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CLINICAL NOTES
Bruce Fink, (1999). ‘Engaging the Patient in the Therapeutic Process,’ A Clinical
Introduction to Lacanian Psychoanalysis: Theory and Technique (Cambridge, MA &
London, England: Harvard University Press), pp. 11-27.
What does it mean to engage the patient in the therapeutic process? How does the
Lacanian clinic differ from other forms of psychoanalysis? How should the analyst
initiate the patient into the analytic situation?
These then are a few of the questions that will interest those interested in the theory,
technique, and practice of psychoanalysis.
Bruce Fink, a Lacanian psychoanalyst, sets out to answer these and many other
questions in a book that he wrote on clinical methods in 1997.
I summarize some of the main points raised and analysed by Bruce Fink on the
preliminaries of the analytic process in these clinical notes.
The most important misconception in the minds of patients is that the analyst is just
like any other friend in whom they might confide or share their difficulties and who
in turn will do the same with them. This is not only a convention of friendship but
also broadly speaking of what we mean by communication.
That however is not the case in any form of psychoanalysis. The psychoanalytic
relationship is neither a form of friendship not is it a contractual relationship where
the patient is in the locus of the client.
Bruce Fink is also at pains to emphasize that the relationship between the analyst
and the patient is not based on reciprocity like most forms of social relations; it is
instead conceived of as asymmetrical where the patient does most of the talking and
the analyst will respond only as and when necessary to further the analysis.

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Before the actual start of an analysis, there are preliminary meetings in which the
analyst tries to get a broad outline of what is bothering the patient along with some
idea of his background.
This leads to a preliminary diagnosis that is not communicated to the patient - only
after that is the patient asked to free-associate on the couch.
The main challenge in these preliminary interviews is to find out whether the patient
is suffering from a neurosis or a psychosis.
These interviews happen face-to-face to make it easier for the patient who is not
used to asymmetrical relationships and to minimize the possibility of misdiagnosing
a psychotic as a neurotic in the preliminary interviews.
These preliminary meetings are also an attempt to isolate a few symptoms with
which the analysis can start instead of the vague sense of uneasiness or affects that
the patient may be aware of. Sometimes the patient has a presenting symptom and
may be too preoccupied with that to the exclusion of the analytic process as a whole.
What the analyst would like is for the patient to go beyond the presenting symptom
and make an autonomous demand for analysis. This is a formulation of Jacques-Alain
Miller.
What it means is that as the analysis gets underway, the patient should be willing to
partake of the analysis in the larger sense of the term rather than be fixated on the
presenting symptom.
This may not always be the case or easy to do since the presenting symptom may be
embarrassing or traumatic for the patient and he would like to be done with it at the
earliest. Most sexual disorders, including ‘psychic impotence,’ come under this
category.
But analysts don’t work at the level of the individual symptom since they know from
experience that the patient will displace the affects and generate another symptom if
they are able to relive him of a particular symptom. They therefore differentiate

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between the symptom and the structure within which the symptom presents itself
for analysis.
These mental structures in Lacanian psychoanalysis, in the first instance, are
differentiated under the categories of the neuroses, the psychoses, and the
perversions.
Neuroses can be further sub-divided into hysteria, obsessions, and phobias. The
psychoses include their own typology including paranoia and schizophrenia.
The main preoccupation in the preliminary meetings then is to ensure that the
patient is not misdiagnosed.
The analyst will have to ask himself honestly whether the mental structure in
question is within the reach of his therapeutic abilities or the analytic method and
then proceed accordingly. Most analysts, for instance, are not willing to analyse
psychotics and would rather refer away such patients to a psychiatrist.
Since all psychoanalytic interventions depend on the positive transference, it is
important for the analyst to manage the expectations of his patient.
The analyst has to also be on the lookout for a ‘negative therapeutic reaction’ in the
early part of the analysis.
Sometimes patients drop out of analysis because they experience an immediate
symptomatic relief when they have somebody in the know to talk to; they then
conclude that is all there is to it.
We can refer to this as a ‘positive therapeutic reaction.’
Needless to say, a positive therapeutic reaction can be as misleading for the analytic
process as a negative therapeutic reaction because in both cases the expectations of
the patient will be difficult to manage and the analysis cannot be completed.
If the analysis gets past these transferential responses, and the patient begins to free-
associate as a matter of course, then, the analyst will have decide when and if he
should interpret what the patient is saying.
Most Lacaian analysts prefer to say as little as possible until they are sure that the
positive transference is in place.
Even when that is indeed the case, they prefer to ‘punctuate’ rather than interpret.
What this means is that they might slightly rephrase what the patient is saying to
make it resonate in his unconscious.

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Or, if required, they might punctuate as though to say that something important has
been said by the patient; and that, therefore, they should declare that particular
session over. This form of intervention is known as ‘scanding.’
If the level of resistance on the part of the patient is too high or if the patient decides
to over-intellectualize his response on the couch, the analyst may scand a session
within a few seconds or a few minutes until the patient drops his resistance and
begins to free-associate.
These forms of interventional techniques are not deployed outside the Lacanian
schools.
They constitute an active approach to analysis; most schools of psychoanalysis prefer
a passive approach because they are afraid that the patient might act-out.
Needless to say, it takes a lot of clinical acumen to pull off techniques like this in
clinical practice. But, if deployed correctly, the patient is bound to respond.
There is a celebrated instance of the active technique. Lacan had a patient who was
giving him a lecture on the poetics of Dostoevsky. When Lacan tried to scand the
session, the patient revealed that he was suffering from a fantasy of anal pregnancy.
This fantasy might have remained a secret for ages in the passive approach to
analysis. Lacan’s high-risk intervention however led the analysis in a different
direction altogether.
The point here is not that Lacanians do not take a passive approach to interpretation
at all because like most analysts that is what they do most of the time.
The success of the active technique depends on using it sparingly and in ways that
can minimize the possibility of acting-out. It is not something that beginners are
expected to be good at.

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While all Lacanians try to vary the length of the session to emphasize the importance
of something the patient said or is refusing to say, that is not the same as scanding in
the strong sense of the term.
Bruce Fink also points out that day-to-day communication between an analyst and a
patient is complicated by the fact that in analysis nothing that a patient says or
demands can be taken at face value.
What this means is that there will be any number of difficulties in scheduling
sessions; finding out why patients did not show up as promised; deciding whether
to charge them for the sessions that they might have missed; and collecting the
payments that are due to the analyst.
The patient’s resistance to the treatment will show up in any one or more of these
aspects of the analytic situation.
It is therefore important for the analyst to be vigilant about whether the patient is
making a straight-forward demand in the analytic situation or whether he is stating
his desire in the transferential sense to the analyst.
Bruce Fink differentiates between the form and the content of the transference in
terms of whether or not the analyst can pull up the patient for not being aware of the
similarities between how he used to relate to significant others in his childhood and
how he relates to the analyst in the here and now.
Fink argues that it is okay to interpret the content of the transference without calling
attention to the transference as such.
As the analysis progresses, Bruce Fink argues, the patient should be able to state his
desire as a question.
This process of questioning or learning to question those aspects of his life that the
patient took for granted is what will determine how far the patient will go in the
treatment.
These questions might include those in which the patient tries to differentiate
between what they want and what somebody else wants for them. This is broadly
put the difference between the ‘desire of the subject’ and the ‘desire of the Other.’
In the attempt to find an answer to these types of questions, the patient constructs a
genealogy of his own desire.
He begins to get a better idea of what forms of identification can be presupposed for
him to desire in the specific ways in which he does.

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The patient also encounters the fact that not all forms of desire are related to the
subject; most of what we desire is related to the symbolic Other.
What is really at stake is ‘subjectification’ – i.e. the question of whether we have
internalized the desire of the Other and made it our own or whether we treat it as an
intrusion into the self.
Most of the analysis will revolve around taking each element of desire and
rethinking it in the context of the relationship between the desire of the subject and
the desire of the Other.
Neurotics are those who have a low level of internalization of the desire of the Other
or who are willing to act on the desire of the Other if compelled to, but fall ill in the
attempt to do so.
The psychoanalytic technique of ‘working-through’ is an attempt to identify, situate,
and process the affects and ideational content related to the source of any given
desire.
Lacan also uses the term ‘dialectic’ in this context; what he has in mind is the
difference between forms of desire that can be ‘worked-through’ in analysis and
those which are subject to the forms of libidinal fixation that produce symptoms in
place of desire.
The purpose of analysis then is to set this desire in motion.
SHIVA KUMAR SRINIVASAN