On loss and mourning

How did your book, The New Black, come about?
Over the years, I was very curious to see differences in the way that my patients responded to the relatively brutal experience of loss that happens with a bereavement. I was also curious as to why, after Freud's essay on mourning and a few others, all the literature looks at the various phases we go through, the external manifestations of mourning, and it doesn't really look at the unconscious processes. In my practice, certain things kept cropping up for patients in the years following a bereavement, which indicated that things were moving along because changes had happened at an unconscious level. I wanted to explore that. So, more than any of the other things I've written, this book comes from my patients, and trying to explore the logic behind what they are saying.

Is depression something you have struggled with yourself?
Any research comes from experience, but not necessarily a direct experience. But the first question we have to ask is whether there is such a thing as 'depression', and this is one of ideas that the book slightly goes against. It is saying that depression is different for different people, hence you have to attend and listen very, very carefully to what it is for each particular person. That's why one of the arguments of the book is that as you listen more to people who are given the blanket term 'depression', you see that very often stories and experiences of loss and unresolved mourning lie behind it. I say right at the beginning of the The New Black, that not all depression covers over a problem with mourning, but it happens often enough to make it worthwhile thinking about.

The most well-known stages of mourning were introduced by Elisabeth Kübler-Ross, which many are familiar with. However you are quite critical of these stages; when I read your critique, it seemed almost sacrilege!
Some people, when seeking bereavement counselling, often feel absolutely enraged that they're being put into a kind of box – now this is this stage, and then it'll move to this one, and then it'll move to this. Mourning doesn't have such neat stages. It's a very complicated thing, it takes a long time, and it can also never happen. The nub of the question is, are the important moments in a mourning process conscious or not? And crucially most of the time we don't mourn. I went back to an essay Freud wrote about mourning and for the first time, it really registered: he talks about revolt in the human mind against mourning. Why? Because mourning is so painful and it's easier in a sense to deny a loss than to try to engage with it. Which is an amazing thing: it means that even though we all lose relatives, family, people who are important to us, maybe most of the time, mourning doesn't take place.

In the book you discuss four main 'markers' that can provide a sense of how the mourning is progressing.
Let me go through the first 'marker' which is signalled often by dreams. In fact, it's so common for people in the mourning period. Not necessarily immediately, but sometime after the experience of loss, rather than having dreams about the person you've lost, there may be a dream about your telling someone else about that person, or about the loss, as if something has changed in your relationship with the person you've lost. This sort of dream suggests you're no longer inhabiting the same space; you could have dreams maybe for a year or two, that you're fighting with a dead person, and then you could have a dream where you're on a stage talking about them. That's very different, it means something's changed: you no longer inhabit the same space as the dead. So many rituals in different societies are about quite literally banishing the dead to a different space. Our culture often encourages us to do the opposite, which is to live in the same space as the dead: think of the internet memorial sites where you can stay in contact with the voice and the image of the dead person, or endless TV shows about dead celebrities.

The second indicator of the work of mourning is 'killing the dead'. Very often people have dreams where they're killing someone who's already dead – why was that necessary? Again, many rituals in different cultures involve someone being buried twice; there's a first burial and then a year later, or six months later there's another burial, which implies that now the person is finally laid to rest. It suggests that there's a difference between biological death and symbolic death.

Is this the same thing as letting go?
I'm not sure it is. This might seem trivial, but one of my patients makes a very fine distinction, when talking about his dead father, between letting go of him and letting him go and for him these two are radically, totally different things. Something more has to happen in relation to the one we've lost than their simple empirical absence. Mourning is never an automatic process.

We do have rituals around death, for example when people scatter ashes at a particular location. Is that what you are getting at?
Well, that's very interesting, because scattering ashes often creates great problems in families, because there's no set ritual for it. You hear it all the time, what do you do with the ashes? How are they divided between the relatives? Where do you scatter them? Many people can't bear to separate from the ashes, so they never scatter them, they put them under their bed or they're in the garage, they don't know what to do with them. It's something we see more and more today, in many different contexts linked to death. People have to invent their own rituals because there isn't the dominance, or availability, of set cultural rituals. That's a very interesting change in our times.

That does relate to the other point you've written about, the concept of a social dimension of mourning.
Yes, I think very often you need to engage with how other people show that they've responded to a loss, for your own mourning to get going. A classic example is Hamlet – he's not really grieving for anyone until he sees Laertes grieving in a ridiculously ostentatious way for his sister Ophelia. It's only then that he can start to engage with his loss.

Think of the situation in a family, when someone dies and everyone carries on as if nothing has changed. How's the child going to be able to mourn, if no one else is registering a loss? So you get some very complex and important transactions between mourners. Mourning isn't an individual enclosed process; we need to relate to other people's experiences of loss in order to do something with our own experience, to work it through. And that's one of the important aspects of human culture, which provides us with arts, literature, cinema. It shows us the way that people have made something out of an experience of loss, and that can help us in making something for ourselves.

The third 'marker' for the work of mourning involves what you describe as symbolising the dead.
Yes, it's the idea that on an unconscious level, we start to engage with the fact that maybe there was something about the person we have lost, that we didn't know, and there was always something perhaps strange and unknown about them. Very often you find that, in later phases of mourning, someone will look at a photograph or a memento and it will seem strange to them; it's like, who is that? It's a very, very odd experience. It can happen in a dream, that someone you loved can somehow seem totally alien to you, totally strange; you know them, but who are they? What do they want? When we love someone, we're always imposing our own projections onto them. In the work of mourning, there's a process whereby those projections are questioned or challenged or stripped away, and we're confronted with the tension between our projections and the reality of that person, which can be a very disturbing experience.

You also speak about a process of 'settling debts' with the dead.
The thought 'I should have done more' can haunt someone for decades after a death. That's a pretty normal reaction to a loss, but sometimes this can become amplified and exaggerated and take over a whole life. There are two dimensions of debt – the idea of a debt that you could actually, in reality have paid, such as, 'if I had paid more money for the casket, it would be OK.' Or, if I had said to this person how much I love them before they died it would be OK, or if I had spent this money on the flowers. All these things are treated as if they could be settled in reality, if you could just turn the clock back. But there is another more fundamental debt we have. For example, the debt of life, what you might owe to a parent. Those debts can never be settled and often in mourning you have a confusion of the two debts, as if…

…the more superficial debts are really about something else.
Yes, they start to take on the place of the impossible debt that can never be repaid, and so you'll spend your whole life tortured by these ideas of what you should have done. So in mourning it's very important to distinguish things that can be paid and things that can't. This can happen at an unconscious level, it can happen in therapy, it can happen without therapy. It happens in different ways for people, there's no rule.

In your book, you differentiate between mourning and melancholy in relation to what we tend to simply label as 'depression'.
I am not using melancholia in the everyday sense of the term, as a sort of self-absorbed, nostalgic sadness. It's used in a very specific sense, as a diagnostic category, very different from mourning, in which the person makes a wholesale, massive identification with the dead person. It is as if, when someone dies, you 'die' with him or her; or when they go away, you become 'dead'. At an unconscious level, the person is quite literally dead, which might mean that they'll kill themselves, or their life will be totally mortified, or they might have hallucinations where parts of their body are parts of the corpse. So it's a very serious thing, which modern psychiatry doesn't really understand. For Freud, the main feature of melancholy was self-reproach – the person would very vocally blame him- or herself for being the cause of all the problems in the world. Actually, they are reproaching the person they've lost, but that's turned inward, and they have incorporated them, so attacking them means that you attack yourself. Spears become boomerangs. We see that again and again. It's very important to understand that in order to do work with people that have melancholia.

How does this relate to large-scale incidents of loss, such as traumas like September 11 or casualties in war?
It is crucial that we continue to give importance to the arts, because the arts are instruments for the work of mourning – art gives us tools to help us think through losses. It does this by showing us how it's possible to make something – it's the very principle of the memorial. You don't leave the place where something terrible has happened the same – you change it in some way, you make a minimal symbolic, artificial intervention. That shows that you've made something, you've created something from an experience of loss.

I'll give you a clinical vignette. One of my patients was obsessed with the footage from 9/11 and would spend all day, every day watching again and again all the available footage of the towers. She didn't know why she was doing it, but she had to do it, as if there was something so unimaginable about the whole thing that all she could do was try to see it from every possible viewpoint. Then she remembered that when she was a child she also, for several months, spent all her time trying to represent from every possible angle, a particular scene in which there had been a savage act of violence between her parents, which she could only see from one angle. It's very interesting to see the comparison and how it was the engagement with what had happened in the towers that brought back her childhood memories. It shows that one's response to a tragic event, on a public scale, will have very different resonances for different people on a private scale.

As a psychoanalyst, do you find you see the world differently from most people?
It's not so much me that does, it's other people! If I go to a party and say I'm a psychoanalyst, suddenly they'll either spend the whole evening telling me their dreams, or they'll become incredibly aggressive because they or a relative had a bad experience. Someone sitting next to me at a dinner party the other night found out I was an analyst and spend the next three hours telling me, in great detail about all her dreams, of being eaten by a big shark!

It seems psychoanalysis still carries the association of being a practice of the 'chattering classes', the bourgeoisie.
A lot of people who do analysis come from working-class backgrounds. The great thing about Lacanian analysis is that there's no fixed-length session, and you don't charge people set fees, so people who don't have money, who aren't privileged, pay a few pounds and people who come from other backgrounds will pay more. If you only see people for a certain number of sessions per day, you're effectively excluding other people from being able to do it. In the Lacanian tradition you have people from all different walks of life and all different backgrounds thanks to this flexibility.

So it's a myth that only the wealthiest sectors of the population receive analytic treatment?
People think psychoanalysis is about bored housewives who've got money and a few minor neurotic problems. Actually psychoanalysis is a very real thing for people with very serious problems. If someone comes in and they just want a natter, and not engage in any real work – which is uncommon – they probably won't be taken on by the analyst. More than half of the cases in most analytic practices today involve psychosis. So we are dealing with very real levels of human suffering. But, you know there probably will always be that myth about chattering classes, too.

It's also related to what we associate with Freud, which of course psychology is a product of.
Reading Freud often undoes what we associate with Freud – we realise that his arguments are far more subtle and complex than their standard expositions. Just take one example: look at what Freud says in his 1915 paper 'The unconscious' about the relation between ideas and affects. Isn't this far more sophisticated than most current cognitive theories?

It seems that cognitive behavioural therapy is on the rise, and risks crowding out other forms of therapies such as psychoanalytic psychotherapy. Is this the case?

This is already happening in many areas of the public health sector. CBT, after all, offers a value system congruent with that of the State. The interesting thing is that now some psychoanalytic therapists are trying to repackage their own work as a version of CBT. This new psychoanalysis dispenses in practice with the unconscious, infantile sexuality, etc. These new therapies radically change the philosophical underpinning of clinical work – they see human beliefs not as the expression of some inner truth, but as scientific hypotheses about reality. So you can now tell someone seeking a particular form of therapy that they are wrong, that it won't help them. The next logical step is the regulation of religions, as if people can be told what is a correct belief. This is a very dangerous line to cross, as it ignores the meaning that beliefs have for a human being

But surely CBT can be effective and help treat depression?
CBT is of course helpful to many people, but for reasons which cannot be subsumed in the cognitive model. CBT has been around in different forms for a long time, and in the last ten years it has expanded exponentially. For example, if you work in the NHS and are using a form of psychotherapeutic or psychoanalytic therapy, drawing on say family systems or psychodynamic work, management are telling you, 'Don't do that, you can't do that, you need to focus on the management of the patients symptoms.' The overwhelming stance is that these therapies don't work because they are not 'evidence-based'. Thus the criteria for the evaluation of therapies has moved to a very narrow view of evidence, based on the medical model of randomised-controlled trials. This is the medical model of a trial experiment, with a control group, and so on. You can't do that with therapy, because the whole point of therapy involves the beliefs the person has initially about their treatment or therapeutic experience. So you can't randomly assign someone to a therapist. The second point is that, regardless of the tradition being used – whether it's Lacanian, Freudian, whatever – the work is done by the person in therapy, not really by the therapist. The therapist facilitates, but the patient makes the choices.

The current CBT model is seen as basically business. Involved in the 450 rules for the conduct of psychoanalysis is something called 'skills for business'. It's all based on a business model and a business ethic – you are providing a service to users, they need to be kept happy, you avoid risk, all the things which are pretty incompatible with psychoanalysis. Politically, cognitive behavioral therapies are forcing out other traditional forms of very valid work in this country, which is a serious thing. This ideology is infiltrating the trainings of other non-cognitive approaches, so trainings will be more and more pushed into the cognitive model, where there's no place for the unconscious, no place for human history, no place for the dignity of human beliefs.

How are you, as a psychoanalystand scholar, responding to this?
It's an uphill struggle. Every day my colleagues and I have literally hundreds of e-mails going round about this issue. So I am engaging with government, trying to make the arguments heard, though it's very difficult because most of the time they're not heard at all; there's no listening taking place. In fact, to be more precise, today's society is about listening not hearing. There are cosmetic listening processes to make people feel understood, but they are never really heard

Is the main difference between a cognitive behavioural approach and a psychoanalytic one in the way you work with unconscious dimensions of human experience?
Yes. And the key difference is that in the field of 'mental hygiene', which is what cognitive therapy is, you know in advance what's best for the patients – for example, they need to get back to work, be economically productive, not have too many visits to see shrinks, not have too many problems fitting in with society. So the difference is that if you have symptoms you can either see them as something to be got rid of or you can see them as a clue to exploring your inner life. Symptoms can either be got rid of or given a voice.

But what if people don't necessarily want to explore their inner life?
Absolutely, most people don't. That's why you can never impose therapy on anyone. And that's why cognitive therapies suit many people and why they should be available. The problem is that cognitive therapies are pushing out other forms of therapeutic practice, and introducing methods to different therapies, such as the technique of going through a checklist of points at a session. It's a method, which presumably means you'd get pretty much the same results, or you'd hope to. But, of course, why should anyone be obliged to do that? The government has embarked on a project to 'provide' psychotherapy in Islamic communities to young people suspected of harbouring terrorist aspirations. Therapy here is seen as a tool of re-education, a procedure to be applied to a passive recipient. This breaks radically from traditional conceptions of what therapy is.

I guess in some ways we haven't come very far from the 1960s and 1970s when people like R.D. Laing and the transpersonal movement challenged the politics of psychology and its potentially coercive applications in mental health.
It's interesting – in the 60s and 70s the big focus on ethics in medicine was in psychiatry. Today this has moved to genetics, and a few other areas, and the whole debate about ethics and psychiatry has taken a back seat. In many ways, the 60s and 70s were much less repressive than today, and the parameters of mental health work are actually more restrictive today. Who could get funding today for the community experiments of the 70s?

From very early in your career as a young adult, you've had a strong attraction to psychoanalytic work. What was it that attracted you?
Initially, I think it was the fact that psychoanalysis didn't restrict me to learning about one thing. If you study Lacanian analysis, you have to read history, economics, philosophy, mathematics. Psychoanalytic work is absolutely full of references to the plurality of different disciplines, and to understand what that means, you have to study lots of different fields. It's a way of engaging with some general questions about culture and the history of science, which I find fascinating.

The most interesting thing about a Lacanian approach for me is the fact that it does take seriously that analysis involves words, and hence you need theories about language and interpretation. Also, the tradition that Lacan comes out of is early 20th-century psychiatry. Early psychiatry had a lot of bad things about it, but it also had some very good things. Psychiatrists back then were very interested in listening to their patients and trying to make distinctions, rather than grouping everyone together into one category. Rather than seeing madness as that which is abnormal and which we need to just shut away, there was an attempt to try and engage with madness and see what could be learnt from it. That's the tradition that Lacan comes out of, and that's very important today in terms of general approaches to so-called mental health and psychiatry. At the beginning of the 20th century, in most psychiatric articles you actually hear the patient's words. That is rare in psychiatric papers nowadays.