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BOOK REVIEW

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WORKING WITH TRAUMA: Lessons From Bion and Lacan, by Marilyn Charles, New
Jersey: Jason Aronson, 2012, 118 pp., $29.99, ISBN 978-0-7657-08680-5
Reviewed by

Frank Summers, PhD, ABPP


Feinberg School of Medicine, Northwestern University
There is a growing trend in contemporary analytic theory that emphasizes the unique
experience of the individual patient more than the discovery and communication of certain
truths. In this way of thinking, the clinical encounter is more about the process, the
engagement between patient and analyst, than a means for arriving at knowledge. The
clinical music engages the patients unique subjectivity, and the purpose of the process is
to establish and expand the patient as a subject. Working with Trauma: Lessons from Bion
and Lacan fits this evolution in analytic thought and extends it significantly by showing
its utility for severely disturbed individuals.
Marilyn Charles book is a deeply thoughtful, highly sensitive account of how a gifted
clinician works with traumatized individuals. The book is a major contribution to psychoanalytic clinical theory on two levels. First, this volume is a seminal contribution to the
psychotherapeutic treatment of severely disturbed individuals. Dr. Charles provides invaluable insights and guidelines for the psychoanalytic treatment of the most severely
disturbed patients encountered by the clinician. In fact, the patients she uses to illustrate
her clinical points suffer from the severe dysfunction that many clinicians dread working
with and avoid if they can. In most mental health organizations psychotherapy is
considered irrelevant and useless for such patients. In this age of medicalization of mental
health treatment, Dr. Charles is among the few brave voices insisting on treating such
patients with the respect and empathy that should be accorded all psychotherapy patients.
The second level is reflected in the subtitle, Lessons from Bion and Lacan. Charles
demonstrates with utmost clarity and acuity the clinical usefulness of those two iconic, but
enigmatic analytic theorists. Commonly regarded as interesting, innovative, even brilliant,
minds, their influence in the U.S. has been minimal because many analysts regard their
theoretical work as difficult to understand and even more difficult to apply clinically. Even
after some of the content is grasped, the clinician is often left wondering how one would
apply Lacanian or Bionian concepts to the clinical process. For example, with regard to
Lacan, one may well wonder: How does the division of mental processes into the real
the symbolic and the imaginary change ones clinical approach? How does the lack
affect clinical technique? For Bion, the analytic clinician may be puzzled by how his grid
can be used to understand patients and how it is possible to enter every session without

Correspondence concerning this article should be addressed to Frank Summers, PhD, ABPP, 333
East Ontario Suite 4509B, Chicago, IL 60611. E-mail: Franksumphd@gmail.com
Psychoanalytic Psychology, 2015, Vol. 32, No. 2, 366 370
2015 American Psychological Association, 0736-9735/15/$12.00 http://dx.doi.org/10.1037/a0037333

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367

memory or desire or why one should do so. Books written with the express purpose of
showing the clinical use of these theorists tend to leave many readers as perplexed about
the clinical usefulness of Lacan and Bion at the end of the monograph as at the beginning.
In my experience this book is singular in the clarity with which it shows the clinical
applicability of Lacan and Bion without sacrificing theoretical complexity.
From Bion, Charles draws on his concept of binocular vision, a term that refers to two
vantage points of the same scene. She sees Bion as attempting to get the therapist to look
beyond his own perspective to see that of the patient as well, and by not adopting either
vantage point exclusively, moving beyond simplistic ways of understanding. In this
regard, one of the targets for Charles acute clinical criticism is the imposition of theory
on the patients experience. She reads both Lacan and Bion as taking stands in strong
opposition to this dangerous analytic tendency. In fact, she champions both theorists as
advancing a notion of analytic therapy that places fealty to the patients experience at the
top of the analytic value system. Dr. Charles tells us in the introduction that she believes
Lacans most lasting clinical contribution may well be keeping in mind the Subject of the
inquiry (p. 6). Here she deploys Lacans concept of getting lost in the desire of the
Other in place of finding our own desire. Charles is steadfast in her reading of Lacan as
a champion of the particulars of meaning over conforming to authority. For Charles, a
Lacanian analysis is an exploratory voyage of discovery, the end result of which cannot
and should not be foreseen.
In Bion, Charles finds a very similar interpretation of analysis that uses different
language. She emphasizes Bions fundamental concepts of attention and notation, both of
which are functions, not contents. Notation is an active aspect of our listening that serves
to focus our attention on the patients experience. So, from Bion, too, Charles derives a
concept of analysis as placing top priority on attending to the patients experience. Charles
interprets Bions famous admonition to enter every session without memory or desire to
mean the analyst should jettison theory and be open to the patients experience wherever
it leads. Bion invites us, says Charles, to move beyond words to the purposes they serve.
Applying this principle to psychosis, Charles sees in Bion the idea that psychosis is not
an inevitable otherness, but a human process, existing to some degree in all of us, that
needs attention. The psychotic part of the personality is characterized by symbolic
equation, the failure to distinguish symbol and symbolized. This concreteness becomes a
psychotic thought process because the inability to tell the difference between a symbol and
what it symbolizes means thoughts cannot be linked together, and then the psychotic tries
desperately to relink disconnected thoughts.
In Lacan, Charles finds a different psychoanalytic accent: the tension between self and
other. It is the human condition, says Lacan, for ones desire to become all too easily lost
in the desire of the Other, and the result is a lost Subject. The purpose of the analytic
process for Lacan, as for life, is to develop the Subject. We need to be aware of the degree
to which we are born into the world already defined by others in order to define our own
desires. The purpose of analysis is to find and develop the Subject. One can see here that
in Charles interpretation of Lacan analysis is not about the resolution of any particular
dynamic, but a process of finding ones own voice, the development of the unique human
subject. Minimized here is any notion of the patient as recipient of analytic expertise.
According to Charles, Lacan sees the analytic process as a way for the patient to learn
from her own experience, rather than a means for gaining knowledge, just as for Bion the
goal is to learn from experience. Thus, Charles derives from both figures her most
fundamental therapeutic principle: fealty to the patients experience. Charles reads both
Lacan and Bion as saying that the analyst should avoid being the one with knowledge to

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BOOK REVIEW

impart to patients or the savior who rushes to action to relieve suffering. Bion conceptualizes the analyst as fellow traveler, rather than expert, and Charles adopts this way of
interpreting the analysts role.
Central to the Lacanian emphasis on engaging the patients experience is the
notion of limit. For Lacan, the human condition consists of the conflict between
individual desire and the desires of others embodied in social rules. No matter how
successful one may be in becoming a Subject, conflict with the limits imposed by the
social order cannot be avoided. The tension between individual meanings, the imaginary,
and social rules, the symbolic, is inherent in all analytic therapy, and a major developmental task is to come to grips with the no imposed in the name of the Father. The
psychotic individual, being unable to accept the limits imposed by the social order, rather
than making accommodations to the desires of others attempts to live in denial of them,
and that requires psychotic beliefs. Charles uses this Lacanian formulation to understand
and engage the psychotic process.
Charles derives two principles from Lacan for working with this patient population.
First, the unconscious, according to Lacan, reveals itself by the gaps displayed in the
patients discourse. For Lacan, the slips and omissions in the patients speech constitute
the intrusions of unconscious desire into consciousness. The alert analyst recognizes the
gaps and finds the unconscious meaning. This technique is standard for analysts working
within a Lacanian framework; however, unique to the traumatized patient is the inability
to symbolize her experience, which results in showing the experience to the therapist
rather than telling what it is. The analysts job is to read the impact of the patients
experience on the analyst, a process not recognized by the patient as a communication.
The analytic process for the psychotic patient, then, lies in finding meaning in the
patients behavior and making it conscious, but that is not because the result is an
accumulation of knowledge, but because the process itself is ameliorative. By bringing the
unsymbolized into language the patient can now speak in another register. The experience previously conveyed through the symptom can now be expressed through the
symbolic via language. It is out of this process, Charles avers, that the space for the
symbolic, for meaning, can take place. The treatment of the psychotic is not about
provision of understanding, but the engagement of a process of experiencing with its
inevitable confrontation with limits. It is this process, she argues, with its provision of a
new space, that gives the patient the opportunity to locate herself as a valued subject, the
ultimate goal of psychoanalytic treatment. The threat the psychotic patient feels in
response to limits need not be an insurmountable obstacle if the analyst is willing to
respond to the patients experience with the tact and sensitivity accorded the experience
of other patients.
In both of these technical suggestions Charles is using Lacan, although her application
of Lacanian theory to psychosis is not standard fare for Lacanians. Many inside and
outside the Lacanian movement see the theory as exclusively a theory of neurosis. No less
a figure that Andre Green left France to become a visiting professor at the University
College of London for two years in order to gain a closer appreciation of Winnicottian
inspired ideas about treating character pathology analytically. Although there is a growing
number of clinicians who use Lacan for the treatment of psychosis (e.g., Appollon,
Bergeron & Cantin, 2002; Davoine & Gaudilliere, 2004), Charles may be said to be
breaking new ground in the way she uses Lacan to engage the experience of the psychotic
patient. The willingness to treat psychotic phenomena as a mode of human experience that
can be understood and engaged as an understandable reaction to life circumstances puts
her work squarely within the great tradition of the American psychoanalytic approach to

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369

psychosis. This historical movement reaches back to Sullivan, and many others since who
have persisted in exploring the experience of the psychotic individual despite the hegemony of biological psychiatry.
It is especially important in this era to give voice to those who oppose the hegemonic
culture by resisting the medicalization of severe emotional disturbance. To be sure, seeing
Lacans work as a way of responding to human experiencing is not unique to Dr. Charles.
What is innovative about this book is its creative integration of Lacanian concepts with the
sensitive attunement to the psychotic experience Dr. Charles displays in her clinical work.
The way Charles uses Lacan especially for the engagement of psychotic experience is
fresh, creative, and constitutes a seminal contribution to the field.
Into this approach Charles integrates Bionian ideas about the psychotherapeutic
process in general, and the treatment of psychosis in particular. While Lacan emphasizes
tolerating limit and lack, for Bion the key to the analytic process is interest in learning
versus turning a blind eye. Trauma fragments some patients so that they are unable to
know. For Bion, trauma interferes with linking thoughts, so the patient knows and does
not know. The analytic focus is on bringing both sides of the ambivalence to light. The
patient will continue to attack linking by dissolving therapeutic progress. Here Charles
makes a crucial point: Rather than becoming discouraged by what appears to be a
psychotherapeutic process that appears to be going nowhere, the analytic task is to survive
the destruction (Winnicott, 1971) so that the various de-linked thoughts can be brought
together in the analytic space. If there is a third figure to whom Charles owes allegiance
it is Winnicott whose concepts of transitional space, fear of breakdown, and survival of
destruction are integrated well into Lacanian and Bionian concepts. All three theoreticians
influenced each other, but Lacan and Winnicott had a special affiliation in their developmental theories around the importance of the gaze of the other, mirroring, in the origins
of the self.
It is perhaps banal to state that I cannot possibly do justice to all the clinical
wisdom contained in this slim volume, but I hope I have said enough to show the
reader the exceptional value of this work. For analytic therapists who, like me, have
had difficulty using Lacan and Bion clinically, this is an invaluable addition to
the contemporary clinical literature. Charles has an exceptional ability to take abstruse
concepts, which may appear to exist only in the ethereal atmosphere of the conceptual
world, and bring them down to Earth in a way usable for the clinician. I have seen no
work that better demonstrates the clinical value of Lacan and Bion, not even among
the adherents of those two theorists.
Dr. Charles easy, clear, and straightforward writing style can cause the reader to miss
the innovative nature of this work. Both Bion and Lacan can be read as promoting the very
antithesis of Dr. Charles interpretation of them. In some of his conceptualizations Lacan
appears to be an essentialist: the Father as the third who represents no disturbs the
mother child unity. There is an inherent meaninglessness to life with which all patients
must come to grips. One can critique Lacan for imposing a theoretical structure on the
patients experience. Furthermore, Lacan reads the unconscious with such rigidity that
Lacan decides the session is over when he decides he has read the unconscious. Those
attitudes would seem to oppose the principle of fealty to the patients experience and the
goal of the development of the Subject. Nonetheless, Charles deploys Lacan in exactly the
opposite way. In my view, there is no value in arguing which is the real Lacan; both can
be found in his work. What matters is that Charles has been able to read and use Lacan
in a way that is responsive to the individual subject and clinically useful not just for
neurotic patients, but for the traumatized, psychotic individual.

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This volume succeeds in providing understandable and very useful clinical strategies
based on Bion and Lacan that can be deployed by any clinician working with the severely
disturbed individual. In my view, the importance of this book resides in the fact that one
gets a sense of how Dr. Charles approaches and helps patients whom many clinicians are
reluctant, even fearful, to engage in a meaningful therapeutic process. The principles seem
so simple and straightforward: respond to the patients unique experience, try to understand unconscious meanings, know ones limits, be alert to gaps in meaning, open the
space for patient exploration, do not try to cure, but provide opportunity for discourse.
However, the reality is that these principles are difficult for most clinicians to apply
consistently, especially with the severely traumatized and psychotic patient. The many
vignettes and clinical descriptions Dr. Charles provides indicates how she uses these
principles to engage experience that appears to be incomprehensible from a rational
viewpoint.
So, this book is a must for any clinician who wants to find a way to make use of Lacan
and Bion in the therapeutic process, but it is also a necessary read for any clinician who
does or aspires to do meaningful psychotherapy with those who live on the edge of reality.
This volume is the best work I have seen in some time on applying analytic concepts to
patients who are all too easily ignored and forgotten about even by mental health
professionals. Dr. Charles is one of the brave souls who have bucked the Zeitgeist of our
time to keep alive the tradition of treating all patients, no matter how disturbed or difficult
to understand, with respect and sensitivity. But, this is not just a call to empathyit is a
sophisticated way of engaging psychotic experience and offers the clinician invaluable
practical tools and concepts for engaging the human experience in all its complexity,
ambiguity, and mystery.

References
Apollon, W., Bergeron, D., & Cantin, L. (2002). After Lacan: Clinical practice and the subject of
the unconscious. Albany, NY: SUNY Press.
Davoine, F., & Gaudillere, J. M. (2004). History beyond trauma: Whereof one cannot speak, thereof
one cannot stay silent. New York, NY: Other Press.
Winnicott, D. W. (1971). Playing and reality. New York, NY: Routledge.