Some people start a psychoanalysis by presenting complaints that may look like a somatic discomfort or difficulty. It may sound remote from emotions or unconscious desires. One instance of such cases, is the complaint about difficulties to fall asleep, or repeatedly wake up during night sleep, or in general a vaguely defined poor sleep quality. The impact of the sleep problem on daily life can no longer be ignored by the patient. In diagnostic systems, the severe cases, lasting beyond 3 months and with high frequency per week, are called insomnia. Sleep’s physiological role for memory consolidation, metabolic clearance, modulation of immune system underlines the importance of sleep perturbation in a longer term. Sleeplessness has become a globally spread, but above all an accepted, seemingly innocuous form of complaint, a state of things clearly reflected in the increasing number of methods and volumes of medical expert literature in the last half a century.
However, sleep, dreams and sleeplessness have for long been the realm of poetry and poetic truth. Macbeth’s sleeplessness comes to mind. Curiously, the classic poets offer little of a complaint. Their visionary songs, haunted by dark shadows under closed eyes of lonesome night, were supposed to carry a moment of truth and reveal a looming guilt. At any rate, the desire to sleep and truth seem frequently engaged in a dialogue in dreams that our ego doesn’t even recall. No surprise that Freud’s most well-known work, The Interpretation of Dreams, spins around a quite polysemic notion of dream as “the guardian” of sleep —a truth Sayer cloaked as the guardian of nocturnal rest can scarcely be trusted by a restless ego.
In modern popular culture, movies capture and distort this same wide spread phenomenon. Erik Skjoldbaerg’s Insomnia from 1997, with Stellan Skarsgard, and its Hollywoodian remake was directed by Christopher Nolan in 2002, both were praised by the critique for their treatment of that twilight-like state of restlessness and angst that follow a prolonged period of insomnia. As the protagonist of both films display, drugs that make you sleep have almost overwritten poetry’s nocturnal visions. In a study covering five European countries on the use of Benzodiapzepines (a family of drugs called in general ZD, different flavours are dominant in different countries, for instance alprazolam and oxazepam in France or lorazepam in Germany), the researchers found that even though the efficiency of these drugs remains unproven and a prolonged consumption entails severe side effects (addiction to the drug is the most notable one), their usage is widely extended beyond the four weeks recommended by the public health agencies. They are simply prescribed too often and for too long periods of time with serious implications for patient’s health.
This situation is the background for this article. Many general practitioners in China also encounter the persistent request from patients for prescription of sedative drugs, even though patient’s problems obviously are not limited to sleeplessness. That poses an ethical dilemma for the practitioner who in rare moments dare refer the patient to a psychoanalyst.
Another treatment recommended by the mainstream health care is Cognitive Behavioural Therapy, a combination of controlling mechanisms (using internet-connected devices for keeping diary, counting hours, reminders and rewards; in sum a milder version of the old Pavlovian conditioning response. A dead dog buried here), relaxing practices such as good old Yoga, all aiming at a change of behavioural patterns. This battery of devices and methods are certainly quite useful as they all mean receiving higher degree of attention from others and some good guidance and advice. Common-sensical ideas; relaxing is certainly better than a state of agitation before going to bed, bodily exercise is always good for maintaining good health. Or at least it never hurts. Unsurprisingly, any kind of standardized study will find these methods efficient, more “efficient” than drugs, and perhaps sufficient for people who think they only suffer from a disease called sleeplessness, about which they complain when they are awake— however we define wakefulness.
As a psychoanalyst, we question this implicit or explicit assumption that sleeping irregularities constitute a disease in itself. When someone initially complains about sleeping problems, and if this same person further on describes a life situation punctuated by suffering, disrupted emotional relations, existential questions or mourning, then do we, as a psychoanalyst, have the right to arbitrarily isolate insomnia as a disease and ignore what is laid before us? The reader may expect that the answer to this question should be “No”. However, this is not my answer, as psychoanalysis does not consist of an aggregate of prescriptive rules. Its ethical principle relies upon the responsibility of a person for his or her life. It is vital that the symptom is taken seriously, not only as what it stands for (underlying structures that cause the sleeplessness in the first place), but in its own right as well. What we oppose to is the arbitrary isolation of a symptom as if it is a disease, understood as the effect of a pathogen in a linear, causative relation. This is the pharmaceutical ideology that serves certain interests. This ideology amount to say that Jaundice (yellow tint to the whites of your eyes and skin) would not be a sign for an advanced hepatitis, but instead a disease in itself. That would surely mislead any practitioner, even though cosmetics and make up industry would certainly publish evidence-based studies to show how efficiently they can treat the yellow tint of the skin. I use this example to underline the absurdity involved in ideas that have led us to believe that sleeplessness can be qualified as a disease, instead of being symptoms of social and emotional structural factors. It is in this context that the discourse employed in contemporary mental health has unfortunately evolved into a managerial direction in the West. Real caregivers or digital devices are there to execute sleep management, anger management and so on. With this logic, we will have a long list of impersonal, oracle-like Alexa micro-managers, but no deeper understanding of what causes the suffering. We will be equipped with a presumably well-intended super-ego, but we will forget the meaning of a responsible attitude towards life. In older cultures, with recourse to a rich literature and alternative conception of human interaction with its living world, this cold path may be intelligently avoided.
The Cabinet
At the meeting with a psychotherapist, the client does not perceive himself or herself as a patient, an identity defined by the medical discipline. The request by the person needs to be read as a sign, a meaningful entry point for potentially retaking responsibility for one’s life and future. As I have noticed, there is a misconception among young therapists that they feel obliged to inform the patient using some technical jargon, be it pop psychological, Freudian or Lacanian terminology, and they stick rigidly to some rules as if they are following a manual. This attitude is far from a Freudian approach and it is indeed counter-productive in the transferential situation. The reason or excuse is that they try to “educate” the so-called “healthy” part of the ego, whereas in reality it is a way to handle one’s won anxiety as a therapist. To “address the healthy ego” is an idea from American psychoanalysis, more specifically from Kohut’s so-called self-psychology in the 1960s and Hartman before that. Not only it doesn’t differ in its foundations from the epistemological assumptions of cognitive behavioural therapy, such an approach also implies that there is a neutral, universal knowledge represented by the analyst. It has opened the door to all kind of mystifications of psychoanalytical practices. If Lacanian theories mean anything, it is above all its marked distance from such power relations and a defence of Freudian notion of the unconscious. Psychoanalytical approach is fundamentally different. Instead of creating an illusion of a mysterious knowledge that can pin down all the client’s (or the supervisee’s) anxiety. A therapist listens above all to the narrative presented, works together with the client through the lacunae and affective connections within the narrative, through the granularity of the narrative structures, sometimes singling out a signifier that opens up the closed narrative. All this is guided by one single definition of the therapeutic framework: To be present when a successive train of decisions implying an assumed responsibility for the implications of that narrative is at hand.
Noise
Let us now take a step back and ponder upon the increase of sleep disturbances and the use of sleeplessness as an entry point at the encounter with a psychotherapist.
In a broader context, many societies have gone through a transformational phase in the wake of the industrial revolution. This process was significantly accelerated after the second world war. The over-abondance of stimulant substances present in food and beverage, the increased speed of life, exposure to chemical pollutants and an unprecedented density of urban habitat, are all recent features in the long history of humanity. As a side effect of this accelerated development, a general repetition of the American suburb ideals from 1950s has been staged in patches of the planetary reality. One part of this transformation is a quest for being “normal” in a rapidly shifting and unstable world of value systems. Some would rather sedate themselves with sleep pills rather than constructing a viable path of their own.
Hence and more fundamentally, one may wonder what pushes us with such an unbending force towards self-sedation. In clear words, contrary to the initial question, this complaint about sleeplessness raises a more decisive question as to why we want to fall asleep when we are awake. Are we really awake when we don’t sleep?
In a much-quoted dream interpreted by Freud, we read about a sick child who just has passed away and is laid to rest in his bed. The father, sleeping in the next room, wakes up after dreaming that the child reproachingly ask him: “Father, don’t you see that I am burning?”. After waking up, the father found that a fallen candle had caused fire in the child’s bed. This dream, that is seemingly a duplicate of an external reality, reveals the ambiguity of the state of sleep and what it means to be awake. The said dream has also received a remarkable treatment by Lacan in two of his seminars. The gist of Lacan’s comments is the question we have already posed here. In clear terms, the desire for falling asleep and failing to do so has often something to do with being deprived from wakefulness while we do not sleep. It has all the thinkable connections with doubts, memories and concerns that we forcibly pushed away, neglected or denied during daytime, and which we strongly suspect would haunt us when we finally are alone with ourselves.
A more realistic understanding of the complaint about sleeplessness cannot treat it as an isolated factum, a disease, but as a polyphonic alarm, a sand castle with each grain of meaning assisting a new embarkment, a new arrangement of minute particulars of life beyond arid binary models. In the next article, we will detail the dream of Burning Child reported by Freud and Lacan’s remarks.
References
An international survey of insomnia: under-recognition and under-treatment of a polysymptomatic condition” Current Medical Research Opinion. 2005 Nov;21(11):1785-92.
Soyka M, Wild I, Caulet B, Leontiou C, Lugoboni F, Hajak G. Long-term use of benzodiazepines in chronic insomnia: a European perspective. Frontiers in Psychiatry. 2023 Aug 2;14:1212-028.
Sigmund Freud. The Interpretation of Dreams, Chapter 7, p. 509. The Standard Edition, Vol V. London: Vintage/Hogarth Press.
