10) C0) ATV Bie Segg ese SYMPTOM Ele ou) The incurable indubitably interrogates the ends and limits of psychoanalysis as a clinical practice and discourse. Freud certainly encountered a vast array of obstacles in his quest to treat his patients. He exhausted his faculties, in the end, over the dilemma of the “negative therapeutic reaction,” his patients’ paradoxical de- fense against the cure and its entailments. After continually butting up against this “resistance against the uncovering of resis- tances,” Freud was met with “the central difficulty of psychoanalysis”: treating the symptom that satisfies. The precise func- tion of the analyst and even psychoanalysis asa clinical enterprise were radically called into question insofar as Freud was solicited to provide the antidote for something that went beyond the bounds of what was clini- cally possible. By Freud’s assessment this was the monumental impasse of castration. Continuing to conceptualize the objective nature of this incurable excess, however, is a central task for maintaining the speci- ficity of psychoanalysis, and the ethics of its cause. UMBRl) 4Given the status of the incurable as a negative entity we can only hope to ap- proach it obliquely. The clinic of psycho- analysis is exemplary in this regard, given the fact that the style of its theory and practice Is modeled after the very object of Joutssance that it questions. One need only consider the psychoanalytic understanding and treatment of the unconscious produc tion of the symptom in order to appreci- ate the importance its practice places on following the detours, and half-sayings, of signification. Accepting that symptoms only allude to something, somewhere, that is structurally failing, Freud came to consider these pathological elements as variations (on a universal theme: the inconsistency of, the subject's relation to sex. Intrigued by ‘what the source underlying and supporting their construction might be, Freud was ul- timately compelled to disconnect his clinic from the standards of all previous discur- sive regimes. Thus he established his own principles and, with them, psychoanalysis’ proclivity for contesting the very criteria used for circumscribing and constituting the real. Aithough the symptom brings psychoanal- ysis into contact with medical discourse at the level of the word, it essentially distin- ‘guishes psychoanalysis from science at the level of the concept. The political and so- cial consequences of analysis’ conjectural act are not to be ignored, and more impor- tantly, beg for further elaboration. As the subject outside of psychoanalysis is more and more mistaken for merely a biological entity, a rampant medicalization of the symptom has ensued. Such anesthetizing practices are indicative of a general push, within contemporary discourse, toward the de-subjectivation of society. The symptom, in this epoch, 1s typically viewed as a hap- less neurological accident whose effects ‘must first be quantified and then silenced as efficiently as possible. For psychoanaly- sis, however, the symptom is conceived as the encasement of the truth of the subject. At its core, then, the symptom is taken to be a meaningful invention, the inaugural attempt to contain an unwieldy sufferance. This is to say, ultimately, in opposition to other medical practices, psychoanalysis asserts that the silencing of such symp- toms would be to irremediably sever the subject’s relation to desire. We might even say that the symptom begins, for the subject of psychoanalysis, where science fails—the exposure of a necessary limit internal to the scientific ‘method of paranoid critical disclosure. Wit ness the hysteric—that most unmanageable subject—finding strange comfort in using her body to signify the very ignorance of the scientific Other, who vainly searches to know the cause of her affliction. Psycho- analysis does accept that science, in the form of psychiatry and its discursive bedfel- lows, may produce knowledge, but asserts that none of it will properly correlate with the reality of these symptoms. The inten- sity of their effects will only strengthen (oraawn,i when mitigated sheerly with a combina- tion of feigned certainty, in the form of prefabricated knowledge, and the reckless drive to cure. To use Freud’s phrase, there {san inevitable “lacuna in the knowable,” which suggests that the standardizatfon of care, at its core, is an epistemological failure. What these sciences overlook is the bare fact of singularity, or more specifically that a singular, displeasing satisfaction is the square root of these symptomatic for- mations. Science will not accept into the circuitry of its discourse the knowledge that something of the subject goes against life. The process of psychoanalysis, by contrast, could be conceived as a work of reduction solely intended to bring one to encounter this element. That is, rather than demand that this element be purged, the psychoanalytic clinic elevates it to the dignity of a unique knowledge, accepting it on its own terrain. ‘Our wish to reinscribe the obscure sense that is the incurable within the field of dis- course requires the transfiguration of the subject’s symptomatic insistence. In the very repetition of its presentation, some- thing fs hit upon that signals a brush with the real. The analytic act does not ental! a dismantling of the particularity of each symptom, but the realization that each~in the end-is a singular bid to signify some- thing wholly dissimilar to signification. ‘There is a form of knowledge locked within the symptom that 1s essentially incommu- nicable, marking the limit of what can be said, while at the same time manifesting ‘the insufferable and “forbidden joulssance that fs the only valuable meaning that ts offered to our life.”' Thus, while the im- potence of castration was the end point of Freud’s ctinical theory of the incurable, it 1s the constitutive impossibility advanced by Lacan that rearticulated the limit of the psychoanalytic project. The impossible, much like the return to the inanimate that Freud pondered, can only be hypothesized, fiven that it is strictly unaccounted forwithin the symbolic. Nevertheless, to the credit of psychoanalytic discourse, such a point can and must be inscribed in a structure. The ethic of the psychoanalytic clinic ts to be located in this very act of positioning this impossibility at the heart ofits practice. Such a constitutive failure in determining the subject is the affirmation of the fundamental fact of the subject's ex- istence: its non-coincidence with itself. It 1s impossible for one to directly approach, cor possess, this incurable truth. One can, however, suspend and even seperate oneself from its incendiary effects. All ‘that psychoanalysis and its epistemologi- cal allies demand ts that this impossibility be formalized, that {s, that one seek to establish a discourse that coheres while still containing a non-signifying element. Heeding this demand comes from the real- ‘zation that ft fs the logical way out of the subject’s metonymic slippage between the remedial sembiances that contemporary life readily traffics. i Jacques Lacan, “Of Structure as the Inmixing fof an Otherness Prerequisite to Any Subject, Whatever,” in The Structuralist Controversy, feds. Richard Macksey and Eugenio Donato, (Baltimore: Johns Hopkins, 1970), 195. lu bi dE by 4 aed (oheawnIS A PEDAGOGY OF HEALING POSSIBLE? georges canguilhem ‘As an event within the relation between patient and doctor, healing is, at first sight, what the patient expects from the doctor, but is not always ‘what he obtains. There is thus a disjunction between the patient's hope, founded upon a presumption about the powertthat the doctor supposedly possesses by virtue of his knowledge, and the doctor's consciousness of the limits ofhis own efficacy. Thisis undoubtedly the principal reason why, of all the objects treated by medical thought, healingiis the one that doctors have considered least often. But this reluctance is also due tothe fact that the doctor perceives in healing an element of subjectivity, a reference to the beneficiary's evaluation of the process, while, from his objective point cof view, healing is the goal of a treatment that can only be validated by a statistical survey of its results. Without making an ungenerous allusion to those laughable doctors who make their patients responsible for their ‘own therapeutic failures, one can agree that the absence of cure will rarely induce a doctor to doubt the commitment of his patient to applying his prescriptions. Inversely, whoever wants to speak pertinently about an individual cure should be able to demonstrate whether or not healing, defined as the satisfaction of the patient's expectations, is really the direct result of a prescribed therapy, scrupulously applied. For, such a demonstration has never been more difficult to produce than itis today, given the use of the placebo method’, observations about psychosomatic factors, the interest in the intersubjectivity of the doctor-patient relation, and the presumption by certain doctors that the power of their own pres- cence has the power of a medication. We now know that, when it comes to remedies, the way of giving them is sometimes more important than what one gives.” In brief, for the patient, a cure is something that the doctor owes him, while, still today, for most doctors, what he owes the patient is the best studied, tested, and widely used treatment currently available. Whence the difference between a doctor and a healer. A doctor who does not succeed in healing anyone can still be called a doctor, licensed by a diploma sanctioning a conventional set of knowledges to treat patients whose illnesses are explained, in the medical textbooks, in terms of their symptomatology, their etiology, their pathogenesis, and their therapy. UMBR(a) 9‘UMBR(=) 10 Ahealer can only be one in fact, because he is not judged on the basis of what he knows, but for his successes. The doctor and the healer thus have an inverse relation to healing. The doctor is. publicly licensed to claim to cure, while its the cure itself, experienced and avowed by the patient, even when it remains clandestine, that bears witness to the healer’s “sift” in a man whose own, resumed power, very often, has been revealed to him by the experience of others. To verify this point, there is no need to go observe the “savages.” In France itself, forms of wild medicine have always prospered on the doorstep of the Medical School Itis therefore not surprising that the doctors who first addressed healing as a problem and subject of interest are, for the most part, psychoanalysts or men for whom psychoanalysis exists, as a occasion for questioning their own practice and its presuppositions, men such as Georg Groddeck who, in 1923, in his The Book of the It, is not afraid to reduce medicine to charlatan- ism,’ or such as René Allendy in France.‘ If, according to the traditional medical optic, a cure was considered the effect of the treatment of causes, and functioned to sanction the validity of a diagnosis and the prescription that follows from it, and thus to manifest the worth of the doctor himself, according to the psychoanalytic optic, a cure becomes the sign of the patient's rediscovered capacity to surmount his own difficulties.® A cure was no longer ordered from the outside; it became a form of regained initiative, because the illnes= was no longer treated as an accident, but rather a failure of conduct, if not a conduct of failure: It is well known that, etymologically speaking, to heal isto protect, to defend, to arm in a quasi- ary fashion, against an aggression or sedition. The image of the organism thus emerges as ‘the image of a city threatened by an external or internal enemy. To heal is to guard, to harbor [Guérir c'est garder, garer]. This was the image well before certain concepts of contemporary physiology, like those of aggression, stress, or defense, entered into the domain of medicine and its ideologies. The tendency to reduce healing to an offensive-defensive riposte is so profound and originary that it has penetrated the very concept of illness, considered as a reaction of op- position to an effraction or a disorder. This is the reason why, in certain cases, the therapeutic. intention was able provisionally to respect the very ill that the il person expected would be tar- ‘geted without delay. The justification for the apparent complicity between therapy and illness gave tise to certain writings, the best known of which is entitled Treatise on Mlinesses That It Is Dangerous to Cure,’ a turn of phrase that J.M. Charcot used for his own purposes, in 1857, in the conclusion of his thesis, On Expectation in Medicine. This thesis, which claims that the illness is 1 doctor in spite of itself, along with an extenuated Hippocratic tradition, latent beneath many ‘mechanical or chemical disguises, from the 17th to the middle of the 19th century, contributed tothe representation of the animal organism as an “economy.” The animal economy is the set of, rules that preside over the relation between the parts of a whole, in the image of the association between the members of a community, governed for its own good by the authority of a domestic ‘or political leader. Organic integrity was a metaphor of social integration before becoming thematerial for the inverse metaphor. Whence the general tendency to conceive of a cure as the end to a disturbance and the return to a previously existing order, which is evidenced by all the terms with the prefix re-that serve to describe the healing process: restore, restitute, re-establish, reconstitute, recuperate, recover, etc. In this sense, a cure implies the reversibility of the phe- nomena whose succession constituted the illness; it isa variant of the principle of conservation or invariance that form the basis for classical mechanics and cosmology.” Itis possible to see that, thus understood, a cure can easily be contested, except in certain patently benign cases, such as coryza or oxyurosis, because the restitution or restoration of the previously existing organic state can frequently turn out to be illusory if it depends on confirmation by functional tests instead of simply referring to the satisfaction of a man who had stopped saying that he feels il Beginning with the last quarter of the 19th century, physiology began to replace the concep- tion of the organism as a compensatory mechanism or a closed economy with a conception of an organism whose autoregulatory functions are intimately coupled with the functions of adaptation toa milieu. If, a first sight, homeostasis might seem comparable to the spontaneous work of conservation celebrated by classical medicine, itis nonetheless not the same thing, because, in the latter case, an opening onto the outside is considered to be constitutive of properly biological phenomena. Of course, prephysiological medicine did not disregard the organism's surroundings, the climate, and the seasons. Whence the theory of constitutions. But these surroundings had only to do with popular illnesses, epidemics, which acted like military campaigns. They took the weather into account, in the words of Syndenham, for whom illnesses followed “the particular ‘weathers of the year, much like certain birds and plants.” Knowledge about circumstances was not researched in order to discover the constitution of the disease, but in order to know the es- ssence of the disease in question and what type of therapy should be used to stop it. It would thus be a mistake to seek in the old theory of epidemic constitutions an anticipation of the theory of miliens advanced by August Comte” and developed by the positivist doctors of the Société de Biologie, which was contemporary with the constitution of physiology as a science." ‘The opening of the organism onto a milieu, even if it could never have been conceived as a simple relation of passive subjection, gradually came to be understood as something subordinate to the maintenance of constancy, expressing itself in relations where the expenditure and gain {n energy are controlled by regulatory cycles. But the apparent equilibrium or stationary state of such an open system is in no way exclusive of its submission to the second prineiple of thermo- dynamics, to the general law of irreversibility and of non-return to a previously existing state. All the vicissitudes of an organism, therefore, whether it is healthy or sick, or considered cured, ‘would thus be marked by the stigmata of degradation. Despite the persistence of the confused image of Apollo the Thaumatuge within the symbolic of therapy, no doctor cannot not know that acureis never a return. Indeed, when Freud, in the most discussed part of his work, reactualized the concept of return, it was a return to death, to the inorganic state that preceded life.” (nvawn,2 ‘UMBR(e) I thermodynamics is, with respect to its original object, the science of the steam engine, itis also, with respect to the type of society associated with the scientific institutions out of which it emerged, a science that is characteristic of the earliest industrial societies, primarily societies of urban populations, in which the demographic concentration and the workers’ conditions of labor contributed greatly to the development of infectious diseases, and in which the hospital imposed itself as the place of generalized treatment of anonymous individuals. The discoveries ‘made by Koch, Pasteur and their students of the phenomena of microbial or viral contagion and immunity, the invention of antiseptic techniques, serotherapy, and vaccination, put massively ‘effective means at the disposal of public hygiene, which, until then, had been helpless. Paradoxi- cally, it was the success of the first curative methods founded on microbiology that allowed the personal ideal of curing disease to progressively give way to the social ideal of disease prevention, At the limit, it was not absurd to hope that a population docile enough to preventative measures ‘would achieve a state of collective health in which no individual would find himself in the situ- ation of having to be treated and cured of any given disease. In fact, atthe present time, within Western societies, there are almost no further cases of smallpox to cure, because the systematic application of anti-smallpox vaccinations has achieved the result of rendering itself obsolete. The image of the skilled and attentive doctor from whom singular patients expect a cure has little by little been effaced by the image of an agent who executes the orders of the state apparatus, assigned to watch over each citizen's right to health, as an extension of the duties that the col- lectivity declares that it must assume for the good of all. ‘The progress of public hygiene and the development of preventative medicine were supported by the spectacular success of chemotherapy founded, during the early years of the 20th century, upon the research of Paul Ehriich on the artificial imitation of natural processes of immunity. ‘This is perhaps the most revolutionary invention in the history of therapeuties. Antibiotics did not only provide a means of healing, they transformed the concept of cure, transforming the hope for life. The statistical calculation of therapeutic performances introduced an objective measure of reality into the subjective anticipation of being cured. But this measurement ofthe curein terms of a statistically calculated duration of survival inscribes itself within an overall picture that also includes the appearance of new diseases (cardiopathies) and the more and more frequent oc- ‘currence of old diseases (cancers), affections whose rapid course is underscored by the elevation of the average lifespan, Therefore, the fulfillment of the two ambitions of traditional medicine, to cure illnesses and to prolong human life, had the indirect effect of saddling today's doctors confronted by disease with new forms of anxiety about the possibility or impossibility ofa cure. Cancer took up where tubereulosis left off. If lengthening the individual human lifespan only confirms the fragility of the organism and the irreversibility ofits decline, ifthe only effect of the history of medicine is to open human history to new diseases, then what is healing? A myth?Although doctors are ordinarily critical of the popular notion of healing, itis not forbidden to attempt to legitimate it. Our language knows the word to heal, an active verb, and to heal, an in- transitive verb, like to flower or to succeed. In popular terms, to heal is to regain a compromised or lost good, that is, health. Despite the social and political implications ofthis concept, due to the recent fact that health is often perceived as a duty with respect to socio-medical powers, health remains the organic state about which the individual considers himself a competent judge. Even iff doctors have good reason to think that itis illusory to define health as life within the silence of the organs (René Leriche), recalling that this silence can mask a lesion that has already reached an irremediable state, itis still worth conserving the criteria of feeling wel, that is, feeling well in the situations that one must confront. Health is the a priori latent condition, lived in a pro- pulsive sense, of all chosen or imposed activity. This a priori ean be decomposed, a posteriori, by the science of the physiologist into a plurality of constants from which discases represent a more radical departure than a norm determined by an average variation. However, by substituting the objective analysis of these conditions of possibility for the whole of a living subject’s lived rela- tion to his power to “face up to,” one ends up substituting a constituted language for a mode of expression that has been refused the dignity of being considered a language. The doctor is not far from thinking that his science isa well-constructed language, while the patient expresses himself in jargon, But since the doctor began as a human being, at an age when he was unsure whether he would become God, a table, or a basin, he retains a few memories of the original block from which he was sculpted; and, in principle, he retains a few elements of the jargon that has been devalorized by his learned language. It can happen, therefore, that he consents to understand that the demands of his clients are no more than an attempt to lend a certain quality to the desire tolive, or to rediscover something equivalent, without worrying whether the objective tests of a cure are positive or concordant. Inversely, a doctor will not understand a patient, at the end of a prescribed cure that has been executed and has eliminated an infection or a dysfunction, who refuses to call himself cured and does not behave as someone who feels better. In sum, from the standpoint of medical practice, fortified by its scientificity and technology, many patients remain satisfied with much less than they are owed, and certain other patients refuse to recognize what ‘was done for them is all that they were due. It comes down, therefore, to the fact that health and healing pertain to another genre of discourse than the one whose vocabulary and syntax are transmitted in medical books and clinical lectures. ‘When, in 1865, Villemin presented what he thought was the solid proof that tuberculosis is contagious, much more was required for his contemporaries to see things his way, because many of them, such as Bricheteau, invoking the Draconian ordinances that had been in place since the 19th century in Spain and the Kingdom of the Two Sicilies, thought contagion was an idea that could only have been born in the Southern imagination." Even as they struggled against it, (onenn“ UMBR(e) doctors had managed to integrate a popular reaction of fear and rejection into their conception of disease. Between human tuberculosis and bovine or avian tuberculosis, whose identity or differ- cence remains a subject of debate, medicine established the active presence of a determinant that, should, for lack of a better term, be called “psychological.” Tuberculosis was a cause of terror much as leprosy had been in the Middle Ages. To name the disease aggravated the symptoms." For, this disease entailed social exclusion as much as organic consumption. For a long petiod, ‘one became ill from being cured of such a disease, to the extent that the patient perceived all around himself the suspicion that he remained a cartier. Even confirmed by laboratory tests, ‘a cure remained incomplete when the patient was reintegrated into existence, more because he continued to suffer from the anxiety caused by segregation than because of the reduction of his vital capacities. This form of cure, which could be called pathological, now rare in cases of tuberculosis, has become frequent in cases of cancer, because of a similar reaction of anxiety caused by the patient's idea of the idea that other people will have of this unpardonable disease. However, in addition to patients who simply do not assume their own cure, behaving like cured people who have resolved to confront, perhaps differently than before, the question of existence, there are patients who have found that their disease is good for them [il y a des malades qui trouvent dans leur maladie un bien d leur mesure) and refuse to be healed. In such cases, the patient's passive resistance to medical intervention functions as a kind of compensation for his diminished state, dominated by illness. In the therapeutic relation, the patient thus makes sure that he keeps the initiative.” Unoriginal asit may be, this summary of the pathological configurations that make it impossible to envisage the cure in the traditional way as an end and a new beginning, forbids us to conceive the relation between doctor and patient as the relation between a technician and a deranged mechanism. Nonetheless, the education that doctors receive in the medical schools prepares ‘them very poorly to athmit that curing is not determined exclusively by interventions of a physi- cal or physiological oder. There is no illusion of professional subjectivity worse for the doctor than their confidence in the strictly objective foundation of their advice and their therapeutic gestures, their contempt, or the self justifying forgetfulness of the active relation, be it positive ‘or negative, which cannot not arise between the doctor and the patient. In the positivist age, this relation was considered to be an archaic residue of magic or fetishism. The reactaalization of this relation is thus to the credit of psychoanalysis, and there have been too many studies of it to return to them here." But it remains urgent to question whether the attention granted by a singular doctor to a singular patient can still make any claims upon our attention in a medi- cal space increasingly occupied, in the so-called developed nations, by sanitary equipment and regulations, and the programmed multiplication of “curing machines."“Things had reached the point that my brain could no longer bear the worries and torment that ‘were inflicted upon it. It said: T give up; but if anyone here cares about my preservation, let him relieve me ofa tiny bit of my burden and we will make some more time.’ At this moment, when the brain apparently has litle left to Jose, the hung presents itself. These debates between the brain and the lung, which took place unbeknownst to me, must have been frightful to witness.” Or again: “I have the same relation to tuberculosis today as a child who is hanging onto his ‘mother’s skirt... Tam continually seeking to explain the disease, since, after all, T did not come ooking for it. I sometimes have the feeling that my brain and my lungs signed a pact with one another without my knowledge.” All patients, all tuberculars in particular, are not Kafkas. But Who does not recognize in Kafka’s words the truth of these distressing situations, of psychosocial origin, which are likely to generate the type of organic exhaustion favorable to the explosion of infectious disease? Indeed, these situations become even more recognizable in cases of illnesses that affect the neuroendocrinal system, from chronic fatigue to the gastrointestinal uleer, and, ‘more generally, the so-called adaptation disorders. Because these distressing situations are often manifestations of blockage on the level of struc- tures of society and communications, shouldn't the study of remedies for them be the concern of sociological disciplines? What would the society look like that hs a health organization at its disposal that exploits the most sophisticated information about the distribution and correlation between factors that cause disease, in order one day to relieve the doctor of the often desperate task of helping individuals deal with the distress of their anxious struggle for an aleatory cure? ‘And why, finally, should we make any attempt to hide from people that itis normal to get sick from the moment one is alive, that it is normal to get better, with or without the cooperation of medicine, and that disease and healing are inscribed within the limits and powers of biological regulations? But biological normalities have no other guarantee than their factuality, unless they are given a metaphysical foundation, in which itis not forbidden to see no more than the consecration of this factuality itself. Life must become a given in order for it to become believ- able as a necessary possibility. The organisms of living beings are capable of alterations in their structure or disturbances in their functions that, i they do not destroy the being, can compromise the execution of tasks that their specific heredity has imposed on them. But the specific task of the human being has revealed itself to be the invention and renewal of tasks whose exercise requires both apprenticeship and initiative within an environment modified by the results of this very exercise. The diseases of ‘the human being are not only limitations of his physical power; they are dramas within his his- tory. Human life is an existence, a being-there for a non-preordained becoming haunted by its own end. The human being is thus exposed to disease, not by some condemnation or destiny, g s‘UMBR(2) but by his simple presence in the world. In this sense, health is not an economic exigency sup- ported by legislation; itis the spontaneous unity of the conditions for the exercise of life. This exercise, upon which al other exercises are founded, founds for them and like them implies the risk of failure, a risk from which no state of socially normalized life can protect the individual Health insurance, invented and institutionalized by industrial societies, finds its justification in the project of procuring for man, now certain of being compensated for his eventual economic deficits, a confidence and audacity that allows him to accept tasks that always entail, to some degree, a risk to life, It has today become a matter of working to cure human beings of the fear of eventually having to be cured, without guarantee of success, of diseases whose risk is inherent in the enjoyment of health.” On this point, itis rather surprising that Kurt Goldstein's theses, developed in Aufbau des ‘Organismnus, have received so little response outside of philosophical circles influenced by the ‘work of Maurice Merleau-Ponty.™ Perhaps itis because Goldstein himself presented his theses as ‘an epistemology of biology rather than as a philosophy of therapeutics. Nonetheless, in the final pages of his work, the activity of the doctor is compared to that of the nedagogue. ® Goldstein has formulated concepts of ordered behavior and catastrophic behavior based on observations relat ing to the conduct of men suffering from cerebral lesions. A bealthy organism engages with the environing world in a way that enables him to realize al of his capacities. A pathological state is the reduction of the initial latitude of intervention within the environment. The anxious endeavor to avoid situations generative of catastrophic behavior, the tendency simply to conserve a reside of power is the expression ofa life inthe process of losing its “responsiveness.” Ifone understands ‘a cure to be the set of processes by which the organism tends to surmount the limitation ofits ‘capacities that comes with disease, then it must be admitted that to heal is to pay the price of the effort necessary to retard the process of degradation. “The patient frequently has the choice whether he wants to accept—according to the change caused by the disease—a limitation of the milieu and the resulting limitation of freedom, or less limitation and more sufiering instead. Ifthe patient bears more suffering, he will gain in possibilities of performing since therapeutic measures may be apt to reduce suffering but at the same time diminish the performances.” Under such conditions, what attitude should the doctor assume? Should he become an advisor or a guide? Goldstein thus articulates questions for which Balint's work received perhaps less deserved no- toriety. The doctor who decides to guide the patient along the difficult path of a cure ‘will be able to doo, only if he is completely under the conviction that the physician-patient relationship is not a situation depending alone on the knowledge of the law of causality but that it isa coming to terms of two persons, in which the one wants to help the other gain a pattern that corresponds, as much as possible, to his nature. This emphasis on the personal relationship between physician and patient marks off, impressively, the contrast between the modern medical point of view and the mere natural-science mentality of the physicians at the turn of the century."i Instead of being shocked, which is easy to do, one should try to understand, The indifference or hostility thatthe large majority of doctors show for the questions raised by certain contestatory movements within their profession, about their abandonment of their healing vocation in favor of regulated undertakings of tracking, treatment, and control, ould be explained inthe follow- ing manner. Nothing is more widespread today than proclamations in the name of anti-x. twas antipsychiatry that started the trend; and antimedicalization soon followed. Well before Ivan lich’ exhortation that individuals must take over the regulation oftheir own health, manage their ov healing, and their own death, popularized versions of psychoanalysis and psychosomaties promoted the idea that it would be desirable to convert the patient into his own doctor. People ‘thought that they were inventing something new, but they were merely reprising the millennial theme of healing oneself.* Since times are hard and prospects are grim, an increasing number of practitioners of non-scientific therapies—for whom science is the enemy—flatter themselves for having achieved what they reproach doctors for neglecting or lacking. Whence the appeal to disappointed patients: come tell us that you want to heal, and with your help we will do the rest. The arguments used are often so hollow, and so vainly peremptory that one could almost lament the progressive demise of the type of doctor who, as Goldstein complains, is stuck in habits of thought informed by physical science. It is possible to see why the conceptual triviality proper to the propagandists of sef-cure prevent many doctors, already quite ill at ease in their role as often impotent therapists, from giving their support to an ideology that, despite its good inten- tions, has lite interest in self-critique. Antimedicine, ike antipsychiatry, exploits the initial advantage gained from arguments of principle. Supposing the problem resolved, let us do like Brutus Caesar. Perhaps Brutus suffers from lingering pains in the region ofthe stomach tht, for long periods, recur violently every day.” ‘The medical counter-information has taught him about the symptoms of an uleer, and about the effects of emotions upon hormonal secretions. He has heard about the epidemic of ulcers among the population ofthe city of London during the bombings of the last world war. Will Brutus first consult a psychotherapist about his marital difficulties with Portia, or wll he run to the nearest radiologist? While he is deciding between the two, will he adopt a strict diet and take bismuth salt to calm his pains? As one can see, Brutus has become, unbeknownst to himself, a mirror that reflects the faces of many different doctors. Those who wish to be liberated of technocratic solutions find themselves caught in the net of a medicine that remains in search of its own best ‘weave, Brutus thus tries to free himself by going to a healer. Because doctors, who have enough trouble keeping their training up to date, tend to neglect to inquire patiently about the affective distress of their clients, less on principle perhaps than forlack of time, must one conclude that they are inferior tothe frst therapist to come along who ascribes everything to psychosomatics? Would the later be better qualified to treat a case of, obesity, if it was first brought on by eating habits related to affective compensation, but is now (onugwn ae ‘UMBR(a) determined by a thyroid or surrenal disorder? When it comes to therapeutic reductionism, is psychologism any better than physiclogism? Let us consider resolved the problem of the time necessary for long therapeutic interviews, the problem of the inevitable multiplication and the remuneration of doctors educated to listen to the loaded complaints of their clients. Must the education of future doctors in hospitals and universities now include teaching in “convivial” participation and thus tests and exams in apti- tude for human contact? Or must one resolve the difficulty differently, by forming health care teams in which several highly motivated doctors and paramedical personnel seek to recreate the individual’ relation to the body, to work, and to the collectivity? Are such solutions, which willingly align themselves with the Left, exempt from all ideological collusion with the Right? Human contact cannot be taught not learned in the same way as the physiology of the neuro- vegetative system. To turn away from the medical profession all those people who are not gifted in “convivial” participation would amount to instituting new criteria of inegalitarian selection. Within a team of health workers, there are always people who are only responsible for being. engineers, while others are content to be supervisors. Finally, is it certain that the systematic ‘campaign to demedicalize health will not obtain results that are the opposite of what it intended? In promoting the best individual usage and the best collective conditions of health, in the image of ‘amore equitable distribution of wealth, can one be sure that one is not instigating a pathological obsession with health? After all, itis a kind of disease to consider oneself permanently deprived, by the current state of medicine, of the health that one deserves. Itis one thing to obtain the health that one believes one deserves; it is another to deserve the health that one procures. In this last sense, the part that the doctor can play in healing would consist, once a treatment required by the organic state has been prescribed, in teaching the pa- tient about his undelegatable responsibility in the conquest of a new state of equilibrium with the demands of the environment. The doctor's objective, like that of the educator, is to render his own function obsolete. It does not seem indispensable to celebrate the virtues of an untamed medicine, making claims about the necessary critique of certain practices of the civilized medical profession. But the time hhas come for a Critique of Practical Medical Reason that would explicitly recognize, within the ordeal of healing, the necessity of collaboration between experimental knowledge and the pro- pulsive non-knowledge of an a priori opposition to the law of degradation. For, health represents ‘the always fragile success of this opposition. This is why, ifa pedagogy of healing were possible, it would consist in the equivalent of what Freud called “reality testing.” Such a pedagogy should exert itself to obtain the subject's recognition of the fact that no present or future technique orinstitution will guarantee the integrity of his powers in relation to men and to things. The life of the individual is, from its origin, the reduction of the powers of life. Because health is not a constant of satisfaction, but the a priori power to master perilous situations, this power uses itself up in mastering successive perils. The health that comes after being cured is not the same health as before. The lucid consciousness of the fact that healing is not a return will help the patient in his search for the state ofthe least renunciation possible, even asit liberates him from his fixation upon his previous state. One of the last writings of F. Scott Fitzgerald, The Crack-Up, begins with these words: “Of course all life is a process of breaking down...” The author adds a few lines: “The mark of a first rate intelligence is that it is capable of holding two.contradictory ideas at the same time without losing the ability to function. One should, for example, be able to understand that things are hopeless and remain committed to changing them."** To learn to heal is to learn to become familiar with the contradiction between today’s hope and the failure that comes at the end. Without saying no to today’s hope. Is this intelligence or simplicity? ‘Translated by Steven Miller 6b (nawn 009 988 292” Cea I eee cece. eege ‘s SPe S08 D Coe 0008 Seeesse Seo ae 288 886 es seecceces 3332333 | eee @'@ eogece eee e‘The essay translated here originally appeared as “Une pédago- Ble de la guérison est-elle possible?” in Ecrits sur ia médecine (Paris: Seuil, 2002), 65-100. 1, See Frangois Dagognet, La raison et les remédes (Paris: P.UF,, 1964), in particular, Chapter 1; Pierre Kissel and Daniel Barrucand, Placebos et effet placebo en médecine (Paris: Masson. 1964); Daniel Schwartz, Robert Flamant, and Joseph Lellouch, L'Essai thérapeutique chez "homme (Paris: Flammarion, 1970). 2, Throughout this essay, I have chosen to translate guérir and guérison in various ways. In French, guérir covers the ‘meanings of both to heal and to cure; so that, depending on the contest, I have alternated between these options. When is concerns the transitive act oF an ongoing process, I have translated guériras heal and guérison ashealing. But when itnames a completed process or the aim to complete the pro- ‘cess, Thave opted respectively for to cure or cure. Accordingly, ‘Where Canguithem simply speaks of le malade nd la maladie, Thave regularly alternated, again depending on the context, between patient, sick person, illness, and disease. [Trans] 20 ‘UMBR(2) 3, “tested and used all sorts of medical treatments in one way cr another and I discovered that all roads lead to Rome, ‘those of science no less than those of charlatanism. Georg Groddeck, Le livre du ca, trans. Lily Jumel (Paris: Gallimard, 1973), 302. Inhis Preface to this work, Lawrence Durrell writes that *Groddeck was more of a healer and a sage than a doctor.” 4 René Allendy, Essai sur le guérison (Paris: Denoél et ‘Steele, 1934); and, already, Orientation actuelle des idées ‘médicales (Paris: Au Sans Pareil, 1927). One could also cite, because of his collaboration with Allendy, René Laforgue, Clinical Aspeets of Psycho-analysis, trans. Joan Hall (Lon- don: Hogarth, 1938), particularly Lecture 7; “Curing and the Completion of Treatment,” which does not exclusively ‘concern the psychoanalytic cure. {5 “Itis not the doctor but the patient who reaches the end of ‘the illness. The patient cures himself using his owm power, Just as he walks eats, thinks, breathes, and sleeps under his ‘own power.” Groddeck, 304. . See Auguste Comte, The Positive Philosophy of Auguste ‘See Yvon Belaval, Les Conduites d'échee (Paris: Gallimard, 1953). Dominique Raymond, Traité des maladies quil est dan- gereux de guérir (Avignon: E.B. Mirande, 1757). New expanded edition, with notes by M. Giraudy (Paris: Brunot Labbe, 1808). See Charles Lichtenthaler, “De Vorigine sociale de eortains concepis scientifiques et philosophiques grees,” in La Mé- decine hippocratique (Neuchatel: La Baconniére, 1957); B. Balan, *Premiéres recherches sur Yorigine et la formation du concept d'économie animale,” in Revue Phistoire des sciences XVII (1975): 289-326. G.W. Leibniz, theoretician of the conservation of fore, i. scribes into his system the Hippocratic theorem ofthe eon servation of organic “forces,” a point of agreement between rival doctors—Halle and Stahl, animists, and Hoffmann, ‘mechanist: “Iam not astonished men are sometimes sick, but Tam astonished they are sick so little and not always. This also ought to make us the more esteem the divine contri. ance ofthe mechanisms of animals, whose Author has made ‘machines so fragile and so subject to corruption and yet sj capable of maintaining themselves: for it is Nature which ccures us rather than medicine.” Theodicy, trans. EM. Hug: gard (London: Routledge & Kegan Paul, 1953), 130-191. Comte, trans. Harriet Martineau (New York: D. Appleton and Co., 1853), 356-376. ‘See Emile Gley, “La Société de biologie de 1849 & 1900 TYévolution des sciences biologiques,”in Essais Phistoiree de philosophie de la biologie (Paris: Masson, 1900). 187; and alzo, the article on “mesology” in the Littré and Robin Dietonnaire des sciences médicales. See Jean Laplanche, “Why the Death Drive?” in Life and| Death in Psychoanalysis, tans. Jeffrey Mehiman (Balt ‘more: Johns Hopkins University Press, 1976), 109-124. The author shows to what extent and in what way Freud relied, not without confusion, upon the works of Hermann von} Helmholtz on energetics.4g, Foradiscussion ofthe different concepts and evaluations of, the cure, see Jacques Sarano, “Que sae?" in La Guérison (Paris: P.ULF., 1955). 14, Onthe history of tuberculosis, see Marius Piéry and Julien Roshem, Histoire de la tuberculose (Paris: Doin, 1931); Charles Coury, La tubereulose au cours des Ages (Suresnes: Lepetit, 1972). 15, Jean-Bertrand Pontalis recognizes the ambiguity ofthe term psychology, which designates at once a discipline and its object, as ifthe representation of self were constitutive of the representing subject. Entre le réve et la douleur (Paris: Gallimard, 1977), 135. 16. “Potain would never say that my lungs were affected; he employs the formulae usual in such a ease, the bronchial tubes, bronchitis, &c...tis better to know exactly...So 1am consumptive. And only since two or three years. In short, itis not suficiently advanced to kill me, only itis very tiresome.” Marie Bashkirseff, Journal of Marie Bashkirtseff, trans. Mathilde Blind (London: Virago, 1890), 574-575. Note that 17, Tam not speaking here of cases when the patient's indul- gence of his illness aims to delay his eventual return to professional activity after taking a hiatus. 18. See Jean-Paul Valabrega, La Relation thérapeutique, ‘malade et médecin (Paris: Flammarion, 1963). 19, See Michel Foucault, Blandine Barrett Kriegel, Anne ‘Thalamy, Francois Beguin and Bruno Fortier, Les Machines ‘A quérir (aux origines de ’hépital moderne) (Paris: Institut de "environnement, 1976). 20. These two citations aretaken from Klaus Wagenbach, Kafka par lui-méme (Paris: Seuil, 1968), 197-38. 23, See the reflections of Professor P. Cornillo, “Quatre vérités surla santé," in Autrement 9: Franes-tireurs de a medicine 4977). The author shows that the notion of absolute health contradicts the proper dynamic ofall biological systems, and ‘hat, consequently, relative health is an unstable state of dynamic equilibrium. “Relative health remains an apparent. 27, state, which implies no guarantee in relation to the silent evolution of ulterior pathological processes that escape the Vigilance of the natural mechanisms of struggle against aggression, infection, or deperonalization, in the biologi- cal or psychological meaning of the term” (234). Edouard Brissaud writes: “The most flourishing health does not pres- age the longest life. One could watch one's hygiene, avoid imprudences and vices that accelerate aging, but ness will occur in spite of everything. Didn't one of our teachers—a hypochondriae, it is true—define health as ‘a precarious state that remains transitory and presages nothing good’?” Histoire des expressions populaires relatives a Vanatomie, 4 la physiologie, et @ la médecine (Paris: Masson, 1892), 93-94. From this, one could conclude that Doctor Knack was older than Jules Romains. First published in 1934, this work was translated into French under the tile La Structure de lorganisme (Paris Gallimard, 1959) Its regrettable that, to this day, ithas not been reprinted since then. [For an English translation, see Kurt Goldstein, The Organism (Cambridge, Mass.: Zone Books, 1995). Subsequent references are to this edition.} Ibid, 380. Ibid, 34 ti. See Evelyne Aziza-Shuster, Le Médecin de soi-maéme (Paris: P.UR, 1972), ‘A great oncologist from Toulouse, justly famous for his generous devotion and his indefatigable concern for the personal problems of his patients, taught that, when it ‘comes to stomach ulcers, the diagnosis can be made on the telephone, F. Scott Fitgerald, The Crack-Up,ed. Edmund Wilson (New ‘York: New Directions, 1994). (naw irawilly apollon THE UNTREATABLE At the very heart ofits development, all analytic experience encounters an internal limit that manifests itself in the form of what Freud called a “negative therapeutic reaction.” Once thas reached a certain point, the analytic process itself founders and seems bound to lead nowhere. The royal road ofthe dream becomes kind ofmpasse that prevents what sat stake in analysis from finding an opening toward its representation. When Freud encounters this difficulty with the Wolf man, he does something that analysts today find shocking. He places a limit upon the experience by informing his patient ofthe date when he will terminate the proces. But Freud thus introduces this strategy of the analyst into analytic tech- nique, a strategy that Lacan will cll the maneuver, which consists in constraining the patient to make a decisive change in his ethical postion in relation to what is happening within the analytic experience. This difficulty is internal tothe very process of the analytic experience and, for obvious reasons, to psychoanalytic treatment itself. Moreover, the analytic symptom seems tobe the nodal point at which this difficulty ‘becomes stumbling bloceforpsychoanalyses. In fact, tis quite possible that tis the origin of many deviations within analytic technique, within the theory ofthe clinic, and within the history of the psychoanalytic movement. It would be fascinating to verify this hypothesis. The facts, however, that many analytic cures fil because ofthis central difficulty | of analytic experience. For some time, the detractors of psychoanalysis, or anyone who wishes to reproach it for being non-scientific, have been able, without knowing how or why, to rely upon the support of this | intemal difficulty. We must, therefore, examine the knot atthe center i cf this difficulty, because it brings us a specific knowledge about the human whose decisive importance Lacan, after Freud, never ceased | to uphold, In order to give it a preliminary form, we could say that the “negative therapeutic reaction” presents a difculty because it pertains toan unbearable knowledge about what remains unpresentable within the jouissance that constitutes the human subject. POSTMODERNITY, THE DIFFICULT MOURNING OF MODERNITY Peychiatry and the neurosciences, which take pride in taking control of the human in orderto give it scientific dimension, assign themselves the mission of deferring the inevitable work of mourning modernity within ' the field of subjectivity. Science is the principal heritage of modernity. ‘UMBR(e) 234 5 Even as it unburdens us of the illusions of religion, it is supposed to guarantee the reign of rationality. This substitution of reason for the Other is supposed to guarantee the promise of happiness, taking charge of human destiny through the enterprise of reason. Modernity thus initiated the hope, if not the illusion, that the empire of reason and—why not? —the signifier, ‘would make it possible to cure all the ills that derive from affectivity and its imaginary avatars. Today, we willingly believe that we have long since abandoned such illusions, shattered by postmodernity, which has accustomed us to the work of analysis, demystification, and decon- struction. Nonetheless, we have not ceased to think, along with a certain science, that all of our ills are of biochemical nature and that it wil only be a matter of time before we rid ourselves of them. Advances in biochemical and neurobiological science hold out the promise of happiness. Ifthe great ideologies have progressively assumed the place of religions, which used to found and legitimate the ideals and norms that govern our lives and civic coexistence, and they have themselves gradually disappeared and evacuated the horizon of the signifier, then one might claim that this empty place has been filled by the extreme ideology of scientism, the only thought that upholds the achievements of science as the basis for new social and historical ideals. But the appearance of such achievements is perhaps deceptive. Instead of Western Europe, America now carries the torch of a chosen people invested with the mission either to bring the good news to all other peoples, to civilize them, or, as with the United States today, to bring them the democracy that would guarantee peace along with economic de- ‘velopment and well-being for all. The paranoid mania, a kind of gentle madness, to believe itself superior to all other peoples and to assign itself the mission of becoming their saviors, supports allother values. Although official ideologies have no other function than politically to legitimate this madness, it is not, as we are often encouraged to think, simply the province of the extreme right. This maniacal thought permits a certain science to remain at the level of an epistemology that dates from the Christian middle ages, according to which the human spirit benefits from share of divine thought, 60 that it can possess an exact representation of the world such as it is constituted in the mind of God. Our mental representations would thus not be human con- structions, but rather veritable reproductions of the structure of the universe. Truth can then bbe conceived as the adequation of our representations to the structure of the objects observed within the universe. This schema, which has survived for centuries because it partakes of the religious justification for dominating peoples, still animates the epistemology of certain sciences and informs their experimental dimension, charged with controlling the reaction of subjects. Nonetheless, the contemporary advances of physics and mathematics, which serve as a refer- tence point forall ofthese sciences, are more and more foreign to such claims abont the relation between our mental representations and the reality of our observations.‘THE ILLUSION OF TREATMENT" ‘This censured and implicit epistemology today dominates the domain of practices in the health sciences. Within the field of mental health, in particular, all of ourills are supposed to become the ‘more or less long term object ofthe best care with the best results, thanks to the now irresistible advances of science and, especially, of neuroscience. The question of treatment introduced by psychoanalysis is thus often confused with the problematic of care that dominates the field of medical practice. Doctors and hospitals have plenty of treatments to offer, using the best means placed at their disposal by the health sciences. They treat physical troubles whose biochemical and neurological causes and consequences are clear, well known, and experimentally demon- strable and verified by third parties. On the one hand, there is thus a structure for physical and medical treatment that implies that the caregiver will intervene on the level ofthe cells, tissues, organs, and systems or functions of the organism that becomes the object of care. On the other hand, the treatment revolves around a relation, structured and framedby an institution, between 1 team of caregivers and the patient, along with his friends and family. The act of giving care is, conditioned by these structures and cannot be abstracted from them withoxt affecting its results. Within the limits imposed by the object of its intervention, such an act cannotdo without a mini- mum of involvement on the part ofthe patient. But it remains fundamentally the intervention of a technician or a specialist upon the organism of a client. This intervention is clearly delimited and makes it possible to caleulate a result that has been predicted and agreed upon by everyone. In everyday discourse, if not official discourse, this dispensation of care is more and more often confused with what psychoanalysis evokes with the concept of treatment. This confusion has grown to the point that it tends to make the incurable indistinguishable from the untreatable, sustaining the illusion that treatment is possible in milieus dominated by the administration of care. Moreaver, this confusion is repressed in the English language, as if it were the object of an interdiction upon thought, especially within milieus where the human is regularly reduced, from an epistemological standpoint, to its biological functioning, Indeed, care is not treatment. When we speak of treatment within psychoanalysis, we are in an entirely other register than that of care. Psychoanalysis delimits a domain of application in which the concepts and practices of care are hardly applicable. One will thus say that a psychiatrist cares and that a psychoanalyst treats. An interesting French idiom allows us to underscore this difference. When one says of someone that he is intraitable, this means that he is intractable, that he refuses to compromise his principles. In more Lacanian terms, one could say that he refuses to give up on his desire. The notion of psychoanalytic treatment is of this same order. Contrary to care, which centers on the action of the caregiver or the team of caregivers, the notion of treatment is centered on the relation between the subject and something without which his sz