Duquesne University Duquesne Scholarship Collection Electronic Theses and Dissertations Summer 2011 Neurosis or Perversion? A Lacanian Psychoanalytic Diagnostic and Clinical Approach to the Treatment of Paraphilia at a Forensic Outpatient Setting: A Case Study and Exegetical Method Stephanie Swales Follow this and additional works at: https://dsc.duq.edu/etd Recommended Citation Swales, S. (2011). Neurosis or Perversion? A Lacanian Psychoanalytic Diagnostic and Clinical Approach to the Treatment of Paraphilia at a Forensic Outpatient Setting: A Case Study and Exegetical Method (Doctoral dissertation, Duquesne University). Retrieved from https://dsc.duq.edu/etd/1256 This Immediate Access is brought to you for free and open access by Duquesne Scholarship Collection. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Duquesne Scholarship Collection. For more information, please contact [email protected]. NEUROSIS OR PERVERSION? A LACANIAN PSYCHOANALYTIC DIAGNOSTIC AND CLINICAL APPROACH TO THE TREATMENT OF PARAPHILIA AT A FORENSIC OUTPATIENT SETTING: A CASE STUDY AND EXEGETICAL METHOD A Dissertation Submitted to the McAnulty College and Graduate School of Liberal Arts Duquesne University In partial fulfillment of the requirements for the degree of Doctor of Philosophy By Stephanie Swales, M.A. August 2011 Copyright by Stephanie Swales 2011 NEUROSIS OR PERVERSION? A LACANIAN PSYCHOANALYTIC DIAGNOSTIC AND CLINICAL APPROACH TO THE TREATMENT OF PARAPHILIA AT A FORENSIC OUTPATIENT SETTING: A CASE STUDY AND EXEGETICAL METHOD By Stephanie Swales Approved April 15, 2011 ________________________________ ________________________________ Bruce Fink, Ph.D. Jessie Goicoechea, Ph.D. Professor of Psychology Assistant Professor of Psychology (Committee Chair) (Committee Member) ________________________________ Robert Coufal, Ph.D. Adjunct Faculty (Committee Member) ________________________________ ________________________________ Christopher M. Duncan, Ph.D. Daniel Burston, Ph.D. Dean, McAnulty College and Graduate Chair, Department of Psychology School of Liberal Arts Professor of Psychology iii ABSTRACT NEUROSIS OR PERVERSION? A LACANIAN PSYCHOANALYTIC DIAGNOSTIC AND CLINICAL APPROACH TO THE TREATMENT OF PARAPHILIA AT A FORENSIC OUTPATIENT SETTING: A CASE STUDY AND EXEGETICAL METHOD By Stephanie Swales August 2011 Dissertation supervised by Bruce Fink, Ph.D. The work of Jacques Lacan (1901-1981) provided clinicians with three main diagnostic ontological structures: neurosis, psychosis, and perversion. All three diagnostic structures indicate fundamentally different ways of solving the problems of alienation, separation from the primary caregiver, and of castration, or having limits set by the law on one‘s jouissance. Of the three, perversion remains by far the least understood and least discussed. To date, Lacan‘s diagnostic system—not to mention his corpus in general—has been largely ignored by psychotherapists in the United States. Where Lacan has been taken up within psychotherapeutic discourse, discussions are often restricted to the field of psychoanalysis and are usually theoretical, rather than clinical, in nature. There is a shortage in general of published clinical case material utilizing Lacan‘s diagnostic structures, and in particular of cases of perversion. In addition, even in texts on Lacanian theory, very little has been written on what Lacan said about perverse structure. In this dissertation, I strive to make Lacan‘s perverse structure—and, by iv extension, his diagnostic system—not only comprehensible to psychotherapists and psychoanalysts alike, but indispensable. I elucidate perversion by utilizing two main methods: qualitative clinical case study and qualitative hermeneutic reading of what Lacan said about perversion. Perversion is compared and contrasted with neurosis, and Paraphilia is seen as a descriptive diagnosis that could apply to either perversion or neurosis. Both of the case studies presented here involved an outpatient forensic context, and so I also address forensic treatment concerns. Implications for the psychoanalytic and forensic treatment of sexual offenders are discussed by making crucial distinctions between neurotic and perverse individuals. v DEDICATION Dedicated to my parents, with gratitude for their love which brought me here. vi ACKNOWLEDGEMENTS I give my thanks to the great many people who, through their teaching, mentorship, support, and encouragement, helped me complete this dissertation. I owe my profound thanks to the patients about whom I wrote in this dissertation. They trusted me to assist them in their brave explorations of their psyches, and I hope that they found their participation in the psychotherapeutic process made a lasting positive impact on their lives. I hope that they have continued the sometimes difficult but ultimately immeasurably rewarding process of psychotherapy. Dr. Bruce Fink directed this dissertation with enthusiasm, careful attention to detail, and his vast knowledge of Lacanian theory and its clinical applications. I am deeply grateful for the opportunities I have had to work closely with Dr. Fink over my graduate student years. In his various roles as my dissertation director, clinical supervisor, professor, mentor, and author of numerous excellent books, Dr. Fink has profoundly influenced my understanding of Lacan‘s oeuvre, my clinical work, and my ways of thinking about human life and psychopathology. What is more, Dr. Fink encouraged my own style of thinking, writing, and working with patients. Dr. Robert Coufal, who served as a committee member for this dissertation, has also had a significant impact on my clinical work and interests. With his tireless commitment to individualized clinical care, he showed me that forensic clinicians can make an impact both on the lives of forensic patients and on the forensic system as a whole. Dr. Coufal‘s humanistic, existential-phenomenological, and psychodynamic perspectives on forensic psychotherapeutic work impressed and inspired me. I am lucky vii to have had such a kind, supportive, thought-provoking, and ethically sensitive clinical supervisor and dissertation reader. Dr. Jessie Goicoechea not only contributed to this dissertation as a committee member, but also as a professor and clinical supervisor responsible for orienting my introduction to clinical work. Through her teaching, Dr. Goicoechea passed on her compassion and respect for those who undergo psychotherapy. I am grateful to Dr. Goicoechea for having supported my growth as a clinician and having taught me her nuanced understandings of using reflexivity as a clinical tool. Frank Scalambrino, my fiancée, has contributed much to this dissertation and to my growth as a clinician and thinker through his support, encouragement, and love. His passion for helping others and courageous exploration of the psyche will continue to inspire me. I am blessed to love and to be loved by Frank. I am thankful to Duquesne‘s McAnulty College and Graduate School of Liberal Arts for having provided funding for this project in the form of their 2009-2010 Dissertation Fellowship Award (2009-2010). Dr. Constance Fischer was, from the beginning of my graduate studies, a major influence on my growth as a person and as a provider of psychotherapy and collaborative assessments. Dr. Fischer touched me with her kindness, moral courage, unflagging encouragement, and wisdom. That which Dr. Fischer brings to humanistic and existential-phenomenological approaches to clinical work makes her one of the great psychologists of our day. I am thankful for her mentorship and for her helpful comments on an early version of my dissertation. viii Many other members of the Duquesne University faculty and staff deserve my gratitude. I learned much from Dr. Roger Brooke, who as my professor and clinical supervisor shared his expertise on psychoanalytic and existential-phenomenological approaches to psychopathology and providing psychotherapy. Dr. Ezequiel Peña provided excellent clinical supervision and taught and modeled for me compassionate and respectful ways of conceptualizing diversity that strive to avoid imposing one‘s own values onto others. Dr. Leswin Laubscher, through his brave intellectual curiosity and moral sensitivity, taught me the benefits of pursuing a path of questioning regardless of what may or may not be present at the end of my search. Dr. Daniel Burston, with his insatiable intellectual curiosity, empathy, and attunement to ethical issues, taught me much about the benefits of studying the intersections of continental philosophy and psychology. Dr. Paul Richer taught me what it means to be a good teacher. Dr. Russ Walsh taught me how to be a reflective reader and researcher. Marilyn Henline provided much logistical support and encouragement throughout my years at Duquesne. Likewise, Linda Pasqualino assisted me by virtue of her warmth, spirit, and incredible organizational skills. My thanks also goes to my supervisors and colleagues at Gateway Foundation. Drs. Michael Colombatto and William Hillman have supported and encouraged my clinical work and have expanded my understandings and appreciation of the humanistic and psychodynamic traditions. I am grateful to Shana Small for her spirit-lifting presence and for broadening my theoretical horizons by her sensitive clinical work. I am also thankful to Dr. Marie Durka for her encouragement and for our thought-provoking discussions of the theory and practice of psychoanalytically-informed