4

Know-how in Clinical Practice: Doxa as the Result of Impotence and Impossibility

INTRODUCTION

A completely comprehensive theory, supported by an effective epistemology, would seem to be an illusion. Nevertheless, Candide must continue to cultivate his garden (translator’s note: as in the final pages of Voltaire’s Candide). Clearly, for the field worker, job satisfaction in itself is not enough: her work must also be conceptually grounded, which is why she scours the markets seeking the definitive scientific justification for her job.

Such “definitiveness” quickly becomes relative, and yesterday’s certainties have become today’s cast-offs. For a growing number of people the ensuing doubt is barely tolerable. Consequently, we see the emergence of a highly characteristic solution, which was anticipated and critiqued as long ago as Socrates: if epistèmè (knowledge) is unable to found arètè (truth), people fall back on doxa (opinion), or in today’s terms “paradigm.” We have already seen this in Kuhn (1970), who re-introduced these ideas into contemporary terminology.

The contextualizing paradigm’s real function, apparently, is to guide. Depending on which psychological theory is chosen, one intervenes in x or y manner. Still, as the years go on, it is becoming increasingly clear to me that the most divergent paradigms do not necessarily lead to particularly divergent practices. Indeed, in a number of cases, such practices proved profoundly monotonous, compared to the raucous ways the various doxa competed with one another. Presently we will see how even what seem to be diametrically opposite paradigms ultimately amount to the same thing, particularly when it comes to their mutual disdain for the subject.

In other words, the paradigm’s function is not, after all, to guide a practice, whatever people might say. It has recently become increasingly clear that the effective factors in therapeutic practice are very much the same, beyond and above the various different paradigms. Every theoretically based clinical practice (psychoanalytic, cognitive behavioral, systemic, experiential…) has its good and bad therapists, and this evidently has less to do with the particular theory than with the way these therapists are (un-)able to handle these common factors. No, the paradigm’s real function is to create nest warmth, that is to say, to offer an articulated and hence security-providing framework for its followers, collected around a central credo that supplies a comforting answer to the ever-threatening Real of the clinic. We will subsequently see how this framework only incidentally influences clinical practice, and that these influences are not as diverse as one might imagine.

What we might call the “props” of these doxa can be very large or quite limited. Because of their small size, the smaller ones immediately reveal what is involved. A quick, if ironic recital gives us the Exemplary Case, the Latest One-Hit Wonder and the Guilt-tripping Drama Queen. In practice these three are frequently found in combination with each other such as, for example, every Latest One-Hit Wonder also contains a Guilt-tripping aspect as well, and an Exemplary Case is always useful to have on hand.

Exemplary Case Paradigms

Exemplary case paradigms are all those famous, if not infamous, case studies that are perpetually being rehearsed within certain circles. A quick glance back shows how every clinical master had one or even several star patients: for Charcot, it was Blanche Wittman; for Janet, Madeleine and Nadia took center stage; Flournoy chose Hélène Smith; Jung had Helene Preiswerk, and for Binswanger it was Ellen West; Mary Barnes performed the role for the Kingsley Hall Therapeutic community…The list is endless, and as a final example, we offer Freud’s own five case studies (see Ellenberger 1970, pp. 891–893, and Maleval 1984, p. 112).

Beyond this, it is an open secret that the principal patient of each of these great figures was himself. The exemplary, or any rate first case of this is to be found in Robert Burton, with his Anatomy of Melancholy (1621). Even Pavlov only came to the study of psychiatry after a so-called heart neurosis (Ellenberger 1970, p. 850). Freud himself begins from the same point as any student of the humanities: everyone always looks first for him- or herself in the array of theories, but this more or less always fails. Despite whatever his masters told him, and everything that was written in the textbooks, Freud, with his problematic train phobias and hypochondriac complaints, was unable to recognize himself. All that was left was to start looking for his own subject, Sigmund. That his patients aided him in his search is known by everyone in clinical practice. Hence, from Studies on Hysteria to The Interpretation of Dreams and The Psychopathology of Everyday Life, we get the story of a journey of discovery through the continent called Sigmund Freud. That he, and a number of other major figures, was able to go beyond this starting point and to elevate it into a theory is precisely why they are major figures. Ellenberger talks about “creative illness” and makes the inescapable comparison with the shaman (pp. 888–891 and passim).

The heroic historical narratives prefer to pass over this aspect in silence, instead presenting an image of an isolated toiler, neglecting wife and children and inventing earth-shattering theories for starvation wages while producing a number of unforgettable standard case-studies along the way.¹ Their paradigmatic effect can be seen in the way the second generation, that of the master’s students, is unable to produce its own case studies perpetually returning to those of the master’s, which are then deemed classics. To give an example, it is very difficult to find a psychoanalytic study or clinical demonstration of a psychotic patient who is not constantly being compared with Schreber. It almost seems as if every modern-day psychotic has to model himself according to the near perfect Schreber-profile, whose case thus comes to function as a kind of clinical bed of Procrustes.² Originally these case studies introduced innovative conceptual and pragmatic insights; now they have become standard weights obstructing every change.

What I call the Latest One-Hit Wonders start out from the idea that simplicity is the primary attribute of truth, and that anything can be explained on the basis of a limited etiology. Treffers (1988) likens this to a traveling circus: “Decades-long group discussions, symposia and workshops were organized during those years, […] There are a number of other traveling circuses, and the names of the most important acrobats and other attractions are easily filled in: the now bankrupted traveling MBD Circus (Minimal Brain Damage), a traveling circus for The Whole Family, a traveling circus for Body Language (extended thanks to popular demand) and the traveling circus for Autism. Recently I was confronted with the traveling Incest circus.”

These limited exploratory frameworks follow one another in rapid succession (fear of failure, borderline, ADHD…) and have apparently only one thing in common beside their short-lived nature: the initial enthusiasm of their followers, which frequently appears in the form of a proselytizing zeal. Thus I was once asked by an alarmed doctor whether it was “really true that everything could be explained by and treated as hyperventilation?” Yet there is another, more important mutual factor: the cause or etiology is always situated in an accusatory way outside the subject, in some so-called third party. Either the parents didn’t do their job or the social machinery failed, launching one onto the somatic roller coaster. This is even more true of those I refer to as the guilt-tripping drama queens, as this is their leading trait.

The chief difference between the Latest One-Hit Wonders and the Guilt-Tripping Drama Queens is the much wider range of the latter, a quality that always appeals to the sense of guilt ever-present in everyone (“Use every man after his desert, and who shall ‘scape whipping?”—Shakespeare, Hamlet, Act II, Scene 2), cleverly channeling it into larger, nameless entities. The example that first comes to mind is youth addiction. Over three decades, we have had four different exploratory models, each creating its own individual furor at the time. In the ’60s, drug addiction was explained as an expression of youth protest against an authoritarian society. Yet, in the wake of the bankruptcy of May ’68, the same addiction was explained as the alleged general feeling of defeat and alienation among the youth of the very same society. From the ’70s on, in contrast, drug use was interpreted primarily as one of the effects of a society of excessive consumption, overloaded with well-being and opportunities. But this failed to account for similar drug problems in underprivileged and poor segments of society. The explanation was then sought in the weakening of family ties: the torrent of divorces and open marriages operated as a destabilizing factor for youth. At the same time, it was discovered that young people coming from stable economic and strict family structures had their own drug problems, collapsing this exploratory framework as well. In the ’80s the one-size-fits-all response was economic insecurity combined with unemployment, until the discovery that drug abuse was the order of the day in certain highly specialized, professional circles (Di Gennaro 1987). All this calls to mind the image of a weary social worker who, casting anxious eyes to heaven after his latest ongoing training session (“Remotivation of Unemployed Addicted Youth”), shuffles into the nearest bar and orders a double whiskey.

The next example belongs to the same, albeit larger field: youth deviance. Summing up the commonsensical attitude that has characterized the prevailing approach for a number of years, Walgrave (1979) observes,

Our society is heavily directed toward economic progress and hence, has become too competitive and too materialistic. A number of people cannot cope with the daily struggle any more […]. Therefore a group of people exists on the borders of normal society. […] These families live an irregular life, the kids are neglected. In such situations, it is normal for young people to be unable to adapt to society’s demands. They remain psychologically immature, have a lack of psychic inhibitions; they do poorly at school, remain unemployed. […] The prevailing image of youth care programs immediately follows on from these ideas. While society must defend itself against such behavior, the teenagers themselves ought not to be regarded as responsible for it. They are in fact the victims of the circumstances in which they are forced to live. [pp. 2–3]

Immediately after presenting this oh-so-understandable explanation, Walgrave proceeds to throw cold water on it. Within scarcely a page, this comprehensive construction falls to pieces. In accordance with the Porterfield study and ensuing research into the “dark number,” it is revealed that this framework does not so much present us with the etiology of deviant behavior, but rather with the jurisdictional criteria³ for selection, scarcely covering 15 percent of the estimated total…⁴

It should be evident that these are examples of a form of social critique. The accusatory and exculpatory aspects seem self-evident because it is a matter of youth, drugs, and deviant behavior. But these aspects, as we will see, go much further than that. The question of guilt lies at the heart of the more global paradigms as well.

A Word about Paradigms

The larger paradigms are found alongside and through these more limited and limiting conceptual frameworks. Their size does not prevent them from formally displaying the characteristics of a doxa, which can be briefly summed up as follows: blinding you to what lies outside the frame, they force you to see what lies within it—even with the trigger-effect: “Can’t you see it?”—while simultaneously reifying it.⁵ In the preliminary interviews, the therapist imagines herself to be discovering things, while in most cases she will do nothing but confirm—confirm what was presented in the training. Real discovery means one has to leave the well-trodden paths of the doxa and blaze one’s own trail. Hence the therapist and the patient both need the same thing: the ability to reflect that makes both distance and choice possible.

Today, we can identify three such paradigms, each one initially seeming quite different from the others: the medical-biological one, the psychological one, and the psychoanalytic one. The last is considered corny and outdated, while the medical paradigm has increasingly become the Real Thing, as the psychological paradigm is doing its utmost best to lose its soft image and look as hard as possible by importing elements from the medical corner. My argument is this: in spite of their differences, these three paradigms are identical to the extent that their application makes them function as a University discourse (as discussed below). This doesn’t necessarily have to be the case, but clinical practice testifies to it being less often the exception than the rule.

These paradigms can indeed be studied as realizations of the University discourse, the latter being a regression from the Master’s discourse. Here the power of discourse theory lies in its predictive value: whatever the differences between the paradigms in terms of content, on a formal level they will institute the very same social bond, including the identical relations of impotence and impossibility. This is the most important thing: beyond the ever-present seduction of different concepts, theories, and explanations, we must concentrate our full attention on the almost incidentally created social relations.

THE MEDICAL-BIOLOGICAL PARADIGM, OR THE WET DREAM OF HARD SCIENCE

Because this approach sounds simple, it is therefore easy to sell: the cause of all human affliction is located in one way or another in the body. Therefore, diagnosis and treatment ultimately have to be grounded there as well, at least once science knows everything that there is to know. The old fashioned anatomical (or anato)-pathological model has today been replaced by a neurobiological-genetic one, but this is nothing but a turning of the tables. History, however, has shown that things are a little more complex.

From Dualism…

The starting point of what we call “reductive materialism” can be found in the fifth century B.C., with Democritus. Its basic argument is that both the ontological and the actual can be reduced to their fundamental composite particles. With Descartes and Newton, the emphasis is on mechanics, whose laws would explain “everything.” In Descartes’ Discourse on Method, the laws of mechanics are the same as the ones governing nature. With Newton, this becomes “the billiard ball universe.” Its explicit application to mankind is found in De La Mettrie’s Man as a Machine (1758), with Changeux’s Neuronal Man (1983) as a modern variation.

Meanwhile, Plato inaugurated a division between soul and body one that became hierarchized in medieval times: the soul is the highest good, the flesh is weak and perishable, subordinated to the eternal soul. With Descartes, this philosophical background will cause a division in thought and hence in education: the body belongs to the medical department, the soul is reserved for the shepherds of the soul—or the psyche as psychologists call it. Since the Enlightenment, the shift in emphasis from the religious-spiritual to the profane-material has brought the vilified body back into the center of the scientific enterprise, always within this materialistic-mechanical way of thinking, and along with the already mentioned division between body and soul.

Applied to our subject, psychopathology and psychodiagnostics, the same dualistic ideas quickly reappear.⁶ At this point, we can turn to Condillac and eighteenth-century materialism, of which positivism is a later offshoot. Prototypical for Condillac is his concept of “the statue.” He begins with a fictional human statue that initially has only one sense-organ, resulting in a single perception. After the statue acquires a second sense-organ, and hence a second perception, other functions get installed: a memory of the first perception; a comparison between the first and the second; a judgment containing a reflection and, finally, a desiring imagination that is able to present the no longer visible object. These are the so-called human faculties, which, for Condillac, always come down to transformed perceptions focused on the body as a material medium. We will encounter these faculties again in the psychology of the functions, dressed this time in somewhat more contemporary garb.

The scientific method that is based on these premises can be described as follows: science is a mental activity that always begins with the observation of phenomena, that is, sensation, whose aim is the application of a systematic ordering of that observation through the comparison, differentiation, and classification of the elements according to their resemblances and differences. In other words, decomposition and recomposition based on observation. The entirety is orchestrated by language, hence Condillac’s famous remark that a perfect science would be a perfect language. With regard to psychodiagnostics, this would lead us to the ideal of a perfectly closed nosological system of categorizations and denominations.

It must be emphasized that this approach was primarily dualistic, meaning that the psyche and the soma occupied equal places. For instance, half a century later, we will encounter this again in Leuret, who in his Fragments psychologiques sur la folie (1834) places hallucination into two categories:

1. Psychic hallucinations, missing the sensory element, but with a xenopathic or “alien-subject” character. Its normal variations can be found in “inspiration,” which seems to come from outside the subject and does not necessarily have to be sensory or sensual, as with the Muses, for example.

2. Psycho-sensory hallucinations resembling the first, but with a sensory quality. This quality is explained by referring to a perceptual-neurological factor that is thought to play a role here.

The two types sit beside one another in the dualistic line of reasoning of Pinel and Esquirol, where certain psychopathological deviations are the consequence of clearly visible, somatic disorders, such as idiocy. In contrast, madness in its pure form, has no lesional basis and can be described as an unknown functional change in the psychic apparatus.

…to the Opposition between Anatomists and Functionalists…

This dualism was gradually left behind, firstly with Gall’s phrenology at the end of the eighteenth century. As a neuroanatomist, Gall discovered the difference between the grey and white matter in the brain. From this, he developed a speculative theory about where the mental faculties in the cortex were located, convinced as he was of a quantitatively proportional correlation: the larger a certain region in the brain, the more important the faculty that it contained. This is the theory of the so-called cranial knobs, which postulates that each psychic function belongs to a part of the brain that can be topographically identified and isolated. In this manner, Gall and his pupils isolated some thirty-five faculties in as many corresponding knobs, including ones for poetry, for mathematics, and even one for conflict.

The immense success of this theory is still evident in certain colloquial expressions in German and Dutch where to “have a knob” for something means to have a particular talent for it. Nevertheless, this success was unable to prevent Gall’s phrenology from being officially condemned by the Austrian government in 1802 (because of its allegedly antireligious content), forcing him to leave the country. One of the reasons for its success was that it seemed as if he had found a material substrate for monomania, a nosological category of Esquirol’s that was causing a great furor at that time. As partial afflictions involving a single faculty, the various monomanias were thought to correspond with the yet-to-be discovered responsible knobs. In complementing each other perfectly, the success of these theories was more or less inevitable.

From Gall onward, two different approaches to psychopathology went into action: it was the anatomists versus the functionalists. The anatomists toed the phrenological line, advocating a certain monism: every mental alienation presupposes a specific cause in the brain that must be hunted down. Pinel’s moral etiology and treatment was tossed out as old-fashioned. More skeptical, and remaining within the dualistic reasoning of a Pinel and Esquirol, were the functionalists. For them, cerebral lesions are in most cases either undetectable or their relationship to psychopathology cannot be demonstrated. They do not deny that the body plays a role, but refuse to recognize it as the exclusive causal factor. For the functionalists, the cause of psychopathology lies outside the body but has effects on this body’s functions. Hence their name: functionalism, functional disturbances.

After Gall, the opposition between the anatomists and the functionalists gets consolidated by Georget. He will introduce a division that will continue to govern the clinic until today. In On Madness (1820), he distinguishes between:

1. Mental deviations that are merely symptoms of a known organic disorder. The causal factor lies in the body. From a nosological perspective, he locates the “acute delusions” here, which are nothing but a symptom of an already discovered organic disorder. In this category, for instance, we find delirium caused by fever, brain damage, and the intoxication psychoses.

2. “Madness” proper, as an idiopathic affliction whose cause is unknown, and which is expressed by purely functional disturbances. While the symptoms are of a psychological nature, this does not mean that they have no impact on the body. The cause must be sought in the moral realm.

Furthermore—and this is what is new—Georget introduces the idea of evolution within these afflictions, an idea that forms the basis for what will later be called the “dynamic” point of view.⁷

This division is the precursor to the subsequent partition of neurology and psychiatry, recently given new form in the split between neuro-psychology and clinical psychology. Here, too, we find another of today’s oppositions: the first group focuses primarily on the illness, the second on the patient.

As a result, the two conceptions that originally sat alongside one other, or even merged with one another, are now replaced by an opposition between the anatomists and the functionalists. But the scales will soon tip heavily toward the anatomical side because of a certain discovery. From that moment onward, anato-pathology becomes the new Enlightenment in nosological thought. I refer here to Bayle’s discovery of paralytic dementia.

…to the Anato-pathological Paradigm

Appearing in 1822, Bayle’s discovery emerges almost simultaneously with Georget’s theory. Nevertheless, its effect will only appear some twenty years later and, under Kraepelin’s influence, will color contemporary nosological and diagnostic thought in a lasting way.

The effect of this discovery has to be seen against its historical background. The phenomenon of general paralysis (paralysie générale) was known long before Bayle, and was considered to be a symptom or complication of the terminal stages of several diseases. It is precisely this thesis that he will reverse: general paralysis is caused by a single organic factor; it is a single disease that evolves through different stages. At a stroke, nosology seemed a whole lot simpler. At least three different illnesses could be reduced to a larger whole, of which each is an evolutionary stage; the previously random symptom of general paralysis is now unified into a single syndrome whose organic causality has been proved. Bayle’s discoveries can be briefly summarized as follows:

1. General paralysis is caused by a chronic inflammation of the brain (meningitis of the arachnoid membrane).

2. This inflammation leads to a psychopathology that normally undergoes three stages, spread over several years:

   • delusion with exaltation (or occasionally depression);

   • delusion with mania, megalomania, furor, agitation, logorrhea;

   • delusion with deterioration, amnesia and dementia.

We will come back to the question of the value of this description. Bayle propagates his discovery as the prototype for the entire field of psychopathology: every psychopathological disturbance is merely a symptom of an underlying anato-pathological process. From 1850 on, this idea becomes ubiquitous. Research into psychosis, chronic alcoholism, epilepsy, and even hysteria becomes the search for their underlying somatic bases. “General paralysis,” better known to us as “paralytic dementia,” becomes the Medusa-head around which a whole generation of researchers became paralyzed, with Kraepelin as her principal victim. With this discovery, the balance is also tipped and etiological research becomes exclusively directed at the body: every psychopathology has an organic base and is therefore organically treatable. Anato-pathology is a fact. Virchow’s Cellularpathology (1858) becomes the leading paradigm that extends into the entire field of medicine, culminating in enormous progress in this field.

As for the value of this discovery for psychopathology, we have to consider it carefully—one must first distinguish between the value of the discovery itself and the idealizing generalization that followed afterward. Bayle’s discovery became the subject of subsequent research, enabling Fournier in 1879 to demonstrate a connection with a syphilitic etiology, while in 1905 Schaudinn discovered Treponema pallidum in the infected sexual organs.⁸ In 1913, Noguchi demonstrated the presence of Treponema in the brains of paralytic dementia patients. These therapeutic attempts were topped off with Mahoney’s 1943 discovery that penicillin could be used, making paralytic dementia today a rare phenomenon. Such, at least, were the discoveries, still revolutionary today.

But once we examine the accompanying idealizations, the Medusa-head aspect becomes more equivocal. Paralytic dementia becomes the paradigm par excellence of the syndrome, as developed later by Kraepelin; according to Kraepelin, psychopathology ought to distinguish among syndromes that possess the same cause, exhibit the same somatic and psychological clinical picture, and follow the same evolution.

Unfortunately, even in the case of paralytic dementia, this idea of a uniform syndrome is more dream than reality, something that is usually forgotten thanks to the subsequent idealizations. Despite its clear organicism, the unequivocal factor is missing, meaning that the diagnosis isn’t unequivocal either. Only a limited number of syphilitic patients develop paralytic dementia, for example, forcing one to rethink its organic causality. The long cherished idea that there could be two viruses at play, only one of which caused paralytic dementia, was never proved and finally had to be given up (see Ey and colleagues 1974, pp. 835–836). The clinical evolutionary picture for psychopathology, for instance, can take many different forms; every textbook presents different classifications, most of which, moreover, contain “rare” or “atypical” forms. For example, the most frequent form before the turn of the century, megalomania, appears to have been replaced after the First World War by a simple form of dementia, a shift that a famous clinician like Rümke recognizes as being the effect of the dominant discourse, and which certainly doesn’t tally with the idea of an unequivocal somatic cause (Rümke 1971, p. 78).

These difficulties argue against an exclusively organic approach. We may conclude with Bayle then, that the somatic part of a certain disorder was indeed discovered, but that the mind–body division and—in the case of general paralysis—the exclusion of the psyche, inevitably lead to the classic deadlocks of the artificial dichotomy psyche–soma; all we can do is make an entreaty to try to think beyond this dichotomy.⁹ The unequivocal and one-to-one correspondence between somatic etiology and psychopathology that Kraepelin so desired is an illusion, leading Nijs, in 1987, to invert Kraepelin’s statement in the following way: “Organically caused psychiatric disturbances are typical to the extent that they are atypical.”

The Paradigm: Kraepelin and the Uniform Syndrome

Despite the difficulties of applying the idea of the “uniform syndrome,” paralytic dementia became the leading paradigm. The idea of the uniform syndrome is nothing but another name for the Platonic invariant. As a result, in the second half of the nineteenth century, research concentrated on the search for the anatomical substrates of every psychopathology, and for epilepsy, chronic alcoholism, and hysteria in particular. Autopsy became the primary research method, through which one hoped to find “it,” despite not really knowing what “it” was.

Nevertheless, the results failed to materialize. Consequently, that conviction weakened and, instead, the idea of degeneration took center stage as a reversed illustration of Darwin’s theory of evolution. With Freud, however, a new path was blazed: psychopathology concerns not simply the body but also and even primarily the psyche. The failure of anato-pathology in hysteria—see Charcot—inaugurated psychotherapy and psychodiagnostics. From this period onward, the anato-pathological conviction wanes and there is renewed attention to more wideranging approaches that take the interaction between the individual and his surroundings as a central theme.

This does not exclude the idea of an organic determination continuing to play in the background. The power of this ideal increased once clinical experience with paralytic dementia disappeared. Indeed, thanks to successful treatment, it has become quite rare, meaning that many clinicians in training do not experience the restrictions of the purely organic causal factor described above. The Kraepelinian ideal will receive fresh blood from the 1950s onward, due to the purely accidental pharmacological discovery of the precursors of neuroleptics. If chemical substances can exercise a more or less normalizing influence on psychotic behavior, then its cause and etiology must be on the biochemical level as well (Bouhuys and Van Den Hoofdakker 1986).

Meanwhile, this anato-pathological model has more or less become history, having been replaced by a new show pony, namely genetics and, more specifically for our field, behavioral genetics. Dressed up in a different outfit, it is the very same belief. A torrent of quantitative research has been published in the past decade, all demonstrating that certain behavioral characteristics are significantly determined by genetics, with only a limited environmental influence (for a review and a critique, see Fonagy et al. 2002, pp. 97–145). Nevertheless, it is enough just to examine recent changes in elementary bodily characteristics (such as bodily length, onset of menses) to see that the environment has a massive and, above all, barely understood influence on features that are undeniably genetically determined. It becomes all the more complex once we study non-elementary characteristics such as schizophrenia and delinquent behavior.¹⁰ Nevertheless, this conviction is rapidly gaining ever more ground as the new doxa. Rather than “anatomy is destiny,” the bell now tolls: “genes are destiny.” The difficulty of thinking about the interaction between nature and nurture is avoided. Behavioral genetics are the Latest One-Act Wonder.

The Hidden Moral in the Story: The University Discourse

So far we have recounted the history of this paradigm, emphasizing its factual content. But beyond this, we need to call attention to another aspect, namely, its formal mode of operation. My argument is that such a paradigm operates chiefly according to the University discourse, through which certain relationships and positions are imperceptibly imposed on the participants. Furthermore, this occurs independently of both the content and the scientific quality of the paradigm.

The reason why we encounter the University discourse here has to do with the radical impossibility of maintaining the Master’s discourse (Lacan 1991 [1969–1970]). The University discourse is easier and, moreover, fits in with today’s scientistic climate. The positions and disjunctions remain the same, but the terms have undergone a quarter-turn shift from those of the master discourse.

To put it schematically: this time the agent is the knowledge base from which the diagnostician and therapist approach the other as an object to whom this knowledge can be applied. Behind the agent lies the unquestioned and unquestionable master signifier. The product of this approach is that the other, placed in the position of an object, becomes more of a divided subject than ever. The relation between this subject and the master theory comes down to an unbridgeable gap, meaning that the upper relationship becomes impossible as well. The whole is moreover supported by a certain conception of science that ultimately excludes the subject as such. In spite of its apparent objectivity, this approach is fundamentally morally-ethically colored through and through. Let us look at it more closely.

Compelling Explanations

Knowledge, S₂, occupies the place of the agent. This knowledge is not merely knowledge per se, but first and foremost a certain conviction: it has to be so, reality has to correspond to this knowledge. To the extent that reality doesn’t yet correspond to it, it is only a matter of time. The basis of this conviction is found in a now incontrovertible master signifier S₁, which serves as a shining example. We already found one such compelling expectation—a doxa—back in 1917 with the reference to Kraepelin and paralytic dementia:

The nature of most mental disorders is still unknown. But there can be no doubt that future research shall enlighten the question and uncover new facts in a science which is for the moment only in its infancy. In this domain, the disorders caused by syphilis provide us with a vast field of investigation. It is logical to assume that we will succeed in discovering the causes of other forms of madness, and hence to prevent them, maybe cure them, although for the moment we don’t have any indication whatsoever. [Quoted in Szasz 1983, p. 45]

In response to this, we can cite another celebrity: “In an attempt to go further into the psychological, people cling to newly discovered somatic phenomena, or pin all hope on experiments through which something measurable, visible, a curve that can be mapped onto a graph, must finally come to light.”¹¹

The scientific outlook is the positivist, even scientistic paradigm.¹² Its specific conviction with respect to our field can be put this way: every psychological disorder has, that is to say, must have an organic cause. While this cause has already been found for a number of disorders, the others need further, intensive research, which will eventually lead to their discovery as well. In the meantime, for lack of anything better, we must content ourselves with psychotherapy, but the day will soon come when a pill, or a surgical intervention will suffice. The implication of such a scientific approach is immediately clear: if schizophrenia, for instance, is caused by a disturbance in neurotransmitters, then psychotherapy doesn’t make much sense. Rather, one must consider pharmacological, even neurosurgical interventions, if necessary. From this perspective, research into the schizophrenogenic family is an outdated anachronism that ought not to be funded.

We have already seen how the unprovability of this paradigm can be conceived in terms of an epistemological impossibility; this means that what we are dealing with here is a doxa. Its success, despite its lack of scientific persuasiveness, has to do with its hidden moral component, which we shall come to shortly. Put in terms of discourse theory, what we see here is the relation between knowledge (S₂), as the apparent agent, and a belief in the master signifier (S₁) occupying the position of truth and in fact governing the whole thing.

Illness as an Essence

If we pursue the structure of the University discourse further, we find that the other is reduced to an object, producing a heightened awareness of division and subjectivity on the patient’s side. Illness is defined as a nosological essence, for which the patient supplies only the fertile soil, a temporary dwelling. To put it more strongly, as a substrate, the patient muddies the disease’s pure expression, just as soil that is too barren or too rich has effects on the form of the plant that happens to grow on it. “Anyone who describes an illness, has to make a careful differentiation between the symptoms that necessarily go with it and are specific to it, and the symptoms that are only accidental and coincidental, such as the symptoms depending on the temperament and the age of the patient,” writes Sydenhan in 1772 (cited in Foucault 1997, p. 27).

The very same subdivision between the essential, which belongs to the illness’s essence, and the secondary, which is caused by the specificity of the patient, can be found throughout the history of nosology, in Charcot (real hysteria versus “formes frustes,” or weaker versions), just as in Bleuler and Schneider (primary versus secondary symptoms), to name only the principal figures. The emphasis of medical science is not on the patient but on the illness, an idea we have already seen in the DSM with its stress on the various “disorders.” The patient must be abstracted away if a clear picture is to emerge: “The Creator has established the course of most diseases by means of invariable laws that can be discovered quickly enough, if the patient does not interrupt or disturb the course of the illness.”¹³ When the body is considered a mere substrate, the subject is at most the passive victim of an organic agent. The etiological agent lies, like a “foreign body,” a Fremdkörper, outside the subject itself, who has little to do with it aside from being “overtaken” by it.

To put this in terms of discourse theory, in the University discourse, one finds an object rather than a subject in the place of the other. Objectification and desubjectivation are well-known in medical practice. This is, in fact, the classic critique of the medical model: being reduced to a “case” (the ulcer in room 2B) generates indignation in the patient—that is, a demand for recognition as an individual human being. But there is one tiny detail: in this discourse the subject is, quite precisely, produced by this approach; without it, there would not have been any subject whatsoever. With this approach, it appears in the position of the product. Such a protest, incidentally, conceals an underlying benefit for the subject itself, and therefore needs to be taken, at least partially, with a grain of salt. This becomes clearer once we take the ethical-moral aspect into account. The argument is quite simple: if a certain psychopathology has an organic explanation, then there is no such thing as a guilty party. There are only victims of accidental gene combinations, of external, nonhuman toxins, and so on. The parties themselves are not to blame, that’s the ultimate message.¹⁴ However, should the same disorder have a psychological etiology, then we would have to look for a cause in the psyche itself, and hence for a causal agent, either in the environment or, more frighteningly, in the mirror. This opens up a quasi-juridical process in which it is not just the patient, but the parents and the partner as well, who must all take their places in front of a prosecuting jury of psy’s (Fischer and van Vliet 1986, pp. 137–139, 148).

This is the advantage of the anato-pathological paradigm for the patient: he or she is acquitted and, moreover, can protest that his or her subjectivity wasn’t taken into account. The consequences of such an approach go much further than one would imagine. In fact, they color the entire mentality of our health-care system,¹⁵ which can be summed up in the following slogan: “Health is everyone’s free right.” The result, predictably enough, is that everyone avoids their own responsibility and choices. Lung cancer? No problem, just sue the tobacco industry, it’s all their fault! Alcoholism? That is simply an illness that one “has” (I have the flu; I suffer from alcoholism), what an awful tragedy!

Put in terms of discourse theory, what we encounter here are the disjunctions, which go considerably further than the purely anato-pathological or medical aspect of this approach. On the upper level, it becomes apparent that knowledge is never fully able to grasp the object; there is always a gap and a remainder. On the lower level, it is clear that the subject, in the position of the product, neither has nor wants anything to do with the master signifier S₁ in the position of cause and of truth. The double bar // will never be overcome.

We are now in a position to examine the other paradigm in which the moral element is explicitly foregrounded.

THE MORAL TREATMENT PARADIGM: TO TEACH SOMEBODY MORES

We could, fairly arbitrarily, begin with Pinel (1754–1826), one of the founding fathers of what would later become psychiatry and psychopathology. Like every founding father, he is described in mythical terms: heir to the French Revolution, severer of the chains that fettered the mentally ill, and so on. His essential significance lies neither in the field of nosology nor in that of theory. Pinel is important because of his method: he was the founder of the clinic, that is to say, of the determined and systematic approach through which mental illness acquired its distinctive status, institutions, and treatment.

With regard to theory, he took a rather peculiar stance: he remained skeptical of any form of theory that, as far as he was concerned, moved too rapidly away from observation. Hence one cannot talk about Pinelian theory. Rather, he proposed a pragmatic approach, a form of know-how (savoir-faire) that enters history under the name of the “moral treatment” (traitement moral). This approach accords with his views on etiology. He distinguishes between three groups of pathogenic factors:

• Physical causes (trauma, organic diseases);

• Hereditary causes (debility);

• Moral causes.

Deeming the first two practically incurable, he concentrates on the third group. His ensuing treatment model recalls the Hippocratic idea of illness, in which illness is the body’s healthy defensive reaction to an imbalance, and whose normal result is health. It is clear that such a conception of illness has important repercussions for the way the person who was then called the “alienist” responds. Pinel sums this up in three basic rules:

• He has to wait;

• He has to avoid any intervention that disturbs the natural course of the illness (because its ultimate goal is health);

• He must help the illness progress.

It is precisely this last that constitutes the “moral treatment.”

The underlying theory originates in sensationalism: the contents of the sick mind stem largely from deleterious perceptions and sensations, that is, Pinel’s third etiological factor. Consequently, curing boils down to the presentation of health-inducing perceptions and sensations, combined with the patient’s removal from the harmful environment so that his or her psychic “faculties” can recover their balance. The practical effects of this project meant that special institutions had to be created for the recovery process—psychiatric hospitals—where the healthy perceptions could be effective. This gave rise to the application of a variety of cures (mud, water, sun and other baths) intended to create healing perceptions. Each one of these cures forms only part of a total approach because these institutions will eventually give birth to the clinic, the characteristic, all-encompassing regime that is to effect moral healing in the form of a kind of strict paternal order that is incarnated by the clinical director himself.

With this we have already sketched a brief outline of the core of the moral treatment model: people become mentally ill because of deleterious perceptions, ideas, norms; psychotherapy occurs by grace of a master figure whose correcting interventions take place within the context of a larger environment, or—more precisely—inside a totalitarian discourse that has no room for the subject’s division. Note here that morals are considered health inducing. After Freud, this gets reversed, and morals seem to become the most significant deleterious factor (Vandermeersch 1978, p. 45). Later on, this core will be mitigated somewhat, but in essence it remains unchanged. For instance, for Pinel, the mental faculties were autonomous and nonhierarchized. Psychic functioning was a process of interaction in which upsets of balance could take place, resulting in psychopathology. From Esquirol (1772–1840) onward, a hierarchical order gets introduced: at the top of the faculties lies a function that controls, selects, and synthesizes, namely, the ego as the center of attention. Consequently, psychological disturbances are conceived as an effect of an imbalance between the lower faculties and the higher attention function of the ego.

This shift is significant because it continues to determine contemporary thinking; even today, psychology is frequently simply an “egology,” with the emphasis today on what are termed cognitions. While in Pinel’s time people were permitted to be both passionate and rational, now rationality dominates. Throughout history, the pendulum has swung back and forth: in pragmatic eras, man is thought to be rational (cool), while in more expressive periods passion is allowed. Anyone unlucky enough to respond to period X with image Y deviates from the ideal norm.

Guislain and Phrénopathie

Somewhat closer to us in time is Guislain (1797–1860). He replaced what was then termed madness (folie) with phrénopathie, understood as “a psychological reaction to a state of phrenalgia.” We can extract two things from this description: a psychological reaction and phrenalgia. Guislain looks for the model of the psychological reaction in normality. For him, there are always both normal and pathological variations, and he remarks dryly that the success of the treatment depends on the degree of distance between the pathological and the normal. He conceives of “phrenalgia” as a moral affliction (une douleur morale), and it is precisely this aspect that will subsequently become a bone of contention. As a general practitioner in Ghent, he was able to keep abreast of the same families for many decades, which taught him, firstly, that the cause of psychopathology was always to be found in what he called the moral sphere and, secondly, that this cause was almost invariably kept from outsiders. As a result, his position was that “one must look behind the scenes.” This idea finally became commonly accepted, and influenced, for example, Griesinger’s theory of conflict, and consequently Freud as well (see, for example, his notions of conflict and defense).

With regard to specifically nosological classifications, Guislain remains adamant that the pure forms are very rare and that one mostly encounters hybrid forms in the clinic. This is unquestionably true. What is weird is how the vast majority of us continue to think and rationalize in terms of strictly separated species, turning clinical experience into a kind of aberration of the pure, rational, nosological system.

The beauty of it—which is precisely why Guislain was picked here—is the superb confusion that appears in his terminology, which is by no means accidental: in it, “moral” states are rechristened as medical-organic afflictions (phrenalgia, phrenopathie), blurring the differences in content between the two paradigms.

Protagoras to Pinel

We took Pinel as an arbitrary starting point. We could just as easily add a number of other writers from around the same time to the discussion, but this won’t be necessary for our purposes. The moral conception of illness actually goes directly back to Protagoras and from the beginning exhibits the very same paradox. This sophist from the fifth century B.C. became well known for his argument that “man is the measure of all things” (homo mensura), thus reducing all perceptions to the subjectivity of the perceiving subject, and hence to a merely individual truth. What person X perceives is not necessarily the same as person Y; but the two different perceptions of the same reality are nevertheless each “true,” albeit only for a single person. Even Protagoras, however, allowed that certain perceptions are better than others, namely, those belonging to healthy rather than sick persons. He conceives of a pedagogical role for the therapist, who must teach the patient-pupil the proper perceptions. What is better is what has better actual effects. As a result, we are faced with a paradox: the actual is only subjectively perceptible, while different “better actual effects” result from different perceptions. The master position becomes inevitable here, and that is precisely what we find with Pinel’s chef de clinique. Historically speaking, it is here that the enlightened appeal to reason always shows up as the decisive argument, from Kant (“The only feature common to all mental disorders is the loss of common sense (sensus communis) and the compensatory development of a unique, private sense (sensus privatus) of reasoning”) to Monod.¹⁶

In this way a line can be drawn from the Greek sophists to Pinel. We can pass over this quietly—it is old-fashioned, goes back to prescientific times, and the like. However, when we make the step to contemporary psychological approaches we are in for a double surprise.

Firstly, we find almost exactly the same problems in today’s psyclinical practice. You don’t need much clinical experience to discover that most psychological problems are concerned with psychosexual identity (“What does it mean to be a man? What does it mean to be a woman?”), with the psychosexual relationship (“Where do I stand in relation to the other, my partner?”) and with the relationship toward authority (classically the father, nowadays less clear). It is also well known that these problems always imply a conflict between pleasure and unpleasure in every conceivable form (from anxiety to jouissance). The contemporary clinic, in other words, is still very much a moral clinic, although the signifier “moral” has been unilaterally replaced by the “psychological.”¹⁷ The reason for this substitution is not only historical, but also epistemological. The term “moral” doesn’t fit very well into a positive-scientific way of thinking, and “ethical” only barely, but “psychological” does the job nicely.

The second surprise concerns the difference between the contemporary clinic and the medical-biological approach described above, which one would expect to be substantial. Isn’t the subject, after all, the main focus of clinical psychology, not the body? Closer examination, however, reveals a surprising result. The difference between clinical psychological and medical biological approaches is minor, provided that in both situations they take place within the University discourse. The most important difference seems to come down to the fact that, compared with the organic-medical approach, today’s “moral treatment” is unable to convincingly refer to a master signifier in the same way, so that it is more a question of aspiring toward a guaranteeing master signifier S₁. This is, incidentally, more or less the sole difference, for we encounter the same ideas again, with the very same deadlocks. Consequently, the implications of today’s moral treatment, that is, psychotherapy within the terms of the University discourse, are identical to those of the organic-medical treatment, with the exception of the aforementioned aspiration. We have already mapped them out through the University discourse, and can take them up again here virtually unchanged. To avoid repeating myself, I shall pay special attention to the subject, because one would expect it to have a central place within this approach.

The Exoneration and Infantilization of the Subject

The upper level of the University discourse shows how an object appears in the position of the other to which knowledge is then applied. In the organic-medical approach, the subject is regarded as a victim of external biological agents. In what we might call the hidden moral paradigm, the subject is a victim of its environment (parents, family, job), which must be objectively studied and mapped out—the enmeshed family, the disengaged family, the schizophrenic mother, the hysterogenic father. This means that the medical-biological line of reasoning can also be applied, but with psychological concepts for content. The psychological becomes pseudo-medical. This equivalence doesn’t mean that psychology acquires medical contents (in the sense of MBD, ADHD,¹⁸ or lack of oxygen at birth, for example), but points to a formal similarity: the etiological agent is located outside the subject, who remains more or less unimplicated in it but is, rather, assailed by it. The medical and the psychological are both alienating discourses precisely because of this exclusion of the subject.

Hence, in the University discourse (whether clinical-psychological or anato-pathological), we encounter a diagnostic logic that excludes the subject: the subject is merely a product that an agent, such as a foreign body, psychic virus, or bacteria, has acted on. Such an etiology can seem quite psychological. Every time anxiety, for example, is explained and diagnosed through reference to a birth trauma, or hysteria by a traumatic experience before the patient was four, or learning difficulties by the parents’ divorce, it sounds quite psychological.¹⁹ Nevertheless, this logic is fundamentally alien to the subject, referring to something that comes from the outside and that can be objectively retraced.

The metaphor that we used with the organic biological paradigm, where illness was a plant and the subject its soil, applies here as well. This time the poorly developed plant represents the subject that has languished because of a bad soil. Both diagnosis and treatment start with the definition of an ideal plant and an ideal terrain. The subject—the plant—comes into the picture only as a goal, a final product of the process that is primarily concentrated on the improvement of the potting mix. Diagnosis here does not so much measure the subject’s difficulties as the distance between the subject and the presented ideal. We obtain, as it were, a picture of a gradually elaborated path that starts out far from the norm and ends up in perfect accord with it. The subject will be situated in its corresponding place on this continuum through which one can then estimate the distance he or she still has to cover.²⁰

What is striking in this approach is how difficult it is to found the treatment: what is one to do with the irrevocable “facts”? An external etiology implies an external treatment. In bronchitis, the subject becomes the victim of an attack by a bunch of little critters; one is given antibiotics to kill the bacteria. But what should one do if the subject is the victim of a birth trauma, the parents’ divorce, or…? In such cases, the only real antibiotic, in the etymological sense of the word (translator’s note: Anti-biotics: literally anti-life), would seem to be that most radical one, evoking the mè funai of the chorus in Oedipus Rex: “It would have been better never to have been born.” In this context, one reaches for a double arsenal, with reparative techniques (the original learning process must be redone) and various abreaction predicaments (re-birthing, primal scream) on the one hand, and recovery techniques for changing the originally faulty substrate into an ideal form on the other. In both cases, therapy runs the risk of deteriorating into a patronizing helping hand. The subject, in all of this, is exonerated of guilt; it is purely the environment that is to blame. The price is infantilization. As a flawed product, the subject is nothing but the raw material upon which other, better designers will do their job; nothing but the starting point for a new improved edition.

Enforcing the Ideal

This turns the vast majority of contemporary therapeutic approaches into covertly moral projects, not so much because they conduct everything under the banner of the ideal (in whatever version) but because they coercively enforce it. Hence, psychopathology is considered a failure to correspond with a certain ideal and treatment boils down to an educative process, a kind of relearning of this ideal. The moral dimension is expressly present, although now disguised under a pseudoscientific veil: psychological health becomes a coercive yoke, an obligatory conformity to a prescribed norm as the incarnation of the health ideal. The difference between psychotherapy, education, and re-education becomes completely blurred.²¹

No wonder that educational psychology, cognitive psychology, and psychotherapy have become confused today, and that one frequently talks about psychological training, preferably in groups where the effects of transference and identification are much greater. When Foudraine wanted to demedicalize his ward in Chestnut Lodge, the most fitting new name he found for it was “School for Living.”²² What makes this still weirder is that, after Freud, we do have some concept of the subjective implication: ideas such as the “benefit of illness” and “choice of neurosis” can serve us as beacons for avoiding this subject-infantilizing approach. We might add that Freud himself originally used these ideas of external factors, because that was how his hysterical patients presented it: something attacked them from outside—see his first theory of trauma. But long before he officially gave up on this theory, he wrote that the so-called “foreign bodies” formed part of the subject’s ego, meaning that from the early Freud onward we must look for the etiology in the subject itself (Freud and Breuer 1978 [1895d], pp. 6–16).

The results of such an external approach can easily be foreseen: maintaining this objectifying and patriarchal mode will lead patients to denounce the entire psy-enterprise, just as they did with the older medical model.²³ Nevertheless, complaining about it doesn’t prevent them also from benefiting from it, through the patient’s self-exoneration, which is why the system endures. But it also creates fertile ground for all kinds of alternative healers, some of whom may be more willing to listen than regular therapists.

Rejecting the Subject

The idea that, as a result of the moral approach, the subject itself can be blamed and therefore rejected is at first sight perhaps even more surprising than simply the chill exclusion of the subject. Unexpectedly enough, we find an illustration of this in Thomas Szasz. This well-known freedom fighter from the anti-psychiatry movement has always presented himself as a defender of the rights of the mentally ill; he was a relentless critic of everything and everyone who threatened these rights. It is less well known that he ultimately rejected the patient, and that this is a necessary consequence of his approach.

His basic thesis is as simple as it is seductive: psychopathology is an effect of oppression, comparable to the medieval Inquisition. Moreover, he makes a black-and-white distinction between illness on the one hand and psychic difficulties on the other. Illness is biological and belongs to the field of the positive medical sciences, the world of laboratories and scanners. Natural science for him is the only genuine form of science. In contrast, psychiatry and psychology, to which psychic troubles belong as general problems in human life, inevitably have to enter the fields of morals and ethics, and therefore are unscientific by definition (Pols 1984, p. 58 and passim). As a result, he argues against enforced institutional psychiatry and in favor of what is known as “contractual” treatment, whereby patients come for consultation of their own free will with the aim of regaining their lost freedom or autonomy.

These arguments seem beautiful, human, modern, and so on. Nevertheless, they become somewhat less attractive once we follow his reasoning through to its final consequences, which inevitably lead to a deadlock and a paradox.

Let us deal with the deadlock first. Everything to do with institutional psychiatry Szasz interprets in terms of the relationship between oppressor and oppressed. In itself this is not new. As an idea it can be put into the context of much wider theories than anti-psychiatry, where mental illness is reduced to a question of power and oppression. Let us sum them up. In philosophy, we encounter this idea in Hegel, Schopenhauer, and Nietzsche. In our own field, it already takes center stage from the moral treatment model onward. In Freud, the important but often neglected opposition between passive and active is apparent throughout his work. In Adler, we find the theory of masculine protest and organ inferiority. Behavioral therapy is an open-and-shut case of power at work, while in systemic therapy the ideas of one-up and one-down speak for themselves. In ego analysis, the concepts of resistance and adaptation are fundamental. Lesser gods are Bakker with his theory on the territorium and Laborit with his similarly ethologically inspired ideas of hierarchy and dominance. With Foucault, we find an explicit relation between discourse and power. Finally, Lacan equates the discourse of the unconscious with the discourse of the Master and considers the latter the necessary precondition for every possible discourse and hence for every possible social relationship. Consequently, he does not naively reject this master discourse but links it structurally to the three other discourses.

In other words, if Szasz centralizes the idea of power and oppression, he inserts himself into a long tradition. But with this he makes a substantial error of interpretation: the relationship between oppressor and oppressed is primarily internal to the subject that is divided between its desire and its truth, and this relationship only becomes externalized afterward, resulting in the creation of oppressive instances, institutions, and so forth. For both Lacan and Freud, family and society are the effects of a certain subject-formation, not causes, albeit in a perpetually circular relationship (Freud 1978 [1930]; Lacan 1990 [1974], pp. 28, 30).

Szasz concentrates on these effects and calls them causes. His error becomes visible in the deadlock we can observe in his treatment: when one removes all external oppressive factors, the individual psychopathology remains. Precisely at that moment, Szasz’s attitude shifts into the rejection mentioned above: the patients cannot cope with their liberty, with their autonomy.

This brings us to the paradox. Despite all of his pleas for freedom and autonomy, his theory finally amounts to a direct rejection of the patient. Why? Because his (in many respects justified) critique of institutional psychiatry, and his black-and-white distinction between science and ethics lead him back to the moral treatment model of the alienist, upon which his thought acquires a remarkable moral stance. He advocates the freedom, responsibility, and autonomy of the subject, values that he assumes institutional psychiatry shuns. Yet this implies that, for Szasz, the patient appears in a totally different light. In place of the medical psychiatric criterion that in a certain sense declared the patient both innocent and helpless, Szasz now gives us a moral value judgment that very rapidly becomes a prejudice. The striking thing about his line of reasoning is that it enables us ultimately to align Szasz with someone like Slater (1961, 1965), who argued that hysteria does not exist and that hysterical symptoms, lacking biological foundation, are proof that the patient is healthy.

For Szasz, mental illness does not exist, but the associated behavior does. So-called psychiatric patients are people who avoid their responsibility, who make unjustified use of their sick role. Thus we find the following notable saying from this liberator of the mentally ill: “The facts are, that, in the main, so-called mad-men […] are not so much disturbed as they are disturbing; it is not so much that they themselves suffer (although they may), but that they make others suffer (Szasz 1976, p. 36). With this, Szasz not only distances himself from the vindicating effect of certain psychotherapeutic theories (the subject is himself responsible for his behavior and has to assume this responsibility), but goes a considerable step further (if they don’t assume their responsibility, they are “disturbing mad-men”). Finally, we encounter here an accusatory prejudice that returns us to the idea of simulations, infantile adults, even criminals. Psychopathological labels are turned into pseudo-scientific excuses to “punish” “deviants,” a process that is not all that rare in the psy-enterprise. Already in 1939, Hartmann noted that his colleagues had no difficulty claiming “that those who do not share our political or general outlook on life are neurotic or psychotic.” That this still happens today is well known.

Aspiring toward the S₁: The Appeal to the Primal Father

In the Discourse of the University, the other is turned into an object of knowledge, forcing the subject to feel its subjectivity more than ever as the product of such a de-subjectivizing approach. This discourse is supported by an underlying master signifier that serves to guarantee the discourse’s accuracy.²⁴ In the anato-pathological approach, we could locate the paradigmatic discovery of dementia paralytica in this place, which has been replaced by behavioral genetics today. In the clinical-psychological-moral approach we see this function become personalized: the guarantee becomes embodied in a specific master-figure. Just as “made in Germany” guarantees quality, “Mr. X has said that…” certifies its truth.

In itself, this is a very interesting arrangement and a direct confirmation of Lacan’s interpretation of the Freudian Oedipus complex. The father as a guarantee can only function by grace of a super-father, a primal father. While Freud believed this to be historical reality, for Lacan it is a neurotic illusion: there is no “big Other” founding “the Other” although in itself this hasn’t prevented both Freud and Lacan from being installed or even installing themselves in the position of the master signifier S₁.

Such a personification of the university discourse’s underlying guarantee has far-reaching consequences: the guarantee is not so much given by the master’s theory as by his or her associated ideology. This is easier to see in the field of clinical psychology because the problems it treats are indeed moral problems.²⁵ It will become more visible still once we go from diagnosis to treatment—which is, after all, the aim of psychodiagnostics.

With regard to treatment, we encounter an ostensible opposition: either one strives for a completely objective approach—which is impossible—or one goes in the opposite direction and the therapist becomes the new Messiah, or meaning provider. Both approaches presuppose a master-figure in the form of the therapist who both knows and is able to instruct his patients in how psychologically normal people behave. A third possibility—that of abstinence (cf infra)—is entirely overlooked.²⁶ Abstinence means that, in an attempt to handle this division differently, the therapist avoids imposing her desire onto the other and creates a situation in which the subject’s own subjectivity and accompanying division can be taken into account.

Where this does not happen, diagnosis and the cure become an authoritative form of help in which the therapist wants “the best” for his client. This best, however, implies a value judgment and, hence, can only ever be arbitrary: thus homo mensura must call upon a “superhomo supermensura.” Here we find the same deadlock as in the biological approach, where the underlying dualism between psyche and soma inevitably gives rise to an internal dualism, namely, the homunculus theory: someone has a headache because a smaller person in his brain has a headache, which is caused by an even smaller person in his even smaller brain, and so on.

The foundational master signifier S₁, the Other of the Other, continues to recede ever further toward the horizon. Some idea of the danger of benevolent therapeutic help can be given by a Lacanian saying. He scans it in three bars that each time delineate the enclosed problem more sharply: “It is a fact of experience that what I want is the good of others in the image of my own. That doesn’t cost so much. What I want is the good of others provided that it remains in the image of my own. I would even say that the whole thing deteriorates so rapidly that it becomes: provided that it depends on my efforts.” (Lacan 1992 [1959–1960], p. 187). Here we can turn to Freud who, not coincidentally in a paper on transference, categorically dismissed such an attitude, precisely because “psycho-analytic treatment is founded on truthfulness” (1978 [1915a], p. 164) by which he simultaneously recognizes its greatest ethical value.

Nostalgia for the Father

This issue has become all the more problematic as a result of the social evolution of attitudes toward authority. Roughly speaking, for half a century the overly severe father has been regarded as the cause of every psychopathology in his children: the patriarch, the leader of the primal horde who raised his children into neurotically contorted milksops. The sexual revolution, antiauthoritarian models of upbringing, learning-in-freedom and Sommerville schools were all corrections to this, based on its opposite. Quantitative criteria were used as well: an overly severe father causes frustration and neurosis in his children; an excessively severe monster-father goes a step further, causing psychosis in his offspring. Strangely enough, we hear pleadings, almost supplications today for the return of this father patriarch: “More structure!”…“the Name of the Father has to be installed!” A severe father might not be all that much fun, but an absent father is even worse. People talk more generally about the loss of the grand narratives, the myths: human beings need a meaning-bestowing belief in something, whether it is religion, politics, or…science. A final, desperate attempt to sit on the fence is found in the eternally returning quantitative logic: the father must be authoritarian, but not too much so.

Here, the moral treatment model turns into nostalgia for the primal horde: “Long before he was in the world…there was the father who knew that a Little Hans would come who…”²⁷ The anato-pathological model has less need of this nostalgia because there the installation of the S₁ seems more secure. From a psychoanalytic perspective, two comments can be made. First, this pleading for a return fails to make an essential distinction between the real father, the imaginary father image, and the symbolic function of the father. Second, with Lacan we can go beyond the Freudian call for the primal father-master (“You are looking for a master, you will find one”)²⁸ as a typically neurotic and perpetually failed solution to one’s own self-division; the failure is inherent in the structure of the Master discourse itself. This is not to say that this type of solution is not exercised just as much in science (deus sive natura), in politics (Papa Stalin and Co.), and in religion (from the Pope to Khomeini) as on the individual-clinical level.

The application of the two paradigms, the savoir-faire (know-how) of both medical and psychological practice, is nothing but a phenomenalization of the University discourse. To found a practice upon this demands the politics of the ostrich. Without awareness of that one is confronted with impossibility and impotence. In our field, this can be seen in Freud’s concept of the “impossible professions”: educating, governing, analyzing. Nor did this stop his own theory from being turned into a paradigm in a very short time as well.

THE ANALYTIC PARADIGM: PROMISE AND DECAY

Freud’s originality lies in his daring originality. This tautology can be found at the origin of every scientific innovation: every time someone risks leaving the beaten path, the chance of something new appears. The associated paradox is that, following this fruitful side track, a group of disciples emerges to defend the master’s orthodoxy. Anything is allowed, so long as it is written by the master. In the name of an original thinker, originality itself becomes forbidden.

Before examining the psychoanalytic paradigm, I will first explain Freud’s original vision of psychopathology, for which a well-known expression can serve as a guide: the flight into health. Next we will look at Freud’s own evolution, which, starting out from a positive scientific model and colliding with its deadlocks, inevitably culminated in certain ethical implications. Moreover, it will become clear that this ethic was implicitly present from the beginning despite its being hidden under the various different names of objectivity. Finally, we will be able to pinpoint the moment when, after Freud, this decay into an “analytic paradigm” occurred.

Freud: The Flight into Health

One reproach often leveled at psychoanalysis is that it makes any behavior suspect, constantly shifting the border between what is normal and abnormal. This reproach has to do with Freud’s expansion of the concept of the symptom; from an analytic perspective, anything that can be traced back to the history of a subject’s formation is a symptom. Such a statement says nothing about the pathological or normal character of this symptom, only about its place, signification, and function within the economy of a particular subject. Israel (1984) expressed this position in terms of a wish: that one day a diagnostics independent of all pathological connotation would emerge.

The reproach, therefore, doesn’t go far enough. Freud didn’t so much shift the frontiers between normality and abnormality as explode them. The “flight into health” of our title can serve as a paradoxical leitmotif here. We encounter it, for instance, in a case study of obsessional neurosis (1978 [1909d]), where it refers to what is no doubt quite a remarkable process: the patient recovers in order to escape from the truth that is on the brink of emerging through the analytic process. In his paper “On Beginning the Treatment” (1978 [1913c], Freud uses the metaphor of the set of scales: on the one side is the loss, namely, the subjective pain caused by the symptoms; on the other, the gain, the primary and secondary advantage of the illness. This balance as fully determines the moment when someone appeals for treatment as when they stop it.

This is, incidentally, common knowledge for every clinician: the moment that someone asks for help is almost never contemporaneous with when the symptom started. Typically, the pathological structure is much older, while the demand for help almost always seems to come too late. This is the most important starting point for the intake sessions: Why has the patient come now, at this specific moment? To put it differently, what has changed in the symptom’s balance sheet of gains and losses that makes a demand for help needed now? At the same time, the equivocal quality of many demands for help becomes transparent: most patients want nothing more than a restoration of the original balance, not the dissolution of the structure—this is evident from another Freudian case study, this time concerning a hysteric (1978 [1905e]). Hence the consultations will be stopped once the balance is restored, while nothing has fundamentally changed—this, then, is the flight into health. Its opposite is still more paradoxical: the therapeutic negative reaction, in which the analysis runs beautifully, but the patient suffers even more profoundly. The revelation of too much truth is not always easy to take, and it is not by chance that Lacan puts an ethical imperative at the foundation of the analytic process and of the unconscious: “Whatever it is, I must go there” (Lacan 1994 [1964], p. 33).

The subversion of health into illness suggests a fundamentally different vision of psychopathology in general, and of the symptom in particular. After psychoanalysis, it is well known that a psychopathological symptom is an attempt at cure, more specifically, an attempt to reach a solution within a given psychic structure. This still revolutionary idea is in fact age-old as it perfectly reflects the Hippocratic view of illness (as discussed above): illness is an organism’s healthy reaction to an imbalance, a reaction that normally ends in health. Its accompanying symptoms are attempts to adapt to it. In the first half of the twentieth century this mechanism was even reversed. A psychosis? No problem. Transform it into malaria and the psychosis will vanish (known as the “Von Sackel” treatment). It is almost like the implicit rule of folk psychology: solve a problem by creating a bigger one.

Back to Freud then. His explosion of the border between the normal and the abnormal can be seen at any number of points. It is enough simply to consult the index of the German Gesammelte Werke under “Normal” and “Normale Menschen.” It extends over ten columns, and we encounter just about every pathological phenomenon.²⁹ His foundational texts present the same combination every time, from The Interpretation of Dreams to The Psychopathology of Everyday Life and Jokes and Their Relationship to the Unconscious: there is practically no difference between the “healthy” and the “sick” mind. It is not by chance, moreover, that this intermingling occurs; it takes on an increasingly structural importance throughout the development of Freud’s theory, as can be illustrated through three main themes.

First, sexuality. The so-called normal sexual relationship is a normative illusion; there is only a “norm-mal(e),” a male norm, whose short-term variations are provided by the periodical statistics supplied, à la Hite and Masters and Johnson, and which any interested person can consult freely to see how many orgasms she or he is entitled to within the various age categories. For Freud, the human being starts out from a polymorphous perverse sexuality whose original instincts get perverted into the typical human drive. There is no natural norm for human psychosexuality. The central diagnostic problem concerns the difference between the perverse traits that are found in everyone, and the perverse structure of the subject (see Chapter 14 of this book).

Second, repression. From his earliest writings, Freud uses the terms normal and pathological to describe this process. The difference between the two kinds will never be elaborated except in quantitative terms: pathology implies an excessive repression. The moment he formulates the concept of primal repression as a necessary preceding state for “secondary” repression, it becomes evident that this primal repression is structurally necessary for every subject, thus blurring the distinction even more.³⁰

Immediately following this, we encounter the idea of the splitting of the subject, the Spaltung. Originally, Freud limited this to extreme cases of hysteria, but eventually he will universalize this process: every subject becomes divided during its development, and this division is focused on the acquisition of language and the accompanying loss of immediacy (Freud 1978 [1940e], pp. 275–276). Freudianly speaking, this enables one to specify a person’s pathology on the basis of their relation to the lack that language has installed: repression, disavowal, foreclosure. With Lacan, this will become the subject’s relation towards the lack in the Other, opening up the idea of a structural clinic. As someone once quipped, there are three ways of being normal: neurotically, psychotically, and perversely.

The World of Make-believe

Therefore, the reproach we began with is at least partly on target: psychoanalysis has undeniably exploded the difference between normality and abnormality. The question now is whether this is justified? Is it possible to neglect this difference? Is it not rather that analysis has created an unfortunate artifact? The story of the Emperor’s new clothes can serve to illustrate this. Freud takes the place of the child who dares to reveal the truth in the face of reigning appearances: everyone knows that the Emperor is walking around naked, but no one has the guts to say it.³¹ This is precisely one of the fundamental characteristics of what Lacan calls “le monde du semblant,” the world of make-believe, and the reproach directed at Freud belongs to it. An example of this is found in the remarkable screening list designed to detect psychic anomalies in schoolchildren.

1. School problems such as low scoring, top scoring, and irregular scoring;

2. Social problems with peers and brothers and sisters, such as the aggressive child, the submissive child and the braggart;

3. Relations with parents and other authority figures, such as annoying behavior, docile behavior, obsequiousness;

4. Clearly perceptible behavior, such as tics, nail-biting, thumb-sucking and interests that are more appropriate to the opposite sex, such as the boyish girl and the girlish boy. [Radin 1962, p. 392]

No further comment is needed here.

Freud’s Evolution: From Scientism to Ethics

Right from the start, Freud wrestles with what he calls the choice of the neuroses (the Neurosenwahl): how is it that someone chooses this particular psychopathology, and not a different one? The term itself is a little misleading: it does not concern just the neuroses, but also what Freud later called the narcissistic neuroses, that is, psychosis. As an illustration, it is enough to recall the peculiar term, neuropsychoses of defense (Abwehr-Neuropsychosen), among which Freud includes hysteria as well as paranoia. What is striking is his introduction of the idea of choice: the subject itself has always been a part of its pathology; it is not just the victim but the actor as well.

In this light, it seems as if Freud has been concerned with differential diagnostics from the outset. This is only partially true, because this distinction is developed through and together with the treatment. To the extent that Freud discovers hysteria and obsessional neurosis, he is developing the psychoanalytic method. The classical pre- and, more especially, post-Freudian gap between diagnosis and treatment thus entirely disappears. The way a patient goes through his or her analysis—more accurately, the specific form that the transference takes—enables a diagnosis to be made, with the result that the final diagnosis can only be made during the treatment.

The choice of neurosis, the “Neurosenwahl,” therefore does not exist as a kind of separate diagnostic field: nosology, analytical theory, and practice together form a single indivisible whole. Freud’s developments can be divided into two major strands. The first concerns the discovery and theory of defense. The second deals with the transference as the relationship between the divided subject and the Other. One can formulate this differently: the first concerns the primacy of the pleasure principle and the signifier, the second puts forward the dimension of the Real, where the Lacanian idea of jouissance is found. We will see that there is a special relationship between these two developments, making it possible, for example, to locate psychosis more precisely. This will subsequently form the touchstone for the decay of the psychoanalytic paradigm.

Defense

First of all defense, the pleasure principle and resistance. The subtitle of Freud’s well-known paper of 1894, “The Neuro-Psychoses of Defence,” already indicates the reach this concept is supposed to have: “An attempt at a psychological theory of acquired hysteria, of many phobias and obsessions and of certain hallucinatory psychoses” (1978 [1894a]. Freud believed he had found the key to practically the entire field of psychopathology: the ego finds itself in a conflictual situation and manages it through a form of defense. The development of this thesis will form the heart of Freud’s theory and practice, at least for as long as the pleasure principle serves as a fundamental axiom. This theory is relatively simple: every subject strives for pleasure, which means as low and as constant a level of tension (in today’s terms: arousal) as possible. A conflictual situation creates an unpleasurable rise in tension, which is precisely what the defense, whether pathological or not, aims to avoid (because there is also such a thing as a normal defense for Freud). It is precisely the changing of this fundamental axiom that will generate the second major strand, through which psychosis, perversion, and neurosis can be radically distinguished, which is not yet the case with the first. See Freud’s main title: “Neuro-Psychoses of Defence,” and the enumeration in the juxtaposed subtitle.

Freud will develop this first strand from three different angles that each provide an answer to a question about the choice of neurosis. The questions can be put as follows: Defend against what? When? How? In the first place, the question of what is being defended against will produce a medically inspired differential diagnostics. This is the theory of trauma. Freud distinguishes between an external, etiological agent, which he calls the foreign bodies (Fremdkörper), who attack the subject from the outside, as it were. Once his trauma theory has been completed with the theory of fantasy, however, this will change: the subject plays its own part in this etiology, hence the term “choice of neurosis.”

This first distinction soon proves insufficient. Consequently, Freud poses another question, namely, When did the defense become necessary? In his famous correspondence with Fliess, he describes a number of life stages, each determinative for a specific pathology.³² A couple of years later, Karl Abraham would take this up again with his theory of libidinal development. We see a sort of psychoanalytic genesis here, whose implicit presupposition is that the earlier a pathology establishes itself, the more severe it will be. The limited value of this idea can be shown through a specific application of it: from such a perspective, the earlier determined hysteria should be a more severe pathology than the later determined paranoia (Lacan 1977 [1949], p. 5).

This approach is also insufficient for grasping the diversity of the clinic, and Freud continues to search. The next question he poses concerns the “how” of the defense. In answer to this, he elaborates the following idea. Every form of psychopathology has a mechanism of defense of its own. Thus hysteria can be characterized by repression, obsessional neurosis by isolation and reaction-formation, psychosis by projection.

It is important to underscore how this threefold conceptualization in Freud’s first theory only becomes clear in the post-Freudian retake of it. In Freud himself, these three approaches are parts of a larger whole. After Freud, each approach will be individually seized upon as a unique explanatory model. In my discussion of the decay, this will be well illustrated for psychosis.

The Real and the Transference

That’s it for the first major strand we find in Freud. We can understand it in terms of the upper level of a discourse: the agent tries to grasp the other but comes up against an impossibility each time.

The second major strand in his theory will undermine this first one in its very fundamentals, and can be understood as the lower level of a discourse, wherein the product can never come into relation with the truth that drives it. This second line of development concerns the Real and the transference, that is, the discovery of the importance of the Other in subject-formation. It is precisely here that Lacan will transform his “return to Freud” into a continuation of Freud, with his concept of jouissance and the double disjunction that inheres in discourse.

Let us look at this in more detail. Until 1920, Freud thinks almost exclusively in terms of the pleasure principle, that is, a human being always aims at abreacting the tension caused by a desire until it reaches zero. Psychopathology boils down every time to a failure of this pleasure principle—whose result is unpleasure, that is, tension—whether because of an external trauma, or because at a certain point in the development something went wrong, or because of the wrong defense. Both the defense and the treatment run according to the laws of the signifier, that is, according to this pleasure principle, as one can read it in its entirety in “Beyond the Pleasure Principle” (1978 [1920g]). Desire is expressed in words, in “representations.” Defense works on these representations by shifting them, repressing them, reversing them into their opposites, occasionally even rejecting them, with the result that the original words and their accompanying desire are no longer available to consciousness. Therapy tries to counter this by neutralizing the defense and making the original representation available to consciousness once more. In this way, a conscious abreaction can take place following the laws of the normal pleasure principle. Treatment can thus be pragmatically understood as a means for realizing full speech, whose consequence is that normal satisfaction becomes possible. The entire enterprise is grounded by the strong conviction that “everything” can be said, that “the” perfect sexual relationship does exist and that “the” father therefore forms the guaranteeing keystone.

Incidentally, this way of thinking closely corresponds with certain behavioral and later educational-psychological principles: the anxiety-provoking stimulus becomes linked (as Freud puts it, verknüpft) or associated with another stimulus that itself will provoke anxiety later on; therapy needs to undo this bad linking or association and bring the original coupling to light, and must subsequently extinguish it. The whole thing is governed by the conviction that the human being wants to avoid pain. Right from the outset, there are enormous differences as well. For example, Freud will be much more interested in the how, the what, and the why of the defense mechanisms causing these associations. The chief difference concerns something of a more conceptual order; early behaviorism presupposes a correspondence between objects and signifiers (hence the eternally returning demand in early behavioral therapy for the complaint to be concretized), while Freud’s later evolution is based entirely on the lack of correspondence between them, as described already in his “Project” (1978 [1950a (1895)]). The starting point is also different. Freud will always be attentive to the internal drive, that is to the actual source of the anxiety that only becomes associatively hooked onto an external hanger in a second moment.

In this first period, Freud believes his treatment can offer a definitive solution through verbalization. Meanwhile, the problems with which his patients are wrestling can be brought into clearer focus: they are all sexual problems, in the widest sense of the word. His patients are wrestling with questions about their psychosexual identity and the accompanying sexual relationships. These questions, moreover, are always combined with (the narrative of) the parents and hence with authority. Freud will recap this in his theory of the Oedipus complex. Therapy must put patients into a position of being able to verbalize the defective mode by which they feel pleasure, and replace it with the correct one.

Along the way, he gets confronted with the impossibility of bringing the treatment to an end. In the course of this evolution, his first theory—that of the pleasure principle—collapses with the discovery that there is something beyond the pleasure principle, something that always causes the pleasure principle to fail; the discovery, in other words, that full speech, the ability to say everything, is impossible. Here Freud rediscovers the dimension of the Real and this time he will take it wholly into account.³³ Beyond representation, that is, beyond the signifier, lies something that cannot be libidinally bound and therefore cannot be abreacted, something for which even the repetition compulsion fails, so that the pleasure principle can never achieve a total discharge of tension.³⁴ He finds the basis for this in the first narcissistic injury in the relationship between child and Other, and will ground a new theory of the transference precisely at this point: the idea of a transference neurosis (Freud 1978 [1920g], pp. 18–23).

We can best chart this by using the disjunctions of Lacanian discourse theory. In neurosis, the disjunction of impossibility is central: the pleasure principle is ultimately doomed to fail, and every life’s story is a depiction of the various attempts to cope with this failure. This first disjunction (impossibility) masks the underlying grounding and guaranteeing disjunction of the impotence, that is, the incapacity of the subject to get hold of the Real through the product of discourse. In clinical terms, there is no final signifier, no final story that will grasp psychosexual identity, and, hence, also no symbolically preset relationship between the two genders. No single authority—no oedipal father—is able ultimately to define this signifier or this relationship. Instead, the four discourses sketch four different routes through which the subject can elaborate four different forms of social bonds around this impotence to obtain total satisfaction. This is as much as saying that there are four ways of circling around the Real at those points where the Symbolic fails: the function of the father, sexual difference, and the sexual relationship. Neurosis, or even more broadly, culture, is always an attempt at an answer. In this, one consults a guaranteeing, self-establishing authority who installed a normative and conventional attitude toward pleasure and desire, and who makes it possible to adopt an attitude both toward one’s own body and toward the body of the other.

At this point, the psychotic fault line comes into view. The psychotic stands outside discourse, outside the auto-constituted oedipal father and, hence, outside the securing effects of the discourse framework. The impotence is missing, meaning that the impossibility is no longer guaranteed. The Real remains unprocessed, with the result that the transference, as an imaginary processing, is missing and appears in another form that is experienced as “monolithic.” The narcissistic injury Freud talks about as the foundation of neurosis in “Beyond the Pleasure Principle” is of a totally different order here; it may even be absent. Hence the expression, “narcissistic neurosis.”

Ethics and the Guaranteeing Figure

Regarded thus, Freud’s theory is characterized by two main strands: on the one side, the signifier, and on the other, the Real. The dimension of the signifier implies both the Symbolic and the Imaginary, two orders that circle the Real and characterize a particular neurosis. Psychoanalysis as a treatment is based on a neurotic disposition, which is to say that it is based on the disposition of the signifier. It became clear to Freud, even at this stage, that this was not enough, and that such a treatment, at least, contains a structural impossibility. This later becomes the problem of the so-called interminable analysis, for which one must look for a method of treatment that can offer something beyond words.

One can thus read Freud as a scientistic, positivist thinker, a Freud, Biologist of the Mind (Sulloway 1979). From such a perspective, one invariably ends up in the same deadlocks as positive science itself, as becomes more apparent from its paradigmatic applications where something of the order of the Real keeps escaping. Nevertheless another reading is possible, one that shows how, starting indeed from the angle of the hard sciences, Freud finally confronted its deadlocks. Looking back over these deadlocks shows, moreover, that the ethical dimension was implicitly there from the beginning. The reason for this is simple. Ethics, both in the larger social sense as in the narrower, subjectively determined meaning of the word, is an essential part of every clinical practice because each patient’s demand for (and in) the treatment carries an ethical problem.

Ethics as the core of every treatment. But if this is the case, how come Freud paid so little attention to it in the course of his psychoanalytic conceptualization? Beginning in a time of the hard sciences, a laboratory atmosphere even, Freud will be the first to chart the problems of the desiring subject. The scrupulously careful schemas of “The Psychopathology of Everyday Life,” the unraveling of the dream mechanisms, the dynamic relationship between repression and symptoms, these “Selected Topics” testify to a research mentality. The frequently mechanical-seeming descriptions in the hydraulic model didn’t leave much room for ethical questions, as has become even more apparent in post-Freudianism.

But this applies only for what we’ve called Freud’s point of departure. The reason that Freud remains one of the determining figures for contemporary thought, alongside Marx and Darwin, is precisely because he was able to overcome the problems of his starting point. This overcoming can be summed up in a nutshell. Firstly, Freud heard the ethical implications of his patients’ demands: neurosis is always the effect of a conflict between a desire and a prohibition in which the desire seems to belong to the subject and the prohibition appears to come from the outside (recall “Studies on Hysteria”). Following this, Freud tried throughout a certain period to answer the neurotic demand by taking on the role of the father himself, albeit in a corrected re-edition (the highlight of this moment was “Totem and Taboo”). Finally, he discovered and questioned the internal impossibility of this response and of taking this position, so that psychoanalysis comes to join the list of the impossible occupations (Freud 1978 [1937c] and 1978 [1939 (1937–1939)]).

The conflicts at the base of neurosis can have as many contents as there are subjects. In terms of a formal structure, however, there is a recurrent phenomenon: the divided subject always seeks an external figure who can provide a form of certainty, that is, a figure that can serve as a guarantee against one’s own self-division, firstly with respect to the drive and secondly with regard to the Other. Freud came to understand this fairly early on and discovered, moreover, that this sought-after figure is colored by infantile memories of the parents, primarily of the father. The therapeutic instrument thus becomes the transference through which the therapist comes to carry the weight of the original authority.

With such reasoning, no distinction can be made between the classical moral treatment and this first Freudian conceptualization. In both cases, the original, failed authority is replaced by a new, improved re-edition. The difference begins only from the moment Freud discovers the ever-recurring failure of the guaranteeing oedipal function, and the subject’s implication in both the construction and destruction of this figure. The laborious process of construction and working through thus becomes the core of the cure, and simultaneously founds the difference between therapies that operate on the basis of suggestion, and analysis whose task is to analyze the conditions of the possibility of suggestion.

This is what Freud described as transference: the weight assigned to the therapist comes from elsewhere. Furthermore, experience shows how this weight always has an ethical character, in that the patient expects yet fears judgment, wants advice, approval, and to be loved, and all this invariably in relation to what yields either pleasure or unpleasure. In brief, she or he searches for a master (S₁) who preaches knowledge (S₂) in an attempt to make the drive manageable. The therapist is put into position of the oedipal guarantor, or let’s simply say, the primal father who, according to little Hans, has an intimate relationship with God because he appears to know everything (Freud 1978 [1909b], pp. 26–27). I say, appears, because this is where the next set of troubles begins: sooner or later, the guaranteeing figure fails, and this failure is then also transferred onto the figure of the analyst in the course of the treatment. It becomes increasingly clear that it is this relationship that is central, both in pathogenesis and in the course of the treatment, and that all previous conceptualizations must be reconsidered in this light.

Lacan takes this up and reconceives it in terms of the subject’s formation, which takes place in relation to the Other. The symbolic system developed meanwhile displays an essential lack—there is no Other of the Other—whose consequence is that the discourse of the Master contains both an impossibility and an impotence. The confrontation with this lack in the “all-knowing” symbolic system and hence in the Other, provokes an anxiety about the unprocessed Real, resulting in a never-ending search for an imaginary master figure who should nonetheless be able to provide an answer.

The radical difference between this and the previously discussed paradigmatic ideas can now, with the Lacanian conceptualization of the last Freudian shift, be made out: it is senseless to identify the therapeutic figure with the master figure. The Freud who assumed he could teach Dora how to desire falls off his pedestal. The core of Freud’s treatment model is that the master figure is a creation, a neurotic construction built in an attempt to rid oneself of division. To the extent that the therapist permits the patient to turn him into this master figure through the transference, and insofar as the therapeutic process stops at this point, he merely repeats the original process. Psychoanalysis, rather, is ultimately the analysis of this construction process, of its necessity and subjective modalities. Its aim can be defined in these paradoxical terms: the aim of analysis is to analyze that which originally made analysis possible, namely the transference.³⁵

Deterioration: Dr. Ernesto Morales and the Last Freudian³⁶

At this point the reasoning pertinent to the anato-pathological paradigm can be repeated. It is not because psychoanalytic concepts are used that we have escaped paradigmatic deterioration. Each discourse can be filled in with any kind of signifier. It is its formal structure that determines how it is manifested. Whenever psychoanalytic jargon is used within a university discourse, the implications are the same as in the two other paradigms.

To repeat the argument behind this would only be to repeat myself—I thus leave its application to the cognitive abilities of the reader. What must be underscored is that the psychoanalytic model is unfortunately very apt for what I want to call the oedipalization of clinical theory and practice. Both Lacan and Freud became preeminent master figures, so that it is enough simply to cite them to turn an argument into a truth, a sin my own work occasionally falls into as well although I try to avoid this as much as I can.

Psychosis and the University Discourse

Applying the psychoanalytic model according to the terms of the university discourse like this will inevitably mean choosing certain contents from this model. It is not by chance that in the subsequent paradigmatic decay, the focus is on the first Freud, that of the scientist, thereby avoiding the deadlocks of the second. This is what post-Freudianism illustrates: certain ideas are picked out from the first theory and become subsequently generalized. The first angle, that of the trauma and its defense, for instance, appears in those approaches to psychosis that in one way or another foreground a particular parental intervention as the causal factor for psychosis. This is, amongst others, typical of a certain Anglo-American approach to Freud and psychosis (Freud 1978 [1911c]). His standard model, Schreber, had a father who is described as a Prussian fanatic of indoor gymnastics, with a taste for a variety of sadistic instruments. He then forms the cause, the external traumatic cause, of his son’s psychotic pathology, an idea upon which two successful plays were actually based. It is clear that this approach is not only insufficient, but even wrong (Schreber 2000).

The same idea—psychosis based on defense against an external etiological agent—can be found in another, if less immediately recognizable manner from an area that analysts usually reject as foreign to their discipline, namely, the field of organically caused psychoses. The logic remains the same: an organically caused psychosis implies a biological agent that the subject has fallen victim to—analysis is superfluous here and analysts leave the field free for the medical doctors. But this is also wrong, because even the so-called somatic psychosis cannot unilaterally be explained merely by appealing to an external etiological agent. For an example, we can look to the previously discussed icon of such an approach, that is, paralytic dementia. Its relative rarity today means one forgets that only a small percentage of syphilitic patients developed paralytic dementia (Ey et al. 1974, pp. 835–836). The somatic etiology seems inadequate for explaining this psychosis. This goes for every psychopathology that invariably must be considered a result of a complex interaction between dispositional and environmental factors, in addition to which, moreover, we must also take the subject’s choice into account.

The second approach—when to defend—will be also be developed in the post-Freudian period as an explanation for psychosis. Here we see the theory of object relations and the libidinal developmental stages. With this, Abraham’s original vision has been forgotten and suddenly everyone is convinced that psychosis must be the earliest established pathology, going even as far back as the prenatal stage. Therapy becomes a question of a monitored regression to this stage when things went wrong, followed by a monitored progression to genital normality. This approach is also inadequate, albeit only because it cannot explain the emergence of psychosis at a later date. This way of thinking, moreover, inevitably leads to the idea, along the lines of Melanie Klein, that everyone possesses a “psychotic nucleus” which, under the right conditions, will come to light; thus there is no structural difference between the neurotic and the psychotic positions.³⁷

The third perspective—how to defend—was developed primarily by Anna Freud, with her famous The Ego and the Mechanisms of Defence (1979). Ego psychology will be founded on it, culminating in the analysis of defense. For psychosis, projection was initially put forward as the characteristic mechanism, but the vagueness of this concept, combined with its generalized nature, meant that this was abandoned fairly quickly. In its place, we commonly get nothing more than the pronouncement, “psychotic defenses,” which are then usually specified by saying they concern processes that were established “very early on” and have every chance of opening pathways to “regression.” In other words, despite the lack of an individual mechanism, the idea that a specific mechanism of defense lies and must lie at the root of psychosis is maintained.

The same idea can be found in certain Lacanian approaches to psychosis. It has, in the meantime, become fairly well known that Lacan offered the mechanism of foreclosure as a working hypothesis and guiding concept for research. Today it seems as if this hypothesis has already deteriorated into an established and hence confirmable knowledge. Psychosis is the expression of a special kind of neurosis, meaning within the reign of the signifier. In addition, the clinical aspects become immensely narrowed down: it is a matter of the foreclosure and the psychosis, exemplified by the binding model of Schreber. The incontrovertible heterogeneity of the clinic is not reflected in the theory, so that the plea one hears everywhere for a structural approach ultimately comes down to the already-mentioned historically datable idea of the unitary psychosis. Lacan himself was much more nuanced: “It can be argued—albeit not without some hesitation—that clinical types arise from structures. Only in the case of the hysterical discourse is this certain and transferable” (Lacan 2001, p. 557).

The Place of the Subject

The diversity of these types of theories carries with it the risk that a certain vital question gets overlooked: What is the place and role of the subject itself in the development of its psychopathology? As we saw earlier, the University discourse inevitably results in an objectifying approach, resulting in both the exoneration and infantilization of the patient. Freud offered a more nuanced perspective from the start: both dispositional factors and the environment are influential, but the patient him- or herself also has some element of choice in the pathogenesis. Hence the idea that the patient is supposed to take an active role in the treatment. What happens to this view after Freud?

To my knowledge, Janet, a contemporary of Freud’s, was the first to take aim at this idea when he described psychoanalysis as “a criminal inquiry which must find a culprit, a past event responsible for the manifested troubles.”³⁸ Here we find two possibilities for the deterioration. Either the patient is once again exonerated, and something or someone else lies at the root of the pathology; or the patient him or herself is blamed as the sole cause of his or her pathology. In both cases the complexity of Freud’s theory is lost.³⁹ The exoneration is well-known, it is the famous unhappy childhood that is taken into account as mitigating circumstances. Blaming the patient (see above with Szasz) is rarer, but it is there whenever depression is said to come down to a moral mistake and cowardice on the patient’s part. We even find this in Freud, specifically in the Studies on Hysteria, where he talks about a relation between moral courage and cowardice in the emergence of hysteria, an idea that Lacan takes up again with regard to depression in Television (1990 [1974]).⁴⁰

It thus becomes clear how every paradigmatic application of the University discourse—regardless of its theoretical and actual content—has a central impact on the position of the patient. This impact has far-reaching repercussions, both for the diagnostics as for the treatment, both of which—no matter how scientific and objective they may appear—always imply the adoption of an ethical position.

1. In the light of the heroic historical narratives, it is no coincidence that the English Standard Edition of Freud’s works excels in its de-subjectivation. I refer to the way Freud’s originally informal language has been turned into a technical and impersonal jargon (Besetzung becomes cathexis, Anlehnung is turned into anaclitic, and so on; “The biggest shortcoming of the translations is that, through their use of abstractions, they make it easy for the reader to distance himself from what Freud sought to teach about the inner life of man and of the reader himself. Psychoanalysis becomes in English translation something that refers and applies to others as a system of intellectual constructs” (Bettelheim 1983, p. 6 and passim).

2. Procrustes was one of Theseus’ challengers whose bed could fit anyone, albeit rather uncomfortably. If it was too short, Procrustes would chop off the offending lengths of limb; too long, and the victim’s limbs would be stretched to fit the bed. See Plutarch’s Life of Theseus.

3. Incidentally, I am convinced that the same form of reasoning can be applied to patients in residential psychiatric care. While Morel’s concept of degeneration may have become politically incorrect, it has not disappeared; it has just gone undercover. A study by Giel, Wiersma, and De Jong (1987) concerning the relationship between social class and psychic disorders demonstrates that in the diagnosis of schizophrenia, too, it is more a question of social selection than of social causation.

4. The etiological question that has to be asked here reverses the classical one. Walgrave (1979) appropriately asks now: “Why did x % of youth get stuck in delinquency while the rest did not?” The same reversal can be applied to the study of perversion. Moll was the first to discard both the degeneration and traumatic incidents hypotheses (Sulloway 1979, pp. 303–305). Every childhood suffers these last in all of their far-reaching banality, which is the reason one must ask why a particular individual remains a pervert while another normalizes (see Chapter 14 below).

5. An unforgettable illustration of this for me is that of the onion skin and the blackbird’s testicles. When I was a student, everyone who went through practical training in biology sat through a session in the first hour in which it was patiently explained, with the aid of enormous panels (Power Point did not exist), what slivers of onion skin and blackbird testicles would look like under the microscope. Then came the magic moment when 120 young, would-be scientists simultaneously bowed their heads over the enchanted instrument and, with half-closed eyes, discovered a hitherto unsuspected world. It was our luck to have a malicious training assistant who convinced everyone that we actually saw “it” (mitochondrion, nucleus, etc.)…despite the light not being switched on under the slide. I have never needed another warning against suggestion.

6. Much of the ensuing historical account was derived from the following sources: Beauchesne (1986), Bercherie (1980), De Kroon (1999), Ellenberger (1970). The classic works of Michel Foucault also continue to provide a source of inspiration.

7. This evolutionary aspect, with its concentration on etiology and case histories, has meanwhile more or less been wiped out by the DSM approach. Hence, as in the game, it’s back to the beginning: “Do not pass Go. Do not collect $200.”

8. This discovery is itself a beautiful example of a paradigm’s effect: the anatopathologists were unable to make the cause of paralytic dementia perceptible because their methods, founded on their paradigm, had the exact opposite effect. Schaudinn, a zoologist, used different techniques emerging from his own paradigm (without the coloring of the slides) and obtained immediate results.

9. This is a long-standing appeal that has delivered little in the way of results. The reason for this has to do with our shortage of concepts for so-called holistic thought: our vocabulary continually forces us to think in terms of division, which literally “speaks for itself.”

10. The following are two classic studies. With regard to schizophrenia, it was shown that adopted children with one schizophrenic parent do indeed run a higher risk of psychiatric disorders, on condition that they have been adopted into a dysfunctional family (Tienari et al. 1994). Bohman (1996) showed the same thing for children of convicts, who—after adoption—run a higher risk of offending, with the same condition that the adoptive family was dysfunctional. The most persuasive research comes from Suomi (1997, 2000) concerning an impressive experimental-empirical research with…rhesus monkeys. Genetically highly reactive individuals display highly reactive behavior as adults (including alcoholism), if they were peer-reared and maternally deprived, whereas if reared by the mother, the genetic effect was canceled. His conclusion is very clear: genetic vulnerability is reversible.

11. My italics. The first is from Kraepelin (1917), One Hundred Years of Psychiatry, pp. 151–152, quoted in Szasz (1983, p. 45). The second is from Karl Jaspers, Allgemeine Psychopathologie, p. 5 (quoted in Vandereycken 1988, p. 79). One encounters the same logic in a publication by Van Praag (2000). He reexamines an earlier publication of his, dating from 1974, in which he expressed the hope that biological research into depression would provide us with more precise referrals and more selective antidepressants. Twenty-five years later, he is obliged to conclude that this has not happened, but seeing as how his expectations have also not been contradicted, he holds to his hope. While there is life there is hope, that much is clear.

12. On this point, Lacan made a provocative statement that—unsurprisingly—created the usual uproar: modern science can be regarded as an expression of paranoia (Lacan 1992 [1959–1960], pp. 129–132). Such a statement has to be understood within its larger context to avoid its becoming simply a catchphrase. Lacan starts out from the idea that, through acceding to language, we lose the “Thing” for all time, even the very Thing we are-in-ourselves. This is how he reads what is found both in Kant and in neo-Kantianism, and that meanwhile has become common knowledge in contemporary epistemology: science can only approach reality by way of models or constructs, period. The re-finding of the object can only occur through the auspices of an unsublatable lack, hence every approach must ultimately fail, resulting in a continual metonymy. Lacan applies this idea to what he calls the three great sublimations, that is, art, religion, and science, which he links respectively with hysteria, obsessional neurosis, and paranoia. Art and hysteria are always organized around this lack; creativity is based on the recognition that the Other can never definitively fill in this void, and that the Other, moreover, is held responsible for this impossibility. Religion and obsessional neurosis try to avoid the lack by installing an Almighty Other in the center, who is supposed to supply the Answer; the lack and the accompanying guilt are then assumed by the subject itself. Today’s empirical science and paranoia start out from a disbelief in the definitive loss of the Thing and thereby ground themselves in a correlative omnipotence of thought, through which the complete mastery of reality can be imagined. From a Lacanian perspective, it is more effective to recognize the lack as such and to shape science from this recognition accordingly. In neo-Darwinian terms, the aim is not so much to find the “missing link” as it is to take the “missing” bit seriously. By this I mean the bar indicating both the division in every subject and the bit that remains perpetually unreachable because of this division.

13. My italics. Zimmerman (1800), Traité de l’expérience en médecine, quoted in Foucault (1997, p. 35).

14. In an informal study in a British outpatient center for children, parents were asked what they considered the cause of their child’s problems. “It surprised no one [of the researchers] that they all put brain chemistry at the top of the list. It was more surprising that “bad genes” came second, peers third, and early life experiences a poor fifth, just ahead of food additives.” (Fonagy et al. 2002, pp. 98–99). This clearly shows how the neurological-genetic paradigm has penetrated the contemporary popular discourse. The advantage of this for the subject is discussed above.

15. Translator’s Note: The Belgian national health care system is a single-payer, government-funded system comparable to those in Scandinavia.

16. Protagoras of Abdera, in P. Edwards, ed., 1972. The Encylopaedia of Philosophy, vol. 5, pp. 505–507; Kant, “Anthropologie in pragmatischer Hinsicht,” in E. Cassirer, ed., 1922. I. Kant’s Werke, Berlin: Bruno Cassirer, VIII. After a scientific rejection of all “natural” or “religious” laws of human behaviour, Monod makes a plea for scientific-rational objectivity as the basis for all human endeavors. He is smart enough to name this objectivity as an ethical, and therefore arbitrary stance (Monod 1970, p. 188 ff).

17. Over the last decade there has been a change in the demand for psychotherapy in that it has been extended toward what is clearly a “moral” direction. The reason is probably connected with the loss of the grand narratives on the one hand, and the omnipresent psychologizing of everything and everyone, on the other. As a result, patients infrequently come for consultation because of clearly defined symptoms. Rather, they come into the consultation room bearing their soul on a platter—“la condition humaine” (Malraux)—expecting the therapist to be the new provider of meaning. This reminds me of Freud’s final sentences in Studies on Hysteria (Freud and Breuer 1978 [1895d]), where he says that his treatment can transform his patients’ hysterical misery into common unhappiness, but that the normal human problems inherent to life he is unable to help with. I get the impression that a number of today’s consultations begin at the point where Freud drew the finish line.

18. Anyone who might find these abbreviations irritating should consult Orwell’s 1984, more specifically, his reflections in the appendix on the power of abbreviations in Newspeak.

19. This has meanwhile become common parlance. A colleague working in prisons told me that inmates themselves nowadays explain their criminal behavior by referring to their unhappy youth—James Joyce’s “He had a great future behind him” in reverse. The opposite can also be found as analysands discover in analysis that, in spite of their present symptoms, they have had a happy childhood.

20. See earlier, where normality was discussed as an ideal.

21. For utter clarity: Every form of psychotherapy implies an educative process. My critique concerns how this process is applied. A good way to express this is in terms of Lacanian discourse theory. In the University discourse and the discourse of the Master, the pupil has no impact whatsoever. In the yet-to-be discussed Analytic discourse, the stress is on the subject’s own input. This may seem trivial at first sight, but it is not. One of the factors that has meanwhile been discovered regarding the efficacy of any treatment concerns precisely the amount of input the patient him- or herself has in the therapeutic process. It is precisely this input that is rendered impossible by the discourses of the university and the master.

22. “I forbade the ‘patients’ to use this language and told them to use the term ‘students’ instead. The word ‘patient’ became taboo. I renamed Upper Cottage a ‘School for Living’ and Julia had the job of making a large sign stating ‘THIS IS A SCHOOL FOR LIVING’ to hang on the wall. The sign ‘Nursing Office’ became the ‘Educational Office’, and when the staff asked to be included I renamed them ‘assistant educators’ ” (Foudraine 1973, p. 337). My critique notwithstanding, this book continues to be a must-read.

23. The repetition of history is a tragicomedy. The first psychoanalytic approach argued that psychopathology originated in unconscious determinations. The treatment was directed toward bringing these into consciousness, which in Freud’s initial phase came down to imposing interpretations that would lead the patient to “insight” and, consequently, to choose the correct path. Within a very short time the treatment became a conflict—many patients didn’t want the master’s “correct” knowledge. The result became known as resistance. The same thing is about to happen now with cognitive behavior therapy. They too have discovered that psychopathology is the result of the patient’s faulty cognitions that must be corrected. They will soon discover their own version of resistance. In Lacan’s follow-up of Freud’s later theory, he argues that one of the central problems of psychopathology and subject-division is this not wanting to know, and this requires a different approach than pure insight-therapy.

24. Elsewhere I have called this “automaton”-science and have outlined the consequences of such an epistemological choice. One of them is that automaton-science must always appeal to an ultimate, final cause, a point of certainty outside itself that guarantees the truth of the system, the deus sive natura. With Freud, we can identify this as the oedipal father. From a Lacanian perspective this is “the Other of the Other,” or the all-guaranteeing master-figure, while in terms of discourse theory, it is the S₁ (Verhaeghe 2002b).

25. This is becoming much less the case in the natural sciences. Nevertheless, hard scientists are recently coming to the conclusion that their methods are inevitably colored by subjectivity, with the result that such subjectivity is increasingly becoming their object of study (see Norretransders 2001).

26. During the fiftieth anniversary of the Dutch Society for Psychotherapy, Bergin (1980; for a discussion, see de Haan 1980) openly said that religion and morality co-determine the degree of the cure’s therapeutic efficacy, and that the role of the therapist boils down to giving a moral judgment about the client’s lifestyle. His comments received a violent reaction. Seven years later, a conference was organized in Holland around the theme of mental health and philosophies of life. Dijkhuis (Dijkhuis and Mooren 1988) stated unequivocally that therapists pay too much attention to the constituent problems and don’t focus enough on the problems in the underlying philosophy of life. This is paradoxical, because “The core of the psychological view of human behavior is ultimately located in the normative determination of this behavior, determined by what people consider good or bad in their social behavior with others. Emotional, cognitive and psychosomatic reactions take place in the light of qualitative and normative dimensions of human life: that is, the way one gives form to one’s own norms and values in the social relations with others and oneself” (p. 15). He drew out the obvious therapeutic implications: “Psychotherapy is more than creating a condition in which specific symptoms can be changed; it is also the creation of a condition in which the clients’ normative attitudes can change” (p. 29). In the same discussion, Mooren pointed out that many therapists are convinced of “the impossibility of combining directions and roles when questions about the philosophy of life enter the discussion” (p. 43). The danger lies in the therapeutic modeling, the hidden preaching, driven by the unspoken feeling of superiority of someone possessing a certain religion or ideology (e.g., the believers vis-à-vis the poor heathens, but also the enlightened freethinkers against the naive believers).

Freud had already foreseen the danger long before the term “modeling” became fashionable: “otherwise the outcome of one’s [therapeutic] efforts is by no means certain. It depends principally on the intensity of the sense of guilt; […] Perhaps it may depend, too, on whether the personality of the analyst allows of the patient’s putting him in the place of his ego ideal, and this involves a temptation for the analyst to play the part of prophet, savior, and redeemer to the patient. Since the rules of analysis are diametrically opposed to the physician’s making use of his personality in any such manner, it must be honestly confessed that here we have another limitation to the effectiveness of analysis; after all, analysis does not set out to make pathological reactions impossible, but to give the patient’s ego freedom to decide one way or the other” (1978 [1923b], SE 19, p. 50).

27. The allusion is to Freud’s intervention with a 5-year-old phobic child; see Freud 1978 [1909b], SE 10.

28. This is the prophetic answer that Lacan gave to the May ’68 students who interrupted his seminar (Lacan 1977 [1969]).

29. Freud, “Gesamtregister,” Gesammelte Werke, vol. XVIII, pp. 295–399.

30. This has been extensively discussed elsewhere. See Verhaeghe (2000a, pp. 25–55, 141–195).

31. Hence the confusion the moment the institutions got rid of the uniforms: Who was the patient? Hence, too, the way TV documentaries about “psychiatric patients” almost inevitably put mentally handicapped or geriatric patients on display; at least with these groups “it” is visually clear.

32. See the letters of May 30, 1896, and December 6, 1896, in Masson (1995, pp. 187–190, 207–215).

33. I say “rediscovery” because he had already been confronted with it at the time of his first theory of trauma. Nevertheless there is an important difference. In this first theory, the causal trauma is largely external (the traumatizing other). In his second theory, such an external trauma adheres to a structurally determined inner trauma, more specifically the subject’s own drive that can never be finally abreacted. Lacan will later reiterate this with his laconic term “object a” and, more broadly, as the register of the Real (see Chapter 12).

34. Repetition compulsion is a mechanism aimed at decanting certain elements of the Real into words but also one that, because it is unable to do so, continues to function compulsively (see Chapter 12 on the traumatic neurosis, where the trauma is continually repeated in nightmares, without the dream ever succeeding in imaging “it”). The aim of this verbalization is to enable the traumatic Real to be psychically elaborated and dischargeable in the manner of the pleasure principle (see Freud 1978 [1920g]).

35. An important question is whether analysis then automatically leads to individual choices, to a personal ethic in the analysand. The medieval Catholic rereading of Socrates reappears here: know thyself and you will become virtuous. In this context, it is worth mentioning the Lacanian aim of analysis: to install a new social bond through the analytic discourse, “one that would not be a semblance.” This implies that a social bond should be possible beyond the collage-effect of the assembling master figure. This seems like a beautiful but almost impossible dream, because it goes precisely against the essential division of the subject. Either this division is not essential, and hence can be modified, whereby another discourse becomes possible, or it is indeed essential and then this other discourse remains only an ideal to try to emulate.

I have no answer to this. Instead, I shall present a specific clinical experience that was also familiar to Freud: it is surely no coincidence that neurotics always belong to the category of people who try to be too moral, who—as Freud put it—want to be better than they ever can be. The end of the treatment becomes therefore not so much the creation of a new morality, but more the creative assumption, the taking upon oneself of a previously existing, arbitrary ethic, that until then had only been followed or fought against. And this, too, is a choice.

36. See the novel The Treatment, by Daniel Menaker, Knopf, 1998.

37. Along these lines, we get, not all that rarely unfortunately, the following conclusion to a diagnostic inquiry: “The patient shows a neurotic upper structure with an underlying psychotic layer.” All that is missing now is perversion.

38. Janet (1921), Les méditations psychologiques, p. 224, quoted in Roudinesco (1986, p. 252).

39. In Part II, on the formation of identity, I will show how this complexity has to do with another conception of the relationship between I and Other or the inside and outside.

40. “Thus the mechanism which produces hysteria represents on the one hand an act of moral cowardice […]; more frequently, of course, we shall conclude that a greater amount of moral courage would have been of advantage to the person concerned” (Freud and Breuer, 1978 [1895d], SE 2, p. 123). “For example, we qualify sadness as depression, […] But it isn’t a state of the soul, it is simply a moral failing, as Dante, and even Spinoza, said: a sin, which means a moral weakness, which is, ultimately, located only in relation to thought” (Lacan 1990 [1974], p. 22).