La clinica (ENG)

(The analysis has now ended.)
(The publication has been authorized.)

 

Assumption

The problem from the point of view of languages
So let us attempt to tackle the Mind Body problem, that of the two languages, which, as per tradition and privilege, deal with the two sides of the mind body problem.
The languages of psychology and medicine, which study the mind starting from the experience of the living body and the so-called biological body.
Let us now attempt to specify (rigorously) which is or which could be the relationship that each language maintains with its own specific object.
Namely, the mind and the body, understood as mirroring of each other.
Would there exist a psyche, as we understand it today, without the psychology that studies it, defines its boundaries and nature, its shape and dimension? Were we to eliminate the tradition of psychological studies, we would simply be in the impossibility of seeing the psyche in quality of psychological dimension of life.
Evidence lies in the fact that in our archaic culture and in many cultures around the world, a psychological man does not exist and a psychological science does not exist. The psyche as object or as phenomenon does not exist for any science, in the sense that a representation posing it does not exist.
We are clearly disconcerted when we notice that the same holds true for medicine and the science of biological life. Were we to eliminate the whole tradition from which these sciences arise, the tradition that not only educates them but also skillfully and instrumentally informs them, with their examination and research tools, - even their objects, from neuron to cell, from seeing to hearing, etc. - , they would cease to exist.

 

Taking as an example the dream event
The point is that every science institutes its objects, just as Galileo reminds us (in nature we find what we put in it), otherwise we would not know what to search for or how to search for it.
Hence, going back to our example, we see a dream not despite but precisely through the apparatuses of psychoanalysis, from metapsychology to setting.
What I intend to say is that dreams, as psychoanalytic dreams, exist only within psychoanalysis.
While elsewhere they are something completely different, a message from the gods for example.
Then of course there exist the dreams that are dealt with in neurophysiology, of a different kind compared to those of psychoanalysis; it is another phenomenon that, without the neurophysiological tradition, would clearly not exist, precisely in the terms in which it is thought of in neurophysiology.
As noted, I do not believe the point is to determine whether the psychoanalytic dream is truer than the neurophysiological one. Each bears its degree of truth within the practice that institutes it. The point is to understand that the dream, as such, beyond any read we apply to it, whether psychoanalytic, neurophysiological, religious, mythological, superstitious, or of the tarot, does not exist.

 

The two languages
Now, a very important and delicate problem remains, which requires careful consideration: how can (if they can) the two ‘opposite’ languages, medical/neurophysiological and psychoanalytic, dialogue?

 

Back to the dialogue between psychoanalysis and neurophysiology
It is well knownthat we conceive of the dialogue between disciplines as a practice dominated by the ideal of méthexis or warlike hybris.
We have two alternatives: determining a ground of common contact - in terms of reciprocal validation or confirmation - or determining the primacy, or greater veracity, of one over the other.
The second version takes shape when, for example, we ask psychoanalysis to descend onto the terrain of positive, hard, scientific discourse.
Yet is it really so?
The point is that both strategies presume the same gesture. The gesture by which there exists a thing out there in the world, that is the same for everyone, and we must account for it, possibly, by agreeing and determining once and for all which version is the truest.
In other words, the point is that, whichever road we choose, the way of thinking remains epistemologically identical: the object of study and the scientific practice that deals with it remain inherently independent. Not only, both roads presume possible a gesture that actually reduces the investigated object to a finite epistemological phenomenon.
A consequence that is impossible to bear when the object of study is life, sexuality, the unconscious!

 

The third version
Beyond reciprocal validation and the need to determine a sort of primacy of one discipline over the other, there exists a third version, just as strong. It holds that the dialogue between the various disciplines is senseless, hence, the traditional psychoanalytic position in the face of the neurophysiological one is useless.
For many analysts, the mediation between the two languages, medicine and psychoanalysis, is an epistemological absurdity that is risky for both. For example, according to them, there is no point in translating such a cardinal concept as the ‘repetition compulsion’ (the incoercible repetition of past painful events) into the language of neurobiology, that is, into certain electric regularities that are present in the brain and measurable with the electroencephalogram. The price of such operation, as they say, is that of dulling both references to the extent of theoretical insignificance [1].
A respectful silence to avoid contenders’ embarrassment is far more desirable.

 

Ignoring medicine
Yet ignoring medicine today, and particularly neuroscience, is senseless; we wish to suggest another possible road. That by which the game between the two languages and their encounter does not aim at the upper hand or blend of objects that are not identical, neither in reality nor in thought, but a game that aims at allowing each discipline to detect, through the encounter with the other, a better and deeper knowledge of itself. It aims at protecting oneself from the illusion (metaphysical, universalistic) of possessing the whole truth of the matter. The debate between medicine and psychoanalysis should occur precisely with the twofold intention of using the other discipline for a deeper re-elaboration of its own conceptual architecture, and for an ethical review of the omnipotence of its discourse. This would be to the advantage of the event that both medicine and psychoanalysis, in their own way, attempt to account for: human life, nothing more, nothing less.
Even through clinical practice, we can see other fundamental reasons that fit with a (deep) modification in the way of feeling in a session when both languages are used.

 

Clinical practice
When in treatment we happen to oscillate between the two reads, we feel that something is lost, while something else comes through, in both ways, while, in coming through, it defines differing functioning. Thus, we analysts become witnesses and active participants to the sense of disorientation that is taking place. It is a matter of moving away from interpretative clichés, noticing the movement of ideas and affect that tend toward their ‘material’ structure, almost dissolving in it, while the ‘material’ structure, at times (in flashes) takes shape in new representations and affect.

 

A powerful therapeutic factor
When we swing between unthought-of territories using our customary symbols, we help our patients begin to feel their body (naming it and naming its functioning), because we enlarge substance, blending the first nucleus of an authentic ‘bodily’ Self.
For example, speaking to a patient in session of his loss, using different languages, gives a greater sense of truth; not because it sets forth the bodily as concrete and real data alongside the mental, but because the use of different symbolic grounds allows to experiment with a strong difference in level as such, hence, in a coming and going of major forces both ways, a sort of continuous rebound between mental and bodily.
It seems we are brushing the ‘surface’ or falling into ‘depth’, but it is not the case. We are simply learning to inhabit the difference in level as such: this fills us with vivid sensations that carry new, active rhythm. Moreover, it occurs that the different levels of discourse, albeit withholding their specific autonomy, do not lie drastically isolated or tended to by different professionals.

 

A clinical case

“Even Aristotle declares it to be quite possible that a dream may draw our attention to incipient morbid conditions which we have not noticed in the waking state (...) and some medical authors, who certainly did not believe in the prophetic nature of dreams, have admitted the significance of dreams, at least in so far as the predicting of the disease is concerned” [2]

Martina
She is a long, slender and blonde twenty-five year old. She is a model. She has traveled the world because of the continuous transfers of her father, a diplomat. After years of hesitation, her mother and father separated a few years ago. Martina left her family at twenty, studied, reads a lot, has a good job, some friends (gay, considering her work environment is mainly gay), some flings with difficult boys.
She begins a three-session weekly analysis with me, rich with dreams that she narrates in detail and interprets. In fantasies and in some dreams at the beginning of the analysis, her parents appear, young and infatuated. In one dream, Martina sees herself behind a glass, almost as if in an ‘autistic’ bubble, as she looks at her father’s camera continuously filming her mother, who is so fused with her idealized image as to have no room for the three children and especially for her, the cub of the family.
She has a severe form of spastic colitis that has always reacutized in the most tense moments between her parents. During a particularly lonely summer, she is sent to a foreign country to an unknown family, and her colitis becomes ulcerative.
She tells about how the year before beginning the analysis, on her way back from a long flight, she had a severe lung embolism, after a previous thrombosis in a lower limb. In the course of the long hospitalization, she was physically very ill and “went haywire” (the symptoms referred are of anguish and pre-psychotic).
As a medical doctor, I reflect upon the connection between embolism and thrombosis. We talk about it. In predisposed people a state of immobility (as her long haul flight) is sufficient, and thromboses in limbs may become lung embolisms. Talking about it, naming facts and symptoms, allows us to visualize a thrombus stuck in a leg, moving and sliding up to a lung, while she is forced to immobility.

 

The pathology
It is simultaneously ‘concrete’, dream and metaphor.
Martina’s idea of the causes and connections differs from mine. She believes in the mechanical development of consequences. She makes her illness depend on emotions in a direct fashion, fol126 lowing a linear causality. She cuts the story short by saying “it was the stress”. Among the various circulatory conditions she also has Raynaud’s syndrome, a lack of vasomotor control of extremities for neurovegetative reasons, especially in very cold temperatures or when emotions are overwhelming. A vasoconstrictive phenomenon is followed by excessive vasodilation, so, for example, hands first become white and ache, then red, cyanotic and swollen.
I speak with Martina about the fact that the causes of this illness are multiple and complex (there is no linear cause); I tell her that, even if certain auto-antibodies came out positive in her case, positive auto-immunity does not signify, as she has always believed, that the body tout court turns against itself. Instead, there exists a strong analogy between her neurovegetative system which poorly regulates itself, and her personality. In the sense that, she either finds herself controlled, rigid and blocked, or lost in the void, without boundaries, with the feeling of fading away or flying away, like Mary Poppins.
For a good part of the analysis, coinciding with the end of her medical therapies and the decrease in Raynaud symptoms, Martina tells me about a dream that is very different from the usual ones, very ‘mechanical’, almost ‘hyperrealistic’. From the analytic couch the index of a friend’s left hand pops up, very large and blown up to the smallest detail, it is cracked, broken lengthwise, a long and profound ulcer. Her friend puts a drop of anesthetic and feels no pain. Martina illustrates the dream with gestures. The dream continues staging her anesthetized way of reacting to separative facts. For example, a butterfly precipitates onto the street with a clumsy flight from a window high up. But there is a man (the analyst?) in the street who is waiting for it and saves it.
We ask ourselves, in a somewhat automatic way: “Why this dream now that you are feeling good?”
Anxiously, I think it is only a dream, yet so strange and so different from her truly dreamt dreams.
Together, we firstly search for moments of absence of contact or emotional regulation in sessions, which might have caused that dream. We then search for her ‘feeling bad’ that is hidden by the anesthetic, the defense against separative anguishes and the drive world that is awakening. I think about the strain, about Martina’s jolts, who nonetheless proceeds along her path; I think about the arrests, albeit random, of her emotional-affective tissue as it deals with a particularly difficult separative and individuative path, amongst a thousand visible stops especially in the body dimension: an initially spastic then ulcerous colitis, a thrombosis, the embolism, the Raynaud syndrome...
Of course, speaking in analysis about anguishes that were anesthetized because they were painful to the point of causing death is easy for both, yet Martina seems to understand it only in theory.
In any case, something does not add up, a dream so different from the others, to the point of seeming a fragment of reality. Knowing theories is not enough, knowing that it might be a dream that foretells a psychotic break. Again, the somewhat obsessive and obtusely repeated question arises, as if, in the game of projective identifications and counter-identifications, we had lost the possibility of associating and reasoning; as if there existed in me an imperious need to give sense:
“Why now?”.
At this point, I believe the dream truly is serious, indicating that the patient perceives in herself a profound psychic split taking place, a sort of vertical crack, the psychotic crack at play.
The little man appearing on the street at the end, who seems to help the butterfly showing it how to move its wings, could be the emergence of a maniac side of Martina’s, against the anguish unleashed by the feeling of ‘cracking’.
In any case, with a certain sense of (defensive) relief, I find myself considering that there is not a real deterioration (yes, here I do think about the term ‘real’, indicating ‘concrete’). Ultimately, it is only a dream... which attempts the first mise-en-scene of the separative fact and related anguishes. At the moment, Martina can only represent detachments in this way (clumsy jumps, holes, flights, the risk of dying, acute anguishes alternated with anesthesias, little men-analysts who might save her).

 

Psychotic transits
When in session a sort of total void intervenes, undoing any search for sense.
Clinical practice undoes any theory: through the non-sense, the void, it seems one might just reach the ‘thing’, go through it, to reach a minimal possibility of sense, of ‘real’ sense.
The psychotic void that revealed itself in the crack of the ‘dream’s’ split - the ulcer in the skin of the friend’s finger - opened another dimension, a large empty space. We did not
define/understand the oneiric hole of the finger, we happened to live it.
Again, in session, feelings of void and of claustrophobia alternate, as if everything occasionally risked becoming a cage again. Vanishing, flowing away into a space that is too open, being there again, staying there again (in the too closed), feeling heavy, suffocating, perceiving it together, saying it, then moving away from the feeling of sense every time we reach it. The unknown of the body, upon which transference, countertransference and psychoanalytic communications operate, is outside sense. It is never reachable. I notice that Martina needs me to think and speak of the cage again, interpreting.
“The cage is not only the illness with its relapses, the repetition of ulcers, but also my possible rigidity; even the obligation of necessarily finding sense in the analytic work, and the disappointment because we think we understand but then the bad feelings return; especially, it is your need for me and for the analysis, more intense and authentic, and the rebellion because now you acknowledge this need and not only in words”.
... “An analysis, with its inevitable “cage” moments, is the necessary effort to build healing, not as you intended, suddenly and once and for all, but in the sense of new functions, a new tissue of thoughts and emotions, the collagen of the new ‘bone’ structure that is forming”...
I find myself speaking and explaining a lot.

A couple of months of good analytical work follow, after which comes a winter separation experienced by Martina in an almost maniacal and liberating way: she goes to Rome where she dances in a club with a small group of friends for nights on end, smoking whatever she finds.
Upon returning, an ulcer, albeit not so deep but very long, truly appears on the index of Martina’s left hand, vertically cracking her finger.
I go through a moment of peculiar uncertainty and disorientation, with a single certainty: the doctors immediately prescribe a test (it is called capillaroscopy), which highlights a clear worsening of the finger’s tissue.
With this test, the doctors diagnose a scleroderma, or rather, a tendency toward the illness, a scleroderma pattern (scleroderma is a disease of the immune system, whereby the collagen progressively cages tissues, making them stiff and amimical).
We speak about it several times in session. Precisely in medical terms. I find myself thinking about the Scleroderma as one of Martina’s cages: the bodily cage par excellence.
The concrete data of the ulcer-hole, along with a medical diagnosis and prognosis that are now quite negative, push me, as if I had to take a physical and imaginative leap, upwards; away from the ‘floor’ of the so-called concrete data, towards the ‘ceiling’ of abstract data, our usual symbols.
Without that floor of ‘concrete’ data (read by medicine), I would never even have been able to imagine that leap.

 

My considerations
Yesterday I believed that in analysis you can ‘fly’ thanks to theories - the ceiling of our symbols - and to countertransference, today I need to indulge for a long while on the ‘floor of concrete, universal, data’, which mean nothing in our psychoanalytic language, they refer to nothing. I need to oscillate between my symbols and those symbols used by medicine (which happen to be more appropriate to speak of the body).
In the course of the sessions, a strangely analogical language develops (the grip of our dyadic cage is the concomitant tendency toward scleroderma and vice versa). No symbolic interpretation of the scleroderma pathology, no identified correlation between the organic pathology and the dyadic situation, only moments (experienced together) of a strong analogy between the two languages, as if the two languages almost spoke of the same thing, as if they hinted at a quasi-identity between body and mind. This double language operates as a potent modulator of sensations in the most chaotic moments, bringing bone structure to emotional tissue, soothing guilt without falsifying the intensity of deficits and conflicts. I believe that an analysis carried out taking into account the facts and data that we are used to calling ‘concrete’ (clearly, they are always facts experienced between two people, the patient and the professional), bears greater ethical concreteness.
In this way, I feel that with Martina the leap outside the cage, not only the scleroderma cage, bears greater chances of succeeding. For the analytic dyad, the cracked finger can now become a metaphor: almost a birth that, underneath, lets show a scleroderma cage. A birth outside the cage, that nonetheless remains imbued with fear because of the sign of worsening highlighted by medicine.
I think about the two opposing poles that coincide for a second: the illness (ventilated) by the ever caged bodily coincides with the great potential for life, the leap outside the cage of the dyad, outside the collapse into the maternal body. I attempt to put together the real ulcer of the finger, the hole, the painful and concrete void, an out-of sense par excellence, with an ulcer made softer by the sense of symbolization.

I tell her that the hole also evokes a vital form, that is, it brings to light and shows me certain aspects of the overall experience lived by Martina, traces of vital forms experimented and shielded in memory.
I speak to her of vital hole-dynamics [3], as a window on (phenomenic) re-built experience: “Making and undergoing holes one’s whole life, until the body really gets punctured: a little hole in a swollen index. The experience of the hole is happening here and now and it is truly real: it is in its nature not to be able to be thought or expressed in words while it is ongoing... It is in the hole’s nature to just be... void, absence”.
Now we may talk and say together that based on the thousand subjective-objective holes suffered until now, finally the Hole formed, which, summarizing all the previous ones, probably leaves her like that butterfly which many times, as a child, she thought she was: truly free from the chrysalis form.
It is the first attempt to truly leave the cage (even the scleroderma cage).

 

The traditional hypotheses
This young woman, a true psychosomatic case, had poor mentalization thus somatized a lot!
Or, this woman was affected by a mix of deficits and unconscious conflicts that translated into the body, constantly ill. Hence, there was a strong mental basis to her organic pathology!

 

My hypothesis
In nature there is no and we find no biological basis that may explain mental phenomena, neither is there a mental basis that explains somatic phenomena, simply because there exists no basis, neither for mental nor for organic phenomena. And there exists no psychosomatic illness[4] either, because no illness is only psychic or only somatic. And in nature there exists nothing that is detached from us, so to speak. There exists only the encounter between us, our disciplines with their tools, and what we believe objects to be (in this case, pathologies), which we name time and again. And because we can only name distinctively and consecutively, it seems that the objects we name truly exist and are separated from one another. According to the tools we equip ourselves with to observe it, we define the pathology in question as organic or psychic.
Of course, all this does not mean that, if we diagnose ‘organic’ illnesses in which it might be necessary to intervene surgically, for example, these illnesses are merely ideal, the fruit of our nomination: illnesses ‘exist’, by all means, but we can see them and diagnose them only thanks to our theories and tools, among which the specific language. They appear within the specific language we use to name them; outside, they do not exist.

Martina is undergoing analysis to acquire a life (hers) and a competency of drives, a psychic ‘freedom’, that is, a certain plasticity that may give back motility to the investments; in other words, a richer, more ductile and variable emotional-affective-cognitive tissue (a mentalization).
At the beginning, Martina felt confusedly, she poorly distinguished feelings and experienced chaotic emotions; she reasoned and dreamt but in a mechanical way, self-interpreting almost everything, albeit not without an ironic vein...
It makes no sense to search for mental reasons underlying her complex somatic pathology, unless we refer to the fact that, in etiopathogenesis, which always blends with expressivity along a continuum (as in any illness), the emotional and cognitive tissue is involved in varying ways. Vice versa, it makes sense to search for feedback, a continuous rebound between certain phenomena interpreted by medicine and certain events interpreted by psychoanalysis; it makes sense to read them simultaneously and continuously, without a solution of continuity. For example, I believe the forming of the pre-scleroderma tissue in the finger to be the moment of maximum tension of the dyadic cage (let us remember that we are imagining walking on a sphere-shaped body, or unrolling on a scroll).
The para-autistic cage, with which Martina protected herself for a long time, and that of the compulsion to act during separations; the analytic cage that protects her by “saving her, yet from which at times she wishes to escape”, both sound like the reference to the cage of the scleroderma pattern. A pattern that presents itself at a certain point of treatment in its twofold guise as sign of ultimate illness (it would be very serious should it become severe scleroderma), and as a push that stimulates the analytic couple towards that leap from bridled repetitions, towards new freedoms. While alerting doctors for more ‘effective’ examinations and treatments.

 

Chiasmatic units
Then, beyond feedbacks, in the attempt to overcome any trace of mind body dualism (that we use to nominate), I think about the levels of identity and existence. Which cannot even be localized, because they are not found here or there, they do not have a locus or a spatiotemporal position; rather, they continuously move, taking shapes that relentlessly dissolve in indiscernible areas as they sever any preceding ties. They are mind body ‘quasi-identities’, chiasmatic units inside a purely relational psycho-soma that exists only as relational pattern, indeed, which naturally acquires substantial and material existence - so to speak - when we equip ourselves with certain tools and languages.
Martina exists, I see her, I hear and feel her, I speak with her, her hole in the index of her left hand is quite real, it has a presence, a force. Her reality in every moment is my new starting point.
When she comes to therapy with her hole in the left index, from which a scleroderma tissue ‘transpires’, it creates ‘actions and reactions’ in me that move us away from caging structures, towards an infinite path, in search of what we shall never find. In any case, in search. Salvation lies in the experience of this search: today, four years after the beginning of the analysis, there is no trace of the old organic (quiescent?) symptoms, and Martina is somewhat falling in love.
Yet as we know, symptoms and pathology also serve to protect us from intolerable feelings of loss and for this reason too, as Freud says in Analysis Terminable and Interminable, abandoning suffering is a long, tortuous road.
As I was saying, what is underway at this point of Martina’s analysis is a process of such a nature as to not be localizable or categorizable. It is only a way, a relational entity, immersed in a continuum that the analytic couple may fulfill, as it sets forth on the ideal spheric body, or rolled carpet.

 

Image 1: The Möbius strip

 

Image 2: The rolled Carpet

 

 

[1] On this matter, Merciai and Cannella report the danger of collapse, in their interesting and exhaustive book “Psicoanalisi nelle terre di confine” (Milano: R. Cortina, p. 15, 2009), when for example they point out (in criticizing it) a fragment of the International Journal of Psychoanalysis, by David Olds and Arnold Cooper (1997, 78, 2:223): “[The encounter with neuroscience is necessary] to avoid gross errors in conceptualizing the past, such as interpreting the organization difficulties of a patient with attention deficit disorder as masochistic, or considering obsessive-compulsive disorder as deriving from solely anal or oedipal issues”. It is by no means a matter of considering a patient’s difficulties only as masochistic or only as hyperactive disorder! Olds and Cooper’s way of arguing is almost absurd. Neither is it a matter of finding exasperated confirmations to Freud’s biological attempt; rightly so, Kandel (2012) underlines this by criticizing neuropsychoanalysts such as Solms, who views every element of Freudian conceptualization as perfectly validated by current neuroscience.

[2] Freud S. (1900), L’interpretazione dei sogni. O.S.F. vol.3.

[3] Stern D.N., (2010) “Le forme vitali”, Milano: R. Cortina, 2011

[4] Trombini G.& Baldoni G. (1999) “Psicosomatica”, Bologna: Il Mulino.