incorporate into their own theorizing ideas from different phases of
his long career.
The Mirror Stage: The Scenario of Ego formation
Lacan wrote his paper on the mirror stage in the late 1930s when he was still part of the
International Psychoanalytic Association (Feher Gurevich, 1999). In this paper he elaborated the
formation of the ego as the encounter of the subject with the other in what he terms the
imaginary realm of existence. Lacan will later make a distinction, critical to an understanding of
all his later thinking, between the registers of the real, the imaginary, and the symbolic,
but at this stage of his thought his views on the imaginary were only beginning to take form.
For Lacan the imaginary realm is characterized by conscious life; the way the subject is
immersed in his reality and how he perceives it. The encounter with the imaginary realm is what
Lacan calls the mirror stage. While Lacan seems to have initially regarded it as a developmental
stage, he soon came to view the mirror stage as reflecting the very nature of human subjectivity.
For Lacan, the mirror stage is a structural formation that accounts for the formation of the ego,
and what is ultimately experienced in the transference between the patient and the analysts ego.
The mirror stage is primordial not because of its developmental status, but rather because it
prefigures the dialectic between alienation and subjectivity, what Lacan terms the divided
subject (Lemaire, 1986).
Lacan early on became fascinated by the discoveries of Wallon and later Baldwin (Evans,
1996) that the child obtains self-recognition in the mirror between the ages of six and nine
months, during a period when the child gradually becomes conscious of his body and his image.
These researchers noted that unlike a chimpanzee, who quickly realizes that his image in the
mirror is illusory and thus loses interest in it, the human child becomes fascinated with his image
in the mirror and seems to comprehend that it is an image of himself. This recognition becomes
the foundation for the formation of an image of the self via identification with an other, who is
outside. According to Lacan the entire process of identification is grounded in the imaginary
dimension.
Lacan elaborates on the concept of the imaginary by comparing animal instincts with the
human drives. He describes how animals are naturally drawn to the satisfaction of their needs
and can grow to function competently in a short period of time. On the other hand, a human baby
is underdeveloped during the first six months of life, specifically in terms of motor coordination
and motility. However, this immaturity is balanced by a strong sense of visual perception. The
child can recognize a human face very early in life and respond to it. When the child recognizes
himself in the mirror he feels joy, which is a sign of awareness, and the beginning of his fantasy
life.
According to Lacan, the mirror stage occurs in three successive phases. First, the child
confuses reflection and reality by looking for himself behind the mirror. Second, the child
understands that the image is a reflection, not the real being. Third, he understands that it is not
only a reflection of himself but that it is different from the image of the other.
Lacan holds that the mirror stage is the key to the formation of the ego. The child
experiences his body as fragmented and uncoordinated, but because of the advanced
development of his visual system, he is able to recognize himself in the mirror in spite of the fact
that he lacks control of his own movement. The child sees his image as an integrated gestalt,
which contrasts markedly with the fragmentation of his own bodily experience. While initially
there is an aggressive tension with this image, the child resolves this tension by identifying with
it, leading to an imaginary sense of mastery and wholeness (Lacan, 1956).
The identification with the image in the mirror extends as well to the identification with
other children. When he is around other children his age, the child expresses his identification
with the human form with the others in his games: the child who strikes will say that he has
been struck, the child who sees his fellow fall will cry (Lacan, 1977). According to Lacan, the
child now wishes to be recognized by others in his newfound sense of self, and even imposes
himself on the other and dominates him. We see here the imaginary processes at work, a merging
of self and other, and, according to Lacan, it is in the other that the child lives and registers
himself (Lemaire, 1986). On Lacans view, the experience of the mirror is prior to the capacity
for cognitive recognition and also to the advent of the body schema (Dor, 1997).
The identification with the mirror image and the body is fragmented, but its function is to
unify the self, to bring about a total representation of ones own body. However, the childs
identification with an image outside of himself also carries a negative connotation, in that the ego
becomes, in effect, a narcissistic image with an inverted structure, the very nature of which is
external to the subject and objectified.
Lacan follows a tradition in French philosophy that regards the ego as an objectified
phenomenon that is outside of, and alienated from the human subject; the ego is above all a
construct produced by the gaze of the other. For Lacan, the ego is hardly the seat of
subjectivity, judgment, reality testing, etc. that it is for the ego-psychologists, it is rather a
narcissistic construction utilized by the subject to provide a false, and alienating, sense of
coherence and value. This is a key concept in understanding Lacans critique of ego-psychology,
and will be of significance to any Lacanian deconstruction of the borderline concept.
According to Lacan, through the mirror stage the child acquires a sense of the totality of his own
body but only does so by way of narcissistic identification with the others, and in the process
establishes a fundamental alienation in an image that will produce a chronic misrecognition. In
other words, the child identifies with an optical image of himself, rather than with his own
subjectivity.
According to Lacan, it is because of this alienating identification with an image outside

of itself that misrecognition becomes the fundamental characteristic of the ego. Far from being
the governing agency of the subject or self as it is in ego-psychology, the ego, for Lacan, is a
snare and an illusion. While ego psychologists hold that by analyzing defenses they allow the
ego to recover its discerning abilities and recognize external reality, Lacan holds the opposite
view, namely that the ego is the psychic representative, not of the reality principle, but of an
imaginary reality (Lacan, 1966). The ego is trapped in the fundamental division of the subject,
who is alienated and is unable to understand why reality constantly disappoints him. This
misrecognition also has profound implications in the realm of language and speech. We have a
mistaken belief that we know what we are saying when we speak, but we speak about a self that
is fundamentally alienated and displaced.
Lacan provides other far-ranging criticisms of ego-psychology, one being that since ego-
psychologists identify the subject with the conscious ego, they neglect Freuds dictum that the
the ego is not the master in its own house and, as such, neglect the fundamental discovery of
psychoanalysis itself, the unconscious. For Lacan, ego-psychology, like modern man in general,
has identified with the object in the mirror, to the neglect of his genuine subjectivity. As we
will see, since that object in the mirror is essentially the other, the identification with the ego
leads to an acceptance of the desires of the other, at the expense of the true desire of the subject
or self. In elevating this misrecognition, ego-psychology furthers a program of identification with
the analyst and adaptation, which is at complete odds with the radical, liberating nature of
psychoanalysis.
Lacan recognizes that misrecognition serves an adaptive function as the instinct of
survival does for the animal. However, this adaptive function is at the expense of the subjects
own truth. However, all is not lost. Misrecognition is not ignorance; as Lacan states, if the
subject is able to misrecognize something, he must know something that needs to be recognized.
For Lacan misrecognition is the content of consciousness. According to Lacan, when we work
exclusively with the patients ego, our patients dont progress; in fact they continue to suffer and
wonder about their symptoms, sometimes to the point of deteriorating psychologically.
Out of the asymmetry of the mirror stage, the ego defenses arise. For Lacan, there is no
point in differentiating ego from its defenses, since the ego itself is a defense, a cover-up for the
fragmentation and then for the split that constitutes us as subjects. With the process of primal
repression the subjects original sense of helplessness retreats to the unconscious. However, it is
only with the advent of the symbolic order (or acquisition of language) that the child will bring
his/her ego into the realm of the symbolic and the ego will appear more integrated. However,
each time the image of the other imposes itself on the ego, the subject will be challenged again,
in all his or her social relations. According to Lacan, this is most obvious in subjects who feel
insecure in their recognition by others or who fear being devoured by others, but it is present in
all of us.
Lacan has a number of other things to say about what American analysts speak of as pre-
Oedipal formations which presumably impact upon later adult structure. Lacan views the pre-
oedipal period as the time of total dependence on the mother. However, the child must come to
terms with the fact that the mother is not always available, or that at times she does not
understand his needs and frustrates them. This unavailability produces frustration and confusion,
even rage. (Here Lacan is close to the object-relations theory of Melanie Klein.) The question
that arises in the face of Lacans account of these pre-Oedipal events is how the human subject
(child and later the adult) can organize itself with respect to this essential loss, as well as with
respect the alienation incurred by the mirror stage, and, in effect, replace what is missing. This is
the crisis that Lacan places at the entrance to the symbolic order, via the acquisition of language
and along with it, the birth of the unconscious
.
Lacans Critique of Developmental Psychoanalysis
It is important to point out that while Lacan, in articulating his theory of the mirror stage
(and other pre-Oedipal phases), appears to be presenting a developmental theory of the ego, he
does not, in the end, propose a developmental study of the child. Lacan goes so far as to state that
it is not the place of psychoanalysis to conduct infant research. Infant research belongs to the
field of developmental psychology or other pertinent disciplines. For Lacan, what is known
psychoanalytically about the childs psychological universe, psychic structure, and human
motivation is always understood retroactively; it is always a construction made a posteriori
(Feher Gurevich, 1999). Further, according to Lacan, the subject matter of psychoanalysis is
neither child development nor personal history per se, but the unconscious as it is studied in the
context of the psychoanalytic situation. For Lacanian psychoanalysts it is more appropriate to
discuss structural moments of psychic development rather than developmental phases or stages.
This is why language and its rules are crucial to the understanding of these structures as they are
produced in the analytic exchange between analyst and patient.
It will be worthwhile to reflect in some more depth on Lacans position in this regard, as
it constitutes a major difference between Lacanian psychoanalysts and their American
counterparts, and could prove a major stumbling block in their potential communication. While
Lacan may be criticized on the grounds that he utilizes developmental concepts and then denies
that they are developmental, I believe that, at least in his more mature formulations, Lacan
conceives his mirror stage (and other concepts, including the Oedipus Complex), in
logical/structural as opposed to developmental terms. He certainly does not hold that human
psychopathology emerges according to a set sequence, at critical periods, during prescribed
libidinal or developmental stages. Although in other contexts Lacans theories might be
conceptualized in quasi-developmental terms and even be put to empirical test, and it is clear that
at least in the case of the mirror stage he was stimulated in his thinking by developmental events,
in his own work, including his thinking regarding the mirror stage, etc. is based upon
reconstructions from working with adult patients.
Lacans distrust of developmental approaches to psychic structure follows in a rather
straightforward manner from his view of language, and hence his view of narration and history.
Just as the significance of a chain of signifiers and each of its elements along the way is not
revealed until the end, the significance and structure of the subjects psyche is only reinterpreted
and resignified as an adult, particularly in the psychoanalytic situation. For Lacan, makes no
sense to try to understand adult psychological functioning through an analysis of meanings that
were present for the child, as these meanings have been altered and resignified in the adult
psyche.
Lacan articulates certain moments in the constitution of human sexuality via the Oedipal
complex, by re-working the topics of privation (the mother gives or deprives according to her
wishes), frustration (when the child does not receive what he needs), and castration (the
understanding of the child that the mother is lacking something and that he is not the one who
can satisfy her). These moments, Lacan argues, are necessary but are not developmental phases
that follow a prescribed temporal sequence; they occur at some point when the child is dealing
with the contingencies of his environment. They can occur at one age for one child and another
age for another. Further, and most importantly, these events do not have the same meaning at the
time of their occurrence as they do in the psychoanalytic situation.
Lacan explains that the timing of human development is not evolutive but logical. In
Ecrits (1945) he concludes that the modus operandi of the unconscious, what he calls the
formations of the unconscious (dreams, parapraxis, symptoms) follows a logical, but not
temporal sequence. This logic implies that for an individual to arrive at his or her truth each
significant psychic event implies a time, as he puts it, to see, a time to comprehend and a
time to conclude. (Lacan, 1945). This is the logic followed by the unconscious processes, and
has nothing to do with objective time. Although these moments are described as a temporally
ordered sequence, they are in fact atemporal. The following general account of the way Lacanian
analysts work using the so-called short (but really atemporal) session should help clarify the
atemporality of the analytic process.
When a patient relates his or her history in treatment, he/she makes a historical
presentation of the facts and events that occurred during his/her life, accentuating or underlining
what he or she believes is important (usually the suffering related to the symptom). This
narrative constitutes the patients psychic reality. Regardless of what occurred objectively (if
such a concept even makes sense) what matters is the analysands psychic experience. At a
certain moment in the session, the patients says something that the analyst is puzzled about and
the analyst makes a punctuation, by, for example, repeating or questioning what the patient has
said. The patient listens and processes the new data. (This is the moment of seeing). The patient
may elaborate further. However, the analyst decides to interrupt the session and suspend the
analytic process. (This cut of the session indicates the moment of conclusion). When the patient
comes in the next session, he may have come back to the words he spoke and the exchange with
the analyst in a different way; the patient may have done his working through outside of the
session (This is, according to Lacan, the moment of understanding). As a result of analysis the
patient has constructed a new logical discourse regarding something that at one point had a
different meaning. Thus, according to Lacan, chronological time has no meaning in analytic
work. The actual events in objective time are not analytically meaningful until they are signified,
understood and re-signified by the patient. Further, the actual length of the analytic session is
also unimportant. The words exchanged in five minutes may be enough for a patient to open a
new chain of signifiers, whereas a hundred sessions may prove ineffective for this purpose.
Indeed, if the analyst would have extended the session to forty-five minutes, everything could
well have been lost in a torrent of words that confuse things to the point where neither analyst
nor patient knows what they are working on.
In terms of infant development, Lacan does not deny the existence of growth and
development; however, such development is not explicitly relevant to the psychoanalyst, whose
work is directed to the issues of discourse and unconscious processes. We want to hear the
history of the patient, not because we want to find evidence for possible causes of the patients
suffering, but rather because, as analysts, we must attend to the particular linguistic structures the
patient chooses, and, most significantly the position the patient occupies in his discourse with the
other. Lacan does not deny the role of time in child development. However, he holds that in
focusing on such development the analyst will inevitably fail to understand the structure of the
human subject.
Another example can be useful in explaining Lacans position: the significance of a
traumatic situation. According to Lacan, whether an event has a traumatic effect is not the
result of the intrinsic nature of the trauma but rather because such trauma represents a re-
signification of that which was structurally traumatic on an earlier occasion, one for which, as a
result of primary repression, the subject has no recollection. Although the mechanisms of trauma
and resignification may be universal, the singularity of each subject renders different meanings
for presumably similar or even identical life events. For example, life in a concentration camp
(which all would regard as objectively traumatic) may be overwhelmingly traumatic for one
individual, who commits suicide or allows himself die, and a challenge to live and achieve
meaning for another (Frankl, 1959).
In effect, Lacans problem with a developmental psychoanalytic approach to the structure
of the human psyche is analogous to a historians objection to our trying, say, to understand the
significance of events in Germany in the 1920s, without reference to Hitler and World War II.
No amount of contemporary narrative from the 1920s will substitute for our re-comprehension of
those same events after the war. All understanding for Lacan is apres coup (after the fact). While
we may be able to learn much about the child by observing him/her in his development, the
phases and events in childhood are only explanatory of adulthood to the extent that, they are
presented in the form of symptoms, slips of the tongue, etc. Having said this, however, Lacan
found it impossible not to speak in terms of historical developmentalbeit a development that is
understood in terms of its re-signification in adult life.
The Symbolic Order
For Lacan, the acquisition of language marks a new structure in the mind of a child, one
that is characterized by the loss of his world vis--vis his mother in order to become his own
being. The symbolic order is the order of language and culture, a structure into which the child is
unknowingly inscribed even before he was conceived. As we will see, the childs inscription in
the symbolic order marks, for Lacan, the point of differentiation between neurosis, psychosis and
perversion. However, for Lacan, the symbolic order, like the imaginary order, is one more
vehicle through which the individual is trapped by the other, and his subjectivity possessed by
something that is outside himself. Lacan, will also hold that language has a liberating function,
but (in the logical sense) it is at first alienating, and at the very origin of the unconscious.
To elaborate upon this aspect of the symbolic order, Lacan takes the example of Freuds
observations of his 18-month-old grandson who would throw and retrieve a spool as he uttered
the words: fort, da (gone, there). Freud understood this event as the way the child could
master the situation of the loss of his mother by taking symbolic control through words indirectly
referring to his mothers presence and absence. However, as the child is expressing a certain
mastery through his words, his feelings of loss are being repressed. Lacan interprets the fort/da
as an indication of primary repression, and this, according to Lacan, is how the unconscious
comes into being. From then on, the unconscious will be the repository of all phonemic traces,
words and subsequent representations of lack or loss. This moment inaugurates the childs
subjective experience in the world of language and as he increases his vocabulary, he grows to
encompass many possible experiences and facts of reality. The acquisition of language is a
paradoxical process; on the one hand, it provides the child with a certain autonomy, on the other
hand, it is deceptive in so far as the subjects unconscious remains bound up with the signifiers
of the others desire. What Lacan means to say by this is that since the child is born into a
language he/she inherits from others (his parents, grandparents, and general society/culture), the
language through which he expresses himself, the language within which he resides, and the
language he represses insures that his subjectivity is not his own but is rather completely
inundated with the purposes and desire of an other. It is because the language we speak is
imbued with others meanings and intentions, that our unconscious is, according to Lacan, not
something that simply resides within our own intrapsychic depths, but is rather, more properly,
something that resides out in the world. For Lacan, language both saves and deceives; it causes
both the formation of the subject and, like the imaginary constructions provided by the mirror
stage and the ego, it fosters the subjects splitting and alienation.
However, unlike the imaginary, the register of the symbolic offers an opportunity for the
subject to transcend his alienation and partake of a new subjectivity that is only possible through
the act of speaking. This is why Lacan believes that language is such a powerful tool, and in fact
the only proper tool, in psychoanalysis. On the one hand words alienate, they are composed of a
signifier and a signified (which Lacan symbolically divides with a bar) and thus express and
embody the division between what the subject says consciously and what is barred from the
conscious discourse. As Lacan states it in his Ecrits (1977): We can say that it is in the chain of
the signifier that the meaning insists but none of the elements consists at any given moment. We
are forced, then, to accept the notion of an incessant sliding of the signified under the signifier.
(1977, p. 153). However, it is only in the register of language that this sliding can, at least
temporarily, be brought to a halt, and the subject can learn to differentiate his subjectivity and
desire from the demand of the other (see below).
Lacans Conception of the Oedipus complex
For Lacan, the symbolic order is instituted as a result of the Oedipus complex, and the
resultant insertion of the paternal metaphor into the unconscious psychic structure. The Oedipus
complex as we know it from Freud is an unconscious set of relationships that occur in a
triangular form and is characterized by specific affects related to the parents (Freud, 1908). In the
positive form of the complex, the subject desires the parent of the opposite sex and develops a
rivalry with the parent of the same sex. The child enters the complex around the age of three and
leaves it by the age of five or six when several important factors emerge: the child identifies with
the rival and as a consequence resolves gender identity, the superego develops as an
internalization of the parental prohibitions as a self-censoring agency, and the child enters a new
phase, latency, in which sexual desires are displaced by other more intellectual interests prior to
adolescence.
Freud argued that all psychopathological structures could be traced to a problem in the
resolution of the Oedipus complex (Freud, 1910). By 1910, Freud had made the Oedipus
complex the central focus of psychoanalytic investigations into the neurosis and after that time, it
became the motor of psychoanalytic theory.
Lacan initially addressed the issue of Oedipus in 1938 in an article called The Family.
Lacan defined a complex as a whole constellation of interacting imagos or the earliest
internalization of the subjects social structures (parents, grandparents, and other meaningful
actors in the life of a child even before his arrival to the world). These multiple identifications
provide a script in which the subject is led to play out the drama of conflicts among the members
of the family (Lacan, 1957).
In the 1950s, Lacan began to produce a distinctive re-conceptualization of the Oedipus
Complex. In his view, whether the subject is male or female, the subject always desires the
mother, and the father is always the rival. Lacans thinking here produces a radically
asymmetrical way of understanding the Oedipus Complex and has enormous consequences for
the issues of sexual difference and gender identity. However, of greatest significance in the
present context, the Oedipus complex is, for Lacan, a paradigmatic triangular structure opposed
to all dual structures, via the introduction of a third term between the mother and the child,
namely, the father (inserted through language). According to Lacan, this complex represents the
passage from the imaginary phase to the symbolic phase, and in the process the subject is
confronted with the problem of sexual difference. Further, the Oedipus complex has important
consequences for the formation of the symptom and for the psychic organization of the adult.
We can ask ourselves if the oedipal tragedy can actually represent the human condition
and the vicissitudes of human sexuality. Lacan believes that without the Oedipus Complex,
psychoanalysis cannot be sustained. However, he makes several changes from the original
version of the myth as it was interpreted by Freud. First, he disassociates the complex from the
primal scene and all the specificities of the familial relationships, that is, he elaborates this
complex as a structural moment that occurs at the level of discourse. He asks the question: How
is sexuality established in human beings? The answer is related to the German word Trieb,
(English: drive) a word that has a very different meaning than its usual English translation as an
instinct. Animals have sexual instincts, they have a copulating season, they mate always for
reproductive purposes and they dont have conditions in their choice of mates. Human sexuality
is completely different. Our anatomy does not absolutely determine our sexual identity. In
addition, we can have sexual relationships only for pleasure, with the frequency and intensity we
wish, and we have specific conditions for choosing one mate over another or for selecting an
object to fulfill our sexuality. All of these issues are determined as a result of the oedipal
vicissitudes.
The Three Stages of the Oedipus Complex
In Seminar V, The Formations of the Unconscious (1958) Lacan identifies three stages
that are necessary in order to achieve the passage to the symbolic order. These stages follow a
logical as opposed to chronological order.
Lacan holds that the first phase or time of the Oedipus Complex occurs in the context
of the imaginary level of existence; the other is the mother, and the child is initially involved in
a dual relationship with her in which the child comes to recognize himself somewhere else
beyond himself, i.e. in the mirror or in the mothers gaze. If the child is someone, it is only
because he is someone for his mother. This position of total dependence leads the child to
believe that his satisfaction is tied to the place he occupies for his mother. The child wants to be
everything for her, to be that which she desires, and the compliment of her fulfillment. We are
here in the realm of primary narcissism, in which the child, having no symbolic substitution for
himself, is a blank surface for the mother to write upon. However, according to Lacan, any
attitude of the mother that will favor her possession of the child will alienate the child from
subjectivity and a place in society.
Although it appears that there is a dyad functioning between mother and child, there is
already a triangle between the mother, the child, and that which the mother lacks. It is this lack
which Lacan terms the phallus. For Lacan, the phallus, is not to be confused with the
biological organ, but is rather simply a representation of what the mother lacks or desires. In
identifying himself with the phallus, the child is simply trying to satisfy the mothers desire, and,
in effect, become the phallus for her. Lacan regards the presence of the imaginary phallus as the
third term in this early stage of the Oedipus Complex, indicating that even here the imaginary
father is already functioning, representing that object which the mother desires beyond the child
(unless the mother is implying that the child is occupying that place which means she does not
lack anything). Therefore, there is never a dual relationship per se. In this stage, we have the
prohibition of the father already operating over both mother and son/daughter.
Lacans introduction of the concept of the phallus is a potential source of controversy and
confusion. Lacan uses the term phallus to indicate that what concerns psychoanalysis is not the
biological presence of a penis but the signifier of desire (that which we lack).
Freud referred to the concept of phallus as the fantasy of having or not having. It is
unclear if he made a clear distinction between phallus and penis, but it is clear that he referred to
the fantasy and not to the real thing in most of his discussions on sexual difference.
In Lacans writings, the concept of the imaginary phallus in the first stage of Oedipus,
differs from Freuds conceptualization, inasmuch as, according to Lacan, both the mother and the
child are marked by a lack, namely, the imaginary phallus. For the mother, the lack is that which
she desires beyond the child, and for the child, the lack is the place in filling the mothers desire
that he wants to, but cannot, occupy. With the strong emergence of sexual impulses in the child
(infantile masturbation), anxiety in the child increases. As a result, the child is filled with
feelings of impotence and confusion. In Freudian terms, this stage is what is denominated
primary repression and is constituted essentially by alienation.
In the second phase of Oedipus, there is an intervention by what Lacan refers to as the
symbolic father. According to Lacan, if the father is to be recognized by the child, the mother,
who acts as a sort of gatekeeper to the child, must first recognize his speech. (Lacan, 1977). It is
speech alone that gives a privileged function to the father, and not the recognition of his role in
procreation. This is called the Name-of-the-Father. (Lacan refers to this as the power of
heterogeneity, which is the basis of the symbolic order as opposed to the power of homogeneity,
the fusion with the mother, which occurs, in the imaginary order). The fathers speech denies the
mother access to the child as phallic object and forbids the child complete access to the mother.
This intervention, which is called castration in psychoanalytic theory, has an implication of
privation. However, while the father initiates this privation, it can only operate via the mediation
of the mother. The mothers acknowledgment of the fathers presence enables the father to
occupy the third position in the Oedipal triangle in which the child sees the father as a rival for
the mothers desire. In Freudian terms, this second stage of the Oedipal phase is called
secondary repression and essentially corresponds to a phase of separation.
The third time of Oedipus is marked by the real intervention of the father who signals
to the child what he can and cannot have. Lacan discusses that the father, in introducing to the
child the law of the symbolic order, relieves the child of the anxiety associated with occupying
the place of the phallus for the mother. He can thus, identify with the father and transcend the
aggressivity inherent in his imaginary identifications. This is what Lacan calls the normative
function of the Oedipus complex, as it introduces a law establishing difference between the
child and his parents as well as the norms of generational and sexual difference. If the child does
not accept the Law, or if the mother does not recognize the position and speech of the father,
the subject will remain identified with the phallus and continue to be subjected to his mothers
desire. If on the other hand, the child does accept this law, he identifies with the father, who, in
the childs mind, possesses the phallus. In this way, the father reinstates the phallus as the object
of the mothers desire but the child is no longer identified with it. According to Lacan, this
process, allows the child to give and receive in a full sexual relationship and to also have a
Name, which for Lacan constitutes a place in a family constellation that promotes the realization
of the self through participation in the world of culture, language and society.
Thus for Lacan castration is understood in both a negative (limiting) and positive sense;
the negative aspect enforces the prohibition of incest and the positive aspect assures the childs
inscription in the generational order of a family and society. Castration is not the fear of losing
the penis, castration is the symbolic operation that cuts the imaginary bond between mother and
child, and grants the child (boy or girl) the ability to symbolize this loss in words. This Law is
not proper to the father; it is actually inscribed in a language that was already present before any
of the participants in the oedipal triangle were born. We must emphasize the obvious fact that for
Lacan, the childs parents also had to experience the situation of loss with their own mothers.
When Lacan discusses the father, he does not generally refer to the real father, but
rather to the one who implements the paternal function, a function that could be carried out by an
uncle, a friend or another female, or even an institution.
Freuds case of Little Hans (Freud, 1909) provides an important illustration of the
oedipal vicissitudes as they are interpreted by Lacan, and the consequent development of a
phobia incident to these vicissitudes. In this case, we have a very permissive mother who is very
attached to her son and a father who, in spite of being quite sympathetic, is unable to separate
Hans from his mothers excessive loving demands. For example, Hans would bathe with his
mother, and his mother would at times take him to her bed. The father who wanted to be a
friend to his child placed no restrictions on him. (see Ferrari, 1999). When Hans starts, around
the age of five, to experience sexual feelings accompanied by masturbatory activity, he becomes
very anxious. At the same time, his sister Hanna is born and his mother becomes less available to
him; in fact, she is busy with the baby and can no longer devote the same time and attention to
him that she had previously. Subsequently Hans develops a phobia to horses. What is it that Hans
is anxious about? He is anxious about his sexual pleasure, which is linked to his mother coupled
by the abrupt appearance of his sister as a threat to the loss of love that he represents for his
mother. On a Lacanian view, the presence of the baby represents the evidence that he is not
everything for his mother, (and here we see the birth of sibling rivalry). Thus, the phobia of
being bitten by a horse becomes his protection against castration anxiety. As long as the horse is
feared, he does not experience anxiety. Like other phobics he has demarcated a specific
(presumably manageable) territory for his anxiety. He only has to avoid that territory, i.e. avoid
the phobic object, in order to avoid experiencing anxiety. We can infer that Hans father,
although with the best intentions, did not intervene in separating Hans from his mother, which is
clear from his own decision to consult with Freud about his sons symptoms. This necessary
separation would have enabled Hans to identify with his own father, without the need to project
his anxiety regarding sexuality and loss onto a phobic object.
The Prohibition of Incest
Lacan studied carefully the myths described by Freud in Totem and Taboo and took a
great interest in the regulation of culture and the transformation of the law of nature to the law of
culture. Lacan took note of the structural anthropologist Levi-Strauss (1949), who pursued this
theme in field studies that he carried out in Australia and South America on the rules governing
various social practices, primarily those concerning the exchange of women, words and goods,
the institution of marriage and the establishment of familial relationships. In his book The
Elementary Structures of Kinship Levi-Strauss described how in society there are laws that
govern these relationships, and that these laws are organized in ways that are analogous to the
structure of language. He defined a structure of kinship as a system in which all the members
who are related in a family fall into two categories: the possible marriages and the forbidden
ones. Through his analysis of the changes allowed or prohibited in a social system, Levi-Strauss
believed that he was able to establish that the prohibition of incest constitutes the foundation of
the symbolic system, separates animals from humans, and marks the division between nature and
culture.
A man or a woman is separated from his/her biological family in order to be united with a
member of another clan assures the perpetuation of the species (Feher Gurevich, 1999). What is
so original about Levi-Strauss work is not the discovery of the law, but the fact that the
individuals who operate within it are unaware of the conditions for mating, which operate at the
an unconscious level; that is, these individuals know the rules of marriage without being
conscious of the principle of prohibition imposed on the blood marriages.
On the basis of Levi Strauss findings, Lacan re-formulated the theory of the prohibition
of incest within a psychoanalytic framework. Contrary to Freuds statements that this prohibition
is transmitted phylogenetically, Lacan states that this prohibition is cultural. According to Lacan,
the childs fantasies actually defy the law of the prohibition of incest (if not literally then
imaginatively) that is imposed on the subject by the culture. This is not a natural event; rather it
is a cultural/symbolic one that raises the child out of the realm of biology into the matrix of
language, culture and law. Further, Lacan implies that prohibition is a necessary condition for the
existence of desire. In our culture, we have certain sexual prohibitions, but in other cultures such
prohibitions might differ. It is not the specific prohibition, but the very fact of a prohibition that
is universal, and makes human sexuality unique. While it can be debated whether the objects of
incest prohibition are completely trans-cultural, the imposition of some sexual prohibition is is
universal. An imposition of our occidental culture, a condition of our language, is that the
symbolic father is the representative to cut the bond with the mother.
If the name of the father operates, the child is empowered to speak about his own lack,
and is thereby further empowered to enter into the world of interpersonal relationships. While,
according to Lacan, a psychotic individual may be able to speak, his language does not reflect
the inscription of the Name of the Father, and he is therefore not fully inscribed in the symbolic
order. As a result, the psychotic is not able to express his loss and lack as a full desiring subject.
We will later explore how this theme is of significance in understanding differential diagnosis
and in particular the inability of the so-called borderline patient to withstand intimate
relationships without losing his/her sense of personal integrity.
Why is it that Lacan insists on the significance of the metaphor of The-Name-of-the-
father, and how is it that we can apply this metaphor in our daily clinical work? The most
important function of the paternal metaphor is a symbolic one. It provides the child with an
explanation of his or her origins and pre-history, intimates how his parents desires were played
out, and situates other family members such as grandparents, aunts and uncles, in the childs life.
Finally, according to both Freud and Lacan, the paternal metaphor represents a boundary or limit
that permits the child entry into the laws and traditions of his culture, and enables him/her to
achieve an adult identity that will permit him/her to establish his/her own family.
The Imaginary, the Symbolic and the Real
One of Lacans most innovative contributions is his distinction between the three
registers of the symbolic, the imaginary and the real, distinction, which plays an important
role in his structural diagnoses, and his conception of the essence of neuroses, psychoses, and
perversion. We have already discussed the register of the imaginary in the context of the mirror
stage and Lacans critique of the ego, and we have discussed the symbolic register (or order) in
the context of Lacan's understanding of the Oedipus complex and the role of language in the
structuring of the unconscious. We will have more to say about these two registers in the context
of Lacanian diagnostics. However, it remains for us to describe what is Lacans very difficult
conception of the third register, the real.
Although Lacan's use of the term real shares something with both common sense and
its application in the history of philosophy, the real should not be confused with "reality " as it is
commonly understood. In the first place for Lacan "reality" is often used in a sense that is
completely opposite to that which he refers to by the real. For Lacan reality, as we normally
use the term, is completely enclosed and determined by symbolism and language, whereas the
"real" is used to indicate a register that is completely opposed to and unassimilated by language.
For Lacan, the "real is closer to what to philosophers have referred to as being in itself," that is,
a pre-linguistic being that exists prior to the subjects constructions of or about it. According to
Lacan, the real is completely undifferentiated in itself and is absolutely without fissure (Lacan,
1954). It is only the symbolic that introduces a "cut into the real, and it is only language that
permits the real's differentiation into a world of things. The real, as it was formulated by Lacan in
the early 1950's, is simply that "which resists symbolization absolutely" (Lacan, 1953) In Ecrits,
Lacan says the real is whatever exists outside of symbolization and language (Lacan, 1953).
In Seminar 11, Lacan, refers to the real as "the impossible." The reason for this is that the
real can neither be imagined nor symbolized, and as such it is impossible " to attain it in any
way. It is because the real is not assimilable by the subject that it takes on a traumatic character.
However, the real as trauma cannot be permanently identified with any specific objects or things,
but simply appears in experience as that which is intrusive and traumatic, and beyond the power
of the subject to conceptualize and symbolize. In Seminar Four Lacan describes the real elements
that intrude upon Freuds "Little Hans": the real penis as it is experienced in masturbation, and
the birth of Little Hans sister. Such elements will later take on imaginary and symbolic
significance. However, at the moment of their initial entry into consciousness they represent a
traumatic intrusion of the real. Common examples of the real might be a car that seems to come
out of nowhere to cause an accident, or a sudden, and unexpected natural disaster, elements that
enter the psyche but which at least, initially, escape a linguistic narrative. Lacan also links the
real to the concept of matter and especially to the realm of biology, particularly the human
body in its pure physicality (as opposed to its imaginary and symbolic functions).
For Lacan, the real is the primal object of anxiety. Since it is completely unmediated
and cannot be "understood by the subject, its intrusion into experience is traumatic and anxiety
producing. The real need not necessarily intrude upon the subject from the outside, however.
Lacan points out that when an experience cannot be assimilated into the symbolic order, the
real may return in the form of a hallucination. This might occur, for example, as the result of a
trauma that returns to consciousness as flashbacks and intrusive dreams, until such point that the
individual is able to symbolize and thereby assimilate their experience. For Lacan, the real is
both outside and inside the subject (Lacan, 1959). It can be either material or psychical. It is by
no means an equivalent of external reality. The real represents a limit to both imaginary
construction and symbolic knowledge. While at times Lacan seems to suggest that the real can be
assimilated to reason, it most often serves in his psychology as a radical unknown.
For Lacan, both the imaginary and symbolic orders are superstructures that are built upon
a foundation of the real. He will go on to describe neuroses, psychoses and perversion in terms of
the various linkages between these three registers. Further, certain Lacanian theorists (e.g.
Muller) have held that a failure to bind the real effectively is characteristic of so-called
Borderline psychotic states (Muller, 1982).
Because the real is connected with the limits of human experience it becomes a major
concern for psychoanalysis. In fact, Lacan holds that whereas psychology focuses upon
(symbolized) reality, the job of the psychoanalyst is to approach the real. For Lacan,
psychoanalysis is committed to "treating the real by means of the symbolic."
The Unconscious
According to Lacan, the subjects unconscious is fully constituted by his/her insertion in

the symbolic order. As we have seen, according to Lacan, the unconscious has the structure of a
language. Its elements are organized according to particular laws which Freud denominated
condensation and displacement and which Lacan refers to as metaphor and metonymy. The
language of the unconscious is always revealed in speech, the arena of spoken language. This
speech is what Lacan calls the chain of signifiers. It is not a reflection of the language in which
the child lives and also the tongue spoken to the child by its mother (Nasio, 1998). Lacan names
this particular language, la langue.
As we have seen, aspects of the unconscious are formed even prior to the childs birth.
This is because even before the child is born he is assigned a place in the world of language.
While his mother is expecting him, carrying him in her body, the parents symbolize the child in
their minds, give him/her a name, and ultimately, the child comes to carry the burden of the
parents expectations regarding their own desires and even those of their own parents. As such,
the parents signifiers are projected onto the child at the time of his birth. By the time the child
learns how to speak these signifiers have had their impact upon the childs unconscious. This is
what Lacan refers to when he says the unconscious is the discourse of the Other. It is important
to point out here that the signifiers in the unconscious are not an already formed chain of words
with a given meaning; rather the unconscious is always something that is actualized in speech, or
in a dream according to metonymic and metaphoric processes one signifier taking the place of
another (metonymy/condensation) or one signifier being replaced by an adjacent one in the
associative chain (metaphor/displacement).
The role of the analyst is to listen for these key signifiers and to be in tune with the
patients discourse. For Lacan, as for Freud, free association is the main tool for accessing the
unconscious; the signifier moves constantly as free association proceeds. In Lacanian analysis
the affects or emotions of the patient are also treated as signifiers. The complaint that a patient
shares regarding her husbands aloofness may in fact reflect her current marital situation;
however, the analyst may be listening to the marriage of the patients parents.
Jouissance
Lacan elaborates upon the concept of the function of the pleasure principle that Freud had
discussed in 1920 (Freud, 1920). According to Freud, it appears that most of our symptoms tend
to repeat in a constant search for pain that contradicts the principle of constancy, according to
which the psychic apparatus tends to reduce the tension to a minimum or to keep it as constant as
possible. Freud, in Beyond the Pleasure Principle, recognized that interpreting the meaning of a
symptom to a patient does not end his or her suffering. There appears to be an investment that
many patients have in maintaining their neurosis.
Freud believed that in order to explain such therapeutic failure he needed to go beyond
the pleasure principle. Lacan too, takes up this theme by arguing that if people do not learn
from their painful past experiences, continue to engage in self-defeating behaviors, and repeat
negative relationship it is because they have a great investment in their suffering.
Again, Lacan uses developmental metaphors to describe his understanding of what he

refers to as jouissance. According to Lacan, an infant has an enormous amount of energy that is
completely focused upon its own organism. However, as the child grows, he is obliged to limit or
drain that energy from his body in order to conform to the demands of its social environment;
such as weaning, education, rules, and the norms of social life. This environment or as Lacan
calls it (the other) insists upon the systematic inhibition and, ultimately, emptying out of the
pleasure that the child takes in its body. According to Lacan, a portion of the energy
corresponding to this pleasure is trapped in what we call erogenous zones, and a portion of it
comes to constitute the symptom, which can be expressed as bodily or psychological suffering.
According to Lacan, the symptom represents that portion of primal pleasure or enjoyment that
has refused to be articulated and returns, in effect, to make the subject suffer.
For Lacan,. there is a paradox inherent in the pleasure principle as the principle actually
comes to function as a limit to enjoyment; it is a law that commands the subject to enjoy as little
as possible. At the same time, the subject constantly attempts to transgress the prohibitions
imposed on his enjoyment, to go beyond the pleasure principle. The result of this transgression
is not more pleasure, but pain, since there is only a certain amount of pleasure that the subject
can endure. Beyond this limit, pleasure becomes pain, and this painful pleasure is what Lacan
calls Jouissance. According to Lacan, enjoyment is actually experienced most of the time as
intolerable suffering. The energy and feeling that represents a transgression of the symbolic
structure of language, which is almost a pure expression of unconscious drives, is not hedonistic
pleasure, but on the contrary it is an energy that keeps returning to provoke suffering.
How does this process occur? In order to answer this, we must review the idea of Trieb or
the drive. Lacan describes the circuit of the drive starting at the erogenous zone, circumventing
the object and returning to its source, to re-start the circuit over and over again. Lacan underlines
the fact that the drive never appropriates the object, but just goes through it. When the drive is
trapped in the linguistic expression, it becomes a discourse, which is the complaint we hear from
the patient. While manifested in discourse, the drive is to a certain extent, appeased; however it
continues its path to return to the source of pleasure and to re-start the process all over again. The
amount of pleasure produced represents a surplus that the subject cannot tolerate. This excess of
satisfaction is the subject of Freuds essay, Beyond the pleasure principle (1920).
The position of the subject in relation to his jouissance, i.e. his painful enjoyment, is, as
we will see shortly, the avenue Lacan takes to confirm diagnosis.
Need Demand Desire
Lacans theory of desire is central to his conception of psychoanalysis. Lacan situates

his discussion of desire in the context of two other concepts, need and demand. For Lacan "need"
is the biological instinct that drives hunger and other requirements of the organism. According to
Lacan, need is something that human beings share with animals. Need is the basic stance of a
human infant at the time of birth; he or she is completely at the mercy of a caretaker who is
generally the mother but who may be any person or institution responsible for the infants care.
Lacan holds, however, that the power of the motherer actually fosters an experience of
helplessness in the child that goes beyond the one that he/she is born into. This is not only
because the caretaker can appease the babys sensations by producing pleasure. It is, moreover,
because the motherer is a speaking being, immersed in the world of language, that whatever she
hears or senses from the child is mediated through her own interpretation. Soon the growing
infant learns that he must understand what the mother wants in order to keep receiving pleasure
and avoid pain. Further, the mother appears and disappears from the childs immediate
experience, while at the same time speaking to the child and immersing the infant in language.
As the infant becomes attuned to the mothers communications and desires, he learns how to
manage his suffering while she is absent.
The childs basic needs are soon transformed within a relational context via the register
of language. When the child asks his mother for something, the specifics of the request are not as
important as the nature of the mothers response. According to Lacan, the childs need-driven
requests are transformed into a demand for the mother herself. The child will continuously
demand something, which appears to be a request to satisfy a need, but in actuality, is a demand
for love.
Thus "demand" is initially the child's articulation of its needs vocally and eventually in
speech. However, because the "other," (generally the mother) becomes associated with the
fulfillment of the child's demands, she attains an importance that goes beyond the mere
satisfaction of the child's needs. As such, the child's demands become for the mother per se, and
with this his demand becomes a demand for the mother's love. However this demand for love
cannot be completely satisfied. Even if the mother fulfills all of the child's needs, there is still an
excess of demand for the mother's love.
According to Lacan, while a need can be completely satisfied, a demand is always a
demand for an object that cannot be supplied. Children demand continuously, not because they
need something, but because they are demanding love. However, according to Lacan, the child
pushes its demands to the point where the mother cannot meet them, and in this way learns what
the mother cannot give. At this point demand becomes the opposite of need. This is because,
according to Lacan, the child is actually demanding his own separation, and in order to
accomplish this, he/she places impossible demands on the mother. In this way the child proves to
himself that his motherer cannot provide everything, and it is in this way that he will, on Lacans
view, begin to identify his own desire.
That which constitutes the childs excess demand and that which can never be completely
satisfied is what Lacan calls desire." The reason why children are so demanding is that it is only
through demanding the impossible that they can begin to understand what it is that they
themselves desire.
Thus, for Lacan, desire takes form when demand becomes separated from need. It is the
nature of desire that it can never be satisfied. Whereas need can be satisfied, with the result that it
ceases to motivate the subject, desire can never be fulfilled and, according to Lacan, desire seeks
to perpetuate and reproduce itself in a nearly infinite "chain of signifiers," as the subject
continuously displaces his desire onto new objects that he mistakenly believes will fulfill
him/her. Thus from the concepts of need and demand Lacan derives the concept of desire, which
for him is the mark of the subject and the arena in which analysis does its fundamental work.
The difference between demand and desire is important in clarifying certain issues of
diagnosis. For example, an anorexic young woman who has decided not to eat satisfies a desire
that goes beyond the demand of her mother. This position of the daughter, with a symptom that
represents a refusal to eat is the expression of her desire; she wants to eat nothing. According
to Lacan, desire is always unconscious, and is to be contrasted with a wish, which is something
that we want consciously. Desire is equivalent to the process of distortion that converts a wish
into a particular image. Desire dominates our lives and sets us apart from the animals. Desire,
according to Lacan, is another word for lack, that which is the missing object of desire. Desire
changes objects that are also revealed in dreams and slips of the tongue; that is why in
psychoanalysis it is less important to listen to the content of a phrase than to the particular words
chosen by the patient.
Lacan holds that man's desire is "always the desire of the other." This famous phrase has
a number of meanings, which according to Lacanians are complementary. One does not desire
the other as an object to be possessed, but rather as a subject who reciprocates one's own desire
in love. Lacan illustrates this view that desire is for the desire of the other in his description of
the first time of the Oedipus complex, where the child desires to be the phallus that is the all-
fulfilling object, for the mother.
Another meaning connected to the desire of the other is that our desire is always for
that which is desired by others; it is the others desire that makes what we desire desirable. A
third meaning is that desire is always for something other than what we have. In fact, Lacan tells
us, one cannot desire what one already has. While the objects of desire constantly escape the
subject, desire can be articulated in speech, and for Lacan the purpose of analytic treatment is
this very articulation.
To summarize: a need belongs to the biological realm, to sensations of the body and
refers to something that can be given (like food, warmth), demand is always for an object that
cannot be given (this is what neurotics do all the time, they demand from the other endlessly).
Desire is for an object that sometimes can be reached but because of its metonymic essence,
once achieved, it is no longer desired and another object takes its place. To take a mundane
example, we want to own our dream home and surmount many difficulties to obtain it; however,
once we have it, something else becomes our desired object, we even forget how important the
house was for us.
For Lacan the subject is always alienated from his desire. According to Lacan, it is not
only the illusions of the mirror stage that alienate the individual from his own desire (by making
him believe that he is something that he is not), but the entire symbolic order that envelops the
subject in its network of language, rules and communal structures. The symbolic order is
therefore another source of the subjects alienation. However language, which on the one side is
a source of alienation, also provides the avenue for a partial escape from the network of
symbolism that threatens to dominate and obliterate the individual subject.
Lacan holds that desire is continuously being displaced into a symbolic demand. The
subject is continuously attempting to articulate his or her desire. However in doing so he moves
from one demand to another, from one signifier to another, each of which is meant to fulfill the
lack or want-of-being at his core, and each of which he futility believes will be the answer to his
own desire. Human life becomes a chain of demands as the subject moves from signifier to
signifier in a vain effort to fulfill himself. According to Lacan, the ego is intrinsically related to
this metonymy of desire, as the individual's identity is continuously linked to each of the
demands she makes in an effort to fulfill herself. In addition to seeking a material fulfillment for
its demands, the ego seeks fulfillment in the other. Learning to recognize and to speak of the
essential gap in ones being, of the futility of ones succession of demands, is a condition for
psychoanalytic cure.
Diagnostic Considerations in Psychoanalysis Lacanian Views
Lacan takes seriously the question of what makes for a psychoanalytic diagnosis in
contrast to a medical or even psychological diagnosis. The question was posed by Freud himself,
as he realized the contradictions inherent in the problem. We use a diagnostic framework to
make decisions regarding treatment; however, diagnosis evolves during the course of treatment
and in the process, a very different picture may emerge.
In order to make a medical diagnosis, the examiner has at his disposal technical and
biological instruments that allow for the collection of objective data (MRI, blood samples, X-
Rays, etc). This type of assessment leads to a classification of diseases that includes a wide range
of pathologies. A medical doctor can then, establish with a reasonable degree of certainty the
presence of a particular illness.
The psychoanalyst, according to Lacan, has only one instrument: his/her listening skills.
Although the patient can relate a history of suffering in a convincing manner, his speech is
saturated with the fantasies and deceits that underlie all human communication. Even when the
subject wants to be honest, Lacan asserts that he is always blind to his suffering. What he or
she says cannot be taken at face value for diagnostic purposes. The direct observation of a
patients symptoms is unavailable as well.
Lacan agrees that diagnosis and treatment are interconnected. Thus, in order to be
consistent with a psychoanalytic approach Lacan suggests that diagnostic inferences and
treatment interventions are to be suspended for a period of time during the initial interviews with
a potential patient, and no contract between patient and therapist should be formed until after a
series of initial sessions.
Lacan approaches the problem of diagnosis through an extensive series of preliminary
interviews, where the analyst allows him or herself to wonder about the patient, to allow a
transference to be established and, most importantly, to listen to the unconscious at work.
Lacans preliminary interviews are considered a trial period in which the work of the patient is to
produce speech, i.e. to speak of whatever he wishes to speak about. The beginnings of a
diagnostic picture will be drawn primarily through the analysts careful listening to the patients
choice of words rather than through the content of the patients discourse. From the utterance of
the patients words a particular structure will appear. One question that underlines and directs the
importance of the analysts attention is, What is the position of the subject, in his discourse? or
What position does he occupy in relationship with his desire of others?
Lets examine an illustrative example. A patient, (a fashion designer) at the beginning of
her analysis makes the following statement: I believe that it is possible to be a man and a
woman at the same time. We listen to that statement from the Lacanian diagnostic premise:
Why did she utter these particular words in the form of a statement that expresses her presenting
problem to the therapist? What is the position of the subject in her discourse? On first
observation, she enunciates a clear ambivalence at the level of gender, and following her words,
something that reminds us that choosing to be something also implies losing what is not chosen.
We can start thinking that the patient has an issue in the realm of the imaginary, in her struggle to
be one or the other. We suspend judgment here to find out more from her own account. In a later
session, she discusses her job and she says that her work is to produce an image of a woman and
she keeps thinking of the image of a pregnant woman that imposes itself on her drawings more
than any other image, in spite of her believing that it is not a marketable idea. How is it that she
came up with this choice of words and images? Does her mother populate her thoughts by being
together with her? Is her image of a male/female fusion the way she resolves the issue of sexual
difference? It appears that the direction of her treatment will be directed to a problem that is
connected with her image, perhaps the way her mother saw her. It is interesting how in clinical
work we can almost see the way the words trace a circle around the major, unconsciously
determined, structural issues. There are a multitude of words that she might have chosen to
express her concerns; however, we create hypotheses on the basis of the language she chooses to
express her suffering.
Structure and Diagnosis
Psychic causality is very difficult to determine since its laws, if any, are not, according to
Lacan, manifest in fixed, and predictable ways. Even when we are aware of the subjects
dynamics and we understand his intrapsychic and interpersonal vicissitudes we cannot make an
immediate logical correlation between his psychic structure and the nature of his psychological
symptoms. Our clinical practice shows us that psychopaths have sadistic behaviors without
possessing the structure of perversion, and even an obsessive-compulsive personality can have a
strong histrionic component in his presentation, yet remain essentially obsessive in his structure.
Therefore, we are not justified in making a diagnosis based on symptom manifestations.
Lacan modifies Freuds famous phrase about dreams by calling speech the royal road to
the unconscious. This formulation allows us to understand Lacans statement that his theory is
essentially a return to Freud. The psychoanalytic experience finds in the unconscious the
whole structure of language (Lacan, 1954). Lacan, like Freud, holds that symptoms, are always
overdetermined, that is linked to the primary process, via displacement and condensation. Lacan
states, A symptom is a metaphor, a signifying substitution and a metaphor is a signifier that
stands for another signifier which represents the subject (Lacan, 1954). The chain of
associations continually substitutes one signifier for another in the very manner Freud had
described in his Interpretation of Dreams (Freud, 1900). The choice of words is left entirely to
the fantasies of the subject. And no matter how clear a subject is in his communication, the fact
that he utilizes language and must choose one form of expression rather than another, assures
that he will be misunderstood. As Lacan constantly reminds us, we, as subjects, are alienated by
language.
So, if the symptom has no fixed meaning, what is the analyst relying upon? He/she is
relying upon listening and observing the way the subject handles his desire, which will reveal a
particular psychic structure. This operation occurs in the presence of the analyst, as desire is put
in motion in the transference.
Lacans understanding of the transference is one of his unique contributions to
psychoanalysis. The analyst is invested by the analysand with what Lacan designates as the
place of the supposed knowledge, in which the analyst is presumed to know the causes of the
patients pain. This supposition, which exists only in the mind of the analysand, is, according to
Lacan, the motor of the transference in analysis. This is an interesting observation in light of
Lacans insistence that the analyst has no special knowledge to give to her patients. According to
Lacan, this paradox exists in all human relationships, parents and children, lovers, teachers and
students, etc. One supposes that the other has something to give. Lacans view here is
particularly opposed to the common idea of a psychoanalyst as someone who objectively has a
particular expertise on psychic problems and moreover, as a model who the patient can emulate.
It should be clarified that Lacan does not believe in the concept of mental health or
normality, but like Freud, holds that all individuals exist in varying degrees of disease. For
Lacan, disease is not something that happens to living things but is the very condition for life.
There are no normals to be contrasted with, but a variety of pathologies. On Lacans view
everyone is neurotic, psychotic or perverse. These three categories are essentially those that were
formulated by Freud. According to Lacan, the subjects desire is involved and expressed in
different ways in each of these structures. Throughout the interviewing process, through careful
listening of what is said, the manner in which it is said and, moreover, what is not said, the
analyst follows the subjects own desire, in order to induce the patients cause of his desire, his
efforts to have his desire fulfilled, and the factors that stand in the way of that fulfillment.
Lacan conceptualizes the three main categories of diagnosis through the particular
mechanism of negation that determines what he calls the position of the subject, rather than
through a classification via symptoms. The mechanism of negation functions differently in
neurosis, psychosis or perversion. Lacan leans in part on Freuds description of repression in the
neurotic versus disavowal in the pervert. Lacan describes a third mechanism of negation in the
psychotic, which he terms foreclosure, and which, for Lacan, represents the impossibility of
accepting or rejecting that which is negated. This method of arriving at a diagnosis, i.e., by the
way someone negates something, is the single defining characteristic of Lacanian diagnostics.
(Fink, 1997).
Lacanians do not look favorably upon the multiplication of categories and subcategories
that continues to grow in the American psychiatric literature on diagnosis. This system utilizes
literally dozens of pathological categories such as dysthymia, polysubstance dependence,
panic disorder, etc, each of which can be combined with other features such as personality
traits, psychotic traits, etc, in specifying a diagnosis. This is essentially the system adopted in the
various editions of the DSM. The method that psychiatrists use in order to make a diagnosis is to
break down each part of a patients presentation into its constitutive parts and then bring them
back together to form a syndrome. Lacan is critical of this tendency of the medical model that
arrives at overly specified diagnoses by considering human beings as mechanisms which can
then be treated with mechanically designed and approved remedies. Lacans conceptualization
of psychopathological structures is far broader. Although the number and presentation of
symptoms can vary throughout the life of a person, their essential structure does not change. For
example, a man may be diagnosed as a substance abuser, and this diagnosis is evident in the fact
that he uses certain drugs with a particular frequency, etc.. However, if we conceptualize his
psychic structure as that of an obsessive, then we understand that the role played by the drug use
in his adult years may be the same as his defiance in early school years, and his controlling
approach in his relationship with his employees and wife.
Psychosis
For Lacan, the psychic structure that refers to psychosis is produced by foreclosure of the
Name-of-the-father (Lacan, 1955). As has been elaborated in previous sections, this refers to the
absence of the symbolic function of the father. Foreclosure involves the rejection of the
particular element that, on Lacans view, anchors the entire system of the symbolic order for the
individual. The paternal function does not refer to the real person of the father but rather to that
which is symbolized by the fathers name, which can be effected in the presence or absence of
the real father, which can be carried out by another person who is not the father of the child, and
which can even function beyond the death of the father or his disappearance. Indeed, the paternal
function can even operate with only a name, as an authority and as the carrier of the law of
prohibition. For example, a child who never met his father but carries his name will have a
mark of the father. Later interpretations made by his mother and family about his father can re-
signify the name of the father; however, the child knows he carries that name and the name
situates his place in the family and society as a whole. As we have seen, the paternal function
involves separating the child from the mother when the childs independence is threatened by the
mothers desire or by the perception of the child that he is everything for the mother.
Although cultural norms differ and change over time, and with them the role of the
father, Lacanians hold that it is universally the case that a restriction, the fundamental function of
no must come from a third element that is inscribed beyond the relationship between mother
and child.
When Lacan discusses the paternal function in relation to psychosis he holds that it is an
all-or-nothing occurrence, in the sense that the paternal metaphor either enters into the childs
language as a symbolic function or does not. There is, on this view, no room for borderline
structure, a claim that we will examine carefully in later chapters. Psychoanalytic treatment can
help to make psychotic symptoms recede but, for Lacan, there is no cure for psychosis.
Lacanians assert that an individual either has a psychotic structure or does not, and even those
who have their first psychotic break later in adulthood have always been psychotic, and further,
there are those with a psychotic structure who often remain undiagnosed by virtue of never
having had an overt break.
It is helpful to make a clear distinction between the real father, the imaginary father and
the symbolic father in the theory of Lacan. The real father is the father here and now, the one
who is the actual, biological father. However, this real father is never the one who operates
directly in the course of the Oedipus Complex; this is the role of the imaginary father. The child
does not grasp the idea of a real father until much later; what he receives is the imaginary father,
a paternal imago which reflects the childs experience of the father according to his imagination,
coupled with the idea of father given by the mother, via the way the mother speaks of him.(Dor,
1987). According to Lacan, the symbolic father is a signifying effect within the oedipal dialectic
that produces a new structure: a child inscribed in castration and therefore, in the world of
language, of signification. Lacan uses a particular linguistic image to indicate the function of the
paternal metaphor, in which the symbolic father overrides, for the child, the desire of the mother:
Name of the father

Mother as desire
So far we have seen that the real father has no (direct) implications in this process; in
some ways it is irrelevant if he is present or not, if he is deficient or not. Issues pertaining to the
real father do not affect the entrance of the child into the symbolic order. This is because it is
only the father who is imagined and signified that enters into the childs psychic structure. Thus,
it is the relationship of the child with the imaginary or symbolic father that will have important
consequences. What is structuring for the child is that his father is the origin of the childs words,
and that the child is able to fantasize a father. Lacans observations with respect to the paternal
metaphor is that as much as this function regulates certain aspects of life from sexuality to
responsibilities and obligations, the law of the father is also fairly distributive. This means that
while the father signals what is his, he also signals what belongs to his child. While the father
may deny something, he gives something else in return.
Lacans insistence on the primacy of the imagined over the real father in the structure of
psychosis would seem to close off hypotheses regarding the absence or failure of actual fathers
in the etiology of psychosis, and, by extension, borderline states. However, without questioning
Lacans view that it is the childs signification and experience of the father imago that is relevant
to his theory, we can say that his view implies that the absence and/or behavior of actual fathers
will impact upon the development of psychotic (and other psychopathological) structures. One
reason for this is that the actual father provides an occasion or opportunity for fantasy and
signification. It would not, in my view, be a stretch to argue that Lacans theories suggest certain
empirical hypotheses: one of which is that, all other things being equal, absent, malevolent or
inadequate fathering may contribute to psychotic structure.
Returning to our discussion, the question arises; what are the tools that Lacanians rely
upon to confirm a diagnosis of psychosis?
Although the best indicator of psychosis in American psychiatric circles is always the
presence of hallucinations, Lacanian analysts suggest that the presence of hallucinations is not
definite proof of the presence of psychosis. In fact, hallucinations are a form of primary process
thinking, used very early on by the infant and which play an important role in ordinary
daydreams, fantasies and dreams. Further, it is important to differentiate between true
hallucinations and voices and visions that non-psychotic people have. Such individuals, although
reporting a vision or having heard someone who was not present, may be surprised and wonder
about these phenomena. Fink (1988) reports on a patient who believed he saw his ex-wife at the
end of a corridor in his home. He was surprised but at the same time questioned this vision,
thinking that he had to have noticed her entrance or the possibility that he let her into the house.
He did believe he had a vision but did not believe in its content. This example recalls Froschs
patient (discussed on chapter I) who felt the floor tremble and asked her neighbor about it, but
who later postulated that this trembling was a projection of her own orgasm. In both Finks and
Froschs cases, the patient hallucinates but is able to recognize the phenomenon as part of his or
her psychic reality. In spite of the hallucinatory symptom, the capacity for reality testing is intact,
and the diagnosis of psychotic structure is not substantiated.
Further, many hysterics have the most elaborate fantasies that are so hypercathected that
they appear to be real; they see and hear things that are not present to others and experience them
as if they were palpable. (Indeed, the diagnosis hysterical psychosis was at one time quite
widespreadsuch patients may be classified today as dissociative disorders). However,
according to Lacan, in the end, the hysteric will be doubtful about the veracity of his experience,
which again speaks to her intact reality testing and the ruling out a psychotic diagnosis.
Therefore, the symptom of hallucinations and the whole question of reality is not a
foolproof guiding principle for diagnosis since it is difficult to distinguish socially-constructed
reality versus psychic reality. For Lacan, the characteristic most salient in psychotic thinking is
that of certainty. The psychotic patient is certain that reality in the form of a thought, vision,
noise, etc, has a meaning and that the meaning involves her or him. The psychotic thought is
without error or misinterpretation. Statements such as; My wife is trying to poison me, or The
CIA is reading my thoughts are found in psychosis, and are made without hesitation or doubt..
The certainty of their statements is irreversible for the psychotic. On the other hand, hysterics
and obsessives always doubt. Doubt is a characteristic of a neurotic process.
In sum, when hallucinations are reported, the clinician has to explore this phenomenon
conscientiously, if there is no conclusive evidence one way or another, other criteria should be
employed.
These other criteria are focused around language disturbances. Lacan goes so far as to
say, Before making a diagnosis of psychosis, we must make sure that language disturbances
exist (Lacan, 1955). He states that the psychotics relation to language is quite different from
that of a neurotics. In order to fully comprehend this assertion it is important to again think in
terms of the registers mentioned earlier, the imaginary, symbolic and real. As described above,
the imaginary register is the first structure that organizes the chaos within which the child lives
(i.e. his fragmentation, uncoordinated perceptions and sensations). As we have also seen, this
register provides an image of the self that is invested libidinally by the child... Later his parents
and other caretakers will provide a better definition of this sense of self, yet one that is still not
developed to the point where the child becomes capable of uttering the word I. The symbolic
order, on the other hand, actually pre-exists the child, as he is immersed in it by being subjugated
to his parents language. The language of the parents, their approval of and recognition of the
child, through their gestures, voice and words, ratifies his mirror identification. The earlier
formation of the mirror stage, which represents a somewhat primitive organization, is finalized
through a symbolic act that comes from outside the child. (Lacan, 1955). This supremacy of the
symbolic over the imaginary is instrumental to the formation of subjectivity. Where aggresivity
and rivalry were the main affects in the imaginary order, in the symbolic order the child is
organized around different criteria: guilt, law, performance, achievement, etc. The symbolic
order is linked to the castration complex, which, according to Lacan, initiates this new order for
the child. On Lacans view, this initiation occurs in neurosis and perversion but not in psychosis.
In psychosis there is no symbolic process overriding the imaginary order, therefore, the
psychotic person lives in an imaginary world where even language is imaginarized. For the
psychotic, language is not assimilated but rather imitated. The idea of foreclosure of the name
of the father is rooted in the notion that the psychotic has no chance to reject or accept a
symbolic function, for there is no precedent for him to even consider. Freud discussed this
process in relation to the concept of ego ideal; as the child internalizes his parents values and
expectations, he himself sees his actions in accordance to what his parents have seen. Without an
ego ideal to rely upon, the individuals self-image is fluid, transient and ephemeral.
Therefore, with the establishment of the symbolic order several interrelated factors are
put into motion: the function of the paternal metaphor, the overriding of the imaginary world, the
separation of the child from the mother, the creation of desire (for that which is prohibited will
be desired), and the immersion of the child in the world of language. According to Lacan, the
paternal function ties a knot amongst the three registers of the real, imaginary and the
symbolic, i.e. between the fathers law and a specific meaning to particular words (socially
constructed reality). If this does not occur, if this initial knot is not tied, the individual will have
no anchor point in a public language; indeed he will create his own language, leading to the
language disturbance that is evident in psychosis. Psychotic patients will have difficulty
producing a whole sentence, as they will be unable to punctuate, anchor and convert the chain of
signifiers. The anticipatory and retroactive movements involved in producing meaning (that is,
the possibility of the metaphoric substitution) are absent in the psychotic person. Words become
things (Fink, 1999).
Neologisms are the most salient evidence of psychosis. The formation of neologisms in
psychosis replaces the metaphoric function, by creating new words with an idiosyncratic
meaning known only to the psychotic himself. Thus these terms do not refer to others in
language; we cannot infer any meaning by association or contiguity. They are untranslatable.
Among other criteria of psychosis, Lacan discusses the predominance of imaginary
relations. While the neurotic generally has conflicts derived from his struggle with the symbolic
order, such as conflicts with parents or other authoritative figures, social expectations or issues of
self-esteem, the psychotic typically presents with conflicts related to someone approximately
their own age usually in the figure of a peer or a lover. The issue for the psychotic is not manifest
in terms of obtaining parental approval; rather, according to Lacan, psychotics have the
experience that someone is usurping their place. The phenomenon of paranoia is typically
encountered in psychosis as a type of imaginary relationship. Lacan holds that because there is
no true access to language the psychotic is directly related to the imaginary world. However,
while this relation to the imaginary is an important feature of psychosis, a positive diagnosis is,
according to Lacan, only possible when language disturbance is present.
One interesting aspect of Lacans theory of psychosis relates to the notion of the drives.
Whereas the neurotic organizes his libido, refocusing it from his body as a whole to his
erogenous zones, the psychotic feels invaded by libido, his body is taken over by it. This,
according to Lacan, touches upon the register of the real. We have seen that, according to Lacan,
as we enter language and the process of socialization is initiated, our body slowly gets emptied
out of its libidinal contents. The body is literally, as Lacan puts it, overwritten with signifiers,
biology is for the most part lost, only maintained in the erogenous zones. In the psychotic person,
however, we can usually hear in our clinical work the extreme sensations of the body, the
ecstasy of the body or the unbearable pain in the body for which no medical problem is found
(Kaplan H., Sadock B, 1994). This lack of hierarchy in the drives organization is a result of the
failure of the symbolic order, and is, according to Lacan, also associated with a lack of morality
or conscience. This means that the psychotic is prone to, in the face of any slight provocation;
express his or her lust or aggression overtly. Because there is no repression, guilt is not present in
these patients and when they are hospitalized for a criminal act towards others they do not feel
genuine guilt for their actions.
Another symptom that is present in psychotic men is a slow process towards
feminization. Schreber (Freud, 1911), the paranoiac who Freud discussed in his initial study of
the psychotic process, initially related how the rays of God were penetrating him. This thought
evolved into the belief that he was the wife of God. In clinical practice some psychotic patients
claim to feel like a woman and they sometimes request sex change surgery. For Lacan, the
attitude of the father towards his son is to delimit a space for the child, in a distributive way, by
giving himself certain rights and bequeathing others to the child. This important aspect of the
paternal function does not occur in psychosis. A father may act in an authoritarian, antagonistic
or aggressive manner towards his child. He could also be an all-demanding father whose sons
behavior is never good enough and who is unable to set limits for himself or his children. At this
point the child may take the feminine position before this dominating imaginary figure,
especially when no triangularization is possible. If and when the patient later becomes psychotic,
he may feel that this feminine position is imposed on him. Therefore the presence of
feminization appears to be the result of identification with an imaginary father but not a symbolic
one. Although this feminization may take place in a neurotic person as well, it is usually
intermittent and of short duration, whereas the psychotic person feels invaded by a feminine
identity that he cannot escape.
A final note on the issue of diagnosis in psychosis is provided by Lacan in his discussion
of the absence of self-questioning in psychotics. While neurotics ask themselves about their
desires and those of others and they change in the course of therapy, psychotics are
characterized by inertia of movement, in their thoughts and interests in general. The psychotics
phrases are always the same, presented in a cycle of repetition without end. Lacan adds, where
repression is missing, desire is missing as well (Lacan, 1953). The failure of desire is seen in
the failure of movement in the psychotics language.
Neurosis
For Lacan the defining mechanism in neurosis is repression. Further, according to Lacan,
primary repression effects an individuation of the unconscious in the individual subject. As
mentioned above, the fort-da, or the naming of the childs demands in words, are interpreted
by Lacan to perform the function of filling an absence with words. At that time the unconscious
is constituted in a singular way for each particular individual. The child inserts himself in
language, in the Other, where all signifiers exist, and positions himself in the discourse.
However, in this immense world of signifiers, some things escape the child, things that remain
outside of signification, as he/she cannot control all language. Therefore, the position that the
subject occupies allows him a place but also represents a loss, one that is tied to the lost promise
of being the phallus of the mother, the object that will be lost forever. According to Lacan, this
object never existed, but throughout life we keep looking for it. This loss is what he denominates
primary repression. From this moment on, other things will be repressed by association,
provoking an excess of pleasure, a most painful pleasure, that is beyond the pleasure principle,
a pleasure that is at once sexual and traumatic and about which the patient consistently
complains.
In contrast to the psychotics foreclosure where a thought or a perception is never even
granted entry, in repression (which characterizes neurosis) reality is initially affirmed in some
way and is later pushed out of the realm of consciousness. According to Lacans reading of
Freuds (1915) On Repression, the unconscious is formed by thoughts that can only be
expressed in words or signifiers. Repression impacts upon the connection between thoughts and
affects, and this disconnect is the source of neurotic symptoms; for example, the neurotic may
experience emotions that he cannot link to any knowledge; even his own rationalizations fail to
explain his emotions. However, the different neuroses have specific modes of repression. For
example, hysterics have an overabundance of feelings without thoughts, whereas obsessives have
a profusion of thoughts that evoke no feelings. Repressed thoughts and affects reveal themselves
in what Freud denominated the return of the repressed (Freud, 1915), which, for example, in
the conversion symptoms of hysteria, may be expressed as bodily symptoms
For Lacan, all neurosis is rooted in the symbolic order. The more interesting question
from a Lacanian point of view is the differentiation of one neurosis from another. According to
Lacan, since all neurotic symptoms, even those that appear to be somatic, are governed by the
laws of language, the key to distinguishing neuroses is to understand how the neurotic is
linguistically or significantly situated in connection to what he calls the locus of the other. This
locus refers to the fundamental fantasy of how the subject positions himself in relation to the
other in the imaginary realm. Lacan writes a formula to depict this relationship: ($ a) where the
barred S denotes the division of the subjects unconscious and conscious experience, the a
stands for the cause of desire (in the other, in French autre) and the diamond is the
relationship between them. Lacan utilizes this formula to clarify how the subject imagines him or
herself in relation to the Other. Hysteria and obsession can be defined as radically different ways
in relation to the Other. (Fink, 1997).
In analysis, the analysand is always recreating his or her fundamental fantasy in relation
to the analyst, by pleasing the analyst, making her anxious or neglecting her, etc. and in this
transference the patient always recreates his position in his fundamental fantasy. According to
Lacan the individuals reaction to separation from the primary object constitutes his/her
fundamental fantasy and as such constitutes the basis of Lacanian structural diagnosis.
Lacan describes three sub-categories of neurosis and thus three fundamental fantasies:
hysteria, obsession and phobia.
Why is it that there arent more than three categories?
The positions of the hysteric, obsessive and phobic, that we are about to describe are,
according to Lacan, simply the three positions that clinical experience has shown analysands take
up in the transference. Psychoanalysis is concerned with the position of the analyst in the
transference as a means to orient the interventions with different patients. Further, Lacan studied
and worked with these three fundamental neuroses in a manner that neither Freud nor other
analysts had ever done previously. Lacanians have long affirmed that these three categories are
extremely useful in clinical work and that there is no need for further classifications.
The Hysterical Structure
In Lacanian practice, in order to diagnose a structure we need to assess the subjects

economy of desire, his position in the discourse (in relationship to the others and the analyst) and
the problematic of the phallus for each particular individual. As we have explored in our
discussion of Lacans theory of the Oedipus Complex, as long as the mother can realize the
presence of the father and let him lay down the law, the symbolic father will be established as
the vehicle through which the child is brought to the third and final phase of Oedipus, what is
termed the register of castration. The child will then realize that not only is he not the phallus
of the mother, but that he does not possess it, and cannot, therefore, be an all fulfilling object for
her. The possibility of castration is based on the idea that someone has it and someone does
not have it. This quest for the possession of the phallus, this idea of having it, is the quest of the
hysteric. The hysterics assumption is that he/she has been unfairly deprived of the phallus and
must re-appropriate it. Although sexual difference is an important determinant of the way
hysterics behave, (e.g. being a woman who pretends to be a man, or a male hysteric who is
unsure of his virility), both male and female hysterics have the same fantasy: the conquest of the
phallus.
Thus, the other, the one who is supposed to have it carries the enigma of what the
hysterics desire entails. This other serves a very important identificatory function and is the key
to all meaning that emerges in analysis. When Dora pursues Mrs. K, in the famous case of
hysteria analyzed by Freud, (1905) what she wants is the answer to the question: what does a
man want from a woman? This question presupposes that Mrs. K knows the answer, that she has
the key to the enigma of what constitutes a woman, and it is on this tacit assumption that Dora
pursues her endlessly. The hysteric makes herself into the object of the others desire so she can
master it. It is important to note that the hysteric can also take the position of the male partner
and desire as if she were him. Many hysterics find themselves in love triangles in which they
identify with the mans desire and thus, desire the other woman. The quest is always to
complete the object of their desire. That is why the hysterics main question has something to do
with sexual difference. Am I a man or am I a woman? This question has a direct connection with
the dual identification of their desire. In the case of a satisfied couple, the hysteric always finds a
way to provoke a desire for something else that her partner does not have. It is a typical scenario
to hear a hysteric speak about the highlights of her partners life: his achievements, his looks etc.
This characteristic is a subtle way of shining through the other, by displacement. Hysterics are
capable of self-sacrifice and self-abnegation in order to fulfill what they imagine as the others
desires. Therefore, we can encounter hysteria at the level of being the phallus for the others
desire, or having the phallus by identifying with the male partner.
This position appears to be a reflection of an earlier residue in hysterics relationship with
their mothers. Hysterics always feel that they have not received enough from their mother and
this comes through via their identification with the phallus; instead of being an ideal object
worthy of total love, they see themselves as devalued and unworthy objects. Their sense of
identity is always deficient and unfulfilled. The search to become the perfect object is always
present, and as a result of this stance, the hysterics desire is always unsatisfied. The ideal object
is an impossible object, but the hysteric never ends the cycle of aspiring to be one. Therefore all
of their efforts tend to be drawn towards a phallic narcissistic identification as a way of avoiding
the issue of castration (or the lack thereof). When they put on a show, they put themselves in
the others gaze as the embodiment of the ideal object (Dor, 1997).
This is the most important aspect of hysteria. They are to be the cause of the others
desire (Seminar IV) by identifying with this perfect object (the phallus). This position assures
that the hysteric will forever be linked with the mother. Throughout his/her life (and within the
psychoanalytic transference) the hysteric will maintain a posture of being the pleasing object for
an Other imbued with knowledge and power. The phallus could be represented in the arena of
the image, or through their speech or in their bodies. The way they do this, the hysteric
method, is to keep the other in suspense, to delay their satisfaction, to produce an enigma. The
hysteric always manages to keep the other unsatisfied so as to ensure a permanent role as an
object of the others desire.
How does the hysterical woman approach this encounter? Curiously, with ideas based on
stereotypes supported by the culture. This search for the ideal is viewed through the eyes of the
models of beauty and femininity that are purported in the media. In the hysterical woman,
beauty equals femininity and in that sense, she does not spare any efforts, as perfection as it is
culturally defined (i.e. defined by the other) is her goal. The hysteric is very critical of herself
and attempts to erase all of her imperfections. As the ideal cannot be attained, we usually hear
self-descriptions such as I have too little of this, I dont have enough of that, My face should
look like that, etc. As a result, her behavior and speech will reflect a permanent state of
indecision and doubt and at a later date she will voice regrets.
Hysterics are plagued by indecision and doubt. The difficulty the hysteric has in making
up her mind is very acute in relation to a choice of lover. She will pick a lover but continue to be
absent in the intimacy of the relationship, as she needs to remain unsatisfied at any cost. Her
indecision is a reflection of her imperfection, and she will do many things to cover it up, masking
her doubts with the most sophisticated moves: speeches, role playing, clothing, and intellectual
remarks. This is why hysterics appear to be phonies, they have an emotionally labile and
inauthentic aspect. In many cases, she tries to cover up her lack of knowledge as in her mind,
knowledge has to be absolute. Either you know everything or you are totally ignorant. The
hysteric woman will try to gain access to peoples knowledge in various ways, for example, by
becoming an unconditional supporter of the wise one. In this way she imagines that she
overcomes her deficits.
The search for perfection is related to another characteristic of hysteria: the identification
with a woman from which she will learn what femininity is all about. In this case, we have the
emergence of a hysterical homosexuality that is not related to a choice of love object but to an
identificatory process. As a result of this identification, the hysteric wants to think like her, be
like her, love like her, to have her men, etc. as if the other woman has somehow achieved a
perfected state of femininity. Many times the hysteric will steal the other womans man. The
choice of lover plays the most important role in the hysterics life. Perfection is that to which she
aspires, therefore, there is always a man better equipped, more charming, more intelligent than
the one she has.. What is important to address is that the man she pursues is always unattainable;
if she could get him, she would not be interested in him any longer.
In the area of sexual encounters the hysteric has a discourse of claim or demand usually
surrounding phallic potency. This challenge to men usually starts a cycle of continuous
misunderstandings; the man trying to desperately prove his virility and the hysteric constantly
disappointed. The quest of the hysteric is to continuously claim dissatisfaction which, according
to Lacan, actually incidentally constitutes her only pleasure.
It is important to underline a common error that clinicians make when they presuppose
that the hysteric is looking for a man who can be a substitute father figure. According to Lacan,
this is not really the case. Hysterics are looking for a man that is complete, what could be
represented as an ideal father. Usually we find hysterics dating men of importance, full of
knowledge, powerful men. These types of men will make up for the deficiencies of her
imaginary father. Along these lines, it is common to hear the fantasy of prostitution in hysterics
who are in treatment. In the figure of a prostitute, we have a woman who can offer herself for
money to all men, insofar as she can give herself to only one, the pimp. This man does not really
possess any special talent but the assurance of lacking something. He needs her and her money to
be complete. The more she pays, the more she completes him.
The sacrificial position of the hysteric is a very important topic. It relates to the operation
that Freud (1912) referred to as versagung and later adopted by Lacan. Versagung is the
renouncing of that which is the essence of ones self, ones desire. In the name of that
renouncing we constantly hear in the clinical work how people renounce their own pleasure in
favor of that of their children, their husbands, their country, etc. This position allows the hysteric
to keep her desire unsatisfied (many of the protagonists in opera portray this aspect of hysteria
quite well). The versagung was taken by the post Freudians as frustration, however, Lacan sees it
as refusal. The word versagung implies a relationship in which there a refusal of the demand of
another (the root sagen implies saying) (Laplanche, Pontalis, 1987). The term frustration
implies that the subject is frustrated passively, from the exterior, whereas the term versagung
suggests an act of relinquishment. A good example of this occurs in the case of those people who
become ill when they are successful, where there appears to be a mechanism by which the person
refuses the satisfaction of his desire.
As we will see, the idea of sacrifice is noteworthy in the obsessive individual as well. In
the name of his sacrifice he will give up everything to keep his desire impossible and
unattainable. In analysis, we must ask ourselves, what is the subject renouncing when he presents
to the analyst an endless list of possible motives for his sacrifices? What benefits does this
sacrifice have? Lacan answers pure jouissance. It is in the role of the martyr that the hysteric
and the obsessive find the most pleasure. It is not only important to sacrifice but to let the others
know about ones actions; thus the hysteric is continually drawing attention to her sacrifice and
martyrdom.
Hysteria in Men
Hysteria in men is difficult to diagnose because of the way it is concealed by our culture.
On the one hand we have a refusal of the medical community to recognize it, and on the other,
the environment supplies apparently reasonable explanations for mens behaviors. Instead of
looking for explanations within the psyche of a man, external causes are found to explain the
male hysterics behaviors. Joel Dor (1987) states that traumatization (such as war traumas and
post-traumatic stress disorders) are good examples of means for camouflaging male hysteria.
However, from the psychoanalytic point of view, hysteria concerns men, particularly those who
parade their traumatic symptoms as trophies in the eyes of everyone who gazes at them, and later
obtain secondary gain for having them. Lacan will describe a particular group of men who share
similar characteristics that resemble the hysteric presentation. These men exhibit the following
presentation: 1) major outbursts of rage as a result of frustration. Although these frustrations
involve every day events, it appears that these men are prone to exaggeration and pathetic efforts
to call for negative attention. This rage appears to be the expression of some impotency that is
mainly repressed; 2) the presentation of somatic, conversion symptoms and hypochondria. In
contrast to the womens presentation (which usually evokes a part of the body), the mens
complaint is typically directed to the whole body. In every other sense, the position of the
hysteric male resembles that of the hysteric woman, in the effort to obtain or be the all-satisfying
object. Like their female counterparts, hysterical men pursue dissatisfaction and always desire
that which they dont have and which appears so much better in their eyes. Regrets and
complaints regarding what he does not have are plentiful. His pleasure in unfulfilled
satisfaction usually sets the stage for self-defeating behaviors, which are typically manifest in
the hysterics professional activities and love relationships. A belief in his incapacity also leads
him into trying to compensate for his impotence by using alcohol and drugs. In the context of
male hysterics, these substances provide a compensation for a sense of not feeling adequate as a
man. Under the influence of alcohol the hysterical male feels more at ease picking up women or
ridding himself of a male competitor.
In the area of sexuality, hysteric men (as hysteric women) place the feminine other in an
idealized place that is totally unattainable. Further, they never experience women as desiring
subjects, but rather view them as challenges to their virility. Therefore, the hysteric male avoids
women as much as possible, hiding behind a mask of homosexuality or impotence. This type of
hysteric male men is not a true homosexual since his choice is not for a male love object but is
rather based on an avoidance of women. In the case of impotence and in the related cases of
premature ejaculation, we have a subject who confuses virility with desire (Joel Dor, 1987). In
psychic terms the confusion is based on equating the phallus with the penis (the organ) and the
impossibility to be the phallus leads him to present himself as not having a functional penis.
There are several typical cases that Lacanians conceptualize as hysteric men: one is the playboy
or Casanova. This man searches for one woman after another as trophies that he shows off to
everyone, in particular, other males. Clinical work with these men reveals that they are generally
impotent with the women they select, in part, because the only women who can mobilize their
desire are their mothers and in part as a function of their rivalry with other men (who in their
mind possess the phallus). In the eyes of the others, they are really manly men but in the
intimacy of their bedroom they cannot satisfy a woman (which in their mind is the phallic test
they are suppose to pass or fail).
Obsessional neurosis
Although it appears that most obsessive neurotics have a special or privileged

relationship with their mothers, it is important to underline that this perception is not entirely
correct. When we take into consideration the oedipal vicissitudes and the position of the four
elements of the process: mother, child, phallus and the father, we can understand the way the
obsessive has arrived at a resolution of his own that carries the mark of obsessive traits: an
emotional distancing from all relationships.
Typically, the appearance of the symbolic father should produce an identification with
the phallus in the figure of the father. Only after accepting that a certain place belongs to his
father, the child realizes that he has the possibility to have the phallus someday (in the sense of
having a special knowledge about what can satisfy a woman, whatever that may be). However, if
the mother is enigmatic about her desire, the child may still believe that he can fulfill her in spite
of the fathers intervention. This is the scenario of obsessional neurosis, one in which the child
continues to believe he can be the total satisfaction for the mother. If that would actually be the
case (i.e. if the mother fully colluded in this idea) we would have a perversion instead of a
neurosis. In obsessive neurosis, the mothers desire turns to the father but she does not seem to
get everything she wants from him. A space of dissatisfaction is created in which the child
perceives himself as a possible supplement in providing the mother complete satisfaction. If the
mother appeals to the child to supply that which she is missing, the child may be libidinally
charged by her. This is clearly seen in the erotic fantasies that obsessives have: they are plagued
by passive-aggressive fantasies with respect to women who seduce them and at the same time,
abuse them. Because of this particular relationship with the mother, the future obsessive will
have difficulties accessing the fathers law and therefore will subsequently have difficulties with
all authority figures.
What is the position of this child with the father? We find here the key to what Freud
called the anal character, in which an interminable struggle with the representative of the Law
is always at stake. This interminable struggle is displaced into different routes of libidinal
investment, with perseveration, obstinacy and defiance being typical. The obsessive does not
want to dethrone the father, but rather to constantly erode the value of his power, to repeat the
scenario by which he is captive of his mother in the presence of his father.
The law of the father is always present in the obsessionals desire, and because of his
privileged position with his mother, he cannot but feel extremely guilty. Further, the fear of
castration is always an imaginary threat that haunts the obsessive. Since the paternal figure is
always present, he also has feelings of rivalry and competitiveness with him, constantly wishing
to take his place (the same situation occurs with any other person who occupies a place of
authority and who symbolically represents his father, such as a boss, a trainer, or a professor).
The child cannot articulate his own desire as it is tied up with his mothers. Thus, the obsessional
person has difficulty articulating a demand to express his desire. This is because the emergence
of desire is absolutely threatening. The obsessional cannot manage to find his desire, and
sometimes asks others to do so for him. Such passivity puts him at risk to be sadistically
mistreated by others.
The fear of castration in obsessive neurosis is what is at the basis of the obsessives
intolerance for loss. Any loss is equated with castration. Obsessives want to master everything to
make sure they will lose nothing of the other. As a result, we see the rigidity and constant
attempts to control the behavior of others that characterize the obsessive personality. The
experience of totality, of achieving a global experience is a compensation for the obsessives
castration anxiety.
On the surface, obsessives are law-abiding citizens, to the point of becoming preoccupied
with legal matters and of exhibiting a rigid adherence to rules. However, this is a reaction
formation or a way to defend themselves from the wish to transgress. It is in this area of
transgression of the law that they deploy their defenses most consistently. The use of isolation is
manifested in their rituals and pauses of speech. In this way, speech becomes the vehicle for rigid
control and detachment of feelings, even when they are on the verge of a crisis.
It should be noted that generally obsessives are unlikely to seek analysis. They prefer
conducting their own self-analysis or writing their dreams in a journal. They usually explain to
themselves that it is better to work out their problems by themselves. What makes them come to
therapy? Usually an intense manifestation of the others desire that the obsessive cannot manage
to control precipitates anxiety and serious self-doubt. The abrupt and intense emotional opening
of someone close, or an imminent loss of a dear one could disarm the obsessive and prompt an
analysis.
When in treatment, obsessives have difficulty free-associating, which is experienced as
threatening to their self-control. Rather, they prefer to express themselves in long speeches filled
with rationalizations. They also make use of black humor or sarcasm both in therapy and in the
public arena. Obsessives use their words as tools of control of the other and in the process they
acquire a secondary gain of discharging affect. This sarcasm is designed to neutralize the others
feelings. Undoing, in which an act or a thought is treated as if it never occurred, is another
defense that obsessives use to neutralize contradictory affects such as love and hate,.
For the obsessive a relationships becomes an all and nothing situation (Fink, 1997)
Since the obsessives core issue is his fear of castration, the condition for a relationship is that his
partner is passive, not in touch with her own desire, and will, in effect, play dead and not
desire anything for herself. The lover is thus, experienced as complete, lacking in nothing. In this
way, the obsessive can continue to control a being who has no desire of her own. On the other
hand, any threat of abandonment on the part of the lover, will immediately be experienced as a
loss that the obsessive will go to great extremes to prevent. There is nothing that the obsessive is
not willing to provide, give or offer to keep his lover in place. The relationship resembles very
much a jailhouse in which everything is provided to the lover on the condition that she will
relinquish all subjective desires that do not include her partner. Pleasure cannot be experienced
without his authorization.
Frequently in long term relationships, the partner of an obsessive is turned into an
undesirable image by which the obsessive guarantees the death of he own wishes, sometimes
imposing conditions on her looks, her clothing, insisting in that she adopt a prudish and morally
correct appearance. If, on the contrary, the obsessive views his partner as an attractive, erotic
object, he interprets that fact as a reflection of his own value and prides himself on his
possession. These men can treat their partners like a trophy; another of their personal belongings.
It is noteworthy that Lacan does not discuss the question of the etiology of neurosis, but
only indicates that repression is its primary mechanism. His few comments on the process by
which an individual becomes a hysteric or an obsessive suggests that social causes are involved
in the maintenance of these structures. Lacans position seems to be that in Western society,
desire is organized predominantly around the symbolic phallus. It would be interesting to record
differences or changes in neurotic structures as social roles vary within the cultures and as a
result of changes in contemporary society.
Phobia
Lacan considered phobia the most radical form of neurosis. (Lacan, 1960). He also
considered it to be the most extreme form of the problem of the establishment of the paternal
metaphor (Fink, 1997). In phobia we have the presence of a weak father function and a strong
attachment between mother and child. As the paternal metaphor is diffuse or precarious, the child
has to instate it him or herself by replacing it with a symbol that substitutes for the fathers
failure to cancel out the mother. Lacan did not consider phobia to be a separate structure,
however, it is clearly a neurosis as it successfully addresses triangularization by providing a
symbolic solution. The case of Little Hans in Freud (1909) clearly illustrates how the child
creates a limit to his engulfing mother, as his father is unable to separate mother from son. Hans
was usually allowed to sleep in his parents bed or to watch his mother change in the bathroom.
(Ferrari, 1999). As his mother forces the child into placing himself as her imaginary phallus, he
experiences an excess of sexual pleasure that he cannot tolerate. As Hans father does not fulfill
the symbolic function of castration, one that would create a limit to the childs pleasure, a horse
phobia is marshaled by Little Hans to perform the paternal function (Horse = Name-of-the-
father). For Lacan, phobia is closer to hysteria than to obsessional neurosis in the sense that the
subject is placed in a situation where he must constitute himself as an object of completion for
the other, to be the object of the others desire.
Perversion
Most patients, who by descriptive criteria are diagnosed as perverse, are, for Lacan,
neurotics or psychotics. Further, for Lacan, all human sexuality is descriptively perverse and
polymorphous as we come to this world as pleasure-seeking beings with neither a fixed object
nor a higher purpose to guide our sexual drive. Such perverse behavior, which has no
connection to our reproductive function continues throughout life and is unrelated to the
diagnostic category of perversion. In Lacanian psychoanalysis the so-called perverse sexuality
is a position of the subjects desire produced as a result of his oedipal vicissitudes. Thus,
perversion is not a derogatory term to designate a deviation from the norm but a structural
category in its own right.
In order to understand what is at stake in the diagnostic structure of perversion we must,
according to Lacan, keep in mind the questions of the mechanisms of negation and the Name-of-
the-father. Whereas in psychosis there is an absence of the law, and in the neurosis a
reinstatement of the law in fantasy, in perversion, the subject struggles to bring the law into
existence.
Lacan terms the negating mechanism at work in perversion as disavowal. According to
Lacan this is the very same negation that Freud had distinguished from the repression at work in
neurosis. Freud had made this distinction in 1938: whereas repression relates to the putting out of
mind a perception of the internal world, negation involves a disavowal of a perception in the
external world. (Freud, 1909). However, for Lacan the barrier between outside and inside is more
equivocal. Lacan agrees with Freud (1938) that repression involves pushing away a thought
related to a drive (which gets dissociated from its affect and returns as a symptom), and that with
negation, a thought related to a particular perception of the real world is put out of mind. (Freud,
1938). However, as the latter negation/disavowal is connected to a thought, some part of which is
related to the psychic reality of a subject, the barrier between inside and outside is broken.
Actually, neither of the two mechanisms involves perception, and each is applied to thoughts.
Lacan is critical of the idea that we can distinguish internal from external dangers, threats and
anxieties, as each of these are dependent upon the subjects thinking or signification.
For Lacan, disavowal clearly involves the father and all the themes related to him; the
law, the fathers name and the fathers desire. As we have seen, as the oedipal vicissitudes
become the stage for a triangular relationship the child will have to relinquish part of his
jouissance with his mother. This occurs as the paternal metaphor institutes a distinction that will
bring about an identification with the father and with it, the hope to enter the symbolic world.
However, the pervert will not relinquish this pleasure (associated with masturbatory fantasies
with the mother or mother substitute). He refuses to do so. (I am using the pronoun he in the
context of perversion as Lacanian psychoanalysts consider perversion a male diagnostic entity).
So, who accepts the fathers law and who refuses to do so? Perversion usually occurs in
the context of a very strong relationship bond between a mother and a male child who provides
her with sexual pleasure. This contributes to a situation in which the child narcissistically invests
his penis with an erotic power that he is not willing to relinquish. This mother constantly
demands that her child satisfy her. This situation is coupled by the presence of a weak father
(who is unsure of his own desire) or a father who is confused about his role and is overpowered
by the childs mother (who has a secret pact with the child). At this point, we need to remind
ourselves that mothers will somehow make a demand (by naming it) regarding her dissatisfaction
(either with herself or with her husband). When the mother names what she lacks she creates a
desire in the child to sort out her enigma: What does my mother want? Desire is put in motion
in the search for the answer. In the mothers pervert, however, no demand has been named, there
is no signifier provided by either parent that will articulate the mothers lack at the symbolic
level; the child does not actually have to wonder what his mother wants, in fact, he knows what
she wants and that is the child himself. She is completely fulfilled with her child; symbolic
castration is not permitted to disrupt the dyad as there is no rival in the mother-child relationship.
This is what in other contexts might be called an oedipal victory on the part of the child, or
collusion between mother and child to deny the fathers power. The denial of the symbolic father
and the denial of the sexual difference represent a disavowal based on the fact that the mother
does not lack anything, therefore she is complete, and nothing is missing. We sometimes see
these cases in mothers who experience their child as a narcissistic extension of themselves, as an
object of their desire and cause of their bodily pleasure and we may view them as attachment
disorders. This is the oedipal vicissitude of the future adult pervert.
The child, who is identified as the phallus of the mother at the imaginary level, cannot
accede to the symbolic register in the same manner as a neurotic can. He will be that which
completes the mother forever. Although the first stage of the oedipal process was achieved
successfully (the child is placed as the imaginary phallus of the mother), the second stage which
renders separation from the mother, does not occur as the paternal function is not strong enough
to name the mothers lack and separate her from the child. However, this oedipal victory or
denial of the paternal function is unsettling for the pervert who fears being engulfed by the
maternal object. As such, in these cases the child himself supplies the paternal function through a
fetish, a shoe or a punishing act in an attempt to separate himself from the mother and at the
same time, to bind the anxiety that he feels by being engulfed by this overwhelming Other.
This is the function of the perverse object in the fetishists scenario. The presence of the element
of perversion, whether it be a fetishistic object, a ritual, or a sadistic activity, needs to be
repeated ad infinitum, as no one-single-event can resolve the situation for the pervert; he must
engage in a scene that must incessantly be staged same way to fulfill its function.
Although the suffering of the pervert at times resembles that of the melancholic, or a
severe depression, it is very difficult for a pervert to be in analysis. From one day to the next,
they can reverse a terrible feeling and feel absolutely nothing (disavowal of pain). They
usually start treatment after having suffered a significant loss or if they are facing death in some
way (like suffering from an incurable illness). The topic of death is usually in the perverts
vocabulary, representing the only inscription of time. When faced with these circumstances,
perverts suffer from agitated anxiety.
Another difficulty for the progress of treatment, if started, is that the pervert wants to be
the cause of his analysts desire, instead of the analyst being the cause of his desire, making the
transference almost impossible to be established. Moreover, perverts tend to e acting-out
behaviors in which they diminish the analyst, humiliate him/her and try engendering castration
anxiety in the analyst.
Table 2 incorporates some elements that help us in the diagnosis of the three main
diagnostic categories. (Fink, 1997)
Table 2: Psychosis, Neurosis, Perversion
Psychosis Neurosis Perversion

Symbolic Order Is lacking, thus does not Exists in all cases Must be made to exist. It is
exist as such. The brought into existence by the
psychotic tries to subject enacting his own law.
provide this function by
creating a metaphoric
delusion.
Jouissance Total invasion Avoidance He is seduced by setting
limits to it.
Mother Never barred by the Barred by the name of The pervert brings about the
name of the father, the father. Neurotic law to bar the mother in order
psychotic never emerges as a subject. to exist as a separate object of
becomes a separate her desire
subject.
Mothers desire Psychotic whole body Neurotic achievements The perverts real penis is
and being is engulfed are required but never required by the mother.
with the mother suffice as the mother
always wants
something else.
Oedipal stages Psychotic never grows Goes through three Pervert does not go through
out of the imaginary stages of Oedipus with the second stage that is the
level. He is trapped in the focus on the Others separation from the mother,
alienation with the ideals which render due to the inability of the
mother. different types of name of the father to name
neurosis. the lack of the mother.
Chapter Four
The Case of Katherine
I
n this book I have proposed a theoretical and clinical dialog between Kernbergian and
Lacanian schools of psychoanalysis. Central to this dialog is the question of whether
psychiatry, and moreover, psychoanalysis has provided a satisfactory account of the
borderline personality disorder to justify its existence as a distinct diagnostic entity, requiring a
conceptualization and treatment that is, for example, distinct from the neurosis and psychoses.
Further, if Borderline Personality Disorder is indeed a viable and distinct diagnosis, the question
arises as to whether Otto Kernberg, as the pre-eminent proponent of a psychoanalytic theory of
the borderline, has provided an adequate diagnostic and therapeutic characterization of this
structure. Finally, the question also arises as to how patients considered by Kernberg to be
borderlines are handled both clinically and theoretically from a Lacanian psychoanalytic point of
view.
The borderline diagnosis has implications for psychoanalytic theory as a whole, as
several important issues including, (1) the relationship between psychoanalytic and psychiatric
diagnosis, (2) the meaning of psychoanalytic "structure", and (3) the controversies surrounding
the question of whether psychoanalysis is essentially a study of unconscious, as opposed to ego
and relational, processes, come into sharp focus when one considers the so-called borderline
patient. Psychoanalysis, one might say, reaches its most controversial moment in the topic of the
borderline personality disorder, as the whole body of psychoanalytic thought is relevant to this
issue, and potentially stands to be revised in the process.
In Chapter One I introduced the problem and the Borderline personality. Subsequently, I
presented the points of view of two psychoanalytic thinkers, Otto Kernberg and Jacques Lacan,
who have interpreted the main tenets of psychoanalytic theory in what appear to be radically
different ways. At the same time, I explored their roots in Freudian thought and how they were
influenced or (in the case of Lacan) largely rejected the post-Freudian developments of the past
40 years. My goal, from the outset, was not only to provide a basis for understanding the
theoretical issues raised by the borderline diagnosis, but also to consider the implications for
clinical/therapeutic practice in the differing conceptualizations of Kernberg and Lacan. To this
end, it is my intention to structure much of the subsequent "dialog" between Kernbergian and
Lacanian points of view around a clinical case. The presentation of such a case will, I believe,
not only further clarify the dialog between contrasting Kernbergian and Lacanian positions, but
also provide clinicians working with severe personality disorders an opportunity to clarify their
thinking regarding clinical interventions with severely disturbed patients.
The clinical case I am about to present is an altered, and to a certain extent composite and
fictionalized version of a case that I treated over a three year period. The procedure of altering
and fictionalizing this case was utilized in order to protect the identity of the patient. However,
every effort has been made, at all points to retain the essential features of the clinical
presentation and treatment. As I will discuss in more detail later in this study, the procedure I am
about to use is illustrative as opposed to probative; the entire thrust of this work being one of
hypothesis generation as opposed to hypothesis testing. The case of Katherine serves as a test
case only in the following sense: that it permits us to consider Kernbergian and Lacanian
conceptualizations in the context of actual clinical material.
I will begin by describing the history of the patient, outline the presenting problems at the
time of her entry into treatment, provide a description of the basic therapeutic problems that were
encountered, and describe diagnostic considerations based on the two different approaches
(Kernbergian and Lacanian) to clinical interviewing. Both Kernberg and Lacan hold that the
course of the initial interviews, and the analysand's responses to certain early interventions, can
provide extremely valuable diagnostic information. In this regard, Kernberg and Lacan agree on
the importance of the first meetings between analyst and patient as a means of maximizing the
value of the interview as a tool for clinical diagnosis. As such, I will occasionally use excerpts of
the case, derived from my notes of the early interviews, to illustrate some of the issues in
differential diagnosis.
The Case of Katherine 109
I should point out that my work on this case was conducted during a period (which
continues to this day) during which I was struggling with the conceptualization of severely
disturbed patients from both object-relations (Kernbergian) and Lacanian points of view. In
presenting the case here I have attempted to be as descriptive as possible, limiting any theoretical
intrusions for subsequent chapters, where I will discuss this case from each of the dual
perspectives that have been the subject of this book.
"Katherine": The Presenting Problem
Katherine is a 25-year-old single woman living in New York City. She was seen in
psychodynamic treatment with the writer for three years. Sessions, which were paid for by the
patient on a minimal fee/sliding scale basis, and were scheduled for one to two times per week,
as dictated by the needs of the treatment and the capacity of the patient to tolerate more than one
weekly session. The setting of the treatment was a university-based psychology clinic.
When Katherine entered treatment, she presented a long list of complaints, including
feeling fatigued, depressed and isolated, experiencing severe family conflicts and feeling
misunderstood by her boyfriend. She was also concerned that her aggressive thoughts might, at
times, make people fear her and therefore make her as she put it undesirable in the eyes of
others. She related that the smallest slight or hint of rejection would be extremely upsetting to
her, and that she was unable to recover from such upset, sometimes for days.
Early on in the treatment Katherine expressed feelings of uncontrollable rage towards her
father. However, as she reported in other sessions, she experienced similar rage in connection
with several other significant others, including her boyfriend, Christian, her sibling, Michael (age
23) and half-sibling, Susan (age 30). Just prior to commencing treatment she had run away
from home for two days and had made several phone calls to family members in which she
accused her father of abusing her, and of rejecting her boyfriend and calling him a "bum." As a
result of these incidents, the family had initially been offered structural family therapy . As is
quite common amongst chronically unstable individuals, it later became clear that Katherine had
a history of varied and multiple treatments, including group psychotherapy and

psychopharmacological treatment.
Katherine reported that she was unable to earn enough money to rent her own apartment.
She continued to live with her father and stepmother, but managed to arrange for her own food
stamps, as well as welfare benefits, in the amount of $150.00 a month. She reported that her
father insisted that she pay her share of the apartment rental and she complained bitterly of
this, stating that she had very little money left over for her own use. She further complained that
although she paid rent to her father every month, she did not have her own bedroom and was
sleeping in the living room with no privacy. By way of contrast, her sister and her parents had
their own bedrooms. As later became clear, Katherine had episodically moved from her parents
home to a neighbor, as well as briefly into the homes of several other new nice people who she
had met while out in the streets, and her situation in her parents' home was far from stable.
Katherine found her inability to achieve a career or sustain a creative outlet, very stressful. This
stood in stark contrast to her brother's professional success.
Family Structure and Childhood History
Katherines father (age 55) is a construction worker. The family resides in a middle class
section of Brooklyn, in a two-bedroom ground floor apartment. Katherines stepmother, Betty,
age 57, works as a housekeeper in the neighborhood. Katherines brother Michael, 23, is a
computer engineer who recently graduated from a small west coast college and who has obtained
a job in a major corporation. Michael had always lived with his biological mother and moved
out of her home when he went to college. Katherines mother, who was originally from South
Carolina, lives in Virginia, where she is currently employed as a hotel receptionist. Katherines
mother has never remarried and complains in her weekly phone calls to Katherine that she is
terribly lonely. Katherine also has a 30-year-old half-sister, Susan (from a former relationship of
Katherines mother) who lives in a Buddhist community in South Dakota. Katherine describes
her as reclusive and non-communicative, and reports that she has been diagnosed with
depression in the past. Katherine also reports that Susan had been treated with psychiatric
medications but after a few years had stopped taking them in favor of meditation. Katherine has
had very little contact with this half-sister.
Katherine was born in New York City and lived with both parents until the age of ten.
Her mother met Katherines father (who is of Italian descent) in a bar in New York City where
she was working as a cook. Katherine at times describes her mother as cold and detached. She
also relates that her mother is extremely moody, has an unpredictable temper, and suffers from
extremely low self-esteem. Katherine relates that her mother seemed to be uninterested in her
role as a parent and that she worked all day, returning home very late almost every evening.
Katherine also relates that her mother was "like two different people in one," at times behaving
in a crazy manner. For example, Katherine recalls that as a child if she would upset her
mother, she (Katherine) would be left alone on the sidewalk while her mother went inside their
home, leaving Katherine in a state of extreme emotional distress.
Based upon Katherine's descriptions it appears possible that her mother suffered from an
affective disorder. As an adult, Katherine felt a certain responsibility for her mothers well being,
calling her every week at home, and constantly urging her to seek treatment for her depression.
With regard to her mothers cold and aloof stance, Katherine initially stated that her mother is a
woman totally lacking in maternal instincts. However, Katherine did not blame her for this,
preferring to feel sorry for her, and offering justifications regarding how difficult it must be to be
a mother. However, as the treatment progressed it became clear that Katherine believed that
her mother was aloof only in regard to her, and not, for example, in regard to her brother.
Katherine described her father as a chauvinistic second generation Italian-American male
who was all talk, and although she remembers him as her primary caretaker, she also
describes him as violent and abusive towards herself and her mother. She depicted her father as a
domineering, explosive man who would vent his anger on the women around him and constantly
ridicule them; behaviors which enraged Katherine. Katherine spoke about her father during
almost every session and this relationship and the intensity of her rage towards him, was the
major theme throughout at least the first year of treatment. The tense relationship between
Katherines parents ended in a separation after her father left the home.
When her parents divorced, Katherine's mother took the children to another state without
the father's consent. A court battle ensued between the parents and Katherine and her brother
became a negotiating chip between the couple. Katherine became so upset about the conflicts
between her parents that at age 14 she ran away from her mothers home and lived in various
homes where she was taken in, as she put it, as a daughter. For example, at one point she
moved into her boyfriend's home, where she was treated as another child in the family. On
another occasion, she became friends with an older widow who took her in and she spent six
months living with her, taking care of her pets. However, almost immediately after Katherine
would start a relationship, she would start lying and (sometimes stealing) in the new home until
such time that she outstayed her welcome. At such times she would find another person or
people who would become the new good parents. At the age of 23, she returned to New York
to live with her father in spite of her perception that he, like her mother, was a neglectful parent.
Katherine herself came to realize that in spite of her hatred for him, her father was always
providing for her and she would turn to him in moments of crisis.
A pattern of idealization and later, frustration and disappointment were the characteristics
of the encounters with people in Katherines adolescence and continued to be reflected in her
interpersonal relations as she became an adult. This pattern was observed to occur with friends,
in particular her boyfriend, employers, and, most clearly, with the therapist herself.
Work History
During the first year of her treatment Katherine was pursuing a degree in
communications at a public College in New York City. However, it soon became apparent that in
spite of her above average intelligence, she lacked both focus and motivation to remain in
school, and after a semester of excessive absences she decided to leave school without
completing any of her courses. She was constantly concerned about not being able to pay her
tuition, complaining that the financial aid office was denying her the help she needed. She later
confessed that she had outstanding loans from previous attempts to begin college. She explained
that this combination of circumstances rendered her incapable of continuing her studies.
Katherine had a series of short-term jobs that ranged from an attendant in a geriatric
home, to a boutique salesperson, a florist, a tour bus guide and a belly dancer. However, she quit
one job after another, each after only a few weeks of employment. A common scenario was a
conflict with an authority figure, in which she would feel she was being overly observed by her
employer, wrongly judged and finally driven away. Katherine felt singled out by her supervisors
and she engaged each of them in heated arguments that at times led her to threaten them with
lawsuits. Katherine would generally leave her job after she had been out several days as a result
of somatic symptoms (pre-menstrual cramping, headaches, digestive problem) that exhausted
her. In sessions, it became clear that her decisions to accept employment were always
impulsively undertaken and never well thought through. Typically some superficial aspect of the
job had appeared to offer her a sense of meaning and/or financial opportunity. However, each
time she would fail in a job, she would single out certain elements of the job (e.g. number of
employees, working hours, type of setting, or the job location) and add them to a list of to
avoid factors in any future job search. Each of these experiences left Katherine tired,
disillusioned and more pessimistic regarding her prospects of becoming a self-supporting adult.
Course of Treatment
During the initial interview session Katherine was asked to describe the nature of her
problems and how they impacted upon her life. Katherine expressed discomfort with this open-
ended inquiry, and requested that the examiner ask her more direct and specific questions about
her condition, a demand that initially appeared to both express her need to feel more in control of
the interview and to serve as her means of evaluating the therapists own experience, knowledge
and ability. She stated quite openly that the idea of freely discussing her concerns made her feel
uncomfortable. The interviewer inquired about this discomfort, asking Katherine to explore its
origins, after which Katherine immediately began discussing her depressive feelings and how her
body was affecting her mood. She described what she referred to as her imbalanced hormonal
state which she said led her to experience very painful pre-menstrual pain and periodically
rendered her unable to function. She presented these somatic preoccupations in the context of her
depression and she wondered if she might be "contributing to her pain in some way."
At the time Katherine entered treatment she was already being seen by a hospital
psychiatrist on an outpatient basis and had been prescribed Prozac, 20 mg. a day. She reported
that her psychiatrist had found it helpful to bring in her father and stepmother to discuss her
mental and emotional status. In one of these meetings Katherine had voiced the opinion that her
father and stepmother believed she was mentally challenged, mean with other family
members, and had caused them worry and constant concern. Her stepmother wanted to bring the
whole family into therapy but her father refused on the grounds that Katherine was again
playing tricks." Katherine also asked this interviewer if it would be useful to bring the family in
to help her clarify her emotional issues. I suggested leaving the family out of her individual
therapy until this issue could be explored further.
Katherine denied any history of alcohol or substance abuse. However, she early on
acknowledged periodically engaging in episodes of self-injurious behavior that took the form of
making superficial cuts on her stomach and/or her arms. Although Katherine described these as
suicidal acts, it soon became apparent that they largely functioned to prompt others into
providing her with attention and concern. These episodes would mobilize her boyfriend and her
parents and would typically lead either to a brief hospitalization or a period of at-home care
where her stepmother would continuously watch her. Katherine reported that during her
suicidal episodes she would feel out of control. Her gestures which suggested serious
deficits in frustration tolerance and impulse control emerged at times of intense rage. In addition,
her actions appeared to be designed to re-establish control over the environment by evoking guilt
feelings in significant people in her life. These episodes would invariably be followed by a
period of severe depression, characterized by sleeping late in the mornings, decreased energy,
lack of motivation, boredom, social isolation and withdrawal from nearly all of her activities. At
such times Katherine would typically complain about some medical or physical ailment that
accompanied her emotional suffering (mostly focused on her reproductive/genital area). The
issue of management of potential self-destructive behavior, however, was a delicate matter, as
any increase in attention (number of sessions, or phone calls) threatened to reinforce and
encourage further negative behavior. Yet, in this regard, the self-mutilation although serious, was
not the most severe type, and could have been managed on an outpatient basis. With the passage
of time, the therapist learned that the patient was honest about the severity of her intentions and
did not actually have suicidal intent. While she reported that she also had aggressive fantasies
towards others, she denied any plan or intent to act on them.
In addition to her severe menstrual cramping, which typically disabled her for several
days just prior to her menstrual period, Katherine complained of being overweight (an evaluation
she initially attributed to her boyfriend), experiencing tightening in her chest, and difficulty
breathing. However, her incessant somatic complaints contrasted markedly with her involvement
in various sports and her investment in developing a powerful and trim physique. Katherine was
a strong bicyclist who spent several hours per day on the road, often riding to the point of
exhaustion. She was also an avid swimmer and reported that she had taken several parachute
jumps. She explained that her physical activity was very important to her and that she would try
to push herself as much as she could. As Katherine related to the therapist, she was always
trying to find a causal relationship between her physical illness and her depression. She was an
avid reader of psychiatry, psychology and self-help books. She explained her illness as a
depression caused by a chemical imbalance in her brain.
Katherine revealed that she had made numerous previous visits to a local psychiatric
emergency room due to suicidal ideation. However, none of these visits to the emergency room
resulted in her being admitted to the hospital. Katherine reported she was well known to the on-
call hospital staff, who had indeed diagnosed her as a borderline personality. Indeed, her
psychiatrist and an on-call resident each described Katherine as someone who engaged in acting
out behavior and sought the attention of the medical community to enhance her victimization
role. Katherine complained that the hospital doctors appeared not to be concerned about her
pursuing an actual act of aggression directed towards herself or others, but she insisted that at
such times she was really very dangerous. Although she never actually hurt or attacked anyone
directly, Katherine's own concern in this regard underlined the vivid aggressive fantasies she
expressed in regard to her parents, employers, and (when at work) her clients.
One salient symptom that Katherine reported was a sense of depersonalization, which
was generally accompanied by the sense that she had lost memory for certain periods of her life.
As treatment progressed, she reported that certain memories returned in connection with her
sexuality, her family history, and her early childhood experiences.
Katherines treatment lasted nearly three years. When treatment began, she requested that
she be seen twice weekly. However, she would frequently be excessively late or cancel her
appointments, so a new schedule was set for a once a week, 45-minute session. An agreement
was reached that in time there would be an increase in the number of sessions if that seemed
appropriate. The schedule, frequency, and length of sessions varied throughout the treatment.
Her commitment to the therapy increased over time, as reflected in the depth of the material and
her willingness to share it.
Several themes soon dominated Katherine's associations. She had a strong ambivalence
regarding her family and boyfriend, as shown by her continually expressing a desire to be closer
to them yet at times, acting out against them in ways that assured their distance. Katherine's
acting out was usually directed at her father or her boyfriend Christian, but at times, it was
directed against an authority figure (e.g. an institution such as a school, the subway system, the
police, etc).
Father and daughter would argue intensely. She would scream at him until the neighbors
would threaten to call the police. Katherine accused him of being an abuser and not providing for
her, of eavesdropping on her phone conversations and controlling/restricting her use of the
phone. On the other hand, Katherines father made terrible scenes whenever she brought a
young man home. He was particularly harsh with her boyfriend, Christian. He would make fun
of his education and his pursuit of a career in fashion. Her father regarded Christian as an
adventurer with no prospects. On other occasions, Katherines father would be completely
oblivious to Katherines requests or demands, to the point of indifference (from Katherines
point of view). Once, when driving with her father in his car, she went so far as to jump out of
the moving car in protest against his indifference to her.
Katherine was also highly conflicted regarding her relationship with her boyfriend. Her
demands for attention took a toll on their relationship, mostly as a result of her doubting his
feelings for her and the genuine nature of his love. A cycle would ensue in which Christian
would leave Katherine and then she would follow him, begging for his forgiveness to the point
of becoming obsessed with the loss. They would finally make up, usually after an intense sexual
encounter, and the cycle would begin again with another argument. At the same time, Katherine
would seek the attention of other men, for example, friends in college or a man she would meet
bicycling in the park. Although she reported not being aroused by these encounters, she allowed
other men "to touch her."
A similar pattern was clear in Katherine's relationship towards the therapist. On one hand,
she came to trust the therapist enough to share deep and intimate thoughts and feelings. Yet in
the session immediately after such a sharing, she would often become resistant trying to upset the
therapist, at times by missing sessions, appearing at the wrong time or openly devaluing the
therapy.
The treatment initially centered on the development of trust and the working alliance.
Katherine was very needy at that time, calling the clinic frequently and at all hours to talk to the
therapist. When the therapist returned her repeated phone calls Katherine was agitated and
unable to calm herself, stating for example, that she absolutely could not wait to talk until her
next session. My position during these phone calls as it was throughout the early phases of the
treatment was to provide some containment for Katherines anxiety, and assure her of my
presence in spite of distress, her acting out and the expression of negative affect towards the
therapy.
During the first year of treatment Katherine had a quarrel with Christian that resulted in
his requesting a temporary separation during which time they would both have time to think over
their relationship. Katherine acknowledged that the theme of loss and separation was very
difficult for her, and she attempted to hold on to her own fragile sense of being during this period
by having encounters with other men. She reported that she would not have sexual intercourse
with them, but allowed them to touch her as she passively enjoyed being "physically
manipulated". After two weeks of not hearing from her boyfriend (who had taken a trip),
Katherine made a suicide gesture/attempt by swallowing 25 aspirins. She explained that late one
night while everyone was sleeping in her family's home, she became more and more thoughtful
about Christian, felt betrayed and lied to, convinced herself he was never going to return, and
had the urge to "do something to herself" in order to alleviate her pain. After Katherine
swallowed the aspirins she developed stomach pains, and her step-mother was awakened by her
moaning. Katherine confessed her act, the family became very concerned, and she was brought
to a local hospital.
The emergency admitting psychiatrist concluded that Katherine was indeed very
depressed and admitted her to the hospital. She was discharged a week later against her wishes. I
spoke with her treating psychiatrist several times to discuss her aftercare. The psychiatrist
diagnosed Katherine as suffering from a Borderline Personality Disorder and it was agreed that
her psychiatric aftercare would consist of psychopharmacological treatment (Prozac, 40 mg. a
day), with continued psychotherapy sessions, and a group psychotherapy at the hospital from
which she was discharged. Katherine took up the recommendation and joined a women's
psychotherapy/support group. However after a few months she left the group reporting that the
other women thought she was monopolizing their time and had confronted her about this. In
addition she felt that they were jealous of her as she was the youngest and, in her view, the
healthiest of the group members.
At this time, it became clear that the patient's and therapist's earlier goals would need to
be scaled back in an effort to stabilize her acting out and regressive behavior. It also became
apparent that it was important to establish short-term goals and be prepared for serious regressive
behaviors when Katherine was confronted with separation and loss.
We explored issues of trust and separation at great length and took certain steps to
minimize the risk of a psychiatric decompensation when I was away. For example, I would
communicate to her by phone and send her a postcard when I was on vacation. It was important
for her to conceptualize that I was not lost forever.
Transferentially, at the beginning of treatment, Katherine either idealized or devalued the
therapist and the treatment. She had previous therapeutic experiences, had made frequent visits
to hospitals and psychiatrists, and fancied herself something of an expert on therapy. However,
only when the therapist placed limits on her intense demands did Katherine actually become
interested in the therapeutic process, and began questioning herself and her actions, allowing the
transference to become more firmly established.
Strong countertransferential feelings were evoked in me, as a result of the patients
frequent and intense demands. Feelings of being suffocated by this patient along with fantasies
of terminating her were at play as well. These feelings were discussed in my supervision and
personal analysis, in order to facilitate my own growth and clarify my stance with this patient.
As the case progressed, I began to encourage Katherine to engage in free association.

Over time a dialogue between Kernbergian and Lacanian perspectives on treating this patient
began to emerge in my own mind. A theoretical exploration of the two techniques and how they
could bring about therapeutic change evolved as my work with Katherine proceeded.
Chapter Five
Katherine as a Kernbergian Borderline
T
here can be little doubt that Katherine can be understood as a borderline within
Kernbergs understanding of this term. In this chapter I will review Kernberg's
diagnostic procedure and demonstrate how the use of the interview techniques he
prescribes reveals Katherine to have both the "presumptive" and "structural" characteristics that,
according to Kernberg, define borderline pathology.
As we have seen in Chapter Two, Kernbergs technique has been influential in
differentiating between neurotic, psychotic and borderline syndromes. In contrast, as will be
described more fully in Chapter Seven, Lacan would assert that the call for a borderline structure
is the result of a failure to conduct a subtle and comprehensive analysis within the diagnostic
categories of neuroses and psychoses. I will show how from a Lacanian perspective, in spite of
the claim to go beyond descriptive psychiatry, Kernbergs analysis involves a re-labeling of
descriptive criteria as structural personality features. For Lacan, descriptive diagnosis is of
virtually no psychoanalytic value.
In Chapter Seven, I will show how from Lacanian point of view Katherine can be
conceptualized within a neurotic structure, without recourse to a "borderline" diagnostic
category. The strengths and limitations of each of these approaches will then be considered.
Katherine as a Kernbergian Borderline 121
Katherine as a DSM-IV "Borderline"
As discussed in Chapters One and Two, Kernberg's criteria differ from, but are in many
ways compatible to, the criteria for Borderline Personality Disorder set forth in the Diagnostic
and Statistical Manual of Mental Disorders by the American Psychiatric Association (Fourth
Edition, Text Revised, 2000). As these criteria have become prevalent in a majority of clinical
settings, it will be instructive to briefly examine Katherine in DSM-IV-TR terms.
Even a cursory review of this case reveals that Katherine meets the DSM-IV-TR criteria
for Borderline Personality Disorder. We can here recall the DSM-IV-TR criteria for Borderline
Personality Disorder:
a pervasive pattern of instability of interpersonal relationships, self-image and affects,

and marked impulsivity beginning by early adulthood and present in a variety of contexts,
as indicated by five (or more) of the following criteria:
1) Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or
self-mutilating behaviors covered in Criterion 5.
2) A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation.
3) Identity disturbance markedly and persistently unstable self-image or sense of self.
4) Impulsivity in at least two areas that are potentially self-damaging e.g. spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-
mutilating behaviors covered in Criterion 5.
5) Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior.
6) Affective instability due to a marked reactivity of mood (episodic dysphoria, irritability, or

anxiety usually lasting a few hours and only rarely more than a few days).
7) Chronic feelings of emptiness.
8) Inappropriate intense anger or difficulty controlling anger (e.g. frequent displays of

temper, constant anger, recurrent physical fights).
9) Transient, stress-related paranoid ideation or severe dissociative symptoms.
During the introductory (diagnostic) sessions at the beginning of Katherine's treatment, it became
abundantly clear that she met at least seven, if not all nine of these DSM-IV criteria. Her
desperation and suicidal gestures in the face of the threatened abandonment, her idealizations
regarding boyfriends, employers, and job opportunities which invariably turned to devaluations,
her inability to form and maintain a stable self-image, the extreme reactivity of her mood to
various interpersonal and bodily events, her feelings of emptiness in response to perceived
abandonment, her sudden displays of temper, and her brief paranoid episodes in connection with
each of her employers, clearly qualified Katherine for a DSMI-IV diagnosis of Borderline
Personality Disorder.
Kernberg's Presumptive Criteria
As will be recalled, Kernberg's diagnosis of the borderline condition involves a two-

tiered process (Kernberg, 1984). Initially a "presumptive" diagnosis is made on the basis of
certain symptomatic features, which even if they are not part of a structural diagnosis, are
descriptive features that a clinician should observe (and even elicit) while interviewing the
patient. They include one or more of the following: (1) pan-anxiety, (2) polysymptomatic
neurosis, including: a) obsessive-compulsive symptoms, especially in conjunction with paranoid
or hypochondriacal themes, b) multiple and severe conversion symptoms, c) dissociative
reactions, and, d) hypochondriasis, (3) polymorphous perverse sexual trends, (4) pre-psychotic
personality traits, including paranoid, schizoid, hypomanic and the cyclothymic personality
features, (5) impulse neurosis and addictions, (6) lower level and/or narcissistic personality
features (including shallow affect, limited empathy, intense envy and ego exhibitionism
(Kernberg, 1975).
Again, in Katherine's case, Kernberg's presumptive criteria are easily met based on the
clinical data. Katherine presented with chronic, diffuse anxiety accompanied by bodily concerns.
She presented several neurotic complaints and symptoms such as inappropriate preoccupations
and obsessions, which she had in conjunction with brief dissociative episodes (periods of
memory loss in connection with her bodily experiences), hypochondriasis (pre-menstrual
cramps, digestive problems) and paranoid trends (expressed in her relationships with others,
mostly with authority figures, but also with the interviewer). As described in Chapter Three, the
presence of hypochondriasis in combination with paranoid trends is, according to Kernberg,
particularly suggestive of a borderline personality organization.
Katherine also presented with certain perverse sexual trends that became the focus of
considerable attention in her treatment. She insisted on taking a submissive, masochistic role in
the context of aggressive/sadistic sexual encounters. Although this presentation was not bizarre it
involved the replacement of genital pleasures by partial ones, as when she allowed strange men
to fondle her without sexual intercourse.
The presence of impulsive behavior was evident in several contexts, the most
noteworthy being her suicidal gestures, her episodic and often ego-dystonic sexual acting out,
and her sudden rages against family members and employers. Although in the initial interviews
Katherine had denied use of alcohol and drugs, it later became clear that in her adolescence she
had used marijuana and alcohol, at times to excess. During the treatment I wondered whether she
might not be "addicted" to her psychiatric medication, as she became extremely distressed when
she could not get her prescriptions filled and would sometimes wait for hours in the waiting
room of an emergency psychiatric service for a prescription renewal from her psychiatrist.
Katherine's need to substantiate a "chemical imbalance" as her explanation for her problems may
have helped her rationalize an underlying addictive tendency. Katherine also presented a
preoccupation with obesity and weight loss that became evident later in treatment. Kernberg
suggests that this is another form that addictive behavior can be manifest in borderline patients
(Kernberg, 1984).
Finally, Katherine exhibited features of several "lower level character disorders" that,
according to Kernberg often signal the presence of an underlying borderline organization.
Katherine's masochistic, impulsive and infantile personality traits were unmistakable, as were
certain narcissistic features, such as her intense envy and exhibitionism.
Any or all of the above-described traits may, according to Kernberg, point the clinician
in the direction of a diagnosis of a borderline personality. However, the diagnosis can only be
confirmed by a careful assessment of certain structural characteristics that involve the quality of
the individual's object relations, his/her defensive organization, and the presence of certain
identity issues (Kernberg, 1975).
Kernberg's Structural Diagnosis
As we have seen in Chapter two, according to Kernberg, the presumptive diagnosis of

borderline personality is only confirmed when a structural interview reveals certain features that
are characteristic of the borderline personality structure. These features are: (1) certain
manifestations of ego weakness, including poor anxiety tolerance, a lack of impulse control, a
lack of developed sublimatory channels, and a blurring of ego boundaries (2) a shift toward
primary process thinking, in spite of intact reality testing, (3) specific defensive operations,
including: splitting, primitive idealization, projective identification, primitive denial,
omnipotence and devaluation, (4) a pathology of internalized objects, (5) identity diffusion, (6)
excessive pre-genital aggression, and in general, (7) a primitive and unintegrated superego
corresponding to a fragile ego and self. In addition, Kernberg describes the borderline as having
differentiated self and object but having failed to achieve a sense of libidinal object constancy, as
described by Mahler (1972).
The Structural Interview
For Kernberg (as for Lacan) the diagnostic interview is not simply a gathering of
information. Rather, the structural inquiry involves a sophisticated level of listening and
observational skills, hypothesis formation, interventions and other techniques that are part of the
psychotherapeutic process (Kernberg, 1981). Only by implementing such techniques can the
interviewer gather the data necessary to form a "structural" diagnosis based on an assessment of
ego functioning, typical defenses, object-relatedness, etc. Technically, an initial interview
extends from one and a half to two hours. The diagnostician faces simultaneous tasks during the
structural interview. First he/she needs to keep his/her attention constantly on the patient,
observing her behavior and listening to the verbal communications, while generating hypotheses
regarding her symptoms. At the same time, he/she needs to assess the nature of the interaction,
utilizing his/her own emotional reactions as a means of clarifying the nature of the patient's
object relations and use of defensive operations.
At the start of the interview the patient will be asked for a description of her symptoms
and difficulties, her reasons for seeking therapy, and her expectations regarding treatment. The
open-ended nature of the initial contact has great value for the diagnostic process. Kernberg
encourages clinicians (and particularly those who have limited experience with this type of
interviewing) to perform a systematic search by following the cycle of anchoring symptoms
(Kernberg, 1984). This cycle follows a path from neurotic symptoms to character traits to the
major marker of borderline condition (identity diffusion) and then to psychotic symptoms (reality
testing and functional symptoms) to the more organic brain syndromes (based on an evaluation
of sensorium, intelligence and judgment). In contrast to the classic psychiatric interview,
Kernberg proposes specific challenges to the patient's defensive structure that will permit the
structural hallmarks of the borderline conditions to emerge. A further advantage of the structural
interview is its flexibility, as it permits the clinician to move to a more classical format (what is
referred in clinical settings as the Mental Status Exam) in cases of organic and/or functional
psychosis or back towards a more structural approach if more neurotic or borderline
characteristics appear. Although the structural interview poses a risk of raising primitive
defenses too early in the treatment, the classical interview as performed in most outpatient
settings, has the disadvantage of allowing the patients defenses to go underground, making it
easy for the patient to "adapt" to the questions and mask important personality traits, while at the
same time decreasing anxiety and blocking early transference developments that would
themselves be of diagnostic (and later therapeutic) significance.
As a clearer picture emerges from the interview the clinician should focus on the
exploration of significant symptoms and traits, but now emphasizing their appearance in the
current interviewing situation. It is at this point that Kernberg begins more active efforts to
clarify those aspects of the patient's presentation that appear incongruous. This is done by
confronting the patient with that material (verbalizations, ideas, affects and behaviors) around
which the patient is clearly ambivalent or confused, and by being attentive to how the patient
handles the interviewers query. Further, the therapist, following Kernbergs procedures, moves
constantly from clarification to confrontation when the patients incongruities arise. This helps
the therapist focus attention on a major cluster of symptoms, at the same time, monitoring the
quality of reality testing, especially in the context of regression.
Katherine: The Diagnostic Interview
The initial phase of the interview with Katherine provides an illustration of Kernberg's
ideas regarding the structural vs. classical interview. Almost immediately Katherine herself
attempted to control the interview, requesting that the analyst move away from her open-ended
(structural) approach and ask her a series of questions (perhaps corresponding to the more
classical history gathering and mental status format) that she was expecting. As the interviewer
challenged the patient to talk freely about herself, defensive operations accompanied by an
increase in Katherine's anxiety became obvious. This anxiety is judged by the clinician to be
intense but manageable. Katherine became vague and "off target" when trying to pinpoint her
problems and complaints. As the therapist continued to press her, Katherine became more
intellectualized and avoidant. Had she become more disorganized, showing signs of disabling
anxiety, acute paranoia, or psychosis, the interviewer would have indeed shifted to the more
classical mental status/history examination.
It is clear from the outset that Katherine had difficulty communicating in the therapeutic
setting, and was quite vague regarding both her symptoms and conflicts. Her vague, inadequate
and confusing communication was evident in spite of otherwise strong verbal skills and a level
of intelligence that, based upon an assessment of her vocabulary and linguistic style, was, at
least, in the average range. However, neither severe verbal disturbances nor bizarre thinking
were noted.
In Kernberg's style of interviewing, the psychoanalytic and psychiatric thinking and
technique go hand in hand in an effort to collect data that will enable the clinician to make
inferences regarding the major categories designated by Kernberg in his structural analysis. I will
examine each of these areas as they apply to Katherine's case.
(a) Identity Diffusion: Neurotic Integration vs. Borderline Fragmentation

A lack of an integrated identity is perhaps the defining feature of borderline organization
and manifestations of this lack are thus important markers for the borderline diagnosis. Amongst
such manifestations are the patient's complaints of emptiness, evidence of emotionally lability
with respect to self and others and a flat, impoverished personal and interpersonal perception in
which the patient cannot convey a clear and adequate idea of himself and others to the clinician.
(Kernberg, 1984).
The therapist should evaluate the issue of potential identity diffusion in detail, probing
and even confronting the patient regarding any verbalizations about self and others that are
contradictory in character. It is here useful to examine the criteria used by Kernberg to define
self-integration, which, on his view, characterizes neurotic individuals. Kernberg states there
should be a central subjective integration of the self concept on the basis of which the
interviewer can construct a mental image of the patient" (Kernberg, 1984). If after a reasonable
period of time, the construction of such a mental image is impossible, there is prima facie
evidence for "identity diffusion." As we shall see later in connection of our discussion of
Katherine from the perspective of Lacan, this criterion opens up a controversy regarding the
issue of integration in neurotics vs. borderlines as a distinctive feature in differential diagnosis.
For example, it was evident from the description of the jobs she held and the sense of self
she attempted to forge around them how porous Katherines ego identity was. At one time, she
wanted to be a nurse, speaking enthusiastically about serving people in disadvantaged
circumstances, wanting to be of assistance to others (even volunteering in a homeless shelter). At
other times, she saw herself more as a performer who attracted men and felt a sense of being
when she was on the stage being looked at, as when she took a job as a belly dancer. However,
this sense of identity did not last long. Soon after she spoke candidly about her skills as, and
desire to be, a physical trainer, and so on.
This perspective on integration vs. diffusion of the self allows the therapist to form an
initial hypothesis, which may or may not be sustained through the current and subsequent
interviews. The patient may be exhibiting poor self-concept formation within a range from a
mild identity crisis to a full identity diffusion state, one that may result in a presumptive
diagnosis of a borderline personality organization. It is noteworthy, in Katherine's case, that as
she began to regress, her anxiety was transformed into physical discharge (scratching, rocking,
and squirming), and she was unable to articulate her feelings or the position of herself in relation
to others, leaving the impression of an empty core about which nothing could be said. Kernberg
states that in borderline organization there is enough differentiation between self and others to
maintain a porous ego boundary, in contrast to a psychotic presentation in which the ego and the
objects are fused and virtually no differentiation has been achieved. Kernberg theorizes that the
origin of this lack of differentiation rests on a failure in the transition from a symbiotic to an
individualized phase of development (Mahler, 1967).
Kernberg emphasizes the issue of time management as a diagnostic marker of identity
diffusion. The way borderline patients report their past history is so contaminated with the
negative and confused experience of their present psychopathology, that it is mostly unreliable.
The patient's historical account has a chaotic quality making it difficult to interpret or link past
material with the present symptoms. In his view, this is an important marker differentiating
borderlines from neurotics whose accounts of the past flow naturally and for whom dynamic
links can be made quite easily, thus, yielding the possibility of a therapeutic interpretation.
When Katherine was asked to describe in detail the argument she had with her father the
day before a particular session, and to elaborate on the themes of that heated argument, she
instead related her suffering with him as a child, describing her lonely mood after spending many
hours alone in the family apartment. This was followed by a description of how abusive her
father had been with her in the past, as she remained oblivious to the therapists request that she
speak about the events of the prior day.
By inquiring into the history of the patient, the therapist is not so much concerned with
data gathering per se, but should be more attentive to the capacity of the patient to differentiate
past from present and to forge a link between them. One looks for evidence of a contamination of
the past with present events as a marker of borderline personality organization. When discussing
a topic, Katherine would interchangeably discuss her feelings as a girl and as a woman with little
or no awareness of the temporal differences or the different qualities of affect expression and
experience in the child and adult, and certainly without considering the series of events that
might have impacted upon her experience during the years in between. Katherine had difficulty
differentiating her past boyfriends from her current boyfriend. Frequently, the therapist found
herself confused about who she was referring to.
In borderlines, the past and the present cannot be linked, material is presented out of
order, fragmented in pieces, reminding us of how a dream might be presented. The borderlines
presentation not only express her intrapsychic conflicts, but also the fragile nature of her ego, the
fluidity of her experience of space and time, and the failure to link present with past life events.
(Kernberg, 1984). This lack of integration reflects the patient's poor comprehension of her
whole life.
Kernberg does not advise pursuing the exploration of the past and its linkage to present
material in the form of an interpretation in borderline cases. This is because an attempt to do so
may render the patient incapable of making such connections herself, as she is overwhelmed by
the emotional intensity of the here-and-now (which extends into the past but cannot be
articulated as such for the moment). It is typically easier to make such linkages in the treatment
of a neurotic (although in some cases the neurotic patient will be limited in her understanding by
the repressive barrier of her unconscious).
The therapists perception of Katherines emotional experience was that of a wounded,
vulnerable child. However, in testing the limits, it became clear that Katherine's blurring of past
and present, and of self and other, was not psychotic in nature and that for the most part her
reality testing remained grossly intact (see "Reality Testing" below).
The issue of identity diffusion is inextricably linked with that of the borderline's
defensive operations. In neurotic individuals the exploration of conflict brings the defense
mechanisms to the fore, yet the presence of more adaptive defenses such as repression,
rationalization or intellectualization are difficult to pinpoint in the course of an early interview

since these defenses do not immediately intrude on the therapist's work, appearing in the verbal
content but not generally affecting the therapeutic interaction. However, in interviewing a
borderline and particularly in the exploration of the patients identity diffusion, the activation of
primitive defenses (such as denial, projective identification, etc.), affects not only the patient's
verbalization but the whole interaction with the therapist which becomes distorted, altered and
radically transformed. This, according to Kernberg, is a significant structural criterion for the
diagnosis of borderline personality organization.
For Kernberg, identity diffusion is clinically evident in a poorly integrated concept of
both the self and significant others (Kernberg, 1984). The chaotic nature of Katherine's object
relations was reflected in her interactions with the interviewer, and involved acting out behaviors
regarding all aspects of the treatment, demeaning verbal communications in session and constant
questioning of the format of the meeting and the payment for the therapy. If the therapist would
ask to change a session time, she would agree; however, she would not show up or cal to change
or cancel her appointment. Katherine also expressed little regard for others in her immediate
environment, in spite of complaining about how everyone in her life was abandoning her. For
example, in one session, Katherine reported that she started reading some letters that her father
had sent her stepmother years ago when they were first dating. Although she felt guilty about the
fact that she did not have permission to do so, she was more worried about being caught than by
the fact that she was disrespecting her familys privacy. Katherines chaotic interpersonal
relationships were evident in her strong ambivalence regarding family members. She would
complain about the warmth of the relationship between her mother and brother, but when invited
to attend a show with them, she would reject the invitation even if it meant that she was going to
spend the night alone.
In sum, with respect to the issue of identity diffusion the interviewer will attempt to
arrive at a picture of the patient's self and object representations and their integration or lack
thereof. She will also evaluate the patient's thoughts, affects and behaviors and judgment (as in a
mental status exam). Lastly, the interviewer will evaluate the patients stance towards the
therapist's needs and experience, which will reflect the patients level of relatedness, capacity for
empathy and reality testing. By each of these criteria, Katherine showed clear evidence of
identity diffusion as it is defined by Kernberg.
(b) Use of primitive defensive mechanisms - Projective Identification

For Kernberg, the nature of defensive functioning is another important structural marker
of borderline pathology (Kernberg, 1984). In contrast to neurotics who utilize such higher
defenses as repression and intellectualization, borderlines and psychotics tend to utilize such
primitive defenses as projective identification, splitting, primitive idealization, denial,
omnipotence and devaluation. Contradictions in the patient's communications reflect the
presence of conflict, and are typically accompanied by either adaptive (neurotic) defenses or the
predominance of primitive defense processes (in borderline or psychotic states).
For Kernberg, the function of primitive defenses in the borderline is to avoid intense
experience of anxiety and severe conflict, an avoidance that is achieved at the cost of weakening
the adaptive functions of the ego. One of the most salient of these defenses is the mechanism of
splitting, which protects the ego from conflict by keeping self and others representations
dissociated in such a manner that it becomes impossible for the individual to have contradictory
(good and bad) experiences at the same time. When anxiety arises, one or the other ego state is
activated and this serves to control anxiety that might otherwise overflow the ego (Kernberg,
1975). Kernberg asserts that the interpretation of splitting to a borderline patient can be tolerated
and improves her functioning. By way of contrast, for a psychotic individual, where splitting
protects the patient from a complete disintegration of self and other boundaries, interpretation of
splitting promotes further regression.
The use of defensive splitting was evident in Katherine's often contradictory descriptions
of her mother. Katherine sometimes portrayed her mother as a plain and simple hard worker who
cared for her children as she was subjugated by her husband's severe temper. At other times,
Katherine portrayed her mother as a sadistic, unpredictable and domineering woman who was
calculating and self-centered. The patient was unable to differentiate the times and events that
led her to form such contradictory images of her mother. While she was indeed able to tolerate
an interpretation of this contradiction she never achieved a single image of a mother with both
good and bad qualities.
Another example of primitive mobilization of defenses is evident in the following excerpt

from one of the early interviews. An initial negative feeling towards the interviewer is here
characterized by mistrust and detachment. As the interviewer continued to challenge the patient,
further weakening of her ego functions occurred in the context of the interaction, and the use of
paranoid defenses and projection, typical borderline defenses, emerged:
I: Have you noticed that you have remained vague when asked to elaborate the issues
you have with your father?
(Patient squirms in her chair as she begins scratching the surface of her arms by
reaching each arm with the opposite hand, leaving red marks everywhere). Silence sets
in and the patient continues with the scratching, adding a rocking movement while
looking down at the floor.)
I: I can see that you are certainly quite uncomfortable with this topic. However, I
wonder if you can see my point about avoiding discussing the last interactions you had
with your father that might have brought you to therapy?
K: I was trying to make a point about how bad my father has treated me all these years.
Are you suggesting that it is all my fault?
I: It appears that my asking you what specific difficulties you had in the last weeks with
your father has been interpreted by you as an accusation that you are to blame for
something Are you hearing that from me?
K: Well, I did not hear it, but I certainly feel that there is a possibility that I have done
something wrongsomething that he really hates from me.
In the above excerpt, Katherine's own guilt is projected into the person of the therapist.
However, when this defense is questioned, Katherine is able to assimilate the interpretation and
regain her reality testing. In making such trial interpretations the experienced interviewer creates
a number of hypotheses related to defensive functioning, object relations, and anxiety tolerance.
The following excerpt is a continuation of the previous one, and further illustrates the use of
primitive defenses.
I: So, what I am hearing is that you become very anxious when something goes wrong
and more anxious if you have to review it, no matter what it is, call it your father, your
health.
K: Yes, indeed.
I: How are you feeling right now, here sitting with me talking about all of these topics?
K: A bit better now, but distressed. I had a therapist before but she disliked me very
much. As a matter of fact, she terminated our treatment saying that I did not cooperate
with it. I admit having difficulties to arrive on time, but with my depression it is very
hard at times to get up from bed.
In this case, the interpretation of this defense led to a decrease of anxiety and
improvement of the patient's functioning within the interaction, but at the same time, a
displacement of her feelings of rejection and abandonment onto the figure of her past therapist.
The use of denial was quite common in Katherine. In the early interviews it became clear
that she denied the emotional implications of many of her actions in relation to both self and
others. For example, she would calmly describe putting herself in a dangerous situation without
giving voice to affects that would normally be elicited by such danger. For example, when the
therapist inquired about Katherine's throwing herself out of the moving car, she just dismissed
the event as her father "overblowing everything she did". She projected a nonchalant and at times
callous attitude that actually reflected her denial of the emotional impact that her actions might
have on herself and others.
Katherines primitive defenses were manifest not only in the way Katherine expressed
her problems (e.g. instead of discussing her difficulties regarding her father, she started
somatizing and expressing them in body language), but also in the relationship with the therapist,
who, as a result of the patient's projective distortions began to feel more restricted in her freedom
to interact with her.
c) Assessment of reality testing

Clinically speaking, intact reality testing is recognized by the absence of hallucinations
and delusions, the absence of grossly inappropriate or bizarre affect, thought content and
behavior, and by the capacity of the individual to empathize with others points of views. On a
more subtle level, reality testing is grossly intact when the patient proves capable of responding
in a generally realistic manner to challenges to her major distortions. For example, in the
interaction with her therapist described above, Katherine distorts the implications of her
therapist's questioning (regarding her avoidance) and says "Are you suggesting that its all my
fault?" However, when asked if she actually heard blame from the therapist she responds: "Well,
I did not hear it but I certainly feel that there is a possibility that I have done something wrong."
To take another example, Katherine related that during her adolescent years she had an
experience in which a few classmates tried to sexually seduce her in her room during a camping
trip. She stated that she finally overpowered them and threw them of her tent. She reported to the
therapist that she heard the voice of one of her girlfriends inciting the boys to this behavior.
Upon exploration, however, the patient was able to cast doubt on her own beliefs about what she
had heard (she stated that she was under a lot of stress that night). The voice was described as
something she heard, coming from outside of her mind but which ultimately was experienced as
an intrusive thought. In light of Katherines description of the event, the therapist again found
herself with an unclear picture of what had occurred, how the patient felt, perceived the events
and handled the situation. However, it was clear that Katherine was able to take a reality-oriented
attitude even towards her own perceptual distortions.
Based on this and other data as well as the overall clinical presentation of this patient, a
psychotic organization could be ruled out. As Kernberg puts it: "The presence or absence of
identity diffusion differentiates borderline from non-neurotic character pathology, and the
presence or absence of reality testing differentiates borderline personality from psychotic
structures" (Kernberg, 1978).
d) Non-specific ego weaknesses

The non-specific ego weaknesses in the borderline patient are, according to Kernberg,
reflected in the presence of anxiety and poor impulse control, each of which the patient has
difficulty managing, both with others and in the transference relationship. Further, such
individuals lack sublimatory channels for enjoyment and achievement. It is noteworthy that
Kernberg differentiates specific from non-specific ego weaknesses. Specific ego-weaknesses,
which are also present in borderline patients, refers to a weakening of the ego as a result of the
predominance of primitive defense mechanisms that renders the individual dysfunctional in spite
of a faade of "tolerable social functioning
Katherine had very low tolerance for frustration which interfered with her capacity to
formulate and implement life goals. Under circumstances that evoked anxiety, she would
typically engage in an impulsive act that was undertaken virtually without any self-monitoring.
For example, on one occasion she had an argument with her college financial aid office. She had
applied for a scholarship and it was denied. She was offered a federal loan but she felt so angry
that she walked out and never returned to the school. It took several sessions in treatment before
Katherine was able to examine the negative consequences of her impulsive behavior.
Further, she made several important life decisions impulsively. She would quit a job out
of anger and frustration with no other employment lined up; on one occasion she angrily packed
her belongings and left her parents home only to realize a few hours later that she had nowhere
to spend the night. Her lack of sublimatory channels was reflected in her jumping from hobby to
hobby and from job to job without ever committing herself to a sustained creative or career
pursuit, in spite of her stated wish to do so. At one point she expressed interest in pursuing a
sewing project and at another point, in taking a class in sculpture. Yet in the first instance, after
an initial effort, she decided that her work was unacceptable, and in the second instance she quit
after an argument with her teacher following his attempt to counsel her on a particular technique.
None of her hobbies or pursuits ever resulted in a finished work or a sense of personal
achievement.
It could be argued that Katherine's extreme physical activity (i.e. working out in the gym)
had a sublimatory function. However, the approach that the patient had towards these activities
appears to have had more of a compulsive, aggressive quality and might be better understood in
light of her aggressive and self-destructive tendencies. Her excessive biking to the point of
exhaustion, her pursuit of high-risk physical activities such as parachuting, all had a self-
destructive quality.
Katherine's poor impulse control was also clearly evident in such acts as a turnstile
jumping on the subway and stealing money from her father. Impulsive aggressive acts also
emerged in the treatment, especially on occasions when the patient felt blamed for her feelings
towards the therapist. Her impulsive acting out included stealing a pen from the therapists
office, taking out food from her bag and beginning to eat in the middle of session, and cursing at
the clinic receptionist when she was told that she had arrived early for her session.
(e) Lack of Superego Integration - Excessive pre-genital aggression

In classical psychoanalytic theory, the superego is thought to evolve out of the resolution
of the Oedipus Complex, and to embody identifications with an ego ideal and the development
of a moral conscience that reflects the childs understanding of right and wrong. Depression and
obsessive-compulsive disorders are thought to be characterized by a punitive, rigid, critical
superego that reproaches the ego regarding its wishes or behaviors and demands their
modification.
It is often thought that because borderline pathology is mostly associated with pre-
Oedipal issues of development, the effect of superego is not particularly important (Goldstein,
1985). However, in typical neurotics, the superego, although severe, is well-integrated. In
borderline disorders, Kernberg asserts that in addition to, and along the same lines of a poorly
integrated ego, the superego of these patients, while variable in its effects, typically reflects a
lack of integration. This lack of integration is manifest in the individual's contradictory attitudes
towards self and others that swing from idealization to aggressive devaluation according to the
patients mood.
The presence of a victimized self-concept is evident when Katherine initially suggests

that she is to blame for her ailments. When asked to elaborate on her thoughts, she is unable to
do so. This self-punishing quality of the superego is typical of borderline organization, and
reflects parental introjections and identifications:
K: I think I am feeling quite ill today, and although I know I suffer from chronic PMS, I
have always wondered if I am somehow responsible for making myself sick.
I: How is it that you experience this idea of making yourself sick?
K: Well, I am very depressed and I wanted to stay in bed today more than ever, you
know the day of our first meeting, and I just think that my sadness and lack of energy
might be related to my PMS.
I: If I heard correctly, you also think that there is a possibility that somehow you are
able to put yourself in that situation, making yourself sick. How is it that you do that?
K: I just, I just have a series of problems that have happened to me over and over and I
thought...maybe its me.
I: What sort of problems are you referring to?
K: Since I was a little girl, I have been physically and verbally abused by my parents,
well, some psychologists call it neglect, but I feel its more of abuse because it has been
constant. My father used to scream at me for the slightest misbehavior and you see....
He is such a malicious man, very selfish and the least concerned about me.
The quality of Katherine's superego functioning indeed paralleled her wavering self-
concept and was manifest in an alteration between antisocial behaviors, intense aggression
towards others, and an extremely harsh, aggressive and self-punitive relation towards her own
self. On the one hand, Katherine presented a sense of entitlement that was expressed in ego-
syntonic, antisocial behaviors. She would lie and create fictional stories about herself, at times
with the ostensive purpose of gaining an advantage with others. At other times, however, her
deceits seemed to be motivated by the desire to punish others or herself. An alternating cycle
between masochistic/passive versus aggressive/sadistic superego features was reflected in
aspects of the therapeutic relationship. As we have seen, she would become inordinately upset,
even tearful, if the therapist announced a vacation or requested even a slight alteration in the time
of her session. However, she would become enraged at those points when she interpreted the
therapist's intentions as agreeing with the narrow-mindedness of the authorities. At one point,
for example, she complained about the clinic receptionist who would not immediately release her
records to her treating psychiatrist. When I explained to her that there was a simple written
release procedure that applied to everyone, she angrily told me I was petty and narrow-
minded. Further, she would frequently devalue and attempt to negate any progress related to our
work in therapy, an act that both expressed her aggression towards the object (her therapist) and
aggression towards the self (I guess it is nice to talk to a pleasant woman about my personal
life, but I do not see the value of being questioned so much). This primitive aggressive core was
transformed, on occasion, into paranoid ideation. At such times her masochistic, submissive
attitude was converted into an openly hostile response towards the therapist and the treatment.
(This whole thing is a scam to steal peoples money!)
Kernberg traces the genesis of the borderlines superego development to the
internalization and identification of an overpowering parental figure perceived as omnipotent and
cruel. While on one hand Katherine reported intense gratification in her aggressive fantasies,
which included cutting others, shooting them or pushing them to their death, on the other hand,
she could be totally manipulated by men in a sexual context, resulting in her feeling humiliated
and depreciated. This combination of sadistic fantasies and masochistic behaviors not only
illustrate Katherine's primitive, pre-genital aggression--one of the hallmarks of borderline
structure--but also the primitive, unintegrated nature of both her ego and superego functioning.
Kernberg invokers the concept of "excessive pre-genital aggression" in order to explain
the complexity of symptom formation in the borderline patient. Kernberg theorizes that all the
processes involved in the unconscious resolution of the oedipal vicissitudes acquire destructive
and primitive qualities that are expressed later in masochistic-sadistic and paranoid tendencies.
On the other hand, the possibility of idealization of a love object (because of its absence and
longing) is rapid and total. Therefore, the borderline can shift from total dedication to an other,
to total rage or withdrawal. This was amply evidenced in her expressed feelings and attitudes
towards her boyfriend, father and the therapist.
Kernberg underscores the idea that frustrated oral dependency needs expected from the
mother are displaced onto the father, increasing castration anxiety in girls in the form of penis
envy and severe superego prohibitions against genitality in general. It is possible to find distorted
and severely aggressive versions of the primal scene that impact upon the future sexuality of the
girl in her choice of love objects. Further, because of gender identity conflicts around the figure
of the parents, there is a tendency towards bisexuality in the condensation of both sexes in both
parents. These sexual features of the fantasy of the patient may not be accessible in the first
interviews but appear in long-term treatment, in the exploration of the sexual difficulties that the
patient eventually acknowledges. As Katherines treatment evolved she discussed her fantasies
of being raped by a man and/or a female, or of being forced into performing oral sex. These
fantasies typically, and contradictorily, also involved her as the seducer of her sadistic partners.
In sum, a review of Katherine's case reveals her to meet both Kernbergian "presumptive"
and "structural" criteria for the borderline diagnosis. Kernberg's structural interview is a multi-
step task that requires psychological, psychiatric and psychoanalytic knowledge. It also demands
psychotherapeutic experience on the part of the interviewer along with a substantial clinical
background. From one perspective, this type of interview reflects a fusion between descriptive
psychiatry and psychoanalysis in a highly effective form. As we shall see, an alternative, more
critical point of view, suggests that Kernberg perpetuates descriptive psychiatry by importing its
terms and criteria into, and under the guise of, psychoanalytic theory.
Chapter Six
Katherine as a Lacanian Patient
The Demand for the Desire of the Other
Having discussed Katherine from within Kernbergs perspective on the borderline it

remains for us to pursue a Lacanian interpretation of this case. The analysis I will provide will
not only serve to illustrate significant differences between Lacan and Kernberg but will also
document a shift in the direction of the therapeutic process in Katherine's therapy, as certain
Lacanian notions were incorporated into the treatment. The interpretation presented here will
draw upon several of the Lacanian concepts that were introduced In Chapter Three but is by no
means meant to be exhaustive or complete.
A Lacanian perspective takes its cue from the very first moments of the initial interview.
Recall that in the initial interview when Katherine was asked to describe the nature of her
difficulties, she expressed discomfort with this open-ended request, and answered this question
with her own request that the examiner formulate direct and specific questions about her
condition. From a Lacanian perspective, Katherine's request, in effect, her opening gambit, in the
initial encounter with the therapist, provides important data regarding how Katherine chooses to
position herself with respect to the therapist, as well as towards others in general. Whereas from
a Kernbergian perspective the request for a more structured interview mainly signals a weakness
or fragility in the structure of Katherine's ego, for a Lacanian, the request for an "interrogation-
Katherine as a Lacanian Patient 141
type" of interview can be understood as potentially suggesting something regarding Katherine's

fundamental (unconscious) fantasy.
When asked why she wanted to be questioned in such a manner, Katherine simply stated
that the idea of freely discussing her concerns made her feel uncomfortable. An inquiry into
the nature of this discomfort led not to a description of anxiety about a particular mode of
questioning, but rather into a description of some of her core symptomatology. These included
her depressive feelings, the impact of her bodily states on her mood, and reflection regarding
whether she herself might at least in part be responsible for her own pain. This move into a
description of her symptoms represents a subtle break in the associative chain, as the therapist's
questioning of the particular interpersonal stance that Katherine "signs in with" leads to an
expression of her core symptoms.
Here, at least, either a Kernbergian (fragile ego) or Lacanian ("fundamental interpersonal
fantasy") perspective fits the data, as each perspective can explain how it is that Katherine would
become "symptomatic" in response to the initial patient-therapist exchange. At this point, it is not
a question of eliminating one or the other point of view, but rather of recognizing the possibility
for both Kernbergian and Lacanian perspectives. However, we should note that a "choice" on the
part of the therapist at this very early juncture in the treatment--whether to see Katherine's
behavior as an expression of the state of her ego or an expression of her fundamental fantasy will
have ramifications that will ultimately pervade and condition the diagnostic picture, and even the
therapeutic process.
From a Lacanian point of view, Katherine's insistence that the therapist pose her own
direct and specific questions can be seen as the patient's demand to know what the other wants or
is looking for. In the previous chapter, we considered the possibility that this demand is a
conscious attempt on Katherine's part to learn something about the therapist's techniques and
abilities. Here, I am suggesting that it may well (also) be an expression of an unconscious pattern
of interpersonal relatedness. From a Lacanian point of view, Katherine's request is not so much
an expression of the ego's conscious goals, such as a need to control the therapeutic situation or a
means of managing first-visit anxiety. Rather, it speaks of some profound style that the patient
has developed throughout the years, which would be manifest not only in the here-and-now with
the therapist, but with her family, her boyfriend and others: the idea that Katherine must figure
out the nature of a demand coming from an external source which she feels prompted, even
compelled to fulfill. This fundamental fantasy would, if verified in other instances and contexts,
suggest for Lacan, the likelihood of a hysterical neurotic structure. So with one turn of the
interpretive dial we have already moved from a way of thinking that is considering a "borderline
personality" to one that may have no need for such a purported new structure, and which, at least
for the moment, considers Katherine within the more traditional psychoanalytic category of a
presumptive "hysterical neurosis."
Of course, both the Kernbergian and the Lacanian perspectives are, at this very early
stage of the diagnostic interview, simply hypotheses, to be refuted or confirmed by subsequent
data that will emerge as the interviews and analysis proceed. There is, of course, a danger here of
being locked into one's initial hunches and then seeking (and finding) only data that confirm
one's theoretical prejudices. Katherine's hesitancy to take the lead in her own discourse may
simply be an example of the resistance that nearly all psychoanalytic patients' have to their
analyst's request to engage in free-association. More data is needed. Such a problem, however, is
endemic to all forms of psychotherapy and is neither unique to Kernberg or Lacan, nor, for that
matter, to psychoanalysis. So let us proceed and see where the Lacanian perspective leads us.
As we will see, this patient's demand to be questioned by the therapist will indeed prove
to be a key to the "Lacanian Katherine," for, repeatedly throughout the course of her treatment,
asks of the other: "What do you want to hear, what do I need to be?" The patient, we will see,
appears to be invested in questions (and answers) ready-made by others. For example, during
many of our sessions, she would enter the office, sit down and ask, What is the matter with me?
Tell me, you know what is going on, what do I have that people seem to dislike me so much?
How should I be so that Ill be liked? Early on in treatment, the therapist's response to these
queries was to reflect the question back on Katherine herself; What are your thoughts about
what's wrong with you? However, this approach yielded little if any insight or working through.
In response, Katherine would resort to repetitive discussion of daily family situations and a
therapeutic opportunity would be lost. Rather, it was only when the therapist shifted the
discourse from what the others found wrong with Katherine, to querying more directly
regarding the significance of her, What do you want? that Katherine was forced to move off
her attempts to please others and examine (how little she was aware of) her own desire.
Katherine would often inquire of the therapist How are you feeling today? Is everything
OK with you? In spite of never having discussed or being encouraged to discuss any aspect of
the therapist's personal life, she was intently invested in discerning the desire of the analyst and
to position herself in such a manner as to become its cause.
It might be said that rather than questioning herself, Katherine was in search of a
question. During the interview process, when the therapist refused to meet Katherine's demand,
and instead asked why she was feeling uncomfortable, Katherine began to describe her general
symptoms, and inquired about the condition of her suffering, but eluded any self-questioning that
could lead her to the condition of her own desire.
Identity or Desire?
Indeed, Katherine is very astute in ascertaining what she presumes to be the desire of the
other, but is almost without a clue with respect to what it is that she herself wants. She moves
from school to job and then job to job, finding herself engaged in a varied matrix of "pursuits"
without ever settling on what it is she "desires." She is a an attendant in a geriatric home, a
salesperson in a boutique, a florist, a tour bus guide and a belly dancer, and each of these jobs
ends in a conflict with her employer. From a Kernbergian perspective, we have a failure to
consolidate a unified ego or strong identity along with lack of sublimatory channels (in what has
been described as an "as if personality). From a Lacanian point of view, we have a failure to
understand and own one's desire. Once again, what for Kernberg is a structural weakness in the
ego, for Lacan understood in terms of the unconscious. Lacan is uncompromising in his focus
upon the unconscious. It is as if he is telling us, "Whenever you are tempted to understand the
patient's symptoms or behavior as a manifestation of his or her ego-state, ask yourself how the
behavior or symptom provides a clue to his or her unconscious desire." This, in essence, is
Lacan's famous "return to Freud."
Lacan states that desire is the central point or crux of the entire economy we deal with in
analysis (Lacan, Seminar VI, 1959). When the desire of the patient becomes the center of the
treatment, then both therapist and patient lose interest in a discussion of everyday social reality,
as these are generally not reflective of who the patient is as a subject. Indeed, one can say that
when the analysand begins to speak about his or her desire, she moves from being a patient
describing symptoms and occurrences (making demands), to being a subject of desire. As a
"patient," Katherine is happy to be asked and to answer every question of an ordinary mental
status or psychosocial evaluation, and is uncomfortable or even unable to relate in the
psychoanalytic "free-associative" manner that alone can provide the clue to her desire.
The Didactic Phase of Treatment
Since Freud, psychoanalysts have recognized that it is important to be somewhat didactic

in the initial interviews and phase of analysis, to teach the patient what the goal of an analysis is,
and to provide him or her with a hint as to what kind of communications (manner of speech and
subject matter) are useful in an analysis and which ones are not.
Thus, the early part of the analysis is devoted to an explanation of the role of the analyst
and the expectations of the work that the patient is embarking upon. Following Freud's
instructions on this, the patient needs to hear that any and all of her communications are
important, that she should speak everything that comes to mind (no matter how ugly,
unacceptable or insulting it may appear). An emphasis is placed on the analysand bringing
material related to dreams, forgetfulness, fleeting thoughts and fantasies, along with blocked
actions and misunderstandings. The analyst, from her side, must continually and without fail
encourage the patient to share her thoughts.
It appears that despite all of her previous treatments, and her report that in at least one of
her prior treatments she was in analysis, Katherine had not been taught what was expected of
her in analytically oriented treatment. Often therapists mistakenly take for granted that their
patients, especially those with prior experience in therapy, know what is expected of them as an
analysand.
In a Lacanian analysis what is important is that the patient puts a particular aspect of her
life into question for the analyst, and also that she initially (though this must eventually change)
experiences a desire for her symptoms to disappear. Early on, when questioned about the
possibility that she bears some responsibility for the production of her own symptoms,
Katherines anxiety would peak. Such inquiry when conducted too early or too forcefully may
constitute a technical error as it may actually deter the patient from becoming motivated for
treatment. Further, had Katherine's underlying personality structure been psychotic, a persistent
confrontation by the therapist could have resulted in a severe psychological decompensation.
While it is true that the preliminary interviews are utilized to attain an overall life picture of the
patient and to make a determination regarding the clinical structure, it is not always possible to
attain clarity in these matters in a few sessions. The therapist should not attempt to push the
process beyond the patient's capacity simply in order to quickly arrive at a diagnosis. Indeed, the
very process of diagnosis goes hand in hand with determining in a more refined manner what
position the analyst must take with respect to the patient in question. (Fink, 1997).
From Interview to Treatment
One important technical milestone in any treatment is the sorting out of the therapeutic
value of the preliminary interviews versus the treatment proper. During the interviewing process
the patient brings a presenting problem that she/he tries to explain by associating it with some
present or past event that brought about a crisis which led her to therapy. In the treatment proper
phase, the patients whole life is put into the question as the transference relationship is initiated
with the analyst who supposedly knows something that the patient does not. This starts the
beginning of an analysis.
Lacanian Structural Diagnosis
The goal of Lacanian structural diagnosis is to determine the correct position of the
analyst in the transference, the specific interventions that can or cannot be attempted, and, hence,
the treatment approach that will be most suitable for the individual patient, The most important
distinction that must be made (with due care but as early in the treatment process as possible) is
between a neurotic versus a psychotic structure. As we have seen in Chapter Three, Lacan
accomplishes this through a careful assessment of the defining mechanisms of "negation" that
appear in psychosis (foreclosure), neurosis repression), and perversion (disavowal). These
mechanisms of negation are not to be confused with the ego's mechanisms of defense, which,
according to Lacan, are a secondary development. Rather they are constitutive of the pathology.
In Lacan's view, repression is the cause of neurosis, not just a characteristic of it, while
foreclosure constitutes psychosis and disavowal constitutes perversion. This strict way of
conceiving diagnosis would seem to rule out the possibility of the borderline diagnosis, since no
particular form of negation is associated with it. (Lacan, 1953).
For Lacan, an important diagnostic marker involves the use of language, particularly the
choice of words. What is the particular use of language that this patient brings to each of her
sessions? Listening rather than observing becomes the most important part of this work.
Although the patient discusses numerous symptoms related to her physical conditions (her pre-
menstrual pains, headaches, fatigue, etc.) the clinician should not be led into producing a list of
symptoms that can classify the patient in one or other nosological category. Patients with severe
hysterical presentations have such a vivid fantasy life that they can relate, and seemingly produce
at will, virtually any symptom imaginable; these imaginative inventions" are particularly
common in hysterical dissociative states". Obsessive patients also can be so persistent in their
perseverations as to be confused with paranoid psychotics..
It is important to note here that, for Lacan, the capacity of the patient to work with and
achieve insight through free-association to dreams and other materials is a mark that he or she is
conditioned by "repression" and therefore has a neurotic, as opposed to a psychotic structure.
Thus, the therapist's tentative efforts to work with dream material can provide important insights
that will help formulate both diagnosis and treatment (Fink, 1997).
The Analysis of Two Dreams
In this regard, it is important to note that an important turning point in Katherine's

treatment came as a result of two dreams she brought into therapy after she was released from
the hospital subsequent to her suicidal gesture (during which she ingested 25 aspirins). The
analytic work with these dreams gave the therapist a better picture of the meaning that Katherine
gave to her body and in particular, to her genital/reproductive organs. More importantly, the
dreams provided both patient and therapist an entrance into several important aspects of
Katherine's repressed desire.
At the time, Katherine was advised to attend twice-weekly sessions in order to help
process and contain her intense affect. While she reluctantly agreed at that time, increased
contact paid off with an intensification of productivity in the verbalization of her thoughts and
emotions.
1st Dream:
Patient had a dream in which she was entering a deli with her mother and
brother when she saw her friend Maria eating from the salad bar. She was
amazed at Maria's lack of "table manners"; she was eating with her hands and
stuffing food in her mouth and swallowing it in great gulps. The patient tried to
stop her and explain the correct and acceptable behavior but her friend looked
puzzled and responded with incoherent speech.
The following week the patient brought a second dream to session.
2nd Dream:
She is looking at herself in the mirror and she sees herself naked from the waist
up. She turns around as she is frightened by an image she has seen in the
mirror, which looks like a small red knife that is coming at her at a fast speed.
She quickly moves away but the knife hits her in the wrist opening up a hole.
She is horrified.
As will be explained in due course, the first dream, which Katherine reported at the time when
her boyfriend abandoned her, became a marker of a new phase in her treatment. The second
dream, which she reported a week later, marked the experience of a structural change. As we will
see, it is this dream that marks Katherines movement from an incessant aggressive posture
towards males to an exploration of feminine needs and her relation to the maternal figure. What
follows is a condensed version of the associations and interpretations of three dreams that arose
over several sessions.
In the first dream, the patient dreams of a friend who is a 22-year-old pregnant runaway
girl. Katherine had made her acquaintance in a shelter for women where she went twice a month
to do volunteer work. Katherine had taken a special interest in this young woman who she
described as a heavy smoker and as possibly mentally ill. Katherine was concerned about how
poorly her friend took care of herself and she made various attempts to assist her in improving
her hygiene, dress, eating habits, and make-up. Katherine's associations to this dream revealed
that she had projected her own conflicts onto this young woman. In the dream, her mother and
brother accompany Katherine. We should recall that whereas Katherine had described her own
mother as completely lacking in maternal feelings towards herself, her mother had expressed a
strong tenderness, and in fact had been quite loving, in relation to Katherines brother. As the
associations to Katherine's dream developed, it became clear that the dream image condensed a
projection of Katherine's oral maternal needs and her feelings of sibling rivalry towards her
brother. Katherines own associations led to the judgment that "needing something very badly"
can be interpreted as "bad manners or bad behavior." After all, wasnt Katherine herself the
hungriest of all in her need of a maternal figure?
The patient's associations led her to conclude that she not only felt that she did not have
enough of her needs fulfilled ("oral needs in psychoanalytic terms) but that she had also been
deprived of attaining an understanding of what it was to be a woman, as her father had raised her
and had taken on many of the roles that Katherine felt should have been taken by her mother.
(This conclusion pointed to genital identifications that were unfulfilled as well). In associating to
the bleeding of the second dream, Katherine recalled that on the day she experienced her
period for the first time, her mother was not at home, and her father was the one who was
available to her. She told her father what had happened and he sent her to bed to rest. When her
mother arrived home late that night Katherine told her about the change. Katherine initially had
feelings of satisfaction for being a grown-up woman and also experienced a need to be hugged
by her mother. Profound dissatisfaction ensued when her mother refused to discuss the subject.
The second dream advances the working through and enabled Katherine to change her
position, as she recalled other events in her life that were totally blocked from consciousness
until she freely associated to them in session. Katherine, in part, answers the questions raised in
the first dream. The image of the mirror (process of identification) now is on the experience of
the body, yet, she wonders if this is truly her own body. Katherine questions who is in the mirror.
Is it herself or her mother? From a Lacanian point of view this dream involves a fantasy of the
imaginary fusion between the self and the imaginary other.
The second moment of the dream, in which she observes an object coming at her in the
form of a red knife, brought many associations. One of them was to an accident that Katherine
sustained as a child as she was playing on a seesaw. Her brother was sitting on the other side and
at one point, Katherine who was in the air, lost hold of the seesaw and landed hard on the
ground. She started to bleed in her trousers. Her mother became so anxious about this incident
that she not only brought her to the pediatrician but also demanded that he examine her for a
possible loss of [her] virginity. This incident brought a further association regarding an
incident that Katherine heard about, but which she had not recalled for a long time. The incident
related to her mother being seduced by a family member in Katherine's grandparents' home. This
had been a chapter in the family history that precipitated all kinds of blaming and self-loathing in
her maternal grandparents.
As the patient's associations continued, it became clear that the hole opened by the
entrance of the knife established the definition of a woman and further the particular definition of
what it is to be a woman in Katherine's family. Women in this family took pleasure in a
masochistic stance. Further, Katherine views herself in this dream as "a failure" in comparison to
the figure of the brother, who is "on top", the one that does not fall or bleed. In discussing her
brother, Katherine explored in depth her feelings of jealousy and envy. Her brother's
relationship with their mother had been very different from Katherine's. Her description of a
cold, detached woman did not seem to comport with her brother's experience. Further, her
brother grew up to be a successful young man who had achieved what he desired ("he was on top
of the game"). However, as she was describing her feelings about her sibling, it became clear that
women in her family had a destiny marred by depression, failure and loneliness, and further, that
they, herself included, had difficulty enjoying a sexual relation.
The analysis of these two dreams produced a turning point in Katherine's therapy, one in
which productive work began in several important areas, in regard to Katherine's failure to
acknowledge her own needs and assume her own desire, her relationship to her mother and with
men, and Katherines quest for personal achievement. These analyses also provided much insight
into the inter-generational role and destiny that Katherine was repeating in each of these areas, an
insight that, as I will discuss below, becomes possible within a Lacanian treatment.
Dream analysis as the analysis of primary process and the libidinal significance of
linguistic structures is often avoided in the treatment of "borderline" patients. As such, this
material might not have been available given the limitations that psychoanalysts often have with
so-called "borderline patients." Such clinicians are often concerned about "tipping the balance"
of an unstable, weakened ego structure and of pushing such patients into a psychotic break by
asking them to free associate to such primary process material. Although it is important to
determine, before plunging headfirst into dream analysis and free-association, whether the
patient has a psychotic structure, this cannot be accomplished through a descriptive diagnostic
procedure. Some individuals (such as Katherine) who meet descriptive criteria for borderline, or
even psychotic disorders, are excellent candidates for analytic work. This, according to Lacan, is
because they have a neurotic structure constituted by repression. The work with Katherine's
dreams seemed to verify that in spite of her florid borderline symptomatology, her structure was
indeed neurotic in Lacan's sense, and it is Lacan's view that we simply cannot create a psychosis
in a neurotic individual.
I should also point out that Kernberg (1984) limits interventions with borderline patients
to interpreting defenses in the here and now and does not advise the use of genetic interpretation
and reconstruction in borderline cases. However, I would argue that the dream work described
above permitted Katherine to profit from a genetic (i.e. historical) understanding of her conflicts.
Oedipal Vicissitudes
Another important phase in Katherine's treatment was marked by an in-depth exploration

of her parent's marital relationship. Katherine had brought into treatment concerns about her
mother's bouts of depression. As Katherine would contact her mother weekly to "check on her
depression" a pattern appeared that showed that most of the time these conversations between
mother and daughter were closely followed with some of Katherine's most heated arguments
with her father. The interpretation of this pattern opened up a wealth of significant associative
material. In one session in particular, Katherine stated that she was convinced that her mother
was still in love with her father in spite of the years that they had been separated. When asked
about the particularities of their divorce and the circumstances surrounding the separation of the
couple and its impact upon the children, Katherine explained that her mother was always very
busy outside the home in an attempt to increase her income by working overtime. As such,
Katherine's mother would leave early in the morning and return late at night. It appears that
Katherine's mother accused her husband of having an affair with a woman who Katherine did not
know. Katherine's father denied this when his wife confronted him. However, they seemed to
share very little if any enjoyment.
Katherine expressed surprise that she had spoken about this "other woman" with the
therapist. She then reported that as time went on, and her parent's quarrels increased, this woman
became increasingly central to her parents' arguments. On those occasions, her father would
recriminate his wife for her greediness, lack of sexual interest and her self-absorption.
Katherine's father never admitted to the affair. However, after the couple's separation, common
friends of the couple confirmed the veracity of the extra-marital relationship. It appears that this
affair, although it lasted throughout Katherine's parents' marriage, did not continue after the
divorce. Katherine's father met his current wife a year later and married to her soon thereafter.
Katherine's recollection of these sets of relationships is extremely important. Katherine
grew up in a home-setting where there was an absent mother, a father who was fulfilling part of
the maternal function, and where the shadowy presence of another woman signified the desirable
qualities that her mother did not have in order to maintain her father's interest.
It became evident from Katherine's statements about her boyfriend, that she would
scrutinize carefully his interest in other women. In fact, at times, she became convinced that he
was cheating on her. Such a thought not only justified her "feeling abandoned" but also provided
a new element in the circuit of desire: another woman. On the other hand, it helped us to
corroborate Katherine's partial identification with her mother, with her depression, and with the
idea that "men are not to be trusted" since there is always another woman more interesting and
desirable than oneself. Further, her inhibitions in the enjoyment of sex, out of solidarity with her
mother, ensured a faithful tie between them.
Katherine's Subjectivity
According to Lacan, an individual's sense of subjectivity is comprised of a very complex

network of meanings that not only belong to the person in question but carry forth
representations from parents and even earlier generations. Katherine's unconscious
representations of her parents along with what has been said or unsaid in her family had
enormous consequences for her process of individuation. Lacanian thought does not place a
unique emphasis on the dyadic relationship with the mother. For Lacan, the subjective human
condition involves the interplay between at least four elements that are always present: the
mother, the child, the father and language/culture at large. Even the body is overwritten by
language and this, according to Lacan, is why it is possible, for example, to have a
psychosomatic illness. Given this complex schema, and the potential obstacles it places in the
path of the child's becoming someone, we can imagine how difficult it is for a child to achieve
the process of individuation.
For Lacan, the process of becoming oneself involves loss and aggresivity and in his
model, this process originates in the mirror stage. However, the aggresivity that the child needs
to marshal in order to assert his individuality is not connected in any way with the aggression
that Melanie Klein and later, Kernberg will discuss. Kernberg's view is that at the root of the
borderline disorders is an excessive amount of primitive aggression that fuels the borderline's
rage against a mother-object who has not provided sufficient affirmation. By way of contrast,
Lacan makes a distinction between aggresivity and aggression. While aggression is associated
with a violent act, aggresivity refers to the tension present in all relationships which in Lacans
view involve both love and its opposite. This tension is referred to, in Freud, as ambivalence,
and, according to Lacan, it has its origins in the mirror stage. The child feels extreme tension, as
the wholeness he sees in the mirror or in his mother is not reflective of the sense of
fragmentation and disintegration that he experiences as a helpless human being. This
fundamental ambivalence underlies all relationships from then on and all future forms of
identification (linking it to the development of narcissism) and leads, according to Lacan, to
aggresivity. According to Lacan, it is not only the borderline who experiences this sense of
threat, fragmentation and rage but all humans. Thus the presence of ego-fragmentation in
Katherine is not diagnostic of any disorder, but is rather endemic to the human condition. The
topic of borderline pathology and the human condition is a matter that we will return to in the
final chapter.
Lacanian Inter-Generational Analysis
One of the most important tasks in a Lacanian psychoanalysis is to arrive at an

understanding of the place of the patient in the generational representations of the family. In the
current case, one must inquire regarding Katherine's understanding of her place in the fantasies
of her mother and father. In essence we ask what questions did Katherine carry for her mother
and father that they did not address with their own parents. It is interesting to note that a key to
understanding some of this material was derived from Katherine's dream associations. Here I
will underscore several of her associations/recollections to Dream #2 described above, especially
in regard to her childhood bleeding accident and her mothers response to it. It was in this
context that Katherine first (and to her own surprise) expressed her recollection that her own
mother had been sexually abused by a male relative and had never worked that problem through
with her own mother, who blamed Katherines mother for the incident. We might here ask
whether Katherines mother's neglect of her own daughter might be reflective of this painful
experience that she herself never discussed with her own mother. And how did Katherine's
mother's early traumatic experience with a man impact upon Katherines father? Of greatest
significance, of course, is the question of how these events are signified and later re-signified in
Katherine's own psyche.
Although it was relatively far into the therapy, Katherine eventually turned a questioning
gaze upon her own casual encounters with men. After the above noted dreams, she spent
considerable time discussing this matter in treatment, and began to unravel her own puzzle in
regard to the history of her family's encounter with femininity. As briefly mentioned earlier,
Katherine reported that at the age of 17, during a High School weekend trip, she found herself in
a difficult situation. Like some of the other students in her group she had smoked some
marijuana and drank a fair amount of liquor. The group had gathered in one of the hotel rooms
and girls and boys were conversing, and playing cards. When the group dispersed after a school
supervisor indicated it was time for bed, Katherine went to her room. Not long after, a group of
three of her male classmates entered her room and made sexual advances towards her. Although
she initially engaged them, she refused any further contact with these boys and requested that
they leave. On further exploration Katherine explained that she had overpowered these boys
one by one, and afterwards she locked herself in the room and stayed awake all night long,
fearful of their return. As time went on, she became convinced that one of her girlfriends had
sent these boys to her room. The next morning an enraged Katherine walked up to her friend and
started a quarrel. As we have seen, Katherine initially stated that she recalled hearing the young
woman's voice urging these young men into her room, but later came to doubt that this could
have possibly been the case.
In the process of working through her recollection of this event, Katherine not only made
many references to her mothers sense of revenge related to men (also reflected in her
relationship with Katherines father) but also to a deep sense of being a slut in the eyes of her
own mother. As Katherine proceeded with her work, she formed a link between her mother
having been abused as a child, her mother's neglectful and scornful attitude towards herself, and
her own self-image of being a "slutty woman." This example is illustrative of how the core of an
identification that seemingly appears to belong to a patient in question is often best understood as
the residue of another persons identification. This unprocessed identity was later foisted on the
patient and she carried it throughout her life. Katherine was taking her mothers badness on her
own shoulders in order to exculpate her and free her mother from any guilt. We should here
recall how Katherine referred to her mother in the initial interviews, characterizing her as lacking
in maternal instincts but not blaming her for it, even justifying her aloofness on the grounds of
the intrinsic difficulty of the maternal function.
Here again we see with a so-called "borderline" patient that it is only through a free-
associative analysis and an articulation of hitherto unrecognized (repressed) thoughts into speech
that the patient can attain an insight that will enable her to move beyond the desire of the other
and achieve her own individuation. According to Lacan, such work must occur within the
context of what is called the Symbolic Register in the presence of the other (analyst) who
enables the recollection to be fully explored.
The Name of the Father
Having explored several of the vicissitudes in relation to Katherine's mother, we are left
to ask about Katherines position in relation to her father. How did Katherine deal with the
passage from the first love object (the mother) to her father, and how was the inscription of the
name of the father achieved?
As the treatment progressed it became clear that Katherine experienced herself as a
repository of her mothers rage and self-loathing. As noted above, the work that began with
associations to Katherine's dreams revealed that this was the place that she had been assigned
within the context of the family. This unprocessed enraged affect as a result of an identification
with a depressed, abused mother was now projected onto her father, who, in Katherines own
view was her primary caretaker. On the one hand we have the presence of a father who is
fulfilling some aspects of the maternal function. On the other, we have a father who is the source
of desire for Katherines mother but who comes to reject and abandon her. Katherines father is
not interested in his wife but he is invested in his daughter. It is interesting that Katherine will
become an important part of their negotiations in their conflicted divorce. Her brother, who was
always by her mother, and was of little interest to their father, was able to develop his own
individuality without having to overcome major hurdles. Katherine, on the other hand, ended up
being cared for by her father all the time, and proved unable to live as an independent adult. It
appears thus far, that in her relationship with her father, several important psychological
problems occur; on the one hand, Katherine identifies him with a maternal figure who can
protect her, yet, on the other hand, this maternal figure is a man who desires a woman who is not
Katherine's mother.
The work of analysis, thus, becomes a reconstruction of a true identity by traversing the
different meanings that have been placed upon us by others. That is why it is not enough for an
analyst to be an empathic listener and try to produce what Lacan might call imaginary reparation
in the transference (as in a Kohutian analysis). Rather, every patient has to conceptualize his/her
symptoms through his/her own words and articulate the particular meanings of his/her history
that have hitherto resisted symbolization. Such meanings, we might say, first appeared in a
"traumatic" fashion and thereby escaped representation and meaning. In Lacanian terms, this
initial lack of symbolization places them in the so-called Real register. There is thus a defect in
articulation, a defect in symbolic transmission that appears as a formation of the unconscious.
Noting this defect, and further articulating it in the Symbolic Register is, according to Lacan, the
only real tool that the analyst can count on in the process of the cure. Therefore, for Lacan the
unconscious is not a place somewhere in the brain, but a process put in motion through
language in the presence of the Other (Lacan, 1954).
The symptoms related to Katherine, including her inability to succeed as an adult, her
poor relationships in general, and in particular with her father and boyfriend, her somatic
complaints, and her depression were ultimately put in motion within the transference. The
question of aggressivity or the intrinsic ambivalence in all relationships is also demonstrated in
the negative transference. However, Lacan suggests that this aspect of the imaginary realm in
transference, although identified, is not central to the relationship between analyst and analysand.
Rather than interpreting these feelings, Lacan moves into the symbolic axis of the transference,
the world of words themselves. According to this view, transference refers to "the subject
supposed to know" (Lacan, 1964). As we have seen, treatment begins when the transference is
established, and the belief that the analyst knows something that patient does not know. It is the
analyst's response to this belief that is the motor of the treatment. Indeed, Lacan insists that the
analyst must refuse to use this power of knowledge given by the patient. This refusal thrusts the
work of the analysis back onto the patient, who must ultimately surrender the fantasy that the
secret of her being is contained in an other, and in this way begin to assume her own desire.
While classical psychoanalysis takes the idea of interpreting the transference as one major means
of producing insight in the patient, Lacanians reject this view of insight. For example, in the
present case, pointing out the difference between Katherine's aloof style towards the therapist
(resembling her relationship with her mother) or interpreting the underlying commonalities of
her anger towards her father, boyfriend and therapist does not, in Lacan's views helps produce
insight. Such interpretations rest on the belief that the analyst has a better grasp on reality than
the analysand, and that by interpreting her relationships in light of past ones, the analyst will
address that part of the ego that is conflict-free, has rational understanding and is capable of
restoring the patient to health. For Lacan, this position reduces psychoanalytic treatment to a
suggestive method and keeps the patient in the neurotic position of assuming that knowledge of
her desire rests in the other. For Lacan, the curative quality of interpretation in the context of the
transference is illusory. Rather than interpreting the fact that Katherine might be angry with the
therapist in the same way that she was angry at her father, it is better to question directly the
content of the speech to produce more associations. The work of the therapist resembles the work
of in inquirer rather than of an interpreter. The cure develops when the patient begins to shed her
self-defeating identifications with the desire of the other, and assumes the direction of both her
treatment and life.
Katherine as a Neurotic Individual
As described above and in Chapter Three, the particular mode in which a subject negates
his/her desire or the law (the name of the father or castration) serves as the basis for Lacans
distinctions within his structural system of diagnosis. Although the simplicity of the theory may
appear to make matters easy to elucidate, the determination of which mechanism is at work
requires a great deal of clinical acumen. The three mechanisms of foreclosure, repression and
disavowal provide the bases for neurosis, psychosis and perversion respectively (Lacan, 1956).
These particular modes are determined by the way the "name-of-the-father" (or what Lacan
denominates the paternal metaphor) operates in the individual, i.e. how the symbolic order
overwrites the imaginary realm of being. As described above, the world of the imaginary that of
visual images, olfactory sensations, mirror perceptions and fantasy is re-interpreted through the
words or language provided by the childs caretakers. In this way the cultural and the linguistic
come to overwrite what is natural in the human condition. The predominance of symbolic
relations through which the imaginary realm is subordinated characterizes neurosis, and it is in
neurosis that the paternal metaphor or symbolic function has operated and separation from the
mother has occurred On the other hand, the predominance of imaginary relations is the
predominant feature in psychosis, where the paternal metaphor, and hence the symbolic/cultural
order is "foreclosed". When the Name-of-the-Father is foreclosed in a particular subject, it leaves
a "hole" in the symbolic order that can never be filled. When the Name of the father reappears in
the real, the subject is unable to assimilate it. This marks the onset of psychosis, characterized
by the presence of hallucinations, delusions and language disturbances. (Lacan, 1954).
Therefore, in psychosis, even though the individual makes use of language, his speech is
imaginarized (Fink, 1999). The psychotic individual is at the mercy of his imaginary structures
and to use a non-Lacanian metaphor, his ego boundaries are totally non-existent. Lacan links the
psychotic's inability to produce new, original metaphors (e.g. neologisms) to the absence of "the
essential (paternal) metaphor."
As the child matures, he/she is forced to give up a particular pleasure with the mother via
the institution and representation of the paternal law. This imaginary and later symbolic law
produces a prohibition that neutralizes the mothers desire for the child as well. Repression then
occurs. Although repression has a qualitative difference in both genders, the basic result is the
same. So the first meaning that the paternal metaphor introduces is that the longing for the
mother is wrong for the child, establishing a first No! According to Lacan, this initial
prohibition is what ties social reality to language in a constitutional way and serves as the basis
for all linguistic meaning.
How did this mechanism work in Katherine? Repression certainly worked. Katherine had
words for her symptoms (a description of her suffering), recovered memories in session
(indicating the presence of repressed material), the capacity to doubt her speech (she would
wonder about her level of responsibility for her symptoms and she questioned their meaning),
and the tendency to have pleasure in fantasy as opposed to direct sexual contact (cf. Fink, 1999).
Further, the presentation of conflict related to authority figures, such as supervisors, teachers,
and adults in general, indicates the presence of the paternal metaphor as having instituted
repression as a mark for castration. Whereas in psychosis the reality of something is totally
refused, in repression, the reality in question has to first be accepted in the psyche and later
pushed out of consciousness. Katherines management of dream material, the fact that she was
able to bring dream materials into session, free-associate and make connections between the
dream material and her early life, was, in Lacanian terms, clearly indicative of the presence of
neurosis. However, in the actual course of therapy, where Katherine presented with so many
"borderline" features, the diagnosis of a neurotic structure could not be achieved for quite some
time. It was only in the unfolding of the therapy and its progress, and a constant active listening
to the verbalizations of the patient that would lead to this conclusion. Indeed, many of
Katherines communications could have been interpreted as suggestive of a psychotic formation,
and at several points early in the treatment were hypothesized as such in the mind of the
therapist. A good example, which we have already referred to, is evident in Katherine's
recollection of the sexual scene on her high school trip, where she reported "hearing" a young
female friend purposely sending a group of men to her room. However, such auditory
perceptions, or even "hallucinations" that are common in psychosis do not suffice to make a
diagnosis of psychosis according to the Lacanian model. Many traumatized people going through
an acute anxiety crisis, and easily suggestible hysterics have experiences of this sort without
possessing a psychotic structure. As I have indicated, Katherine had great difficulty in free
associating at the beginning of the treatment; a difficulty which Kernberg tells us is typical of
borderlines. From a Lacanian perspective, in the early phases of treatment, Katherine can be
considered a "borderline," not because she has a borderline psychic structure, but rather because
her therapist is unsure in making a determination regarding the true (neurotic or psychotic)
nature of her pathology.
As it turned out in Katherines case, it ultimately became clear that not only had the
paternal metaphor been inscribed in the patient's psyche, but the influence of the (symbolic)
father had surpassed anybodys expectations, since the father occupied a space she yearned her
mother to occupy.
The next question from a Lacanian perspective is what kind of neurosis does Katherine's
represent? Since repression is verified in the eyes of the analyst through the return of the
repressed, then the manifestations of such a return must take a particular form. We have
previously discussed the importance of the historical/familial network into which the child is
born, and we must here again raise this issue in order to arrive at an understanding of the
fundamental fantasy of the subject.
What does Katherine know about her parents? Why did they have her? What did she
represent for them and at the same time, what is her significance in comparison to her brother?
It is in the vicissitudes of the separation with her mother that, Katherine encounters the
difficulties that define the precise nature of her neurosis. As we have seen in Chapter Three, for
Lacan the issue of separation forces the child to experience the loss of the intense satisfaction
characteristic of the infant-mother relationship. The child is confronted with the loss of the object
of satisfaction, which is identified with the mother. In actuality such a totally satisfying object
never really existed, which is why, according to Lacan, the search for "the object" is always
unsatisfactory. When we encounter what we call satisfaction in an object, it never appears in the
form that was expected and thus, it always carries some form of disillusionment. However, when
the child is confronted with the initial loss he/she refuses to passively accept it. He or she will try
to compensate for it in some fashion. In hysteria, this separation from the object is what creates
hysteric desire: "she will be the object" that the mother has missed. The hysteric's loss will be
interpreted as the mother's loss, not only to ensure that she is not the loser, but to retain the
power of being the source of desire itself. A space of being is thus guaranteed for her.
The peculiarities of Katherine's early family life, and thus the specific and complex
nature of her oedipal triangle laid down conditions that were particularly conducive to the
development of a hysterical neurosis. It appears that at the time Katherine was growing up, her
mother's absences and unavailability made her mother a sort of "enigma" and therefore an object
of great interest. Moreover, as there was another woman in her father's life, this yielded the
perfect scenario for Katherine to believe that she cannot only be there for, but actually become
the object of desire for her mother. As a result of divorce and a new life change, Katherine's
mother's depression also increased. The mother's need for the daughter (who retains a grasp on
the father's desire) leads to a reinforcement of Katherine's hysteric solution. Katherine now
becomes necessary to the mother as a negotiating chip in the mother's effort to reclaim the
father's interest. The father does not want the mother, but wants Katherine, and Katherine thus
becomes a pawn in the vicissitudes of her parents desires. In exploring the events surrounding
the divorce, Katherine described how at the time, she was extremely concerned for her mother,
and that her mother would beg Katherine to go back to the city where her father lived, to find out
about her father, carrying letters for him in which she would ask him to reconsider their
marriage.
In effect Katherine's neurotic solution to her oedipal loss was to believe, on some level,
that she is the object of the mother's desire. This, however, was a particularly pernicious belief,
as the mother actually only desired the father through Katherine, and, as was repeatedly evident,
never showed much genuine affection for Katherine herself. Thus in attempting to be the
"phallus" for the mother, Katherine was doomed to play the part of one who is never genuinely
desired but is rather "seen through" as a vehicle to the desire of another. It is no wonder that her
own desire is so hard to fathom in treatment. It is buried under layer upon layer of the others'
desire that defines her, in Lacanian terms, as an alienated human subject.
Chapter Seven
Lacan and the Borderline Conditions
I
n this Chapter I will discuss a number of broad theoretical issues that inform or underlie the
Kernbergian and Lacanian approaches to Katherine that were described in Chapters Five
and Six, formulate aspects of a dialog on the question of the borderline, and consider the
possibility that certain aspects of Lacanian theory can be formulated as testable, empirical
hypotheses.
My goal in the previous two chapters was the modest one of attempting to show that a
patient who meets DSM-IV, as well as Kernbergian (presumptive and structural) borderline
criteria, can be conceptualized and treated from a Lacanian point of view, without resorting to
the introduction of the borderline category. My analysis of the Katherine case is not an empirical
demonstration, nor is it a refutation of the Borderline diagnosis, even as it might be applied to the
limited case in question. Rather, the case of Katherine has been utilized as a vehicle for
presenting two quite different approaches to diagnosis and treatment of an individual who
presents with severe pathology, and who might be regarded as meeting criteria for a Borderline
Personality Disorder.
The value of the exercise I have undertaken in the two previous chapters is far more
hypothetical and theoretical than it is empirical or probative, and it has been undertaken with the
simple goals of (1) familiarizing American psychologists with the Lacanian perspective on
diagnosis and treatment, and (2) stimulating dialog on the issue of the borderline between those
in the Kernbergian and Lacanian camps. In critiquing Kernbergs concepts my goal is certainly
not that of disproving his theory or eliminating his diagnosis, but the more modest goal of
providing an initial critique of Kernbergs borderline concept from a Lacanian point of view.
Lacan and the Borderline Conditions 163
This being said, it will become clear in this closing chapter that a Lacanian perspective on
borderline personality can lead to a questioning, if not a deconstruction, of the borderline
diagnosis.
Before proceeding, however, it is important to clear up one potential source of confusion.
The case of Katherine was analyzed herein from a Lacanian perspective, as a case of neurosis,
more specifically hysterical neurosis. As I will discuss momentarily, it is my view that the rise of
the borderline diagnosis shows an interesting correspondence to the decline of interest in
hysteria amongst psychiatrists and specifically, American psychoanalysts. It is thus worth
considering the hypothesis that many individuals who exhibit borderline features might also,
or better, be conceptualized as hysterics in either classical Freudian or Lacanian terms. This does
not, however, mean that it is my view, or a proper Lacanian view, that all of Kernbergs
borderlines are hysterics. Indeed, such an assertion would be very far from Lacans own
suggestion that in the case of the so-called borderline it is the analyst, and not the patient, who
is on the border (Lacan, 1954). As Di Ciaccia (1999) points out, the borderline concept was
originally introduced in regard to cases that were difficult to diagnose from either a descriptive
or psychoanalytic perspective. So we might reasonably expect that a certain percentage of
descriptive or Kernbergian borderlines would end up, from a Lacanian point of view, having a
psychotic, neurotic, or perverse structure.
We must keep in mind that for Lacan, these structures are in no way defined by
symptoms, or even by the nature of the patients ego and defenses, but rather represent different,
mutually exclusive, ways in which the individual positions him or herself in relation to the other,
his/her own and the others desire, and the Symbolic Order (the paternal metaphor, language, and
the law). Thus, it was perhaps only an accident that our borderline (i.e. Katherine) turned out
to be a neurotic hysteric. A Lacanian diagnosis and therapy of another so-called borderline might
very well reveal the presence of another type of neurosis, or a psychosis or perversion.
Elements of a Lacanian Critique of the Borderline Concept
The task of bringing together the theories and practices of two giants of psychoanalysis
such as Kernberg and Lacan is a difficult one. As I have attempted to show in earlier chapters,
each theory is highly sophisticated and complex, and each is based upon certain fundamental
metapsychological and even philosophical assumptions that create an immense divide between
American and French psychoanalytic thought. Here I will only be able to map out the territory
for further dialogue, first presenting the fundamental elements of a Lacanian critique of the
borderline concept, and then by briefly examining certain aspects of Lacanian theory through
what French analysts will surely seem to be a very foreign lens: the lens of empirical, even
experimental psychology.
The Merger of Psychiatry and Psychoanalysis
From a Lacanian perspective, the problem of the borderline can be understood as

resulting from an American psychoanalytic tendency to merge descriptive psychiatry and
psychoanalysis (Di Ciaccia, 1999). As we have seen in our discussion of Lacans critique of
American ego psychology, by focusing on the various functions, defenses and adaptations
of the ego, the ego-psychologists, beginning with Hartmann and continuing through Kernberg
have downplayed the significance of Freuds initial insights regarding the unconscious. Amongst
these insights are that nearly all of human behavior is comprehensible as a function of
unconscious conflicts, and that therefore nearly all human behavior is interpretable in terms of
the mostly unconscious intentions and motivations of an actor or subject who is defined by a
cultural/linguistic web of meaning and significance.
In formulating an ego-psychoanalytic theory of the borderline that accounts for this
disorder in terms of "incomplete," "inadequate," "primitive," or "broken" structures, Kernberg
and others have imported descriptive psychiatric categories into the unconscious and discarded
the essential psychoanalytic insight that symptoms are a symbolic manifestation of unconscious
motives, that they are the expression of a "wish."
Kernbergs " borderline structures" are, from a Lacanian perspective, actually relatively
abstract descriptions (e.g. of ego weaknesses, poor anxiety tolerance, a lack of impulse control,
lack of developed sublimatory channels, a shift toward primary process thinking, intact reality
testing, identity diffusion, the presence of specific defensive operations, etc.) that remain largely
at the same level of analysis as his presumptive (and the DSM-IV) criteria. Kernbergs theory is
not, on a Lacanian view, a proper psychoanalytic structural theory, one that would account for
the existence of certain symptoms and behaviors by appealing to an individuals unconscious
intentions, motivations, and goals. Rather, Kernberg runs the risk of treating the borderline as a
mechanism, more specifically, a maladaptive mechanism whose failure at adaptation is the result
of various deficits in cognitive, perceptual, and affective regulation, rather than a desiring human
subject in need of insight and understanding.
Defenders of Kernberg can point out that that even Freud himself (e.g. in his distinction
between the actual and psycho neuroses(Freud, 1895), held that there were certain
symptom pictures that lay outside the frame of unconscious meaning and conflict. On the
Kernbergian view, the borderline is not analyzable as a neurotic, precisely because his or her
psychic apparatus has not developed to the point where it is beneficial to make genetic
interpretations (Kernberg, 1984). As the borderline patient improves, he or she may take on
aspects of a neurotic structure, and thus become the subject of more traditional (interpretive)
psychoanalytic techniques.
The Critique of the Role of the Symptom
Lacanians are critical of the use of symptoms and symptom complexes in diagnosis. A
Lacanian critique is especially applicable to Kernberg's use of such "higher order" symptom
complexes such as "identity diffusion" as structural criteria for a borderline diagnosis. From a
Lacanian point of view the important question to be asked about identity is not whether it is
diffused, but rather precisely how it manifests itself in contradictory ways at conscious and
unconscious levels, and at the levels of the Imaginary, Symbolic and the Real.
For Kernberg, diagnosis does not begin with the identification of symptoms but rather
from an understanding of typological organization (Di Ciacca, 1999). While Freud originally
held that a typical symptom was necessary for diagnosis, a problem emerged for him when the
symptom was atypical, as was illustrated most forcefully in the case of the Wolfman (Freud,
1918) (where obsessive and psychotic symptoms were present but the patient functioned well
socially). Within the Lacanian framework of diagnosis, a symptom that appears to be atypical
within the general picture of one individual may belong to the imaginary order, while in another
subject, the same symptom is better analyzed as part of the symbolic order. Thus, at an
imaginary level (at the level of the fantasy of the person about himself, i.e. the Lacanian "ego") a
man can have a feminine identification, whereas at the symbolic level of everyday life, the
person identifies himself exclusively as a man. For this reason, the whole idea of identity is
difficult to pinpoint and must be elucidated in the particularities of each subjects analysis. For
Lacan, the subject of the unconscious takes one position and the self another one opposite to it.
This is how hysterical and obsessional symptoms can co-exist in the same individual. This
complex view of who we are has clear implications for the construct of identity and further, for
Kernbergs criterion of identity diffusion.
For Freud and Lacan a symptom represents a substitution. This substitution is not a
directly observable fact, but must be pursued at the level of meaning. For a Lacanian, the issue of
Katherines so-called identity diffusion amounts to a question of what does it mean to be a
woman? While this question can be answered in an indefinite number of ways, it is important
for the analyst to ascertain what the unique answer is for Katherine. Kernberg, on the other hand,
takes a symptom or a manifestation of an ego structure (e.g. identity diffusion) and makes a
diagnosis without any reference to subjective meaning.
The Treatment of Borderlines
Lacanian analysts hold that since the advent of ego-psychology, American analysts have
become seduced by defenses, levels of object-relations and adaptive mechanisms, and have, in
many cases, even failed to consider the unconscious, and how an interpretive perspective can be
brought to bear on many severely disturbed patients. In working with Katherine, I myself was
impressed by the degree to which an interpretive psychoanalytic perspective was indeed
applicable to her case.
It is noteworthy that clinicians in general and psychoanalysts in particular share intense
countertransferential feelings towards these difficult patients. These attitudes reflect the
aggressive and chaotic fantasies that patients have (in general) and leads the clinician to make
recommendations that, at times, may not be properly thought through. The question of face to
face treatment versus the couch, the issue of avoiding dream analysis and, further, the question of
having contracts drawn with these patients in which they agree to not kill themselves or go to
the next emergency room, etc., may only reflect our deep countertransferential feelings towards
these patients. Amongst such countertransference feelings are a sense of responsibility for the
patient (experienced as a burden), feeling intruded upon, and at times being devalued as a
professional, etc.
The Role of the Ego and the Ethics of Psychotherapy
It is an implicit and at times explicit view amongst ego-psychologists that once Freud
developed the structural model of the mind, that he discarded, or at least downplayed the
significance of the topographical model of unconscious, preconscious and conscious. Lacan
argues that by working only at the level of the Freudian structural model, the subject is lost.
Psychoanalysis, from a purely structural point of view, essentially becomes an adaptive model of
human behavior, one in which the ego is understood as forging an adaptive compromise between
its drives (id) and the demands of society (superego). Within this model, certain ethical questions
arise: Who is to say what is adaptive or not? Who is a healthy individual and who is mentally ill?
The importance of such an ethical context and the whole question of "adaptation vs. the
assumption of ones own desire" provide the basis for a further Lacanian critique of the
American perspective on the borderline. Kernberg and other American theorists argue that the
therapeutic task with borderline patients is one of supporting, shoring up, and, eventually,
building the patient's ego. As detailed in Chapter Three, for Lacan, the ego, including its various
functions of defense, reality testing and adaptation is an illusion that obscures the genuine
psychoanalytic subject. The ego, in Lacans theory, is a self-deceptive and alienating product of
the mirror stage. It is, according to Lacan, a product of illusory identifications with, and the
objectifying gaze, of the other, and is responsible for the subjects alienation from his own
desire. By centering their theory of severe pathology within the vicissitudes of ego-functioning
the borderline theorists participate in and perpetuate the basic deception that, according to Lacan,
is at the core of psychopathology. Further, from an ethical perspective, the use of ego-building
techniques in the treatment of so-called borderline patients runs the risk of promoting an
adaptation to the desire of the other which suppresses the subjectivity and freedom of the patient
him or herself.
While Kernberg does not directly state that identification with the analyst is central to the
therapy of borderline disorders, the practical work with borderlines often amounts to an
interpretation of their primitive defenses without genetic interpretation (Kernberg, 1974), and a
modeling of a presumably more rational approach to one's relationships and conflicts, which the
patient can incorporate through identification with the analyst. However, for Lacan, the analyst
cannot serve as a model for the patient. To the extent to which borderline or other patients
internalize the analysts ego characteristics, such a patient becomes further enmeshed in the
desire of the other and further from their own subjectivity.
Advocates of ego- and self-psychology are, of course, open to retort that not all
identifications are as self-alienating as Lacanians would suggest; some, it would seem, are
necessary for the development of and fulfillment of the self. In discussing the case of Katherine,
we saw that even for Lacan there is a period of education/identification that must take place in
order for an individual to become a psychoanalytic patient. It would also seem that the
analyst/therapist cannot help but be an identificatory object for the patient, as the patient must
learn to identify and ultimately assume the analysts curiosity about himself. The question
nevertheless remains, as to whether the psychotherapeutic process with borderlines and others
should primarily be one that strips away identifications or creates new ones
Lacan and Family Therapy
Here I would like to point out that Lacans emphasis that the individual pathology can
also be understood as an expression of inter-generational conflicts, meanings and significance
should make Lacan of interest to family therapists, those working outside of as well as within a
psychoanalytic framework. Such theorists typically hold that the deep structure of an
individuals symptoms and pathology cannot be traced to the individuals psychology alone, but
is rather a function of events that have transpired within a family, or wider interpersonal system.
Lacan shows a similar interest in the manner in which the patients parents, grandparents, etc.
enter into and condition the individuals psyche, to such an extent that (at the start of analysis)
what the patient generally feels as her own desire, is inevitably someone elses desire that she
has adopted through unconscious identifications. The goal of analysis becomes the working
through of these various obscuring identifications so that the analysand can develop as a subject
conscious of her own desire. In this way Lacans theory adapts certain notions that are
compatible with a family systems perspective on pathology and places them within a
psychoanalytic and existential context.
The Pre-oedipal vs. Oedipal Controversy
Several other Lacanian notions that I will consider here in brief relate to the general
critique of American ego-psychology. One of these is that by emphasizing pre-oedipal
developmental issues in their theory of the borderline, American analysts have again moved
away from the intrapsychic conflict model and the theory of the unconscious that were the core
theoretical constructs of Freudian psychoanalysis. Further, focus on such pre-oedipal issues as
separation/individuation prevents the Kernbergian analyst from gaining a full understanding of
patients relationships to others, their interpersonal conflicts, and relationship to their own and
others desires, that are constitutive of adult (as opposed to infant) functioning. With regard to
Katherines case, as was pointed out in Chapter 6, it is clear that one could understand this
patients pathology in terms of the pre-oedipal or narcissistic issues that resulted from her
mothers failure to fulfill her maternal function, and the ensuing deficits in Katherines identity
and object-relations. However, as became clear later in the treatment, superimposed upon this
early narcissistic issue was the role that Katherine was forced to play in the triangle between
herself, her father and her mother, and the way in which her experience of this triangle produced
a new re-interpretation of her early childhood experiences. For Lacan, the distinction between
oedipal and pre-oedipal issues is itself an illusion, as on Lacans view, the human infant is born
into a world in which he or she already has significance in the wider family and culture. We are,
according to Lacan, born into a web of language and symbolic meanings that have existed for
generationsit is not only when we learn to speak that we become conditioned by culture and
language. Before we have uttered our first word we are embedded in a maze of others
meanings, conflicts and desires.
The focus on attachment and so-called pre-verbal developmental issues in the theory of
the borderline raises the question of the role of language and speech in the constitution of human
subjectivity. Lacan views the subjects alienation in the Other as structural (i.e. universal) rather
than accidental (occurring in some cases and not in others). For Lacan all human subjectivity is
constituted, immersed in and annihilated by languagea language that pre-exists the individual
subject. The belief that one can focus on pre-verbal issues fails to recognize the all-
pervasiveness of language in the development of human subjectivity and the re-structuring of
former psychic formations once language is acquired.
A further criticism of Kernbergs reliance on object relations theory (see below) relates to
its shift of emphasis from oedipal issues to the mother-child interaction, while disregarding the
important factor of triangularization and the effect of the father.
The Critique of Objects Relations Theory
Kernberg can be described as a theorist that blurs the distinctions between object
relations and ego psychology, since, on the one hand, he focuses mainly on objects (self and
object representation rather than drives) while on the other hand he places a strong emphasis on
the defensive structure of the ego, its autonomous functions and the concept of adaptation.
While there are certain similarities between Kernberg and Lacan's approach to intersubjectivity,
there are radical differences, not only with respect to their understanding of the ego, but also in
their conception of the nature of the object and its relation to desire. For Lacan, there is no
possibility of complete satisfaction between subject and object (Lacan, 1953). In Lacanian
terms, the object of object relations theory is not the symbolized, psychoanalytic object, but
rather the object of biology, without reference to any symbolic function. Lacans polemic with
object-relations theory has enormous consequences with respect to treatment; for example, when
analysts expect their patients to achieve "mature object relations" or "genital aims." For
Lacanians, the designations of "good object" and "bad object" involves an ethical, even
moralistic, position that is dangerous in the field of psychoanalysis. The same can also be said
with respect to the ego psychologists concept of reality testing which comes dangerously
close to legislating for patients what they should experience and believe. For Lacan reality is a
construct, based upon the pleasure of the subject (Lacan, 1959).
Borderline Structure as Part of the Human Condition
As we have already remarked in passing, a further critique of the borderline concept is

that the particular difficulties that presumably characterize the borderline personality are
endemic to the human condition as a whole. For example, the notions that borderlines suffer
from broken structures and an unintegrated self suggests that others are not broken and that their
selves are integrated. Lacan follows Freud in holding that the human subject is essentially
divided and unintegrated. It may well be that what is projected on to the borderline is, in fact, a
universal human condition. The broken, divided nature of human experience may be easier to
contend with it is confined to a particular group of impaired individuals. However, for Lacan, it
is not just borderlines who suffer from a division of the self; such a division is the inevitable
result of our immersion in a language and problem of identification with the other. As we have
seen, even before the child himself begins to speak he is caught in the symbolic/linguistic web of
his parents, family, and community, and his needs and their satisfactions are channeled through
the language of his family/culture. According to Lacan, as the infant develops, his bodily
feelings are gradually linguisticized, taken away from the body, and the body is thereby emptied
out. What was once pleasure becomes anxiety, as a distance is set up between need and its
satisfaction.
The subject of the analytic inquiry is thus split, divided, an idea that has important
implications when compared with the holistic view of a bio-psycho-social integration portrayed
by much of what goes under the name of personality theory (Harari, 1986). The idea that only
"borderlines" are split, broken and divided is according to, Lacans way of thinking, predicated
on the ego-psychological (and common) illusion that there is a normal state of "wholeness" and
"unity."
The belief in an integrated self, according to Lacan, is a function of our taking our
specular image for the real subject. Another of the effects of the mirror stage is the illusion of
autonomy. Any adult who is questioned about himself will insist that he knows that he is free,
knows what he wants and he has to do, etc. because he is his own person.. However, this view of
the self is a narcissistic illusion, whereby the ego hides its imaginary identifications and presents
them as its own choices. Moreover, we also believe we know what we are saying, that we own
our words, a belief that can be expressed as I first think, then I select my words and finally I
enunciate them. Psychology typically adheres to this view, in its study the acquisition of
language as if it is one of the egos cognitive functions. Lacan, on the other hand, believes that
the subject is an effect of language, rather than the other way around. For Lacan the subject is
inscribed in a language that is hardly of his own choosing.
The Continuum of Diagnosis
A further criticism of the borderline construct stems from the notion that it appears to
open the door to an indefinite number of new diagnoses. Indeed, the ego-psychological construct
of the borderline rests on the view that there is a continuum of psychopathology. The borderline
is said to share certain ego strengths with the neurotic and certain ego weaknesses with the
psychotic. Thus an indefinite number of gradations of pathology are possible between neuroses
and psychoses, and several borderline theorists, e.g. Meissner (1978), have attempted to
enumerate a number of them. For Lacan there is no continuum between the three basic
structures. Whoever is neurotic cannot become psychotic or perverse. The continuum view
actually undermines the very idea of structures.
On the other hand, Lacan himself can be criticized for holding an overly rigid view of the
strategies that can potentially shape the human subjects relationship to the other, language,
culture and desire. For Lacan, there are only three major strategiesthose described in our
discussion of psychosis, neurosis and perversion in Chapter Threeand several sub-strategies
that define the various types of neuroses. Here Lacans existentialism seems to come into
sharp conflict with his structuralism. The theorist who rails against any attempt to rob the
subject of his freedom and to define the patient in mechanistic terms, holds a structural theory of
the human psyche that appears to do just that, limiting the subject to just one of three possible
illusory life-strategies. Lacans view is that once one has completed analysis one can, to a
certain extent, shed the identifications that obscure ones own desire (Lacan, 1981), but there
remains within his thinking, a fundamental tension between the potential for liberation afforded
by psychoanalysis and his structural analysis of the human personality. Indeed, it may well be
that it is precisely this tension between fixed structures and freedom that generates Lacans
dialectical appeal.
The Rise of the Borderline Diagnosis

and the Decline of Interest in Hysteria and Perversion
As we have seen, according to both Kernberg and Lacan one cannot diagnose
psychopathology on the basis of symptoms and behavior. For Lacan, this is because most
symptoms and behaviors can occur in the context of any of Lacans three basic structures:
neurotic, psychotic and perverse. Any symptom, obsessions, phobias, poor impulse control, even
hallucinations and delusions can each be present in the context of each of the three basic
psychopathological structures. Here I would point out that hysterics and individuals who suffer
from severe dissociative disorders (e.g. Dissociative Identity Disorder, Possession states) can
present with auditory hallucinations and delusions without having a psychotic structure in either
Kernbergian or Lacanian terms. Followers of Kernberg would typically classify such individuals
as borderlines, whereas Lacanians might give prime consideration to a possible diagnosis of
neurosis. One can easily forget how psychotic Freuds and Breuer hysterics were. Anna O,
who was later revealed to be Bertha Pappenheim, a woman who later emerged as one of the
founders of social work and the womens movement in Germany, suffered from all sorts of
delusional and hallucinatory experiences (Freud and Breuer, 1895). Such hysterical individuals
were the common psychoanalytic patients around the turn of the century, but, as Michele Tort
has pointed out, interest in hysteria, particularly in America has all but disappeared. Tort (1999)
suggests that the appearance of the borderline diagnosis coincided with a decline of interest in
hysteria, and may possibly be understood as a reframe of the hysterical patient, who has
certain symptoms that appear to be psychotic, but who does not suffer from a formal thought
disorder or broad and chronic disruptions in reality testing. In this regard, one might question
how a Lacanian would understand the various multiple personalities, possession states, fugues
and other dissociative disorders that have recently become so common in certain
psychotherapeutic circles. Clearly, the question of patients who have psychotic symptoms but not
psychotic structures is one that has emerged into prominence in recent years.
A further thought, also suggested by Tort (1999) is that as with hysteria there has been a
progressive decline in interest in perversion within psychoanalytic circles, except as it is
narrowly defined as a sexual deviation or paraphilia. As we have seen, for Lacan perverse
structure is a position of the subject in relation to others rather than a sexual deviation per se.
From a Lacanian perspective, those who have interests in the character pathologies, e.g.
borderline. narcissistic, and anti-social personality disorders, would be well to consider whether
the dynamics of some of these patients can be accounted for in terms of the perverse strategy
Recall that for Lacan, whereas in psychosis there is an absence of the law, and in the
neurosis a reinstatement of the law in fantasy, in perversion, the subject struggles to bring the
law into existence. For Lacan the negating mechanism at work in perversion is disavowal,
disavowal of the father and all the themes related to him: the law, the fathers name and the
fathers desire. Perversion is a refusal to relinquish the pleasure associated with ones (pre-
oedipal) jouissance and thus a refusal to form an identification with the father and the law.
Perhaps, new insight can be gained into the anti-social, unempathic, and overly-entitled
presentation of many so-called borderline and other personality disordered patients by

reconsidering them in the context of Lacans perverse structure.
Empirical, Philosophical and Ethical Considerations
If we are to truly make an effort to create a dialogue between American ego psychology
and Lacanian psychoanalysis we will do well to consider a Lacan's major contributions to
psychoanalytic theory and practice apart from the idiosyncratic and polemical context and
language in which he presents them. While Lacanians themselves would be hesitant to move in
this direction, a number of Lacans contributions can be reframed as empirical hypotheses that
may be subject to clinical, field, sociological, and even experimental study. Other Lacanian
propositions fall in the realm between empirical science and philosophy, and might be referred to
as meta-theoretical. Finally, a significant group of Lacan's claims fall more properly in the realm
of philosophy, or what might be termed the conceptual foundations of psychology and
psychoanalysis; a subset of these are correctly termed by Lacan as ethical propositions.
Amongst the Lacanian propositions that are most readily reframed as empirical
hypotheses are:
Lacan's assertion of the critical significance of both the actual and symbolic father in the
genesis and structure of psychopathology. (Here studies could be reviewed --and conducted--
regarding the image and concept of the father held by children and adults with various
disorders, or regarding the implications of the actual father's absence, aggression, etc. on the
development of psychopathology).
Lacan's emphasis on the role of language and its inherent connection with law and
convention in the genesis, structure and treatment of psychopathology. (Here studies could be
conducted regarding the language of psychotics, for example, testing Lacan's proposition that
the psychotic patient exhibits unpunctuated speech. Such a lack of punctuation might even be
operationalized and measured.)
Lacan's views on the specific genesis of desire from need and demand, his claim that the
child desires to be an all fulfilling object (what he refers to as the phallus) for the mother,
and that individuals with specific structural pathology engage in distinct "fundamental
fantasies" in their interpersonal relationships. (Here such fantasies might be assessed in a
variety of ways, e.g. via an analysis of the individuals images and ideation during
masturbation and sex).
Lacan's views on the emergence of the oedipal triangle in the establishment of language and
law in the family and society. (Here again, studies might be reviewed and conducted
regarding the impact of paternal absence and familial discord, and the individual's processing
of such absence and discord on the use of language and internalization of societal norms in
children).
Lacan's thesis that psychosis involves a failure of the paternal metaphor, that is, a failure of
the psychotic to internalize the paternal restrictions on the child's relationship with a maternal
object. (Again, projective and qualitative interview studies could be used as a means of
operationalizing this concept).
Lacans criteria for the diagnosis of psychosis, including hallucinations coupled with
problems in reality testing, specific language distortions (e.g. their inability to construct
complete sentences), inundation by their own libido, feminization in males, absence of self-
questioning and the failure of desire. (Each of these criteria could potentially be
operationalized and efforts to describe "presumptive" Lacanian criteria for psychosis could
be worked out).
The assertion that social and cultural forces are the major if not exclusive determinants of
individual motivation, and that these determinants are unknown to the subject and, in
particular, are present in those motives that he initially regards as his own. (Desire is always
desire of the other). (Here qualitative studies could be conducted regarding what individuals
identify as their own motivations in comparison to the values and motives that appeared in
parents, grandparents, and their sub-culture).
While Lacanians might argue that restating Lacans theses in empirically testable terms
distorts their meaning, and that such ideas can only be properly understood within the context of
the psychoanalytic situation, we are entitled to hold that his theory should make some, at least
potentially testable, predictions. Operationalizing and testing specific Lacanian hypotheses is
beyond the purview of this study, but it is reasonable to suppose that as Americans become more
familiar with Lacans work several of the hypotheses I have enumerated above, as well as others,
will be subject to empirical and even experimental scrutiny.
Among Lacan's more conceptual contributions are:
Lacans conceptualization of the ego as essentially linked with an illusory narcissism, and
his critique of the possibility of the ego as a reality oriented, conflict free agency.
His notion that psychological defenses are best conceptualized as linguistic structures
dependent upon metaphor and metonymy (as Lacan defines these terms).
Lacans theory that meaning is always after the fact (apres coup), i.e. that language is
always reinterpretable in terms of subsequent contexts, and that (developmentally) early
events are always re-signified at later points in the individuals life.
While it is difficult to see how such ideas can be formulated in testable terms, it is also difficult
to picture Lacanian theory without them. These, like the ideas considered below, have a certain
philosophical moment, and are likely to be subject to more conceptual debate and discussion
than empirical testing. As is the case with all theorists, Lacan makes certain untestable
assumptions.
As I have indicated, a number of other Lacanian contributions are more properly

philosophical or ethical. Amongst these are:
Lacan's view that both the imagination and language are critical elements in the
construction of reality. Lacan's view that reality is constructed is at odds with the
fundamental logical empiricist position that until recent years dominated Anglo-
American philosophy. His views have more in common with post positivist philosophy of
science, as exemplified, for example, in Kuhn's The Structure of Scientific Revolutions
(Kuhn, 1996), where it is argued that there are no facts independent of theory, no data
independent of interpretation.
Lacan's theory that the human subject is essentially constructed, lives within, and only
transforms himself in the context of language.
Lacan's ethical charge that the work of psychotherapy is to permit the patient to forge
himself as a creative subject rather than to adapt him or herself to reality. This thesis is
the foundation of what Lacan regards to be the ethics of psychoanalysis, resulting in a
debate with American ego psychology, which he sees as promoting identifications with
the analyst and adaptation to society, at the expense of the freedom and creativity of the
individual.
It is important to distinguish between those aspects of Lacans thought (and his implicit
critique of the borderline concept) that can be subject to empirical test, and those which are
meta-theoretical or philosophical in nature. Because many of the differences between Kernberg
and Lacan are best understood as theoretical and philosophical in nature, we cannot expect
empirical research to settle all the differences between them (any more than it has settled the
philosophical differences between other major theories and paradigms in psychology).
Nevertheless, we are entitled to demand of Lacanian psychoanalysis, as we demand of any other
theory in psychology, that at least some of its propositions be put in testable form.
The Borderline Diagnosis in Children and Adolescence
The questions that have been raised in this study regarding borderline pathology take on
particular moment when this diagnosis is utilized in connection with children and adolescents.
The reason for this is that to call a child or adolescent "borderline" clearly has a disparaging
connotation which can have a negative impact not only in the mind of the child's therapist, but
upon the child's teachers and others in the childs world. As such, the controversy regarding the
existence of this diagnostic entity takes on significance in a child-psychological setting,
something that has been recognized by a number of practitioners (Gualtieri, Koriath and Van
Bourgondien, 1996). Some practitioners have suggested, for example, that the diagnosis of
borderline personality in childhood actually represents a re-labeling of children who suffer from
Post-traumatic Stress Disorder (Famularo, Kinscherff and Fenton,1991).
In this context, it is important to recall that studies of early child development have had a
profound impact on the evolution of the borderline concept within psychoanalysis. In this section
I will briefly review some of the direct contributions by psychoanalytic developmental
psychologists to the theory of borderline personality disorder in children along with the problems
that this diagnosis poses when it is applied to children and adolescents.
Mahler (1958) identified children with severely impaired object relations but who
evidenced a less severe presentation than psychotics. They were conceptualized as a mild or an
attenuated variant of psychosis. Mahler supports her findings with observational studies on the
separation individuation process. According to her, the infant is not able to differentiate between
self and object representations and experiences his or her primary caretaker in a symbiotic mode.
It is not until the child is approximately ten months of age that he will differentiate his psychic
identity as separate from his mothers. The process of separation and independence is long, and
is accompanied by intense anxiety, as the child understands that he has very little control over his
caretakers and the satisfaction of his needs. Mahler describes different stages in the development
of individuation, (a process that takes place from 12 to 36 months) and which involves
internalizing soothing mechanisms and acquiring the capacity to achieve affective equilibrium as
the child eventually achieves an awareness of his/her position with respect to others and the
environment. If the child can accept the reality of self and others, he will achieve object
constancy. Mahler defined object constancy as the capacity to maintain relationships and evoke
the loving and comforting image of the loved person in spite of separation or frustration.
The etiology of borderline disorders is thought to be related to a derailment of the normal
developmental process described above. If this is indeed the case, one would expect to find
evidence of such failures in separation/individuation at various points in both childhood and
adolescence. Indeed the psychoanalytic literature soon began to provide a clinical description of
children whose impulsivity, low frustration tolerance, uneven developmental patterns, tendency
to withdraw into fantasy, primitive responses to stress (primary process response), lack of
structure, pervasive intense anxiety, and multiple neurotic symptoms (such as compulsions,
rituals, phobias, somatic complaints and sleep disturbances) suggested that they were on the
psychological path predicted by the developmental account of borderline personality disorder.
Paulina Kernberg (1982) contends that the borderline diagnosis in children under 12 is
indeed valid. She states that children have particular patterns of thinking, perceiving and feeling
that endure over time and any pattern that becomes rigid, chronic and maladaptive or produces
subjective distress warrants a personality disorder diagnosis. However, only careful long-term
studies can clarify if the children diagnosed, as borderline today will be the borderline
adolescents and adults of the future. Paulina Kernberg is largely in accord with the
developmental views of Mahler and goes further to describe a particular affect in the borderline
child: excessive aggression. According to Paulina Kernberg, the childs aggression threatens the
good object and splitting occurs to keep the good and the bad as separate as possible. This
defense is the protection that is necessary to keep the bad introjects away from the ideal good
object. The bad introjects are activated by separation, frustration or an inability to live up to the
expectations of others.
Clarification of terms such as introjects, good and bad object, aggression, maternal and
paternal representations, etc. are necessary in order to further a consideration of the problem of
the borderline in children. In particular the issue of subject and object as it is understood in
object relations theory must be adequately contrasted with Lacans use of these terms.
James Masterson and Donald Rinsley (1975) are also in accord with the view that
borderline psychopathology in children is due to a particular pathological mother-child
interaction that affects the separation-individuation process. They further describe the type of
mother of a borderline patient; she is characterized as one who finds gratification in her childs
dependency, rewarding clinging behavior and sanctioning any move towards autonomy. Such
mothers are warm and loving when the child is helpless and in close proximity but punishing
when the child strives towards independence. They argue that the behavior of such mothers
fosters a split in the mother representation in which gratification is associated with dependency
and punishment associated with autonomy. This pattern becomes particularly acute in times of
psychosocial change and identity crisis such as adolescence.
G. Adler (1986) follows the theory of Donald Winnicott in utilizing the notion of the the
holding environment as a theoretical construct useful in explaining the genesis of borderline
pathology in children. When the parent fails to provide a caring environment the child
internalizes a maternal object representation that does not provide soothing and comfort when
separation and distress arises. The child, therefore experiences a sense of emptiness that needs to
be constantly mollified with transitional objects such as food or, later, drugs,. Such children (and
adults) also become angry and manipulative in order to call the attention of others.
As indicated above, a number of authors have suggested a close link between so-called
borderline pathology in children and post-traumatic stress. For example, Guzder, et. al. (1999)
cite sexual abuse and parental criminality as the major factors discriminating borderline from
non-borderline children. Goldman, et. al (1992) showed that "borderline" children have a greater
prevalence of physical and combined physical/sexual abuse, leading them to suggest that
borderline personality may be in part a function of such trauma. Johansen (1992) has suggested
that abused children develop symptoms of borderline personality disorder because they are
rejected repeatedly when entering into various situations that would normally produce caring.
Criticisms of the Borderline Concept in Children
The question of a borderline personality in children is riddled with conceptual

difficulties, foremost of which is that a personality disorder is universally understood to be a
relatively enduring and pervasively maladaptive pattern of experiencing, relating and coping.
Children and adolescents are involved in a fluid developmental process in which their
personalities are in formation. As such, one can ask whether it is even valid to ascertain a distinct
personality disorder in childhood. Further, there are well-known difficulties inherent in any
attempt to distinguish childhood borderlines from children diagnosed with several other
disorders, such as Attention Deficit Disorder, conduct and eating disorders. For example, when
borderline and non borderline children (ages 6-12) after admission to a psychiatric hospital, were
compared in an effort to discriminate specific borderline traits, the following variables were
identified: self-destructive behavior, irritable affect, anhedonia, and externalizing behaviors.
None of these symptoms are useful in distinguishing the borderline from the conduct disordered
versus the antisocial child or the sexually abused child (Wood, , D., Arents,1992). In another
study it was noted that the borderline label was not helpful for treatment planning or disposition,
and in some instances the negative impact of the label was actually detrimental (Gualtieri,
Koriath, Van Bourgondien,1997).
Some studies have suggested that "borderline" behavior in children can be produced on a
transient basis by stress. For example, a study, which examined this problem from a qualitative
point of view, indicated that disruptions in foster care placement and neglectful situations
produce behaviors that resemble those of borderline children (impulsivity, conduct disorder,
defiance to authority, poor school performance) (Aquino,1998).
Other researchers (e.g. Berg, 1992) associates borderline children with impulse control
problems and emphasize the role of learning problems and neuropsychological problems in the
disruptive behavior of individuals diagnosed with s conduct disorder, borderline personality, and
ADHD. Although there appears to exist some overlap of these conditions, some studies indicate
children with these problems often grow to become borderline adults.
Other studies have focused on a present vulnerability to separation anxiety that is present
in these children from birth. It is associated with hyperarousal and panic and makes these
children more vulnerable in the case of parent unavailability. As they grow these children feel
helpless and angry. The rage appears as self or other destructiveness and their dramatic behavior
represent a protection against their perceived neglect from others which confirms the
unconscious affirmation of their inner badness.(Bemporad, 1982)
Joseph Palombo (1982), in his article A critical review of the concept of the borderline
child, argues that there is no data to support the assumption that there is similarity between the
concept of borderline in adults, as we know it, and the concept of the borderline child. He
criticizes the explanation that the borderline condition arises in childhood as a result of poor
nurturance or improper parenting. Rather, this author holds that some of the symptoms displayed
by these children may be found in the presence of minimal brain dysfunction or a severe learning
disability.
Gunther Klosinki, (1980) in his paper Diagnosis of borderline personality organization
in adolescents criticizes the term borderline personality as a diagnostic category for
adolescents. On his view, each of the behavioral characteristics of the so-called borderline
personality is also typical of the normal adolescent, that is: the presence of free-floating anxiety,
multiple phobias, compulsions, dissociation, hypochondria, depression, sexual perversions, and
loss of impulse control. Both groups of adolescents alternate between their identifications with
idols and feeling completely impotent, reflecting their compensation for self-doubts and identity
crisis. Klosinki (1980) believes that most young people diagnosed with borderline personality
disorder are in fact in the early stages of schizophrenia, while others are going through a difficult
time in their normal adolescent crisis. He finally advises to avoid the use of this diagnosis in
adolescence, as many of these young men and women will have a much more favorable
diagnosis or none at all by the time they become adults. He concludes that making the borderline
diagnosis and associating it with biological and developmental problems such as ADHD can
itself lead an adolescent to become more vulnerable to problems in self-esteem, impulse control
etc. affecting his self-esteem and his regard within the family and at school, which in turn creates
a series of negative responses.
In short, there is as much if not more controversy regarding the etiology and nature of
borderline conditions in children and adolescence as there is with respect to adults. This has led
Gualtieri, et. al (1997) to assert that clear guidelines for this ambiguous and controversial
diagnosis in child psychiatry were nonexistent.
The Present Study and the Borderline Concept in Children and Adolescence
The present study has only indirect implications for the diagnosis of borderline
personality in children and adolescents. The Lacanian critique provides one more vantage point
from which to question the utility of this diagnosis in both adults and children. Criticisms of the
borderline concept in children on the basis that borderline symptoms are actually common to
many if not most adolescents parallels the Lacanian view that the broken structure of the so-
called borderline adult is actually part and parcel of the human condition. In the present study,
the case of "Katherine" illustrates a situation in which a young adult manifests with both
presumptive and so-called structural criteria for this disorder, but who can profitably be
understood and treated from a Lacanian perspective as a neurotic. Such a situation can be
expected to occur frequently amongst adolescents who, because of the turmoil and chaos
associated with this developmental period, are very likely to exhibit the markers of "borderline
personality" in a way that may mask their neurotic (psychotic or perverse) Lacanian structures.
Indeed, Katherine, at age 25, appeared to have many characteristics of an extended adolescence,
and it may very well be that it was these characteristics that were being manifest when she
appeared to meet borderline criteria. Child, adolescent and school psychologists may wish to
consider this possibility prior to settling upon a borderline (or equivalent) diagnosis and to
consider the possibility that diagnosis and treatment in accord with Lacan's notions of the
fundamental fantasy, the major forms of negation, and the alienation of desire may be an equally,
if not more useful approach in the treatment of more enduring features of adolescent's
psychodynamics.
Limitations of Interpretive Theory
The limitations of the current study flow from several factors, some of which are intrinsic
to hermeneutic theories in psychology as discussed before. The nature of interpretation is such
that it is always subject to re-interpretation. In the present context this indefinite regress of
interpretability not only applies to the case that I have used for illustrative purposes, but also to
my understanding of the theories themselves and their relation to one another. In the case of
Lacan, not only are their conflicting interpretations of Lacan, but conflicting interpretations of
his interpreters. As such, the possibility of anything like a definitive reading of either a case, or
even a theory about a case, is, on the very assumption of a hermeneutic theory impossible. While
the limitations in terms of verifiability and consensus of an interpretive theory of the human
psyche are obvious, its strengths, on the view of this author, more than make up for its
shortcomings. One does not have to be a Lacanian to recognize that human beings are
themselves interpreting agents who live in a world that is constituted as much by values,
meanings and significance as it is constituted by things. We are continuously interpreting,
understanding, misinterpreting and misunderstanding each other, and (according to
psychoanalytic theory) ourselves. A psychological theory that takes as its starting point the
interpretive nature of the human condition has this much to recommend itself: it considers people
as they actually are, rather than what an operationally driven science dictates they should be in
order to measure them and pin them down. What a hermeneutic psychology loses in precision it
gains in scope and depth.
With regard to this particular study, as I have repeatedly emphasized, its main purpose is
to generate dialog on the subject of the borderline from a Lacanian point of view. The case study,
which has been presented, perhaps provides some prima facie evidence that a Kernbergian
borderline can be diagnosed, and treated, in Lacanian terms without recourse to the borderline
concept, but even here we cannot be definitive. The presentation of a case study is by necessity
selective; indeed the selection process has already begun in the consulting room, and is
conditioned by the clinicians own interests, prejudices, etc. There is no raw data so to speak,
available to check this authors hypotheses and assertions, and even if such data were available,
e.g. in the form of videotapes of all the Katherine sessions, that data would itself be colored by
the direction that the therapist chose to bring the treatment, again, according o her theoretical
prejudices, etc.
Further limitations of studies of this kind are inherent in the fact that the author herself
was a participant in the case which serves as its main illustration, and she conducted the
treatment. Her own limitations in her understanding of both Kernberg and Lacan, and the
broader psychiatric and psychoanalytic scene within which these theorists, and the theory of the
borderline are imbedded are also potential sources of confusion. As this study attempts to
articulate the Kernbergian and Lacanian theories in some detail, and to place them into the
beginnings of a dialog, the value of this study will be, of course, limited by the authors own
limitations in her understanding of the theories presented and discussed, limitations that, it is
hoped, will be overcome by future participants in what promises to be an interesting and fruitful
dialog between American psychoanalysts and the followers of Jacques Lacan.
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Index
abandonment, 12, 19, 101, 121, 122, 133 anorexic, 78

Abend, S., 18, 187 anthropology, 22, 44
academic psychology, 5 antisocial, 6, 26, 137, 182
adaptation, 9, 15, 16, 58, 164, 165, 167, 170, anxiety, 9, 14, 19, 27, 28, 30, 33, 37, 41, 67,
178 68, 69, 73, 100, 104, 105, 117, 121, 122,
addiction, 28 123, 124, 125, 126, 128, 131, 133, 135,
Adler, A., 21, 187 139, 141, 145, 159, 164, 172, 179, 180,
Adler, G., 181 182, 183
affective disorders, 9, 10, 11, 12 aprs coup, 53, 63, 177
affective instability, 12, 121 Aquino, D., 182, 187
affective organization, 14 Arents, M., 182, 198
aggresivity, 88, 152 as-if, 9, 14, 17, 26
aggression, 14, 26, 32, 33, 34, 35, 37, 38, atemporality, 61
90, 115, 124, 136, 137, 138, 152, 175, 180 Attention Deficit Disorder, 182, 183
aggressive, 18, 31, 32, 33, 35, 36, 37, 38, 57, avoidant personality, 29
90, 99, 109, 115, 123, 136, 137, 138, 139, Azevedo, B., xiii
148, 167 Balint, M., 23
aggressivity, 68, 156 being-in-itself, 72
Akhtar, S., 6, 26 Bemporad, J., 182, 187
alcoholism, 28 Benveniste, E., 50, 187
alienation, 56, 57, 59, 64, 68, 79, 106, 168, Berg, M., 182, 188
170, 184 Beyond the Pleasure Principle, 75
ambulatory schizophrenia, 7 black humor, 100
American Psychiatric Association, 10, 12, Bleiberg, E., 4, 5, 11, 188
121, 187 Bleuler, E., 6
American psychoanalysts, xi, 1, 5, 13, 43, Bonaparte, M., 46, 48
44, 163, 186 borderline conditions, 1, 9, 11, 14, 21, 22,
anger, 8, 10, 12, 26, 111, 122, 135, 157 23, 125, 183
Anna O, 174
Borderline Personality Disorder, xii, 5, 12, demand, 64, 76, 77, 78, 79, 95, 96, 100, 104,
13, 107, 118, 121, 122, 162 113, 141, 142, 143, 176, 178
borderline state, 6 dementia praecox, 6
boredom, 26, 114 denial, 31, 32, 39, 47, 104, 124, 130, 131,
Bourgondien, 179, 182 133
Bowlby.J., 18 dependency, 9, 38, 139, 181
Breuer, 45, 174 depression, 9, 10, 14, 33, 105, 110, 111,
British empiricists, 45 113, 114, 115, 133, 150, 151, 152, 156,
British school, 22, 25, 31 160, 183
broken structures, 171 depressive position, 14
Carr, 30, 41 dereistic thinking, 7
Cartesian rationalists, 45 descriptive criteria, 6, 13, 102, 120, 150
Casanova, 98 descriptive point of view, 13, 26, 27
castrating, 37 desire, xiii, 18, 54, 58, 64, 67, 68, 71, 76, 77,
Catell, J., 3, 4, 192 78, 79, 81, 82, 83, 84, 85, 88, 90, 92, 93,
certainty, 80, 87 94, 96, 97, 98, 99, 100, 101, 102, 103,
chain of signifiers, 52, 53, 60, 62, 74, 78, 89 104, 105, 106, 116, 128, 138, 142, 143,
character pathology, 26, 29, 135 144, 147, 150, 152, 155, 157, 158, 160,
chimpanzee, 56 161, 163, 167, 168, 169, 171, 173, 174,
clarification, 2, 40, 126 176, 184, 198
confrontation, 40 desire of the other, 78, 157, 168
contradictions, 39, 80 deterministic, 37
Contradictions, 131 Deutsch, H., 14, 40, 188
contradictory, 20, 34, 39, 41, 100, 127, 131, devaluation, 10, 12, 31, 33, 36, 121, 124,
136, 165 131, 136
conversion, 27, 91, 97, 122 Devaluation, 33
coping style, 11 developmental, 5, 18, 31, 36, 55, 59, 60, 61,
core borderline, 9 62, 75, 169, 170, 179, 180, 181, 183, 184,
countertransference, 118, 167 195
culture, 1, 16, 45, 63, 64, 69, 70, 71, 94, 97, developmental theory, 5
152, 170, 171, 173, 177 Di Ciaccia, A., 163, 164, 188
cure, 79, 85, 156, 157 dialectic, 56, 85
cyclothymic, 28, 42, 122 didactic, 144
De Mijolla, 46, 47 disavowal, 54, 83, 103, 104, 105, 146, 157,
deconstruction, 57, 163 174
defense, 3, 14, 18, 23, 26, 31, 32, 36, 58, dissatisfaction, 95, 97, 99, 104, 149
100, 129, 131, 132, 133, 135, 146, 167, dissociation, 11, 34, 183
180 dissociative, 10, 11, 12, 87, 122, 123, 146,
defense mechanism, 14 173
defenses, 11, 13, 16, 18, 21, 30, 31, 39, 40, dissociative disorders, 11, 174
41, 58, 100, 125, 129, 131, 132, 133, 134, Dissociative Identity Disorder, 173
150, 163, 164, 166, 168, 177 dissociative reactions, 28
defensive mechanisms, 131 Dor, J., 53, 54, 57, 85, 94, 97, 98, 188
Dellis, 2 Dora, 93
Index 201
dreams, 19, 50, 54, 61, 73, 78, 82, 86, 100, Formations of the Unconscious (Lacan
144, 146, 147, 148, 150, 154, 155, 190 Seminar), 66
dreamwork, 53 "fort, da, 63
drives, 5, 23, 31, 33, 35, 36, 37, 56, 66, 76, France, viii, xi, 1, 22, 44, 45, 46, 47, 48, 49,
89, 102, 103, 167, 170 188, 195, 197, 198
DSM, vii, ix, 4, 5, 12, 13, 41, 42, 83, 121, Frankl, V., 62
122, 162, 165, 191 free association, 74, 119
dysthymia, 83 French psychoanalysts, 2, 22, 44, 45, 47
eating disorders, 182 Freud, A., 21, 23, 48
Ecrits, 53, 57, 61, 64, 72 Freud, S., 1, 21, 22, 23, 25, 26, 31, 44, 45,
ecstasy of the body, 89 46, 47, 51, 53, 54, 58, 63, 65, 66, 67, 69,
Efrain, E., 4, 187 70, 71, 73, 74, 75, 76, 80, 82, 83, 88, 90,
Ego, viii, ix, x, 44, 55, 167, 188, 192 91, 92, 93, 96, 99, 102, 103, 144, 153,
ego functions, 15, 132 164, 165, 166, 167, 171, 174, 188, 189,
ego ideal, 32, 35, 88, 136 190, 191, 194, 197, 198
ego-fragmentation, 153 Freudian, vii, xi, 21, 22, 29, 44, 46, 49, 54,
ego-psychological, 23, 25, 26, 36, 42, 172 68, 108, 163, 167, 169, 198
ego-psychology, xi, 57, 58, 166, 169 Fromm, E., 21
Elementary Structures of Kinship (Levi- Frosch, J., vii, 15, 16, 86, 191
Strauss), 70 Gabbard, G., 22, 23, 191
empirical, 3, 4, 7, 41, 60, 86, 162, 164, 175, genetic, 4, 150, 165, 168
177, 178, 196 genital, 35, 37, 38, 114, 123, 124, 136, 138,
empirical research, 3, 178 147, 148, 171
emptiness, 10, 12, 14, 26, 34, 122, 127, 181 Gill, M., 29, 196
erogenous zones, 75, 89 Girl Interrupted, 1
ethical, 167, 171, 175, 178 Goldman, S., 181, 191
Evans, D., 53, 56, 188 Goldstein, 18, 26, 27, 30, 34, 37, 41, 42, 136
existential, 22, 169 good and bad, 14, 24, 31, 35, 36, 131, 180
existentialism, 22, 45, 55, 173 good object, 24, 32, 33, 171, 180
experimental science, 45 grandparents, 64, 65, 71, 149, 169, 177
Ey, H., 46 gratification, 33, 38, 138, 181
Fairbairn, W., 23, 24, 29, 31, 188 Greenberg, J., 23, 191
family Therapy, x, 168 Grinker, R., 3, 4, 8, 9, 192
Famularo, R., 179, 189 Gualtieri, 179, 182, 183
Fatal Attraction, 1 guilt, 14, 32, 33, 35, 42, 88, 90, 114, 132,
Feher Gurevich, J., 50, 55, 60, 70, 189 155
Fenton, T., 179, 189 Gunderson, J., 2, 3, 4, 9, 10, 25, 41, 191
Ferenczi, S., 21 hallucinations, 3, 6, 7, 11, 15, 16, 27, 73. 86,
Fink, B., 83, 86, 89, 92, 102, 145, 146, 158, 87, 134, 158, 159, 173, 176
159, 189, 193 Harari, R., 172, 192
Fliess, W., 46 Hartmann, H., 21, 29, 48, 164, 192
flooding, 19 Hegel, G., 45, 47
foreclosure, 54, 83, 84, 88, 91, 146, 157 Hegelian, 55
Heidegger, M., 22
hermeneutic, 184 instinct, 58, 66, 76

heterogeneity, 68 integration, 14, 22, 31, 33, 35, 38, 127, 128,
heterosexuality, 37 129, 130, 136, 172
Hoch, P., 3, 4, 7, 192 International Congress of Psychoanalysis,
homogeneity, 68 45
homosexuality, 37, 95, 98 International Psychoanalytic Association,
Horney, K., 21 22, 43, 46, 48, 55
human condition, 66, 152, 153, 158, 171, interpersonal functioning, 40
184, 185 interpersonal relationships, 8, 9, 12, 18, 71,
Husserl, E., 22 121, 130, 176
hyperarousal, 11, 182 interpretation, 39, 41, 45, 82
hypochondriasis, 10, 28, 97, 122, 123, 183 intersubjectivity, 170
hypocondriacal, 27, 28 interviews, 34, 40, 80, 108, 123, 128, 132,
hypomanic, 26, 28, 122 133, 139, 142, 144, 145, 155
Hyppolite, J., 47 intrapsychic, 13, 14, 20, 30, 39, 64, 81, 129,
hysteria, 91, 92, 93, 94, 95, 96, 97, 102, 160, 169
163, 174, 198 introjection, 25, 33, 137
hysterics, 87, 91, 93, 94, 95, 96, 97, 159, introjects, 24, 31, 180
163, 173 Jakobson, R., 50, 53, 192
Id, vii, 34, 44, 190 Johansen, R., 181, 192
idealization, 10, 12, 14, 19, 31, 33, 36, 39, jokes, 54
112, 121, 124, 131, 136, 139 Jones, 45, 48
identification, ix, 15, 20, 24, 25, 31, 32, 33, jouissance, 75, 76, 96, 103, 174, 189
53, 56, 57, 58, 65, 68, 88, 90, 93, 94, 95, Jouissance, viii, 75, 76, 106
99, 103, 131, 136, 137, 138, 148, 149, judgment, 15, 30, 57, 81, 125, 130, 148
152, 153, 154, 155, 157, 165, 167, 168, Jung, C., 21, 45
169, 171, 172, 174, 178, 183 Kant, I., 45
identity, 8, 9, 10, 11, 15, 17, 26, 34, 36, 38, Kaplan, H., 89, 192
39, 40, 65, 66, 71, 79, 90, 94, 108, 124, Katherine, ix, x, 107, 108, 109, 110, 111,
125, 127, 128, 129, 130, 135, 139, 143, 112, 113, 114, 115, 116, 117, 118, 119,
154, 156, 165, 166, 169, 179, 181, 183 120, 121, 122, 123, 124, 126, 127, 128,
identity diffusion, 26, 34, 127, 128, 130, 129, 130, 131, 132, 133, 134, 135, 136,
131, 166 137, 138, 139, 140, 141, 142, 143, 144,
Identity disturbance, 12, 121 145, 147, 148, 149, 150, 151, 152, 153,
imaginarized, 88, 158 154, 155, 156, 157, 158, 159, 160, 161,
imaginary, 55, 56, 57, 58, 63, 64, 66, 67, 68, 162, 163, 166, 168, 169, 184, 185
69, 72, 73, 81, 85, 86, 87, 88, 89, 90, 92, Katherine, case of, xii, 107-120, 140-162
96, 99, 102, 104, 106, 149, 156, 158, 166, Kernberg, O., vii, viii, ix, xi, xii, 5, 13, 14,
172, 198 17, 18, 21, 22, 23, 25, 26, 27, 28, 29, 30,
imaginary father, 67, 85, 90 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41,
imaginary phallus, 67, 104 42, 43, 107, 108, 120, 121, 122, 123, 124,
impulsivity, 10, 12, 26, 121, 180, 182 125, 126, 127, 128, 129, 130, 131, 134,
infant, 14, 24, 31, 59, 62, 75, 76, 86, 160, 135, 136, 138, 139, 140, 142, 143, 150,
169, 171, 179
Index 203
152, 159, 162, 163, 164, 165, 166, 167, lack, 9, 14, 18, 20, 30, 31, 32, 34, 35, 38, 48,
168, 170, 173, 178, 180, 185, 192, 193 63, 67, 71, 78, 79, 89, 94, 95, 104, 106,
Kernberg. P., 180 114, 124, 127, 128, 129, 130, 135, 136,
Kernbergian, ix, xii, 107, 108, 109, 119, 137, 143, 147, 151, 156, 164, 175, 180
120, 139, 140, 141, 142, 143, 162, 163, Laforgue, 46
165, 169, 173, 185, 186 Lagache, 48
Kety, S., 11 Laplanche, J., 25, 96, 195
Kinscherff, R, 179 latent schizophrenics, 8
Kinscherff, R., 189 law, 50, 68, 70, 71, 75, 84, 86, 88, 93, 99,
kinship, 50, 70 100, 103, 106, 157, 158, 163, 174, 175,
Klein, M., 11, 14, 21, 22, 23, 25, 31, 32, 59, 176
152, 193 L'Evolution Psychiatrique, 46
kleptomania, 28 Lemaire, A., 51, 56, 57, 195
Klosinki, G., 183, 193 Levi-Strauss, C., 22, 49, 70, 71, 195
Kohutian analysis, 156 libidinal, 31, 33, 36, 37, 60, 89, 99, 124, 150
Koriath, 179, 182 linguistics, 22, 47, 50, 51, 54
Kraepelin, 6 Little Hans, 69, 73, 102
Kriss, E., 21 Lowenstein, R., 21, 46, 48, 192
Kuhn, T., 178, 194 Mahler, M., 18, 36, 124, 128, 179, 180, 195
Lacan, J., viii, x, xi, xii, 1, 2, 22, 26, 41, 42, Major, R., 44, 195
43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, masochism, masochistic, 14, 19, 28, 37, 38,
54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 123, 124, 138, 139, 149
65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, Masterson, J., 18, 180, 195, 196
76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, Meissner, W., 17, 172, 196
87, 88, 89, 90, 91, 92, 93, 95, 96, 97, 101, mental apparatus, 38
102, 103, 107, 108, 120, 124, 127, 140, mental status examination, 40
142, 143, 146, 150, 152, 155, 156, 157, Merleau-Ponty, M., 22, 47
158, 160, 162, 163, 164, 166, 167, 168, metaphor, 51, 53, 54, 65, 71, 74, 82, 85, 86,
169, 170, 171, 172, 173, 174, 175, 176, 88, 102, 103, 158, 159, 163, 176, 177
177, 178, 180, 184, 185, 188, 189, 192, metaphoric, 54, 74, 89, 106
193, 194, 195, 196, 197, 198 metapsychology, metapsychological, 19,
Lacanian, viii, ix, x, xi, xii, xiii, 2, 21, 22, 164, 196, 197
43, 44, 48, 54, 55, 57, 60, 61, 72, 73, 74, metonymic, 53, 54, 74, 79
80, 81, 83, 86, 92, 93, 102, 103, 107, 108, metonymy, 51, 53, 74, 79, 177
109, 119, 120, 140, 141, 142, 143, 144, Mirror Stage, viii, 46, 55
145, 149, 150, 152, 153, 156, 158, 159, misrecognition, 57, 58
160, 161, 162, 163, 164, 165, 166, 167, Mitchell, S., 23, 191
169, 171, 173, 174, 175, 176, 177, 178, moment of conclusion, 61
184, 185, 186, 188, 189, 195, 196, 198 moment of seeing, 61
Lacanian psychoanalysis, 21, 54, 102, 175, moment of understanding, 61
178, 189 moral insanity, 6
Lacanians, xi, 2, 44, 78, 83, 84, 85, 86, 92, mother, v, 9, 18, 20, 24, 36, 37, 38, 59, 60,
98, 157, 165, 168, 171, 174, 175, 177 63, 65, 66, 67, 68, 69, 71, 74, 76, 77, 78,
81, 84, 85, 88, 91, 93, 94, 98, 99, 102,
103, 104, 106, 110, 111, 117, 130, 131, panic disorder, 83
139, 147, 148, 149, 150, 151, 152, 153, Pappenheim, P., 174
154, 155, 157, 158, 159, 160, 161, 169, paranoid, 6, 12, 14, 26, 27, 28, 37, 42, 122,
170, 176, 179, 180, 196 123, 132, 138, 139, 146
Muller, J., 73, 196 paranoid position, 14
multiplicity, 19 paraphilia, 174
mutability of the sign, 52 parental, 35, 37, 65, 89, 137, 138, 181
Name of the Father, x, 54, 71, 155 parenting, 4, 20, 183
narcissism, 67, 153, 177, 190, 193 parents, 20, 24, 64, 65, 68, 69, 71, 74, 82,
narcissistic, 18, 26, 42, 57, 94, 104, 122, 88, 89, 102, 110, 111, 114, 115, 135, 137,
124, 169, 172, 174, 187, 193 139, 151, 152, 153, 160, 161, 169, 171,
Nash, 48 177
Nasio, 74 Parmelee, D., 182, 198
National Institutes of Mental Health, 10 passivity, 9, 15, 100
need, 7, 18, 19, 26, 27, 32, 45, 70, 73, 76, paternal function, 69, 84, 85, 88, 90, 102,
77, 78, 79, 92, 93, 104, 113, 118, 123, 104
141, 142, 148, 149, 160, 165, 172, 176, paternal metaphor, 54, 71, 102, 158
192, 196 penis, 67, 69, 73, 98, 104, 106, 139
negative therapeutic reaction, 14 perceptual distortions, 15, 134
neuroses, xi perfection, 95
New York Psychoanalytic Institute, 18 perversion, xi, 1, 7, 44, 50, 63, 72, 73, 82,
normative function, 68 83, 88, 99, 102, 103, 105, 146, 157, 163,
obesity, 28, 123 173, 174, 198
object relations, 1, 18, 19, 22, 23, 24, 25, 28, phallus, 67, 68, 78, 91, 93, 94, 98, 99, 101,
29, 33, 36, 42, 43, 124, 125, 130, 133, 102, 104, 161, 176
170, 179, 180 phenomenological, 22, 26, 49
Object Relations Theory and Clinical phenomenology, 4, 45, 55
Psychoanalysis (Kernberg), 36 philosophical, 22, 44, 164, 177, 178
object representations, 14, 19, 25, 33, 36, 38, philosophy, 22, 44, 45, 47, 55, 57, 72, 175,
39, 40, 130, 179 178
object-relations theory, xi, 59, 171 phobia, 69, 92, 102
obsessive, 10, 82, 84, 92, 96, 98, 99, 100, Phobias, 27
101, 122, 136, 166 phobics, 69
obsessive-compulsive, 10, 27, 82, 122, 136 Piaget, J., 49
oedipal, x, 18, 54, 59, 60, 68, 106, 136, 151, Playboy magazine, 34
169 pleasure, 66, 69, 75, 76, 91, 95, 96, 97, 102,
oedipal victory, 104 103, 104, 149, 158, 159, 171, 172, 174,
Oedipus Complex, viii, 54, 60, 65, 66, 67, 191
85, 93, 136 points de capiton, 52, 53
omnipotence, 31, 33, 35, 39, 124, 131 Polatin, P., 7
operationalizing, 176 Polymorphous Perverse, 28
oral, 33, 37, 38, 139, 148 polysubstance dependence, 83
overwritten by language, 152 Polysymptomatic, 27
Palombo, J., 182, 196 polysymptomatic neurosis, 18, 122
Index 205
Porter, M., 18, 187, 194 psychopathy, 6

position, 5, 14, 24, 45, 50, 52, 55, 60, 62, 67, psychosis, xi, 1, 2, 4, 11, 13, 15, 16, 25, 26,
68, 76, 78, 81, 83, 90, 91, 92, 93, 94, 96, 33, 36, 44, 50, 53, 55, 63, 83, 84, 85, 86,
97, 98, 99, 101, 102, 117, 128, 140, 143, 87, 88, 89, 90, 103, 125, 126, 146, 150,
145, 149, 155, 157, 166, 171, 174, 178, 157, 159, 163, 173, 174, 176, 179, 198
179 psychosomatic, 47, 152
possession states, 173 psychotherapy, 3, 4, 26, 27, 30, 34, 110,
post positivist philosophy, 178 118, 142, 178, 193
post-Freudian, 21, 22, 108 psychotic borderline, 9
Post-traumatic Stress Disorder, 179 psychotic character, 15, 16, 17
pregenital, 9, 18, 35, 37, 38 psychotic-like symptoms, 11
pre-linguistic, 72 rage, 7, 9, 34, 37, 59, 97, 109, 111, 114, 139,
pre-oedipal, 18, 26, 59, 169, 174 152, 155, 182
preschizophrenic patients, 8 Rank, O., 21
presumptive, 26, 27, 29, 120, 122, 123, 124, Rapaport, D., 8, 29, 196
128, 139, 142, 162, 165, 176, 184 real, 8, 12, 15, 24, 33, 55, 56, 67, 68, 69, 72,
presumptive criteria, xii 73, 84, 85, 86, 87, 88, 89, 103, 106, 121,
Prichard, J., 6 156, 158, 172
primal scene, 66, 139 real father, 84, 85
primary process, 8, 18, 30, 53, 82, 86, 124, reality principle, 58
150, 165, 180 reality testing, 9, 14, 15, 16, 18, 30, 38, 57,
primary process thinking, 30 87, 124, 125, 126, 129, 131, 133, 134,
primary repression, 91 135, 165, 167, 171, 174, 176
primitive, 8, 9, 15, 17, 18, 30, 32, 33, 35, 39, relationship with reality,, 15
50, 88, 124, 125, 130, 131, 132, 133, 134, repression, 26, 31, 59, 62, 63, 68, 83, 90, 91,
135, 138, 139, 152, 164, 168, 180 101, 103, 129, 131, 146, 150, 157, 158,
projection, 14, 16, 25, 31, 32, 87, 132, 148 159, 160
projective identification, 14, 18, 31, 32, 33, resignification, 62
36, 39, 124, 130, 131 resignified, 60
promiscuity, 7, 10, 37, 38 resistance, 3, 17, 27, 142
Prozac, 114, 118 return of the repressed, 91, 160
Psychoanalysis, viii, x, 43, 44, 45, 59, 80, return to Freud, 1, 22, 47, 82, 143, 193
92, 107, 164, 167, 189, 195, 196, 197, 198 Rinsley, D., 18, 180, 196
psychoanalytic, xi, xiii, 2, 3, 4, 5, 13, 14, 17, Rorschach, H., 8, 30, 196
19, 23, 26, 29, 40, 41, 42, 45, 46, 47, 48, Roudinesco, E., 44, 197
49, 51, 54, 60, 61, 62, 65, 68, 71, 79, 80, Sadock, B., 89, 192
82, 94, 97, 107, 120, 127, 136, 139, 142, Salpetriere Clinic, 45
144, 148, 157, 163, 164, 165, 166, 167, sarcasm, 100
168, 169, 171, 174, 175, 177, 179, 180, Sartre, J., 22
185, 192, 195 Saussure, F., 22, 47, 50, 51, 52
Psychodynamic, 3, 191 schizoid, 17, 18, 26, 28, 42, 122
psychological testing, 2, 3, 4, 5, 8, 9, 30, 38 schizophrenia, 2, 4, 6, 7, 9, 17, 183, 188,
Psychopathology of Everyday Life (Freud) , 192
45 schizotypal, 7
Schreber, 90 subjectivity, 55, 57, 58, 63, 64, 67, 88, 152,
Searles, H., 19, 197 168, 170
second topographical system, 44 suggestibility, 15
secondary process thinking, 30 suicidal, 12, 114, 115, 121, 122, 123, 147
self-defeating, 37, 75, 97, 157 Sullivan, H., 21
self-destructive, 9, 26, 114, 136, 182 superego, viii, ix, 25, 29, 32, 33, 35, 44 65,
self-psychology, 23, 168 124, 136, 137, 138, 139, 167
sexual, 4, 7, 10, 11, 28, 34, 37, 38, 65, 66, Sutherland, J. 23
67, 68, 69, 71, 81, 91, 93, 95, 102, 104, symbolic, 19, 50, 54, 55, 59, 63, 64, 65, 66,
116, 117, 122, 123, 138, 139, 150, 151, 67, 68, 69, 70, 71, 72, 73, 74, 76, 79, 84,
154, 159, 174, 181, 183, 191 85, 87, 88, 89, 90, 92, 93, 99, 101, 102,
sexual difference, 66, 104 103, 104, 156, 158, 159, 164, 166, 170,
Shapiro, T., 4, 40, 197 171, 175, 198
signified, 51, 52, 53, 62, 64, 85, 151, 154, symbolic order, 50, 54, 59, 63, 65, 66, 68,
177 71, 73, 74, 79, 84, 85, 88, 89, 92, 158, 166
signifier, 51, 52, 53, 54, 64, 67, 74, 79, 82, Symbolic Register, 155, 156
104, 192 The Family (Lacan), 65
Singer, M., 3, 8, 9, 19, 191, 197 thought disorder, 174, 197
Singer, M., 2 three Freudian structures, xi
Single White Female, 1 three registers, 72, 73, 88
sliding of the signified, 53, 64 topographical model, 51, 167
slips of the tongue, 50, 63, 78 Tort, M., 174, 189
Societe Psychoanalytique de Paris, 46 transference, 3, 4, 18, 30, 33, 40, 56, 80, 82,
Society Francaise de Psychanalyse, 48 92, 94, 105, 118, 125, 135, 145, 156
specular image, 172 trauma, 4, 11, 62, 72, 73, 181
Spitzer, 10, 13 Treatise of Insanity (Prichard), 6
splitting, 14, 18, 26, 29, 31, 32, 33, 36, 37, unconscious, 15, 22, 24, 25, 40, 41, 46, 50,
39, 64, 124, 131, 180 51, 52, 53, 58, 59, 60, 61, 62, 63, 65, 70,
Stern, A., 13 72, 74, 76, 78, 80, 82, 91, 92, 107, 129,
Stone, M., 2, 198 138, 141, 143, 152, 156, 164, 165, 166,
stress interview, 41 167, 169, 182
structural, xii, 2, 3, 4, 5, 14, 17, 22, 26, 28, versagung, 96
29, 35, 36, 40, 41, 42, 44, 50, 54, 56, 60, Volkan, V., 19, 198
66, 70, 72, 81, 92, 103, 109, 120, 122, Wallon, H., 47, 56
124, 125, 126, 127, 130, 131, 139, 143, Willick, M., 18, 187
145, 148, 157, 162, 165, 167, 170, 173, Winnicott, D., 23, 181
176, 184 Wolfman (case of S. Freud, 166
structuralism, 44, 49, 50, 55, 173 Wood, I., 182, 198
structuralist, 49, 51, 54 Zilboorg, G., 7
Structure of Scientific Revolutions (Kuhn),
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Borderline Personality Disorder: A Lacanian Perspective

Borderline Personality Disorder: A Lacanian Perspective v

En ella y solo en ella estan ahora

- Jorge Luis Borges ( El Hacedor, 1960)

I. The Borderline Concept in America 1

II. Otto Kernberg and the Borderline Conditions 21

The Superego in the Borderline Structure 35

III. Lacanian Psychoanalysis 43

IV. The Case of Katherine 108

V. Katherine as a Kernbergian Borderline 120

VI. Katherine as a Lacanian Patient 140

Oedipal Vicissitudes 151

VII. Lacan and the Borderline Conditions 162

Liliana Rusansky Drob

I would like to express my gratitude to Beatriz Azevedo, my psychoanalytic supervisor

The Borderline Concept in America

Difficulties in the Definition and Study of the Borderline Personality

Early Conceptions of Borderline Pathology

Psychological Testing Models

Borderline Pathology in Descriptive Psychiatry

In 1968, Grinker et al, conducted a study of 53 hospitalized patients in order to establish

Post-traumatic and Dissociative Models

More recently a number of clinicians have come to see borderline personality as a

Borderline Personality in the DSM

The American Psychiatric Association officially acknowledged the Borderline

a pervasive pattern of instability of interpersonal relationships, self-image and affects,

1) Frantic efforts to avoid real or imagined abandonment.

Psychoanalytic Conceptions of the Borderline Patient

In an effort to clarify the underlying psychological characteristics that characterize

Early Psychoanalytic Contributions

Froschs Psychotic Character

Later Psychoanalytic Theorists

(affective lability, poor frustration tolerance, ego-weaknesses, lack of self-cohesion, primitive

conflict between individuation and symbiosis, and experiences individuation as synonymous

Otto Kernberg and the Borderline Conditions

Post-Freudian Developments in Psychoanalytic Theory

Interestingly, in spite of the various schisms in post-Freudian psychoanalysis, and the

Kernbergs Theory of the Borderline

The Descriptive or Presumptive Diagnosis

Kernbergs descriptive model consists of a number of symptoms that he believes are

(2) Polysymptomatic Neurosis: This includes:

(3) Polymorphous Perverse Sexual Trends: According to Kernberg, patients who

Kernbergs Structural Analysis

(4) Pathology of internalized objects: According to Kernberg,. the building blocks of

The Id in the Borderline Structure

Kernberg emphasized an excessive amount of pre-genital aggression in the borderline

The Superego in the Borderline Structure

The Genetic-Dynamic Analysis and Developmental Theory

Closely linked to Kernbergs ego-psychological/structural model of the borderline

As we have seen, Kernberg provides a rather deterministic theory of the factors

Kernbergs Three Psychic Structures

Table 1: Kernbergs Structural Criteria for Neurosis, Borderline and Psychosis

The Interview as a Diagnostic tool

aware of potentially conflictual and incongruous aspects of their presentation. Interpretation

Empirical Assessment of Structural Diagnosis

The Clinical Value of Structural Analysis

Theoretically, Kernbergs structural diagnostic approach is meant to contrast with the

The History of Psychoanalysis in France

As is well known, Freud had an important first-hand experience of French psychiatry

Having provided a brief history of psychoanalysis in France, it remains, by way of

Lacans Novel Psychoanalytic Ideas

As I have indicated in the previous section, any understanding of Lacanian

The Mirror Stage: The Scenario of Ego formation