A.L.I.

Since we are among analysts of different theoretical conceptions, it seemed necessary to me, in order to introduce the instruments and the ideas of our own, concerning psychosomatics (and which come from Lacan’s indications and their development by Charles Melman), to start by the clinics and situate them in parallel with those of a non-Lacanian author. That’s why I retained a recent article in The International Journal of Psychoanalysis (HP 1988,69: 43-53) of a canadian author called Paul Lefebvre, entitled : « The psychoanalysis of a patient with ulcerative colitis. The impact of fantasy, affect and the intensity of drives on the outcome of treatment ». I shall rapidly summarize it, after which I shall bring in a few elements of a personal case in order to try to situate our convergences and our divergences.

The patient of P. Lefebvre is a 30 year old woman, depressed, assuming badly her role as a mother and feeling unable to work. Her ulcerative rectocolitis had started three years ago when she left her husband to return to her mother, and since then, it evolves, as it is customary, in outbreaks. These are principally determined by love affairs : she gets an outbreak when she meets a man, and another when she leaves him (and the first effect of analysis is that she will meet many men, what Lefebvre interpets as an acting-out). Her father, she says, was emotionally inaccessible, but to her mother, on the contrary, she was and is still very close while at the same time she feels this proximity with horror.

P. Lefebvre starts her analysis foreseeing that it will be difficult, and if he reports the case, it is because he considers the outcoming result after five years of analysis followed by six years of irregular treatment, as insufficient and because he aims to precise the reason why. What he retains, let’s say it immediately, is of an economic nature: the principal barrier to change is, for him, the abnormally high intensity of all the drives that he attributes to the early traumatic experiences through a fantasy that we shall discuss further.

Schematically, his argumentation is as follows : his starting point is a clinical trait which is certainly not specific neither of the ulcerative rectocolitis nor even of psychosomatic diseases in general, but the frequency of which I think we would all agree to recognize : his patient is always in search of an idealized and perfectly gratifying person and she definitely cannot adapt to others unless they appear as doubles of herself.

This « narcissistic impasse » is explained by Lefebvre referring to Karl Abraham by the impossibility to internalize the object. The object, he says, is either too close and thus threatening or too far and she would then feel abandoned and unable to give it up as lost. She defends herself against that object relationship, he adds, by an oral incorporation fantasy, but her narcissistic rage is such that the incorporated object is destroyed and expelled as a debris of no value (the reference here to Melitta Sperling is patent even though it is implicit). To these fantasies of incorporation and of expulsion, affects are associated, but they are denied and, for this reason, are at the origin of the rectocolitis. One of the aims of analysis is therefore bringing these affects to consciousness, in the transference. But transference, Lefebvre insists, is particularly difficult to handle : the first period where the analyst is either too near or too far, is followed by a second period where the patient is seized by a real « hunger of transference ». Nevertheless, finally, a certain degree of internalization of the object, of symbolization and of capacity of giving it up as lost will be attained but which, as I have already said, the author finds insufficient. The central point of this conception is, therefore, the impossible, or at least very difficult, internalization of the object. In this P. Lefebvre is very close to Pierre Marty but he differentiates from him because he situates afantasy at the origin of the psychosomatic disease. He calls it « faustian fantasy » in reference to the myth of Faustus and describes it as a bargain concluded with the parental power by which « security and satisfaction » could be reached, the price paid in return being « the sacrificial renunciation of one’s autonomous difference and the loss of one’s sense of ownership of psyche and soma ».

The personal case from which I shall evoke rapidly some traits is that of a 22 year old young man, also suffering from ulcerative rectocolitis and undergoing face-to-face treatment for three years. He asked to undertake a psychotherapy because his rectocolitis kept evolutive in spite of the medical treatment and because he considers it as psychosomatic, but he does not complain about his disease. What he complains about - I quote his own terms - is not being able to enjoy a « happiness without limits ». He feels an « absolute intolerance » with respect to any rule, nevertheless without being capable of revolt, and he wants to « change the order of the world » to establish an order without any constraint. His father, because of his mediocre success and of his inhibitions, represents « what he does not wish to be ». He claims to have been deprived of his mother because she used to take care of other children and to have been sent to school too early. Adolescence has been the most difficult period of his life ; he says that he could not then « identify himself » specifying that « one identifies oneself in relation to others ». A little time later, he meets a young girl who was « the object of all satisfactions » but who, he felt, nevertheless, constantly betrayed him, exactly as it would happen if his mother forgot to prepare his white coffee for, he says, « love is like hunger ». It is at the moment when his family, including his father who had never given him an order, demands that he leaves this girl, that his rectocolitis breaks out. Continually betrayed, this boy takes refuge in his reveries. The theme of these reveries is most ordinary : love on a deserted island, but the interesting point is that he specifies that they can be expressed in one phrase. This phrase is : « m’envoler par une femme » (it is roughly equivalent to « to fly off by a woman », however this reflexive verb, « m’envoler » has no direct English equivalent).

I shall come back to this point but, first, I shall make some comments starting from the other sentence « I could not identify myself... one identifies oneself in relation to others ». It states clearly the necessity that he feels - and which is obvious in the therapeutic relation - of having in front of him, under his eyes, someone alike, in whose absence he feels annihilated. We understand it as follows : he cannot see himself except through an other (in lacanian terms : « un petit autre », « a little other ») he has no image of his body without the image of the other. We interpret it as the imaginary compensation of a failure in the symbolic identification. As already mentioned, P. Lefebvre, whose patient also needs a double, interprets it as a failure of the object internalization.

It seems important to underline what the lacanian conception implies even though I can only schematize. Lacan considers the dialectics of internalization and of expulsion of the object inadequate to explain the identification of the subject (« symbolic identification »). He starts from what Freud says : the identification to the lost object is realized in regard to only one trait of that object. (« Group Psychology and Analysis of the Ego ») but he gives it a further reaching signification when he says that this trait is not simply a positive trait (like the cough in the example of Freud) but introduces the difference in its pure state ; that is, a difference which is outside the domain of appearances. (That’s why, for example, identical twins may identify themselves as different). But where does this « pure difference » come from ? From language. It is what characterizes the signifier ; the signifier according to Saussure can only be defined in terms of its difference to other signifiers and Lacan adds : different from itself when it is repeated. This, which may appear obscure, means that the subject’s identification is not realized by any other means than by language, and that it is indispensable to treat simultaneously the question of identification and the particularities of language.

In fact, the language of these patients has some particularities. One of the most remarkable, first noticed by P. Marty, is that the signifier seems to have lost (it is not unreversible) its fundamental equivocity to keep only its function of designation (which, in lacanian terminology, characterizes the sign in opposition to the signifier). For example this is shown when patients repeat expressions which have a clear relationship with their physical symptoms without any surprise, and therefore without distancing themselves and making comments. (So our patient repeats that « il se fait du mauvais sang », meaning that he worries and seemingly being unaware of the literal meaning of the expression - « he passes bad blood » and of its relationship to his disease). Here we might say, the signifier is repeated while remaining identical to itself.

Let us now consider Lacan’s idea concerning psychosomatics. As we already know, Lacan endeavoured to formalize the clinical experience and he did it with an extremely simple set-up consisting of only four letters : S1, S2, a, $. S1 is the master signifier or the phallic signifier, the one which determines castration, S2 represents all of the other signifiers, a is the lost object whose loss is the effect of the distance between S1 and S2, and $ is the subject of the unconscious, which is not an entified subject but which results also from the distance between S1 and S2 (as indicated in the notion of distance between the signifiers this formalization cannot be dissociated from a certain topology which will certainly be evoked in other lectures). In psychosomatics, Lacan indicates that there is no distance between S1 and S2, there is, he says, a « holophrase » S1 S2. I shall immediately give an example of a clinical application of this formulation logically implying that neither a nor $ is locatable. When patients whose rectocolitis has just started are questioned, it is noticed that before the start there had been neither a subjective conflict (even though the trigger situation often imposes a choice) nor anguish, nor calling help, nor prayer. Now, the conflict shows that the subject ($) is split by the signifier ; the anguish is determined - Lacan has much insisted on that - by the object a ; as to the calling for help and the prayer, they are an address by the subject to the one who represents S1. We hence see that the absence of these manifestations is congruent with this writing.

But with the formalization of the holophrase (which anyway, is not particular to psychosomatics) some difficulties subsist. This one for example : why speak of S1 and S2 if they occupy the same position, since the only thing that distinguishes one from the other is that they occupy different places. To overcome this difficulty, Charles Melman advances the following hypothesis : there might be at the origin of the psychosomatic pathology the fantasy of a tongue without a phallic signifier (that is, uniquely made of S2 without the contribution of S1).

Yesterday, speaking of the mother tongue, Charles Melman described the situation that one could call normal, in which the tongue is organized by the phallic signifier. The mother tongue, he pointed out, is the tongue where the mother had become forbidden by the effect of the phallic signifier, in other words the tongue offers to the subject a refuge, a « heim » - one is there at home - after the price of castration has been paid. (Inversely the patients we are speaking of have no refuge in the tongue, no symbolic heim, and this is not a figure of speech ; they actually dread exposing themselves whenever they open their mouths, with each word they feel unveiled).

But what does it mean that the mother is forbidden when the tongue is organized by the phallic signifier ? This means that there is no longer an univocal tie between things and words, that words may always be understood otherwise and as a consequence, that a demand can never be totally satisfied (in opposition to the need which can be totally satisfied). On the contrary keeping the tongue free from the action of the phallic signifier is an attempt to allow the demands to be always fully satisfied.

Here the convergence between the hypothesis of Charles Melman and that of P. Lefebvre is obvious since the latter speaks of a fantasy which would assure security and satisfaction. Nevertheless, this convergence is accompanied by an important divergence. P. Lefebvre considers that a sacrifice has been made : that of the true self and of the feeling of ownership of the body and the psyche ; we think, on the contrary, that this fantasy corresponds to the refusal of the only sacrifice that counts, the one ordained by the symbolic law, that is, castration, and that it manifests the wish of a satisfaction which would be without limits. (It seems to us, in fact, that what P. Lefebvre calls true self and feeling or ownership of the body and of the psyche is a way of describing the state of someone who has assumed castration, and that inversely, their loss is the consequence of the refusal of this sacrifice).

This divergence probably has consequences in practice ; if we consider that there has been a sacrifice, we will have to point out to the subject that he has been fooling himself and that he must cease paying, whereas if we consider that it is the refusal of sacrifice which is at the origin of fantasy we can only make him face the fact that he is not abiding by the symbolic law.

This refusal of the symbolic law is clearly displayed by our patient who states his wish to enjoy a « happiness without limits » and who wants to change the order of the world. It is important to notice that the disease starts precisely when the external circumstances come to thwart this fantasy ; in general, the breaking out occurs in situations which impose the observance of the symbolic law : for example, when one has to assume, in one’s own name, an engagement (in professional life or in marriage) or has to separate from his parents or to leave his home (for lack of a symbolic home the real home acquires a capital importance).

I would like now to return to the fantasy of our patient - « m’envoler par une femme » - for it illustrates this absence of distance, this lack of a cut that Lacan formalizes with the holophrase S1 S2. From a non lacanian point of view, it will be the significations of the fantasy which would hold the attention : « m’envoler » (my taking off) evokes the sexual enjoyment, and no doubt the emission of faeces, and then renders those two ways of enjoyment equivalent ; « par » can mean not only « by » but also « through » and thus the expression evokes the penetration and the crossing of a woman’s body ; we may also think of theft (vol) ...

However, it seems that the analysis of a fantasy cannot be limited to its significations because these are not particular, we can find them in a neurotic, a psychotic or a perversion case as well as in the case of a patient with a psychosomatic affection. We also have to analyse its grammatical structure as Freud pointed out with « a child is beaten ». In « m’envoler par une femme » the grammatical structure is very unusual and indeed incorrect, for the association of a reflexive verb with the preposition « par » which introduces an outside agent is not licit. A choice must be made : either to use a reflexive verb or to use a verb in the passive form associated to the preposition « par ». Here the choice - and any choice means a loss - has not been made, with the consequence that there is a confusion between the subject and the object : the subject indicated by the pronoun « m’ » is simultaneously an object because of the preposition « par ».

Whereas this confusion does not exist in the sentence of the typical fantasy of neurosis - « a child is beaten » - Moreover in this case, because of repression, the one who is speaking is unaware that he himself is the child object in the fantasy. Another difference : while in our patient’s fantasy the agent is designated and is a woman (« une femme ») in « a child is beaten » the agent is not mentioned, which, in topological terms, situates him elsewhere, we could even say, since the analysis reveals that it concerns the Father, in a transcendent position. Thus, in « a child is beaten » castration can be located not only in the imaginary - the blows - but also in the cut that structures the fantasy. On the contrary, « m’envoler par une femme » is characterized by the absence of a cut.

If we admit that the fantasy which we used as an example is representative of psychosomatics, we will have to examine the structure of the drive. Does it present any particularities in the psychosomatic cases ? For P. Lefebvre, as we have said, the particularity would be of a quantitative nature and, he suggests, purely biological causes contribute a lot to that.

Going back to the text of Freud, Lacan insisted on the fact that we cannot think of the drive path independently of language and showed that what lies behind it is a grammatical formula. We can therefore, make the supposition that in psychosomatics this formula has a certain structural particularity and that what appears as a quantitative abnormality is only the expression of this particular structure. Moreover, we know the freudian model of an auto-erotic drive : that of the mouth that kisses itself, where the source and the object are thus confused.

I shall illustrate the absence of any cut by evoking briefly the scenario written by a patient with an ulcerative rectocolitis. The story is that of an inseparable couple quarrelling all the time - « it’s your fault », « no it’s yours ! » - who decide, in order to stop these quarrels, to set up a video camera which would determine for sure the responsibility of each. The interesting thing is the patient’s comment: « the camera is not outside, he says, it has nothing to do with religion, it is something immanent » and he adds : « nature for me is a big body ». He is therefore well aware that a third party is needed to get out of the impasse of the relationship between two people, but this third party which is relegated to a machine level should not be anywhere else, it has to be a part of the same « big body », let’s say of the set S2.

This, of course, is not without consequences on transference. The transference of the neurotic is of the paternal type, that is, he addresses himself to whoever represents S1 ; as we can see, it is not the case with these patients and this is undoubtedly why they so rarely come to consult us. However they sometimes do and it seems to me that we will have, then, to take into account two things : on the first hand, the necessity they feel to have an imaginary support (which may impose a face-to-face therapy) and on the other hand, the necessity of making them face what Lacan calls the « wall of language », that is, the impossible which comes to light the moment one speaks. (Returning to our patient’s case : the impossible that speech gives rise to is that there can be no « object of all satisfactions »). As we have seen, it is when their fantasy denies this impossible that they are vulnerable - somatically speaking - to whatever occurs that deprives them of the « satisfaction », this is why the dimension of castration should be introduced in the therapeutic relation. We then see frequently that while the physical symptoms improve, anguish appears, but this does not mean, of course, that the structure is already decisively modified.