Brit J Psychotherapy - 2023 - Goetzmann - Torus Demand and Desire Towards A Psychosomatic Structure of Lung

British Journal of Psychotherapy 00, 0 (2023) 1–20 doi: 10.1111/bjp.
12846
TORUS, DEMAND AND DESIRE: TOWARDS

A PSYCHOSOMATIC STRUCTURE OF LUNG
TRANSPLANTATION
LUTZ GOETZMANN, MARIE EICHENLAUB,

ADRIAN M. SIEGEL, CHRISTIAN BENDEN,
ANNETTE BOEHLER, JOSEF JENEWEIN, ANNINA SEILER,
OLGA GRYTSKA, KONSTANTIN HESSE, UWE WUTZLER
and BARBARA RUETTNER
An organ transplant involves complex psychodynamic processing that has
been explored particularly in terms of object relationship theory. In the
present study, we develop a model of transplantation based primarily on
Lacan’s explanations of the torus. In a prospective study, we examined
40 patients, 2 weeks, 3 months and 6 months post-transplant. Based on the
analysis of a dream, we identified the so-called ‘transplantation complex’
in the form of earlier, for example, oral-sadistic fantasies. In a further step,
we examined the extent to which direct and indirect indications of this
complex were found in the interviews of the total sample. In the present
paper, these results are related to Lacan’s graph of the torus. Our results
display the dialectic of a repetitive demand, especially on the lungs, and
the desire for an object that is basically lost or Oedipally forbidden. This
dialectic may explain both the different quality of life and the frequent
occurrence of feelings of guilt reported by the patients. We also show the
function of identification, for example, with a single trait of the donor.
Overall, the model of the torus may be a way of understanding the
processing of the transplant in a deeper and more coherent psychodynamic
manner.
KEYWORDS: LUNG TRANSPLANTATION, TRANSPLANTATION

COMPLEX, QUALITY OF LIFE, TORUS, DEMAND, DESIRE,
IDENTIFICATION
THE TRANSPLANTATION COMPLEX

Lung transplantation sets a complex psychodynamic process in motion. Processes
involving the psychological integration of the lungs or other organs (Muslin, 1972;
Lefebvre, Combez & LeBeuf, 1973) and the forging of the donor–recipient
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2 Lutz Goetzmann et al.
relationship have already been described from an analytical point of view (Neukom
et al., 2012). In a prospective study, we examined 40 patients in the first six months
after lung transplantation. The interviews of this study were conducted postopera-
tively at three points in time (t1 = 2 weeks, t2 = 3 months, t3 = 6 months), tran-
scribed and qualitatively evaluated. Our psychodynamic approach involved first
examining the dream of a patient (Mr A) immediately after coming around from
anaesthesia. This dream was the starting point of our further investigations. For
dream analysis, we used the well structured Zurich Dream Process Coding System
(Moser & von Zeppelin, 1996; Moser & Hortig, 2019). The results were then coded
according to distinct, well defined categories, and the patient’s waking narratives
were also coded. Based on the analysis of the dream as well as the analysis of the
waking narratives, we developed the concept of the so-called ‘transplantation com-
plex’ (Goetzmann et al., 2019). In the subsequent data analysis, direct and indirect
references to the transplantation complex were formulated as categories and all
120 interviews of the total sample were coded (Goetzmann et al., 2019). For exam-
ple, if a patient spoke about the donor being killed, that phrase was coded as a direct
reference to the aspect ‘the donor is killed’. However, if the topic of killing or being
killed was only discussed in general, we assumed that there was an indirect refer-
ence to the above aspect. We found 596 direct or indirect indications of individual
aspects of the transplantation complex in the total sample. The most common indi-
cations were incorporation (n = 167) and rejection of the lungs (n = 133).1 In this
paper, we link these results to Jacques Lacan’s topological concept of the torus. In
its simplest form, the torus is a ring—a three-dimensional object formed by taking a
cylinder and joining the two ends together (Evans, 1996, p. 211). It initially represents
the structure of the body, analogous to the development of the unborn fetus (as so-
called ‘blastocyst’).2 From this bodily structure emerges the structure of the subject
(Friedman, 2016, p. 166). Therefore, the torus reflects both a topological structure of
the body and of the subject. From a (late) Lacanian view, knowledge cannot be
directly transformed into language, that is, into a written medium (Friedman, 2016,
p. 153). The topology helps us to understand psychodynamic processes, for example,
the processes of transplantation. The torus is particularly suitable here because it
depicts a bodily and a psychological structure. Above all, the torus model makes it
possible to understand the essential processes of need, demand and desire, as well as
the patient’s identification with the donor. It reveals the causes of guilt, fears and frus-
tration, as well as the wish to stay alive. In this respect, the metapsychological torus
model has an immediate clinical and practical benefit.
The following dream was the starting point of our research on the actualization of
an unconscious transplantation complex. The original report of the patient, whom
we call Mr A, reads as follows:
I dreamed that I had moved into a new apartment with my partner. The sur-
roundings seemed relatively familiar to me. It was somewhere I had been
before, but I couldn’t remember. What was also odd was that everything was
green. Big, dense bushes had been planted all around the apartment, so it
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British Journal of Psychotherapy 00, 0 (2023) 1–20
Torus, Demand and Desire 3
was a bit like a Sleeping Beauty castle. It was so overgrown with greenery
that there was no view and I wondered why we were living here at all.
All around us wood was being noisily chopped with an ear-splitting racket.
It then occurred to me again that you couldn’t live like that. After all, you
couldn’t see anything. Everything was green, noisy and quite deafening. On
the one hand, it was a familiar feeling, as I had been in this place before, but
I didn’t know if I felt comfortable living in this apartment. Patchwork families
lived in this apartment. That surprised me, as my wife is not the apartment-
sharing type but moved into this apartment with me even so. And all the people
living in this apartment were not bothered that you couldn’t see anything from
inside it. Somehow, they all thought it fantastic to be a bit sealed off from
everything. Later on, I wondered whether this apartment actually exists—
whether we had viewed it sometime in the past.
We first analysed the dream using the Zurich Dream Process Coding System
(Moser & von Zeppelin, 1996; Moser & Hortig, 2019). Including the aspects
derived from the waking narratives, we re-read Mr A’s dream by connecting the
model of Moser’s dream generation with an interpretation of the dream content; in
the first interview (t1), Mr A spoke of a massacre, or of a traffic accident in which
the donor could have been killed. Here the theme of a factual requirement for lung
transplantation was raised: the donor is killed. In light of the waking fantasy con-
cerning the ‘massacre’, we understood the cutting of wood as an act of killing.
There was also a typical superego conflict created here, namely that the patient only
has a chance of surviving if the other person loses his or her life. This topic also
came up in the interviews with other transplant patients (n = 96). There were direct
references, for example, when Mrs B (t3) stated ‘I really had the feeling that the
donor had to die because of me’. Indirect references involved patients speaking
about the topic of death in general, such as when Mrs C (t2) exclaimed that ‘the
contrasts between life and death are crazy’.
In Mr A’s dream-related associations (e.g., the use of chainsaws to break open
the chest), further aspects of the transplantation complex came to light: the dreamer
moves into an apartment with his female partner. Plants (wood) are cleared outside.
We interpreted the apartment as a body or as a chest. The ribs were cleared: the
body is broken open. In the subsequent interviews of the sample, however, this
aspect was rarely mentioned (n = 5), and if so, then only as a direct reference, as
when Mr D (t3) remarked, ‘I can still feel the scar and the ribs hurt. Most likely
because they had to break them for the operation’.
In the second interview (t2), Mr A disputed the statement of a Swiss politician who
drew an analogy between cannibalism and organ transplantation (in the sense that the
state should not dispose of the bodies of the deceased at will). The patient resented
the comparison of organ transplantation with cannibalistic organ consumption. We
related his omissions to the dream motif in which he entered the new apartment
(body) with his partner (lungs) after a massacre had taken place, and interpreted this
process as cannibalistic incorporation: objects penetrate into the body/are devoured.
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The incorporation motif occurred most frequently in the total sample (n = 167).
Direct references were found, for example, when patients reported that the lungs were
now ‘inside them’. Indirect references related to the incorporation of other objects
such as medicines and syringes, or the mention of inhalations, intubations, food and
liquid intake. For example, Mr E (t1) said, ‘What I have to swallow goes down with
a glass of water. That’s all. But swallowing is not the problem’. In a (delirious-seem-
ing) nightmare, Mrs F (t2), probably identifying with the dead donor, dreamed of
being eaten by worms. Or perhaps she identified with the actual worms:
I had dreams of worms trying to eat me. I probably had these nightmares
because of the medication. I was lying on a decubitus mattress that was con-
stantly filling up with air and deflating. In the dream, I felt like worms were
coming out of this mattress, wanting to eat me.
Mr G (t1) expressed this mutual incorporation as follows: ‘I have a part of him (the
donor). And I am a part of him’. Here, the cross-combination of donor incorporation
and identification with the donor led to an extremely precarious situation, which
raised a double question: who is eating whom in this scene? And who is who any-
way? This identification motif also appeared in Mr A’s initial dream: the patient
moving into the new apartment could be identified with the donor, who was thus
incorporated together with his lungs. Overall, this aspect—the donor is the recipi-
ent—was rarely mentioned in the subsequent interviews (n = 21). This identification
motif appears, for example, in the following quote, where Mrs H reports that she
probably took on the emotions of the donor (as her son in particular suspected):
P: True, one son said it’s crazy, but he said, ‘You must have got a cry-baby’s lungs’.
I: Yes.
P: And he found it funny.
I: Have you had to cry a little more since then?
P: Yes [hesitantly].
A further aspect of the transplantation complex is that the donor is a part of the
recipient’s internal world. As reported by Mr A, the donor now resided in the recipi-
ent as an ‘undead’ being who was both alive and deceased; but perhaps this fantasy
only arose after disidentification from the donor had taken place. In any case, how-
ever, during the third interview, Mr A continued to develop fantasies about the donor.
He compared himself to an adopted child who didn’t know who his biological parents
were, or a pregnant mother who didn’t know what sex her child would be. In this
way, Mr A transformed various motifs into the image of pregnancy that carried the
process forward. He became a mother himself, carrying a baby (the donor). In the
interviews of the whole sample, a total of 82 references to this motif were found. For
example, Mrs I (t1) remarked on the pros and cons of transplantation as follows:
Pro is that you are still alive, which is key. And con, that after the transplant
you are no longer completely yourself. That you are like a twosome and carry
someone else inside. I still feel it as something alien in me, although I am very
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grateful. But otherwise, of course, I wouldn’t have to take so many medica-
tions if it wasn’t something foreign. I also used to think that I was a monster.
Since the lungs can be incorporated into the body but can also be expelled,
another facet of the transplantation complex was mentioned here: the (new) object is
a member of the family of organs that can be expelled. The partner in Mr A’s dream
moved into an apartment in which a patchwork family lived (i.e., the patchwork
family of the other organs). Out of a total of 596 references to the transplantation
complex, 92 were references to the new object (lung) being an (adopted) member of
the organ family. This is how Mrs J (t1) reported her experience of lung transplanta-
tion (in terms of a direct reference):
From the start, I adopted it as my own. It even has a name. And yes, I have it
inside me from her (the donor). It’s already a part of me. I don’t experience it
as a foreign body at all. I’ve adopted it lock, stock and barrel. It’s my lung
now and I’m not giving it away.
We assessed the mention of constipation or diarrhoea as an indirect indication that
some content was being retained or expelled. Here, constipation could indicate a
desire not to have to let go, to ensure that the transplanted lung definitely remains in
the body. The fear of expulsion was mentioned very frequently in the interviews
(n = 133). Direct references existed where patients discussed the possibility of their
new organ being rejected. Indirect references were found when patients reported that
objects were being excreted from their bodies. The mention of diarrhoea (‘I have
continuous diarrhoea’; Mr E, t1) or vomiting (‘Yesterday I had to vomit, today I
managed to keep it [the medication] down’; Mrs K, t1) was particularly common.
The motif of retention and imminent loss also appeared in the dreams, with the loss
being symbolized, for example, as a violent robbery, as when Mrs L (t1) reported ‘I
had been having nightmares for a long time. I dreamed that my caregiver came into
my room and tore out my central venous catheter’. The motifs or aspects of an actu-
alization of the transplantation complex can be summarized as follows (Goetzmann
et al., 2019; Eichenlaub et al., 2021):
• The donor is killed.

• The body is broken open.
• Objects penetrate into the body/are devoured (incorporation).
• The donor is the recipient (identification).
• The donor is a part of the recipient’s internal world.
• The (new) object is a member of the family of organs that can be expelled.
The main motifs are arranged around the oral-sadistic fantasy that the donor was
killed and his lungs or soul were incorporated. Another motif was the identification
with the incorporated donor. Clearly, cannibalistic fantasies and the desire to kill
were actualized over the course of the transplantation. The structure of the transplant
complex can be understood both chronologically and topologically: from a
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chronological point of view, first the donor dies, then the body is cut open and the
organ incorporated, and so forth. From a topological point of view, the organ is
incorporated into the torus, it is part of the torus, and at the same time there is a fear
that it will be excreted again from the torus tube. We now relate these motifs to the
Lacanian concept of the torus, the dialectics of need, demand and desire, the status
of the various objects, and the function of identification. We then conclude this
paper with a consideration of the function of the torus in the processing of a lung
transplant. First, however, we present the Lacanian model of the torus.
WHAT IS A TORUS?
The torus is an ‘intuitive geometric metaphor’ (Lacan, 1961–62a, p. 119). The toric
structure consists of a ring created by stretching a cylinder and joining it at both
ends, as Figure 1 shows.
For the ‘geometer’, according to Lacan (1961–62a, p. 119), the torus is ‘a figure of
revolution engendered by revolving a circumference around an axis situated on its
plane’ (Lacan, 1961-62a, p. 119). Basically, Lacan refers to two related but fundamen-
tally different topological structures: the sphere and the torus (e.g., Lacan, 1961–62a,
p. 122). The sphere is a ball, while the torus is a hula hoop. The sphere can be associ-
ated with the amniotic sac in which the baby floats; nutrients and oxygen are fed
directly into the baby’s bloodstream, so it does not have to breathe or eat for itself. The
moment the baby leaves the maternal womb, it begins to breathe. For the very first time,
it is imbued with a substance outside of itself. As the baby breathes in the foreign air, a
(real) hole is punched in the sphere, which transforms it into a torus (de Florence,
2011). Figure 2 shows the sphere and torus.
Two other phenomena deepen the hole: hunger (in the form of a need) and the
time lag between the onset and disappearance of hunger once the baby is sated. The
early breast can now be lost in two ways: it can be lost in the moment of non-
feeding, and it can be lost because it is unrepresented, that is, ‘real’ in Lacan’s ter-
minology. The breast is doubly unavailable: as a non-feeding partial object, and
because it is not represented—because it is real. The non-feeding aspect and the
state of being unrepresented are intertwined in terms of loss. Lacan designates this
doubly lost (partial) object as ‘object a’. The empty centre of the torus (or the hula
hoop) stands for this object a, and the emptiness now provides space for symboliza-
tions, for example, for the breast as a symbol on which the child’s desires will
Figure 1: Torus (Lacan, 1961–62b, p. 85) [Colour figure can be viewed at wileyonlinelibrary.com]
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Figure 2: Sphere and Torus with Hole (de Florence, 2011) [Colour figure can be viewed at
wileyonlinelibrary.com]
focus: the breast must first be absent before it can be something ‘mental’. In other
words, the empty space is overwritten with a signifier at which the subject’s desire
will be directed. Lacan comments: ‘Through the word—which is already a presence
made of absence—absence itself comes to be named’ (Lacan, 2016, p. 276). Thus,
in its capacity as the first (missing) object, the breast opens up the universe of imag-
inable and symbolic entities. In this context, desire functions as the engine of signi-
fication through which what is lost becomes an idea that promises satisfaction. The
emptiness, on the other hand, harbours the ‘real’ of the first breath, according to de
Florence (2011), but it also contains the lost breast and various other experiences
that stem from the primary objects. In this toric centre lies the ‘navel of the real’,
which maintains contact with the real as well as promoting the progressive develop-
ment of images and verbal symbols. This bodily structure has three dimensions: the
real, imaginary and symbolic. The real structure is not represented; in this respect,
the empty toric centre stands for the non-represented part of the body; it is the
‘navel of the real’. The imaginary dimension is indicated by the body image, which
can be transferred to the symbolic register of the verbal signifiers. When considering
the torus as a psychic structure, the ‘navel of the real’ stands for the non-
represented, real and in this sense the ‘lost’ object a. First and foremost, however,
the sphere and torus are somatic structures, in the Freudian sense (Freud 1923,
p. 26): ‘The ego is first and foremost a bodily ego; it is not merely a surface entity
but is itself the projection of a surface’. The torus can be understood as a physical
structure: it has two holes that could be thought of as a mouth and an anus. There is
an interior that fills first with air, then with milk, and so on. The outer toric surface
forms the outside of the body. The body thus has two surfaces that merge into one:
the skin on the outside and the mucous membrane on the inside. In this respect, the
physical torus is like a Möbius strip (Lacan, 1976/1977, p. 19)—the external surface
is the same as the internal surface. This dual, yet single surface surrounds the centre
of the torus. It is this surface of the body that becomes eroticized in contact with the
other, for example with the mother, and in this sense, the bodily surface is projected
into the mental or psychological dimension: the surface of the body is transformed
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Figure 3: The Psychosomatic Torus as a Möbius Strip, with the Internal Surface (=Inside of the Body/
Subject) and External Surface (=Outside of the Body/Subject) [Colour figure can be viewed at
wileyonlinelibrary.com]
into a mental object (Dejours, 2021), and in this way, the unconscious bodily image
becomes the structure of the subject (Dolto, 1984; Hamad, 2021). We could say that
this psychosomatic surface has both a material (physical) and an ideal (mental) side
(Eichenlaub et al., 2021). In this sense, the psychosomatic torus, in its capacity as a
Möbius strip, develops two dimensions, namely the physical (material) and the men-
tal (ideal). Figure 3 shows the psychosomatic torus as a Möbius strip:
On the surface of the toric ring, so-called ‘circles’ or ‘loops’ (in French: cercles, bou-
cles) can be inscribed (Lacan, 1961-62a, p. 120). Accordingly, the hula hoop rings are
often divided into different coloured sections. Lacan now places two fundamental types
of circles on the torus. By ‘fundamental’, he means that all further circle constructions
are concatenations of these two types of circles. The first circle inscribed on the surface
of the torus is the (full) ‘circle of demand’ (abbreviated as ‘D’ for ‘demand’). This circle
represents a single demand, and the repetition of the same demand is denoted by the
series D1, D2 … In this formula, the ellipsis leaves open how often the demand will be
repeated—or must be repeated (in the sense of a repetition compulsion). Nemitz (2013)
explains: for the sections D1, D2, …, one can, for example, use the demands ‘I want
book A’, ‘I want book B’, and so forth. The concatenation of these circles can be
inscribed on the surface of the torus, as shown in Figure 4.
Lacan distinguishes between demand (D) and desire (d). The demand arises to
satisfy a specific need (that the hunger is satisfied, e.g., via breastfeeding). The
desire refers to the breast as the incestuous and forbidden object that belongs to the
beloved mother. The breast that is desired is an erotic object (Lacan, 1961–62a,
p. 214). Thus, desire (d) is what remains of demand (D) after the point, where the
need has been satisfied, that is, after ‘subtracting’ the need in the equation aiming at
a satisfaction (Friedman, 2016, p. 164). It is exactly the libidinal momentum of this
search for the forbidden object that keeps the ‘circle of demand’ moving. Therefore,
Lacan (1961–62a, p. 123) introduces the ‘circle of desire’ which is—in contrast to
the ‘circle of demand’—empty. The forbidden object of desire (at the centre of the
torus) is retargeted with each demand, but it will inevitably be missed. In this
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Figure 4: The Concatenated Circles of Demand (D) on the Surface of the Torus (Lacan, 1961-62b, p. 94)
Figure 5: The Circle of Desire (d) (Lacan 1961–62b, p. 94)
respect, the objects of demand are metonymic entities that are endlessly replaced,
and the unconscious desire manifests itself in the endless repetition of the demand
(Lacan, 1961–62a, p.189). However, there is another thought: it could be that the
demand may never be completely fulfilled because it would relate to the loss of
some very early, non-represented objects (object a). The libidinal momentum of the
circle of desire would then be used to keep the search for the very early object that
is lost alive (in the circle of demand). In any case, the objects of demand are there-
fore not a sum of D1 + D2 + D3 …; rather, they are the sum of D1 + D2 + D3
+ d, in which the unconscious desire (d) is also constantly present (Friedman, 2016,
p. 170). Figure 5 shows the circle of desire (d) with its empty centre.
Various authors, such as Bon (2006) or Friedman (2016, p. 169 ff) interpret this
circle as the desire itself. Nemitz (2013), on the other hand, refers to a contradictory
statement by Lacan:
There must be something which is related to the little object of metonymy in so
far as it is this object. I did not say that it is desire that is symbolised by these cir-
cles, but the object as such which is opposed to desire. (Lacan, 1961–62a, p. 123)
In this version, the circle does not stand for desire; rather, it is the orbit in which
the objects of demand revolve (Nemitz, 2013). In the present paper, however, we
reserve the centre of the torus for the following types of objects:
1. the object a, which is real and lost;
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Figure 6: The Torus with the Circles of Demand (1) and Desire (2) (Lacan 1961–62b, p. 94) [Colour
figure can be viewed at wileyonlinelibrary.com]
2. the Oedipal object of desire, which is imaginary-symbolic and forbidden;

3. the metonymic objects at which the individual’s demand is directed for as long
as the individual is alive.
The Oedipal object of desire is not lost (as is the real object a); however, fulfilling
the desire to unite in any way with the object, that is, with the mother or with a person
performing the maternal function, is forbidden (cf. Freud, 1924). In this (Oedipal) sit-
uation, the father’s prohibition, which applies to both sexes, makes it impossible to
return to the mother (cf. Evans, 1996, p. 130 ff). As the third object (after the lost and
forbidden objects), the centre of the torus can be occupied by the infinite number of
metonymic objects at which the individual, in the course of desire, directs his or her
demands: for people, bodies, objects, cars, books, real estate, ideas, and so forth
(Evans, 1996, p. 130). Figure 6 shows the basic figure of the torus with the circles of
demand (D, 1) and desire (d, 2).
In our model, we follow the (simplifying) view of Bon (2006) and Friedman
(2016), and state that the circles inscribed on the surface of the torus act as demand
(D) and desire (d), and that the centre of the torus is occupied by various objects
which are lost, forbidden or present, but in any case, coveted. We now attempt to
understand the results of our transplant study according to this toric model. To do
so, we primarily examine the act of incorporation in connection with the psychoso-
matic torus structure (mouth–intestines–anus), and then discuss the results from the
perspective of need, demand and desire, as well as identification. We conclude this
article by considering the importance of the subject’s toric structure in the successful
processing of a lung transplant.
THE TORUS AS A STRUCTURE OF THE TRANSPLANTATION COMPLEX

Mouth–intestines–anus
The psychosomatic structure of the torus consists of two openings that can be under-
stood on a physical level as the mouth and the anus opposite it. The three-
dimensional ring of the torus is clad on a single surface composed of skin (outside)
and mucosa (inside). This is how the openings through the intestinal tract and its
related organs are connected to each other. Two aspects of the transplantation com-
plex are relevant here: the body is broken open (rupture) and the objects are
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devoured (incorporation). The breaking open affects the toric surface. The surgery
implies a severe violation of the torus, and hence of the subject’s psychosomatic
integrity. This rupture of the torus—as the dual rupture of both the bodily as well as
the subjective structure—can lead to massive anxiety, panic attacks or delirious
nightmares, as reported by some transplant patients, particularly during their stay in
the intensive care unit and immediately after the surgery (Goetzmann, 2006). It is
perhaps possible that the oral-cannibalistic fantasy of devouring replaces this idea of
breaking open or rupturing, thereby alleviating feelings of powerlessness, fear and
helplessness that could stem from earliest childhood. Here, the lung is placed in the
psycho-somatic centre of the torus, either by passing through the mouth or by cutting
open the toric surface. In Mr A’s pregnancy fantasy, another variety of incorporation
appeared. In the prenatal phase, the torus was a sphere, and each inscription—or better,
each scratch or notch on the sphere—was a point (‘shrinkable to a point’,
Friedman, 2016, p. 167). This point or spot could be understood as a ‘navel’ being real
(because the idea of the navel, i.e., the point on the sphere, is a placeholder for the unre-
presented in the experience of the unborn child). In the patient’s pregnancy fantasy, the
lungs—like oxygen, food and blood in general—would then be incorporated via the
umbilical cord without the brutality of the cannibalistic act or the body’s cutting open
that would be necessary after birth. This real point (or ‘navel’) is later placed in the
empty toric centre as a real, non-represented and lost object (cf. Nasio, 1996, p. 34;
Leiser, 2007, p. 140). In this sense, the fantasy of a pregnancy, in which the pregnant
mother would be the donor and the unborn child the recipient, could describe a ‘spheric’
variant of the lungs’ incorporation.
The Demand on the Lungs

The demand (D) on the lungs, inscribed on the toric surface as a repetitive circle
appeared in the interviews that we conducted with Mr A, in his fantasy of massacre
and cannibalism. In the following text passage, Mr A (t1) affirmed the demand on
the lungs of the other:
It’s easy to think that if there is a massacre or a bad accident, there is probably
a greater chance of receiving the transplant. That’s why I was also wondering
if something special was happening on the day I had the transplant operation.
If you wait so long for a lung, something has to happen for someone to lose
their life so that the lung can be donated.
In this way, the lungs, which meet the unwavering need for breath, become the
object of implacable demand in that they must be replaced in order for the transplant
recipient to survive (D1, D2). This is not enough, however. After the transplant
operation, the demand must be repeated due to the continuous life-long danger of
rejection that triggers the repetitive demand. However, there are also other objects
in the life of transplant patients onto which the demand is displaced: their partner,
children, job, social recognition, and more-or-less precious everyday objects. In this
respect, the lung is just one in a seemingly endless series of metonymic objects on
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which the subject places a demand in order to survive. Because life is not possible
without the physiological function it performs, however, the lung is an extremely
privileged object. Thus, owing to its fantasized rupture and incorporation, the new
lung becomes a metonymic member not only of the organ family but of the entire
world of the toric subject. On the other hand, if the demands displaced onto the range
of metonymic objects remain unmet in a way perceived as intolerable (e.g., due to a
lack of acknowledgement as a partner, or due to a health-related career break), the
patient’s frustration can lead to severe depression and suicidality (Goetzmann, 2010).
The demand of keeping the lung as a metonymic object is also reflected in the physio-
logical conditions that occur at the outlet of the torus, that is, the anus. This is the case
when patients complain of constipation: the (precious) organs of the body are then
retained. Accordingly, a fear of the lung being rejected or stolen is also frequently
reported in the interviews. Constipation is therefore like clinging to object a, which
must under no circumstances be lost.
The Desire and Ethics of Transplantation

According to Friedman (2016, p. 164), desire (d) is what remains of demand (D),
where the need has been satisfied, that is, after ‘subtracting’ the need. Thus, there
will remain a certain lack of both the level of demand as well as the level of desire:
when the demands are aimed at (traumatically) lost objects, they cannot be fully sat-
isfied. On the other hand, the enjoyment of the forbidden incestuous object is
impossible. This forbidden object is the second, neurotic form of a lost object.3
Thus, desire (d) revolves around the centre of the torus in which the forbidden
object is placed: the desire keeps the demands going and forces their repetition. But
we can also place the transplanted lungs and some other things in the toric centre:
the transplanted lung is then a metonymic object that could be placed in the centre
of the torus (by rupturing the body or chest, or as a result of the cannibalistic fantasy
action of devouring). Here, the demand for breath and life must be met. The patient
on the waiting list lays claim to a lung, and the transplant recipient reaffirms that
claim or demand every day, hoping not to lose the lung, for example, due to acute
or chronic rejection. However, the subject’s demands are not completely met, even
if the lungs are functioning, and even if staying alive is now possible after receiving
the new lungs.
There are two reasons for this lack of fulfilment. Firstly, the donated life always
remains patently unfulfilled because the original object a is lost. In its capacity as a met-
onymic object, the transplanted lung functions merely as placeholder for the actually
lost object a, such as the umbilical cord or the nourishing breast. The demand is
directed towards that which is lost forever, and which cannot be rediscovered by the
mere fact of having survived. Secondly, the lungs are the metaphoric placeholder for
the incestuous, repressed (latent) and forbidden object. Its acquisition that is accompa-
nied by the death of the donor stimulates the anxieties and fantasies of the Oedipus
complex. In this regard, the feelings of guilt are caused not only by the death of the
donor, but also by the unconscious in relation to the hoped-for death of the Oedipal
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father or (in the case of a girl) of the mother. Mr A’s thoughts about the massacre
are an Oedipal fantasy: the donor’s lungs (i.e., the mother) are torn away. Accompanied
by the dreaming ego, he then moves with his partner into a shared apartment,
and the castrating father fells and cuts the (phallic) wood outside the apartment.
The nightmare reported by Mrs L (t1), in which the nursing staff try to snatch the
venous catheter from her, reveals both the fear of losing something for a second time
(i.e., object a or the umbilical cord) and the theme of parental castration. Mr M’s dream
(t3) also focuses on the lost as well as the forbidden object: ‘Sometimes I still dream of
the hospital or that someone wants to cut open my chest, but there is still no organ’.
These dreams reveal both the drama of earlier loss and the drama of the Oedipal desires
and punishment.
The fear of losing a lung, repeatedly mentioned in the interviews, can therefore
come from three sources: it is the fear of rejection, relating to the medical risk, but
it is also the fear relating to the unconscious threat of castration: the acquisition of
the lungs associated with the donor’s death may be a forbidden Oedipal act (or a pre-
Oedipal anal robbery). Fear of castration manifests itself in fantasies or dreams that the
lungs might be removed again, accompanied by feelings of guilt toward the donor’s
family. It is the fear of being punished for taking this step on the path of incestuous
desire. Mrs C (t1) reported the following dream: ‘An evil woman came up to me and
suddenly turned into a doll-like figure and wanted to kill me’. The deepest fear, how-
ever, is that of losing the lost object once more, as in the description of Winnicott
(1974) of the fear of breakdown that had previously been experienced and that could be
repeated again. The rejection of the lung would thus be a repetition of the earlier loss.
Desire maintains the demand on the lungs, which is always due to the fear of loss
and castration, as described above. Without this desire, which is part and parcel of the
life instinct, no subject will survive. The desire sustains the circle of demand, and with-
out the desire, this circle will collapse. If the lung recipient therefore gives up desire, for
example, because of the various frustrations that a transplant entails, death is but a fright-
eningly short step away. Not taking the medication necessary for survival, or only taking
it irregularly (Goetzmann, 2010), is then enough to provoke a rejection reaction endan-
gering the patient’s life. It is not only (as Lacan said) because of the ethics of psycho-
analysis that desire must not be abandoned, but also, in a very existential way, because
of the ethics of transplantation. Without the dynamics of desire, transplantation is essen-
tially a pointless endeavour. The dynamics of desire probably explain in part the signifi-
cant increase in quality of life after a lung transplant (e.g., Goetzmann et al. 2008;
Seiler et al., 2016; Shahabeddin Parizi et al., 2018). Despite this gratifying fact, how-
ever, 40% of transplant patients complain of a decline in quality of life following sur-
gery (Goetzmann et al., 2009). Here, the repetition of the demands comes to nothing. In
the worst case, it strengthens the death drive due to the frustrations (regarding the lost
object), the feelings of guilt, and the fear of punitive castration (regarding the incestuous
object).
In addition (and not only in terms of the lungs), the donor lives on in the phantas-
mic interior of the recipient, like an ‘undead’ that is both alive and deceased. His or
her soul lives on in the recipient, as Mr A reports. Six months after the transplant,
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these fantasies about the donor still continue. However, the patient now says that he
knows nothing about the donor: due to the circumstances of the transplant, in which
the donor remains anonymous, he becomes an object with characteristics of object
a. Like many other patients in our study, Mr A now stretches a fantastic membrane
over the toric centre. This membrane consists of the idea that an adopted child does
not know its biological parents either, or that the pregnant mother does not know
(for a time) the sex of her baby.
Identification with the Donor

In Freud’s work, ‘identification’ denotes a process whereby ‘one subject adopts as his
own one or more attributes of another subject’ (Evans, 1996, p. 82). The processes of
certain forms of identification can be recognized by the formation of symptoms, as
described by Freud in his Fragment of an analysis of a case of hysteria (1905), which
deals with his patient Dora’s famous cough (see Friedman, 2016, p. 171). ‘Dora’ was
the pseudonym given to a young woman, Ida Bauer, whom Freud treated for 11 weeks
around the turn of the twentieth century. One interpretation of Dora’s cough is that she
identified with the coughing father as part of a primal scene fantasy to identify with the
father himself. By way of identification, she could possess her mother, or possibly the
father’s mistress, Mrs K. The identificational adoption of the father’s trait results from
the dialectic of demand (D) and desire (d): D + D + D … + D + d. Freud distin-
guished between primary and secondary identification: primary identification is the
identification with a parent, along with the introjection of the object, which is here a
step in the imaginary register. Secondary identification, on the other hand, is a partial
identification with a single/unary trait or signifier that is unconsciously borrowed. Dora,
for example, borrows her father’s cough by imitating this symptom. This single trait
(symptom) emerges through an act of negation by omitting all further incidental attri-
butes of the object with which one identifies (Friedman, 2016, p. 163). Lacan places his
emphasis on the role of the image, defining identification as a process of transformation
that takes place when the subject recognizes itself in the image. He distinguishes, how-
ever, between the imaginary (primary) and symbolic (secondary) identification:
• Imaginary identification is the mechanism by which the ego is created in the mir-
ror stage. This variant of identification belongs completely to the imaginary order.
• Symbolic identification denotes the identification with the father in the final stage
of the Oedipus complex. Symbolic identification is also based on the imaginary.
It is called symbolic, ‘because it represents the completion of the subject’s pas-
sage into the symbolic order’ (Evans, 1996, p. 82 ff). Later on, Lacan denotes the
symbolic identification as an identification with the signifier. Additionally, the
(bodily) symptom, for example Dora’s cough, is a signifier as soon as the symp-
tom enters the symbolic order.
• Lacan understands the ‘single’ or ‘unitary’ trait (in French, trait unaire) to be a
symbolic term which is introjected to produce the ego-ideal. It becomes a signifier
when incorporated into the signifying system (Evans, 1996, p. 83).
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It is our impression that this form of identification with a single trait, as Freud
and Lacan say, is essential in the processing of a lung transplant: the lung recipient
identifies with a single trait of the donor in order to claim the new lung.
Basically, with the identification, the patient legitimizes the demand on the lungs,
thereby also alleviating the feelings of guilt. Identification with a single trait was
often observed in the interviews: with the (fantasized) name, a quality (athlete) or
the status of the deceased, with the donor’s death. Identification with a single, dis-
tinctive trait is clinically evident when patients report having developed a previously
unknown liking for a particular food, for example, following the transplant opera-
tion. There may be an identification with an introject that leads to fantasies about
the donor. It is also problematic when the death of the donor is the only trait with
which the patient identifies, leading him to commit life-threatening actions
(e.g., driving at high speed), exposing himself to the risk of infection or neglecting
to take medication. Similarly, a phobic fear of leaving the (safe) house could indi-
cate an identification with the donor: the patient behaves cautiously so as not to suf-
fer the same fate as the donor. In the conversational exchange from earlier, repeated
below, the identification relates to the fantasy of having taken on the donor’s emo-
tions (crying), alluded to by one of the patient’s sons. Mrs H (t2) reports:
P: True, one son said it’s crazy, but he said ‘you must have got a cry-baby’s
lungs’. And he found it funny.
I: Have you had to cry a little more since then?
P: (hesitantly): Yes.
Here, too, it is evident that the patient identified with a single trait. However,
there may also be a primary mirror-image identification with the entire (fantasized)
person of the donor, as when Mr A dreamed that he—as a whole person—moved
into the shared apartment with his beloved partner (the lungs). It seems, however,
that the more mature form of identification with a single trait of the fantasized donor
is more central to the transplantation experience, and may be sufficient to facilitate
the acquisition of the lungs, that is, their psychological integration. Thus, in our
model, the identification with the object (i.e., the donor) takes place in the middle of
the torus. The recipient identifies with the donor in order to obtain the object of his
or her demand/desire, that is, the lungs. In this respect, the identification with the
donor is like a function of the patient’s demand and desire to receive the transplant
as their own, as an integrated possession in their own world. In this way, identifica-
tion with the donor and the demand/desire for the lungs are closely linked.
TORUS, SINTHOME AND TRANSPLANTATION

Occasionally, the surface of the torus is endowed with small cells or squares (see
Figure 6). These cells or squares on the toric surface could be understood as sig-
nifiers denoting local realities. We then see a wave of signifiers washing around
the ‘navel of the real’ (Nasio, 1996, p. 34) and signifying the patient’s global
reality. The subject is determined from this signifying wave. In Seminar 9, which
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introduces both the identification and the toric model, Lacan defines the signifier
as follows:
The signifier, as opposed to the sign, is not that which represents something
for someone, it is that which represents precisely the subject for another signi-
fier. (Lacan, 1961–62a, p. 37)
Here, the signifier is the representative, and the subject is the represented. The sub-
ject for another signifier (S2) is represented by the signifier (S1). In this way, the
subject is included in the chain of signifiers: these signifiers (S1, S2 …), the wave
of which is constantly being kept in motion by desire, establish the meaning of the
subject. We could say that the aspects of the transplantation complex are also based
on signifiers: the motifs of cannibalism, massacre, pregnancy or worm infestation.
In their seriality, these signifiers represent the subject undergoing the transplant sur-
gery; that is, the ‘subject of the transplant’ is represented by this chain of signifiers.
The torus as a psychosomatic structure consists, as it were, of signifying honey-
combs. A dynamic unit is created from this diversity, enabling the patient to process
the overwhelming transplantation experience. Under the impact of the fear of death,
the patient’s psychological world—composed, according to Lacan’s (2016) ontol-
ogy, of the rings of the real, imaginary and symbolic—can collapse in the form of a
severe identity disruption (cf. Mauthner et al., 2014). The injured body image can
slip away and suspend symbolic thinking. In this case, the torus serves as a ‘fourth
ring’—as a repairing structure. Transplant patients’ dreams and fantasies are
symptoms or sinthomes (Lacan, 2016) that hold together the patient’s psychologi-
cal reality. Thus, in Mr A’s dream, the ‘apartment’ becomes the sinthomal place
of coherence. Once the medical situation has settled down, the fourth ring can be
discarded. As we observed in the prospective course of the interview study
(Eichenlaub et al., 2021), the transplantation complex will then recede into the
background. We could on one hand imagine that the torus with the dynamics of
demand/desire regarding the life-saving lungs and the identification with the donor
has fulfilled its prominent integrative function. On the other hand, the double toric
structure, existing bodily as well as psychologically, could persist in the back-
ground of the unconscious, functioning as a guarantee for the patients’ will to sur-
vive and to protect their lungs.
ACKNOWLEDGEMENTS
We would like to thank Sanjeev Balakrishnan, London, for his assistance in revising
the final version of the English manuscript.
NOTES
1. The study was approved by the Ethics Committee of the University of Zurich. All patients
gave their written consent to participate in the study and to have the anonymous results publi-
shed. Previous results were published by Seiler et al. (2015, 2016), Goetzmann et al. (2018,
2019) and Eichenlaub et al. (2021).
Sons Ltd.
2. The blastocyst has an inner and outer layer of cells. The inner layer (‘embryoblast’) will
develop into the new human being. The outer layer (‘trophoblast’) will develop into structures
that support the embryo (see https://commons.wikimedia.org/w/index.php?curid=125360929).
3. Generally, there are different forms of ‘lost objects’: (1) the real one that was actually lost,
but without translation into the symbolic register; (2) the real one, being actually lost or not
lost, but with a translation into the symbolic register; (3) the symbolic one, being incestuous,
forbidden and repressed; and (4) the symbolic one, being translated, but not forbidden and
repressed. In any case, the translation to the symbolic register has the effect that the real
object must disappear, being grasped by the process of symbolization.
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Sons Ltd.
LUTZ GOETZMANN studied human medicine. He habilitated at the University of Zurich on

psychosomatic aspects of organ transplantation and is professor at the University of Lübeck.
From 2011 to 2020, he was in charge of the psychosomatic clinic in Bad Segeberg, Germany.
He is a member of the Swiss Society for Psychoanalysis and works in his own psychoanalyti-
cal practice in Berlin. He is the co-director of the Institute of Philosophy, Psychoanalysis and
Cultural Studies in Berlin (https://ippk.de) and co-editor of the journal Y—Journal of Atopic
Thinking (https://www.ypsilon-psychoanalyse.de). He has authored numerous publications in
the field of psychoanalytic psychosomatics and cultural theory. Address for correspondence:
[goetzmann@ippk.de].
MARIE EICHENLAUB studied clinical psychology and psychotherapy as well as legal psy-
chology (MSc). During her double Master’s degree, she gained various experiences in the
psychotherapeutic field. She worked in research at the University Hospital of Hamburg and
the University of Hamburg and is a fellow of the Institute of Philosophy, Psychoanalysis and
Cultural Studies in Berlin. She wrote her doctoral dissertation about the unconscious
processing of a lung transplantation at the University of Lübeck, which was supported by a
doctoral fellowship from the Medical School Hamburg. Results of the doctoral thesis have
been published. She is currently working as a legal psychological expert.
ADRIAN M. SIEGEL (MD) studied medicine at the University of Zurich. He is a fully
trained clinical neurologist and epileptologist. He has been a research fellow at the Dartmouth
College, Hew Hampshire, USA, and a visiting doctor at the Montreal Neurological Institute
and at the Mayo Clinic, Minnesota, USA. His major interests are clinical neurology, epi-
leptology and neuroscience. He is an author of more than 100 scientific publications.
CHRISTIAN BENDEN (MD MBA FCCP) is a paediatric pulmonologist and former Medical
Director Lung Transplant, CF Center Director and the Chairman of the Board of Trustees of
the Transplant Center of the University Hospital Zurich, Switzerland. He trained in paediatrics
in Hannover and London. Additionally, he specialized in paediatric pulmonology and
received training in lung transplantation in Hannover, London and Zurich. In 2020, he was a
senior medical consultant and executive board member at Swisstransplant, the National Foun-
dation for Organ Donation and Transplantation, Berne. Since 2018, he has been adjunct pro-
fessor of pulmonology/transplant medicine at the University of Zurich.
ANNETTE BOEHLER graduated from the University of Zurich Medical School in
Switzerland. She completed her residency at the University Hospital of Zurich. In 1992 she
participated in the Zurich Lung Transplantation programme. She became medical director of
the programme from 1998 to 2013 and contributed to numerous peer-reviewed publications
on lung transplantation. She has carried out different research projects in the field of trans-
plantation. She is a member of national and international respiratory societies and past
Assembly Head of Thoracic Surgery of the European Respiratory Society.
JOSEF JENEWEIN is a medical doctor and specialist in psychiatry and psychotherapy. He is
currently the head of the Department of Medical Psychology and Psychotherapy at the Uni-
versity Hospital Graz, Austria and professor for medical psychology, psychotherapy and psy-
chosomatics at the Medical University of Graz. He is author and co-author of numerous
publications in the field of psychosomatics and psychotherapy.
Sons Ltd.
ANNINA SEILER is a research fellow at the Competence Center for Palliative Care and a
clinical psychologist at the Consultation-Liaison Psychiatric Service at the University Hospital
Zurich. She studied clinical psychology at the University of Zurich and Lausanne in
Switzerland. She trained as a psychoanalytic psychotherapist, and did her PhD on psychologi-
cal adjustment after lung transplantation. She recently habilitated at the Faculty of Medicine,
University of Zurich on delirium in terminally ill patients. In addition, she received a Master’s
in bioethics at the Harvard Medical School in Boston, USA.
OLGA GRYTSKA studied philosophy, media studies and musicology at CAU zu Kiel,
Germany. Her research is focused on philosophy of music, philosophical aesthetic and media
aesthetic. She has been involved in several publications on various philosophical topics as
part of the editorial team and is currently the senior editor of Y—Journal of Atopic Thinking
in Berlin. As a journalist, she is an author for the philosophical magazine of Deutschlandfunk
Kultur Sein und Streit.
KONSTANTIN HESSE MD studied philosophy and human medicine in Munich and Kiel,
and is currently undertaking psychosomatic specialist training. He is a fellow at the Institute
for Philosophy, Psychoanalysis and Cultural Studies in Berlin and has worked as a medical
doctor on various international assignments.
UWE WUTZLER is a specialist in psychosomatic medicine and psychotherapy. He studied
human medicine and obtained his doctorate at the University of Jena, Germany. He completed
his further training as a psychoanalyst at the Institute for Applied Psychotherapy and Psycho-
analysis in Jena (IPPJ) and is a member of the German Society for Psychoanalysis, Psycho-
therapy, Psychosomatics and Depth Psychology. Since 2009, he has been head of the Clinic
for Psychosomatic Medicine and Psychotherapy at the Asklepios Fachklinikum in Stadtroda
and has been chairman of the IPPJ since 2014.
BARBARA RUETTNER MD holds a professorship for clinical psychology and analytical
psychotherapy at the Medical School Hamburg, Germany. She is a specialist in psychiatry
and psychotherapy as well as a psychoanalyst (SGPsa/IPA). She heads the training course for
psychoanalytic psychotherapy at the Hafencity-Institute in Hamburg and has published scien-
tific work in the field of immunology and psychoanalytic psychosomatics.
Sons Ltd.

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British Journal of Psychotherapy 00, 0 (2023) 1–20 doi: 10.1111/bjp.

TORUS, DEMAND AND DESIRE: TOWARDS

LUTZ GOETZMANN, MARIE EICHENLAUB,

KEYWORDS: LUNG TRANSPLANTATION, TRANSPLANTATION

THE TRANSPLANTATION COMPLEX

• The donor is killed.

Figure 5: The Circle of Desire (d) (Lacan 1961–62b, p. 94)

1. the object a, which is real and lost;

2. the Oedipal object of desire, which is imaginary-symbolic and forbidden;

THE TORUS AS A STRUCTURE OF THE TRANSPLANTATION COMPLEX

The Demand on the Lungs

The Desire and Ethics of Transplantation

Identiﬁcation with the Donor

TORUS, SINTHOME AND TRANSPLANTATION

LUTZ GOETZMANN studied human medicine. He habilitated at the University of Zurich on

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