"Mr.M. is anorexic and abulic following a surgery on a sigmoiditis. There has been a lot of postoperative complications but the biological problems are now under controls and doctors don't understand why her general state doesn't improve. Mister M. welcomes me without reluctance, immobile in his bed. His whole body shows a great deal of preserving its energy. He barely turns his head towards me, answers precisely but quickly all my questions that don't spark a spontaneous speech. After ten minutes, he asks me very politely to leave him because he is "overly tired".
Making contact with the patient represents a difficulty because we have the feeling that this excess of physical pain irremediably stops any possibility of psychological development. The patient seems overwhelmed by his physical discomfort. This difficulty of spontaneous verbal expression is disconcerting and the silence and the impression of a lack of truthfulness creates an unease. It is like there isn't any information to exchange except for the ones shown by his body, as if words had become vain.
Mister M. has every right to be tired and it is impossible to pinpoint a psychological or physical origin to his fatigue. Being depressed fatigues and being tired irremediably depresses. Mister M.'s body fully expresses this fatigue that grows stronger when I stimulate him; it prevents or justifies his inability to make contact with me. I overwhelmingly feel this fatigue within me and become suddenly exhausted and powerless. As it has become or only way of communicating, I point to him how everything in him show a profound weariness. His voice and body suddenly become more lively and he goes on with words getting away from his usual politeness to directly talk to me: "What do you want me to say? There's nothing left to say." Telling me this, Mister M. gives me a verbal information that deepens what his body expressed, which allowed me to offer him: "It's that difficult to say?". He will confirm: "Nobody can understand."
It is necessary to offer to those patient a "welcoming ear". The psychiatrist finds themselves involved as an empathetic receiver of communications made of physical and emotional impressions. The empathetic listening allows to be physically taken into this "representative halo" (C.PARA). In a situation where the access to real and psychological life seems to be prohibited, the psychiatrist's body becomes a receptacle where the patient feels themselves existing. The psychiatrist gives to the patient a place of spokesperson that they don't manage to give themselves anymore. The patient's gaze in those problems has nothing inquisitive or aggressive but checks that the lasting of their effective presence; a gaze that is necessary to maintain as to not create panic in the patient if ignored.
From the moment that Mister M. told me that nobody could understand him he started talking about what his illness represented for him who always took care of himself and now find himself dependent and incapable. Then he'll know how to use the interest I show him to heal his self-esteem and work little by little on the meaning of this narcissistic wound inflicted by the illness. Because of his true state of fatigue, this will happen slowly during multiple sessions and will strongly be encouraged by the improvement of his general state.
This involvement of the psychiatrist's body isn't easily recognized as such. It is difficult to avoid it in a context where the body is always at the forefront."
Despite a psychosomatic context a bit far from our aim, this example shows well that the work on the imaginary dimension of transfer, when it is clearly identified as in this observation, allows a psychological reality to be a part of the language again through the found pleasure of the relationship, this imaginary form of the Other that forms the constant basis of the symbolic relationship.
It is vital to understand here that those specular identification mechanisms, of introjection to use another term, are also foundations of the consciousness, premises of all symbolic writing. The subject's identity is decided here, between the objects of consciousness and what founds it.
If Lacan is that careful about constantly separating desire from all form of pinning, which is in fact key to his interpretation, it is that he pinpoints as fundamental the play, the space, the gap between the representations and the subject. This gap allows the implementation of the desire. The identification, the consciousness itself act as traps as they are only established by the representations which are by definition outside of the subject.
Nearly all philosophical traditions show the work of something similar. Those gaps between consciousness and truth are always present in the philosophical tradition since Socrates. If consciousness is always more or less aware of the truth that makes it, it is always limited by its unconscious dimension. This truth of being which surrounds, limits this being's possibilities of existing, using Heideggerian terms, explains how there is for us an unthinkable.
Here we suppose that this plane is represented by the great Other, the imaginary form of the self that allows us to exist in this world of otherness. An ethnologist would here find a lot of common traits with the totems nearly constantly found in talking societies. They could be representation of Lacan's great Other...
This great Other's authority, this modern totem, corresponds to what Lacan called "thelanguage" in a single word, even though I suppose that an unconscious but nevertheless incarnated human representation is always present in the foundations of this universe of representations that is "thelanguage". Essentially, we never fully cross this dimension of the great Other.
In the practice it is better to know that we are confronted to this unmovable foundation than try to cross it, which would lead to inventing the end of an analysis outside of human reality. The failure of the passing process, in the schools that practice it, is probably located there which prevents the analytical groups that use it to base themselves upon a solid reality and explains their weakness.
Going back to our topic, this imaginary authority of the self has a specific use in the psychosomatic process: in this setup, you yourself become your worst enemy. Unlike in autism, the self is accepted. The pleasure it brings with itself is enough to be accepted by the subject but it also brings a negative dimension to oneself. The unavoidable breech comes with a painful contradiction. The complex image of the Other becomes two, bringing both pleasure and displeasure at the same time.
For which reason isn't this toxic part for oneself detectable? Why isn't it differentiated by the subject? Because such a consciousness would represent a dive into autism, the disappearance of the Other which the subject doesn't desire. The Other is still useful enough for the subject to depend on it. Therefore we can define psychosomatic as a defense mechanism against autism by putting in place a tricked Other, Trojan horse implying an undivided but toxic consciousness of the self. Everything happens here in a threshold effect.
In fact, no organism can fully integrates itself in the narcissistic structural chain that leads to symbolic existence. As we saw previously, there are always untranslated leftovers. Repeating ourselves, those leftovers don't only affect feelings, intuitions, they can also be they can also be psychological functions as essential to the subject's function as organs. This as been pinpointed in psychoanalysis as the ideal of the self, the self itself, body image, etc. The list of those essential psychological functions for the subject is probably a long one... It can also happen that one of those functions doesn't find a place in the imaginary authority of the self found in the Other. It will even be strictly forbidden without the interdiction being spoken out or represented. This lack of symbolic representation of important elements of the self, thus gotten rid of, drops those aspects of the structure of the self which will literally stay suffering. As we saw, it is clear that an organ or function that doesn't find a purpose suffers.
On the Other's side, prematurely represented y the parental configuration, a strong resistance is needed to not leave any space for those elements essential to the subject. The relationship's pleasure, main driving force of the Other's integration, occasionally makes room for rejection. His will lead the subject to limit its thoughts to preserve the relationship. The price to pay will be the sacrifice of some psychological functions linked to organic pleasures. It frequently happens during analysis that we need to reconstruct a form of traumatic withdrawal conveyed by more than a need of treatment around the inability to manage personal pleasures.
Here is another clinical example when a "mother" can't make room for the living body of her child:
"There are cases where we observe that the psychosomatic comes from the fantasy of someone else, in particular of the mother.
Things can be arranged in such a way that the mother needs to accept to seek treatment for her child's psychosomatic illness to get better.
On this topic I will talk about the case of a 14 year old girl. She suffers from asthma, eczema, is anorexic and amenorrheic and measures 1,33m. Her asthma sometimes puts her in danger.
A few years prior, I had begun a psychotherapy with her, useless for asthma and eczema. A therapy had also been suggested for the mother but she never got invested in the treatment and she would have liked the same therapist as her daughter. After that, everything was tried: conjoined mother-daughter treatment, separation, without any result.
The mother stayed on her position of omnipotence towards her daughter. She said herself guardian of a knowledge about her and her illness, about what she didn't want to say. She said "I know everything... I have every element with me." Her daughter was "her own reproduction", they were like "Siamese sisters".
In her psychotherapy, her daughter asks herself why her mother only loves her when she's ill and gradually comes to ask herself who she is: "the other, the dead one?" She is referring to one of her mother's sisters who died at 18 months from an illness transmitted by their grand-mother. In fact, the young girl's first name goes back directly to this child's. Adding that she nearly never talked about her father whom also affirmed that she wasn't his.
On multiple occasions, the girl insists to me that her mother now needs to be the one talking.
It is only during an asthma attack more severe than the previous ones and after alarming opinions from the doctors that the mother accepts to start an analysis with me while I stop seeing her daughter.
The improvement of the daughter's state even since the beginning of the mother's treatment is remarkable: maybe explained by the fact that the mother abandoned her position of omniscience and omnipotence when she started opening up and talking.
The mother was stuck in a fantasy that seemed to have a direct effect on the child's body; when her daughter was risking her life during asthma attacks she enjoyed reliving her own sister's death and was coming out of it victorious, stronger than the mother, stronger than death. She said that this scenario was essential for her, it was where she "revitalized herself, recharged her batteries..."
The young girl stopped having asthma and eczema. When she had her first periods, her mother who didn't have eczema anymore since the child's birth, got some on the breast. She grew up, which made her mother proudly say when she put a photo of her daughter on the divan: "She grew up by a centimeter per month". I think what needs to be heard is: "she grew up by a centimeter each month, that shows she never really gave up..."
It seemed to me that this example illustrates well our topic, especially on the therapeutic action revealed by a greater freedom of pleasure, less ambivalent, is open in the relationship of transfer by the lifting of a pathogenic repression, here in the mother whom functions here too much as a residual great Other that secures the subject's very foundations (rebuilding).
I will finish by an important point for the rest of our work: the body's rupture is real and apparent in psychosomatic, way more than psychotic traits where we will see in another chapters that they are more linked to a broken up anxiety than to a split up reality. This split up reality is suffering in the psychosomatic disorder, which didn't get away from the traditional clinicians who talked about hypochondriac delirium, therefore noting that the body's unity is in opposition with the feeling of reality itself and more precisely with the feeling of symbolic reality... The psychosomatic body is divided between its organic, functional existence and its significant registration; the distance between the two is sometimes too important, too brutal. A minimum degree of congruence is necessary between the psychological and physical function's authenticity and subjective logic created.
The body's unity rebuilding therefore has to do with the transfer and goes trough the pleasure of being together, pleasure in which the subject's history's forgotten elements are taken back, with their share of painful afflictions and ambivalence constituting a subject of whom the identity can be remodeled in the pleasure of the psycho therapeutic relationship, foundation of an opening to the symbolic world.
Jean-Michel Turin, who did a remarkable work on the psychosomatic questions at the Inserm, reports a surprising study, of which I don't know it is had been confirmed by another team: in a group of 225 women diagnosed with mediastinum cancer, the survival ratio at 7 years for those who had had one or more confidants was 16% meanwhile the one of those without confident was 7%...
The term of confidant itself implies this profound authenticity between what is said and what is lived!