Keywords: Psychiatry – Lacan – Alliance/Resistance – Medical Sciences – Being-in-the-world|
The alliance of psychoanalytic practice with medical science and psychiatry, emphasizing diagnostic categories and the treatment of symptoms, betrays the fundamental question of the subject's desire. Most important in the treatment is the subject's speech about his/her history in a particular context, which opens onto that subject his/her coming into being in the world, into generation, death and the limits of omnipotence. Giving up presuppositions that may be obstacles to listening calls for a renewed alliance of psychoanalysis with other disciplines.
Alliance? Yes, and a therapeutic one, as we are dealing with psychoanalysis. And here we are straightaway at the core of the transference neurosis, which is tantamount to saying the core of psychoanalysis, the very heart of the process. It is a terrain familiar to me, although at times I have approached it with anxiety, disoriented and unsure of where to turn, what to say in the attempt to resolve a neurotic block. There is certainly material here to consider.
However, this is not the way I want to address the notion of alliances now and today, but instead to commence at the level of their origin and foundations, in order subsequently to attempt to anticipate the future, to examine on which alliances psychoanalysis was constituted, which disciplines it rejected in order to emerge - despite being descended from them, and whether we should consider obligatory maintaining relationships recognized initially. All this presupposes the idea of change, for example, change in the object, aims and methods of psychoanalysis, a change which necessitates questioning. However, also implicit is that its 'allies', 'parents', 'cousins' will also have undergone or required change.
Subsequently, the matter is more complicated than it might initially appear. Freud's point of view is, if not ambiguous, in any case polyvalent; he claimed the status of a natural science for the discipline he created, while his training as a physician led him to found it on a practice whose object is, if not a cure, at least the treatment of certain mental illnesses. At the time, there was little distinction as to whether they fell within the province of neurology or psychiatry (and for some time there was no distinction made between the two areas of "specialization"). The patients in any case were to be referred to the physician. Thus, the question arose of a possible proximity between research and treatment, a question which has not yet been entirely resolved in the context of Freud's particular option: he searched in his own dreams and associations (in the normal, for the most part, but not entirely so, and it would be wise to approach with moderation the disturbance in the normal), which was akin to searching in the dreams and fantasies of the patients. The normal and the pathological were indistinct in certain psychic areas. Were these areas, or instances?
The names designating illnesses are those adopted at the time by psychiatry: hysteria, obsessional and phobic neuroses, paranoia. These categories kept their specific nature and at the same time lost it as they were united by a characteristic which rendered them subject to psychoanalysis: that they could trigger a transference neurosis. Others, bearers of that which would be termed "narcissistic neuroses", remained outside the scope of psychoanalysis.
It is a question of a medical legacy, a question of family ties maintained, according to Freuds desire and claims, despite texts such as Laienanalyse (Analysis Conducted by Non Doctors) and the views which their author exposes therein on the training of the psychoanalyst, views which opened the profession to those other than physicians, provided that they possessed a satisfactory - albeit different - "culture", and a willingness to undergo psychoanalysis. It was a step in another direction.
Adding to this the double aspect (psychological/anthropological) of the Freudian oeuvre, we find ourselves before an epistemological situation of the most complex sort. It is in relation to these different coordinates that the problem of the scientific status of the new discipline arises, a problem which was constantly the subject of debate during the 20th century, a debate reopened at great cost by Lacan and which still rages. The medical alliance becomes more precarious. Even so, it would appear to persist if one refers, in the Lacanian oeuvre, to the position given to and the discourse on the hysteric and to the particular status it confers to psychosis.
However, if we are to shed some light on the area of psychoanalysis and distinguish those in proximity, we are obliged to point out its specific characteristics, and attempt to explain them, after a century of existence, to examine that which remains of its old alliances and determine whether or not they could constitute its singularity and, more importantly, the references for its practice. One may suspect the price psychoanalysis must pay for those traditional attachments and ask whether or not those attachments might not today represent an impediment to its better definition.
The duo alliance/resistance in which the unconscious intervenes massively - intending here the unconscious of psychoanalysts - makes one fearful of venturing into the jungle of psychoanalytical "material" outside the paths beaten by Freud, and confirmed by certain of his successors. Certainly, texts as abundant and rich as those of Freud, or in France, Lacan, demand reading and rereading, with the inevitable, unending commentary. However, on such occasions, does one perceive clearly enough - although a commonplace, it is a question of an effect on the reader of psychoanalysis itself - that each work participates of the reflection of its author, if it is also the expression of a practical experience? But, despite the desire to endow psychoanalysis with the most scientific character possible, its theoretical elaboration cannot be considered as "objective". Point of accusation in this proposition: "narcissism". The very result of the psychoanalytical discovery affirms the unconscious in each proposition, as rational as it might be. Then, we have to consider the respect for the subjectivity of the listener/writer, the social-historical position for the psychoanalytic invention with its parameters, the gap between the epoch in which it emerged and that in which it is discussed at present. We have to evaluate that which subsists - despite the differences between early 20th century nomenclature of symptoms - of the standards of neurosis and that which, according to the coordinates of the psychoanalytic situation, persists as its daily manifestations. (It is not my intention here to discuss psychosis - not because I have not considered it, on the occasion of the inevitable encounters with that which organizes for us all lasting psychoanalytic experience, but it is not my choice of work here.)
How do we, in the listening, which is the daily fare of the psychoanalyst, organize the menu which the patients propose? How do we examine it, or create some substance which might light the way for the analyst, give subsistence to his reflection, but above all, constitute for the patient nourishment which can be assimilated, elements/alimentation of deconstruction/reconstruction?
Freud certainly changed topics, revolutionizing during his own lifetime the very system of drives he had organized. Are we obliged to continue to consider psychoanalytical material as riveted by the clinical chains/alliances and psychiatric nosography he conserved? In fact, we shirk this obligation - as I mentioned elsewhere - when we let fall, naming the "case" of the Five Psychoanalyses, the nosographical references designating them - hysterical or phobic neuroses, paranoia, etc. - calling them by name and surname: Dora, Little Hans, the Wolf Man, and so on. We must take seriously this operation of abandonment and attempt to appraise that which it reveals; roughly, I would say, the accent placed on the person, the individual in his context, on that which he says above all: before becoming a hysteric, Dora became Dora, singular personage in a singular family (or extended family if one includes Mr. and Mrs. K), member of a strange quartet in which pathology, if not talent, appeared quite equally distributed; but above all she became author of her narration. She wanted to be thus in any case and hardly appreciated that the course be too visibly indicated. Was it not that she was considered to be ill and designated as such because, as a young and cumbersome person, she hampered the enterprises of the transgressive other three? Doubtlessly, she coughed, but that was not the pointÉ
And when considering the Rat Man, do we think first of all of the obsessional symptoms which oppressed him or the famous phantasy which he had such difficulty in communicating to Freud and in which the possible interpretation of his neurosis was condensed? The Rat Man is he who recounts rats, just as the Wolf Man recounts wolves (it would have been better, once more, had they recounted without too much encouragementÉ), wolves and rats portraying the phantasy of the original sexual scene, and it is in this "recounting", this being narrated, as Ricoeur would put it, before, during and after the analysis, that the neurosis is created, dismantled, recreated.
Do not approach the symptom head-on, said Freud. (The symptom therefore, supposedly supporting a clinical scene, is attached to a nosography). And how! Not that attention is not paid: it is precisely that which creates suffering, and that suffering cannot be taken into consideration. However, experience teaches us that - as regards the psychoanalytic project of unbinding (déliaison) before any possible reconstruction - focusing on the symptom ends up rooting it further. That which is heard is a narration of life, of past life, of dreamed life, of real life and, often, the impossible future life or a future life upon which the too long perpetuated embargo of "too late" weighs.
Certainly, the psychoanalytical "shibboleths" are inevitably present: one finds confirmation, in the narration with its infinite variants - infantile sexuality, Oedipus complex. However, I believe that to qualify - in the framework of psychoanalysis - a neurotic affection as that which we are proposed daily in the "treatment" of the hysteric, the obsessional or the phobic, to orient the treatment according to these "diagnoses", is not pertinent to the psychoanalytic process.
Not that these categories are not useful. They are somewhat - always for the psychoanalyst - like a conversational shorthand which served for example to jot down aspects of a "case" to be referred to a colleague, as one applies a label to an object. Subsequent to this early-analytic phase in which, obviously, transference and counter-transference can begin to emerge, the psychoanalyst endeavors to discover, despite the patient's resistance, that which will support his narration, according to those past and present modulations, which have played and continue to play a role in his life, seemingly following an established scenario, and those weak points in its construction, the interventions or interpretations of which may cause a mobilization. That implies, imperatively, that on the part of the psychoanalyst, certain coordinates of the psychoanalytic situation be respected. In the first place, those which could be called the "benevolent neutrality" (which can once more be envisaged as analysis of the counter-transference or consciousness and respect of the "cadre"). It is not my intention here to dwell on this point, which is in any case fundamental.
That also implies a certain psychic instability on the part of the patient. In the end, it is perhaps that predisposition which one called and still calls hysteria. Thus, psychoanalytical treatment found there its origin: at least in patients - female, but also male - susceptible of evolving, of having their defenses de-stabilized (the historical origin for Freud, which virtually became a blazon for Lacan.) And, to the extent that present candidates for analysis present more often than not a composite symptom, it is the dose of that psychic instability which makes viable the beginning of an analytical process. However - and once more the forecasts here are uncertain - it is also, very often, dependent on contingent factors, which might have accelerated or not the constitution of the neurotic organization, whether the analytic process will or will not be possible. It is at this point that the question of trauma enters - which, although obviously deserving of all the studies of which it has been and continues to be the subject, finds its place in psychoanalysis only if it can once more be narrated, in a way integrated with the more general questioning of the history of the subject, posed by the subject himself.
I am going too quickly and risk pushing aside persons and ideas. However, it is essential here to gather together, after having been dispersed: here and there, according to emerging subjects (for writing), a conviction gradually formed, a conviction which could possibly be considered presumptuous: "She isn't suggesting the re-founding of psychoanalysis?" Others have applied themselves to it with more reflection and another luggage.
In fact, I would call for more simplicity. And, beyond the preoccupation with internal theoretical coherence or loyalty to one, to highly respectable texts (for example, those of Freud), what must be emphasized is a freer listening (which is no doubt neither more nor less free than free association) to the discourse with which we are presented, to the "material" as it is often referred to. Of course, the question of the orientation of the listening by the presuppositions, the pre-elaboration of the listener, remains equally open for all, including the founders, as I asserted previously. And, in this context, I consider that the way in which the "psychoanalytic clinical practice" is presented does not create a vacuum - far from it. The majority of unconscious processes as seen by Freud remain constantly perceptible: repression, censure, condensation, displacement, etc.; mere numbers should convince. However, all the same; where do our patients lead us? straightaway, then session after session, variously with elan or reserve? through their present worries, their preoccupations with life, their difficulty in loving/being loved? their singular history, evidently, and their objects of complaint: parents, present companions, absence of a companion, obviously. A progression of conflicts with ascendants, present and past disagreements maintained in infinitely varied personal modes and in which they ask us to take their part, proof that we love them as they require to be loved. On this point, Freud places us on guard: if we respond in the sense of their demand, besides being blind to an error of destination - it is only by displacement that we are the object of their love - we risk ruining the transference neurosis, which is the only expedient by means of which change can occur. The same applies to the psychoanalytic situation.
But once more? What can we say? To which point do we always return? To the subject of being brought into the world. Through the Oedipus complex which puts us in the position of partner to father or to mother, according to the individual case, one is at the level of parents, in a sense parent to oneself, fecundating the womb which has borne us, accepting the penis from which we have been begotten. Subsequently, you reject the awkward idea of self-engendering: which makes you your own author, which relegates to the background, so well that it becomes imperceptible - impossible to perceive - the desire between your parents (what a surprise to become conscious!) allowing your desire to take its place, there where it was irremediably missing.
Obviously, the representations of this scenario can only be fleeting and for some remain forever veiled. The body of the mother or of the father, lost, distant, provokes a horror which words can express only with the greatest of difficulty. The tragic view of feminine sex, often approached as a pretext by Freud, is not the only sex in question. The thought of the body of the parent, whether male or female and, even more so, the bodies of the parents together in the sexual act, is an unbearable thought, because it marks the original obstacle. In fact, when one succeeds in overcoming them upstream, inscribing them linearly, one is already more at ease. But that can only occur when one has accepted - or at least perceived that it is a question of accepting - the limitation of one's own power by ones own inscription in the generation. Subsequently, it is not, as is often affirmed, that it is impossible to represent the "primitive scene", but that it is unbearable to the original phantasm governing us.
That phantasy of omnipotence, which places the self-engendering at the center of its orbit and works into the ground the sexuation which flouts it repeatedly (thus, its importance) is the point of encounter of neurotic-analytical trajectories. Everything convenes there, after having followed different routes, before the fundamental broaching of that phantasy by the other, the other immediately given (not an initial monad in my opinion, every nursing baby is always constitutionally dependent. Hilflösigkeit - anguish - reigns, all the more generator of love as it is spectacular - so small, so weak - and the care of the mother, which Freud takes the precaution to include as necessary in the constitution of this monad is always missing or felt to be so. Satisfactions doubtless exist in this phase of existence, but are so little under controlÉ Keenly, for him or her, the Fort-Da, which will permit the adaptation to the initiation by the other).
The progressive course towards this placing in question of being in the world according to the modes of human procreation, the becoming aware of movements of refusal or acceptance, addressed to him/her is, strictly speaking, psychoanalysis. And there are the frustratingly slow advancements which threaten to bog it down, the sudden spurts of elan which accelerate it, the changes of direction which reorient it, which are what the psychoanalyst listens to and which he at times succeeds, in his position in the transference, in making work. Durcharbeitung is the discovery, gradually, of the various plans of construction which make opaque the view of the origin, the infinity of the past, and threaten to prevent being in the moment, the present.
For, if an illness emerges during this process, it is certainly an illness of time. Being there/now is pregnant with personal and collective events, some of which cannot be bypassed and whose memory, although based on a reality, but forged as well - narrated - by the subject, insistent or repressed, should surge eventually at a detour created by an associative sequence. Memory, therefore, weights down the presence, oppresses the day-to-day. The unacceptable begetting has as its corollary an inadmissible finitude. An issue is the certainty of death, our only perspective, which infiltrates its denial rendering that denial impotent, relegating to the status of illusion those moments of pleasure which lighten our mood, permitting the illusion of enjoyment freed of doubt (enjoyment intended here in the ordinary acceptance of the term). For doubt, by threatening enjoyment with destitution is perhaps nothing more than a masked figure of the impossibility of accepting its limits over time. In any case, it is menaced with sinking into the too late, with being canceled for not being immortal. (See Freud's article on the Ephemeral.)
If the tight knot by means of which the past which one has constructed enslaves both present and future is released, then a relief about passing time takes place and anxiety loosens its hold. Sometimes.
Where, in all this, are obsession, phobia, hysteria, paranoia? Everywhere. But one will have considerable difficulty in modulating the interventions or interpretations of the psychoanalyst as regards their symptomatic manifestations. The less attention paid to them, the better. There are, there were, in the positive case, those in which a possible mobilization could be perceived, shelved on a siding where the convoy of original phantasms had broken down. A psychoanalyst is held in transference projections - in both meanings - and is busy with finding with the patient switches to put to work possible investments, more satisfying than symptoms. What is important is to approach, gradually, gently, without desire to convince, without putting into operation the search for a so-called truth (and above all, without taking as a model Freuds way in the Wolf Man case) for all neuroses, respecting the multiple productions, the singular ways of access. There is perhaps no other "psychoanalytic clinic" than the variants - fortunately infinite - of the vicissitudes of a patient's discourse during his treatment. The versions are repeated, but marked over time by small differences, minor variations, which taken together produce the reaction: How extraordinarily life can differ, according to the way in which it is recounted!
Of course, I dont take suffering into small account. Often, as I have said, it is so insistent, so pressing, that before the impossibility of finding immediate relief, it searches for another target. Often, it draws back before the pleasure of mastering - to a certain extent - its very construction. In this contact, that surplus, which I would not define as healing, remains. Is this perhaps a compromise?
If one considers thus psychoanalysis, renouncing clinging to nosographical categories, what will be gained, what lost? Should one claim "they or Chaos", creating the obligation to uphold those categories in an artificial way, in light of what I have attempted to expound? Where are we going, is the suspicious query, and if we abandon them what will then establish the specific nature of analysis? Note that the issue is not new. Even leaving aside Kleinian elaboration which reconsiders certain of those categories and organizes them in another manner, it becomes clear for example that the concern of Wilfred R. Bion or even Piera Aulagnier - in the domain of psychosis in particular - was about indicating other itineraries, other maps of mental discomfort, other references to psychic disorder to make available to psychoanalysis, other than those with which psychiatry was once satisfied.
However, their work - and all research aimed at the "psychoanalytic clinical practice", that is, etymologically, the observation of that which occurs with the patient on the couch (or its substitute) - encounters an obstacle: the difficulty of transmission of that which occurs in the psychoanalytical session. There is no clinical work - in the area from which that notion was taken, medicine - without a report. Now, the sequences reported under "control" or "supervision" are such only in the elsewhere from the session. Those which one attempts to write are never other than of an illusory faithfulness to the infinitely complex course of the analytical discourse, that is, of what the patient says and the scanning of the analysts interventions and interpretations. The rule of "free association" as the only order is responsible of this discourse, although freedom is liable to being placed in question, and it never eludes this questioning. Nothing linear will result but a "psychology in space" perhaps, as Proust said. But this psychology in space is not included in the classical narration of the traditional medical observation type, and the "clinical vignettes" which one struggles to write are nothing more than a caricature of this medical observation. It is almost always impossible to relate the point at which the patient's narration shifts in the direction of an habitable version, the words leading to it, the mini-events accompanying it. Not because it is ineffable, as it was said. But the memory of the two protagonists is too fragile, too tempted to sort out events, then it is unable to recover and to put together the mesh of a vet which has suddenly allowed an awareness emerging from months, years. Even when the analyst has taken notes, s/he will miss the time and rhythm of the discourse which makes it an event. Or maybe flashes, fragments which count on the associations of the writer and the reader to establish a text which gives them some understanding. This can only be a "rough" comprehension incapable of penetrating the intimacy of the process, sufficient to discover persisting orientation, impregnated obviously with the subjectivity of the reader, of the writer. However, in psychoanalysis, is it not better that it be recognized rather than masked, dissimulated behind an alleged objectivity which does not withstand the impossibility of refutation (cf. Popper)?
Impossible, certainly, to enclose within a diagnostic/prognostic/treatment scheme the cases which will inevitably cross the boundaries which separate them. In this context, integration of that which surpasses the norms of the successive D.S.M. is absurd, even more inappropriate than falling back on classical categories, unsatisfactory as they may be. Psychoanalysis is given over to the infinite complexity of the language in progress and obliged to go through it if it is to convey something of what has occurred. (It is in this sense that the reading of Lacan is in my opinion a psychoanalytical reading. Because, despite the reproach he receives, and rightly so, for not having at all - or, in any case, sufficiently - explored the "clinical" in his writings, the method which he utilizes for psychoanalytical questions, if not actually of an associative type, is influenced in that direction. However, I would not call that the "analytical discourse".)
These questions are not new. There was a time when one relegated them to literature: clinical psychoanalytical writing had to have an artistic turn, if it were not to take itself as ideally faithful, it had to become recreation, a piece of work in its own right, oeuvre for oeuvre which constitutes the psychoanalytic treatment. Or, pushed to the extreme absurdity: admitting that there was no true "psychoanalytical clinic" if not in the exhaustive report of the session, even recording itÉ but at the same time perceiving, apart from a deontological impossibility, the destructive effects on what was vital in the session.
Alliances must perpetually be reconsidered. This is as true in the area of knowledge as it is in politics. The tempestuous one between neurology and psychiatry - psychoanalysis in a certain way occupies the position of pseudo-ally of the latter of the two - kept the questioning going through the period 1960s-1980s. In the absence of an epistemological alliance, one could envisage - and practiced, and on occasion some still do - a therapeutic alliance (not in the usual psychoanalytical sense): drugs complete or permit the analysis or psychotherapy, attenuating the symptoms sufficiently to make the words accessible. Recent developments have modified both those participating in the debate and the scenario: the cognitive sciences, using as a support the advances of neurology/ physiology have asserted themselves, and much more aggressively than psychiatry ever did - claiming to occupy alone the area of research on mental functioning, substituting behaviorist methods for psychoanalytical therapy or therapy of psychoanalytical inspiration. It should at this point be clear that I do not support this position which, despite its broad consensus, appears to me a massive regression in thought which effaces a century of psychoanalytical experience, utilizing in the worst way what are, admittedly, indisputable advances in neurology/physiology.
Whatever the impact of these, if my point has been sufficiently made as regards the psychoanalytical process, it should become clearer that the question posed by our patients through the avatars of their personal history influenced by History has every possibility of persisting, of continuing to be the source of torment and suffering. It is, in short, what is peculiar to man: questioning - in the various forms it can take - the meaning of his life, his being-in-the-world, and his ineluctable departure with all its different formulations. Some of those formulations are of the psychoanalytical sort: those accompanied by symptoms affecting the daily functioning of psyche and requiring recourse to therapy. They are not in general, as at the time of Freud, pathologies of sexuality repressed by society. They are illnesses of desire, of the possibility of accepting the parameters of an existence particular to human beings. And the heart of the question is the same as for other, more mastered forms of expression, or those at least which contain a creative element: one finds them in literature and philosophy. Freud knew this and cited Goethe and Shakespeare more than any other authors in his writings. And, although he challenged the philosophers at the psychoanalytical banquet, we perhaps now know better that we certainly cannot ignore Levinas, Ricoeur or Derrida, to mention those closest and most contemporary.
We will not go to them in search of responses which they for that matter do not intend to give us in any case not those responses which could be included in the flow of psychoanalytical sessions (but it is not here a question of teaching). In the final analysis, we can and must find some convergence between their research and our own. The same is true of anthropology: works such as those of Françoise Heritier provide a profitable source of reflection for psychoanalysts. And of History, too, intended as historical research, whose interplay with the history of our patients is constant, and which provides illustrations which never fail to strike. History, on the other hand, alone it makes it possible to approach psychoanalytical theory, not as an eternally established dogma proclaimed as and confused with Truth, but as an integral part of a temporal process of thought, in spite of the timeless versants of the psychic process.
That is, one might object, simply returning to the question of multi-disciplines. It is in any case not a question of neglecting it, but of succeeding perhaps in approaching it in a renewed form. The statement of Freud that psychoanalysis had more to give than to receive illustrates the hopes of a young discipline. Perhaps we have abused this, leaving our interlocutors, as multi-disciplinary, in the expectation of effects which could not be produced if not in the transference process created by the psychoanalytical situation. Unable to accept the obligatory renunciation of omnipotence, incapable of admitting that we do not possess the momentarily glimpsed universal key, we have deceived our interlocutors. Suddenly, the obsolete alliance with psychiatry, in any case ravaged by the current scientific-social-political situation - simply will no longer do. There are other treaties to be considered.
Translated from the French by Joan Tambureno